Rose Medical Center
4500 E. 9th Ave. #660
Denver, CO 80220

Archive for the ‘Narcissism’ Category

Narcissism: A Redefinition and Case Study

Narcissism: A Redefinition and Case Study of Treatment

With Conflict-Focused Couples Therapy

Susan Heitler, Ph.D.

Private Practice, Denver, CO


Author Note

The Author is in private practice in Denver, CO.

Correspondence concerning this article should be addressed to Dr. Susan Heitler, 4500 East 9th Ave, Suite 660, Denver, CO 80220.  E-mail: [email protected].


Narcissism, which creates relationship difficulties, is redefined as a deficit in bilateral listening, i.e., ability to hear both one’s own and others’ concerns.  Narcissists hear mainly their own thoughts, dismissively brushing others’ aside.  Most other traits commonly associated with narcissism are related to this core listening deficit.  Individual therapy poses challenges for helping narcissistic individuals, challenges that may be met more effectively with couples therapy.  A case study with an almost-divorced narcissistic man and his depressed/angry wife details the specific interventions utilized in the initial 3 sessions of a conflict-focused couples therapy. Conflict-focused treatment upgrades listening skills, improves collaborative dialogue and win-win solution-building, and reduces negative emotions like anger and depression. The outcomes after 3 sessions included listening skill improvements; more ability to enjoy a “flow” of collaborative dialogue; reduction of both spouses’ emotional distress, depression, and angry fighting; and increases in marital affection and hope. It would be helpful for empirical studies following up on this case example to:  (a) validate bilateral listening deficits as a focus for assessing narcissism; (b) validate the conflict-focused couples therapy approach, both in general and specifically as applied to narcissism, and (c) assess the sufficiency of psychologists’ training in these interventions.


Keywords: narcissism, narcissism treatment, conflict-focused therapy, bilateral listening, couples therapy.


Narcissism: A Redefinition


Case Study of TreatmentWith Conflict-Focused Couples Therapy

Recent studies in the US and abroad confirm increasing rates of narcissism in general and narcissistic personality disorders in particular (Twenge et al, 2008, Twenge et al, 2010, Wilson & Sibley, 2011).  Yet even though narcissism produces relationship dysfunction and divorce, narcissism, like the anger it induces in others, is not listed in the ICD-10-CM and is generally ineffectively treated.

Initial writers on narcissism such as Freud, Kernberg and Kohut identified what Masterson described as “grandiosity, extreme self-involvement and lack of interest in and empathy for others” (Masterson, 1981).  While these traits clearly commonly appear in narcissistic dysfunction, a recent review by Ronningstam (2012) concludes that the usual depictions offer “low clinical utility and limited guidance for treatment” suggesting “the need for change in the diagnostic approach to and formulation of narcissism.”

This article details interventions in a private practice couple therapy case to illustrate how (a) narcissism, viewed in dyadic interactions, can be viewed as a listening deficit and (b) couples therapy guided by a focus on remediation of listening patterns can reduce the narcissism, bringing relief from personal and relationship distress.

The conflict-focused treatment methods and policies utilized in this case, familiar to many therapists from the training video, The Angry Couple (Heitler, 1995), are outlined in Appendix A and described in more detail in other publications (Heitler, 1987, 1993, 2000, 2001, 2013, 2014).

                                               Diagnostic Perspectives

While narcissism has many facets, it can be defined as, at core, a listening deficit.  Ability to hear and respond appropriately to both one’s own and others’ concerns, a skill for which I have coined the term bilateral listening (Heitler, 1993), is a prerequisite for healthy collaborative relationships.    Narcissistic dysfunction stems from a deficit in bilateral listening.  The listening deficit may be selective, with the handicap particularly pronounced, paradoxically, toward loved ones such as a spouse and children, and more effective with people whom a narcissistic individual looks up to or wants to impress.

Deafness to others’ concerns both causes and is exacerbated by an all about me stance of excessive self-importance and self-preoccupation.  Like the original Greek Narcissus, people who function in a narcissistic manner look into the water of the world and see only themselves, triggering negative reactions in those who feel unseen and unheard.

Spouses and children of narcissists may manifest a complementary bilateral listening deficit, that is, a tendency to hear others more loudly than themselves, putting them at risk for what I refer to as excessive altruism. While an all about you stance may develop to minimize friction and depression vis a vis a narcissistic partner, excessive focus on others invites co-dependency, enabling behavior, and subconscious anger.

Secondary Characteristics of Narcissism

Deafness to others’ perspectives with its associated self-preoccupation generate secondary characteristics of narcissism including following:

Dismissive responses. Narcissistic deafness toward others’ attempts to share information with them utilize three main strategies: (a) disagreement/negation via the words but (e.g., “Yes, but the ….) or not (e.g.., It’s not that…); (b) an impatient, derogatory or contemptuous tone of voice; or (c) ignoring what was just said and continuing on with voicing their own thoughts as if the other has said nothing.

Tall-man syndrome: Specialness and excessive entitlement.  Narcissistic individuals can see themselves as above others, perhaps from so little listening to others and therefore not hearing their merits. This tall-man syndrome (Heitler, 2011) leads to feeling deserving of special treatment.

The histories of many narcissists involve having been treated as extra-special.  A parent may have conveyed that they were “mommy’s little prince” or “daddy’s special girl.” The narcissistic individual also may literally have been taller than others (common in male narcissists), prettier (women narcissists), more popular, athletic, smart, wealthy, politically powerful, or more in any dimension, leading to a generalized feeling of specialness. Parents who hyper-focus on children’s specialness however sometimes alternate this adulation with devaluation via harsh criticism or cold ignoring, creating a substratum of insecurity beneath the over-evaluation.

I’m right; you’re wrong.  The combination of not listening to others plus feeling above others can lead to a dialogue stance of I’m right you’re wrong.  This belief further sustains habits of dismissively brushing aside and disagreeing with what others say.

Chronic feelings of boredom.  Listening only to oneself plus validation and adulation from others blocks the dialectic from new inputs that keeps life interesting.

