398 SCHEMA THERAPY

ent who was cold, needy, or controlling, so that the behaviors of patients
with narcissistic personality disorder often replicate what that parent did
that was hurtful when they were children. These therapists are thus at risk
to revert to their childhood coping strategies with these patients, rather
than reparenting the patient.
It is important that the therapist stand up to the patient, but through
empathic confrontation. The therapist can make statements such as the
following:

“I know that you don’t mean to hurt me, but, when you speak to me that
way, it feels like you’re trying to hurt me.”

“When you talk to me in that tone of voice, I feel distant from you, even
though I know you’re upset and need me to be here for you.”

“When you speak to me in such a demeaning way, it causes me to pull

away from you, and makes it harder for me to give you what you need.”

“Even though underneath you want to be close to people, if you speak

that way to them, they are not going to want to be close to you.”

The therapist points out the patient’s devaluing behavior, showing un-
derstanding of why the patient is behaving in this manner, yet still letting
the patient know the negative consequences of the behavior in relation-
ships—with the therapist and with other people in the patient’s life.
In the following segment, Dr. Young begins to confront Carl’s Self-Ag-
grandizing and Detached Self-Soother modes. In the context of a discus-
sion about Carl’s early relationship with his wife Danielle, Dr. Young
points out that Carl is behaving in a devaluing way toward him.

DR. YOUNG: What did Danielle look like at that time? Was she beautiful?
Was she your ideal?
CARL: She was beautiful. But don’t forget, I was drunk, I was sitting down,
she was sitting down (laughs). I always tell the joke that I would never
have fallen in love with someone so short, except I was drunk and we
were sitting down.
She had the right body type, she had the right hair color.
DR. YOUNG: So she met all these objective criteria.
CARL: (annoyed) They’re not objective criteria. These are the felt, some-
what ineffable criteria that we have, that we don’t know where they
come from.
DR. YOUNG: But she seemed to fit all these things that intuitively connect
you . . .
 Schema Therapy for Narcissistic Personality Disorder 399

CARL: (Interrupts.) Well, she fit close enough. And she was interested in me,
and I was ready. I mean, there’s a confluence of factors here.
DR. YOUNG: (pause) One thing that it feels like as we talk, Carl, is that
when I say something that is slightly off base, maybe like one degree
off base from what you feel, you pick up on it and sort of fight back as
if we were in an argument. Do you know what I mean? Rather than
saying, “Yeah, you’re right, that’s right, but it’s not quite it,” you say,
“That’s completely off.”
CARL: (annoyed) I don’t see it as one degree off. I wouldn’t say one degree
off, but I would say five degrees off—I see it as being different. I’m very
picky that way, aren’t I?

The therapist confronts Carl gently, then Carl responds in a challeng-

ing manner. The therapist continues to speak empathically, while Carl
continues to devalue the therapist’s observations. However, this does not
deter the therapist, who continues to confront Carl without becoming an-
gry or punitive toward him; instead, the therapist repeatedly points out the
consequences of Carl’s behavior in his relationships with the therapist and
with other people in his life. The therapist tries to rise above the immedi-
ate incident, calmly observe the patient, express empathy, and provide ob-
jective feedback and education.

DR. YOUNG: What is the effect on the other person you’re talking to of your
doing that, of your making those corrections?
CARL: I don’t know (laughs softly).
DR. YOUNG: What would you guess? You mentioned that you’re a sensitive
person . . .
CARL: (Interrupts.) I’m sensitive normally to how people are reacting. Right
now, it seems to bother you. It seems to make you upset, that kind of
correction.
DR. YOUNG: Well, I think it would upset other people to be corrected every
time they said something. I’m a psychologist, and I understand that,
with the kind of issues you have, being perfectionistic and getting ev-
erything right on target is very important, so I’m able to say, “Well,
from his perspective, the task of getting everything right is crucial and
important.”
CARL: (Interrupts.) It only seems to be crucial or important to me in a con-
versation.
DR. YOUNG: Yes, but what I’m saying is, with somebody who isn’t a psy-
chologist trying to understand your makeup, if you do the same thing,
the person is going to experience it, I think, as a kind of criticism, that
400 SCHEMA THERAPY

what they said was not intelligent enough, it wasn’t living up to your
expectations for a conversation.
CARL: Or as an unnecessary addendum to a subject that requires no more
continuation.
DR. YOUNG: Yes, but I’m not so concerned about that as the part where
their feelings are hurt, though.

Carl tries to shift the focus away from the idea of hurting other peo-
ple: He tries to keep the discussion at an intellectual level and to justify
what he is doing as not very serious. However, the therapist does not allow
him to get away with this. The therapist keeps gently but firmly reasserting
that Carl’s behavior is hurtful to others. In the next segment, Carl begins to
demonstrate some insight into his behavior in the session.

CARL: So what you’re pointing out to me, which I think is a useful observa-
tion, is that I have a tendency to contextualize all interactions as this
kind of game—you could call it a game—where the object is a kind of
intellectualization. So it’s a very narrow context for whatever interac-
tion is going on.
DR. YOUNG: What it does is that it has the effect of cutting off feelings.
Whatever feelings I’m having about you, or that you might be having
about me, sort of get lost in the verbiage. It’s sort of like reading a book
that is so much about the words that there’s not enough emotion.
CARL: Perhaps it’s my pattern. Perhaps it’s my pattern to cut off the emo-
tion.

Carl acknowledges the truth of what the therapist is saying—that he

intellectualizes and criticizes to avoid his feelings—which is a sign of
progress on his part. However, he soon goes back to deriding the therapist.
Dr. Young brings up Carl’s current therapist, Leah.

DR. YOUNG: One of the things Leah had mentioned was this “dance of
domination”—that’s one of your themes.
CARL: (Laughs mockingly.) I thought it was just something you picked up
on. I don’t know if it’s one of my themes. It’s a catchy phrase.
DR. YOUNG: Yes, she mentioned it, but it seems like it might be relevant in
this context. It might be that in intellectual conversations, there’s a
subtext of two people competing on an intellectual level to see who’s
smarter, or to see who is more precise.
CARL: (challenging) Yeah, yeah. And if you’ll notice, that it takes two to
tango.
DR. YOUNG: (in disbelief) And you’re saying that I enjoyed it, too?