CM E

Transference and Countertransference:

Developments in the Treatment of Narcissistic Personality Disorder
Glen O. Gabbard, MD

CM E

EDUCATIONAL OBJECTIVES

1. Describe the empirical literature on narcissistic personality disorder that discusses our understanding of transference and countertransference. 2. Dene the spectrum of patients who have narcissistic personality disorder and the nature of the condition. 3. Identify common countertransference reactions. Glen O. Gabbard, MD, is Professor, Department of Psychiatry and Behavioral Sciences, and Director, Baylor Psychiatry Clinic, Houston, Texas. Address correspondence to: Glen O. Gabbard, MD, One Baylor Plaza, BCM350, Houston, Texas; fax 713-798-7984. Dr. Gabbard has disclosed no relevant nancial relationships.

directly observe how the patient relates to others outside the consulting room. Transference and countertransference are best conceptualized as the unconscious re-creation of the patients internal object world in the relationship with the psychotherapist. Indeed, the character dimension of personality is usefully conceptualized as involving an ongoing attempt to actualize certain patterns of relatedness that are ubiquitous in the patients life.1 Through interpersonal pressure in the here and now of the clinical setting, narcissistic patients try to impose on the therapist a particular way of responding and experiencing. What we call character traits can be viewed as

the attempt to actualize a wish-fullling internal object relationship that is rmly entrenched in the patients unconscious.2 A patient may wish to be admired by the therapist, and therefore boast about his many accomplishments to elicit an admiring response in the therapist. The method, however, may backre as the therapist becomes increasingly irritated because the patients boasting alienates the therapist. Therefore, the tragedy of patients with narcissistic personality disorder is that they long for self-esteem stabilizing responses in others but nd themselves unable to elicit them. The mode of actualization within the analytic relationship is often referred to

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t is well known that narcissistic personality disorder is one of the most difcult psychiatric disorders to treat. Much of the difculty arises because of challenging patterns of transference and countertransference that develop in the course of treatment. Yet it is just these patterns of relatedness that must be the core of the treatment, since narcissistic patients have enormous problems in maintaining gratifying relationships. One can see the clinical setting as something of a laboratory in which the clinician can

as projective identication.3,4 Stemming from the thinking of Klein and Bion, this model involves the notion that patients always behave in a characterologically driven way that leads them to imagine the therapist into assuming a role that originates within the patient. A narcissistic patient who makes contemptuous comments about the therapist may eventually cause the therapist to have feelings of anger or hate toward the patient. Although this type of interaction may not to be wishful on the surface, even a bad or tormenting object may provide afrmation and safety to some patients for a variety of reasons.2,5 Children who have been abused, for example, may gain a sense of safety in that it is preferable to have an abusive object in a relationship with them rather than have no object at all. Historically, these children have looked to an abusive parent for safety and protection. They may have no alternative. They may also have grown accustomed to the notion that the only way to remain connected to a signicant gure of safety is to maintain an abuser-victim paradigm in the relationship. The repetitive relationships established in the transference and countertransference of the clinical setting may approximate real relationships in the patients past. However, relationships based in fantasy may also be part of a patients internal world. Transference longings often reect intensely wished-for relationships that never really materialized in the patients childhood. Those children who grow up with neglect and abuse may long for an idealized rescuer who will save them from abuse, and they may approach others with that wish, activated in a variety of different settings. EMPIRICAL DATA Most of our knowledge about narcissistic personality disorder has emerged from psychoanalysis and intensive psychoanalytic psychotherapy. We have little research to provide systematic un-

derstanding of transference and countertransference phenomena in large series of patients with the diagnosis. However, recently, a growing body of empirical data has helped illuminate those characterological features that are hallmarks of narcissistic personality disorder.

