The Theory and Practice of Group Psychotherapy (83 page)

More commonly, many individuals with narcissistic difficulties present with features of grandiosity, a need for admiration from others, and a lack of empathy. These individuals also tend to have a shallow emotional life, derive little enjoyment from life other than tributes received from others, and tend to depreciate those from whom they expect few narcissistic supplies.
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Their self-esteem is brittle and easily diminished, often generating outrage at the source of insult.

Appropriate narcissism, a healthy love of oneself, is essential to the development of self-respect and self-confidence.
Excessive
narcissism takes the form of loving oneself to the exclusion of others, of losing sight of the fact that others are sentient beings, that others, too, are constituting egos, each constructing and experiencing a unique world. In extreme form, narcissists are solipsists who experience the world and other individuals as existing solely for them.

General Problems.
The narcissistic client often has a stormier but more productive course in group than in individual therapy. In fact, the individual format provides so much gratification that the core problem emerges much more slowly: the client’s every word is listened to; every feeling, fantasy, and dream are examined; much is given to and little demanded from the client.

In the group, however, the client is expected to share time, to understand, to empathize with and to help others, to form relationships, to be concerned with the feelings of others, to receive constructive but sometimes critical feedback. Often narcissistic individuals feel alive when onstage: they judge the group’s usefulness to them on the basis of how many minutes of the group’s and the therapist’s time they have obtained at a meeting. They guard their specialness fiercely and often object when anyone points out similarities between themselves and other members. For the same reason, they also object to being included with the other members in group-as-a-whole interpretations.

They may have a negative response to some crucial therapeutic factors—for example, cohesiveness and universality. To belong to a group, to be like others, may be experienced as a homogenizing and cheapening experience. Hence the group experience readily brings to light the narcissistic client’s difficulties in relationships. Other members may feel unsympathetic to the narcissistic member because they rarely see the vulnerability and fragility that resides beneath the grandiose and exhibitionistic behavior, a vulnerable core that the narcissistic client often keeps well hidden.
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• One group member, Vicky, was highly critical of the group format and frequently restated her preference for the one-to-one therapy format. She often supported her position by citing psychoanalytic literature critical of the group therapy approach. She felt bitter at having to share time in the group. For example, three-fourths of the way through a meeting, the therapist remarked that he perceived Vicky and John to be under much pressure. They both admitted that they needed and wanted time in the meeting that day. After a moment’s awkwardness, John gave way, saying he thought his problem could wait until the next session. Vicky consumed the rest of the meeting and, at the following session, continued where she left off. When it appeared that she had every intention of using the entire meeting again, one of the members commented that John had been left hanging in the last session. But there was no easy transition, since, as the therapist pointed out, only Vicky could entirely release the group, and she gave no sign of doing so graciously (she had lapsed into a sulking silence).

Nonetheless, the group turned to John, who was in the midst of a major life crisis. John presented his situation, but no good work was done. At the very end of the meeting, Vicky began weeping silently. The group members, thinking that she wept for John, turned to her. But she wept, she said, for all the time that was wasted on John—time that she could have used so much better. What Vicky could not appreciate for at least a year in the group was that this type of incident did not indicate that she would be better off in individual therapy. Quite the contrary: the fact that such difficulties arose in the group was precisely the reason that the group format was especially indicated for her.

Though narcissistic clients are frustrated by their bids for attention being so often thwarted in the group as well in their outside life, that very enlivening frustration constitutes a major advantage for the group therapeutic mode. Furthermore, the group is catalyzed as well: some members profit from having to take assertive stands against the narcissist’s greediness, and members who are too nonassertive may use aspects of the narcissistic client’s behavior as modeling.

Another narcissistic patient, Ruth, who sought therapy for her inability to maintain deep relationships, participated in the group in a highly stylized fashion: she insisted on filling the members in every week on the minute details of her life and especially on her relationships with men, her most pressing problem. Many of these details were extraneous, but she was insistent on a thorough recitation (much like the “watch me” phase of early childhood). Aside from watching her, there seemed no way the group could relate to Ruth without making her feel deeply rejected. She insisted that friendship consisted of sharing intimate details of one’s life, yet we learned through a follow-up interview with a member who terminated the group that Ruth frequently called her for social evenings—but she could no longer bear to be with Ruth because of her propensity to use friends in the same way one might use an analyst: as an ever-patient, eversolicitous, ever-available ear.

Some narcissistic individuals who have a deep sense of specialness and entitlement feel not only that they deserve maximum group attention but also that it should be forthcoming without any effort on their part. They expect the group to care for them, to reach out for them despite the fact that they reach out for no one. They expect gifts, surprises, compliments, concern, though they give none. They expect to be able to express anger and scorn but to remain immune from retaliation. They expect to be loved and admired for simply being there. I have seen this posture especially pronounced in beautiful women who have been praised all their lives simply by virtue of their appearance and their presence.

The lack of awareness of, or empathy for, others is obvious in the group. After several meetings, members begin to note that although the client does personal work in the group, he or she never questions, supports, or assists others. The narcissistic client may describe life experiences with great enthusiasm, but is a poor listener and grows bored when others speak. One narcissistic man often fell asleep in the meeting if the issues discussed were not immediately relevant to him. When confronted about his sleeping, he would ask for the group’s forbearance because of his long, hard day (even though he was frequently unemployed, a phenomenon he attributed to employers’ failure to recognize his unique skills). There are times when it is useful to point out that there is only one relationship in life where one individual can constantly receive without reciprocating to the other—the mother and her young infant.

