Challenges in treatment of NPD
Was this budding optimism supported by the experiences of other clinicians treating patients suffering from pathological narcissism? Unfortunately, patients with NPD were generally viewed by treating clinicians as challenging (Table 1). Changes in NPD patients, while possible, required a lengthy and difficult process. How real was the initial optimism? What made these changes possible? Were those new theories and techniques generalizable to other patients or were they the elusive skills of especially gifted therapists who became enthusiastic following their treatment successes?
To explain frequent difficulties in such treatments, empirical and clinical reports continued to document specific challenges in treatments of NPD that undercut effectiveness of these treatments (for reviews see Weinberg & Ronningstam 2020, 2022). Initially, the literature emphasized individual challenging characteristics of NPD patients. For instance, such characteristics of NPD patients as dismissive attachment (e.g., the tendency to dismiss reliance on others in times of distress), perfectionism, shame, and devaluation worsen the outcome (Black et al., 2013; Blatt et al., 1998; Dozier et al., 2001; Guile et al., 2004). NPD patients tend to provoke negative feelings in their therapists (Tanzilli et al., 2017). Typically, therapists of NPD patients struggle with such powerful reactions as feeling annoyed, used, close to losing one’s temper, mistreated, resentful, and walking on eggshells. They experience sexual tension or feel dread or dislike of the patient, feel criticized, dismissed, competitive and envious, bored, hopeless, and cruel or mean toward the patient. Clinical literature documented the following difficulties that NPD patients bring into therapy (for a review see Weinberg & Ronningstam, 2020): (i) NPD patients’ motivation to come treatment is commonly related to crises and external circumstances, rather than internal and durable reasons for change. Furthermore, it is not uncommon for their motivation to be further undercut by overreliance on the financial support of family and the misuse of status or money. (ii) NPD patients present challenges due to intolerance of alternative points of view, lack of curiosity, pathological certainty about their conclusions, and poor recognition of inner states. (iii) Emotional challenges include difficulty naming and recognizing emotions, persistent boredom as well as excitement seeking, and a sense of meaninglessness and fear. (iv) Interpersonal challenges include impoverished relationships, competitiveness, fear of reliance on the therapist, and paranoid reactions toward the therapist. Some patients report superficially stable relationships with others. However, once the patient faces inevitable disillusionments or the relationship invites deeper commitment and intimacy, their dream-like interest evaporates and they plunge into a state of meaninglessness, until they repeat this cycle all over again. (v) Challenges related to self-esteem regulation consist of seeking self-affirmation as opposed to self-understanding, externalization of responsibility, chronic self-criticism, and perfectionism. (vi) Lastly, compromised moral functioning – another treatment challenging factor – includes lack of responsibility or commitment, dishonesty, lack of capacity for remorse, and exploitation of others.
