See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/340008837

Dos and Don'ts in Treatments of Patients With Narcissistic Personality

Disorder

Article in Journal of Personality Disorders · March 2020

DOI: 10.1521/pedi.2020.34.supp.122

CITATIONS READS
35 15,883

2 authors:

Igor Weinberg Elsa Ronningstam

Harvard University Harvard Medical School
46 PUBLICATIONS 1,629 CITATIONS 97 PUBLICATIONS 3,217 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Igor Weinberg on 24 March 2020.

The user has requested enhancement of the downloaded file.

 Journal of Personality Disorders, 34, Special Issue, 122–142, 2020
© 2020 The Guilford Press

DOS AND DON’TS IN TREATMENTS

OF PATIENTS WITH
NARCISSISTIC PERSONALITY DISORDER
Igor Weinberg, PhD, and Elsa Ronningstam, PhD

This article identifies guiding principles in effective psychotherapies of

patients with narcissistic personality disorder (NPD) and cautions against
some common pitfalls. Individual psychotherapies of NPD patients were
examined by both authors, who tested whether or not some principles,
recommended in the literature, effectively promote these therapies and help
these patients in moving forward with their lives and with effective therapy
use. The authors identify a number of principles that were associated with
more positive therapy development: helping patients identify goals and
direction of their therapies, promoting a sense of agency, promoting a shift
of focus to sense of vulnerability, and anticipating difficulty in developing
and maintaining the treatment alliance. Common mistakes in these
treatments are engaging in a power struggle with the patient, overindulging
the grandiosity of the patient, directly challenging the grandiosity of
the patient, and ignoring treatment-interfering behaviors. Identification
of principles of effective therapies with NPD patients can help with the
development of more effective treatment approaches for NPD.

Keywords: narcissistic personality disorder, psychotherapy, treatment

principles

Narcissistic personality disorder (NPD) is characterized by self-enhancement,

grandiose self-perception, need for admiring attention, exploitativeness, com-
promised empathy, and fantasies of unlimited success among others (American
Psychiatric Association, 2013; Ronningstam, 2009). The prevalence of NPD
varies from 0%–6% in the general population, 1.3%–20% in the clinical
population, and 8.5%–20% in outpatient private practice (Lenzenweger, Lane,
Loranger, & Kessler, 2007; Torgersen, 2012; Zimmerman, Chelminski, &
Young, 2008).
NPD is associated with increased risk of comorbid mood disorder, anxiety
disorder, and substance use disorder (Simonsen & Simonsen, 2011; Stinson
et al., 2008); risk of suicide (Ronningstam & Weinberg, 2013); and vocational,
relational, and marital problems (Pulay et al., 2008; Ronningstam, 2009).

From McLean Hospital, Belmont, Massachusetts.

Address correspondence to Igor Weinberg, PhD, McLean Hospital, 115 Mill St., Belmont, MA 02478.
E-mail: [email protected]

08_G4784_460.indd 122 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 123

NPD predicts worse prognosis for such Axis I conditions as mood and anxiety
disorders and substance use (Campbell, Waller, & Pistrang, 2009; Fava et al.,
2002; Thiel et al., 2013). NPD is stable over time (McGlashan & Heinssen,
1989; Plakun, 1989; Vater et al., 2014), although improvements are possible
and usually occur in the context of corrective emotional experiences related to
achievements, interpersonal relationships, or disillusionments (Ronningstam,
Gunderson, & Lyons, 1995).
Existing treatments are only marginally helpful to NPD patients. A
few theories have suggested treatment approaches to NPD (Table 1). None
of these treatments were tested in randomized controlled trials with NPD
patients, and when NPD patients were included in the sample, their actual
number was either too small for statistical analyses or the results were not
reported separately for NPD patients (Ball, 2007; Ball, Cobb-Richardson.
Connolly, Bujosa, & O’Neall, 2005; Ball, Maccarelli, LaPaglia, & Ostrowski,
2011; Bamelis, Evers, Spinhoven, & Arntz, 2014; Clarkin, Levy, Lenzenweger,
& Kernberg, 2007; Vinnars, Barber, Norén, Gallop, & Weinryb, 2005). In
addition, treatment modalities for NPD patients with comorbid borderline
personality disorder (BPD) have been outlined (Diamond, Clarkin, et al.,
2014). Specific pharmacological treatments for NPD are lacking, and typical
treatment strategies involve symptomatic treatment of comorbid conditions
(Ronningstam & Weinberg, 2013).
When tested, NPD is often associated with absence of progress or nega-
tive treatment outcome. NPD predicts poor use of treatment services, higher
rate of sudden or premature termination of treatment (Campbell et al., 2009;
Ellison, Levy, Cain, Ansell, & Pincus, 2013), and higher symptom persistence
following therapy (Jansson, Hesse, & Fridell, 2008). Clinical observations
suggest that comorbid NPD in BPD patients impedes progress in such thera-
pies as mentalization-based treatment (A. W. Bateman & P. Fonagy, personal
communication, MBT training workshop, June 29, 2013, McLean Hospital,
MA) and transference-based psychotherapy (Diamond, Clarkin, et al., 2014).

TABLE 1. Psychotherapies for NPD

Specific treatments:
Psychoanalytic psychotherapy (Fiscalini & Grey, 1993; Kernberg, 1975; Kohut, 1971; Ronningstam &
Maltsberger, 2007; Rosenfeld, 1987)
Cognitive-behavior therapy (Beck, Davis, & Freeman, 2005)
Schema-focused psychotherapy (Young et al., 2003)
Metacognitive psychotherapy (Dimaggio & Attina, 2012)
Couples therapy (Links & Stockwell, 2002)
Group therapy (Alonso, 1992)
Modified:
Transference-focused psychotherapy (Diamond, Levy, et al., 2014; Diamond & Meehan, 2014)
Dialectical behavior therapy (Lynch & Cheavens, 2007)
Mentalization-based treatment (A. W. Bateman, personal communication, NASSPD Conference, March 28,
2015, Boston, MA)

08_G4784_460.indd 123 3/11/2020 12:36:55 PM

 124 WEINBERG AND RONNINGSTAM

Specific features associated with NPD were found to impede treatment

progress as well. Perfectionism is associated with slower improvement in
treatment of depression, obsessive-compulsive disorder, bulimia (Blatt, Zuroff,
Bondi, Sanislow, & Pilkonis, 1998; Pinto, Liebowitz, Foa, & Simpson, 2011;
Steele, Bergin, & Wade, 2011), and a weaker therapeutic alliance (Zuroff et al.,
2000). Dismissive attachment is associated with a weaker therapeutic alliance,
less treatment commitment, less self-disclosure, more off-topic discussion in
therapy, and longer silences (Bernecker, Levy, & Ellison, 2014; Dozier, Lomax,
Tyrrell, & Lee, 2001; Korfmacher, Adam, Ogawa, & Egeland, 1997). NPD
patients can engage in intensive preoccupation with negativity, blame, and
criticism, as well as in a range of strategies to manipulate, avoid, and dismiss
both the therapist and people or contexts in their lives outside treatment. Other
attachment patterns associated with NPD (i.e., anxious-avoidant and cannot
classify) also limit the therapeutic alliance. These contribute to stalemates, mis-
guided interpretations, and negative enactments. Shame contributes to slower
treatment progress (Feiring & Taska, 2005; Guilé, Mbékou, & Lageix, 2004),
poor attendance (Sheeran, Aubrey, & Kellett, 2007), and a weaker treatment
alliance (Black, Curran, & Dyer, 2013). Devaluation of others was reported
to predict worse treatment outcome (Guilé et al., 2004).
Clinical reports have documented a wide variety of challenges that con-
tribute to worse outcome in therapies with NPD patients (Table 2). In this
article, we suggest a pragmatic treatment approach that promotes change and
self-awareness in NPD patients (see Table 3). It is based on our experience and
is not affiliated with a particular theoretical model. Rather, we expect that it
can inform practices of those who treat NPD patients.

DOS

Taking a practical, goal-, and change-oriented approach is critical in treat-

ment of NPD patients. Avoidance, including emotional and interpersonal
distancing, permeates the lives of NPD patients, and therefore treatment must
offer functional alternatives to the self-defeating solutions they are expertly
adopting. Similarly, therapists must be prepared for patients’ dismissiveness.
Exceptional patience and sensitivity to the patients’ susceptibility to feeling
humiliated, blamed, shamed, entrapped, and defeated are critical. In addition,
repeated expressions of expectation of change and insistence on clear and
measurable change-oriented goals are important.

