Possibility of change in NPD
Empirical studies of the longitudinal course of NPD are especially
informative regarding the question of possibility of change. The
conclusions from the studies of longitudinal course of patients
suffering from NPD are the following: (i) NPD improves over time, (ii)
changes are slow and gradual and sudden improvements were not
documented, and (iii) symptomatic improvements occur faster than
improvements in pathological narcissism as a dimension. No studies in
clinical samples focused on vulnerable narcissism (Weinberg &
Ronningstam, 2022). Studies of pathological narcissism in non-clinical
samples complement and extend the findings from the studies of NPD in
clinical samples. The findings from these studies highlight that
different facets of pathological narcissism improve at a different pace.
The facet of hypersensitivity, that includes such characteristics as
resentment, depletion, sense of entitlement, and roughly corresponds to
vulnerable narcissism, continues to improve throughout the person’s
life, while the facet of willfulness that includes external grandiosity
and exhibitionism, and roughly corresponds to grandiose narcissism,
improves until middle age and tends to plateau thereafter (Cramer 2011;
Edelstein et al., 2012). Taken together these studies show that
pathological narcissism is associated with a slow pace of change and
that compared to vulnerable narcissism traits, traits associated with
grandiose narcissism are more persistent.
While longitudinal studies demonstrated that NPD patients change, the
question remains what processes are responsible for change. So far,
research has documented that some of these changes occur as a result of
life events (Ronningstam et al., 1995; Wenzel et al., 2020). Improvement
in pathological narcissism has been associated with new relationships,
achievements, or disillusionments, especially if those are being
processed in a sympathetic context, including therapy (Ronningstam et
al., 1995). Realistic jobs (e.g., engineering, medicine) are more likely
to be associated with improvements in pathological narcissism compared
to leadership positions or enterprising jobs (Wenzel et al., 2020).
Some studies documented changes in NPD patients in therapy, reporting
symptom reduction and improvement of functioning (Callaghan et al.,
2003; Riordan, 2012; Kramer et al., 2018; Weinberg et al., under
review). While conclusions from these reports are limited by small
sample sizes, pre-post designs, and lack of uniformity in the use of
measurement, they provide hope that treatments can help NPD patients
change.
Research has been lagging in identifying mechanisms of change in
psychotherapy. From a theoretical standpoint, some of the candidates for
such mechanisms are treatment alliance, development of reflective
ability, and mourning. How do these concepts apply to treatments of NPD?
(i) Alliance. Treatment alliance has been identified as the most
powerful predictor of change in treatment (Muran & Barber, 2010).
Alliance provides a leverage for change but also provides patients with
a lived experience of a collaborative, respectful, and emotionally
attuned relationship that on its own is conducive to emotional growth
and self-exploration, and the discovery of new forms of relating
(Lowald, 1980). In fact, numerous meta-analyses estimated that treatment
alliance is the most significant predictor of treatment outcome,
contributing moderately to its prediction (Barber et al., 2010; Baier et
al., 2020; Fluckiger et al., 2018), including behavioral treatments
(Sauer-Zavala et al., 2018; Ovenstad et al., 2020).
However, alliance in NPD is undercut by several factors, including
dismissive and avoidant attachment styles (Diamond et al., 2014) as well
as such characteristics as avoidance of reliance on the therapist,
competitive relationship with the therapist, envy, and attribution of
malintent to the therapist (for a review see Weinberg & Ronningstam,
2020). This limits the ability of the patients to benefit from therapy.
One approach suggests that treatment alliance can be built through
curiosity about the patient’s experiences, an exploratory approach,
helping the patient understand and develop a sense of agency about their
behaviors (Ronningstam 2012). These interventions encourage the patient
to take ownership of their capabilities, and not only their maladaptive
behaviors. Alliance develops based on these interventions as well as a
conveyed understanding that the patient’s experiences can be understood
in context of complex interactions between limitations, capabilities,
motivations, and fears. Another approach, transference-focused
psychotherapy (Diamond et al., 2022), is viewing alliance development as
both a treatment goal in its own right and a mediator of change. This
approach consists of developing a treatment contract to contain
treatment interfering behaviors and careful exploration and
interpretation of negative projections that undermine more positive
reliance on the therapist. Others have suggested that the use of
autonomous motivation that is based on investment in treatment goals
(Zuroff et al., 2007) is an alternative to the fragile alliance of NPD
patients (Weinberg & Ronningstam, 2020). These interventions suggest
that while treatment alliance is fragile in patients with pathological
narcissism, certain treatment modifications can help these patients
engage in treatment and develop alliance as one of the treatment
outcomes.
(ii) Reflective function. Reflective ability – thinking about one’s own
psychological processes, such as thoughts, feelings, and motivations –
overlaps with metacognition – thinking about thinking (Dimaggio et al.,
2007). Many treatments encourage the development of reflective
capacities and view such developments as instrumental in the process of
change (Fonagy et al., 2002). Many treatment interventions are designed
to promote such capacity in patients – exploration of antecedents of
problem-behaviors as well as of progress, exploration of functions of
different behaviors, exploration of thoughts, feelings, and behaviors to
promote pattern recognition and insight into their functions,
motivations, and developmental antecedents (Castonguay & Hill, 2007).
However, research has shown that patients with NPD have decreased
reflective function (Diamond et al, 2014), and clinical observations
describe propensity for detached, intellectual - pseudo-mentalizing
(Drozek & Unruh, 2020), intellectualized reflectiveness (Dimaggio,
2022), and the difficulty to think in a meaningful and reflective way
(Shoshani & Shoshani, 2016). This has led to development of treatments
that promote the development of reflective and mentalizing capabilities
(Choi-Kain et al., 2022; Drozek & Unruh, 2020), thus increasing the
potential of NPD patients to benefit from treatments that rely on
reflective capacities. In fact, preliminary observations confirm that
reflectiveness can improve at least in some therapies, such as
transference focused psychotherapy (Diamond et al., 2014).
(iii) Mourning. Mourning is related to the ability to grieve losses,
unmet needs, and unfulfilled fantasies or dreams, and accept reality,
personal limitations, and realistic expectations, and give up
maladaptive solutions or unrealistic fantasies – all important – if
not critical - aspects of psychotherapy. Traditionally, pathological
narcissism was thought to be associated with a limitation in the ability
to mourn (Kernberg, 1975; Steiner, 1993; Shoshani & Shoshani, 2016), as
pathological narcissism was seen as a complex form of avoidance of the
process of mourning. In that way, narcissistic functioning can be seen
as antithetical to the mourning process, thus introducing challenges to
treatments that rely on intact capacity to grieve. On the other hand,
our understanding of the grieving process has changed. Traditionally, it
was assumed that grieving involves gradual acceptance of the loss and
redirecting the investment into the lost relationship into new ones
(Freud 1917); current findings demonstrate however that giving up
connection with the lost person does not always occur (Bonnano 2009).
For some people such transformation manifests itself in the feeling that
the lost person is still present in their lives through internal
dialogue or through their commitment to make room in their own lives for
what was important to the lost person. For instance, a bereaved husband
might feel connection to his deceased wife though dedicated care for
their grandchildren, viewing them as extension of her. Rather than
viewing treatment as giving up maladaptive aspects of narcissistic
functioning, it can be seen as transformation of them into more adaptive
ones, echoing Kohut’s notion of transformation of narcissism (Kohut,
1966). For instance, a patient might be able to transform aspirations to
become a top scientist in their respective field, into a dedication to
their mentees and students.