Hierarchical orientation. Like our animal predecessors who seek to dominate in order to survive, narcissists tend to experience all relationships through a competitive lens with a fine sensitivity to who’s on top.   Belief that ‘I’m above you’ reinforces the excessive sense of entitlement and tall-man syndrome described above, as well as the attitude of not needing to pay attention to what others say.

Tendency to over-value appearances.  Many though by no means all individuals with narcissistic habits are hypersensitive to appearances, putting a high value on their own and others’ material possessions and status.  Prestige factors such as beauty, clothes, a large house, fancy car, and financial success may have higher than usual appeal.  Cisek et al (2008) suggest that narcissistic individuals’ interest in these factors may be heightened if they expect material possessions to buffer against emotional pain.

Some narcissistic individuals insist that their partner look a certain way, usually a way that, in their eyes at least, impresses others.  Their spouse’s weight gain in these instances can undermine a marriage. Divorcing a same-age wife in favor of a younger and, in the narcissistic individual’s eyes, more beautiful “trophy-wife” exemplifies this pattern.

Inability to pursue win-win solutions to conflicts.  Creation of win-win solutions to differences requires bilateral listening.  Individuals with deafness to others’ perspectives aim to resolve differences with an ear only to their own interests.  Win-lose solutions, with the narcissist insisting on being the winner, put family members and work associates who lose at risk for anger and depression.  Narcissistic individuals’ deafness also can lead them to be prone to exploitative relationships.

Relationship distortions.  Narcissistic selective deafness can lead to experiencing others more like things than like people; people would have feelings and thoughts that differ from theirs.  Things are worth caring for only to the extent they serve a self-enhancing purpose.  Again, divorcing a wife of many years for a so-called trophy wife exemplifies this perspective.

When narcissism blurs the boundary between self and other, the other feels like an extension of the self.  Experience of a spouse or children as a third arm rather than as independent people puts family members at risk for appendage-itis, the author’s term for becoming an adjunct to a another with loss of a sense of personal autonomy and value (Heitler, 2012).

Quickness to anger.  Deaf to others’ concerns, narcissists may become impatient when others do not give them what they want.  They are prone therefore to anger.  Anger exacerbates the narcissistic belief that “What I want is holy; what you want is irrelevant.”

Narcissistic hearing deficits thus can easily invite anger problems and abusive relating.  The controlling behaviors of abusive individuals stem from difficulties perceiving that the partner has an independent subjective experience and the belief that it’s all about me so you should do what I want you to do.

Craving for appreciation and admiration. Narcissistic “Feed me, feed me” craving for positive feedback may derive from inner feelings of unworthiness.  It may also, however, stem from excessive expectations for adoration based on experience with excessively doting parents, or from addiction to the kudos they received from stellar accomplishments in athletics, performance arts, or politics.

Admiration, exemplified by Facebook likes, can become an addictive phenomenon: the more a person gets, the more they want more.  In addition, craving for admiration combined with an all about me pleasure orientation can lead to hyper-involvement in personally self-aggrandizing activities (e.g., athletic marathons, business ventures, politics) that detract from investing time and attention to relationships.

The rules do not apply to me; deception and lying are legitimate for me. Specialness feelings can lead to a belief in being above the rules, increasing the likeliness that narcissistic individuals will become involved in affairs, tax evasion, addictions and other out-of-bounds habits.  Lying and denying become tempting strategies for escaping from consequences, especially after rule-defying behaviors have been uncovered.

Talking excessively about oneself and monopolizing conversations.  Living in an all about me narcissistic bubble with minimal uptake from others, more seriously narcissistic individuals monopolize air-time in conversations.  Their monologues are likely to focus mainly on themselves.  They seldom ask questions to others about their lives. They may redirect conversations about other topics back to themselves.

A lop-sided self-focus in conversations can initially make someone who functions narcissistically seem charming, the prototypical life of the party.  The narcissist strategy of engaging others via tales of woe, using their personal problems to create a victim-rescuer bond, may initially flatter a listener’s rescue-prone ego.  In both cases however asymmetry of focus becomes increasingly off-putting to others over time.

Hypersensitivity to criticism and quickness to blame.  Believing I’m special and I’m right; you’re wrong creates vulnerability.  Making mistakes feels threatening to a narcissistic individuals’ core self-image.  Rather than admit mistakes they are likely to mobilize with a quick angry defense.  Externalizing behaviors–counter-criticisms, finger-pointing, blaming, “You do it too!” and the like—redirect error messages away from themselves.

Personalizing and lack of empathy.  When others’ verbalize their feelings, people with narcissistic listening habits tend to hear disguised criticism. For instance, if narcissistic individuals hear their spouse say, “I’m sad,” they become angry.  That’s because they hear the spouse’s self-description as saying that they have done something to make their spouse unhappy.  Narcissistic it’s all about me self-focus blocks uptake of the actual message and therefore also blocks empathic responses.  The resultant non-expression of supportive concern to their others’ vulnerable feelings in turn typically evokes loneliness, disappointment, frustration and anger in intimate partners.

Relationship difficulties.  Because of these core and associated aspects of narcissism, narcissistic functioning interferes significantly in ability to sustain stable relationships.  To quantify informally the extent to which narcissistic listening deficits undermine marriages, I reviewed the charts of 34 couples with whom I have worked in the past year.  In 82% of these cases narcissistic functioning was a significant factor in the marital/family breakdown.

A developmental perspective may further clarify why narcissism breeds marital difficulties. Infants are dependent on others for taking care of all their needs. They have minimal awareness of their caretakers’ feelings.  Developmentally mature adults, by contrast, both take care of themselves and respond to others’ concerns.  Narcissists, like young children, crave attention from others yet, also like young children, lack interest in others’ desires.  Marriage, alas, is for grown-ups.  Narcissists are insufficiently prepared.

Three Levels of Narcissistic Pathology

Narcissistic habits.  These habits are interpersonally alienating primarily because insufficient bilateral listening can leave others feeling ignored, deprecated, and powerless. While entrapment in an all about me narcissistic bubble may not directly create negative feelings within the self-absorbed individual, loved ones like a spouse, children (Golomb, 1995), and sometimes work colleagues, pay the emotional price. As a result, as described above, even minimal deafness to others negatively impacts the harmony and stability of relationships.

