New directions for treatment of NPD
The burgeoning empirical research on pathological narcissism provided
very much needed information on a wide spectrum of areas related to it
(Table 2; Weinberg & Ronningstam, 2022). It introduces a new
perspective that views the patient in context of multifactorial etiology
and mutually influencing areas of functioning. This invites the
clinician to be attuned to multilayered and fluctuating experiences and
functioning of the patient, to avoid making assumptions, and recognize
the uniqueness of each patient. This introduces an evidence-based and
more optimistic approach to NPD.
This renewed optimism resulted in novel treatment developments,
including formulation of principles of psychoanalytically-oriented
therapy for NPD (Crisp & Gabbard, 2020), transference-focused
psychotherapy for NPD (Diamond et al., 2020), mentalization based
treatment for NPD (Drozek & Unruh, 2020; Choi-Kain et al., 2022),
adaptation of good psychiatric management to NPD (Weinberg et al.,
2019), Metacognitive Interpersonal Therapy (Dimaggio et al., 2020;
Centonze et al., 2023) and formulation of general principles of
treatment for NPD (Weinberg & Ronningstam, 2020; Dimaggio, 2022).
Guided by a pragmatic focus on change, informed by recent research
developments, while keeping an open mind for revision necessitated by
clinical experience, these treatments herald a new era in the treatment
of pathological narcissism.
Another area of optimism is shifting the perspective from the one that
views the patients as holding all the challenges to effective treatment,
to a transactional approach that views challenges at least in part
co-created. Instead of viewing patients’ treatability in context of
their personality factors, the field is moving to the perspective that
treatability is related to patient-therapist match (Kantrowitz, 2020)
and stalemates – are at least in part co-created (Bromberg, 1992).
Treatability is not only a characteristic of a patient but of a
therapist-patient dyad and their capacity to work together. Certain
experiences and characteristics of therapists make them more likely to
succeed with certain patients that might not be treatable by others.
Destigmatization and evidence-based perspective on pathological
narcissism are another component. One aspect of this is avoiding the
“one size fits all” approach, imposing theory, our biases or personal
reactions onto the patient, and judging internal experiences based on
external manifestations. Instead, clinicians are invited to recognize
the uniqueness of each person and seek understanding that aspires to
integrate inner experiences of the patients, their overt behaviors, as
well as the reactions they evoke.
For instance, many NPD patients discontinue treatment prematurely
(Hilsenroth et al., 1998; Gamache et al., 2018). However, not all early
terminations are the same and not all of them indicate that the
treatment has not been productive. Terminations are related to enactment
of various aspects of narcissistic functioning: dismissive attachment,
need for control, fear of change, superiority, competition, envy, fear
of closeness or reliance on the therapist, withdrawal, devaluation, or
entrapment. Terminations could be related to various treatment
processes: fragile alliance, disagreements about goals or lack of
attention to setting explicit shared goals (Dimaggio & Valentino, 2023;
Dimaggio, 2023), overstimulation of attachment through overly empathic
or dramatic interventions, retaliation against therapist, exclusive
focus on treatment relationship or insufficient focus on it; use of
interpretations to assert power differential or intrude and control the
patient. For other patients the judgment of the therapist that the
termination is an “early” one is a reflection of disagreement between
the patient and the therapist about the continuation of the therapy.
This could stem theoretical biases or unprocessed reactions of the
therapist (e.g., anger or overprotectiveness) and may not necessarily
indicate that the therapy itself was not helpful. With other patients,
early terminations are expression of a pattern that consists of
intermittent engagement in otherwise productive therapy (Paris, 2007).
For others, despite early terminations, such treatments “plant the
seeds” for future reflections, insight or change. These processes of
change might occur in future treatments, or as a result of personal
reflections of the patients, or as a result of inner integrations that
might be happening outside of the patients’ awareness.
Novel understanding of the disorder and renewed interest in
understanding the patients suffering from it inspired the recognition
that “NPD is a new BPD” (Choi-Kain, 2020). In other words, similar to
how BPD became a treatable disorder due to advances in research and
treatment development in the 80s and the 90s, it is now the turn of NPD
to undergo the same transformation. This invites a few approaches to
treatment development for pathological narcissism. Some of those
approaches are listed below.
