Developing and Maintaining the Therapeutic Alliance with The Narcissistic Personality

The development and maintenance of a viable working alliance with the narcissistic personality is a task that is often fraught with difficulty. Yet it constitutes the most crucial element in the treatment situation. Though the narcissistic personality is capable of developing a working alliance, it is a fragile one and the instability of the narcissistic transference is a constant threat to it. Often the observing ego is overwhelmed by the powerful surges of infantile demands and reactions to frustration, which cause a temporary (though potentially dangerous) loss of ability to sift out the real from the unreal. At such times only the working alliance may remain relatively free of transference distortions, and its strength alone may determine whether treatment founders or proceeds.

Freud's observation (1913) that a positive transferance is a necessary requisite for the commencement of treatment is even more pronounced with the narcissistic personality. Here the capacity for a swift negative reaction to the therapist frequently creates an impasse in the opening moments which may well result in a desperate patient being lost to therapy. The therapist is often faced with demands or attitudes that he deems unreasonable and, not without justification, may even experience as violations of his own ego boundaries. Thus, he may be confronted in the opening moments with the dilemma of having to accede to a demand in order to have even a minimal basis for the establishment of a working alliance. If he refuses, he risks undermining any hope of therapeutic success. Myerson (1974) describes a case in which a narcissistic patient presented the therapist with an ultimatum, threatening to