At the same time, narcissism at this level tends to be interspersed with healthier functioning, including capacity for insight.  Potential for growth therefore can be high.

Pathological (clinical) narcissism (narcissistic personality disorder). This diagnosis implies more pervasive deafness to others’ input, plus more presence and intensity of the secondary characteristics described above: grandiosity, all about me stance, abusive anger, suffering by those whose lives are intertwined with the narcissistic individual, and often but by no means always, resistance to change.

Poor reality testing, evident in misreading of situations, increases with severity of a narcissistic disorder.  Deception (self-deception, hiding information, and lying to others); engagement in personally gratifying out-of-bounds behaviors such as sexual infidelity or alcohol and drug abuse; controlling and verbally or physically abusive behavior; paranoid projection; deficits in responsibility-taking; quickness to anger; and borderline features also may occur with this level of narcissism, and will tend to increase when the narcissistic individual is feeling stressed.

Malignant narcissism adds more severe paranoid, sadistic, borderline and sociopathic features. Historically, Hitler and Saddam Hussein were clasic examples.

Differential Diagnosis with Borderline Pathologies

There is considerable tendency for men with narcissistic behaviors to be labeled as narcissists and women who are narcissistic to be labeled borderline.  Gender differences in empathy levels have been established (p.327, Zahn-Waxler and Hulle, 2013), which may help account for higher rates of narcissism in men.

At the same time, narcissistic individuals can manifest borderline patterns, and borderlines are often narcissistic.  This co-morbidity may occur in part because regulation of emotion is central to empathy (Eisenberg & Fabes, 1998).  As emotions intensify, input from others becomes increasingly difficult to process.

Narcissism and Conflict-Resolution

Conflicts, within and between individuals and also vis a vis circumstances, inherently produce feelings of distress.  Win-win problem-solving brings a return of inner well-being and also of interpersonal goodwill.  This route, however, is blocked if one participant functions narcissistically; non-listening puts a stick in the wheel of collaborative conflict resolution.

Without the win-win option, the four remaining conflict resolution pathways all detour away from collaborative solution-building, creating the opposite of personal well-being and collaborative relationships.  These options and the specific negative emotions and habits that they produce are (Heitler, 1990): (a) Fight: Anger escalates to enable a conflict participant to dominate and win;  (b) Flight: Addictive and obsessive-compulsive behaviors facilitate escape from conflicts; (c) Freeze: Anxiety within and tension between people emerge from immobilization; and (d) Fawn: Depression results from giving up on getting desired outcomes in conflict situations.  Giving up has survival value in that it prevents injuries from fighting which would imperil survival.

Narcissistic listening deficiencies interfere with collaborative win-win problem-solving.  With that route not an option, narcissistic individuals lean toward the fight route because they typically assume that they are above (stronger, smarter than) others,.  If anger toward the goal of coercion does not succeed, they are left with only the three remaining detours: becoming anxious, depressed or involved in escape habits.


Factors That Can Render Individual Therapy for Narcissism Ineffective

As detailed in a recent article by Kreger and Young (2012), treatment of narcissistic personality features with individual therapy tends to be ineffective for multiple reasons. A couples therapy treatment format, by contrast, eases all these issues.

People do not seek help for narcissistic habits.  While narcissistic individuals may seek therapy for depression, anxiety or distress over a loss, they seldom seek individual therapy for their ego-syntonic narcissistic patterns.  By contrast, narcissists will go willingly to couples therapy if they a) want to fix a spouse who is not doing what they want; b) are upset by their spouse’s anger, depression or affair; or c) have realized that their spouse may leave them.

Individuals with narcissistic features can be difficult clients.  Many therapists become uncomfortable when narcissistic clients vie with them for who is on top, react disparagingly, or ignore their therapeutic input.  While therapists can regard such behavior as opportunity for an in vivo intervention (Goldfried, 2013), confrontation may scare these clients away from further treatment.

In couples therapy structured with the spouses primarily talking with each other, by contrast, narcissistic deafness and I’m above you habits are directed primarily toward the spouse.  Observing the patterns is easier than the dual role of receiver/observer.

Data deficits.  Narcissistic clients tend to be oblivious to their problematic habits, in part because dismissive listening keeps them deaf to the complaints of loved ones.  Consequently, when they discuss their relationship difficulties in individual treatment, their report mainly blames the partner.  Without access to live data, even experienced therapists can mistakenly conclude that the obvious answer to the narcissistic client’s relationship problems is divorce.

In addition, many narcissists are bilingual–social adept publicly and functioning narcissistically primarily at home.  Talking one-on-one with a therapist, narcissistic clients are likely to be charming, showing few of the habits that undermine their relationships.  Moreover, the project of therapy asks them to do just what they do best, which is to talk about themselves.  In couples therapy, by contrast, narcissistic individuals quickly display their problematic behaviors as they interact with their spouse.

The pull of the system.  Gains from individual therapy are likely to be undermined if the spouse is not simultaneously growing.  By contrast, couple therapy enables narcissistic individuals and their spouse to grow in tandem, forming new and healthier circular interactions.

Treatment implications.  For all of the reasons above, couples therapy merits investigation as a treatment of choice for narcissism, particularly when the narcissistic functioning has had detrimental impacts on couple and family relationships. Norcross (2013) reports that 75% of APA Division 29 members offer couples/marital therapy, conducting couples treatment in 13% of their time.  These statistics suggest that psychologists generally do include couples therapy in their intervention repetoire, so adding the conflict-focused interventions described below should be feasible.

Case Study of a Narcissistic/Depressed Marriage Partnership

Mark and Joan (names changed for confidentiality), ages 35 and 33 with a 10-month-old daughter, sought help for their deteriorating marriage relationship.  Mark, who is strikingly good-looking with blue eyes that twinkle when he smiles yet often looks hesitant and anxious, owns a small business. Joan works as a mid-level healthcare professional.  Joan too is strikingly attractive, particularly when she radiates her warm smile.  Both feel successful at work and yet highly distressed at home where tension and frequent fighting keep both spouses angry, unhappy and considering divorce.