We also know that narcissistic personality disorder is not a monolithic entity but a spectrum of subtypes.
Betan et al6 studied countertransference processes in clinical practice and related it to personality pathology. Onehundred eighty-one clinical psychologists and psychiatrists in North America constituted a randomly selected national sample for this study, and each of these clinicians completed a battery of instruments on a patient in their care. Included in these instruments was the Countertransference Questionnaire.7 When the responses to the Countertransference Questionnaire underwent factor analysis, an aggregated portrait of countertransference responses to narcissistic personality disorder patients provided an empirically based description that strongly resembled clinical and theoretical accounts. Clinicians reported feeling resentment, anger, and dread when treating such patients. They also found them-

selves avoidant, distracted, and harboring wishes to terminate the treatment. These feelings were independent of the therapists theoretical preferences. These typical countertransferences are obviously responsive to a set of characterological features that typify narcissistic personality disorder. These traits are the source of characteristic interpersonal problems. Ogrodniczuk et al8 studied 240 consecutively admitted patients to a day treatment program. These patients completed measures of narcissism, interpersonal problems, and general psychiatric distress. Those individuals that were characterized as highly narcissistic had several features in common: they were domineering, vindictive, and prone to intrusive behavior. The domineering behavior was composed of controlling and aggressive features that reected an inability to empathize with others. The vindictive behavior was characterized by vengeful and suspicious features, suggesting incapacity to enjoy another persons happiness or to be supportive of anothers goals in life. The investigators also found that a failure to complete treatment in the program was associated with high scores in narcissism. The dening features of the narcissistic patients in the study can be viewed as accounting for the typical countertransference problems that were described in the study conducted by Betan et al.6 If we understand transference as involving the continuation in the treatment setting of habitual modes of object relatedness by the patient, then characteristic patterns of response occur in the clinicians countertransference. We also know that narcissistic personality disorder is not a monolithic entity but a spectrum of subtypes.9,10 The narcissistic personality disorder dened by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria identify only one subtype of narcissistic patient specically, the boastful and arrogant individual who demands the attention of

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others. This oblivious narcissist9 appears to have no awareness of his/her impact on others. These patients talk as though they are addressing anyone in earshot instead of speaking directly to people. They are unaware that they are alienating others with their arrogance, and their tendency to refer to themselves repeatedly reects their need to be the center of everyone elses attention. They are not capable of mentalizing the experience of others and thus come across as insensitive. Those who know them perceive them as having a sender but no receiver.9 This DSM-IV construct fails to capture another variant on the narcissistic continuum, which is the hypervigilant type.9 Although both subtypes have serious problems in regulating self-esteem, they manifest themselves in quite different ways. Hypervigilant narcissists are exquisitely sensitive to how others react to them. They tune into the facial expressions of others and listen carefully to what they say for any evidence of a critical reaction. They are prone to feel slighted when others have no intent whatsoever to be critical. Therefore, in contrast to the self-absorption of the oblivious narcissist, the hypervigilant narcissist is more other-directed. They may seem shy and inhibited to the point of being self-effacing because they avoid being the center of attention. Although the DSM-IV TR criteria do not represent the hypervigilant variant of narcissistic personality disorder, a number of studies have provided empirical support. Wink11 used the Minnesota Multiphasic Personality Inventory narcissism scales and identied two orthogonal factors: a Grandiosity-Exhibition dimension and a Vulnerability-Sensitivity dimension. He referred to these as overt and covert subtypes, respectively. Both forms shared several key features: conceit, self-indulgence, and disregard for others. However, the Vulnerability-Sensitivity group is characterized as introverted, anxious, defensive, and vulnerable to lifes traumas. By contrast, the

Grandiosity-Exhibitionism group was extroverted, self-assured, aggressive, and exhibitionistic. Hence, one might say that a critically important distinction revolves around narcissistic vulnerability. The hypervigilant narcissist is exquisitely vulnerable to narcissistic wounding, while the oblivious narcissist is more intensely defended against that vulnerability. Hibbard12 identied two subtypes of narcissistic personality disorder in a study of 701 college students. He also found a narcissistically vulnerable style and a phallic grandiose style. He identied that the affect of shame was central in dividing these two groups. The vulnerable narcissist correlated positively with the affect of shame, while the grandiose individual had a negative correlation. Dickinson and Pincus13 also conrmed this distinction and noted the similarities between hypervigilant narcissists and those with avoidant personality disorder. A key difference is that the hypervigilant narcissistic is secretly grandiose, while the avoidant individual is not. The overt or oblivious narcissist may claim to be happy compared with the covert or hypervigilant subtype. Rose14 studied 262 undergraduates and found that overt narcissists score high on traits of entitlement, grandiosity, and exploitiveness, but also rate themselves on measures of self-esteem and happiness. One inference that can be made from this data is that oblivious or overt narcissistic individuals derive certain psychological benets by deceiving themselves compared to ordinary people who cannot maintain that self-deception. If they can maintain a set of unrealistic beliefs about their specialness while viewing others as inferior, they may benet because they are able to defend against shame and pain. The hypervigilant or covert type rated themselves as feeling unhappy or inferior because their defenses against narcissistic wounding are much less developed. One study10 suggested there may actually be three subtypes of narcissistic

