By means of our analytic attitude we implicitly invite our patients to use us in a way that will illuminate the intrapsychic consequences of conflicted or failed relationships. Different patients use us differently. The suffering of those who experience, and reluctantly accept, their relative separateness from others differs qualitatively from those individuals to whom separateness represents the death of some essential part or function of themselves. Thus the way in which our patients unconsciously relate to us and use us reveals whether their symptoms arise from conflicts toward differentiated others, ambivalently loved and hated, or from structural psychic deficits that retard their ability to function as integrated selves in relation to differentiated others.(1) Narcissistic patients fall into the latter category and use us to fulfill structural needs that parental objects failed to fulfill at crucial developmental stages. How we experience, understand, and respond to their use of us will determine whether the therapeutic relationship becomes a traumatic reenactment of the original pathogenic selfobject failure, or a safe environment for the internalization of a relationship that will allow the resumption of arrested structural development.
The argument of this paper may be summarized in three general propositions about therapeutic responsiveness: firstly, the more disturbed the patients' self-structure, the more intense the transference and, consequently, therapists' countertransferences, Secondly, the more narcissistic the patients' disturbance the more likely it will be that the therapists' countertransference responsiveness will be colored by their own narcissistic vulnerability and defenses against this. Thirdly, the greater the therapists' narcissistic vulnerability, the less empathically attuned and capable of containing and responding to the patients' experience they will be.
It is common knowledge that narcissistic patients make extraordinary demands on their therapists' capacity for understanding, relating, and responding optimally. Narcissists use us in a way that distorts our typical therapeutic experience of ourselves, of the patients, and of ourselves in relation to these patients. The profound sensitivity of these individuals' psychic organization to the actions and inactions of others demands an interactional perspective that places interpersonal relations and the subjective experience of relatedness in the foreground of theory and technique. Narcissistic disorders may best be understood as pathologies of relatedness in which the significance of every interaction lies in the subjective experience of the extent to which it enhances or undermines the narcissist's fragile self-esteem. Narcissists' exquisite vulnerability to environmental slights predispose them to experience perceived rejection or misunderstanding on the part of the other as an emotional assault, and a traumatic rupture of connectedness that deprives them of their only source of self-worth. The implication of this is that empathy and empathic failures occupy the center stage in the psychotherapy of narcissistic disturbances.(2-4)
There are two varieties of empathic failure: (1) those empathic failures that arise from inevitable frustration of the narcissist's archaic need for unfailing understanding and affirmation in the context of a containing relationship and, (2), those empathic failures deriving either from the therapist's temporary or chronic inability to maintain experiential contact with the patient's internal world. The former empathic failure creates an environment of hope in which the narcissist's grandiose facade can be gradually explored, relinquished and replaced by internal resources of genuine aliveness and self-esteem; the latter fosters an environment of despair and inner conviction that one's defensive grandiosity can never be surrendered or others trusted with one's deficient self-experience.
The focus of this paper is on understanding the struggle that the therapist has in establishing and maintaining empathic relatedness with narcissistic patients, and the interpersonal significance of failing to do so. …