“Matthew, a single man in his early twenties came to therapy due to chronic unhappiness, poor self-esteem, isolation, and a difficulty getting along with others. He was seemingly engaged in therapy, actively exploring his fantasies of success and what seemed like a perfect life scheme – graduate school in a promising field, making “all the right connections with all the right people” that would eventually catapult him to the top of the professional hierarchy, resulting in wealth, recognition, and power. He expressed pervasive devaluation of others who he experienced as ‘irredeemably stupid and incompetent.’ He repeatedly recognized an exploitative attitude toward others, when he would fake close relationships only to elicit some benefits from the other person. These patterns were acknowledged, though Matthew continued to excuse them in the context of past trauma. Alienating colleagues and friends through haughty and critical behaviors, he was left in total isolation and was enraged and humiliated when nobody showed up for his graduation party. Blaming his therapist and feeling hopeless about the possibility of changing the cycles of mutual rejections, Matthew stopped therapy and refused to pay the balance.”
Is there hope of helping Matthew? Can treatment help him address patterns related to pathological narcissism? What interventions are likely to invite his curiosity and reflection and help him open to the process of change? These questions are at the heart of this Issue of the Journal of Clinical Psychology: In Session, and they have a long history in psychotherapy. Narcissistic personality disorder (NPD), associated with the concept of pathological narcissism, historically has been related to limits of treatability. Originally, Sigmund Freud (1914) theorized that pathological narcissism limits the ability of patients to benefit from treatment. The predominant opinion among his followers was that pathological narcissism was one of the major negative prognostic predictors (Etchegoyen, 1991; Greenson, 1967). “Narcissistically oriented…patients are generally not suitable for psychoanalysis”, Greenson authoritatively wrote in the 1960s (Greenson, 1967).
Earlier pessimism gradually gave way to more hopeful clinical observations that treatment of pathological narcissism was possible. This has been related to discussions of the “scope of analyzability” – or treatability (for a review see Etchegoyen, 1991) – and spurred developments of new theories and modifications of intervention techniques to better understand and treat pathological narcissism. This led to seminal contributions of Heinz Kohut (1971) and Otto Kernberg (1975) both of whom reformulated earlier understanding of pathological narcissism. These developments inspired original contributions of James Masterson (1983), Gerald Adler (1985), Herbert Rosenfeld (1987), John Steiner (1993), John Fiscalini (1993), Andre Green (2001), Arnold Rothstein (1984), Arnold Model (1975), and Andrew Morrison (1993), to name just a few. These contributions proposed novel theoretical formulations of pathological narcissism and suggested modifications of treatment technique. In doing so, they introduced a notion, revolutionary at that time, that treatment of pathological narcissism was possible and that meaningful changes can occur in the lives of these patients as a result of psychotherapy.