personality disorder. These investigators used a random national sample of 1,201 clinical psychologists and psychiatrists, and they asked these clinicians to describe a randomly selected current patient with personality pathology. The clinicians engaged in the study gave detailed psychological descriptions of these patients using the Shedler-Westen Assessment Procedure-II.15 They lled out a checklist of diagnostic criteria from DSM-IVTR personality disorders, thus providing construct ratings for each of the diagnostic entities on Axis II. The descriptions of narcissistic patients were aggregated to identify the most characteristic and distinctive features of the disorder. When the investigators analyzed their data, 255 patients emerged who met DSM-IV criteria for narcissistic personality disorder based on the checklist and 122 based on the construct ratings. Qfactor analysis identied three subtypes of narcissistic personality disorder, which the authors designated as grandiose/malignant, fragile, and high-functioning/exhibitionistic. Grandiose/malignant narcissists were characterized by interpersonal manipulativeness, lack of remorse, seething anger, pursuit of interpersonal power and control, feelings of privilege, and exaggerated self-importance. They appear not to suffer from underlying feelings of inadequacy, nor are they trying to feel other forms of negative forms of affect states except for anger. They blame others for their problems and have little insight into their own behavior. This group of patients has much in common with the oblivious narcissists. The fragile subtype wards off painful feelings of inadequacy, small, loneliness, and anxiety, with a defensive grandiosity. This person wishes to feel privileged and important, and as long as the defenses are operating smoothly, those feelings may be present. However, the defenses are prone to collapse, leading to intense feelings of inadequacy and other nega-

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tive affect states, often accompanied by narcissistic rage. A third subtype, the high functioning/exhibitionist narcissist, is well represented in the clinical literature, but has very little research substantiating the construct. These individuals have an exaggerated sense of self importance but they are outgoing, energetic, and articulate. They often have adapted well to their work setting, and use their narcissism as a motivation to succeed. These individuals may be envious of others and intensely competitive while intolerant of their own defects. Russ et al10 found that fragile narcissists tend to suffer the most and have the worst adaptive functioning. The Grandiose/Malignant narcissist may externalize the behavior to the greatest extent, and the higher function/exhibitionistic narcissist can function more effectively than the other two. COMMON TRANSFERENCES The empirical literature identies prototypes personality subtypes in ideal or pure form. In clinical work, one commonly nds patients who have characteristics of more than one subtype and who reside along the continuum between the oblivious or overt subtype and the hypervigilant or narcissistically vulnerable subtype. Therefore, the transferences that develop are related to the constellation of features stemming from the various subtypes identied, as well as by idiosyncratic patterns of object relatedness that have been internalized in childhood. We do not have good prospective developmental data on what combination of genetic and environmental features produce narcissistic personality disorder. Therefore, we cannot link specic developmental patterns with the transferences that appear in adult patients except by inferring, retrospectively, the childhood patterns that may or may not be accurate. Nonetheless, it is clinically useful to identify themes in the transferences that are relevant for the psychotherapist or psychoanalyst.

Therapist as Sounding Board The oblivious narcissist uses the therapist as a sounding board, a listening ear that exists primarily to enhance the patients self-esteem. Such patients dont really connect with the therapist in the way that neurotically organized patients do. They talk on and on about themselves in a self-aggrandizing way without studying the therapists face to see what is happening in the therapists internal world. This absence of mentalizing is connected with a lack of curiosity about the therapist. Indeed, the oblivious narcissist may relate in such a way that an observer would view the interaction as characterized by an apparent absence of transference. The astute clinician, however, knows that this apparent absence is the transference.16 This apparent mode of non-relatedness is, of course, the way that some narcissistic individuals relate to everyone. Kohut17 viewed this style of relating to the analyst as a version of the mirror transference, where the patient is hoping to receive a conrming validating response from others as a way of shoring up a fragmented self and increasing the patients sense of self-esteem. Kohut referred to these as self-object transferences because the other person is used as a missing part of the self. Hence, in this form of narcissistic transference, the patient is not aware of the therapists separate subjectivity and internal world the person is only there to afrm the patients self-worth. A clinical example will illustrate this form of transference: Dr. S is a 42-year-old academic who came to therapy after getting passed over for a promotion. He talked at length about the unfairness of the situation and insisted that the members of the promotion committee were envious of his talents and writing skills. He elaborated on those skills to his therapist. Dr. S: Im not sure how familiar you are with my writing, but my rst book won a prestigious award that carries tre-

