Narcissistic disorders:  Using EMDR with these difficult clients

The narcissistic character is often identified by his or her grandiose facade concealing an underlying sense of emptiness and worthlessness. To experience the underlying emptiness is so painful for them that these people cut off their inner experience and rely instead on external admiration and praise to support their grandiose or superior view of themselves; their condition is often referred to as a "disorder of the self." Because of their dependence on others for their sense of themselves, they are exquisitely sensitive to criticism or disapproval, often warding off deflation by becoming increasingly grandiose, superior, disdainful or demeaning. Many conceal their grandiosity, maintaining a secret sense of superiority which may be based upon their perfectionism or their quiet devaluing of others. View of others: there is a range of severity of the narcissistic character from personality disorders to a narcissistic character style. People with personality disorders, are unable to form a trusting bond with another person; they view people primarily as interchangeable, performing a function which could equally be performed by many others. Less impaired narcissistic characters, however, are able to form varying degrees of attachments to other people, although their ability to trust and care about other people is limited. Most commonly they relate to people they can idealize or be admired by. People tend to be seen in extremes as superior and powerful or inferior and worthless; supportive and admiring or critical and attacking. Difficulties in using EMDR: Clinically these clients represent a difficult and often frustrating population to treat; they are brittle and easily injured if they do not feel perfectly understood by their therapists, and they will distance at the slightest hint that they are being judged or used. They resist focusing inward and defining their problems as arising within themselves, and find it difficult to sustain any genuine affect, other than perhaps rage. If they feel understood and accepted, however, they will eventually talk about their sense of emptiness and worthlessness and their confusion about who they are and what is truly meaningful and valuable to them. Beck, Young and others have described factors that make it difficult to treat any personality disorder using a cognitive behavioral approach. There have in fact been very few reported "successes" in the literature. Most of the difficulties are related to the self and object splitting characteristic of these clients. These clients have limited access to feelings, limited access to spontaneous thoughts, body sensations, memories, etc., and vague unfocussed presenting problems making targeting difficult. They usually have difficulty with emotional and often intellectual continuity from session to session; they will rarely keep a log or follow through with homework; transference issues often come into central focus and must be addressed before other targets; and their self-defeating beliefs and behavior patterns are extremely deeply held, pervasive and resistant to change. In addition to varying degrees of these difficulties, narcissistic clients present all of the problems in EMDR that they do in more traditional therapies; including their tendencies to act out, deny, and avoid. These and other defenses interfere with completion of segments of therapeutic work and make it difficult for the clinician to keep work focused within one neural network. Self and object splitting leads to continuity problems within or between sessions and a difficulty maintaining clarity about the reason for being in treatment. The client may feel suicidal one week and declare himself or herself to be fully recovered the next. Perhaps the most confirming aspect of the treatment of these clients, however, is their emotionally impoverished pasts; they have very limited experience of nurturing, loving and caring to draw from in order to interweave new meanings and perspectives into traumatic or painful past experiences. Length of treatment: I have found that I have been able to achieve good results with higher level narcissistic clients with whom I have had an established relationship at the time I introduced EMDR into the treatment. My results with clients who have come to therapy asking specifically for EMDR and with whom I have begun using EMDR soon after the beginning of treatment have been generally poorer, varying with the severity of the client's disorder, the less severe doing best. The client needs to be able to establish a meaningful trusting relationship with the therapist; the more severe the client's difficulties with attachment, the more time this process requires. Narcissistic clients do not tend to see their difficulty with vulnerability, trust and intimacy as a problem within themselves. If they are able to recognize personal problems, they are usually in the area of self-esteem and obstacles to achievement. When they are able to resolve some of these latter problems fairly rapidly through treatment they tend to terminate, no longer seeing a sufficient purpose for treatment. In a sense, they can become better narcissists; their grandiose view of themselves is enhanced and they are reinforced in their use of self-sufficiency as a defense against interpersonal vulnerability. I view the relative efficiency of EMDR as a problem for deeper treatment of narcissistic clients because there is less time for the therapeutic relationship to develop and consequently a limited opportunity to impact the client's object splitting. I believe that this is why I have found EMDR with narcissistic clients to be most effective when it is introduced after a therapeutic relationship has had time to develop. Negative cognitions: The early maladaptive schemas of narcissistic clients are pervasive in their lives and point to a plethora of negative cognitions. Typical early schemas are: I must control myself (or my feelings, my behavior, my body) at all times; no one cares; my needs will never be met; I can't trust anyone; I am deeply flawed and unlovable; I am likeable, unattractive to others; I will always fail; my flaws are totally unacceptable to others; I must be perfect or I am worthless; I deserve to be treated more specially than others; I must please others to avoid attack; I'm alone; nobody understands me; I am OK if I am better than others; I am OK only if others admire me. It is often helpful to narrow these cognitions down to make them manageable with EMDR Treatment: In addition to the recommended protocol of establishing a safe space to which the client can retreat if necessary, before doing an EMDR session with one of these clients, the therapist should identify as many of the client's emotional resources possible, in particular experiences if any of having felt loved and accepted and examples of loving people or relationships the client has observed Among other things, these facilitate more effective cognitive interweaves. The initial task in doing an EMDR session with this client population is to establish an appropriate and richly defined target. Since it is more difficult for these clients to access mainly memories in an emotionally alive way, the therapist must be more active in helping the client stimulate the associated neural network as much as possible. In addition to the client's reaction to the plight of children he may be related to or observe (Level I1 training), a rich source of emotional responsiveness and resources is the client's own response to situations he has witnessed in news media, TV, movies or theater. A major challenge in addressing a narcissistic character type using EMDR is tracking the course of the session with these clients and identifying when they drop out of the targeted neural network. This process can be subtle because it requires an ability to differentiate true avoidance from spontaneous associations which may appear at hat to be irrelevant; it requires a familiarity with and sensitivity to the protective or defensive mechanisms they use to insulate themselves from painful memories and affect. As the patterns of movement in and out of the targeted network are identified it is important to use interventions that are experienced by the client as supportive but nevertheless make him or her aware of having wandered. Although the narcissistic client may initiate treatment with the stated goal of improving his performance in specified areas, he will agree upon reflection that the real problem is that he feels an overriding need to perform in order to feel worthwhile. Since he has never known any other way of dealing with his self-worth, he will be skeptical about whether it is possible to feel a sense of worth that is not based upon performance, and it is easy for the therapist to lose perspective and join him in that belief especially while doing EMDR with its potential for reprocessing with extraordinary precision specific obstacles to performance. The therapist must, however, retain her healthy perspective if the client is to learn to accept himself. For more clinical information about treating disorders of the self: 1.) Beck, Aaron T., et al, Cognitive Therapy Of Personality Disorder Guilford Press, New York, N. Y., 1990 2.)Mansfield, Philip, Split Self/Split Object: Understanding and Treating Borderline, Narcissistic And Schizoid Disorders, Jason Aronson Publishers, Northvale, N.J., 1992. 3.) Young, Jeffrey, E, Cognitive Therapy for Personality Disorders: A Schema-Focused Approach, Professional Resource Exchange, Inc., Sarasota, Florida, 1990

Conference

English

Philip Manfield

Manfield, P. (1995, June). Narcissistic disorders: Using EMDR with these difficult clients. Presentation at the EMDR Network Conference, Santa Monica, CA