Abstract
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.
How to best treat persons suffering from pathological narcissism or narcissistic personality disorder (NPD)? As of today, the answer does not come from outcome studies, as they are mostly lacking (Yakeley, 2018; Weinberg & Ronnigstam, 2020). What currently have is only a series of principles that some authors have distilled from the literature on the disorder and from their own clinical work. Researchers have neglected NPD, notwithstanding its prevalence is significant and it is associated with serious levels of suffering, social dysfunction and decline in the second half of life once the dreams of glory of the youth leave room to a sense that paradise has been lost forever and one is doomed to failure.
NPD can be treated (Weinberg, 2023; Weinberg & Ronnignstam, 2020; Yakeley, 2018), the question is: how? In absence of empirically supported treatments, clinicians need principles that guide their action. Weinberg and Ronningstam (2020) have offered pragmatic suggestions for what to do and what not to do when treating NPD, while Dimaggio (2022) have proposed how to tackle with the different aspects of narcissistic pathology. Here we will focus on one aspect which has received insufficient attention, that is how to build, draft and constantly revise a therapeutic contract, one where goals are clear, psychological meaningful and pragmatic oriented, and where patients with NPD understand that doing something is necessary to move towards health and well-being and to restore hope. As Ronningstam and Weinberg (2023) note, “Some therapies proceed without measurable realistic goals”, but why is it difficult agreeing on a therapeutic contract with NPD? We offer here a series of hypothesis, based on an understanding of narcissistic pathology. Then, in the description of the clinical story, we will show how the therapist of a man with NPD tried and addressed some of these problems.
Poor awareness of inner states and of suffering
In order to set goals, and devise tasks suited to fulfil them, persons need to have a clear awareness of the ideas making them suffer and of emotions they experience. But many with NPD have poor capacity for self-reflection. They cannot describe their inner experience, in particular suffering and vulnerability. At the same time, they only offer generic reasons for their disappointing outcomes, such as “society does not offer opportunities for a person like me”, or “women (or men) are shallow”. Consequently, clinicians face difficulty setting reasonable and shared goals, and in designing tasks suited to achieve the desired ends.
Neverending quest for grandiosity. Lack of investment in goals others than the quest for status or for pleasure
NPD often enter therapy feeling empty and bored. Once clinicians explore the reason, patients answer they feel nostalgia for a paradise now lost. They ask to restore grandiosity and they think that would be the only way out from their depression and worthlessness. Clinicians cannot agree on such a goal that would only sustain grandiosity and is unrealistic. Connected to this aspect, is that restoring a sense of a life worth living, requires investing in areas such as intimacy, connection and to experience relaxation and playfulness. Moreover, given that humans cannot take for granted that their strives will succeed, they would better focus on the process of achieving something more than on the result. This means they need to value training, workout and the effort they put while striving to reach an end, instead of focusing on success only. But NPD mostly strives for status and for pleasure, so anything else sounds meaningless to them. Consequently, when therapists try and set goals and tasks in order for example to overcome depression they are not motivated to pursue them as they do not see these will help gain recognition.
Lack of trust in the therapist and ideas that others cannot help
Patients with NPD do experience suffering, which activates their need for help. Problem is that they lack the idea that others are interested or capable of helping them. Their expectation is that if they display vulnerability the other will either a) be uncapable of helping or just will not care; b) will exploit, humiliate or manipulate them; c) will suffer if they show their suffering. The last point seems counterintuitive, but patients with NPD often comes from families where a member had problems such as alcohol abuse, psychiatric or physical illnesses, or faced serious economic setbacks. They learnt that if they display their problems relatives will suffer in turn, which makes them feel guilty. We anticipate this is a central feature of the case described here.
NPD attitude towards the therapist ranges from expecting the therapist has a magic wand so they do not have to display vulnerability, to devaluation and contempt. When therapists try to set goals and tasks, patients with NPD deny any value in their proposal and remain stuck, while at the same time blaming them for lack of progress.
Focus on other as the source of problems and lack of agency over own inner world
Typically, narcissistic discourse if focused on others’ misdeed. Patients spend time complaining others are stupid, non-supportive, or source of problems they have to handle. They focus on how colleagues and bosses do not recognize their exceptional qualities, how romantic partners are dull and boring, or how they are bound to take care for their family instead of receiving the support they deserve. They often focus on the wrongdoings they think they have received and protest against parents, relatives, current and past romantic partners, friends and co-workers. They wait for others to repair their mistakes but in so doing, they swing between anger, resentment and despise. None of these attitudes help them moving forward. In parallel, they are deprived of agency (Dimaggio & Lysaker, 2015; Ronningstam, 2020). Put it simply, they do not think and feel they have power over themselves or to ignite changes in the world. They ruminating about past setbacks or about the problems caused by others, but once faced with the idea they could do something they remain powerlessness and paralysed and do not believe that any action can help. They experience anger, frustration, envy and resentment, and if the therapist suggests they have the power to regulate these emotions and to access to a different state of mind, they answer this is not possible, that their mood is the consequence of events that are beyond their control, and so if the world remains the same, and they do think it will stay the same, their mood will not change.
Underlying fragile, unstable and poor self-esteem
In order to change, persons need to trust they can reach the desired outcome, meaning they need a solid-enough self-esteem. But under the grandiose façade, NPD’s self-esteem is either unstable of fragile (Mota et al., 2020; Ronningstam, 2020). In particular if they experience vulnerability their self-esteem collapses: “I am weak and inferior”. So, they ask for help without disclosing their weaknesses in order to conceal their poor self-esteem. When they are capable of acknowledging their weaknesses, they consider them a sign of inferiority or unworthiness so they fear therapists’ judgment and have no faith they can change.
The above listed elements are among the main reasons for why setting reasonable therapy goals and agreeing on the tasks needed to achieve them is difficult when treating NPD. If therapists are unaware of these problems, they are at risk of negative reactions. One typical relational pattern is the patient pressuring for change and the therapist swinging among guilt, shame, frustration and anger. Therapists can insist on adopting techniques such as mindfulness, guided imagery, behavioural homework, with the results that patients disagree with them, devaluate tasks, or comply formally but do not complete any task.
In order to agree on goals and tasks, a series of operations are therefore necessary. First, therapists need to be crystal-clear since therapy onset about what therapy can promise and how it works. Therapists need to state that they need to understand what the therapy goals are before promising anything. They have to frame goals that are realistic, observable and easy to monitor for the both of them. Then they have to make the case that without active effort to change something in own ideas and attitudes, they cannot promise any sustained change, both in the domain of symptoms and in the realm of social relationship. In other words, therapists need to clear that associated symptom disorders or mechanisms such as anxiety, depression or worry will not disappear without effort. So, they have to invite patients deciding if they agree overcoming avoidance, accepting behavioural activation practices and so on.