Treatment of Alec: “History does not have to repeat itself”
Treatment of patients with pathological narcissism presents several challenges and there is paucity of published case reports that document meaningful and durable change in patients suffering from this condition. Using descriptive and atheoretical language, this paper presents a treatment of a young adult in his transition from young adulthood to middle adulthood while he was negotiating complex residues of his experiences of growing up along with developmental challenges related to work and love. Against the backdrop of these transitions, the patient was working through various aspects of functioning related to pathological narcissism. Initially, given academic pressures and past romantic disappointments, he was confronting issues related to perfectionism, self-criticism, and avoidance. While he was able to move past some of these dynamics and function academically, later challenges related to becoming an independent adult led to a retreat into an avoidant state of futility and pessimism. Working through painful family dynamics related to not being seen and controlled, along with a deepening attachment in therapy as well as confrontation with realities of his life, led him to take steps towards greater independence. Thereafter, his treatment focused on learning from life experiences such as a newly developed career and romantic life, accepting the complexity of self and others, and tolerating disillusionments.
Key words: Pathological narcissism, psychotherapy, adult development
Patients suffering from pathological narcissism are troubled by a pervasive and painful difficulty maintaining a positive and realistic self-perception as well as a tendency to regulate self-esteem through maladaptive mechanisms (Miller et al., 2017). The most extreme expression of pathological narcissism is regarded as narcissistic personality disorder (NPD), characterized by unrealistic self-perception along with a feeling of superiority over others, a feeling of deserving special treatment or exceptions, the tendency to take advantage of others, and a difficulty putting oneself into others’ shoes (American Psychiatric Association, 2013). NPD is associated with an increased risk of suffering from comorbid disorders, such as mood disorders, anxiety disorders and substance use disorders (Stinton et al., 2008). Many NPD patients are troubled by legal, vocational, and relational/marital difficulties (Ronningstam & Weinberg, 2013). They are more likely to attempt or die by suicide (Ronningstam & Weinberg, 2013) and they tend to evoke distress in people close to them (Day et al., 2020). NPD is associated with the persistence and treatment resistance of comorbid disorders (Weinberg & Ronningstam, 2020). Typically, comorbid conditions do not improve until the treatment includes an additional focus on the pathological narcissism that is contributing to the diathesis for these conditions. Another reason for such treatment resistance is related to the misdiagnosis of difficulties related to pathological narcissism as solely stemming from anxiety or mood disorders. In such cases, clarifying the differential diagnosis helps reframe the treatment and make the co-occurring NPD a treatment priority (Weinberg & Ronningstam, 2022).
The subject of the possibility of treatment of patients suffering from pathological narcissism has invited several controversies since the concept of narcissism has been introduced into clinical literature. This led to numerous debates regarding treatability and the possibility of meaningful change, adaptation in treatment techniques, and the specific strengths and limitations that these patients present within treatment (Diamond et al., 2021; Weinberg & Ronningstam, 2020). Increased hopefulness about treatability of patients suffering from borderline personality disorder evoked greater hopefulness that treatment of patients with NPD could bear fruit as well (Choi-Kain, 2020). Preliminary reports suggested that patients with NPD can indeed improve in therapy (for a review see Weinberg & Ronningstam, 2022). In this atmosphere of renewed enthusiasm, several approaches to treatment of NPD and pathological narcissism have been developed, including Transference Focused Psychotherapy (TFP; Diamond et al., 2021), Mentalization Based Treatment (MBT; Bateman et al., 2023) and Metacognitive Interpersonal Psychotherapy (MIT; Dimaggio et al., 2020).
What treatment principles contribute to change and productive engagement in treatment? To answer this question, such principles were formulated as Dos and Don’ts in treatments with NPD patients (Weinberg & Ronningstam, 2020). The list of Dos includes: (i) collaboratively identify realistic measurable treatment goals; (ii) help the patient develop a sense of agency; (iii) help the patient to shift toward exploration of real vulnerability; (iv) develop collaborative alliance through exploration, validation, and confrontation of dismissive and avoidant behaviors in sessions; (v) use treatment contract to anticipate treatment-interfering behaviors. The list of Don’ts emphasize the following: (i) don’t ignore personal reactions to the patient; (ii) avoid power struggle; (iii) don’t directly challenge grandiosity or self-criticism; (iv) don’t indulge grandiosity or self-criticism; (v) avoid overly empathic or overly expressive interventions; (vi) don’t ignore self-esteem-relevant life events (Weinberg & Ronningstam, 2020).
This approach has not been tested empirically, though the individual principles are based on empirical studies (e.g., don’t ignore self-esteem-relevant life events; Wetzel et al., 2020), overlap with other empirically based approaches (e.g., use of treatment contract to anticipate treatment-interfering behaviors; Yeomans et al., 2015), or stem from clinical experience (e.g., develop alliance through exploration, validation, and challenging dismissive behaviors in session; Wallin, 2007).
The case presented below illustrates this principles-based approach. It outlines a twice-a-week individual psychotherapy that unfolded over a period of more than 5 years. The case highlights the complexity and the multifactorial nature of change in treatment and discusses possible pathways and mechanisms of change.