Diagnostic Picture

Mark: Narcissistic functioning with episodes of anger and depression

Joan: Reactive depression with a fixed angry stance toward her husband.

Marriage: Highly fragile. Chronic arguing with both spouses sometimes escalating to rage.

Self-reported levels of distress.  Both spouses rated their personal distress levels prior to the first session at 5 on a scale of 0 to 5.  Both described their five-year marriage as filled with chronic tension, emotional distance and sexual difficulties.

Note that all comments below attribute to Mark or to Joan are direct quotes from the therapist’s verbatim session notes.

Treatment triggers and goals. Replying to a question in the initial session about the triggers for their seeking treatment, Joan replied,  “This last weekend we had a huge argument over nothing. … I feel 100% dismissed or argued with, especially if I’m upset about something.”

Mark added, “Our communication is not good at all.  We argue a lot. Please give my wife and I the tools to communicate and make our relationship better.”

Further therapist observations.  Mark led an all about me lifestyle, occupying himself with work and personal recreational activities (mountain biking, playing guitar, running and swimming) and functioning like a bachelor in terms of minimal involvement in marital or family life.  His habitual pattern of non-listening, brushing Joan off when they tried to discuss issues that concerned her, typically triggered the couple’s arguments. This frequent fighting further discouraged Mark from spending more time at home. Both of these signs point to narcissistic functioning.

At the same time, Mark willingly acknowledged that he as well as Joan needed to learn new ways.  This openness suggested that Mark had capacity to grow in therapy, and also that his narcissism was on the level of habits, not a full-scale personality disorder.

Joan seemed hyper-focused on Mark, eager to please him yet often hypercritical of him.  Whereas Mark’s dialogue difficulties centered on poor listening, Joan’s lay in attacking Mark instead of tactfully explaining her concerns. When Mark brushed her comments or questions aside, Joan sometimes turned her anger inward as self-criticism and depression. Mark’s narcissistic habits and Joan’s critical stance interacted with circular causality.

Treatment Overview

Prior treatment.  Earlier in the marriage Mark had attended a year of individual therapy reportedly with little to no impact on the couple’s marriage difficulties though marital distress was his main presenting problem.  Joan had no prior therapy experiences.

Current treatment.  The therapist (the author) is a clinical psychologist with thirty-five plus years of experience specializing in couples treatment utilizing a wide range of interventions integrated via the conflict-resolution conceptual framework explained above.

Mark and Joan thus far have participated in three 60-minute couples therapy treatment sessions, an initial two sessions one week apart followed by a third after the therapist’s two-week vacation break.  Treatment is in progress, with the couple planning to continue until their goals have been fully realized.

Note that while treatment thus far has been brief, studies by and reported by Lambert (2010) have suggested that progress or lack of progress in the first several therapy sessions tends to be predictive of therapy outcome from treatment overall.

Outcome measures.  As suggested for scientist-practitioners by Castonguay, (2012) as well as by Lambert, I ask all clients in treatment with me to fill out a Session Review form (Heitler, 2014) after each session.  The form includes 5-point scoring of pre- and post-session distress levels and of the session’s helpfulness plus open-ended questions about helpful and unhelpful session events.

First Session Therapeutic Interventions

Prior to the first session Joan and Mark had filled out an intake form (Heitler, 2014) with questions about symptoms, family history and current functioning.  After welcoming the couple to her office, asking about prior treatment experiences, and explaining her policies on session recordings, individual therapy and confidentiality (see Appendix A), the therapist launched directly into diagnostic and treatment interventions.

Identification of dialogue deficits.  Asking the couple to talk together about what brought them to therapy and what they want to accomplish serves two diagnostic purposes: (a) to gather further data about the issues the couple needs to address (the content of their conflicts) and (b) to identify the spouses’ dialogue strengths and glitches (the process insufficiencies).

Mark and Joan began talking amicably, and then quickly became adversarial as Mark responded to virtually every comment from Joan with an inflammatory negation via but and/or not (But that’s not right…”).

Mark:  My goal in therapy is to get help with our communication.

Joan:  I agree.  We fight way too much.  It’s been a long time that we’ve talked about getting help.

Mark: But I went to individual therapy.

Joan:  Yes, you did, and I appreciated your going.

Mark: But therapy didn’t help except for my feeling a bit more relaxed for a short time after each session.

I asked Joan what she felt in response to Mark ‘s but and not responses.  “Dismissed,” Joan said, her eyes welling up with tears.

This initial exercise suggested a diagnosis of narcissistic habits for Mark, and suggested depression for Joan.

Coaching listening skills.  Switching from diagnostic to intervention mode, the therapist explained that but is like a delete key on a computer (backspace delete on Windows), deleting whatever came before. To illustrate, the therapist put a pencil (representing Joan’s words) on the corner-table between the chairs repeating, as Joan had said, “We’ve talked a long time about getting therapy help.”  Then adding the word but, the therapist dramatically knocked the pencil off the table.  Adding Mark’s words “I went to individual therapy” she replaced the pencil with a colored pen representing the data Mark had put forth in place of Joan’s. The therapist kept knocking pencils and pens off the table with each but; the table never had more than one pen or pencil on it.

Repeating the demonstration, this time the therapist instead of but, the therapist used and or and at the same time.  Multiple pens and pencils accumulated on the table, representing the accumulation of data from both participants when the dialogues is additive instead of dismissive.

Mark and Joan both understood now why their conversations felt so blocked.  As Joan said, “With but, we’ve had no flow.”

The therapist then structured a digestive listening practice drill, asking Mark (and then Joan) to respond with but to whatever she said, and then to respond to the same sentences with the word “Yes…” followed by a comment augmenting the point.

Dr. H: The sun is bright today.

Mark: But it’s real cold out.

Dr. H: The sun is bright today.

Mark: Yes, and that’s a good thing because it’s real cold out.

