Susan Heitler, Ph.D.
Private Practice, Denver, CO
Running head: NARCISSISM DIAGNOSIS AND TREATMENT
Correspondence concerning this article should be addressed to Dr. Susan Heitler
, 4500 East 9th Ave, Suite 660, Denver, CO 80220.Â E-mail: firstname.lastname@example.org.
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).
Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Diagnostic Perspectives
While narcissism has many facets, it can be defined as, at core, a listening deficit. Â Ability to hear and respond appropriately to both oneâ€™s own and othersâ€™ concerns, a skill for which I have coined the term bilateral listening (Heitler, 1993), is a prerequisite for healthy collaborative relationships.Â Â Â Narcissistic dysfunction stems from a deficit in bilateral listening.Â 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.
This tall-man syndrome (Heitler, 2011) leads to feeling deserving of special treatment.
When narcissism blurs the boundary between self and other, the other feels like an extension of the self.Â Experience of a spouse or children as a third arm rather than as independent people puts family members at risk for appendage-itis, the authorâ€™s term for becoming an adjunct to a another with loss of a sense of personal autonomy and value (Heitler, 2012).
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.Â 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;Â (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.Â Giving up has survival value in that it prevents injuries from fighting which would imperil survival.
Outcome measures.Â 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.Â The form includes 5-point scoring of pre- and post-session distress levels and of the sessionâ€™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.Â 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.
Visualizationto alleviate Joanâ€™s depression and critical stance.Â Hypothesizing that Joanâ€™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).Â Â 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.
The therapist reviewed the sessionsâ€™ 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.
Sentence starters for sustaining collaborative dialogue.Â Ratherthan 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.Â Her
goal was to give them an experience of, as well as skills for, collaborative dialogue (Heitler, 2014 for these and other handouts).
Coaching win-win conflict resolution.Â Joan and Mark had fought again the past week about where things were; in this case, the culprit was a missing phone charger.Â 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).
On the self-report Session Review forms (Heitler, 2014) that clients fill out after each session, Mark and Joan reported significant improvement.
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Available from http://www.psychotherapy.net/video/angry-couple.
The angry couple manual is available at http://therapyhelp.com.
, S. (2011).
Success can breed the narcissism of â€œtall-man syndrome.â€ http://www.psychologytoday.com/blog/resolution-not-conflict/201110/success-can-breed-the-narcissism-tall-man-syndrome
, S. (2012).
Appendage-itis: When you love too much. http://www.psychologytoday.com/blog/resolution-not-conflict/201202/appendage-itis-when-you-love-too-much
, S. (2013).Â Treating high conflict couples.
In Koocher, G.P., Norcross, J. C. & Greene
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New York: Oxford University Press
The couples therapy treatment utilized in this case utilizes the following conflict-focused principles and policies (Heitler, 1993, Heitler
One therapist for both individual and couple treatment components keeps both fully informed and intertwined (Heitler, 1990).
Susan Heitler, Ph.D., www.TherapyHelp.com and PowerofTwoMarriage.com
Susan Heitler, Ph.D. a graduate of Harvard and NYU, specializes in couples therapy in her private practice at Rose Medical Center and blogs for PsychologyToday.com.Â Her multiple publications include From Conflict to Resolution and The Angry Couple video which emphasize the role of conflict resolution in treatment and Power of Two, now the basis for the online marriage skills training program, PowerOFTwoMarriage.com.
Â by Susan Heitler, Ph.D.
Submitted by Susan Heitler, Ph.D. on October 19, 2011 - 5:24pm.