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.