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Gary Yontef (1993) has made an important contribution to the Gestalt understanding of narcissistic experience and behaviour and the helpful treatment of narcissistic patients.
Yontef looks back on early Gestalt work and notes that character disordered patients were often made worse by Gestalt (as other) forms of therapy: they were frustrating to work with and consequently sometimes written off by therapists as untreatable. However, recent work by Kohut and others in the analytic world has led to a renewed sense of hope for these patients.
Yontef notes that this willingness to learn from Kohut and others has led some Gestaltists 'to abandon the beauty of the Gestalt therapy process theory for a Newtonian, mechanistic frame. In that frame these patients could be said to have a fractured or broken core self.' He adds:
'Of course I prefer not to conceptualise it as: people 'have' a self, but rather prefer a process view -they are themselves, they are living processes and not things that can be broken and mended ln field process terms the patient who is suffering from a character disorder doesn't and can't yet maintain a cohesive sense of self through a succession of here-and-now moments, especially in certain kinds of interpersonal contacts.' (Ibid p.425)
He writes of the necessity for Gestalt therapists to learn from other clinicians and theorists: this is because of the harm that can befall such patients if wrongly treated and also because of the harm that can befall the therapist. Whilst fully acknowledging and using the contributions made by psychoanalysts such as Kohut, Kernberg and Masterson, he does warn Gestaltists that we must assimilate and 'chew over' and integrate our learning from the analysts, rather than their being 'introjected piecemeal into the Gestalt therapy system.' (ibid, p.421).
Writing of people with both narcissistic and borderline character disorders, Yontef states:
'In general they do not maintain the ability to continue self-observation that takes responsibility for behaviour, meets others when there are differences or conflict, struggles with awareness of that which is threatening or painful, or connects the person they are in their present experience with other moments (past or probable) in which they experience themselves differently.' (Ibid p. 426)
Yontef describes the characteristics of narcissists, as discussed above, their grandiosity, exhibitionism, vulnerability to praise and approval by others, propensity to shame, sense of entitlement, selfishness, lack of empathy with others and the tendency to idealise and devalue.
Describing these behaviours from a Gestalt perspective, Yontef comments that narcissists are 'self-centred' but are not centred on their 'true selves'. The true self is 'of the organism-environment field' (ibid, p.426); that is to say, it takes both self and other into account. Narcissists are 'confluent and field dependent' (ibid, p.429); they depend totally on the good opinion of others and believe that others are there to support them. They do not differentiate themselves from the environment in a healthy way.
Even when inflated, the narcissist's experience consists of a ground of shame and worthlessness, pride being temporarily figural. When he is deflated, the shame is figure and the pride ground. Perception can shift as quickly as one's perception of the chalice and the profiles in the famous Gestalt psychology picture.
Yontef notes that when inflated and surrounded by friends and admirers the narcissist may appear to be contactful; when deflated and rageful or ashamed he may appear to be in touch with his feelings. Yet neither is true: there is neither real contact with others nor real contact with oneself.
Yontef agrees with Kohut that a gentle empathic attunement usually works best with narcissistic patients and that premature confrontational approaches lead to unmanageable shame and what Yontef terms the four D's: deflation, depletion, depression and despair. It is not surprising that in the early days Gestalt therapists viewed these patients as impossible to treat, as with very abrasive methods they get worse or leave.
Yontef recommends therapist's attunement, which is, in a sense, responding with the wanted, wished-for response. Thus, pain is met with compassion, anger with respectful addressing of the problem, vulnerability with support, withdrawal with respect for distance and so on.
Yontef recommends treating each patient as an individual and responding sensitively to their individual needs. Some patients are soothed and helped by considerable openness on the part of the therapist, this makes them feel less exposed and vulnerable. Others have no interest in the therapist's experience and feel threatened by any disclosure, as if they might be expected to take care of the therapist and respond to his needs.
Yontef approvingly quotes Lynne Jacobs, who recommends that the experience of the patient that the therapist is a perfectly attuned parent-figure should not be challenged as fantasy but should be allowed to naturally shift as the inevitable disappointments and repairs of therapy proceed. If the 'experience of exquisite, perfect attunement from me' (ibid p.456) is challenged, then the patient will often leave therapy; if however, the patient is permitted to enjoy this idealisation, it will be relinquished as and when the patient is ready to integrate his real experience of the therapist as a fallible, ordinary human being.
Where others (Miller, 1986; Johnson, 1987) speak of the necessity for the narcissist to grieve for the actual pains and abuses of childhood, Yontef speaks of the need to grieve the loss of the fantasy of a perfect world. In this perfect world he is absolutely understood and immediately responded to by a selfless mirroring parent. Initially in therapy, the patient may experience the therapist as this perfect parent and the experience of therapy as a brief glimpse of this perfect world. However, as in any real relationship, there will be inevitable failures and disappointments and it is the continual repair of these (similar to Kohut's conception of optimal frustration), which forms the work of the therapy.
'Contact only approximates that desire (i.e. for exquisite, perfect attunement), at best. What is not possible must be mourned. To heal, one must acknowledge the loss, the limits of what is possible, grieve that loss, and go on. The pace of this with the narcissistic patient must be determined by the patient.' (Ibid p.456)
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