mendous weight in academic circles. No one in the department congratulated me on it. The chairman has never won this award, and he couldnt bring himself to tell me that this was good for the department or that he thought I was a capable writer. I examined the criteria for professor very carefully, and I exceeded the criteria by a mile in every single variable. I know Im intimidating to others in my eld. Phi Beta Kappa from Stanford. PhD from Yale. Rhodes Scholar. I tower over everyone in the department, and they cant handle it. Therapist: I wonder if another issue Dr. S: Please just let me nish here. The other thing I think is going on is that I know the chairman thinks that Jane Morgan is more attracted to me than him. She clearly thinks Im hot. He is an old fogey, and she doesnt care about him at all, and I think it drives him nuts that he cant compete with me in that area. She always sits beside me in departmental meetings, and Im sure that bugs him. Therapist: But dont you think that theres another way of looking at this? Couldnt it be that Dr. S: You dont know these other people, and I think its hard for anyone outside to have any sense of how bad it is there. One of my colleagues who wasnt quite as successful as I, but does some pretty adequate stuff, resigned 2 years ago because he was fed up. I think its actually a minor little department that thinks its much better than it is, and Im denitely going to look elsewhere because Im tired of being treated this way. I think Im entitled to some respect after my accomplishments, and no one seems to appreciate who I am or what Ive done in a relatively short time. And believe me, I havent done anything to alienate these people. Im very respectful of them all the time, but its simply not reciprocated. In this vignette, Dr. S demonstrates clearly that he is really not interested in

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hearing anything that his therapist says. In fact, he interrupts him and simply wants to present his own point of view. Like many patients who are in the oblivious or grandiose/malignant category, Dr. S doesnt give the therapist any space to be a separate mind with divergent viewpoints. He only wants to be heard and validated. One of the paradoxes is that this sort of patient comes to therapy ostensibly to receive help, feedback, and observations from the therapist, but then does not allow the therapist to do the job that he or she is being paid for. Contempt Clinicians must remember that the fundamental disturbances in narcissistically organized patients are feelings of inadequacy associated with difculties in regulating their self-esteem. One common defensive strategy is to devalue others as a way of making ones self feel superior and less inadequate. Patients who come for help may immediately feel in a one-down position with the therapist and need to treat the therapist with contempt as a way of trying to level the playing eld. The grandiose/malignant patient may engage in this contempt, but the fragile or hypervigilant narcissist may also devalue the therapist, especially when feeling narcissistically wounded, ignored, or rejected by the therapist, as in the following vignette: Ms. S: I dont think youre paying attention to me. Your eyes just glazed over when I started telling you about what happened at work today. Are you even interested in anything Im saying? Therapist: Of course I am. Im not aware of any change in my eyes, but I was reecting on what you were saying, not ignoring you. Ms. D: No, you werent thinking. You were zoning out on me. I watch you carefully, and I know when youre really with me and when your mind has left the room. Do you even like this job? You act

like youre bored most of the time and just waiting for the clock to move so you can get me out of here. You use me to get my money. You can pay your mortgage and put food on the table because of me. But I think the minute I leave this room, you forget all about me. I think Im just one of a series of nameless, faceless people that come through here in the course of a day, and that you could care less about. Therapist: Just a minute now, is that really a good characterization of our therapeutic relationship over the time weve worked together? Ms. D: Dont try to deny what Im saying. At least give me the common courtesy of being honest. I know how you feel. You think Im a huge pain. And I really dont think you know what youre doing. Every time I ask for advice, you say that same stupid thing about lets explore this together, rather than helping me gure out what to do. I cant believe you charge the fee you do, when thats the kind of help that you have to offer. In this interchange, a perception of a small change in the therapists appearance leads the patient to erupt in narcissistic rage. This rage is accompanied by contemptuous and devaluing comments about the therapists capacities. The serious doubts about the therapists skills have been present all along, but they only erupt in this orid manner when a perceived slight is registered by the patient. It is important to recognize that transference is not simply measured by what the patient says she or he feels about the therapist. There is an unconscious characterological dimension to transference that is there all the time, and may operate outside the patients conscious awareness. Since the beginning of this therapy, Ms. D related to the therapist as though she had some reservations about him, but did not verbalize them. Another dimension of this contempt relates to envy. Narcissistic patients are frequently envious of those who seem

