Integrative Psychotherapy Articles
Narcissism or the Therapist's Error?
Richard G. Erskine, PhD
Institute for Integrative Psychotherapy
Phillip was in his mid 50's with a full head of perfectly coiffured grey hair. He arrived for his first appointment on time, dressed in a suit and tie that portrayed a stylish, expensive, and immaculate appearance. He rose from the chair in the waiting room with a beaming smile and rigorously shook my hand. As we chatted about the day's news, I observed that he was soft-spoken and highly articulate with a mild Southern accent. His appearance and social demeanor immediately impressed me. Within seconds I formed one of those intuitive first impression questions: Was he genuinely contactful or was his greeting a well-rehearsed, superficial ritual?
As I invited Phillip into the inner office I suggested that he make himself comfortable by removing his tie and shoes. He abruptly refused and appeared to be offended by my suggestion. With words and tone that reflected more of a critical comment than a question; he expressed amazement that I would make such a suggestion. I wondered if I had violated some Southern social norm that was important for him or if he was revealing some aspect of his personality via these first few transactions. I decided to not explain the reasons behind my suggestion but to wait and see if this type of disconnecting encounter would occur again.
A week before this first session an attorney for a large advertising firm had called my office to make an initial appointment for one of the firm's partners. On the phone the attorney told me that Phillip was required to come for psychotherapy as part of the settlement in a harassment and safety-violation lawsuit that had been filed against the firm. The attorney said that Phillip was an important member of the firm who headed a major department and that he was embroiled in two lawsuits for harassing employees. Retaining a partnership in the firm was dependent on his engaging in at least two years of psychotherapy and in making some major behavioral changes. I agreed to do a three-session evaluation and then decide if a constructive working relationship was possible.
Phillip began our initial session by describing himself as a successful executive art director who had won many awards for his firm. His creativity and the department he headed were essential in his firm's success but his position was in jeopardy as a result of two harassment suits. Both of the suits had been resolved out of court but the financial settlements had cost the firm a large amount of money. Some members of the Board of Directors had demanded that he resign.
We had a brief discussion about my potential report to the attorney and the inherent confidentiality necessary for an effective psychotherapy. He appeared to be comfortable with our arrangements. As I asked particulars about his job, he lamented that his work was "only commercial" and "subject to the whims of advertising fashion and the short-sightedness of the clients". Continuing in a critical tone he told me that some of the artists and production people working for him had "no creativity – their only talent is to follow what I design". I suspected that he was using his employees' lack of creativity to justify his behaviors that lead to the harassment suits. I wondered if his comments about his clients were also justifying internal conflicts or relational difficulties.
I asked more about his relationship with his employees. "I only yell once-in-a-while when they screw-up. The rest of the time I treat them very well. I've paid them well. I give them good bonuses. They owe me a lot". His words and tone conveyed entitlement – an entitlement to "yell" because he "paid them well". I felt heavy-hearted as I listened to his lack of empathy and his tenacious self-centered perspective.
Hesitantly, he went on to describe himself as a painter; then he added that he was not painting very often. He expressed how he never showed his paintings because they were "not excellent – not imaginative and innovative" in the view of the New York art reviewers. I wondered if his criticism and hesitancy were an expression of resentment and/or shame. If my wondering actually reflected his experience we would have to come back to both the resentment and shame later, once we agreed to an on-going psychotherapy.
In this first session it seemed necessary to focus on the job situation that forced him into psychotherapy. He added that in order to retain his partnership in the firm he had suggested a compromise: he would commit to an intensive on-going psychotherapy that would last at least two years; he would make dramatic changes in his behavior towards his employees, particularly women; and, he would accept that a female partner in the firm would regularly monitor his relationships with his employees and write periodic reports to the Board of Directors. He said that he was not coming to psychotherapy under duress but that it was he who had suggested the compromises. He knew that he had to change but did not know why he acted the way he did to the women in his department. He alluded that there were other more personal reasons for being in therapy but that he did not want to discuss them during these early sessions.
