As therapists, we encounter cases in which an individual’s first presentation for psychotherapeutic treatment occurs in the context of couple therapy. It is precisely within intimate relationships that manifestations of personality pathology may become particularly pronounced, even when they have remained less apparent for a long time outside the couple—particularly narcissistic ways of regulating self-esteem, dependency, aggression, and the relationship to the Other.
Otto Kernberg—one of the leading theorists of pathological narcissism and the originator of the concept of malignant narcissism—has devoted particular attention to this clinical problem. Together with Diana Diamond, Frank E. Yeomans, and Barry L. Stern, in the book Treating Pathological Narcissism with Transference-Focused Psychotherapy, he describes key aspects of the clinical assessment of couples with narcissistic conflicts:
One often hears in the initial couple therapy session how one partner has long requested that the spouse seek individual treatment for his or her rage, controlling tendencies, arrogance, or demeaning behavior.
The chronic emptiness of a couple’s relationship when one or both participants suffer from severe narcissistic pathology is often palpable to the evaluating clinician, and the operation of narcissistic resistances in one or both of the partners can pose a challenge to the evaluation of the couple and their difficulties.
In the consulting room, this may look, for example, like this:
One partner describes in detail how “unbearable” the other is, yet is almost unable to reflect on their own contribution to the conflict. Any attempt by the therapist to shift attention toward the patient’s own behavior may be experienced as a failure to understand them, as unfairness, or even as the therapist siding with the “enemy.”
Starting from the assumption that couples, often referred by an individual therapist, are being referred for couple treatment, the manifestation of narcissistic resistances in the evaluation process raises several general questions. First, why is the couple consulting now, and what are the actual dynamics that have shifted a previous equilibrium (often a narcissistic–masochistic or depression equilibrium, or a grandiose–vulnerable narcissistic equilibrium)? Is the couple really interested in treatment or is one person forcing the participation of the partner, and how will that influence a decision regarding treatment?
The timing of the initial consultation itself often has diagnostic significance. A couple may have existed for years in a relatively stable, albeit pathological, equilibrium. They may seek help when this equilibrium is disrupted: the partner who previously yielded begins to set boundaries; the dependent partner becomes more autonomous; one partner achieves professional success; a third person enters the relationship; or the possibility of separation emerges. Thus, the question “Why now?” may be one of the key questions in the initial assessment.
To what extent are the problems created mostly by one person’s pathology as opposed to the pathological interaction and its shifts throughout time? This is a particularly controversial question for anyone approaching the couple from a systemic or systemic–analytical point of view, as the focus on one individual’s contributions draws the therapist out of a neutral stance, more or less equidistant from the individual and working with the couple system, and into the very system being assessed.
That being said, there are instances, not infrequent, where one partner’s rage, contempt, and devaluation of the spouse and the therapist eviscerate the potential for work as a couple. When one partner’s rage and devaluation cannot be stanched by the therapist, thus enacting an ineffective and abusive situation in the consulting room, one might opt to meet with that partner individually to raise the possibility of individual work, or of an evaluation of the nature of the work in which he or she may be already engaged.
For example, one partner may repeatedly interrupt the other, ridicule what they say, correct their “incorrect” version of events, and later devalue the therapist’s interventions in much the same way. In such a situation, the behavior observed in the consulting room becomes part of the diagnostic material itself: the therapist directly observes the very dynamics the partners are describing.
Some clinicians, upon meeting intense narcissistic resistances, will engage in a full diagnostic evaluation of the presumptive narcissistic partner. If that evaluation reveals the partner indeed suffers from a severe pathological narcissism or NPD, which contributes significantly to the couple’s conflict, the indication would be for the psychodynamic treatment of that partner. If both partners show significant pathology, the question can be raised to what extent a better equilibrium may be provided by couple therapy, or whether both should be referred for individual treatment.
The extent to which there is still a strong attachment within the couple, in contrast to a situation that seems to indicate a process of progressive dissolution, becomes central in the evaluation. Here the study of the nature and gratification in their sexual relationship, of mutual interests and interaction in their daily life, the feelings of love, admiration, respect, and empathy still available, in contrast to resentment, hatred, and feelings for revenge and contempt, have to be evaluated.
Therefore, it is important to assess not only the intensity of the conflict. Two people may argue frequently while still retaining interest in one another, sexual desire, the capacity to experience guilt, concern for the partner, and the ability to reestablish contact after conflict. In another couple, there may be almost no overt conflict, yet intimacy, interest in the Other, and emotional involvement may also be absent. For the prognosis of therapy, this distinction may be crucial.
A final element in the evaluation of the couple is the extent to which a joint superego system in the form of shared values and life goals, and relationship to family and friends, is still viable and can be recruited in the service of the therapy.
An ideal situation may be the decision to treat a member of the couple with the diagnosis of pathological narcissism or NPD in the context of a couple’s relation that still seems sufficiently viable to tolerate the lengthy and slow process of treatment. Often a preliminary, time-limited treatment of the couple may provide the conditions on the basis of which the couple can tolerate the vicissitudes of a lengthy treatment of one of its members.
The history of the couple is important in evaluating whether there ever was closeness, mutual idealization, a mutual sense of gratification, and being in love with each other that may have been lost but can still be remembered.Such a history strengthens the possibility that, beyond their present conflicts, there may be a basic future for them.
In this sense, asking about the couple’s past is not merely a matter of taking a history. The partners’ ability to recall periods when they loved and admired one another, experienced sexual desire, and derived gratification from their life together may be an important indicator of whether a psychological foundation for restoring the relationship still exists.
Sometimes success or failure in work or the profession of one or both participants has changed a viable equilibrium into an intolerable situation, and when such external circumstances—economic, social, familial—prevail, their therapeutic exploration may provide the stability of the frame required for the treatment of the individual patient.
Thus, when assessing a couple with narcissistic conflicts, the therapist evaluates not only how troubled the relationship has become. It is equally important to understand what has held the couple together, what disrupted their previous equilibrium, and—most importantly—what still remains alive between the partners.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy