<div>Treatment of Alec: “History does not have to repeat itself”</div><div>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.</div><div><b>Key words:</b> Pathological narcissism, psychotherapy, adult
development</div><div>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 &amp; Weinberg, 2013). They are more likely to
attempt or die by suicide (Ronningstam &amp; 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 &amp; 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 &amp; Ronningstam, 2022).</div><div>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 &amp; 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 &amp; 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).</div><div>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 &amp;
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 &amp; Ronningstam, 2020).</div><div>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).</div><div>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.</div>