I can do it (all) myself: Clinical technique with defensive narcissistic self-sufficiency.

The author describes his experience with patients who use activity and selfcontrol to fight off painful internal affects. These behavior patterns reflect powerful narcissistic defenses guarding against rage, grief, and retraumatization in object relatedness. Treatment may begin with cooperativeness, but become stuck. These problems can be understood and dealt with more effectively today because of the variety of theoretical models available for understanding what is going on in the patient and in the intersubjective, transference–countertransference aspects of the relationship. In particular, it is important to be able to move between an actively loving engagement with the patient’s unexpressed dependent longings and a firmly confronting challenge to the destructiveness of the defensive stance. In psychoanalytic therapies we frequently encounter individuals who are energetic achievers with many social involvements and external success but who nonetheless feel unhappy and isolated. These people use activity to fight off painful affects from past traumas and current conflicts. Their activity is a way to convince themselves that they control every element of their lives, so as never to be reminded of their vulnerability to others. In treatment they often begin with an appearance of cooperativeness and earnestness. Despite their devotion to the treatment these patients struggle against acknowledgment of involvement with the therapist or analyst. The challenge is fostering such patients’ engagement while confronting the imperious quality of their defensive system in resisting change. Conceptualized more technically, these patients have powerful narcissistic defenses and structures that are vitally important to them. Their treatment inevitably comes to focus on their adherence to these patterns and their difficulty developing new ones. Because this defensive style is highly adaptive and rewarding, the therapeutic challenge is to find ways for engaging the patient in a process that will lead to change.