Establish a therapeutic alliance with the narcissistic patient

“You’re an idiot, Hokemeyer. Actually, let me clarify that. You’re a *** idiot.”

I was sitting across the room from a senior executive of a pharmaceutical conglomerate, who felt compelled to put me in my place. (The identifying details of the case vignettes in this article have been changed to protect the integrity of the patients and treatment professionals.) If the truth were told, I probably deserved it. We had met only once before and had not yet established a therapeutic alliance. My clinical intervention that invoked his reaction was ambitious, formulated not to pander to but to gauge the level of his narcissistic presentation.

The patient had come into treatment after being “backed into a corner by (his) wife.” After 30 years of marriage, she had had enough of his drinking and philandering and had hired one of New York’s most prominent divorce lawyers to execute her departure. The only reason the patient agreed to see me was to avoid an expensive and embarrassing divorce.

As he said, “She’s asking for half of my net worth. I can’t believe how greedy she’s being … especially after all I’ve done for her. She said she’d hold off pursuing this if we met.” Although from a financial standpoint he would remain extraordinarily wealthy after the proposed settlement, his pride and ego would be crushed in what he would consider a tactical defeat.

Going into our engagement, I suspected he would rate high on the narcissistic scale. Men and women like him frequently do. They have attained extraordinary success in the financial and professional realms of their lives, but have failed miserably in those that require intimacy. They think they have gotten where they are by manifesting the dominant cultural message “nice guys finish last,” and they view emotional vulnerability as a liability to be avoided at all costs.

The intervention that garnered his hostile reaction was my attempt to see if he had any capacity to empathize with his wife. I had asked, “Well, have you ever thought, maybe she’s been impacted by the mistresses you’ve kept over the years?” On a very deep level I knew he had, but that he had submerged those thoughts and their accompanying feelings below his consciousness.

His emotionally charged response to my question was clinically rich. It enabled me to gauge his psychic composition, but it also required me immediately to retreat and make tactical reparations. If I got into a power struggle with him, I would lose. He’d be out the door and racing back down the cobbled path of himself- and relational destruction. Instead of responding through my bruised ego, I needed to assuage his. I said, “I’m sorry if I’ve offended you. I’m just trying to get a sense of where your wife is in all of this.”

My short-term goal was to obtain data I would subsequently use in a long-term treatment strategy that is highly effective in working with narcissistic executives. Central to the strategy is recognizing that deeply embedded narcissism such as his would never be completely removed, but could be softened. To do this, I would have to keep him engaged in the following three-step treatment process:

• Establishing a therapeutic alliance that meets him in his narcissistic personality presentation;
• Crafting clinical interventions that allow him to intellectually appreciate the value of intimacy; and
• Providing concrete tools that enable him to tolerate the extraordinary discomfort he will feel from a new way of relating to himself, other human beings and the world around him.

Some programs’ shortcomings

Unfortunately, too few treatment professionals and programs have the resources to accomplish this labor- and time-intensive task. This is particularly true in the recent deluge of “executive treatment programs” that are more concerned with filling beds than providing culturally competent and clinically relevant care to patients. Instead of working in the patient’s narcissistic personality presentation, these programs either engage in clinical pandering or lose the patient through culturally insensitive interventions.

Clinical pandering is essentially babysitting, using the patient as narcissistic supply (where individuals use objects and people to enhance their self-image) or feeding a patient’s narcissistic ego to garner a financial reward in the form of elevated fees or generous donations. Culturally insensitive interventions are more subtle, manifesting in hostile counter-transference reactions (conscious and unconscious) to the patient. These result in the patient emotionally shutting down or physically leaving treatment.

Recently I learned of a case in which one of the field’s most talented family therapists referred an ultra high net worth patient to an executive treatment facility that mishandled her cultural presentation. Shortly after arriving into treatment, the high-profile woman was challenged by the clinical team for being “too vain.” The patient, a former model, would only appear in the psychotherapeutic community “perfectly coiffed and attired.” Instead of seeing the patient’s physical presentation as an essential part of her being and connecting to her in it, the staff used it to demean her and drive her away. While she remained physically present in treatment for 28 days, as demanded by her husband, she did so in a superficially compliant way.

A more culturally and clinically effective strategy would have been to allow the patient to be herself in treatment until she got her “sea legs.” During this time, her clinician could establish a therapeutic alliance that met her “in her vanity” rather than attempting a culturally insensitive extraction of it. While the attachment was occurring, the therapist would artfully inquire into the patient’s psychic composition and interject subtle questions that would provide bits of personal and relational insights.

In this regard, interventions that are a hybrid of questions and statements are highly effective. As it relates to the treatment of this particular patient, statements such as “You’re a beautiful woman. Does that ever get exhausting?” would have provided her with ego gratification as well as an opportunity for connection through insight. Simultaneous with this individual work, the patient would be connecting with her psychosocial community: men and women whom she viewed as her peers, outside of the structured psychotherapeutic dyad, to test and share her clinician’s interventions.

Handled in a culturally sensitive way, the patient would have become open to maximizing the rich opportunities she was afforded in treatment. Instead, she felt judged and yet again misunderstood. After 28 days of external compliance, she jumped into her private jet and flew back to self-soothe in the isolation of her Park Avenue penthouse, convinced that treatment doesn’t work for people like her.

Ethical obligation

Treatment professionals and facilities that market to executives and ultra high net worth individuals have an ethical responsibility to provide clinical services that address these patients’ unique and challenging compositions. Rather than profit centers, these patients are human beings who exist in a culturally distinct intrapersonal, interpersonal and sociocultural space.

Executive treatment is not purely a function of amenities. Yes, a culturally relevant holding environment is part of the equation, but the real value comes from the maturity, intelligence and artfulness of the treatment team working interpersonally with a vulnerable patient population.