In chapter 12, in the account of Bill and Jan’s relationship, I described many of Bill’s narcissistic modes of relating to other people. Much of his failure or inability to view the world from the position of the other was summed up in a statement he made to the other woman in the group, Gina, after sixteen months of meetings. He wistfully said that he regretted that nothing had happened between them. Gina sharply corrected him: “You mean nothing sexual, but a great deal has happened for me. You tried to seduce me. For once I refused. I didn’t fall in love with you, and I didn’t go to bed with you. I didn’t betray myself or my husband. I learned to know you and to care for you very deeply with all your faults and with all your assets. Is that nothing happening?”

Several months after the end of therapy, I asked Bill in a follow-up interview to recall some of the most significant events or turning points in therapy. He described a session late in therapy when the group watched a videotape of the previous session. Bill was stunned to learn that he had completely forgotten most of the session, remembering only those few points in which he was centrally involved. His egocentricity was powerfully brought home to him and affirmed what the group had been trying to tell him for months.

Many therapists distinguish between the
overgratified
narcissistic individual, like Bill, and the
undergratified
narcissistic individual, who tends to be more deprived and enraged, even explosive. The group behavior of the latter is misunderstood by the other members, who interpret the anger as an attack on the group rather than as a last-ditch attempt to defend the otherwise unprotected self. Consequently, these members are given little nurturance for their unspoken wounds and deficits and are at risk of bolting from the group. It is essential that therapists maintain an empathic connection to these clients and focus on their subjective world, particularly when they feel diminished or hurt. At times, the group leader may even need to serve as an advocate for the understanding of the emotional experience of these provocative group members.
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A clinical illustration:

• Val, a narcissistic woman, was insulting, unempathic, and highly sensitive to even the mildest criticism. In one meeting, she lamented at length that she never received support or compliments from anyone in the group, least of all from the therapists. In fact, she could remember only three positive comments to her in the seventy group meetings she had attended. One member responded immediately and straightforwardly: “Oh, come on, Val, get off it. Last week both of the therapists supported you a whole lot. In fact, you get more stroking in this group than anyone else.” Every other member of the group agreed and offered several examples of positive comments that had been given to Val over the last few meetings.

Later in the same meeting, Val responded to two incidents in a highly maladaptive fashion. Two members were locked in a painful battle over control. Both were shaken and extremely threatened by the degree of anger expressed, both their own and their antagonist’s. Many of the other group members offered observations and support. Val’s response was that she didn’t know what all the commotion was about, and that the two were “jerks” for getting themselves so upset about nothing at all.

A few minutes later, Farrell, a member who had been very concealed and silent, was pressed to reveal more about herself. With considerable resolve, she disclosed, for the first time, intimate details about a relationship she had recently entered into with a man. She talked about her fear that the relationship would collapse because she desperately wanted children and, once again, had started a relationship with a man who had made it clear that he did not want children. Many members of the group responded empathically and supportively to her disclosure. Val was silent, and when called upon, she stated that she could see Farrell was having a hard time talking about this, but couldn’t understand why. “It didn’t seem like a big-deal revelation.” Farrell responded, “Thanks, Val, that makes me feel great—it makes me want to have nothing to do with you. I’d like to put as much distance as possible between the two of us.”

The group’s response to Val in both of these incidents was immediate and direct. The two people she had accused of acting like jerks let her know that they felt demeaned by her remarks. One commented, “If people talk about some problem that you don’t have, then you dismiss it as being unimportant or jerky. Look, I don’t have the problems that you have about not getting enough compliments from the therapists or other members of the group. It simply is not an issue for me. How would you feel if I called you a jerk every time you complained about that?”

This meeting illustrates several features of group work with a characterologically difficult client. Val was inordinately adversarial and had developed an intense and disabling negative transference in several previous attempts in individual therapy. In this session, she expressed distorted perceptions of the therapists (that they had given her only three compliments in seventy sessions when, in fact, they had been strongly supportive of her). In individual therapy, Val’s distortion might have led to a major impasse because her transferential distortions were so marked that she did not trust the therapists to provide an accurate view of reality. Therapy groups have a great advantage in the treatment of such clients because, as illustrated in this vignette, group therapists do not have to serve as champions of reality: the other group members assume that role and commonly provide powerful and accurate reality testing to the client.

Val, like many narcissistic patients, was overly sensitive to criticism. (Such individuals are like the hemophiliac patient, who bleeds at the slightest injury and lacks the resources to staunch the flow of blood.)
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The group members were aware that Val was highly vulnerable and tolerated criticism poorly. Yet they did not hesitate to confront her directly and consistently. Although Val was wounded in this meeting, as in so many others, she also heard the larger message: the group members took her seriously and respected her ability to take responsibility for her actions and to change her behavior. I believe that it is crucially important that a group assume this stance toward the vulnerable client. It may be experienced as a powerful affirmation. Once a group begins to ignore, patronize, or mascot a narcissistic individual, then therapy for that client fails. The group no longer provides reality testing, and the client assumes the noxious deviant role.