HELP THE PATIENT IDENTIFY CONCRETE, REALISTIC,

AND MEASURABLE TREATMENT GOALS THAT
THE PATIENT IDENTIFIES AS HIS OR HER OWN
Identification of treatment goals is an essential component of the treatment
of NPD patients. Such goals must be meaningfully related to what the patient
values or wants to change. They are connected to the person-valued directions
(Hayes, Strosahl, & Wilson, 1985) and the concept of authentic self (John-
son, 1989; Winnicott, 1965). The therapist and the patient work together to

08_G4784_460.indd 124 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 125

TABLE 2. Challenges in Treatment of NPD Patients

A. Cognitive
1. Poor recognition of internal states or psychological causes (Dimaggio et al., 2008)
2. Intolerance of differences of perspectives (Britton, 2004)
3. “Reversible perspective”—denial of awareness accomplished in therapy (Etchegoyen, 2005; Kernberg, 2007)
4. Refusal to accept logical explanations (Kernberg, 2007)
B. Emotional
1. Difficulty to access, label, and express emotions (Dimaggio et al., 2008; Modell, 1975; Ronningstam, 2017)
2. Fear and avoidance (Ronningstam & Baskin-Sommers, 2013)
3. Boredom and stimulus hunger (Ronningstam, 1996)
4. Meaninglessness (Ronningstam, 1996)
C. Interpersonal
1. Impoverished relationships (Kernberg, 2007)
2. Extreme competitiveness and envy of therapist (Kernberg, 2007)
3. Dismissive or “cannot classify” attachment (Diamond, Clarkin, et al., 2014)
4. Fear of dependence on therapist (Kernberg, 2007)
5. Paranoid reactions to therapist (Kernberg, 2007)
D. Self-esteem
1. Search for self-affirmation, not awareness (Kernberg, 2007; Ronningstam, 2005)
2. Externalization of responsibility (Ronningstam, 2005)
3. Chronic self-criticism, self-loathing, or self-hatred (Kernberg, 2007; Ronningstam, 2005)
4. Perfectionism (Ronningstam, 2005)
E. Moral functioning
1. Lack of ownership of responsibility (Kernberg, 2007; Ronningstam, 2005)
2. Dishonesty (Kernberg, 2007)
3. Lack of commitment (Kernberg, 2007)
4. Limited capacity for remorse (Kernberg, 2007)
5. Social parasitism (Kernberg, 2007)
F. Motivation for change
1. External (Ronningstam, 2005)
2. Crises-generated and mood dependent (Ronningstam, 2005)
3. Undermined by parasitic arrangements, misuse of VIP status, or power (Kernberg, 2007; Silverman et al., 2012)
G. Countertransference
Powerful countertransference reactions are likely to lead to treatment-interfering and even
treatment-destructive enactments, if left unexamined.

collaboratively identify realistic, clear, and measurable goals. Treatment goals

are the anchor of therapy, and they create motivation for change and the glue
that helps the patient continue in therapy despite expected difficulties.
Psychoeducation is an important step toward identification of realistic
goals. Discussion and explanation of the NPD diagnosis is also important,
although it is critical to conduct such discussion in experience-near terms, using
the words of the patient and avoiding judgmental, nondescriptive language.
Patients feel understood when they are given a clear formulation of their

08_G4784_460.indd 125 3/11/2020 12:36:55 PM

 126 WEINBERG AND RONNINGSTAM

TABLE 3. Pragmatic Treatment Approach

Dos:
1. Help the patient spell out concreate, realistic, and measurable treatment goals that the patient identifies as
his or her own.
2. Help develop sense of agency; identify patient’s strengths and weaknesses and help connect those to
treatment goals.
3. Help the patient shift from grandiosity and self-loathing to interactive explorations, discussion, and
experiences of real vulnerability.
4. Use validation to verify challenging experiences, threats to self-esteem, and occurrence of vulnerability or
loss of control.
5. Encourage curiosity, coherent narratives, and tolerance of uncertainty and contradictions.
6. Use a problem-focused exploratory strategy to develop a “collaborative alliance” (i.e., patient is an expert
on herself or himself, working “side by side”).
7. Use contracts to anticipate threats to alliance and productive collaboration; attend to and incorporate life-
ultimatums; use treatment-related ultimatums as a last resort.
8. Address treatment-interfering behaviors as they come up in treatment.
Don’ts:
1. Do not ignore countertransference.
2. Do not engage in power struggle or misuse of power (e.g., a noncollaborative relationship).
3. Do not directly challenge the patient’s grandiosity or self-loathing.
4. Do not indulge grandiosity or self-loathing.
5. Do not rely on primarily empathy-based interventions.
6. Do not ignore self-esteem–relevant life events.

NPD-relevant difficulties, how they contribute to other comorbid conditions,

and how they undermine important personal goals. Psychoeducation regard-
ing the purpose and format of therapy as well as realistic goals (i.e., what
therapy can or cannot accomplish) is yet another intervention. Connecting
identified goals to the difficulties with self-esteem regulation strengthens the
alliance, makes the patient feel understood, and increases treatment motiva-
tion. Treatment goals should not be confused with the pursuit of perfectionistic
or grandiose goals. When the patient chooses those instead of realistic goals,
the therapist could open the discussion of what these lofty goals represent in
terms of valued direction (Hayes et al., 1985) and in such a way help refor-
mulate the goals.
Validation of the patient’s motivation and capabilities is yet another way
to promote goal identification. With other patients, identification of goals
requires gradual resolution of various obstacles: fear of failure, procrastination,
emotional avoidance, shame, fear of reliance on the therapist, and hopelessness,
or the tendency to choose the same solution to every problem. Identification
of goals is in itself a challenge to grandiose self-perception, and helping the
patient tolerate these goals is therefore an important step toward change.
Identification of goals helps with development of autonomous motivation
for treatment (Zuroff et al., 2007). Autonomous motivation, which refers to
motivation that patients experience as their own, as opposed to one moti-
vated by guilt, shame, the desire to please others, or compliance with external

08_G4784_460.indd 126 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 127

standards, is especially important. Autonomous motivation was found to be a

strong predictor of treatment outcome, sometimes beyond the contribution of
the treatment alliance (McBride et al., 2010; Zuroff et al., 2007). Because the
therapeutic alliance with NPD patients is vulnerable to ruptures, developing
autonomous motivation for treatment helps to sustain the treatment in the
face of challenges and helps the patient develop a sense of agency and a focus
on change, rather than maintaining the status quo. An important component
of this process is helping NPD patients define goals that they experience as
their own.
Sometimes definition of goals requires a long effort as the patient is
retreating from a meaningful discussion and defines goals through grandiose
self-perception, expectations of others, or attempts to avoid uncertainty or
failure. Patience is required to allow the patient to develop trust in the treat-
ment and the therapist, and to confront obstacles to goal identification. The
therapist has to adopt a curious stance about the patient and invite the patient
to be curious about these obstacles.

HELP DEVELOP A SENSE OF AGENCY;

IDENTIFY A PATIENT’S STRENGTHS AND WEAKNESSES
AND HELP CONNECT THOSE TO TREATMENT GOALS
Defining goals is closely related to helping the patient develop a sense of agency,
which is central for patients with NPD. The sense of agency involves a range
of narcissistic strategies that regulate self-esteem, that is, sense of control, self-
direction, and executive competence (Knox, 2011). Many people with NPD
are indeed capable, some in certain areas or under specific conditions, and
others more consistently within specific areas of competence. Paradoxically,
some NPD patients display remarkable accomplishments, although they still
may lack a sense of agency or ownership of their lives and goals. Self-agency
is an important mediator of change in therapy, especially in NPD patients,
who can have a fluctuating sense of agency (Foster & Brennan, 2011; Knox,
2011; Ronningstam, 2014).
A number of interventions help develop a sense of agency in NPD
patients. First, some interventions that can stabilize or even increase a sense
of agency are indeed behavioral. They vary from taking a job or assuming an
important role in the treatment milieu to gaining a sense of internal control
over problem solving and emotional experiences. Pursuit of treatment goals
is just one example of how treatment helps increase the sense of agency.
Second, reflective listening helps the patient generate a meaningful narrative
about him- or herself (Adler, 2010). Resolving inconsistencies and contradic-
tions in the discourse seem to increase the sense of agency (Adler, Harmeling,
& Walder-Biesanz, 2013). Third, a collaborative therapeutic relationship is
essential to promote self-agency. Knox (2011) labeled this the “co-constructive
relational process.” If this stance is not established, the NPD patient will feel
too vulnerable or disempowered to engage in treatment.
Fourth, other strategies help the patient deal with obstacles to developing
a sense of agency, including extreme self-criticism, self-loathing, self-shaming,
or other types of ruthless self-attacks. Shame—a painful awareness of perceived

08_G4784_460.indd 127 3/11/2020 12:36:55 PM

 128 WEINBERG AND RONNINGSTAM

or actual shortcomings of oneself—decreases general arousal and a sense of

capability, and contributes to avoidance motivation (Schore, 1994; Tangney
& Fischer, 1995). Exploring self-shaming processes (Kris, 1990) and clarifying
conflicting ideas (Morrison, 1989) are other important foci of intervention in
these states. It is important to help the patient recognize the function of these
processes (e.g., holding oneself to a high standard, preserving grandiosity
through self-criticism, motivating oneself through humiliation and punish-
ment), as well as the avoidant nature of the self-critical statements.
Further interventions, ranging from shame exposure (Rizvi & Linehan,
2005) to symbolically disempowering the person inflicting humiliation, have
been described (Torres & Bergner, 2012). Recognizing that for some patients
these feelings serve an avoidant function should prompt an exposure-based
exploratory treatment strategy.

