Outcome and Prognosis
After a year and a half, Mark is
no longer depressed and devitalized, and many features of NPD have
faded. The most evident change is that he now tries and pursues some
personal goal: he acts without giving up and does not lie anymore. Mark
hold now more benevolent ideas of himself and of others: he now
describes himself as entitled to do what he wants, freely, and others as
possibly supportive and sometimes encouraging. He is not anymore flooded
with images of his aunt or sister suffering and blaming for being
selfish and leaving them alone. In fact, he shares his ideas with them,
and to his surprise, they often support him.
Grandiosity is decreased. Mark is considering the possibility of
graduating and then changing jobs to earn more but he doesn’t do it to
catch up with others: he just feels he wants to have more economic
independence and, in general, to be able to do more things for himself.
He also he engages in activities just for the sake of having fun and
exploring and not necessarily for purposes of personal value. For
example in tennis he tells me about the physical effort, the fun with
the people he meets, he often loses but lives it with serenity.
We are currently considering that Mark lives alone after having searched
for a foster care home for Sandra, though this is momentarily on hold,
given that Sandra had serious health issues which both made Mark worry
on a reality basis and triggered his schema-driven guilt. As for social
relationships, Mark wants a romantic relationship and to have friends
and is aware that he must learn that to satisfy these desires he must
control his tendencies to denigrate others and give less space to
thoughts full of envy and resentment. In this regard the contract has
changed. The goal is to have more social, intimate ties, based on
sharing and the first agreed task is to try to refrain from expressing
critical, devaluing comments or implementing passive-aggressive
strategies. Now that he takes more space to go out, he has more
opportunities to see other people, especially colleagues, and therefore
has more opportunities to prove himself. In a recent session he tells me
that he met a colleague of his, Lara, in a wine bar, with whom he has
been spending a lot of time lately. While they were having dinner, a
friend of Lara’s joins them and talks about her holidays and her latest
purchase: a jet ski. Mark tells me:
M: “So, let’s be clear. I bit my tongue and didn’t say anything
to him, but he slammed his jet ski in our faces! she told how cool and
fun she was …. Lara looked at him with dreamy eyes ( imitating
her). I defy anyone not to tell him four!” ( smiling)
T: ”And you? How did you feel at that moment?”
M: Oobviously, the envy started… it was all there! But I swear I
didn’t tell him anything…” (he smiles again)
T: ”Did you notice that contempt was starting and did you regulate
it? Was it difficult”
M: ”Yes, but all in all, I didn’t feel I was worth less because
I’ve never seen a jet ski in my life…”
This is just one example of the work Mark is doing on his way of
relating to others. Even in therapy, he is more open and clearer,
collaborates in defining goals and tasks and does not perceive me as a
threat. Even with me he undertakes to regulate his tendency to
devaluation, he warns me when he feels the urge to do so and we talk
about it together.