Clinical Practices and Summary
Treating patients with NPD and pathological narcissism requires an
ongoing attention to drafting, agreeing upon and revising a clear,
realistic and reasonable therapeutic contract (Dimaggio, 2022; Weinberg,
2023). Goals need to be shared and clinicians have to make sure that
patients commit themselves explicitly to the tasks needed in order to
reach their therapy goal. In the story we have described, drafting such
a contract was problematic because of a series of maladaptive
mechanisms. The patient had poor awareness of his inner world, he blamed
the others for his problems and believed that change did not depend on
him, did not trust his therapist, and often treated her with contempt.
From the first session it was necessary to agree upon a contract, and
continuously renegotiate it. The contract was fundamental in making the
patient active towards his problem. We argue that without this continued
attention, the therapy would have been at risk of stalling or drop-out.
Generalizing from a single case is a longshot, but aware of this, we
suggest that effective treatments for NPD would benefit from an ongoing
focus on the therapeutic contract. In particular therapists need to
learn how to: a) detect the absence of agreed goals and tasks; b) point
out to patients that absence of this agreement will make the success of
the therapy unlikely; c) identify core wishes that can motivate patients
to commit themselves to operations aimed at change; d) help them realize
that change comes with a cost, in terms of having to face negative
feelings and ideas without avoiding them; e) accepting to continue to
act even when negative feelings and ideas emerge, as long as they become
able to overcome them and eventually experience a sense of curiosity,
playfulness and vitality.