HELP THE PATIENT SHIFT FROM GRANDIOSITY

AND SELF-LOATHING TO DISCUSSING EXPERIENCES
OF REAL COMPETENCE AND WEAKNESSES;
ENCOURAGE CURIOSITY AND TOLERANCE OF UNCERTAINTY
The shift toward more genuine self-experience and self-expression is one of
the central processes of change in treatments of NPD patients (Johnson, 1989;
Kernberg, 1975; Masterson, 1981). This process usually happens gradually
when the patients are able to trust themselves as well as the therapist, and are
able to acknowledge and share inner thoughts, feelings, and observations. A
number of strategies and interventions promote this process.
First, adopting an exploratory, open-minded stance is important. Encour-
aging the patient to discuss internal experiences, not just external life events,
and applying a collaborative approach to clarify the patient’s perspective are
most helpful. In addition, clarifying changing and incompatible perspectives
on self and others, and encouraging awareness of triggers, fluctuations in
self-esteem, and adaptive and maladaptive coping strategies can move the
process forward (Ronningstam, 2012). The key components in this process
are (a) the therapist’s curiosity about the inner experience conveyed through
questions about it and detailed exploration of various patterns of thoughts,
feelings, and behavior; (b) the therapist’s neutral validation of the patient’s
experiences; and (c) the therapist’s listening without making assumptions or
holding preconceived notions about the patient.
A second strategy is helping the patient identify the function of grandios-
ity and self-loathing. Grandiose self-perception and self-loathing both serve
the very similar function of distancing oneself from one’s real experiences,
including from one’s body. They also provide pathological certainty and tend
to limit the range of experience and self-expression. Helping the patient move
beyond grandiosity or self-loathing is a gradual process that depends on close
collaboration in therapy.
Third, this shift could happen when the NPD patient confronts real
disillusionment and is able to process it in a sympathetic environment (Ron-
ningstam et al., 1995). The nature of the shift is toward more integrated self-­
representations, a more cohesive self-narrative, a more balanced self-perception,

08_G4784_460.indd 128 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 129

and more grounded experiences of one’s own body. The patient becomes more
able to acknowledge and embrace a wider range of internal experiences and
to develop a sense of ownership over them. As a result, the patient is able
to shift from pathological certainty and pathological curiosity (Bion, 1962;
Steiner, 1994) to the ability to tolerate uncertainty and normal curiosity about
self and others.
Fourth, given the mentalization deficits of NPD patients (Diamond, Levy,
et al., 2014), a number of mentalizing-based strategies are especially helpful
(Allen, Fonagy, & Bateman, 2008). These include challenging assumptions
and beliefs that are held with certainty, redirecting the patient from report-
ing to reflecting, and helping the patient shift back and forth from curiosity
about self versus others as well as from feelings to thinking. Validating sur-
prise, curiosity, and growing interest in understanding self and others help
patients feel supported in developing their new capacities (Allen et al., 2008;
Masterson, 1993).
Fifth, an extreme manifestation of intolerance of uncertainty is not
accepting a difference in perspectives vis-à-vis the therapist (Britton, 2004).
This could lead to attempts by the patient to control the therapist’s interven-
tions and thinking. In this case, continuous validation of the patient’s experi-
ence, curiosity about the patient’s experience, and explorations of the patient’s
reactions to real or perceived differences are critical in helping the patient
develop the capacity to tolerate differences.
Avoiding the following pitfalls is critical in this process. First, pushing the
patient to make behavioral changes that are not connected to values or ideals,
and/or not exploring the meaning and process of making these changes, tend to
distance the patient from developing a more authentic self-awareness. Similarly,
an overemphasis on the therapeutic relationship and ignoring outside events
and influences offers an escape into a fantasy-like world that is disconnected
from life. Finally, an excessive focus on feelings and minimizing real events that
prompt them tend to distance the patient from taking ownership of his or her
life and confronting the consequences of personal actions. In other words, these
interventions are optimally effective when they are accompanied by development
of a stronger alliance with the therapist, development of a sense of agency, and
movement toward realistic, meaningful goals outside of the consulting room.
These changes need to be encouraged and fostered by the therapist.

USE AN EXPLORATORY PROBLEM-SOLVING APPROACH

TO DEVELOP A “COLLABORATIVE THERAPEUTIC ALLIANCE”
Developing a therapeutic alliance with patients with NPD is limited by their
attachment style. Only a few studies have focused on the attachment patterns
of NPD patients, although they consistently document dismissive, anxious-
avoidant, or unable-to-classify patterns (Diamond, Levy, et al., 2014; Diamond
& Meehan, 2013; Meyer & Pilkonis, 2011). Dismissing others takes many
forms, ranging from devaluing them out of fear of rejection or humiliationto
idealizing them in the hope of establishing a “mutual idealization society”
(Wallin, 2007). For other NPD patients, dismissal of others and retreat into
“splendid isolation” helps maintain an illusion of control and protects from

08_G4784_460.indd 129 3/11/2020 12:36:55 PM

 130 WEINBERG AND RONNINGSTAM

unwelcome emotional experiences and a sense of feared vulnerability. Both

dismissing attachment and shame were found to interfere with an effective
therapeutic alliance (Black et al., 2013; Diener & Monroe, 2011). Such pat-
terns are usually understood in the context of relational trauma (Maldonado,
2006). Consequently, the relationship with the therapist is not seen as a safe
haven where self-exploration, growth, and connection are possible; instead,
the relationship is imbued with ghostly presences from the traumatic past.
Literature on the treatment alliance distinguishes between three types
of alliance: (a) a contractual agreement between the therapist and the patient
regarding their work together and goals of therapy,(b) an agreement regarding
roles and responsibilities of the therapist and the patient, and (c) attachment
to the therapist (Luborsky, 1976). These distinctions are helpful in guiding
treatment interventions with NPD patients. In general, the first two compo-
nents are contractual and negotiable aspects of the treatment relationship;
the third component is one of the treatment targets, which, once established,
is also a powerful leverage for change.

Contractual Agreement. Establishing safety is the first major task of therapy

with narcissistic patients. It is related to open discussion of the treatment frame
and of expected and prohibited behaviors. Another aspect of establishing
safety is discussing and anticipating different treatment-interfering behaviors
(see below), which endanger the very enterprise of productive treatment col-
laboration. The safety of the therapist is of critical importance, and discussion
of problems that can put the therapist at risk is a high treatment priority.
We advise taking a collaborative approach to building a therapeutic alli-
ance (Jobes, 2000; Ponsi, 2000). Such aspects of alliance building are reflected
in collaborative goal setting, tracking progress and staying on the task of
making changes, and establishing a constructive approach to problem solv-
ing, including problems in therapeutic relationship (Jobes, 2000). It requires
working “side by side” rather than imposing treatment goals and interventions
(Jobes, 2000). This approach recognizes that both therapist and patient have
roles and contributions to functional and dysfunctional patterns of relating,
and that they are willing to take a look at them (Fiscalini & Grey, 1993).
Curiosity about self and others is encouraged, while pathological certainty
and pathological curiosity are explored (Ronningstam, 2012).

