In order to treat persons suffering from narcissistic personality disorder (NPD) it is necessary to agree on therapeutic goals and om tasks to undertake in order to meet them. This is difficult with NPD, as they have difficulties finding meaningful goals to strive for, other than the quest for status. Moreover, in order to change they need to expose themselves to experience painful feelings such as shame, guilt or fear, feelings that they automatically tend to keep at bay. Finally, they have problems forming a benevolent image of their therapists and to harken to it in order to cooperate towards mutually agreed goals and tasks. As a consequence, NPD patients ask for change but hardly engage themselves in the work necessary to achieve it. Therapists therefore need to pay the uttermost attention to drafting, negotiating and continuously updating a reasonable and realistic therapeutic contract. In this paper we describe the story of a man in his thirties with NPD who was ridden with depression, guilt, envy and anger and did not find ways to pursue the healthy and adaptive behaviors he would need to pursue in order to leave a richer social life. The therapist overcame ruptures in the therapeutic alliance and then involved the patient in a process where they set the steps to follow, making sure the patient was convinced they made sense. After a contract was reached progress became possible. Implications for the role of the therapeutic contract in NPD treatment are discussed.

Historically, patients suffering from pathological narcissism, including narcissistic personality disorder (NPD), were considered challenging and hard to treat. Since the second half of the 20th century new treatments have been developing heralding a growing hope that transformative treatment of patients with pathological narcissism is possible. Recent developments of phenomenology, childhood antecedents, longitudinal course, and putative mechanisms inspired a greater hope as well. This invites clinicians and researchers to take an approach that is evidence-based, destigmatizing, and collaborative that considers that at least some of the treatment challenges as co-created by both the therapist and the patient. Further, new treatments add hope by ameliorating such challenges of patients with pathological narcissism as fragile alliance, limitations of reflectiveness and grieving. Novel treatments are evidence- and principles-based and different approaches to effective treatment development are described. Inspired by these developments in the field, this Issue of the Journal of Clinical Psychology: In Session was conceived as an opportunity for clinicians from different treatment approaches to come together and share their experiences in treating patients with pathological narcissism. The hope is to find common language to understand these patients and their treatment, understand what contributes to change, as well as learn from commonalities and differences among these treatments. In doing so, this Issue is hoping to promote destigmatizing, pragmatic approach that prioritizes evidence-based efforts to understand the patient and collaborative approach to promoting change.

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.

Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalytic principles, while others argue they enhance coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient’s experience and that homework may be an important component of treating personality disorders. We present the case of a man diagnosed with narcissistic personality disorder to illustrate this: the patient, wrestling with social relations and control dynamics within therapy, was assigned homework aimed at curbing his compulsive caregiving and exploring its underlying motives. This exercise led him to understand his actions stemmed from avoidance of exposing his vulnerabilities. Subsequently, he was able to engage with relationships from diverse perspectives and discover new meanings. We advocate that homework tasks can be successfully incorporated into the relational psychoanalytic approach, fostering self-reflection and facilitating transformative change in patients with personality disorders.

EFT is an empirically supported treatment of depression for individuals, and is also considered to be an integrative, transdiagnostic therapy approach focusing on emotions that are the cause of a client's emotional pain and suffering. The target of treatment is to facilitate emotional processing to change unhealthy emotion schemes that underlie current symptoms of depression. The therapist is highly attuned to the client's moment-by-moment process to promote in-session work on emotion, alongside experiential teaching. In-session work is consolidated and expanded by between-session homework, which is viewed as a natural extension of the in-session work. EFT views the therapist as an emotion coach who offers interventions within a client's developmental and experiential learning capabilities to move them to their end goals. A case example is discussed to illustrate how homework is used effectively in treating a depressed client in relation to treatment principles over the course of treatment.

Background Misophonia is often characterized by excessive negative emotional responses, including anger and anxiety, to “trigger sounds” which are typically day-to-day sounds, such as those generated from people eating. Misophonia (literally ‘hatred of sounds’) has commonly been understood within an auditory processing framework where sounds cause distress due to aberrant processing in the auditory and emotional systems of the brain. However, recent evidence from brain imaging shows involvement of the motor system while listening to trigger sounds suggesting that the perception of an action (e.g., mouth movement) produced by a trigger person, not the sound per se, drives distress in misophonia. Observation or listening to sounds of another’s actions are known to prompt automatic mimicry/imitations. Apart from anecdotal evidence and a few case studies, a relationship between mimicry and misophonia has not been evaluated. Method We addressed this ‘gap’ by collecting data on misophonia symptoms and mimicry behaviour using online questionnaires from 676 participants. Results The analysis shows, (i) the tendency to mimic varies in direct proportion to misophonia severity assessed using a self-reported questionnaire, (ii) compared to other human and environmental sounds, trigger sounds of eating and chewing are more likely to trigger mimicking, and (iii) the act of mimicking provides relief from distress to most people with misophonia. Conclusion Mimicry is widely prevalent in misophonia and is elicited by the most common trigger sounds of eating. The data provides support to the model that misophonia is not a disorder of sound-processing but rather its basis lies in social perception.

Objective: Intrusive thoughts are characterized by a sense of intrusiveness of foreign entry into cognition. While not always consisting of negative content, intrusive thoughts are almost solely investigated in that context. Involuntary Musical Imagery (INMI) offers a promising alternative, as it is a type of involuntary cognition that can be used to evaluate intrusiveness without negative content. Methos: In Study 1, 200 participants completed self-report questionnaires to assess several aspects of intrusiveness: meta-awareness, control, repetitiveness, frequency, and subjective experience of INMI. In Study 2, 203 participants completed self-report questionnaires to explore the clinical characteristics (depression, stress, anxiety, and rumination) which might mediate the connection between INMI frequency and INMI negative experience. Results: Study 1 revealed, through exploratory factor analysis, that intrusiveness shares variance with the negative experience of INMI but not with INMI frequency. In study 2, ruminative thinking was found to mediate the relationship between frequent INMI and negative experience of INMI. Conclusion: These results suggest that INMI might be used to investigate intrusiveness in the lab without the potential confound of negative emotions. In addition, the results suggest that neither the content nor the frequency of intrusive thoughts can solely explain why these thoughts are aversive to some but not others. Ruminative style might be the missing link to explain how and why these intrusive thoughts become aversive and obsessive. In other words, we suggest that the cause for intrusiveness lies not in the thought or repetitiveness, but in the thinker.

Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization (WHO)’s International Classification of Diseases (ICD-11). This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of CPTSD. SNT balances interventions that address current day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man. The treatment introduces client tailored coping skills for current minority stress, discrimination and micro-aggressions as well as trauma-focused interventions regarding events from his childhood and the death of his partner and many members of his community due to the AIDS epidemic. Qualitative and quantitative outcomes are summarized. Implications regarding the relevance of SNT for sexual and gender minority (SGM) individuals is discussed.