Challenges in treatment of NPD
Was this budding optimism supported by the experiences of other
clinicians treating patients suffering from pathological narcissism?
Unfortunately, patients with NPD were generally viewed by treating
clinicians as challenging (Table 1). Changes in NPD patients, while
possible, required a lengthy and difficult process. How real was the
initial optimism? What made these changes possible? Were those new
theories and techniques generalizable to other patients or were they the
elusive skills of especially gifted therapists who became enthusiastic
following their treatment successes?
To explain frequent difficulties in such treatments, empirical and
clinical reports continued to document specific challenges in treatments
of NPD that undercut effectiveness of these treatments (for reviews see
Weinberg & Ronningstam 2020, 2022). Initially, the literature
emphasized individual challenging characteristics of NPD
patients. For instance, such characteristics of NPD patients as
dismissive attachment (e.g., the tendency to dismiss reliance on others
in times of distress), perfectionism, shame, and devaluation worsen the
outcome (Black et al., 2013; Blatt et al., 1998; Dozier et al., 2001;
Guile et al., 2004). NPD patients tend to provoke negative feelings in
their therapists (Tanzilli et al., 2017). Typically, therapists of NPD
patients struggle with such powerful reactions as feeling annoyed, used,
close to losing one’s temper, mistreated, resentful, and walking on
eggshells. They experience sexual tension or feel dread or dislike of
the patient, feel criticized, dismissed, competitive and envious, bored,
hopeless, and cruel or mean toward the patient. Clinical literature
documented the following difficulties that NPD patients bring into
therapy (for a review see Weinberg & Ronningstam, 2020): (i) NPD
patients’ motivation to come treatment is commonly related to crises and
external circumstances, rather than internal and durable reasons for
change. Furthermore, it is not uncommon for their motivation to be
further undercut by overreliance on the financial support of family and
the misuse of status or money. (ii) NPD patients present challenges due
to intolerance of alternative points of view, lack of curiosity,
pathological certainty about their conclusions, and poor recognition of
inner states. (iii) Emotional challenges include difficulty naming and
recognizing emotions, persistent boredom as well as excitement seeking,
and a sense of meaninglessness and fear. (iv) Interpersonal challenges
include impoverished relationships, competitiveness, fear of reliance on
the therapist, and paranoid reactions toward the therapist. Some
patients report superficially stable relationships with others. However,
once the patient faces inevitable disillusionments or the relationship
invites deeper commitment and intimacy, their dream-like interest
evaporates and they plunge into a state of meaninglessness, until they
repeat this cycle all over again. (v) Challenges related to self-esteem
regulation consist of seeking self-affirmation as opposed to
self-understanding, externalization of responsibility, chronic
self-criticism, and perfectionism. (vi) Lastly, compromised moral
functioning – another treatment challenging factor – includes lack of
responsibility or commitment, dishonesty, lack of capacity for remorse,
and exploitation of others.
As the field shifted toward understanding that stalemates in treatment
are jointly co-created by the patient and the therapist (Bromberg,
1992), there was a growing recognition that some of the difficulties in
treatments of NPD patients are jointly co-created as well. They
stem from specific relational configurations that develop in treatments
of NPD patients that lead to non-treatment treatments – therapies that
continue even though they do not accomplish treatment goals (Weinberg &
Ronningstam, 2022). Such relational configurations form obstacles to the
productive use of therapy and process of change, and they tend to
develop with mutual contributions of the therapist and the patient.
Usually, such contributions occur outside of awareness of both parties
as they develop interlocking patterns in terms of styles of managing
self-esteem, processing emotions, relating to each other, or their
cognitive processes. (i) Lack of goals. Some therapies proceed without
measurable realistic goals. In these cases, therapies turn into a form
of a psychic retreat (Steiner, 1993) in which the patient is invested in
perpetuating the status quo , avoiding emotional experiences and
the pursuit of reality-based goals. With some patients, this challenge
appears gradually. They attend the sessions and always have something to
discuss. However, after a while one start having a sense of de je
vu : there is no change in what is being talked about, no change in
problems that brought them into therapy in the first place, and they
sessions feel devoid of distress. In some cases, this is related to an
assumption that the patient will develop inner ability and desire to
change as a result of psychotherapy. (ii) Joint collusion with
protracted states of mutual idealization. In these cases, both the
patient and the therapist co-create a form of mutual idealization as a
form of avoidance of discussion of meaningful experiences or pursuit of
treatment goals and focus on “how great they are” (Slochower, 2006).
