Therapeutic approaches to working with fragile selves

The main treatment for individuals with borderline and narcissistic personality traits is centred on various forms of psychotherapy, including Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT). Contemporary treatments commonly involve mentalization-based therapy, transference-focused psychotherapy, and schema-focused psychotherapy. Individual and group psychotherapy may be also useful in helping people with narcissistic and borderline personality disorders.

Indeed, the success of psychotherapeutic treatments for individuals with borderline and narcissistic personality traits is one of the most striking developments that has happened in the analytic world since Freud’s original formulations in 1914. Whereas Freud regarded narcissistic traits as largely untreatable in the psychoanalytic setting and as an obstacle to psychoanalysis, in the second half of the 20th century object relation theorists (both in the United States and among British Kleinians) set about revaluing these traits as defence mechanisms that offered potential access for therapy. The pioneering work of Kohut, Kernberg, Fairbairn, Rosenfeld, McWilliams, and others has shed invaluable light on both the aetiology and treatment of these complex disorders.

Potential difficulty of treatment

One of the initial obstacles to treatment is the fact that many individuals with these personality traits often do not consider themselves to have a problem, due to the peculiar self-recognition difficulties inherent in these specific psychologies. In the past, some therapists have also viewed such patients as being simply too complex or difficult to treat, and may therefore have directly or indirectly excluded those with such diagnoses or associated behaviours from effective treatment.

Therapists can also become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as manipulative, difficult to manage, noncompliant, aggressive, and attention-seeking (Jack Nathan Talk). These behaviours may in turn invoke hostility in those treating these individuals, and they can therefore be dealt with more negatively and dismissively as a result, creating an unhelpful negative feedback loop.

However, as Celani observes, if the therapist is aware of these characteristics, and the personality structures and mechanisms underlying them, psychotherapeutic treatment can be successful, and in many instances rewarding. Indeed, the diagnosis of ‘borderline’ is often today considered ‘the good prognosis diagnosis’, in that people do get better and recovery can be sustained. As Kernberg (2012) concludes, “BPD is an eminently treatable disorder, and patients can be helped”. In the case of BDP, it is estimated that up to fifty percent of patients improve over a ten-year period.

Treatment for individuals with narcissistic traits can be especially challenging because many people with this condition often present with a great deal of grandiosity and defensiveness, again making it difficult for them to acknowledge problems and vulnerabilities. Steiner observes that many such patients are also considered hard to treat as they have such difficulty relating to others, are inward-looking, and detached from ‘objects’, making the therapeutic transference hard to form (this was Freud’s view). However, notes Steiner, the transference can actually be “extremely intense” with this personality group: though they might superficially appear to be ‘cut off’ from the therapist, patients are often acutely observant of them, and affected by them (Steiner, 1993).

Those with pathological or ‘malign’ narcissism may also resist treatment due to the fact that they are peculiarly sensitive to being seen as small, dependent, or grateful – arousing in them problematic notions of ‘progressing’, or of being seen as ‘good’. The internalised sense of being inherently worthless or empty may serve in these instances as a defensive function, and as such any attempt to challenge it may be ruthlessly attacked and torn down (Steiner, 1993). In this precarious mind-set the very idea of ‘therapy’ can be humiliating. It is important to remember that shame is the core affect in narcissistic disturbance – an acute sense of feeling inadequate, which any attempt at self-development, self-discovery, or self-improvement might trigger or provoke. As Neville Symington observes, “Effective therapy must acknowledge these immaturities and face the humiliation and rage their exposure provokes. It then becomes possible for narcissistic traits like greed and envy to be transformed into their positive relational counterpart such as receptivity and respect” (Link to Talk).

It is for these reasons that Nathan advocates a ‘Benign Authority’ model of treatment, involving an empathic approach, setting boundaries and limits, being alert to the therapeutic role in tolerating the counter-transference, and “being actively emotionally involved” (Link to Talk). He notes that in some senses this approach might run counter “to ideas of neutrality” in the analyst, but he points out that where sensitivity to ‘abandonment’ can be so strong in the patient, being ‘neutral’ can all too readily be taken for rejection. As Mollon similarly notes, working constructively with these personality traits “requires empathy, tact, and truth” (Link to Talk).

One of the central aims of treatment is for the ‘central ego’ of the patient to become dominant and not be sabotaged by the Anti/Libidinal Egos, and their Good/Bad Objects (Link to Talk). A positive treatment can see a significant reduction of hatred towards the Rejected Object.

Celani notes that different therapeutic relationships are created by different therapeutic models. He lists four steps that are helpful for all approaches:

1. Become a good object (for the patient). “Listening turns you into a good object.”
2. Gently unearth bad object memories – i.e. without commenting on them at the outset of therapy.
3. Engaging in direct contact with the sub-structures – i.e. knowing what they are, and not making them worse (for example, working on the AntiLibidinal Ego, not the Libidinal Ego).
4. Supporting the re-establishment of development.