Interactional obstacles to empathic relating in the psychotherapy of narcissistic disorders.

Psychotherapy with narcissistic patients exposes therapists to a set of interactional pressures which threaten to disrupt the desired therapeutic stance of empathic relatedness. The therapeutic relationship is a field of unconscious mutual influence in which therapists' own narcissistic vulnerabilities are threatened by narcissistic patients' characteristic interpersonal style. A typical constellation of countertransference feelings and reactions is aroused, characterized by a temporary or chronic state of narcissistic symmetry between patients and therapists. In this relational state both patients and therapists unconsciously defend their respectively tenuous sense of self-esteem from the perceived threat posed by the other, using similar defensive narcissistic strategies. Unless this interactional narcissistic symmetry is diffused a therapeutic impasse ensues, which may jeopardize the therapeutic alliance. This potential is exacerbated in the case of those therapists with characterological narcissistic features, as they unconsciously require constant affirmation from their patients in order to enhance their deficient self-esteem. Enduring, understanding, and adaptively processing narcissistic countertransference responses facilitates the resumption of the desired empathic stance, characterized by an optimal condition of narcissistic asymmetry between therapists and patients.