Both in literature and in clinical practice it is a shared notion that the engagement and maintenance of therapy with the narcissistic patient involve many difficulties.
This has been widely demonstrated with empirical studies and is also evident by the drop-out rates found within mental health services. However, the Narcissistic personality disorder It remains one of the less investigated syndromes and there are no randomized studies on the effectiveness of the treatment for this disorder.
Beyond the description that we find in the diagnostic manuals of psychopathology, the phenomenology of this personality disorder includes numerous relational difficulties: the narcissist Which is often competitive, hypercritical towards others, vulnerabies to humiliation and emotionally distancing. It tends to perceive privileged by showing claims of receiving favor or particular attention treatments, tends to be dominant and has an extreme need for control in the relationship. It can be distant and avoidance at the relational level and manifest manipulative behaviors. Finally, it presents insensitivity and lack of empathy associated with the inability of reciprocity in relationships.
Consequently, even within the therapeutic setting, the narcissistic patient It tends to manifest behaviors in line with its sense of superiority: criticizes the therapist, ignores the other’s observations, has scarce auto-reflexive ability generating feelings of refusal in the careful.
Alternatively, the patient can show non-authentic signs of pseudo-alliance based on an idealization of the other, then coming to have a constant need for confirmation and admiration. Considered together, these interpersonal patterns often cause ambivalent, contrasting or even destructive feelings in the clinician (Freemen & Fox, 2013; Gabbard, 2009).
In light of what has been said, the absence of systematic research on the Therapeutic relationship with narcissistic patients. The few existing randomized studies turn to groups of subjects with a diagnosis of a personality disorder relating to Cluster B (according to the criteria of the DSM-IV- tr) without an evaluation of the individual diagnosis.
The subjects relating to this diagnostic group tended to evoke responses of irritation and less empathy in therapists. In addition, clinicians reported frequent and intense feelings of helplessness, refusal or physical attraction, and this independently of the theoretical-metadological orientation of individual professionals (Betan et al., 2005).
In recent years alone, the first data on the quality of the therapeutic relationship with patients with diagnosis of Narcissistic dp finding feelings of boredom in therapists, anger and distraction with fantasies on the interruption of therapy (Colli et al., 2014).
Within this new vein, a very recent Italian study (Tanzilli, Muzi, Ronningstam, Lingiardi, 2016) conducted on a sample of 67 psychotherapists with different training, investigated the patterns of countertransference recursive with narcissistic patients. The results showed an effective trend of these patients to evoke in the therapist intense negative emotional reactions, capable of damaging the quality of the therapeutic relationship.
In particular, the most found patterns were, primarily, the critical one with counterattrans of inadequacy and self -evaluation and, secondly, the hostile pattern that induces in the other emotions of irritation and resentment. This could depend on the typical defensive style of the Narcissist patients who tend to criticize and devalue others in reaction to their feelings of inferiority in an attempt to raise a floating self -esteem.
A third patterns found in this clinical champion is the detached one, accompanied by feelings of boredom and indifference of the clinician. This lack of emotional connection could derive from the extreme difficulty of these subjects to recognize one’s needs of closeness and intimacy within the therapeutic relationship.
Finally, a last pattern found was the helpless one that generates experiences of ineffectiveness, insecurity and anxiety in the therapist. Furthermore, in the same study they emerge particularly intense countertrans in cases where the diagnosis of narcissistic dp was associated with other personality traits of the B.
Finally, the correlations between emotions of the therapist and personalities of the patient were not significantly influenced by the type of training or other socio-demographic variables of the clinician.
The data of this empirical investigation therefore seem to confirm the weight that certain relational dynamics typical of the narcissistic personality They have on the internal experience of the therapist, generating intense emotions and negatively influencing the quality of the relationship and therefore of psychotherapy work.
For the clinician, the profound knowledge of one’s own experiences is the first fundamental step for the modulation of these same emotions, a condition in turn necessary to manage the requests (often manipulative!) Of these same patients and enforce the limits of the setting.