In sum, within he first ten minutes of the first therapy session, the therapist already had, in a playful way, identified and addressed the core manifestation of Mark’s narcissism, his listening blockage, raising both spouses’ hopes for a better future.

Identification of the conflicts to be resolved.  The therapist invited the spouses to take turns listing issues that have been sources of conflict between them, including topics they avoid for fear that they would lead to fights.  Mark and Joan listed eight:

1) Joan wanted more couple time, complaining that Mark did not make her a priority.

2) Joan felt chronically dismissed, especially when she asked where things like were, like the phone or the charger.

3) Joan’s wanted to be able to make plans as a couple: “I like things orderly, planned, with a clear time frame and he’s more casual and indecisive.”

4) Mark wanted acceptance of “my fluent schedule, especially on weekends.”

5) Joan harbored hurt and anger from specific angry comments from Mark: “You don’t know what you’re talking about;” “I don’t care” and at another time, “I don’t care about you;” “I’m leaving you. This is over.  We’re getting a divorce;” “You’re psycho;” “I wish you had never gotten pregnant;” and “That’s your problem, not mine.”

6) Mark wanted to feel less defensive, over-criticized and under-appreciated.  Joan agreed, acknowledging, “I get so annoyed by everything he says or does.”

Each conflict Mark and Joan listed will serve as a triple opportunity: (a) to fully resolve with win-win outcomes each of these unresolved differences; (b) to launch depth dives into childhood roots of sensitive issues and excessive emotional responses; and (c) to practice the new skills they will develop for collaborative dialogue, anger management, win-win conflict resolution, and expressing more positivity.

Visualization to alleviate Joan’s depression and critical stance.  Hypothesizing that Joan’s chronically critical stance toward Mark stemmed from depression, the therapist utilized a visualization technique to ascertain if Joan was in fact depressed and, if so, to lift the depression (Heitler, 2014).   Based on the conflict-focused therapy assumption that depression emerges in response to a dominant-submissive conflict resolution pathway, this technique verifies first if depression is the correct diagnosis, pinpoints the source of the depressive collapse, restores a normal sense of personal power, and encourages discovery then of a win-win solution to the conflict that had precipitated the depressed state.

Dr. H: Close your eyes Joan and allow an image to come up of someone or something, other than yourself, that you could be mad at.

Joan: I see Mark.

Dr. H: What do you see him doing?

Joan: I see him yelling at me.

Dr. H: Who looks bigger in that scene, you or Mark?

Joan: Mark is bigger.  He yells louder and gets angrier. (Mark’s larger size, with Joan seeing herself as smaller, indicates depression).

Dr. H: How much bigger? (This question assesses the intensity of the depression.)

Joan: I feel like he’s bigger because I’m so upset and vulnerable… he’s a LOT bigger.  I feel like he plays mind games with me and enjoys seeing me cry and be upset.

Dr. H: As you see him so much bigger there, take a few deep breaths, and with each deep breath feel yourself growing.   How much bigger are you now than he is?

Joan: A lot (smiling).

Dr. H: From that bigger size, what would you like to do to help you to feel better?

Joan: (emphatically) I’d like to punch him.

Dr. H: In real life obviously you would not do that; in the visualization you can.  What do you notice after you punch him?

Joan:  It doesn’t really help.  He looks bigger again.

Dr. H: Let’s try then a different alternative.  Take a few more deep breaths and feel yourself grow again with each breath. … Now, from this larger size, what else do you see that might help?  What would you like to do?

Joan: I’d like him to listen to me, and to listen because he likes to listen to me, not because I’m making him …

Joan opened her eyes.  The therapist proposed to Joan that maybe she could express her concerns in ways that would invite less defensiveness and more listening from Mark.  To Mark the therapist asked his reaction to Joan’s desire that he hear her concerns, take them seriously, and think about what he could offer toward a solution. He responding saying “I can see I rush to get away.  I haven’t been listening to her.”

To conclude this intervention, the therapist again asked Joan to close her eyes.

Dr. H:  “Who looks bigger now, you or Mark?”

Joan: “We look the same size.”  She smiled broadly, and reached out to touch Mark’s knee.

                  Clarification of circular interactions that yield fights.  The therapist asked Mark and Joan what each of them typically does in the run-up to arguments.  Taking turns describing, preferably in one sentence, what they each do next, each spouse was to describe their own, not the other’s, contributions–a key shift in focus for this couple.

Mark: When she asks me a question I move fast; I don’t engage in conversations.

Joan: I then get frustrated.  My feelings are hurt and I get angry.

Mark: I try to stay calm, but when her anger keeps going eventually I get angry.

Joan: I get more hurt and angry.  The argument escalates until I have to talk him off the ledge … The argument by then has become about the argument, not the issue.

The therapist asked how often each spouse reacted these ways at work.

Mark said that he slows down and listens to the problem of his workers.  They then figure out together what to do about it.  Joan says she solves problems at her work all day; that’s her job.  We concluded, chuckling, that Joan and Mark both might benefit from bringing their good work skills home to use with their spouse.

Coaching exit/re-entry routines for anger management and zero fighting. To eliminate fighting the therapist wanted to clarify the concept that, like one-handed clapping, fighting stops if one or both partners leaves the room. She demonstrated briefly what an exit looks like, physically taking the actions as she described them: a) Stand up, saying, “I’d like a drink of water” (b) Leave the room (walking toward the doorway);  (c) Distract yourself to cool down; and (d) Return, launching small talk for a few minutes initially to clarify if you both are calm enough to launch a calm discussion.

As one person exits, the other will also exit, simultaneously turning in the opposite direction to go into a different room.  When they feel calm, they too return.  That way no one is “walking out on” or “turning their back on” the other.

The therapist reviewed the sessions’ main points, gave the couple a handout on exit routines (Heitler, 2014), suggested homework reading for the several weeks ahead (Heitler, 1997 on listening and tactful talking skills, Heitler, 2012 on exit routines), and encouraged listening to their session CD to consolidate their growth.

