Metaphor and Early Warning Systems in Psychotherapy with Narcissistic Patients By Roberta Satow, PhD on 2/3/22 - 1:16 PM

The other day, my patient Jeremiah was explaining that he could not sleep because he felt “blackmailed” by a former employee who was demanding excess severance pay. He was in what we had come to identify in our clinical work as narcissistic rage, feeling that the employee’s demands were an assault on his sense of self. But we both knew from prior work that his rage was typically triggered when he felt he had done something wrong that contributed to the situation, which brought with it a sense of shame, a common narcissistic dynamic.

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Jeremiah’s use of the word “blackmail” was the key—you can only be blackmailed if you believe or feel that you have done something wrong and can be compromised if that information is revealed. Once we figured out what he felt guilty about, Jeremiah could acknowledge that he had a choice about paying the severance or not. In our subsequent work, the term “blackmail” has become a shared metaphor. We both now understand that it means he feels forced to give someone something that he does not want to give but feels in danger because of his guilt.

I have found that creating and maintaining a working alliance is difficult with patients suffering from narcissistic and/or borderline personality disorders. However, developing shared metaphors and creating an early warning system has been very useful in my therapeutic efforts with these particular patients.

In psychoanalysis, the core concept of transference is based on a metaphor—the patient is responding to me as if I am their parent. Within that macro-metaphor, a multitude of micro-metaphors emerge in psychotherapy—both the patient’s and my own. There is usually a great deal of unconscious material to be mined from the patient’s metaphors (e.g., the analysis of dreams is based on interpreting unconscious metaphors). The therapist’s use of metaphors is also important, because it can betray countertransference and/or can be a tool to cut through the patient’s resistance.

I have come to appreciate that these shared metaphors create what Winnicott called a “transitional space” in which the patient’s and therapist’s unconscious and conscious overlap. At its best, psychotherapy takes place in that metaphoric, or play, space. The therapist’s job is to bring the patient into a state of being able to engage fully in the metaphoric, as-if scenario—to play. With narcissistic patients, I have found it particularly difficult to develop enough trust for them to be willing to play, which requires a degree of unmonitored spontaneity, vulnerability and trust. Sometimes, when Jeremiah and I are in that play space, I forget that if I go beyond the mirroring response and make an interpretation, I might trigger his narcissistic rage. However, having inhabited that play space together over a course of years, we have developed an early warning system.

Our warning system is reciprocal—sometimes he warns me that I am treading on dangerous grounds, while other times I warn him I’m going to say something he might not like. After ten minutes of inhabiting the same play space we may have a warning interchange as in the following:

Roberta: Maybe you got drunk to get Diana to break up with you?

Jeremiah: Please be careful here.

Roberta: What just happened?

Jeremiah: I don’t want to end the session feeling the connection between us is broken.

Roberta: What did I say that threatened to break our connection?

Jeremiah: You’re making me feel ashamed.

Roberta: I’m sorry. I didn’t mean to do that. [I could have focused on his shame but thought repairing our connection was primary.]

Jeremiah: I know. I’m okay. You can go on now.

In this interchange, Jeremiah gave me a warning that he experienced what I said as a shaming response and that he was in danger of sinking into narcissistic rage.

At other times I give him an early warning:

Roberta: I want to take a risk here.

Jeremiah: Yes, it’s okay. Go ahead.

Roberta: Do you think you are experiencing your partner as if he’s your brother?

Jeremiah: Yes, I can see that. Yes, that’s right.

By warning Jeremiah that I was going to make an interpretation, he was more able to tolerate it. The warning neutralized his potential experience of humiliation.


I have come to value the therapeutic play space in which patients and I use various metaphors to deepen our connection and their self-awareness. The use of shared metaphors with patients like Jeremiah has allowed me to create a safe creative space for our analytic work. This has been particularly important with narcissistic patients with whom I have been deeply challenged to create a working alliance. Since these patients have a special sensitivity to injury and shaming, I have made good therapeutic use of this early warning system to reduce the chances of the rupturing the working alliance and increasing my patients’ resilience when it is broken.

File under: The Art of Psychotherapy, Musings and Reflections