(iii) Collusion with protracted devaluation, competitiveness, or envy.
At other times treatment stalls when the patient is developing a pattern
of devaluation, competition, or envy in relationship to the therapist
who is contributing to these dynamics or colluding with them. For
instance, mutual enactment of devaluation, competitiveness, or envy due
to underlying narcissistic vulnerability in both therapist and patient
can gradually escalate these dynamics to treatment interfering
proportions. In other words, the patient and therapist continuously
provoke each other and escalate the dynamic as a result. For instance,
the patient might be dismissing therapist’s interventions, deeming them
stupid. At first, the therapist might be channeling feelings of
frustration and hurt into efforts to impress the patient by increasingly
complex interventions, trying to “prove” his or her worthiness. Later,
losing patience, the same therapist might lapse into chronically
critical tone in interventions. (iv) Allowing the patient to control the
treatment. While patients need to feel and be in control of their
therapies, once they start dictating major treatment decisions, their
treatment is at risk of a stalemate. Sometimes, this is related to
refusal to participate in additional components of treatment (e.g.,
homework, self-help meetings, pharmacotherapy), or refusal to provide
consent to communicate with other treatment providers or significant
others, or at times direct suggestions of how their therapy needs to be
conducted. In one way or another these patterns interfere with effective
treatment (Hendin et al., 2006). It is not uncommon for the same
patients to later blame the resultant lack of progress on the therapist
as if they have no part in that outcome. (v) Use of treatment for
secondary motives. All patients participate in therapy for a host of
reasons, ranging from change-motivated and those driven by less adaptive
motives. For some patients, their ability to effectively participate and
benefit from treatment is limited by the predominance of maladaptive
motives and agendas. For instance, some patients participate in
treatment to appease worried family members or work supervisors, without
having an actual interest in change. Others come to treatment only to
prove that they are beyond help and therefore either are unable to
change as they can now externalize responsibility on treatment or
celebrate triumph as they demonstrate superiority over their therapist
(Kernberg, 2007). (vi) Pseudo-engagement. In such cases there is an
appearance of effective psychotherapy, but the real engagement is
lacking. In some cases, it stems from an overly intellectual focus of
treatment (Dimaggio, 2022), a mutual avoidance of painful emergence of
emotions by both patient and therapist that a deeper engagement entails
(Cooper, 2016), or the development of misalliance around the power
differential. For instance, the patient creates a façade of engagement
to keep the therapist at bay. Sometimes, this pattern reflects a
repetition of power dynamics from the patient’s past and lack of trust
in the therapist. (vii) Some treatments persist beyond the productive
stage and turn into non-treatment treatments, or the patient avoids
termination and attends treatment to maintain patient role or because of
avoidance of grieving by either or both parties. The avoidance of
termination helps them avoid mourning losses, including accepting that
therapy could not solve all of their difficulties. This is not to be
confused with “lifers” – patients that stay in treatment for life but
use treatment productively (Wallerstein, 2000).
However, yet another reason for these challenges in treating NPD
patients may have to do with the status of our understanding of NPD. Is
it the NPD or, maybe, our own expectations, biases and narratives about
NPD patients that affect treatability? Similarly,destigmatization of other personality disorders improved
treatment outcomes (Ferguson, 2016; Sheehan et al., 2016). Looking at
social media and popular culture, one cannot help to notice that it is
an unfortunate zeitgeist to vilify anyone suffering from
pathological narcissism. In that narrative narcissism is associated with
exclusively negative attributes and adjectives, that inviting blaming
and negative mindset. Not only does this demotivates patient to seek
professional help, but also interferes with therapists’ ability to learn
from each patient from his or her internal point of view. Could
better understanding of NPD patients through empirical research and the
development of novel treatments decrease stigma and improve treatment
outcomes?