Second Session Interventions

Definition of session goals. The therapist begins each session (after the first) with each spouse saying what they would like to focus on this hour. Mark said that they had had three fights the prior week that he wanted to discuss.  Joan wanted to focus on what to do when Mark says No or I don’t know and the discussion suddenly stops.

Sentence starters for sustaining collaborative dialogue.  Rather than focusing on what went wrong in the discussions the past week that had led to arguments, the therapist gave Mark and Joan a handout listing six safe sentence starters.  Her goal was to give them an experience of, as well as skills for, collaborative dialogue (Heitler, 2014 for these and other handouts).

The therapist called out numbers, one through six, each referring to one of the following six sentence starters:

  1. I feel/felt  _______ (to be filled in with a single feelings word or phrase).
  2. My concern is _________________________________________________.
  3. I would like to (Not: I would like you to)_________________________.
  4. What/how do you think/feel about ­­­­­­­­_________________________________?
  5. Yes, I agree that ________________________________________________.
  6. And (or, And at the same time)_____(circling back to starters 1-4)________.

The first of the three fights the prior week had begun when Joan had asked Mark, “Where’d you put my keys?”

Dr. H: (to Mark) Number 2.  You can look at your cheat-sheet.

Mark:  My concern when you asked me “Where’d you put my keys?” is that I don’t want to give an answer if I’m not 100% sure.  I don’t know is an honest answer.

Dr. H: (looking at Joan) Number 1

Joan: I feel angry when you say ‘I don’t know.’ I feel like you’re dismissing me.

Dr. H: (again facing Joan) Number 2

Joan: My concern is that I hear ‘I don’t know’ as a quick answer instead of you taking the time to think about it.  To me it’s your answer to not wanting to take the time.

Dr. H: Number 3

Joan: I would like to feel important enough for you to slow down.

Dr. H: (to Mark) Number 5

Mark: Yes, I agree that I do answer quickly instead of slowing down and thinking about what you’ve asked.

Dr. H: Number 6

Mark: And at the same time… if I don’t know 100% I don’t want to say…where the keys are or the computer is…

Dr. H: Number 2

Mark: My concern is that I don’t want you to feel I’m feeding you a line, saying things without thinking.

After several more exchanges, Joan and Mark debriefed on what they each felt during the exercise.  Both expressed delight that by using the sentence-starters their dialogue had felt radically more cooperative and informative than their usual patterns.

Joan: That conversation had a feeling of flow.

Mark: Yes, I agree….–that’s a number 5!–it did flow.  Our conversations maybe will flow unless one of us, like maybe me, puts up a block.

Joan: Yes! I’d love that…(to the therapist) can we try using the sentence starters on another issue we fought about?  His brother is staying with us.  He has an apartment but Mark hasn’t been direct that he needs to leave.  I feel like Mike is not direct.

Dr. H: Woops.  Check out Number 1.  I feel gets followed by a single feelings word like concerned or delighted or anxiousI feel that Mike is a disguised complaint about Mark, not a feelings statement about you.

Mark: Yes, I agree with Dr. Heitler. (looking down at his pink sheet to find the sentence starter that would enable him to express his feeling) I felt…criticized just now.

Joan: OK.  I’ll try again…. I feel…anxious to get your brother out of our house.

Mike: Yes, and I agree that sometimes I prefer cotton candy to vinegar.  I don’t want to tell people bad news.

Joan: (tearing up) A Number 5! That is something I do not hear often. When you agreed with me just now, I looked at you.  I felt shocked, so surprised that you heard me!

Mark: Hearing that it’s helpful to know how you feel because that’s important [is a new idea for me].  It never occurred to me that taking what you say to me seriously could be that helpful.

Joan: It makes a huge difference. I see now that feeling dismissed all the time was triggering my feeling always so mad at you, and depressed too.  I hate feeling dismissed.

Addressing personalizing.  Joan asked to press onward to see if they could resolve also their third argument from the prior week.  In this situation Mark had been making eggs with a pan that was not non-stick. Joan had mentioned that the non-stick pan might work better; Mark erupted in anger.

Dr. H:  What was your thought when Joan gave you that information?

Mark: “That she was telling me I did it wrong.”

This situation led to a discussion of the common narcissistic habit of personalizing, that is, of taking information from Joan personally, as disguised criticism that’s all about me. Joan certainly had, in fact, been criticizing her husband far too often.  At the same time, when she would genuinely try to convey neutral information, like about the non-stick pan, Mark still heard her comment as another criticism.  Her message, to his ears, was not helpful information but rather reminding him of how he was never good enough.  Mark’s narcissistic feeling of being special could easily flip into “I’m no good.”  He blocked that potential flip with anger.

Third Session Interventions

Coaching win-win conflict resolution.  Joan and Mark had fought again the past week about where things were; in this case, the culprit was a missing phone charger.  The therapist in this case introduced the idea of switching from fighting when something goes wrong win-win problem-solving (Heitler, 2014, Win-win waltz worksheet).

Three additional skills proved helpful.   The first was to identify underlying concerns instead of engaging in battles over who has the best solution or who’s at fault.

Mark: My concern is that when you ask me where the charger is I feel criticized.

Joan: I do feel impatient. I get frustrated when I’m wasting time looking all over.

The second conflict resolution skill was to see the problem as the problem, i.e., something wrong with the system, not the people (Fisher & Ury, 1983). The problem, Joan and Mark decided, was that they needed a better system for storing the charger.

Third, solution-building works best when each partner offers what they themselves might do rather than when each tells the other what to do differently.  Mark offered to buy an additional charger to keep one in the kitchen and one upstairs in the bedroom.  Joan offered to find a nice basket for the chargers so they would be visible and available yet not add clutter.  Both loved the plan.

Enhancing positivity.  All individuals want positive feedback, and especially individuals with narcissistic tendencies, yet Joan and Mark shared few appreciative words or gestures.  After Mark had offered to help Joan with something, Joan had answered merely “OK.” The therapist encouraged her to reply more positively. Joan drew a blank, so the therapist made up a positivity practice game.  The therapist would issue a compliment.  Joan was to raise the positivity level of her responses each turn working up to fully good-humored enthusiasm. The therapist encouraged both Mark and Joan to ramp up their positivity at home as well.  They smiled sheepishly at each other.