Defining Roles and Responsibilities. This is an important area of negotiation

with NPD patients, who are sensitive to the power differential in the relation-
ship, misuse power, or expect misuse of power from the therapist. Therapy
becomes an opportunity to explore and change these areas of vulnerability
(Fiscalini, 1994).
First, psychoeducation about NPD and the nature of psychotherapy (see
above) helps in establishing clear role definitions and responsibilities. Second,
recognizing, validating, and exploring difficulties that NPD patients have in
the process of collaboration and reliance on the therapist are crucial. NPD
patients have inherent ambivalence around the treatment relationship, their
dependence on the skills and help of the therapist, and the nature of the work
together (Kernberg, 2007; Modell, 1975). They are fearful of dependence,

08_G4784_460.indd 130 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 131

which they experience as humiliating, and they can readily respond with envy,
competition, or devaluation of the therapist’s helpful interventions (Kernberg,
2007). Their fear and reluctance can also make them angrily devalue their
work with the therapist or even stop treatment as a way to reinstate control
and independence. Third, exploring various aspects of power differential, real
as well as perceived, is yet another avenue to promote collaboration (Fiscalini,
1994). NPD patients are particularly sensitive to real or imagined misuse of
power or nongenuine interactions. It is important to attend to the patient’s
disappointment, anger, and retaliation in the context of the treatment relation-
ship. Challenging ungrounded assumptions about the therapist’s attitudes,
beliefs, and feelings is central to this process.

Attachment Building. Development of attachment to the therapist is a gradual

and long-term task. It cannot be expected at the beginning of therapy but
requires persistence and close collaboration on resolving factors that interfere
with the formation of attachment to the therapist. Attachment to the therapist
serves an important role in the treatment process by providing an experience
of safety as well as of respectful and collaborative interaction. It also pro-
vides an opportunity to grow from the experience of the attachment itself,
as well as leverage for making changes. Viewing dismissive attachment as a
survival strategy in the context of relational trauma (Maldonado, 2006) helps
the therapist understand patients’ experiences. Longing for attachment—for
caring, dependency, intimacy—is likely to be fended off in NPD patients by
dissociation, intellectualization, anger, and escape into action, including the
use of mood-altering substances. The therapist must closely attend to the
patient’s experience and encourage awareness, experiencing, and sharing of
internal emotional states (Wallin, 2007).
A number of strategies help in building attachment in therapy with NPD
patients. First, helping the patient articulate the experience, including develop-
ing an emotional lexicon and tolerating emerging affects, is important (Jurist,
2005). Labeling emotional states in the patient and judicious disclosure of
emotional reactions to the patient’s narrative can promote emotional recogni-
tion and maintain the emotional focus of therapy. Once emotional experiences
become articulated and named, internal experiences become more manageable
and the patient is less likely to flee from emotional engagement in therapy.
Second, addressing dismissiveness in the therapeutic relationship is a
powerful way to engage the NPD patient. Two different approaches have
been described. One recommends identifying and naming this dismissive and
avoidant attitude with a patient in the here-and-now (Masterson, 1981). This
intervention promotes engagement in therapy and the development of more
secure attachment (Masterson, 1981; Wallin, 2007). Another approach sug-
gests identifying and exploring the function of the dismissiveness in the context
of different interpersonal themes as they unfold in the therapeutic relation-
ship. Exploration and clarification of these themes reveal that many NPD
patients tend to verbally describe one theme while behaviorally enacting its
opposite. For example, an NPD patient might describe how others reject him
or her while simultaneously displaying numerous patterns of avoidance and
dismissal of others. Recognition of this theme could lead to identification of

08_G4784_460.indd 131 3/11/2020 12:36:55 PM

 132 WEINBERG AND RONNINGSTAM

possible reversal of roles and a collaborative formulation and interpretation of

these patterns (Clarkin, Yeomans, & Kernberg, 2015). Repeated exploration
and experience of these dynamics helps establish a more secure attachment
(Diamond, Clarkin, et al., 2014) and provides an increased sense of predict-
ability and control. Identifying reversals is a powerful way to motivate NPD
patients to change, because these reversals contradict their ideal sense of self.
Third, a critical aspect of collaborative treatment engagement with NPD
patients is the ability to learn from the patient, that is, being open to guidance
from the patient regarding what helps and what does not. Some patients com-
municate directly what they think helps them. Others communicate indirectly,
as if they are telling an allegorical tale of what can or cannot help or how
different factors interfere with attachment and therapeutic work. Such com-
munications need to be taken seriously. Incorporating such guidance from the
patient promotes attunement and collaboration (Casement, 1985).
Fourth, viewing both therapist and patient as contributors to the thera-
peutic interaction promotes trust and models humility and the ability to take
responsibility for one’s actions. Acknowledging personal contributions to the
interaction, including apologizing for mistakes (Allen et al., 2008; Kohut,
1971), and viewing interaction as inherently a co-creation by two parties
(Ogden, 1994) promotes epistemic trust (Fonagy & Allison, 2014) and opens
the patient to internalizing new forms of interacting, thus promoting secure
attachment.
Finally, therapists of NPD patients need to maintain independent judg-
ment and a sense of personal limits, as well as reserving the right to interrupt
unworkable arrangements. Such “acts of freedom” can help promote produc-
tive collaboration and use of therapy (Symington, 1983).

USE CONTRACTS TO ANTICIPATE THREATS

TO THE ALLIANCE AND PRODUCTIVE COLLABORATION,
WITH ULTIMATUMS AS A LAST RESORT
Identification of possible roadblocks to effective collaboration is critical,
because many characteristics of NPD patients interfere with building effective
collaboration, including perfectionism, shame, dismissive attachment, defen-
sive devaluation or idealization of others, avoidance, and use of emotional
states (i.e., shame, anger) as well as language and circumstantial descriptions
in the service of such interference. Many times, patients with NPD have dif-
ficulty attending appointments and shift away from the initial agreements,
including disregarding treatment goals and treatment agreements (Diamond,
Levy, et al., 2014; Ronningstam, 2012). They can also engage in a seemingly
committed and reliable alliance but without noticeable challenges and change.
In such cases, the transference may indicate a combination of dependency
upon the therapist and avoidance of life engagement, which tends to preserve
the status quo. Exploration of past episodes of treatment as well as of histo-
ries of important relationships can help anticipate many of the threats to an
effective alliance.
Treatment contracts (Clarkin et al., 2015) are able to anticipate and con-
tain any such developments. Contracts help to maintain an active collaborative

08_G4784_460.indd 132 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 133

relationship with respective therapist–patient roles. If attachment to the thera-

pist is fragile and cannot protect against threats to the collaboration, the
contracts are designed to fulfill that role.
Behavioral contracts are usually negotiated at the outset of the treat-
ment, and they can be based on the changing clinical reality (Clarkin et al.,
2015; Linehan, 1993; Young et al., 1993). They help in increasing compliance
and attendance and in decreasing attrition (Clarkin et al., 2005; Linehan,
1993; Young et al., 2003). Different treatments rely on different versions of
the contract. However, all such contracts suggest making an agreement with
the patient regarding the treatment, including both permitted and forbidden
behaviors, as well as possible consequences (Meichenbaum & Turk, 1987).
With narcissistic clients, contracts are necessary, yet they require longer
and more detailed negotiation, especially understanding and agreement of their
significance and intentions of the therapist. Many NPD clients are likely to
see such contracts as limiting their fantasies of infinite, unlimited power and
success. Setting the contract, including recurrent clarifications of its mean-
ing, helps the patient understand and start giving up narcissistic maladaptive
strategies and expectations (Clarkin et al., 2015). Failure to set contracts is
likely to lead to treatment impasses or treatment failures due to unaddressed
treatment-interfering behaviors. Therapists should beware of the tendency to
set the contracts and ultimatums in response to countertransferential wishes
of control, punishment, competition, or retaliation.
One dilemma in such treatments is the use of ultimatums. On the one
hand, life ultimatums are one of the primary reasons that NPD patients come
to treatment. Life ultimatums are typically challenges to habitual narcissistic
functioning, such as failures, vocational problems, legal issues, marital difficul-
ties, and separation or divorce. The patient is facing a crossroad that requires
either internal change or loss in a major area of one’s life (usually of narcissistic
resources; Ronningstam & Weinberg, 2013). Awareness of this dilemma is
likely to increase the motivation for change. Such ultimatums should be con-
trasted with treatment ultimatums—issuing a statement that treatment will stop
unless the patient meets a certain condition. Many times, treatment ultimatums
reflect countertransference feelings, institutional dilemmas, and intrusions of
the therapist’s self-interest. The therapeutic value of treatment ultimatums is
very limited (Schwartz, 1990). With NPD patients, treatment ultimatums are
likely to engage the patient in power struggles, which often lead to the demise
of therapy. Dismissive attachment makes the relationship with the therapist too
tenuous, not allowing the therapist to use it as a leverage, thus likely making
treatment ultimatums ineffective. To conclude, while life ultimatums are the
most effective motivators for therapy (Ronningstam et al., 1995), treatment
ultimatums should be used only as a last resort (Schwartz 1990).

