How we resist resistance

When patients resist forming a healing relationship with us, we often resist their resistance. Two resisters in the room. And we ask, “Why are we stuck?”

We reject the experience of being rejected. Could we accept this feeling?

We run away from the frustration we feel. Could we accept this feeling?

We avoid our sadness and make it sad. Could we accept our sadness when rejected by a patient in the moment?

We try to force his closed heart to open, making it close even more. Could we open our hearts to his closed heart by accepting it and the story it is telling?

We fear our fear and try to control it by asking the patient to behave differently. Could we accept our anxiety and let its information heal us?

We try to argue with the patient’s insanity to make him sane. Could we accept our anxiety when seeing insanity so he could feel his anxiety when seeing his insanity?

What if projective identification is how the patient awakens the light and dark parts of ourselves so that we can learn to love them? What if we resist patients to resist what is in ourselves? What if we need to love the light and dark places in ourselves so that through our being that love, the patient experiences that his  dark places are worthy of unconditional love too?

We don’t resist patients. We resist what we fail to love in ourselves. We need to love the darkness within, so we can finally embrace what the patient has brought for our healing. 

Narcissism

“Could you please write your thoughts on the most common issues behind narcissistic behaviors? Is it a matter of splitting (“I am totally good, they are inferior, bad etc.”)? Is it a character defense (“I respond to the “glorified” way my “mother” treated me”)? Is it a way to avoid relationships and alienate people (“refined” punitive superego)? Or is it just a “socially reinforced” way to express unconscious anger against others? I would love to hear your view on this.” Thanks to Christos for this question!

Narcissism is a spectrum trait, meaning that some us of have a little narcissism and some of us a lot! Therefore, its implications differ depending where someone is on the spectrum of human difficulties. For instance, we have the common narcissism of preening ourselves a bit in the morning before the mirror. We have the presenter who enjoys showing his work in front of others. [Hmm. This sounds a little too close to home!] And then we have the narcissistic personality who has to be the center of attention, always number one, and devalues other people as “stupid”, “ugly”, and “ignorant.” Sound like any political personality you have heard of? And then we have narcissism in the psychotic patient who, having lost everything following a psychotic break, has a delusion that she is going to give birth to the messiah. In this last example, her brittle grandiosity is a defense against massive loss.

Classically, one way we understand narcissism is that the patient equates himself with his ego ideal. All of us have ideals which guide us through life. We realize that ideals, like the North Star, are ideas which will provide guidance in our lives but which we will never achieve. Why? An ideal is an idea. And we are real. When we fail to live up to our ideals, that tension can help guide us back toward our ideals. The narcissist, unable to tolerate the painful feelings of grief and shame when we fail to live up to our ideals, solves this tension by claiming he is the SAME as his ideal! He projects his weaknesses and failures onto other people whom he devalues, and then idealizes himself and expects others to do the same. Thus, narcissism at this level always involves splitting. The narcissist idealizes his solutions and devalues others who disagree. 

Of course, this results in impoverished relationships. Intimacy means I am real with a real person. The narcissist insists he is unreal (perfect) and that you must be unreal (perfect) as well, or else you will be devalued and thrown away. This is why narcissists tend to choose other narcissists for partners or depressed spouses who accept devaluation and punishment.

As for the anger of the narcissist, narcissistic rage, this is rage split off from mixed feelings toward an all-bad image. The narcissist wants to be idealized by others. If he is not idealized, but is given realistic feedback instead, he will feel massive rage since he experiences reality as a murderous attack upon his fantasy self-image of perfection. In response, he feels murderous rage toward anyone who does not idealize him. This split off rage toward a devalued image does not involve mixed feelings and should not be encouraged, since it only would reinforce his splitting and devaluation.

The split off rage gives the patient a pseudo-experience of organization because he obliterates the other person rather than experiences the obliteration of his self-image of perfection. “If rage enough, painful reality will go away.” However, since reality doesn’t go away, narcissists tend to rage a lot, i.e., every time reality shows up.

From an ISTDP point of view, I view narcissistic personalities as fragile because their primary defenses are splitting, projection, idealization, and devaluation—consistent with patients at a borderline level of character pathology. Unable to tolerate low levels of painful feelings, they use splitting and projection to avoid the internal experience of mixed feelings. The narcissistic structure itself, the image of perfection, is a defense against facing who we really are: real, flawed, imperfect, and guilty.

The narcissist, unable to bear these complex feelings, projects all sense of imperfection onto others whom he judges and idealizes. Although he can be superficially charming, underneath he is paranoid, anticipating attacks from others that he gives out himself. His seeming stability is completely dependent upon receiving idealization. Once the idealization stops, he collapses either into severe depression or elevates himself into an even more manic version of pseudo-greatness.

These patients have a poor prognosis in treatment. This may be because clinicians over-estimate the patient’s capacity based on their superficial achievements. These patients do not show the classic signs of cognitive/perceptual disruption (e.g., dizziness) because they immediately resort to splitting, projection, and narcissistic rage. Premature confrontations will merely trigger massive rage and projection, leading to premature termination. The graded format is called for in these cases with great attention to working on splitting and projection to build the capacity to tolerate painful mixed feelings at very low levels without triggering the regressions into narcissistic rage.