Explorations of family-of-origin sources of Mark’s narcissism and Joan’s criticism.   How did Mark learn his non-listening?  How did Joan learn to be so critical?

Dr. H: Close your eyes. As an image comes up of your family, what do you see?

Mark: I grew up in a family that never expressed appreciation.  Just very critical No dealing in a calm problem-solving way like we did today about the charger.  The tone was aggressive.  I would shut down, draw a blank. I didn’t engage so it wouldn’t escalate.  What Dad wanted was all that counted.

Narcissism in Mark’s family had been the male norm.  When you grow up with parents who speak French you speak French.  With a Dad who spoke narcissism, Mark learned to become deaf to others.

Mark (continuing): As a teenager I fought all the time with my parents and with my brother.  We were a dysfunctional family of 4–divorced, fighting, angry, military. Forget about listening to my feelings.  Everything was about Dad.  We could only feel or do what he wanted…Maybe that’s part of why I always feel guarded with Joan.

Joan: (tearing up): I’m upset because I don’t want you to feel that way with me.  I love you and don’t want to attack or hurt you.  (more tears) But …

Dr. H (intervening immediately): And at the same time …

Joan: Yes, And at the same time, when I’m just trying to have a conversation with you and you become defensive, I get frustrated then approach it the wrong way–aggressive and angry.

Mark: Maybe I could take a step back when I feel myself getting defensive.

Joan: If you did I’d still be mad. I’d be angry thinking you’ll still get defensive.

Dr. H: What could you do Joan instead?

Joan:  (reaching out her hands) I could choke him! (laughing) No, I might want to, but it would be better if I could stay calm…maybe say nicely, “I’m asking you a question. I’m not accusing…”

Mark looked distinctly relieved.

Symmetry of interventions is essential in couples treatment.

Dr. H: Joan, I’d like to go back to a phrase you’ve said multiple times in these sessions: “I hate feeling dismissed. “  Close your eyes and notice what scene from earlier in your life comes up on your visual screen when you think about ‘being dismissed.’

Joan:  My family was angry, dysfunctional, and divorced.  I see parents who had no time or energy to pay attention to me.  They were too caught up in their anger at each other.  I felt dismissed time and time again.

Likely Interventions in Further Sessions

The remaining therapeutic work will be what psychodynamic therapists refer to as working through, i.e., exploring additional situations each week to augment the fledgling insights and foundational skill-development of the first three treatment sessions. This work is likely to require several months of additional sessions.

Outcome of Therapy

On the self-report Session Review forms (Heitler, 2014) that clients fill out after each session, Mark and Joan reported significant improvement. By the end of the second session Mark’s distress had decreased from 5 to 1, and Joan’s from 5 to 2, though these scores are likely to fluctuate in response to inevitable subsequent set-backs.

Specifically, the positive outcomes included (a) conversion of dismissive listening to responsive listening with resultant improved dialogue flow; (b) new skills for anger management; (c) reduction of spouse’s criticism; (d) replacement of fighting with problem-solving; (e) more sharing of affection and appreciation; (g) understanding of childhood roots of current narcissistic and critical habits; and (h) transition from depression to optimism and from marital stress to harmonious goodwill.   Joan and Mark will have completed treatment when (a) their differences and hurts have been resolved; (b) they have consolidated healthier dialogue and conflict resolution patterns; and (c) affectionate harmony has become their new norm.


This case study detailed how redefining narcissism as a deficit in bilateral listening guided treatment interventions in three initial sessions of conflict-focused couples therapy.  The outcome was rapid improvement of (a) a husband’s narcissistic functioning, (b) his wife’s depression and anger and (c) the couple’s near-divorce marriage relationship.

Empirical research would be a helpful next step, particularly (a) to validate bilateral listening deficits as a focus for assessing narcissism; (b) to validate the conflict-focused couples therapy approach, both in general and specifically for narcissism, and (c) to assess the sufficiency of psychologists’ training in these interventions.

In sum, this case suggests that defining narcissism as a bilateral listening deficit can guide effective couples treatment, and that a conflict-focused couples treatment strategy can effect rapid and significant reductions in narcissism.



Castonguay, L. G. (2011). Psychotherapy, psychopathology, research and practice: Pathways of connections and integration. Psychotherapy Research, 21 (2), 125 -140 (reprinted pp 134-136) URL:

Cisek, S. Z, Hart, C. M. & Sedikides, C. (2008).  Do narcissists use material possessions as a primary buffer against pain? Psychological Inquiry: An International Journal for the Advancement of Psychological Theory. 19, (3-4), 205-207. DOI:10.1080/10478400802608848

Eisenberg, N., & Fabes, R. A. (1998).  Prosocial development. In W. Damon (Series Ed.), & N. Eisenberg (Vol. Ed.), Handbook of child psychology: Social, emotional, and personality development. 3, 701-778.  New York: Wiley.

Fisher, R. & Ury, W. (1983).  Getting to yes: Negotiating agreement without giving in.  New York: Penguin Books.

Golomb, E. (1995). Trapped in the mirror: Adult children of narcissists in their struggle for self.  New York: William Morrow & Company.

Goldfried, M. (2013). Evidence-based treatment and cognitive-affective-relationship-behavior therapy. Psychotherapy, 50, (3), 376-380.

Heitler, S. (1987). Conflict Resolution: A framework for integration. J. Integrative and Eclectic Psychotherapy, 6, 3, 1987.

Heitler, S. (1993). From conflict to resolution. New York: Norton.

Heitler, S. (1997).  The power of two.  Oakland, CA: New Harbinger.

Heitler, S. (2000). Conflict resolution therapy.  In Dattilio, F. M. & Bevilacqua, L. J. Eds. Comparative treatments for relationship dysfunction. New York: Springer.

Heitler, S. (2001). Combined individual/marital therapy: A conflict resolution framework and ethical considerations. Journal of Psychotherapy Integration, 11, 349-383.