ADDRESS TREATMENT-INTERFERING BEHAVIORS

AS THEY COME UP IN TREATMENT
Perception of the patient’s difficulty as stemming exclusively from traumatiza-
tion or empathic failures of others may lead to active avoidance of problems
that potentially undermine and eventually may destroy the treatment process.

08_G4784_460.indd 133 3/11/2020 12:36:55 PM

 134 WEINBERG AND RONNINGSTAM

Therapy must help the patient to develop a sense of agency and healthy respon-
sibility that is different from either a grandiose sense of self-importance or
paralyzing shame. This includes taking ownership over treatment-interfering
behaviors (see Table 4; Glick, Stillman, Reardon, & Ritvo, 2012; Grotjahn,
1975; Kernberg, 2007; Silverman et al., 2012). These behaviors become appar-
ent in the patient’s detailed history, especially of the relational history and
experiences of prior treatments. In addition, it is important to explore how
these problems manifest not only with the therapist, but also with others.

DON’TS
DO NOT IGNORE COUNTERTRANSFERENCE
Countertransference enactments, although inevitable, are the most frequent
reason for treatment stalemates and failures with NPD patients. Empirical
studies have confirmed decades of the clinical tradition and have docu-
mented dramatic and difficult-to-bear countertransference responses to NPD
patients. Therapists of NPD patients report feeling annoyed, used, mistreated,
resentful, criticized, or dismissed. They can feel as if they are walking on
eggshells, full of dread. Alternatively, they feel bored or experience sexual
tension, and at times they can even experience wishes to be cruel or mean
toward the patient (Betan, Heim, Zittel Conklin, & Westen, 2005; Tanzilli,
Muzi, Ronningstam, & Lingiardi, 2017). Processing such reactions is critical
in order to minimize risk of enactments—primary reasons that treatments
with NPD patients go awry. These enactments include distancing from the
patient, termination of treatment, expression of irritation, objectification
of the patient, competition with the patient, attempts to “fail” the patient,
or treating the patient as a helpless victim, an unjustly treated genius, an
exception, or even taking on roles in the patient’s life outside the consulting
room. Therefore, one-time or an ongoing consultation with an experienced
colleague should be sought out to transform these countertransference reac-
tions into helpful interventions.

TABLE 4. Hierarchy of Treatment-Interfering Behaviors

1. Suicidal behaviors
2. Substance misuse
3. Attendance problems, including requests for “exceptions” and special treatment arrangements
4. Parasitic arrangements that stall the treatment, including unjustified disability or external support as well as
engagement of others in “enabling” arrangements
5. Withholding, selective reporting, dishonesty
6. Nonpaying for therapy, not making necessary arrangement to pay, employment problems, creating or not
resolving circumstances that interfere with treatment
7. Disengagement through devaluation, idealization, attachment dissolution, or emotional avoidance
8. Extreme defiance of, rebelliousness against, and competition with the therapist
9. Intolerance of different perspectives, rejection of logical explanations
10. Misuse of treatment process and therapist’s interventions

08_G4784_460.indd 134 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 135

Once contained, countertransference provides exceptionally helpful

information about the patient’s internal world and the treatment relation-
ship (Huprich, 2008). Such reactions inform the clinician regarding typical
reactions the patient is likely to evoke in others. Taken in conjunction with
the patient’s history, such information provides valuable hypotheses regarding
possible sources of relational difficulties.
Countertransference sometimes reflects inner experiences of the patient.
In such instances, countertransference reactions provide a snapshot of internal
experiences that the patient may not yet be aware of. Other reactions reflect
what the patient is expecting from others. In both cases, the purpose of the
therapy is to help the patient gradually articulate these experiences and inte-
grate them into the self-concept and the self-narrative.
Other countertransference reactions are informative regarding the
interpersonal pattern that is unfolding in treatment. Feelings of boredom
and a sense of being irrelevant or replaceable might suggest that the patient
is developing a “narcissistic transference,” that is, treating the therapist as
an audience, an irrelevant observer, or a “listening device.” In this case,
the patient is expecting the therapist to listen and not to have an opinion.
Another possible countertransferential reaction involves feeling competitive
with the patient. This could reflect that the patient is also feeling similarly
competitive and is thus avoiding reliance on the therapist in a productive,
therapeutic way. Yet another countertransference reaction involves experi-
encing cruel wishes (Groves, 1978; Maltsberger & Buie, 1974). In this case,
it is likely that the patient is acting in a way that challenges the narcissistic
equilibrium of the therapist (Maltsberger & Buie, 1974). The therapist is
advised to notice and survive (Winnicott, 1965) such behaviors in therapy
and ultimately help the patient become aware of them. With some NPD
patients, the therapist experiences sexual tension. Such a reaction might
suggest efforts of the patient to reverse the power differential in therapy.
Finally, sometimes therapists take on the shame-prone stance of the patients
and might avoid bringing up their countertransference in supervision or
consultation.
However, despite the therapist’s best efforts, enactments (i.e., acting on
countertransference feelings) are inevitable in treatments with NPD patients.
While some enactments can jeopardize the integrity of treatment, other enact-
ments can be used to promote treatment by learning about different relational
patterns, solving interpersonal problems, and realizing that the therapist is
not perfect. The most effective approach to countertransference enactments
starts with the therapist’s acknowledgment of what happened without going
into personal disclosure or extensive apologizing. Then the therapist invites
the patient to be curious about his or her understanding of the enactment, and
of what the enactment brings up emotionally or cognitively. Understanding
such enactments in terms of the history co-created by the therapist and the
patient is the next step. While some approaches use selective disclosure of
how the patient’s behavior contributed to enactments (Fiscalini, 1994), other
approaches discourage such disclosures and maintain a focus on the patient’s
behaviors and inner experiences (Clarkin et al., 2015). Similarly, while some

08_G4784_460.indd 135 3/11/2020 12:36:55 PM

 136 WEINBERG AND RONNINGSTAM

approaches emphasize the central role of apology (Allen et al., 2008; Kohut,
1971), other approaches de-emphasize the role of apologies and underscore
the importance of exploration (Clarkin et al., 2015).

DO NOT ENGAGE IN A POWER STRUGGLE OR MISUSE OF

POWER (E.G., A NONCOLLABORATIVE RELATIONSHIP)
NPD patients need to feel in charge of treatment, and they will invest any effort
to remain in control. A number of power differentials are inherent in the treat-
ment relationship. For example, the patient can change, get to know him- or
herself, or refuse treatment; the therapist can intervene, think differently from
the patient, and rely on knowledge, training, and experience about psycho-
pathology and psychotherapy. Treatment of NPD patients requires sensitivity
to actual power and competence differentials between the therapist and the
patient (Fiscalini, 1994). The reality of these types of power differentials should
be acknowledged at times, and their meaning needs to be explored. However,
authoritarian interventions are not likely to succeed with NPD patients. Some
therapists expect quick changes or enact countertransference feelings and thus
turn into drill sergeants. Others engage in a futile struggle to prove that “they
are right” and the “patient is wrong” or destroy collaboration through forcing
an agenda, treatment goals, or interpretations. These interactions might lead
to either false compliance or an impasse. When a power struggle is present,
many NPD patients are willing to sacrifice appointments, their therapist, and
even the whole treatment. They will refuse to talk or will talk in a superficial
way, get angry, or threaten with and even start a lawsuit to preserve the elusive
sense of being in charge and therefore protected.

DO NOT DIRECTLY CHALLENGE

THE PATIENT’S GRANDIOSITY OR SELF-LOATHING
Both grandiose self-perception and self-loathing have important psychologi-
cal functions (Johnson, 1989; Kernberg, 1975; Kris, 1990; Masterson, 1981;
Ronningstam, 2012). Therefore, disagreeing with either of these beliefs or
even offering evidence that contradicts them is likely to prompt the patient to
further attempts to “prove these thoughts right.” The patient will see challenges
to grandiose self-perception as an offense. Challenging grandiosity outside
of the pursuit of meaningful goals is counterproductive because it decreases
the sense of agency. In addition, it does not offer an alternative action trajec-
tory and precludes a meaningful pursuit of goals. Similarly, disagreeing with
self-loathing or offering praise or evidence that contradicts self-loathing is
usually viewed as invalidating, because these interventions ignore the func-
tions of self-loathing. A more effective alternative is exploring the functions
and effects—both positive and negative—of grandiose beliefs, self-enhancing
strategies, and self-loathing (Hayes et al., 1985; Kris, 1990; Swann, 1992).
With such an approach, patients begin to recognize the dysfunctional nature
of these beliefs and can gradually give them up.