Phillip went on to describe how he had a habit of screaming at his employees. Three years before a woman in his department also sued his firm for harassment after she was unable to return to work following humiliating sexist comments Phillip had made in the presence of many of her coworkers. I contemplated the significance of his description of the "humiliating sexist comments" and wondered how these comments reflected larger relational conflicts, particularly with women. I also made a mental note of a slight contradiction: earlier he said "I only yell once-in-a-while" and now he described himself as having a "habit of screaming". If we were going to proceed with a relationally focused psychotherapy, rather than behavior therapy, it was too soon to explore this contradiction.
He went on to describe that in the most recent incident he screamed personal insults and hurled a bottle of orange juice at one of his artists. The bottle hit another person. The incident frightened several other people and collectively they filled a lawsuit claiming a violation of workers' safety rights. Even though Phillip was a partner, he was about to lose his high-paying position in the firm unless he engaged in a successful behavior-changing psychotherapy. This was his ostensible motivation for coming to psychotherapy. As we ran out of time in this first session I was left with two questions: What other motivations were at play in his request for psychotherapy? How did all this information fit into an unconscious life pattern?
It was too soon to have any idea on how to proceed. I knew that it was essential to keep an open heart and mind. It was necessary to focus on what Phillip needed in our relationship in order to develop an effective therapeutic alliance. I also knew that if I were to do an effective psychotherapy I could not focus only on solving the behavioral problem of his raging at employees; my task would be to facilitate his psychological growth in several domains.
Second Evaluation Session:
In our second session, when I again talked about confidentiality, Phillip revealed that he was involved with Cocaine Anonymous (CA) and was actively working the twelve-step program. He said that he was going to two or three meetings a week. He described joining CA two years ago, after the second harassment suit, when he realized that his raging behavior was in part provoked by cocaine. He was currently cocaine free for two years but he was disappointed in the program. In two years he had two sponsors, both "did not understand me", "they were not psychologically minded", and "I feel all alone in the program".
He went on to describe how he was still "periodically screaming at work" while trying to assure me that his outbursts of rage were far fewer than before and that they were justified by the way people acted. I wanted to engage in several phenomenological inquiries to discover what he was thinking and feeling just moments before his rage, what he meant by "not psychologically minded", and his experience of not being understood. It was still too soon for such an intimate relational interaction. In this session I listened to what he wanted to tell me and only asked a few questions that elicited specific information.
Most of this session was spent talking about his previous use of cocaine and the benefits of being in a twelve-step program. Near the end I asked why, in making the settlement in the harassment suit, he chose to come to psychotherapy as part of the compromise. He said that there were three reasons he choose psychotherapy: first, he needed to keep his previous cocaine habit under control and confidential; second, he knew he needed "professional help"; and third, he had "some other relationship issues to solve". He was not ready to identify or discuss these issues.
I was left feeling intrigued by what he had not revealed and also by his commitment to Cocaine Anonymous' twelve-step program. I was not certain if we could establish an intimate therapeutic relationship. What was genuine? What was superficial? Could I create the quality of relationship that would soften his air of aloofness, arrogance, and entitlement? Did I have the psychotherapeutic skills to connect with the vulnerable man and boy that lived under his self-protective façade? I was not sure.
I sensed that Phillip would provide a challenge for my therapeutic skills to remain interpersonally contactful and psychologically helpful. I was comforted when I remembered Heinz Kohut's (1971, 1977) writings about the treatment of narcissistic patients. Kohut had emphasized the importance of sustained empathy and the fostering of vicarious introspection rather than the use of interpretations, confrontation, or a focus on behavior change. From my previous experience I knew that it would be absolutely essential that I stay empathetic with his emotional experience and that I maintain a contactful presence. The Zen philosophy of "less is more" repeatedly came to my mind as I imagined the potential future of our psychotherapy together.
