- Harry appears to have narcissistic personality disorder, although he also demonstrates features of borderline personality disorder. Rose appears to suffer from borderline personality disorder, with some features of dependent personality disorder as well.
- Supporting the diagnosis of narcissistic personality disorder: Harry is so focused on himself that he is unaware of the way he appears to others, even when it comes to his facial expressions; gets “high” when he succeeds in making money for other people, reinforcing his own grandiosity; blaming the couples’ financial problems as being caused by Rose, despite the fact that she doesn’t actually spend a lot of money on her lunches out with her friends; and his self-esteem is fragile, exemplified by the deep sense of fear and frustration when the “numbers don’t work out.” In addition, his early attraction to his wife was based on her attention to him and her ability to draw him out, the focus remaining on himself. When he feels undervalued by his boss, he displaces frustrations onto wife and children demonstrating infantile rage and aggression. Harry engages in projective identification, lashing out at rose, to force her to become enraged or tearful, and Rose obliges him.
The diagnosis of borderline personality disorder applies to Rose: she rarely finishes a sentence without checking with her husband, stopping in midsentence when she senses his disapproval; her sense of self is quite fragile, as when she only feels empowered to become strong and angry in reaction to Harry, rather than having her own independent reactions; in addition, she engages in splitting, i.e., her husband is experienced as the “bad mother” who devalues her and criticizes her, versus her friends, who represent the “good mother” , are nurturing and who provide her with a sense of solace and comfort. She also exhibits splitting regarding Harry, who she experiences as aggressive and emotionally unavailable versus her fantasy of a partner, a “muscular youthful man with warm eyes and a firm but tender touch.” Her commitment to attend therapy is only sporadic, demonstrating her inability to maintain consistency/commitment in relationships. She lacks a solid sense of self, and is easily reduced to tears by husband.
- I would want to know from this couple what it was about Harry that initially appealed to Rose , which would be a window into her unfulfilled needs, family of origin parenting deficits; I would also want to know whether or not either partner has ever engaged in suicidal behavior or thoughts. Since Harry appears to be a rule out of borderline personality disorder, suicidal behavior would tend to favor establishing is diagnosis of borderline personality, high functioning. Suicidal behavior would also help to confirm the diagnosis of borderline personality for Rose . It would also be important to know more about Harry’s parents, what their marriage was like and how they contributed to his emotional development.
- For Rose, father was a strong positive introject, serving as a model for her definition of what constitutes manliness, and Harry attempts to fill that fantasy, but likely feels a great deal of resentment for depriving himself of getting a piano. One might surmise that her father was a positive interject, because the experience she gets from her friends replicates something that she has experienced, or perhaps lacked, in her upbringing: caring and nurturing. Rose’s mother was a negative introject, rejecting domestic life, disliking housework, cooking, and eating out often, in essence, rejecting her children; the dislike for domestic responsibilities is behavior that has been replicated in Rose. It is difficult to identify Harry’s interjects because there is virtually no information about his experience with his own parents. However, his reaction to his boss, feeling undervalued, indicates that one or both of his parents were critical or apathetic to him, or downright rejecting of him.
- Rose complements Harry by demonstrating his importance to her by letting her actions be so influenced by to his reaction to her; if she even spots him looking disapproving, she stops in “midsentence” reinforcing his perception of how important he is. In addition, early in the relationship Rose paid a great deal of attention to him, and her ability to draw him out emotionally, reinforcing his narcissism. His aggressive, abusive treatment of her confirms her sense of worthlessness, and helps her to justify seeking affection elsewhere, as in the lunches out with her friends.
- Rose continues to go out with her friends, giving Harry the opportunity to blame her for their financial problems. In turn, Harry treats Rose with anger and contempt, giving her justification to continue lunching with her friends in restaurants. In addition, because Rose completely rejects her role as a homemaker, leaving the house messy and unkempt, so that Harry is able to continue to take out his frustrations by berating her because the house is messy. In addition, Harry directs his caring and compassion towards his relationship with his brother, thereby withholding that same affection towards his wife and causing her to be frustrated and angry, seeking nurturing elsewhere.
- I would encourage Harry to discuss his parents, how he was raised by them, and how they related to each other; this would be information that is crucial in understanding Harry’s attitude towards marriage and his partner. In addition, this might be information that Rose has no knowledge about, and it might be helpful for her to know more about the source of his emotional needs. I would also urge Rose to clearly tell Harry how she experiences him and his behavior towards her, since he has so little awareness of his impact on people. I would then have Harry repeat back to us what Rose said, to make sure that he has heard what she has intended to say. Finally, I would encourage this couple to commit to a contract with me for a specific number of weeks, to help both partners make a commitment to me, i.e., to work on the marriage.