08_G4784_460.indd 136 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 137

DO NOT OVERINDULGE THE PATIENT’S SENSE OF

GRANDIOSITY OR SELF-LOATHING
While many NPD patients have a history of neglect, deprivation, lack of
protection, and trauma (Cohen et al., 2014; Maldonado, 2006; Simon,
2005), they are also active participants in perpetuating their suffering. It is
important to remember both of these aspects of their complex functioning
and adaptation. Ignoring the past is erring on side of invalidation, while
ignoring the current role of the patient denies the patient the sense of agency
in his or her life history, as well as limiting hope for change. Commonly,
ignoring the patient’s current role tends to stall the treatment because the
patient’s needs related to maintaining an unrealistic grandiose or hateful
self-­perception are not challenged or are overindulged. Many patients will
respond to these interventions with emotional disengagement, dismissal,
and distrust, because these interventions are not capturing their own inner
complexity of functioning. The normative need for recognition of realistic
talents and accomplishments needs to be distinguished from the need for
admiration. Recognizing realistic talents and accomplishments helps the
patient develop a more realistic distinction between capabilities and gran-
diosity, and it also builds the treatment alliance.

DO NOT USE OVERLY EMPATHIC INTERVENTIONS

NPD patients are sensitive to issues of self-determination, control, and ter-
ritoriality. Consequently, overuse of empathic interventions, validation, or
interpretation can be perceived by the patient as intrusions, attempts to control,
or humiliation (Maldonado, 1999; Ronningstam, 2012). Similarly, validation
and, in particular, empathy may paradoxically tend to escalate the sense of
loss of internal control and be perceived as foreign and anxiety provoking
by patients who were only rarely exposed to them in intimate relationships
(Wallin, 2007). It is as if the NPD patient should be treated as a desert flower
that should be watered sparingly. Thus, empathy should be used with caution,
and the therapist should be ready to explore the patient’s own experiences of
such interventions.

DO NOT IGNORE SELF-ESTEEM–RELEVANT LIFE EVENTS

Life is the best teacher. Life events can critically contribute to changes in NPD
symptomatology, especially if they involve normative disillusionments and are
accompanied by emotional support that guides the patient through grieving
of unrealistic perceptions of self and others (Ronningstam et al., 1995). Being
mindful of natural consequences of the patient’s behavior invites the patient
to have an opportunity to learn about reactions of others and personal capa-
bilities and limitations. Allowing the patient to experience these consequences
is critical for extinguishing dysfunctional patterns and acquiring a realistic
perspective of self and others. Encouraging patients to be involved in life, that
is, not to avoid friendships but to take vocational and social responsibilities to

08_G4784_460.indd 137 3/11/2020 12:36:55 PM

 138 WEINBERG AND RONNINGSTAM

create such opportunities, is crucial. Therapy serves a role of helping patients

to learn from their experiences and to grieve unrealistic expectations, percep-
tions, and beliefs.

CONCLUSION

In this article, we present a pragmatic treatment approach for patients with NPD.
It takes into account these patients’ complexity of adaptation and functioning
and offers treatment strategies to address common problems. We emphasize
gradual exploratory and collaborative goal setting that can help to ground the
patient in his or her values as well as in realistic capabilities and limitations. This
approach emphasizes the development of a sense of agency and autonomous
motivation for change. We discuss the importance of contracts that address
possible treatment-interfering behaviors, and we also suggest that the therapist’s
choices of interventions need to take into account the challenges and peculiari-
ties of the treatment alliance with NPD patients. We offer specific strategies
to address these challenges. In addition, clear, reality-anchored goal setting,
development of autonomous motivation, and careful contract setting can help
the patient to stay in treatment and remain motivated when the therapeutic
alliance is not sufficient to sustain therapeutic momentum.
We also list a number of pitfalls that commonly lead to noneffective
treatments with NPD patients. These pitfalls are related to enacting coun-
tertransference feelings, engaging in a power struggle, directly challenging or
overindulging grandiose beliefs or self-loathing, relying on overly empathic
interventions, and ignoring the mutative role of life events.
This article has a few limitations. First, these treatment recommendations
were not tested empirically. Second, they rely on the experience of the authors
with their individual patients or treatment by colleagues they supervised. Third,
these principles were derived from clinical experience, not from a theory of
NPD. We hope that these treatment principles will be tested empirically by
independent therapists trained to adhere to this approach.

REFERENCES
Adler, J. M. (2010). Living into the story: Agency Alonso, A. (1992). The shattered mirror: Treatment
and coherence in a longitudinal study of of a group of narcissistic patients. Group,
narrative identity development and mental 16, 210–219.
health over the course of psychotherapy. American Psychiatric Association. (2013). Diagnos-
Journal of Personality and Social Psychol- tic and statistical manual of mental disorders
ogy, 102, 367–389. (5th ed.). Arlington VA, American Psychiatric
Adler, J. M., Harmeling, L. H., & Walder-Biesanz, I. Publishing.
(2013). Narrative meaning making is asso- Ball, S. A. (2007). Comparing individual therapies
ciated with sudden gains in psychotherapy for personality disordered opioid dependent
clients’ mental health under routine clinical patients. Journal of Personality Disorders,
conditions. Journal of Consulting and Clini- 21, 305–321.
cal Psychology, 81, 839–845. Ball, S. A., Cobb-Richardson. P., Connolly, A. J.,
Allen, J. G., Fonagy, P., & Bateman, A. W. (2008) Bujosa, C. T., & O’Neall, T. W. (2005). Sub-
Mentalizing in clinical practice. Arlington, stance abuse and personality disorders in
VA: American Psychiatric Publishing. homeless drop-in center clients: Symptom

