CLINICAL PRACTICE AND SUMMARY
Treatment of Alec illustrated that change is possible in treatment of
patients suffering from pathological narcissism. His treatment was
structured around Dos and Don’ts treatment principles that promoted
change (Weinberg & Ronningstam, 2020). His treatment goals included
improvement of first his academic and then his professional functioning
and romantic life. The stance of validation and curiosity invited him to
explore his inner world, his capabilities, and difficulties. The
treatment addressed attachment patterns of avoidance and introduced the
new experience of helpful reliance on others. Attention to life events,
such as navigation of work challenges and a new romantic relationship,
invited further opportunities for growth. The awareness of my own
reactions to Alec promoted constructive relatedness and flexibility.
Following these treatment principles also allowed a measure of
flexibility, such as deciding to continue treatment despite Alec’s
difficulty in following the recommendation to find a job. In doing so,
the treatment took a strategic risk to follow the lead of the patient
and his life context rather than following a “one size fits all”
approach.
Such flexibility was especially important in other aspects of Alec’s
treatment. His treatment had to navigate a constantly changing balance
between the processes occurring within therapy, his challenges and
capabilities, and life-events. Sometimes, processes in therapy, such as
working through his childhood experiences, allowed him greater openness
and capacity to learn, which led him to embark on his own career. At
other times, life experiences, such as a new romantic relationship,
invited him to accept imperfections and adopt a problem-solving,
pragmatic attitude. His ability to engage in treatment and life grew as
a result of his life experiences (e.g., a new partner) as well as his
experiences in treatment (e.g., processing fears that others are not
available to him when he needs them). Such an interaction between life
and therapy is not uncommon in processes of change in people with
pathological narcissism (Ronningstam & Weinberg, 2023) and it is one of
the reasons that the process of change in patients with pathological
narcissism takes a long time (Weinberg & Ronningstam, 2022).
Treatment principles, not theories, are close to what guides individual
clinicians in conducting psychotherapy (Castonguay et al., 2019),
including with patients suffering from pathological narcissism (Kealy et
al., 2017). The Dos and Don’ts treatment principles are friendly to most
if not all theoretical approaches and, therefore, can be incorporated
into practices of clinicians from all theoretical orientations.
Thus, it invites appreciation of the complexity of individual patients
and avoids a “one size fits all” approach. They are relativelyeasy to learn , as opposed to theory-based approaches that require
mastery of theory and lengthy supervision to ensure adherence in
treatment. Finally, the Dos and Don’ts treatment principles have the
advantage of clinical flexibility (Castonguay et al., 2019), which what
is required of the clinician working with complex and fluidly changing
clinical presentations – such as patients with pathological narcissism
(Weinberg & Ronningstam, 2022). Finally, this approach is suitable for
patients that might not be meeting treatability criteria of other
approaches (e.g., not following through with the job recommendation).
Accordingly, an individual patient suffering from pathological
narcissism might be first evaluated for fit for any of the established
approaches, such as TFP, MBT or MIT, and referred. Those patients that
do not meet the treatability criteria, or do not improve in those
approaches, can be referred to the Do’s and Don’ts principle-based
approach.