Heitler, S. (2006). The angry couple: Conflict-focused treatment. DVD.  New York: Newbridge. Available from The angry couple manual is available at

Heitler, S. (2011). Success can breed the narcissism of “tall-man syndrome.”

Heitler, S. (2012). Appendage-itis: When you love too much.

Heitler, S. (2013).  Treating high conflict couples. In Koocher, G.P., Norcross, J. C. & Greene, B. A., Eds. Psychologists’ Desk Reference, 3rd Edition. New York: Oxford University Press. 370-375

Heitler, S. (2014).  Conflict-focused therapy: Handouts, forms, and treatment protocols.

Randi Kreger, R. & Young, J. (2012).

Lambert, M.J. (2010). Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice. Washington, DC: APA

Masterson, J. (1981). The narcissistic and borderline disorders. New York: Brunner/Mazel. (p. 7)

Norcross, J. & Rogan, J. D. (2013). Psychologists conducting therapy in 2012: Current practices and historical trends among Division 29 members. Psychotherapy, 50, 490-495.

Ronningstam, E., (2010).  Narcissistic personality disorder: A current review. Current Psychiatry Reports, 12, 68-75.

Slavin-Mulford, J. (2013). The dance of psychotherapy. Psychotherapy, 50, 419-423.

Twenge, J. M., Konrath, S., Foster, J. D., Campbell, W. K., & Bushman, B. J. (2008). Egos inflating over time: A cross-temporal meta-analysis of the Narcissistic Personality Inventory. Journal of Personality, 76, 875-902.

Twenge, J. M., & Foster, J. D. (2010). Birth cohort increases in narcissistic personality traits among American college students, 1982-2009. Social Psychological and Personality Science, 1, 99-106.

Wilson, M. S., & Sibley, C. G. (2011). ‘Narcissism creep?’ Evidence for age-related differences in narcissism in the New Zealand general populations. New Zealand Journal of Psychology, 40, 89-95.

Zahn-Waxler, C., Shirtcliffe, E. A., & Marceau, K. (2007).  Disorders of childhood and adolescence: Gender and psychopathology.  Annual Review of Clinical Psychology, 4, 1-29.



Appendix A

Conflict-Focused Couples Therapy: Principles and Policies

The couples therapy treatment utilized in this case utilizes the following conflict-focused principles and policies (Heitler, 1993, Heitler, 2006):

1. Poorly handled conflicts lie at the core of emotional distress, so the goals of treatment are (1) to guide the couple to resolution of their existing conflicts; (2) to reduce anger, anxiety and depression in both spouses; (3) to give both spouses the skills to sustain an emotionally calm relationship; (4) to clarify the circular causality of a couple’s difficulties, emphasizing that each partner needs just to change their own parts, not to focus on the other’s; and (5) to deepen the spouses’ growth by exploring the family of origin roots of their counter-productive habits and emotional reactions.

2. The interventions include three foci: backwards-looking (where this problem comes from), present-focused (how to resolve this conflict now) and future-oriented (coaching the skills clients need to handle this kind of situation better in the future).

3. Feelings that arise in a session become an immediate treatment focus, following the Gestalt treatment principle of “go where the energy lies” and consonant with the EFT principle that processing feelings is a vital element in the therapy change process (Slavin-Mulford, 2013).

4. At the outset of each session the therapist asks each spouse’s preferences for what to focus on.  Foci might include a specific dilemma for which the spouses need a shared plan, an upsetting event that has happened, on-going patterns that one or the other has found disturbing, and/or skill development.  Sessions end with a review of progress toward these goals.

5. The therapist addresses every skill mistake immediately, for instance, responding to what the other spouse has said with “But….” Otherwise subsequent talking will become adversarial and unproductive.  The correction may be a re-do prompt, a translation by the therapist into healthier wording, or may include a teaching moment.

6.The treatment includes individual sessions on an as-needed basis, with the majority of the sessions generally conducted in a couples format. Individual sessions can be initiated either by a spouse or by the therapist, and can be either within a couples session (with one partner temporarily stepping out into the waiting room) or as a full individual session.  The therapist also can conduct individual work with the partner observing when the topic is appropriate and both partners agree.

7. At the first session the therapist clarifies policies, particularly regarding multiple therapists, individual therapy, confidentiality, and affairs (of particular likelihood to be relevant with narcissistic clients).  The following policies have been reviewed and approved by the Colorado Licensing Board.

(a) While in couples therapy, both partners must discontinue individual treatment with another therapist with the exceptions treatment for issues out of my realm of competence (e.g., prescribing medication). One therapist for both individual and couple treatment components keeps both fully informed and intertwined (Heitler, 1990).

(b) Confidentiality: Individual therapy session data is owned by the individual client.  The therapist is not free to disclose such information to the spouse.  Issues that one spouse wants to deal with in an individual format session (e.g., illness, an affair, a business setback, childhood traumas) are likely to be vital to be discussed, especially for people with narcissistic tendencies who may have a higher likelihood of affairs and other out-of-bounds mistakes.

(c) Continuation of couples therapy is inappropriate when there is an on-going affair. When an affair has been disclosed, privately or with the spouse, the therapist facilitates the client’s decision-making about ending the affair and offers guidance in the how-to’s of terminating the relationship. If the decision is to continue the affair, the therapist gracefully resigns from the case, suggesting referral options.

8. Physical setup of the therapy room has significant consequences.  So that clients primarily talk with each other rather than to the therapist, I arrange clients’ chairs at right angles to each other, not side by side. My chair is on rollers for moving in close to intervene if one spouse needs support or if the two are sparking, and then rolling back.

9. At the outset of treatment participants sign a session-recording permission form in their intake packet. The therapist checks to ascertain that both have signed.  Homework listening to session recordings accelerates treatment by consolidating new skills via repetition. Recording is contra-indicated if a couple looks likely to end up in divorce court lest one partner use the tapes against the other. Therapists do not keep copies of the recordings unless given additional written permission.

10.  To facilitate conflict-focused treatment therapists need to be well-versed in the skills for sustaining collaborative dialogue and conflict-resolution.  To treat pathological functioning therapists need to be clear about what constitutes emotional health.