These patients may fault-find with the therapist and complain that the therapist is not caring enough, especially if the therapist does not side with their misery and instead attempts to have them see how their tendency to reject others is actually undermining their own needs. They may request phone calls or e-mails between sessions in order to satisfy their underlying dependency needs; however, this will also lead to complaints that the therapist does not care enough when the therapist begins to put limits on these contacts.
Eventually these patients' rejecting nature will cause them to "fire" the therapist and terminate therapy. Complaints about the therapist may also grate on the therapist's own countertransference self-esteem issues, and the therapist may subtly or overtly reject the patient. The therapist may be able to manage these patients by getting them to see their rejecting nature in a neutral fashion, not too early in the therapy, but also not when it is too late.
The president. These patients use the defense of exhibiting greatness to protect themselves from the pain of feeling diminished. They may have had some childhood experiences of ungratified or invalidated strivings from their family or peers. They always need to show strength in everything they do, connect themselves with important people, devalue others and try very hard to be important themselves, e.g., to become the class president or the company president.
These patients can become very aggravated when they are not the center of attention or at the top of their social group, and challenges to their greatness or rejection from partners who are tired of their grandiosity are often the reason they have come for help. They often have a detailed rationalization on why they only need more greatness in order to gain mental stability.
These patients will look for validation of their greatness and seek advice from the therapist on ways to gain more greatness rather than ways to change their life strategies. They may subtly or openly devalue the therapist. If the therapist's countertransference causes them to retaliate the devaluations or if these patients think the therapist is not validating them or when the therapist attempts to guide them to use other life strategies or explores their underlying low self-esteem, these patients may begin to feel diminished and are at risk of terminating the therapy before they have really started to improve the underlying problem.
Sometimes these patients will invest their defense of greatness in becoming a great patient. They will read all about their problem and gain a considerable amount of knowledge of psychology to gain validation from and protect themselves from feeling diminished compared with the therapist. They profess that they have completely eliminated their problem of low self-esteem. It may be possible to enlist these patients' sense of greatness to the therapy's advantage if the therapist can convince them that great people are those that are able to really look at themselves and accept they use greatness as a defense against low self-esteem.
The air traffic controller. These patients use the defense of controlling others to protect themselves from the aggravation of being controlled. They may have had childhood experiences with controlling or authoritarian parents. They tend to try to control others, especially in intimate relations or in the workplace, and have conflict with people in these areas. This is often the main reason they come for therapy.
Patients may get in power struggles about scheduling, cancellation policy or other issues, and begin to argue about the therapist's opinions and complain that the therapist will never see things their way. They need to feel they are right about everything; tend to be argumentative; want the therapist to validate their rationale in arguments they have had with others; will not easily agree to see the types of defenses they use; and eventually terminate the therapy before the therapist can begin to address the process of how to get better. The therapist's countertransference may provoke counter-arguments with these patients.