to have things that they dont. The therapeutic situation presents narcissistic patients with a dilemma: to receive help, they must acknowledge that the therapist knows something that they dont. This situation results in their feeling diminished in comparison to the therapist, who appears to have wisdom and knowledge. A common response to envy is to try to spoil and devalue what one cannot have, much like the sour grapes story in Aesops Fables.18,19 By insisting that the therapist is incompetent and does not really know anything useful, patients can convince themselves that there is nothing to envy, and they do not need to feel inferior about themselves. A variation on this envy was noted in the ndings of the day hospital study reported by Ogrodniczuk et al,8 when they characterized vindictive behavior as reecting an inability to feel good about another persons happiness or to be supportive of anothers goals in life. To do so would be to recognize envy of something good that someone else has. Idealization and Twinship In addition to the mirror transference, Kohut17,20,21 also recognized other types of self-object transferences in narcissistically organized individuals. To shore up shaky self-esteem and to achieve more cohesion of the self, some patients may idealize the therapist. They may perceive the therapist as an all-powerful parent whose presence soothes and heals. By basking in the reected glory of an idealized therapist, they vicariously have a sense of self-esteem conferred upon them. Such patients may come to therapy just to be in the presence of a therapist, and not really show any initiative to analyze or understand the problems that bring them to therapy. They may feel that being with a therapist is an end in itself they have found the ideal person and do not need to look any further. In his last posthumously published book, Kohut21 added a third self-object transference beyond the near and ideal-

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izing transference. He referred to this as the twinship or alter ego transference. In this paradigm, patients perceive the therapist as exactly like them. They actively long to be similar to the therapist in every way. They may dress like the therapist or cut their hair so that they resemble the therapist to a greater extent. They may also pursue interests that they discern in the therapist. They stabilize their self-esteem and feel completed by seeing themselves as identical with someone they respect. In this way they attempt to bypass any exploration of the conicts and decits that haunt them. Fear of Humiliation Narcissistic patients who fall into the fragile or hypervigilant subtype are prone to feelings of shame and humiliation. One of the reasons they are hypervigilant in scanning the therapists face and looking for slights is that they are guarding against an experience of narcissistic humiliation. One of the phenomena that occurs when a patient comes to analysis or therapy is a profound sense of exposure. The hypervigilant narcissist often goes to great lengths to conceal his/her vulnerability, and when such patients arrive in therapy, they undergo a sense of feeling unprotected and unable to hide their shame in a situation where they feel exposed to the therapists gaze and painfully conspicuous.22 These patients tend to avoid the limelight because of the risk of making a fool of themselves. They feel that they are under the scrutiny of the therapist, which can make them feel small, dependent, looked down upon, and humiliated. Any effort the therapist makes to provide understanding can also be humiliating. Therefore, there is a potential slight in anything the therapist says or does. Humiliation is closely linked to shame, which often entails a sense of not living up to ones excessive expectations of the self. However, shame is also intimately linked to a sense of being painfully exposed. Many anxieties in narcissistic