As the field shifted toward understanding that stalemates in treatment are jointly co-created by the patient and the therapist (Bromberg, 1992), there was a growing recognition that some of the difficulties in treatments of NPD patients are jointly co-created as well. They stem from specific relational configurations that develop in treatments of NPD patients that lead to non-treatment treatments – therapies that continue even though they do not accomplish treatment goals (Weinberg & Ronningstam, 2022). Such relational configurations form obstacles to the productive use of therapy and process of change, and they tend to develop with mutual contributions of the therapist and the patient. Usually, such contributions occur outside of awareness of both parties as they develop interlocking patterns in terms of styles of managing self-esteem, processing emotions, relating to each other, or their cognitive processes. (i) Lack of goals. Some therapies proceed without measurable realistic goals. In these cases, therapies turn into a form of a psychic retreat (Steiner, 1993) in which the patient is invested in perpetuating the status quo , avoiding emotional experiences and the pursuit of reality-based goals. With some patients, this challenge appears gradually. They attend the sessions and always have something to discuss. However, after a while one start having a sense of de je vu : there is no change in what is being talked about, no change in problems that brought them into therapy in the first place, and they sessions feel devoid of distress. In some cases, this is related to an assumption that the patient will develop inner ability and desire to change as a result of psychotherapy. (ii) Joint collusion with protracted states of mutual idealization. In these cases, both the patient and the therapist co-create a form of mutual idealization as a form of avoidance of discussion of meaningful experiences or pursuit of treatment goals and focus on “how great they are” (Slochower, 2006). (iii) Collusion with protracted devaluation, competitiveness, or envy. At other times treatment stalls when the patient is developing a pattern of devaluation, competition, or envy in relationship to the therapist who is contributing to these dynamics or colluding with them. For instance, mutual enactment of devaluation, competitiveness, or envy due to underlying narcissistic vulnerability in both therapist and patient can gradually escalate these dynamics to treatment interfering proportions. In other words, the patient and therapist continuously provoke each other and escalate the dynamic as a result. For instance, the patient might be dismissing therapist’s interventions, deeming them stupid. At first, the therapist might be channeling feelings of frustration and hurt into efforts to impress the patient by increasingly complex interventions, trying to “prove” his or her worthiness. Later, losing patience, the same therapist might lapse into chronically critical tone in interventions. (iv) Allowing the patient to control the treatment. While patients need to feel and be in control of their therapies, once they start dictating major treatment decisions, their treatment is at risk of a stalemate. Sometimes, this is related to refusal to participate in additional components of treatment (e.g., homework, self-help meetings, pharmacotherapy), or refusal to provide consent to communicate with other treatment providers or significant others, or at times direct suggestions of how their therapy needs to be conducted. In one way or another these patterns interfere with effective treatment (Hendin et al., 2006). It is not uncommon for the same patients to later blame the resultant lack of progress on the therapist as if they have no part in that outcome. (v) Use of treatment for secondary motives. All patients participate in therapy for a host of reasons, ranging from change-motivated and those driven by less adaptive motives. For some patients, their ability to effectively participate and benefit from treatment is limited by the predominance of maladaptive motives and agendas. For instance, some patients participate in treatment to appease worried family members or work supervisors, without having an actual interest in change. Others come to treatment only to prove that they are beyond help and therefore either are unable to change as they can now externalize responsibility on treatment or celebrate triumph as they demonstrate superiority over their therapist (Kernberg, 2007). (vi) Pseudo-engagement. In such cases there is an appearance of effective psychotherapy, but the real engagement is lacking. In some cases, it stems from an overly intellectual focus of treatment (Dimaggio, 2022), a mutual avoidance of painful emergence of emotions by both patient and therapist that a deeper engagement entails (Cooper, 2016), or the development of misalliance around the power differential. For instance, the patient creates a façade of engagement to keep the therapist at bay. Sometimes, this pattern reflects a repetition of power dynamics from the patient’s past and lack of trust in the therapist. (vii) Some treatments persist beyond the productive stage and turn into non-treatment treatments, or the patient avoids termination and attends treatment to maintain patient role or because of avoidance of grieving by either or both parties. The avoidance of termination helps them avoid mourning losses, including accepting that therapy could not solve all of their difficulties. This is not to be confused with “lifers” – patients that stay in treatment for life but use treatment productively (Wallerstein, 2000).
However, yet another reason for these challenges in treating NPD patients may have to do with the status of our understanding of NPD. Is it the NPD or, maybe, our own expectations, biases and narratives about NPD patients that affect treatability? Similarly,destigmatization of other personality disorders improved treatment outcomes (Ferguson, 2016; Sheehan et al., 2016). Looking at social media and popular culture, one cannot help to notice that it is an unfortunate zeitgeist to vilify anyone suffering from pathological narcissism. In that narrative narcissism is associated with exclusively negative attributes and adjectives, that inviting blaming and negative mindset. Not only does this demotivates patient to seek professional help, but also interferes with therapists’ ability to learn from each patient from his or her internal point of view. Could better understanding of NPD patients through empirical research and the development of novel treatments decrease stigma and improve treatment outcomes?