08_G4784_460.indd 138 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 139

severity and psychotherapy retention in a Cohen, L. J., Tanis, T., Bhattacharjee, R., Nesci, C.,
randomized clinical trial. Comprehensive Halmi, W., & Galynker, I. (2014). Are there
Psychiatry, 46, 371–379. differential relationships between different
Ball, S. A., Maccarelli, L. M., LaPaglia, D. M., & types of childhood maltreatment and differ-
Ostrowski, M. J. (2011). Randomized trial ent types of personality pathology? Psychia-
of dual-focused vs. single-focused individual try Research, 215, 192–201.
therapy for personality disorders and sub- Diamond, D., Clarkin, J. F., Levy, K. N., Mee-
stance dependence. Journal of Nervous and han, K. B., Cain, N. M., Yeomans, F. E., &
Mental Disease, 199, 319–328. Kernberg, O. F. (2014). Change in attach-
Bamelis, L. L., Evers, S. M., Spinhoven, P., & ment and reflective function in borderline
Arntz, A. (2014). Results of a multicenter patients with or without narcissistic person-
randomized controlled trial of the clinical ality disorder in transference focused psy-
effectiveness of schema therapy for personal- chotherapy. Contemporary Psychoanalysis,
ity disorders. American Journal of Psychiatry, 50, 175–201.
171, 305–322. Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-
Beck, A. T., Davis, D. D., & Freeman, A. (2005). Kern, M., Cain, N. M., Doering, S., . . .
Cognitive therapy for personality disorders. Buchheim, A. (2014). Attachment and men-
New York, NY: Guilford Press. talization in female patients with comorbid
Bernecker, S. L., Levy, K. N., & Ellison, W. D. (2014). narcissistic and borderline personality disor-
A meta-analysis of the relation between der. Personality Disorders, 5, 428–433.
patient adult attachment style and the Diamond, D., & Meehan, K. B. (2013). Attachment
working alliance. Psychotherapy Research, and object relations in patients with narcis-
24, 12–24. sistic personality disorder: Implications for
Betan, E., Heim, A. K., Zittel Conklin, C., & Westen, therapeutic process and outcome. Journal of
D. (2005). Countertransference phenomena Clinical Psychology, 69, 1148–1159.
and personality pathology in clinical prac- Diener, M. J., & Monroe, J. M. (2011). The rela-
tice: An empirical investigation. American tionship between adult attachment style and
Journal of Psychiatry, 162, 890–898. therapeutic alliance in individual psychother-
Bion, W. R. (1962). Learning from experience. Lon- apy: A meta-analytic review. Psychotherapy,
don, UK: William Heinemann. 48, 237–248.
Black, R. S., Curran, D., & Dyer, K. F. (2013). The Dimaggio, G., & Attina, G. (2012). Metacognitive
impact of shame on the therapeutic alliance interpersonal therapy for NPD and associ-
and intimate relationships. Journal of Clini- ated perfectionism. Journal of Clinical Psy-
cal Psychology, 69, 646–654. chology, 68, 922–934.
Blatt, S. J., Zuroff, D. C., Bondi, C. M., Sanislow, Dimaggio, G., Nicolo, G., Fiore, D., Centenero, E.,
C. A., 3rd, & Pilkonis, P. A. (1998). When Semerari, A., Carcione, A., & Pedone, R.
and how perfectionism impedes the brief (2008). States of minds in narcissistic per-
treatment of depression: Further analyses sonality disorder: Three psychotherapies
of the National Institute of Mental Health analyzed using the grid of problematic states.
Treatment of Depression Collaborative Psychotherapy Research, 18, 466–480.
Research Program. Journal of Consulting Dozier, M., Lomax, L., Tyrrell, C. L., & Lee, S. W.
and Clinical Psychology, 66, 423–428. (2001). The challenge of treatment for clients
Britton, R. (2004). Subjectivity, objectivity, and with dismissing states of mind. Attachment
triangular space. Psychoanalytic Quarterly, and Human Development, 3, 62–76.
73, 47–61. Ellison, W. D., Levy, K. N., Cain, N. M., Ansell,
Campbell, M. A., Waller, G., & Pistrang, N. (2009). E. B., & Pincus, A. L. (2013). The impact
The impact of narcissism on drop-out from of pathological narcissism on psychotherapy
cognitive-behavioral therapy for the eating utilization, initial symptom severity, and
disorders: A pilot study. Journal of Nervous early-treatment symptom change: A natu-
and Mental Disease, 197, 278–281. ralistic investigation. Journal of Personality
Casement, P. (1985). Learning from the patient. Assessment, 95, 291–300.
New York, NY: Guilford Press. Etchegoyen, R. H. (2005). The fundamentals of psy-
Clarkin, J. F., Levy, J. N., Lenzenweger, M. F., & choanalytic technique. London, UK: Karnac.
Kernberg, O. F. (2007). Evaluating three Fava, M., Farabaugh, A. H., Sickinger, A. H.,
treatments for borderline personality disor- Wright, E., Alpert, J. E., Sonawalla, S., . . .
der: A multiwave study. American Journal of Worthington, J. J., 3rd. (2002). Personal-
Psychiatry, 164, 922–928. ity disorders and depression. Psychological
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. Medicine, 32, 1049–1057.
(2015). Transference-focused psychotherapy Feiring, C., & Taska, L. S. (2005). The persistence of
for borderline peersonality disorder: A clini- shame following sexual abuse: A longitudinal
cal guide. Arlington, VA: American Psychi- look at risk and recovery. Child Maltreat-
atric Publishing. ment, 10, 337–349.

08_G4784_460.indd 139 3/11/2020 12:36:55 PM

 140 WEINBERG AND RONNINGSTAM

Fiscalini, J. (1994). Narcissism and coparticipant treatment of narcissistic personality disor-

inquiry. Contemporary Psychoanalysis, 30, ders. Chicago, IL: University of Chicago
747–776. Press.
Fiscalini, J., & Grey, A. L. (1993). Narcissism and Korfmacher, J., Adam, E., Ogawa, J., & Egeland, B.
interpersonal self. New York, NY: Columbia (1997). Adult attachment: Implications for
University Press. therapeutic interventions in a home visita-
Fonagy, P., & Allison, E. (2014). The role of mental- tion intervention. Applied Developmental
izing and epistemic trust in the therapeutic Science, 1, 43–52.
relationship. Psychotherapy, 51, 372–380. Kris, A. O. (1990). Helping patients by analyzing
Foster, J. D., & Brennan, J. C. (2011). Narcissism, self-criticism. Journal of the American Psy-
the agency model, and approach-avoidance choanalytic Association, 38, 605–636.
motivation. In W. K. Campbell & J. D. Lenzenweger, M. F., Lane, M. C., Loranger, A. W.,
Miller (Eds.), The handbook of narcissism & Kessler, R. C. (2007). DSM-IV personal-
and narcissistic personality disorder: Theo- ity disorders in the National Comorbidity
retical approaches, empirical findings, and Survey Replication. Biological Psychiatry,
treatments (pp. 89–100). Hoboken, NJ: John 15, 553–564.
Wiley & Sons. Linehan, M. M. (1993). Cognitive-behavior therapy
Glick, I. D., Stillman, M. A., Reardon, C. L., & for borderline personality disorder. New
Ritvo, E. C. (2012). Managing psychiatric York, NY: Guilford Press.
issues in elite athletes. Journal of Clinical Links, P. S., & Stockwell, M. (2002). The role of
Psychiatry, 73, 640–644. couple therapy in the treatment of narcis-
Grotjahn, M. (1975). On the treatment of the “beau- sistic personality disorder. American Journal
tiful and famous people” in groups. Group of Psychotherapy, 56, 522–538.
Analysis, 8, 150–151. Luborsky, L. (1976). Healing alliances in psycho-
Groves, J. E. (1978). Taking care of the hateful therapy. In J. J. Claghorn (Ed.), Successful
patient. New England Journal of Medicine, psychotherapy: Proceedings of the ninth
298, 883–887. annual symposium, November 19–21, 1975,
Guilé, J. M., Mbékou, V., & Lageix, P. (2004). Child Texas Research Institute of Mental Sciences
and parent variables associated with treat- (pp. 92–116). New York, NY: Brunner/Mazel.
ment response in narcissistic youths: The Lynch, T. R., & Cheavens, J. S. (2007). DBT for
role of self-blame and shame. Canadian depression with comorbid personality dis-
Child and Adolescent Psychiatric Review, orders. In L. A. Dimeff & K. Koerner (Eds.),
13, 81–85. Dialectical behavior therapy in clinical
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1985). practice: Applications across disorders and
Acceptance and commitment therapy. New settings (pp. 264–297). New York, NY: Guil-
York, NY: Guilford Press. ford Press.
Huprich, S. K. (Ed.). (2008). Narcissistic patients Maldonado, J. L. (1999). Narcissistic resistances in
and new therapists: Conceptualization, treat- the analytic experience. International Journal
ment, and managing countertransference. of Psychoanalysis, 80, 1131–1146.
Lanham, MD: Jason Aronson. Maldonado, J. L. (2006). Vicissitudes in adult life
Jansson, I., Hesse, M., & Fridell, M. (2008). Per- resulting from traumatic experiences in
sonality disorder features as predictors of adolescence. International Journal of Psy-
symptoms five years post-treatment. Ameri- choanalysis, 87, 1239–1257.
can Journal of Addiction, 17, 172–175. Maltsberger, J. T., & Buie, D. H. (1974). Counter-
Jobes, D. A. (2000). Collaborating to prevent sui- transference hate in the treatment of suicidal
cide: A clinical-research perspective. Suicide patients. Archives of General Psychiatry, 30,
and Life-Threatening Behaviors, 30, 8–17. 625–633.
Johnson, S. M. (1989). Humanizing the narcissistic Masterson, J. (1981). The narcissistic and borderline
style. New York, NY: W. W. Norton. disorders. New York, NY: Brunner/Mazel.
Jurist, E. L. (2005). Mentalized affectivity. Psycho- Masterson, J. (1993). The emerging self. London,
analytic Psychology, 22, 426–444. UK: Routledge.
Kernberg, O. F. (1975). Borderline conditions and McBride, C., Zuroff, D. C., Ravitz, P., Koestner, R.,
pathological narcissism. New York, NY: Moskowitz, D. S., Quilty, L., & Bagby,
Jason Aronson. R. M. (2010). Autonomous and controlled
Kernberg, O. F. (2007). The almost untreatable motivation and interpersonal therapy for
narcissistic patient. Journal of the American depression: Moderating role of recurrent
Psychoanalytic Association, 55, 503–539. depression. British Journal of Clinical Psy-
Knox, J. (2011). Self-agency in psychotherapy: chology, 49, 529–545.
Attachment, autonomy, and intimacy. New McGlashan, T. H., & Heinssen, R. K. (1989).
York, NY: W. W. Norton. Narcissistic, antisocial, and noncomorbid
Kohut, H. (1971). The analysis of the self: A sys- subgroups of borderline disorder. Are they
tematic approach to the psychoanalytic distinct entities by long-term clinical profile?

