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.