patients arise from being looked at and may lead them to intensify their narcissistic defenses to avoid a feeling of fragmentation.22 The patient is suspicious of the therapists intent, and perceives in the therapists eyes a wish to hurt, humiliate, and deride the patient. Omnipotent Control One of the most common transferences, regardless of the narcissistic subtype, is an effort to control the therapist. Rosenfeld 23 stressed that for a narcissistically organized person, the greatest concern is an experience of separateness between subject and object. Therefore, much of what transpires is an effort to prevent that separateness. This fantasy of controlling what the therapist does manifests itself in a variety of ways in the transference. Hypervigilant or fragile narcissists may never take their eyes off the therapist, as though through intense scrutiny of the therapists every move, the patient maintains the fantasy that the therapist is completely under the patients control. Erupting in narcissistic rage when the therapist does not conform to the patients expectations also may be related to a fantasy that bullying and intimidating the therapist with anger will subjugate the therapist to come under the patients omnipotent control. COUNTERTRANSFERENCE The countertransference challenges posed by patients with narcissistic disturbances are extraordinary, and at times, perceived as unbearable to the clinician. The capacity to identify, understand, and contextualize these countertransference experiences are central to the effective treatment of narcissistic personality disorder. There are consistent countertransference patterns, some of which will be examined here. One must keep in mind that there are idiosyncratic reactions involving the specic subjectivity of the therapist and patient that may not be covered by the themes examined here.

Boredom Clinicians who practice psychotherapy tend to have a need to be needed.9 Narcissistic patients deprive the therapist of fullling that need to a large extent. The oblivious subtype often is experienced as speaking at the therapist instead of to the therapist.24 Being used as a sounding board makes one feel isolated, what Kernberg18 refers to as a satellite existence. Therapists feel that their independent center of autonomy, their unique subjectivity, their very personhood is not being acknowledged. The therapist may feel ineffectual, colorless, invisible, and deskilled. The common defensive response to this feeling of uselessness is to become bored and disengaged. Therapists may feel a sense of dread when the patients session is due to begin, and they may count the minutes until the end of the session. Steiner25 writes about the transference to the analyst as an excluded observer. Indeed, therapists in the presence of an oblivious and grandiose narcissistic patient may feel chronically excluded, as though they are consigned to the role of silent or approving observer whose insights are not welcome. Steiner stresses that this particular transference is conducive to countertransference enactments. Therefore, therapists may nd themselves judgmental in a way they retrospectively feel was counterproductive. Countertransference is almost always a jointly constructed phenomenon that is determined partly by the clinicians past relationships and internal object relations, and partly by what is induced in the therapist by the patients behavior.3 In fact, one of the therapists principle tasks is to constantly monitor the extent to which countertransference is primarily induced compared with being a reection of the therapists own struggles. Many of those who choose careers in psychotherapy harbor a wish to be loved, needed, and idealized,26 and therapists may be experiencing narcissistic

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wounding that parallels what the patient experiences. Because narcissistic patients tend to treat the therapist as a selfextension, the patient is likely to evoke certain states in the therapist that reect the patients own internal conicts. It is also true, however, that patients may use projective identication to externalize an aspect of their self experience into the therapist. Therefore, a therapist who is feeling excluded and bored may be experiencing what the patient went through as a child who was distanced or excluded by a parent. In other words, some narcissistic patients may actively master passively experienced childhood trauma by unconsciously recreating it in the therapeutic situation.24 Subjugation Symington27 once noted that projective identication can be construed as an attempt by the patient to control the therapists freedom of thought. With narcissistic patients, therapists may feel subjugated by their omnipotent control and therefore feel that they are allowed only a narrow range of thoughts and words. Even movements may feel under the control of the patient. If they dget too much, glance at the clock, clear their throat, or take their eyes off the patient, they may induce a narcissistic injury in a hypervigilant narcissist. Although the countertransference as an excluded observer and the countertransference of feeling subjugated both grow out of the patients need to deny separateness from the therapist, these two states may feel quite different. In contrast to the excluded observer countertransference, the therapist with a hypervigilant patient may feel that she is anything but excluded she may feel under intense scrutiny. The Object of Contempt Feelings of being the object of contempt are unavoidable with narcissistic patients. Therapists must keep in mind

