Outcome and Prognosis
After a year and a half, Mark is no longer depressed and devitalized, and many features of NPD have faded. The most evident change is that he now tries and pursues some personal goal: he acts without giving up and does not lie anymore. Mark hold now more benevolent ideas of himself and of others: he now describes himself as entitled to do what he wants, freely, and others as possibly supportive and sometimes encouraging. He is not anymore flooded with images of his aunt or sister suffering and blaming for being selfish and leaving them alone. In fact, he shares his ideas with them, and to his surprise, they often support him.
Grandiosity is decreased. Mark is considering the possibility of graduating and then changing jobs to earn more but he doesn’t do it to catch up with others: he just feels he wants to have more economic independence and, in general, to be able to do more things for himself. He also he engages in activities just for the sake of having fun and exploring and not necessarily for purposes of personal value. For example in tennis he tells me about the physical effort, the fun with the people he meets, he often loses but lives it with serenity.
We are currently considering that Mark lives alone after having searched for a foster care home for Sandra, though this is momentarily on hold, given that Sandra had serious health issues which both made Mark worry on a reality basis and triggered his schema-driven guilt. As for social relationships, Mark wants a romantic relationship and to have friends and is aware that he must learn that to satisfy these desires he must control his tendencies to denigrate others and give less space to thoughts full of envy and resentment. In this regard the contract has changed. The goal is to have more social, intimate ties, based on sharing and the first agreed task is to try to refrain from expressing critical, devaluing comments or implementing passive-aggressive strategies. Now that he takes more space to go out, he has more opportunities to see other people, especially colleagues, and therefore has more opportunities to prove himself. In a recent session he tells me that he met a colleague of his, Lara, in a wine bar, with whom he has been spending a lot of time lately. While they were having dinner, a friend of Lara’s joins them and talks about her holidays and her latest purchase: a jet ski. Mark tells me:
M: “So, let’s be clear. I bit my tongue and didn’t say anything to him, but he slammed his jet ski in our faces! she told how cool and fun she was …. Lara looked at him with dreamy eyes ( imitating her). I defy anyone not to tell him four!” ( smiling)
T: ”And you? How did you feel at that moment?”
M: Oobviously, the envy started… it was all there! But I swear I didn’t tell him anything…” (he smiles again)
T: ”Did you notice that contempt was starting and did you regulate it? Was it difficult”
M: ”Yes, but all in all, I didn’t feel I was worth less because I’ve never seen a jet ski in my life…”
This is just one example of the work Mark is doing on his way of relating to others. Even in therapy, he is more open and clearer, collaborates in defining goals and tasks and does not perceive me as a threat. Even with me he undertakes to regulate his tendency to devaluation, he warns me when he feels the urge to do so and we talk about it together.