Treating the Narcissistic Injury of a Narcissist By Roberta Satow, PhD on 11/10/20 - 1:40 PM

What happens when a narcissist gets fired or loses an election? These are painful experiences for anyone. But for the narcissist, the primary need is to be the center of attention to support their fragile self-esteem. While healthier people are hurt by disappointment, the narcissist feels completely destabilized by it. They cannot easily get “back on the horse.” The narcissist cannot maintain their sense of worth and is dependent upon others for sustenance. If other people mirror the self-aggrandized self of the narcissist, they are included in the narcissist’s idealized bubble. Hence, people may report that their experience of a narcissist was that they were charming and flattering. But disagreement or criticism by another person, a Board of Directors, or an electorate is experienced as a narcissistic injury. Narcissistic injuries do not feel like hurt feelings, they feel like the narcissist’s very self is being attacked. The narcissist needs constant reassurance that they are special and can spin out of control and attack others venomously when feeling unappreciated.

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Patrick came to see me when he was fired from a large non-profit organization. He was referred to me by another patient, a close friend and who was concerned about his depression. Patrick arrived at the first session dressed in an expensive suit, although he was not working, and explained how unfairly he had been treated. But he wanted to come twice weekly to figure out what he may have contributed to the bad outcome at work. I concurred that it seemed that the process had been unfair and that coming twice weekly was a good idea.

When the first session came toward the end, I explained to him that I charge for missed sessions. If I am not given at least 24 hours’ notice, the patient is charged. If I am given more notice, I offer a make-up time, but if the patient does not take the make-up, I charge for the session. I also explained that I give the patient a bill at the end of the month and expect payment the following week in the session. (This was before the coronavirus pandemic!)

Patrick said he would not pay for missed sessions twice in a week—only one at most.

“There is no way I can do that. What if I have to miss two sessions in a week?” he scoffed.

I knew from the referring patient that he had been paid a salary of a million dollars per year and was collecting severance pay. His resistance to paying for missed sessions was not due to financial considerations. It was clear to me that Patrick needed to feel special. He refused to follow my rules because they did not suit him. This was the first diagnostic sign to me that Patrick might have a narcissistic personality. I could have insisted on my terms, but he would not have started the treatment. I decided to accept his modification.

During the first month, Patrick vacillated between remorse about some of the decisions he had made before getting fired and rage at the board of directors for accusing him of making bad decisions. Each time I thought he expressed some remorse, he immediately became defensive and expressed contempt for the board. Clients with narcissistic personalities try to build a positively valued sense of self on the illusion of not having any failings. The admission of any wrongdoing exposes unacceptable shame.

When the end of the month came, I handed Patrick his bill. He did not give me a check the following week or the week after. I brought up the fact that he had not paid me. He said that he gave the bill to his accountant, and it should be in the mail. I explained that Patrick needed to pay me directly in the session because payment was part of therapy and that the payment was late, but I could not analyze his accountant.

“That’s ridiculous!” Patrick exclaimed. “I’ve never heard of such a thing! My accountant pays all my bills.”

“I am not Con Edison or a credit card company. I am a psychoanalyst, and part of the therapy involves you paying me directly when I give you the bill.”

Patrick laughed. Then he said, “That’s really not convenient for me. I prefer my accountant pay my bills.”

“I understand that,” I said. “But that is not acceptable in therapy.”

Patrick got up and left the office.

I was not sure if he would come back, but he did.

“I called my accountant, and she was late in sending you the check.” He handed me the check.

“Thank you,” I said.

“I don’t know how I will remember to carry my check book all the time…,” he muttered.

“You don’t need to carry it all the time, only the session after I give you the bill,” I said.

He chortled.

“Can you tell me what you’re feeling?” I asked.

“I’m annoyed. That’s what I’m feeling. I think you’re making a big deal out of nothing,” he said. “I want to talk about what happened to me and how to get over it, and you keep talking about your damn bill.”

“You sound angry.”

“I’m not angry. I’m just annoyed that you’re wasting my time on this,” he said. “You’re the one who’s angry because I don’t want to follow your rule.”

Narcissistic patients typically idealize or devalue the therapist. It was clear that this patient was going to devalue me. He was trying to maintain his self-esteem and avoid feeling the shame resulting from having been fired. He was projecting his sense of defectiveness onto me. But it was going to be difficult for me to tolerate being devalued.

Patrick was struggling with trying to admit some of his mistakes in judgement while he was CEO while maintaining his fragile sense of self. If I concurred in any visible way each time he began to explore an error in judgement, he accused me of blaming him and not helping him move forward. I was careful to stay silent and not show any signs of concurring when he admitted a mistake. But he could not contain the conflict; he kept projecting one side of it onto me. I felt drained and hopeless after sessions in which he blamed me for criticizing him and insisted I was not listening or helping. A colleague pointed out that Patrick was still coming to sessions, so he must have an attachment to me and feel I was helping him. Perhaps, my colleague suggested, his narcissism will not allow him to feel helped because that would shake his self-esteem. It took a while for me to fully take in that insight, but once I did, I was more able to stay connected to Patrick by imagining I was in a playground watching a little boy on a see-saw, teeter-tottering between shame and blame, the core of narcissism. The more I was able to stay removed from it, the more Patrick was able to share regrets with me and tolerate them.

After 18 months, Patrick got another high-status job that restored his sense of self-worth. He left treatment still claiming that my payment rules were too rigid. He was going to find another therapist who would accept payment from his accountant and understand him better. At first, I felt defeated, then sad that we were not able to get further. Now I feel that maybe he will eventually recognize the important work we did in his transition period between jobs.

File under: The Art of Psychotherapy, Musings and Reflections