Why Are Narcissists So Hard to Treat?

Given their arrogance, condescension, and lack of empathy, narcissists are notoriously difficult clients. The key to working with them is being direct and transparent about the roiling emotions they trigger in us.

One reason narcissistic clients are so hard to treat is that they’re adept at taking charge of a session and steering the conversation off course again and again, until you feel sorely tempted to give up and let them take the wheel.

Richard, one of my clients, fit the classic profile. He often shifted into self-aggrandizing monologues on his latest brilliant investment, his newly purchased, one-of-a-kind this or that, his powerful business connections, his to-die-for wine collection. Whenever I hazarded an insight into his childhood or suggested that he might be feeling scared, he tried to derail me by saying something like, “I took some psychology classes, too, you know, and I could have been a great therapist.” When talking about his marital problems, he’d say, “My wife has PMS. That’s the problem, not me. You have no idea what I have to put up with and all that I do to make her happy. But it’s never good enough.”

When our conversations ventured toward emotionally loaded material, he shifted into detached mode, denying that he had any feelings. When I tried to get him to see that this is a way of protecting himself from feeling difficult emotions, he demeaned me for my “hokey-pokey, touchy-feely therapy” that had “no relevance” to him. Rolling his eyes, he’d proclaim that he had a perfectly fine childhood and that the only reason for us to look at his past is to satisfy my need to justify myself as a therapist who’s charging a hefty fee.

In my early days of treating these tough clients, I’d want to fight back. Digging my heels into the carpet, I’d silently declare myself unwilling to be defeated by their aggressiveness and arrogant refusal to acknowledge the value of what I had to offer. With Richard, my fantasy was to shout at him, “Of course, you aren’t going to cooperate! Go ahead. Pretend that what’s happening in this room isn’t the same problem you have connecting with your wife, your colleagues, and everyone else you know.”

But blurting out visceral frustration isn’t therapy, and over the years, I’ve learned how to respond to clients’ misperceptions and callous remarks in ways that can move things forward, rather than just reinforce their old relationship patterns. Often this means translating what’s happening for me in the moment into a picture of what it might be like for other people when my clients treat them in the same way.

No matter how obnoxiously narcissists behave, it’s important to remember that their self-aggrandizement almost always covers up painful longings for true connection, intimacy, and a sense that they’re “good enough.”

In fact, rather than being purely entitled and spoiled, most narcissists are wounded, deprived, and avoidant, burdened with unattended loneliness and shame. Typically, they grew up with parents who sought to achieve a more illustrious identity themselves by expecting perfection from their little “chosen one.” While these kids may not have been physically abused, they could never count on being cherished and protected without having to prove their worth.

The emphasis on performance and the lack of attuned connection leads many children who develop into narcissists to become workaholics drawn to addictive, self-stimulating habits—pornography, endless Internet surfing, drugs, and alcohol abuse—all of which serve to keep them distracted and cut off from deeper emotional longings. Indulging in these habits is much easier than trying to connect with anyone honestly.

The Art of Empathic Confrontation
Since the narcissist isn’t motivated to do the necessary work of exposing his vulnerability, the only leverage that allows therapy to succeed is usually the prospect of losing the people in his life who care for him. So to make what happens in my office matter, I need to connect our moment-to-moment encounter continually with what’s going on between the client and the important people in his life. And to accomplish that, I need to show up in the treatment room as a “real” person, someone who can acknowledge the sting of insults and cutting remarks, as well as the decidedly nontherapeutic urge to withdraw or even attack in the face of continual provocations. Calling attention to my reactions to off-putting behaviors as they occur forces the client to confront how that same behavior affects others.

For example, a client recently responded to my attempt to empathize with his struggles with his wife by saying, “Stop acting like you care about what happens to me. You probably think I’m a piece of shit, just like my wife. You’re a woman after all. I may not be perfect, but I’ve seen a lot more of life than you have in your cozy little therapeutic bubble.”

Taking a deep breath, I said, “My hunch is that right now you’re feeling uncomfortable about being here, and that your put-downs about me are your way of handling that. But I have to tell you that what you just said was not only inaccurate, but insulting. Is this what you do with your wife when you’re feeling uncomfortable? If that’s right, I can understand why she keeps saying she’s so fed up with your marriage. I think what you’re really saying is that it’s hard for you to accept that anyone can care for you when you expect to be seen with contempt. So you play the bully to protect yourself.”

This isn’t the kind of warm, supportive exchange that most of us associate with therapeutic conversation, but with narcissists, this sort of self-disclosure and limit-setting is necessary if a bond of honesty and trust is to be established. The truth is that narcissists are particularly adept at ferreting out weaknesses in others and triggering feelings of inadequacy and intimidation in the therapist. For a therapeutic bond to develop, it’s important to establish firm ground rules as well as acknowledge your own triggers and vulnerabilities that can get in the way of treatment.

In the face of a narcissist’s insensitivity and aggressiveness, it’s crucial to balance direct self-disclosure and limit-setting with a concern for creating the sense of safety that comes when the client feels your determination to hang in through all the twists and turns of forming a therapeutic bond. When the narcissist says disdainfully, “This therapy is a waste of time,” it’s crucial not to take that statement too personally, but to see it as an opportunity to explore the links between what’s going on in the moment and the client’s unacknowledged vulnerabilities. So one way of responding might be, “Why would you say that to me? And why in that disgusted tone of voice? You may not have been aware of how hurtful that sounds, but wow! I think there’s something important going on for you, but it’s hard to hear that when I’m sitting here trying to protect myself. Now, please tell me again. What’s making you so upset? What’s going on? But tell me respectfully.”

Keeping It Real
Narcissists tend to be keen observers, who pick up on fakery fast. To be effective with them, you need to display confidence at the same time you communicate openness, a bit of good humor, and a sense of “keeping it real.” Perhaps most important, however, is absolute persistence on your part. Successful treatment is about continuing to show up as a real person, not a jargon-spouting expert. This is all the more challenging because just when you least expect it, the uglier parts of the narcissist will return.

No matter how connected I thought we were, Richard remained capable of surprising me, offering up scathing comments—about me, my office, or even the crookedness of a picture on the wall—that left me feeling blindsided. After years of doing this kind of work, I’ve learned that the best response is usually lightheartedness and transparency. “Sometimes it’s simply amazing isn’t it, Richard?” I’d say. “One minute we’re sharing your deepest feelings of injury and the next you’re picking on me again. Then I get triggered and feel like I just want to fight back or surrender and go home.” Then I’d add reassuringly, “But I won’t. I know this is coming from that ‘tough guy’ part of you that screams, ‘Attack!’ whenever you start to let your guard down. Hey, it’s me, Richard. It’s safe here. You’re not weak: your emotions are the best part of you. I like knowing you.”

Narcissists will rarely shed all their defenses, but therapy can enhance their awareness of what it’s like to be on the other side of a relationship with them. There are no shortcuts to helping them develop that awareness, but with persistence, skill, and commitment to holding them accountable for their actions and statements, it’s possible to help them recognize the consequences of their behavior and the validity of others’ feelings. It all begins with offering a moment-to-moment experience of relationship different from any they’ve ever had before. For the many narcissists who benefit from therapy, it can truly be said that their bond with their therapist, no matter how difficult and continuously tested it may have been over the course of treatment, is the most completely two-sided relationship that they’ve had in their lives.

This blog is excerpted from "Challenging the Narcissist" by Wendy Behary MSW, LCSW appearing in Psychotherapy Networker.