that narcissistically organized individuals characteristically stabilize their selfesteem by devaluing others. We expect them to carry their usual defensive styles of object-relatedness into the treatment, so therapists must prepare themselves for being a devalued object much of the time. The hallmark of countertransference in the empirical study by Betan et al6 was feelings of being devalued and criticized by the patient, accompanied by anger, resentment and dread in working with such patients. A variety of responses can result from feelings of being treated with contempt day in and day out. Some therapists may use reaction formation against their growing feelings of anger and hurt. They may become overly empathic and overly kind to the patient as a way of denying their true feelings. This stance may simply activate the patients envy and rage to a greater extent, leading to a vicious cycle of greater contempt followed by greater reaction formation in the therapist. Other therapists may react by becoming more aggressive and competitive with the patient. The following exchange illustrates this form of countertransference enactment: Patient: Sometimes I experience myself as similar to King Lear. I dont know how much youve studied Shakespeares works, but do you remember the opening of Act III of Lear? Therapist: No, I dont know, I dont recall it. Patient: I gured probably all you read is psychiatry. Most psychiatrists I have known are fairly narrow in their interests. Have you even read Shakespeare at all? Therapist: Yes, in fact, I took a Shakespeare course in college, read the entire Shakespearean canon, and saw King Lear when the Royal Shakespeare Company performed it with Paul Scoeld. I simply dont remember the opening lines of Act III. Patient: Well, arent we sensitive?

Therapist: I just thought I needed to set the record straight that I actually am someone who is knowledgeable in this area, even though you dont regard me that way. The therapist reached a point of exasperation with being denigrated that led him to become defensive and demonstrate his knowledge of Shakespeare in a way that the patient could then mock. He provided the patient with further ammunition to devalue him as a hypersensitive and narcissistically vulnerable individual who had to show off his knowledge. Therefore, the countertransference enactment allowed the patient to projectively disavow his own narcissistic vulnerability and see it only in the therapist. The Object of Idealization Being idealized may not enter the therapists radar screen as a form of transference. Therapists who need to be idealized may experience the transference as simply an example of a patient who recognizes the therapists talents and empathy or the reection of a good therapeutic alliance. Therefore, one reaction to being the object of idealization is to have a blind spot regarding the idealizing transference. Other therapists may nd being idealized to be acutely uncomfortable, as Kohut21 himself described. The experience of idealization may make the therapist feel conicted about the activation of his own grandiosity. His secret or not-so-secret wish to be idealized is being gratied in a way that may make him feel grandiose or extraordinarily narcissistic himself. A common enactment is to prematurely interpret the idealization rather than recognize the patients need for idealization as a way of regulating self-esteem. Admiration Russ et al10 identied a subtype they referred to as the high-functioning/exhibitionist narcissist. Many of these individuals have been quite successful in

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their work. For some patients who are particularly intelligent, physically attractive, or talented, they receive much admiration and validation for their grandiose and exhibitionistic needs. Sports stars, performers, and highly successful professionals may all t this category of the high-functioning narcissist who is used to receiving acclaim. Some of these individuals also have enormous charm that is seductive to the therapist, who feels honored to have been selected by the patient. The so-called VIP patient often elicits this reaction in the therapist. Therapists in these situations may nd themselves admiring and envying the success of the patient and wanting to bask in the patients reected glory. They may nd themselves enjoying the show rather than working therapeutically to help the patient.24 They may have difculty recognizing that they are being treated as an extension of the self and meeting the needs of the patient for validation and afrmation rather than interpreting the patients interpersonal strategies. These kinds of therapies may end up in a stalemate of a mutual admiration society, where both therapist and patient admire each other and complement one another. CONCLUDING COMMENTS Being aware of the common transference-countertransference developments alerts the therapist to potential impasses and resistances in the treatment that must be taken into account. Feelings of boredom and being devalued are difcult to tolerate for long periods of time, but there is certainly an advantage in allowing oneself to be steeped in the transference-countertransference experience, since it reects the characteristic patterns of difculty in relationships outside the treatment setting. A common error is to attempt to confront and interpret the transference before it is well established and understood. Premature interventions may lead the patient to feel misunder-

stood and invalidated. Transference is initially unconscious and is not necessarily accessible to the patient in the way that it is to the therapist. A general principle is to postpone interventions until one is thoroughly familiar with the transference and countertransference phenomena and has a sense of their origins. The challenges inherent in treating narcissistic personality disorder make brief treatment an inadequate option. These patients generally require longterm psychoanalytic psychotherapy or psychoanalysis to adequately address the entrenched problems that have haunted them throughout their lives. Particularly successful patients may not encounter sufcient difculty to seek out treatment early in their lives. Often the aging process brings out narcissistic wounding and depressive feelings that make the patient more amenable to treatment. Hence middle-aged patients may have a better prognosis and be more likely to continue in treatment compared to those who are just starting out in their adult lives. REFERENCES
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