Optimal psychotherapy process for pathological narcissism : an exploration of clinicians' perspectives (original) (raw)
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Therapists' Perspectives on Optimal Treatment for Pathological Narcissism
This study used Q methodology to explore clinicians' perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism, a syndrome of impaired self-regulation. Participants were 34 psychotherapists of various disciplines and theoretical orientations who reviewed 3 clinical vignettes portraying hypothetical cases of grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q set, a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. By-person principal components analysis with varimax rotation was conducted on all 102 Q-sorts, revealing 4 components representing clinicians' perspectives on ideal therapy processes for narcissistic and non-narcissistic patients. These perspectives were then analyzed regarding their relationship to established therapy models. The first component represented an introspective, relationally oriented therapy process and was strongly correlated with established psychodynamic treatments. The second component, most frequently endorsed for the panic disorder vignette, consisted of a cognitive and alliance-building approach that correlated strongly with expert-rated cognitive– behavioral therapy. The third and fourth components involved therapy processes focused on the challenging interpersonal behaviors associated with narcissistic vulnerability and grandiosity, respectively. The perspectives on therapy processes that emerged in this study reflect different points of emphasis in the treatment of pathological narcissism, and may serve as prototypes of therapist-generated approaches to patients suffering from this issue. The findings suggest several areas for further empirical inquiry regarding psychotherapy with this population.
Journal of Personality Assessment, 2013
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Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder
Journal of Personality Disorders
This article identifies guiding principles in effective psychotherapies of patients with narcissistic personality disorder (NPD) and cautions against some common pitfalls. Individual psychotherapies of NPD patients were examined by both authors, who tested whether or not some principles, recommended in the literature, effectively promote these therapies and help these patients in moving forward with their lives and with effective therapy use. The authors identify a number of principles that were associated with more positive therapy development: helping patients identify goals and direction of their therapies, promoting a sense of agency, promoting a shift of focus to sense of vulnerability, and anticipating difficulty in developing and maintaining the treatment alliance. Common mistakes in these treatments are engaging in a power struggle with the patient, overindulging the grandiosity of the patient, directly challenging the grandiosity of the patient, and ignoring treatment-interfering behaviors. Identification of principles of effective therapies with NPD patients can help with the development of more effective treatment approaches for NPD.
Personality Disorders: Theory, Research, and Treatment, 2021
Objective: The present study aims at empirically exploring subtypes of narcissistic personality disorder (NPD), based on patient descriptors of the psychotherapeutic process. Subtype identification and characterization of NPD is central in particular to increase diagnostic precision, linking categorical and dimensional conceptualizations of psychopathology and to individualize treatments. Methods: A total of N = 161 patients diagnosed with NPD undergoing clarification-oriented psychotherapy (COP) were included in the present reanalysis of a naturalistic pre-post process-outcome study. At three crucial time-points of the therapy (sessions 15, 20 and 25), the patient's in-session quality of content, process and relationship are assessed using intensive video-and audio-analyses. Levels of psychopathology were assessed using selfreported questionnaires. Data were analyzed using longitudinal non-parametric analysis. Results: Based on in-session processes across three time-points, a two-subtype solution was retained (optimal vs suboptimal process qualities). Optimal process quality of time was linked with the intensity of narcissistic symptoms; suboptimal process quality was linked with a variety of general symptom loads and problematic personality traits. The two empirical subtypes were predicted by the quality of real-life functioning with an accuracy of over 92% and were partially associated with outcome. Conclusions: NPD may be empirically differentiated between patients engaging in optimal psychotherapy process, vs those who engage in suboptimal psychotherapy process. This differentiation has reliable clinical predictors at the outset of treatment. The present study has implications in terms of personalizing psychotherapy for patients presenting NPD, or pathological narcissism.
