Metacognitive Interpersonal Therapy for narcissistic personality
disorder
Metacognitive Interpersonal Therapy (MIT; as manualized in Dimaggio et
al., 2015; 2020) is an empirically supported treatment for a wide array
of PD including NPD (see Dimaggio et al., 2017; Popolo et al., 2021). It
understands pathological narcissism as featuring: a) problematic ideas
about self and others which make them predict that their goals in the
relational domain will remain frustrated. For example they predict that
if they ask for cares the other will control them or humiliate them; b)
limited awareness of one’s own beliefs and emotions; c) tendency to
intellectualize; d) poor agency in acting according to goals and desires
felt to be one’s own; e) maladaptive cognitive and behavioural coping
strategies; and f) poor capacity to understand what the others think and
feel and to empathize with them (Dimaggio, 2022). These elements are at
the root of impaired interpersonal functioning and pave the way for
comorbidity with anxiety and mood disorders.
In order to deal with NPD, MIT adopts a series of procedures. Some are
devoted to build a shared understanding of patients’ functioning .
Therapists try to overcome intellectualizing asking for specific
episodes and inquiring for specific thoughts and emotions. Once these
are clear to both, therapists try to discover with the patient if the
contents emerging in the episodes correspond to relational patterns. For
example, they may note that in different moments and with different
persons the patient tends to describe himself as searching for
recognition but facing others who are spiteful, envious or incompetent.
As a result, he swings between seeing himself as inferior in some
moments and superior but misunderstood in others. In other moments he
can be driven by the quest for autonomy and appraise the others as an
obstacle. He then reacts swinging between reactive anger in order to
remove the obstacle and resignation and powerlessness. Once patients
become aware that these ideas are not necessary reality-based, therapy
shifts to operation aimed at promoting change , inviting
patients to see the world from a different angle, one from which they
see more benevolent sides of themselves and of others. In particular
therapist try to promote a sense that life makes sense mostly out of
goals such as exploration, curiosity, playfulness and sharing, that
needs to be added to the focus on competition only.
During promotion of change therapists try to form a working alliance
where patients commit themselves to therapeutic tasks, both in-session
and in-between sessions. MIT often uses practices such as guided imagery
and rescripting, chairwork, role-play and, most often, homework in order
to break old patterns and form new ideas about self and others (Dimaggio
et al., 2020; Centonze et al., 2023). Therapy is delivered under a
continuous monitoring of the therapeutic relationship in order to detect
earlier than possible if the patient is seen the therapist under a
negatively light and if the therapist is contributing to the problem.
Only when alliance ruptures are solved (Muran et al., 2021), work aimed
at overcoming symptoms continues.
Finally, therapists pay attention to drafting, agreeing upon and
revising the therapy contract. In other words, they pay the uttermost
attention whether patients agree with the goals and if they are willing
to commit themselves to performing the necessary tasks.
We will describe now the story of the therapy of a man with NPD who, at
the beginning of therapy, did not agree on any reasonable goal. This was
mostly due to the problems that we highlighted before, that is to: a)
poor capacity to describe his inner states and to focus on his healthy
wishes; b) lack of investment in healthy goals and over-focusing on
social status; c) focus on others as the source of problems; d) a sense
of hopelessness and passivity mostly driven by negative views about self
and others; e) problems in the therapeutic relationship, as he
considered the therapist as an obstacle and someone to envy of despise;
e) problematic reactions on the therapist’s side, as she oscillated
between the drive to defend herself in the face of the patient’s
devaluation and the drive to be effective.
We will show how the therapist had to become aware of these problems,
overcome them and then agreeing upon a therapeutic contract. The
clinical history will henceforth be written in the first person by the
therapist (V.V.), last author of this paper.