ENDANGERED BY INTERPRETATIONS Treatment by Attitude of the Narcissistically Vulnerable Patient

Some narcissistically impaired patients present a particularly difficult therapeutic challenge. They often cannot tolerate interpretations because they view interpretations as humiliating evidence that they are shamefully defective. For these patients, “treatment by attitude” and without significant interpretation may be the only way they can feel safe enough to allow the therapeutic process to unfold. Two cases are discussed. In the 1st case, the usual therapeutic attitude of nonjudgmental acceptance was sufficient. The 2nd case was counterintuitive because the patient needed the therapist to demonstrate a complete lack of worry about the patient for her to make progress. Although the therapist’s attitude is part of every treatment, it may be particularly important in the treatment of more severely disordered patients.