When a patient with a narcissistic personality disorder or with infantile narcissism typical of a histrionic personality begins treatment, the early stages are often accompanied by pronounced idealization, as therapy is usually associated with unrealistic, partly “magical” expectations.

Therapy is perceived as a process capable of radically transforming the patient and bringing them to a state that matches their own idealized self-image or idealized vision of life. At the same time, the patient’s expectations — often unconscious — of becoming a perfect version of themselves (in narcissistic personality disorder) or of receiving an ideal life situation from the world (in infantile narcissism) are projected onto the therapeutic process.

But what actually happens in reality?

In practice, working with the method of free associations quickly reveals the unrealistic nature of these expectations.

The patient may consciously acknowledge that therapy is progressing according to the therapeutic contract, but on the subconscious and unconscious levels, disappointment emerges. This disappointment naturally transforms into devaluation of the therapy and the therapist — a defensive response to the frustration of idealized fantasies.

Narcissistic patients often idealize the therapist. They are convinced that the therapist has a perfect life, perfect relationships, perfect well-being, perfect work. All of this triggers intense unconscious envy, and devaluation becomes a reliable form of protection against it.

What does this lead to?

After a period of emotional elevation associated with initial idealization, the patient returns to their habitual inner state — boredom, emptiness, a sense of inadequacy. This return to the baseline affective level activates familiar defensive mechanisms. For the patient, this often becomes “proof” that “therapy is not working,” although in reality it is precisely at this point that the essential material for further analytic work begins to unfold.

Under these conditions (the intensification of disappointment and unconscious envy), the first signs of resistance begin to appear: postponing visits or missing sessions. These are no longer simple organizational difficulties — they become expressions of the therapeutic process and require our professional attention. And here an important question arises: how should the therapist respond when, in the early phase of treatment, the patient begins to miss sessions?

In such situations, we face the need for a delicate yet active stance: to respond with empathy toward the patient and the therapeutic situation, to clarify their hesitations, to remind them of the frame, and to help them recognize that difficulties with attendance are not an obstacle but material for therapy. The sessions that are hardest for the patient to attend often turn out to be the most productive.

In Transference-Focused Psychotherapy (TFP), this behavior requires the therapist to be active. The therapist generally calls the patient, asking about the absence and reminding him or her of the need for regular sessions for the treatment to have a chance. 

If the patient expresses reluctance or ambivalence about attending therapy, the therapist makes it clear that the decision is up to the patient but lets the patient know, in a way that offers a bit of psychoeducation and encourages the expression of affect, that sessions are often the most productive when the patient finds them difficult to attend.

At this point, it is necessary to use TFP techniques—specifically the interpretive process—to approach the discussion of the patient’s resistance.  This is essential because such dynamics, including the cycle of idealization and devaluation, are often characteristic patterns that shape the patient’s entire life.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy