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In severe cases, Behary said, her patients can be so narcissistic, so immune to normal incentives and cost-benefit evaluation, that she has to take a different approach. “It’s a strategy where you actually fill the narcissistic supply,” Behary said. Whereas in most instances Behary would see this as counterproductive and potentially dangerous — the whole point of her style of therapy is to bring her patients back down to earth, to help them to realize their actions have consequences because they aren’t in fact subject to a different set of rules than the rest of humanity — she said that in certain extreme instances it’s pretty much the only option. “It’s what I sometimes refer to as ‘when all else fails,’” she said, and it’s particularly relevant in dealing with “high-profile, tyrannical types of narcissists.” If someone has spent years and years tormenting everyone around them, never being held accountable, standard approaches just might not work.

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