The belief about the importance of appearances will frequently, although not always, extend to those whom the patient views as an exten- sion of him- or herself (e.g., spouse, child): thus the assumption, “My child (spouse) has to make me look good.” Perplexing double binds may arise out of this view for significant others. If they fail to perform in an admirable way (according to the narcissist), they may be ridiculed, punished, or tormented. If they succeed in admirable performance and challenge or surpass the narcissist, they may be ridiculed, punished, or tormented.

Amanda and Lewis arrived at their marital therapy session in a private limousine, courtesy of Amanda’s parents, who always wanted the best for her. Marital tension was focused on Amanda’s growing dissatisfaction with Lewis, and his “unwillingness” to please her. It seems that at 42, his hair was thinning and receding, and he was getting a bit flabby in the middle, although as a sports professional, he remained physically well toned. Slim Amanda proudly pointed out that at size 1, she was the same size as she had been at age 16. Lewis’s unwillingness to please her involved his reluctance to undergo hair implants which, she reasoned, would ensure that he retained some hair as the natural process of thinning progressed. “I just can’t be married to a flabby, bald guy,” she complained. “It would make me look bad.”