“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.