People with narcissistic vulnerabilities often relate to others sadomasochistically—either exerting power, or submitting to others, or both—in order to manage their vulnerabilities and protect themselves from feelings of abandonment. Sadomasochistic experience often involves concrete thinking and limited playfulness or ability to use metaphor. In therapy, these difficulties are often actualized in the patient-therapist relationship so that usual verbal interpretations may be of limited value, and the therapist needs to work to maintain a mutually respectful relationship even as the patient tries to draw him/her into sadomasochistic interactions. Because these difficulties have roots in early childhood and are repeatedly reinforced by later experience, long-term treatment that provides ongoing opportunities for new experience and understanding will be most helpful. These ideas are illustrated with two case examples.