A Sense of Entitlement: Vicissitudes of Working with ‘Special’ Patients

He never wants anything but what's right and fair; only when you come to settle what's right and fair, it's everything that he wants and nothing that you want. And that's his idea of compromise.

Patients with problems of entitlement experience themselves as undernourished while the therapist experiences them as insatiable.

These quotations illustrating ‘a sense of entitlement’ are, I feel sure, recognizable to us all. Patients such as these consider themselves to be especially entitled, with special rights and privileges. Many analysts in the USA were engaged in writing on a sense of entitlement in the late 1980s (Billow 1999; Blechner 1987; Bromberg 1983; Grey 1987; Grotstein 1990; Moses & Moses-Hrushovski 1990; Rothstein 1977, 1979; Tenzer 1987). Moses and Moses-Hrushovski (1990) suggest three categories in attitudes of entitlement - normal, excessive and restricted. Normal is related to that which is reality-orientated, i.e. correctly assessing that to which one is legitimately entitled. My focus in this paper is not on the normal sense of entitlement but on the two polarized extremes - either excessive, with considerable narcissism and grandiosity, or restricted, which they say is often a reaction formation where the patient is found to function in a modest and self-denying way (see also Jacobson 1959). Not surprisingly, we find that these are two sides of the same coin and one masks the other. As Moses and Moses-Hrushovski state, ‘narcissistic overvaluation and grandiosity often are accompanied by a strong undervaluation, a strong sense of worthlessness or impotence’ (1990, p. 69).

Many American theorists have taken as their starting point, Freud's (1916) paper, ‘Some character types met with in psychoanalytic work’, where Freud refers to the ‘Exceptions’, patients who express their sense of ‘deserving’ or of having suffered. These patients consider themselves special in the sense