(i) Modification of treatments for related conditions , such as
BPD. For instance, such treatments as TFP and MBT, that were previously
supported for treatment of BPD were subsequently modified to treat a
closely related condition – NPD (Diamond et al., 2022; Drozek & Unruh,
2020).
(ii) Eclectic treatments – selection of effective principles and
interventions. Another strategy consists of the development of
treatments that combine effective interventions from existing treatment
modalities. The chosen interventions were identified because of the
clinical utility and their ability to address characteristics of
narcissistic patients (e.g., use of treatment contract to address
difficulty stay in treatment; Weinberg & Ronningstam, 2020).
(iii) Development of treatments based on empirical understanding ofmechanisms of NPD (Dimaggio, 2022). This strategy of treatment
development targets putative mechanisms associated with NPD. For
instance, dismissive attachment, that is the tendency to dismiss
reliance on others during distress, in NPD patients invites the
development of treatments that target dismissive attachment.
(iv) Development of treatments that target mechanisms of change in
therapies of NPD. Such treatments address those areas of treatment
undermined by pathological narcissism. For instance, difficulty forming
alliance by NPD patients invites treatment approaches that help target
this area in NPD patients (Ronningstam, 2012; Dimaggio, 2022).
(v) Development of therapies based on cases of treatments
associated with change . Such an approach encourages treatment
development based on therapies that went well. Such cases provide
insight into what works with NPD patients and possibly can inform novel
treatment developments (Weinberg & Ronningstam, in preparation). This
perspective encourages treatment development using an experience driven
approach, as opposed to theory driven approach. This approach is
preferred by clinicians (Kealy et al., 2017) who tend to think in terms
of principles of treatment rather than point by point interventions.
This approach invites development of principle-based treatments. The
tradition of principle-based treatment has a long history in clinical
science (Castonguay et al., 2019). Treatment principles have the
advantage of flexibility in addressing variability, fluidity, and
complexity of cases (Castonguay et al., 2019), such as NPD (Weinberg &
Ronningstam, 2022). Use of principles as opposed to treatment manuals is
especially relevant to treatments of NPD in which therapists struggle
with fragility of alliance. Research shows that for patients who have
low motivation and form fragile alliance – typical for NPD – adherence
to treatment is associated with worse outcome or not related to it at
all; alliance is more predictive of the treatment outcome than adherence
(Webb et al., 2010; Huppert et al., 2006).
(vi) Identification of common factors in different effective
treatments. Such factors are likely putative effective interventions
responsible for change. Building on common factor approach to therapy
(Wampold & Imel, 2015), research identified such factors in
evidence-based treatments for BPD (Weinberg et al., 2011). The
identification of common interventions in various effective therapies,
including case reports of therapies with NPD patients, will help with
the development of novel effective treatments. This approach can be
applied to case reports published in this Special Issue, thus
formulating new hypotheses as to what interventions are likely effective
in treatment of NPD patients.
The present issue of the Journal of Clinical Psychology: In
Session was planned to address some of these urgent questions in the
field. The current approach is based on (i) prioritizing evidence,
including clinical evidence, over theory, (ii) collaborative,
constructive approach, and (iii) pragmatic effort to identify factors
responsible for change. (iv) destigmatization of NPD. Thus, five/six
clinicians were invited to contribute treatments of NPD patients using
descriptive atheoretical language, promoting an understanding of what
allows change in each one of these therapeutic engagements. The goal is
to start a dialogue between different treatments to learn from
convergences and unique interventions and to learn what interventions
worked. This is to inform clinicians and treatment developers regarding
possible helpful interventions, leading to a more hopeful approach to
treatment of NPD patients and spurring new effective treatments. At the
end of the issue Dimaggio and Weinberg will comment the single
case-based papers and try to distill common factors at work, outline
differences and note if they increase our understanding how to best
address the need of a condition like NPD which presents difficulties but
is indeed treatable.