Striving toward useful interpretation while managing countertransference enactments: encounters with a thick-skinned...

Narcissistic patients tend to push the analyst to work harder than usual to contain, understand, translate, and utilize their countertransference states. This is because of the unusually extreme reliance on denial, devaluation, projective identification, and control that these individuals exhibit. Defenses against loss, envy, greed, and dependence create difficult transference states in which symbolic or creative material is flattened, stripped, and neutralized. Feelings are out of the question. This clinical paper explores the narcissistic lack of connection to self and other that endures in the transference as well as in all aspects of these patients' lives. With thick-skinned narcissistic patients, there is a subtle lack of engagement, an underbelly of control, and a complete uncoupling of feeling or link between self and object. Envy is often a cornerstone of such difficult clinical problems and is part of an internal desolation that fuels an emotional firebombing of any awareness of interest in self or other. Detailed case material is used to show how confusing, alarming, and demanding such narcissistic patients can be, trying the very essence of the analytic process. They enter treatment looking for help, wanting a quick fix to their suffering, but resist the deeper understanding, learning, and change that psychoanalytic treatment offers.