Journal of Clinical Psychology, 2023
Pathological narcissism is a personality constellation comprising distorted self-image, maladaptive self-esteem regulation, and difficulties in intimate relationships. Patients with elevated pathological narcissism may not necessarily meet criteria for narcissistic personality disorder, and may seek treatment for a range of mental health concerns across various clinical settings. An understanding of key
Narcissistic Personality Disorder: Progress in Recognition and Treatment
FOCUS, 2013
This review will address pathological narcissism and narcissistic personality disorder (NPD)-the clinical presentation, the challenges involved in diagnosing NPD, and significant areas of co-occurring psychopathology (i.e., affective disorder, substance usage, and suicide). Major depressive disorder is the most common comorbid disorder in patients with pathological narcissism or NPD. Need for self-enhancement and chronic disillusionment with self make these individuals particularly susceptible to substance use. Suicidal preoccupation in these patients is characterized by the absence of depression, lack of communication, self-esteem dysregulation, and life events that decrease self-esteem. The diagnostic focus on patients' external characteristics and interpersonal behavior tends to dismiss the importance of their internal distress and painful experiences of self-esteem fluctuations, self-criticism, and emotional dysregulation. A collaborative and exploratory diagnostic approach to pathological narcissism and NPD is outlined that aims at engaging the patients and promoting their curiosity, narration, and self-reflection. Alliance building with a narcissistic patient is a slow and gradual process and mistakes are common. A central task is to balance these patients' avoidance and sudden urges to reject the therapist and drop out of treatment with the goal of encouraging and enabling them to face and reflect upon their experiences and behavior. Implications for treatment and possible areas or indications of change include: interpersonal and vocational functioning; sense of agency and self-direction; emotion regulation and ability to understand, tolerate, and modulate feelings; reflective ability; and ability to mourn the loss of wished for or unreachable internal self-states, relationships, and external ideals.
Research in Psychotherapy: Psychopathology, Process and Outcome
The present study aimed at examining the associations between specific elements of the therapeutic relationship and Short-Term Psychodynamic Psychotherapy (STPP) outcome. Notably, it focused on countertransference patterns and the quality of the therapeutic alliance evaluated early in treatment, as well as therapists’ subjective experiences in their first clinical interaction with patients, in relation to their symptom changes at the end of STPP. Twenty clinicians completed the Comprehensive Psychopathological Rating Scale to evaluate patients (N = 32)’ symptom severity at the beginning and end of STPP. They also completed the Assessment of Clinicians’ Subjective Experience (ACSE) to assess their subjective experiences of their patients at the first clinical assessment, as well as the Therapist Response Questionnaire (TRQ) and Working Alliance Inventory to evaluate their countertransference reactions and the therapeutic alliance at the sixth therapy sessions. The findings showed tha...
Countertransference When Working With Narcissistic Personality Disorder: An Empirical Investigation
Narcissistic personality disorder (NPD) is one of the most challenging clinical syndromes to treat in psychotherapy, especially due to the difficulties of establishing a good enough therapist–patient relationship. Countertransference responses to NPD can be particularly intense, frustrating, and difficult to manage, as is often reported in the clinical literature though not clearly supported empirically. The aims of this study were to (a) investigate the relationship between patients' NPD and therapists' responses; (b) examine the associations between patient, clinician, therapy variables and clinicians' reactions during treatment of NPD patients; and (c) provide an empirically derived portrait of countertransference with NPD. A sample of psychiatrists and clinical psychologists (N = 67) completed the Therapist Response Questionnaire to identify patterns of countertransference, the Shedler–Westen Assessment Procedure-200, and the Global Assessment of Functioning Scale to assess the personality pathology and psycho-social functioning of a patient in their care. The results showed that NPD was positively associated with hostile/angry, criticized/devalued, helpless/inadequate, and disengaged countertransference and negatively associated with therapists' positive response, regardless of patients' personality and psychosocial functioning. NPD patients with stronger traits of cluster B personality pathology tended to elicit more negative and heterogeneous countertransference reactions than NPD patients without these features. The countertransference patterns with NPD patients were not strongly influenced by the variables of clinicians and therapy, with the exception of clinical experience. Overall, the portrait of therapists' reactions to NPD provided a clinically nuanced and empirically founded description strongly resembling theoretical– clinical accounts. The therapeutic implications of these findings were discussed.
It's the therapist and the treatment: The structure of common therapeutic relationship factors
Psychotherapy Research, 2021
Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. "Confidence in the therapist" and 2. "Confidence in the treatment." Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors. Trial registration: ClinicalTrials.gov identifier: NCT03503981.