Evaluation Session Three:
I entered the third and final session of our evaluation period still not certain if Phillip and I would be able to create the quality of therapeutic relationship that would reveal and heal what I imagined to be his psychological wounds. The morning of his third session I contemplated whether he was serious or not about pursuing an in-depth psychotherapy. Was he motivated to really know himself, his personality-forming history, and his motivations? Or did he merely want to change a problem-making behavior to retain his employment? I was surprised when early in the session he expressed his willingness to pursue an on-going psychotherapy.
I explained that the changing of his behavior would be an important part of our work together but that often it may seem that our focus was elsewhere. I went on to say that if we were to do an effective psychotherapy together, we would have to focus on his whole life experience and particularly the early influences that shaped his personality.
I challenged him with the question, "Are you ready to deal with the discomfort of knowing yourself, your motivations, and the potential alterations in your personality?" He hesitated and then surprised me with a tentative "Yes", adding the proviso that he wanted to be able to both paint again and to display his art at gallery exhibitions. I had surmised from his comments in our first session that his sense of creativity was stymied and that there was a strong reluctance to show his paintings to anyone. I made a mental note to explore this further.
I also noted that he did not mention the "relationship issues" to which he had alluded in the previous session. I asked about his current life: he reluctantly said that he was never married but had a "significant relationship for four years" that "ended drastically" because of their mutual use of cocaine.
It was apparent that if we were to engage in a comprehensive psychotherapy we would have to explore several dynamics in his life:
- the nature of his intimate relationships;
- what appeared to be his style of aloof attachment and entitlement;
- his experience that others did not understand him;
- his use of cocaine as a self-regulator;
- the functions of both his arrogant and his raging behaviors.
I wondered if he experienced the loneliness that I sensed coming from his body tension and non-verbal expressions -- a loneliness that reminded me of previous clients who used a narcissistic façade to cover deep despair. A series of treatment directions were now taking shape. I realized that we were facing the potential of a psychotherapy that would last for more than the two years.
I offered the possibility of our working together three, or at least two, sessions per week. He was willing to come for only one fifty-minute appointment once a week. He announced that he could no longer come during the workday because of the "pressures at work". We struggled with our schedules to find a time that did not disrupt his work and going to the gym or interfere with his attending CA meetings. Suddenly, just as things seemed to be going smoothly between us, we could not find an agreeable meeting time. I wanted him to stay active in Cocaine Anonymous. I knew from experience with alcoholic clients that the specifically defined twelve-step program and the shared experience with other CA members would serve as an important co-therapist and a necessary therapeutic support when we were not having sessions.
We ended our three evaluation sessions by his adamantly saying that he would not cancel any of his evening sessions with his trainer at the gym. He left abruptly without making any future appointment. My first thought was that we ran directly into the classical psychoanalytic concept of resistance – the refusal to engage in the intimate relationship of psychotherapy.
As I considered the concept of resistance and the psychodynamic theory underlying the concept, I was aware that it did not fit my developmental and relational perspective. Interpersonal contact is always a co-creative progression. Conceivably, something other than resistance could be motivating his refusal to adjust his schedule in order to come to psychotherapy. Maybe he was not resisting the emotional vulnerabilities that can emerge in the psychotherapy nor the potentially intimate contact with me. These ideas stimulated me to think about how relationships are developed in early childhood and the human needs for emotional contact, self-definition, and to make an impact.
I wondered if he was struggling to maintain some form of self-support and personal integrity or attempting to enhance his self-esteem. Had I been too forceful in defining our therapy contract? Had I failed to be sufficiently empathic or again violated some personal norm? What had I missed? Was his behavior an expression of narcissism or had I erred in some profound way? To answer these questions without knowing his phenomenological experiences would be mere speculation. I was at a loss.
It was now my responsibility to write a letter of evaluation to the attorney and provide referrals to other psychotherapists. I was left considering who among my colleagues might have the heart and skills to create a caring and healing relationship with Phillip. I have decided to recommend your name as his potential psychotherapist. If you become his psychotherapist what will you do with and for him?
Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press.
Kohut, H. (1977). The Restoration of the Self. The University of Chicago Press.
International copyright: April 1, 2012,
Institute for Integrative Psychotherapy and Richard G. Erskine Consulting, Inc.