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.