08_G4784_460.indd 140 3/11/2020 12:36:55 PM

 DOS AND DON’TS IN TREATMENTS FOR NPD 141

Psychiatric Clinics of North America, 12, Disorders: Theory, Research, and Treatment,
653–670. 5, 434–438.
Meichenbaum, D., & Turk, D. C. (1987). Facilitating Ronningstam, E. (2017). Intersect between self-
adherence: A practitioner’s guidebook. New esteem and emotion regulation in narcissis-
York, NY: Plenum Press. tic personality disorder—Implications for
Meyer, B., & Pilkonis, P. A. (2011). Attachment alliance building and treatment. Borderline
theory and narcissistic personality disorder. Personality Disorder and Emotion Dysregu-
In W. K. Campbell & J. D. Miller (Eds.), lation, 4(3), 1–13.
The handbook of narcissism and narcis- Ronningstam, E., & Baskin-Sommers, A. (2013).
sistic personality disorder: Theoretical Fear and decision-making in narcissistic
approaches, empirical findings, and treat- personality disorder—A link between psy-
ments (pp. 434–444). Hoboken, NJ: John choanalysis and neuroscience. Dialogues in
Wiley & Sons. Clinical NeuroScience, 15, 191–201.
Modell, A. H. (1975). A narcissistic defense against Ronningstam, E., Gunderson, J., & Lyons, M.
affects and the illusion of self-sufficiency. (1995). Changes in pathological narcis-
International Journal of Psychoanalysis, 56, sism. American Journal of Psychiatry, 152,
275–282. 253–257.
Morrison, A. P. (1989). Shame: The underside of Ronningstam, E., & Maltsberger, J. (2007). Treat-
narcissism. Hillsdale, NJ: Analytic Press. ment of narcissistic personality disorder.
Ogden, T. (1994). Subjects of analysis. London, UK: In G. Gabbard (Ed.), Gabbard’s treatments
Karnac. of psychiatric disorders (4th ed., pp. 791–
Pinto, A., Liebowitz, M. R., Foa, E. B., & Simpson, 804). Washington, DC: American Psychiatric
H. B. (2011). Obsessive compulsive person- Press.
ality disorder as a predictor of exposure Ronningstam, E., & Weinberg, I. (2013). Narcissistic
and ritual prevention outcome for obsessive personality disorder: Progress in recognition
compulsive disorder. Behaviour Research and treatment. Focus: The Journal of Life-
and Therapy, 49, 453–458. long Learning in Psychiatry, 11, 167–177.
Plakun, E. M. (1989). Narcissistic personality dis- https://doi.org/10.1176/appi.focus.11.2.167
order. A validity study and comparison to Rosenfeld, H. (1987). Impasse and interpretation.
borderline personality disorder. Psychiatric London, UK: Routledge.
Clinics of North America, 12, 603–620. Schore, A. N. (1994). Affect regulation and the
Ponsi, M. (2000). Therapeutic alliance and collab- origin of the self: The neurobiology of emo-
orative interactions. International Journal of tional development. New York, NY: Psychol-
Psychoanalysis, 81, 687–704. ogy Press.
Pulay, A. J., Dawson, D. A., Hasin, D. S., Goldstein, Schwartz, R. S. (1990). The use of ultimatums in
R. B., Ruan, W. J., Pickering, R. P., . . . Grant, psychiatric care. Hospital and Community
B. F. (2008). Violent behavior and DSM- Psychiatry, 41, 1242–1245.
IV psychiatric disorders: Results from the Sheeran, P., Aubrey, R., & Kellett, S. (2007). Increas-
National Epidemiologic Survey on Alcohol ing attendance for psychotherapy: Imple-
and Related Conditions. Journal of Clinical mentation intentions and the self-regulation
Psychiatry, 69, 12–22. of attendance-related negative affect. Journal
Rizvi, S. L., & Linehan, M. M. (2005). The treat- of Consulting and Clinical Psychology, 75,
ment of maladaptive shame in borderline 853–863.
personality disorder. Cognitive and Behav- Silverman, B. C., Asby, A., Brendel, D. H., Cho-
ioral Practice, 12, 437–447. ras, P., Chu, J. A., Holman, J., . . . Bodkin,
Ronningstam, E. (1996). Pathological narcissism J. A. (2012). Psychiatric treatment of the VIP:
and narcissistic personality disorder in Axis Some paradoxical risks. Journal of Nervous
I disorders. Harvard Review of Psychiatry, and Mental Disease, 200, 545–548.
3, 326–340. Simon, R. I. (2005). Distinguishing trauma-associ-
Ronningstam, E. (2005). Identifying and under- ated narcissistic symptoms from posttrau-
standing the narcissistic personality. New matic stress disorder: A diagnostic challenge.
York, NY: Oxford University Press. Harvard Review of Psychiatry, 10, 28–36.
Ronningstam, E. (2009). Narcissistic personality dis- Simonsen, S., & Simonsen, E. (2011). Comorbid-
order: Facing DSM-V. Psychiatric Annals, ity between narcissistic personality disorder
39, 111–121. and Axis I diagnoses. In W. K. Campbell &
Ronningstam, E. (2012). Alliance building and the J. D. Miller (Eds.), The handbook of narcis-
diagnosis of narcissistic personality disorder. sism and narcissistic personality disorder:
Journal of Clinical Psychology, 68, 943–953. Theoretical approaches, empirical findings,
Ronningstam, E. (2014). Beyond the diagnostic and treatments (pp. 237–247). Hoboken, NJ:
traits: A collaborative exploratory diagnostic John Wiley & Sons.
process for dimensions and underpinnings of Steele, A. L., Bergin, J., & Wade, T. D. (2011). Self-
narcissistic personality disorder. Personality efficacy as a robust predictor of outcome

08_G4784_460.indd 141 3/11/2020 12:36:55 PM

 142 WEINBERG AND RONNINGSTAM

in guided self-help treatment for broadly and clinical treatment. Psychotherapy, 49,
defined bulimia nervosa. International Jour- 492–501.
nal of Eating Disorders, 44, 389–396. Vater, A., Ritter, K., Strunz, S., Ronningstam, E. F.,
Steiner, J. (1994). Psychic retreats: Pathological Renneberg, B., & Roepke, S. (2014). Stability
organizations in psychotic, neurotic and of narcissistic personality disorder: Tracking
borderline patients. London, UK: Routledge. categorical and dimensional rating systems
Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, over a two-year period. Personality Disor-
S. P., Huang, B., Smith, S. M., . . . Grant, B. F. ders, 5, 305–313.
(2008). Prevalence, correlates, disability, and Vinnars, B., Barber, J. P., Norén, K., Gallop, R.,
comorbidity of DSM-IV narcissistic per- & Weinryb, R. M. (2005). Manualized
sonality disorder: Results from the Wave 2 supportive-expressive psychotherapy ver-
National Epidemiologic Survey on Alcohol sus nonmanualized community-delivered
and Related Conditions. Journal of Clinical psychodynamic therapy for patients with
Psychiatry, 69, 1033–1045. personality disorders: Bridging efficacy and
Swann, W. B., Jr. (1996). Self-traps: The elusive quest effectiveness. American Journal of Psychiatry,
for higher self-esteem. New York, NY: W. H. 162, 1933–1940.
Freeman. Wallin, D. J. (2007). Attachment in psychotherapy.
Symington, N. (1983). The analyst’s act of freedom New York, NY: Guilford Press.
as agent of therapeutic change. International Winnicott, D. W. (1965). The maturational processes
Review of Psycho-Analysis, 10, 283–291. and the facilitating environment: Studies in
Tangney, J. P., & Fischer, K. W. (1995). Self-con- the theory of emotional development. Lon-
scious emotions: The psychology of shame, don, UK: Routledge.
guilt, embarrassment and pride. New York, Young, J. E., Klosko, J. S., & Weishaar, M. E. (1993).
NY: Guilford Press. Schema therapy: A practitioner’s guide. New
Tanzilli, A., Muzi, L., Ronningstam, E., & Lingiardi, York, NY: Guilford Press.
V. (2017). Countertransference when work- Zimmerman, M., Chelminski, I., & Young, D.
ing with narcissistic personality disorder: An (2008). The frequency of personality disor-
empirical investigation. Psychotherapy, 54, ders in psychiatric patients. Psychiatric Clin-
184–194. ics of North America, 31, 405–420.
Thiel, N., Hertenstein, E., Nissen, C., Herbst, N., Zuroff, D. C., Blatt, S. J., Sotsky, S. M., Krupnick, J. L.,
Külz, A. K., & Voderholzer, U. (2013). The Martin, D. J., Sanislow, C. A., & Simmens, S.
effect of personality disorders on treatment (2000). Relation of therapeutic alliance and
outcomes in patients with obsessive-compul- perfectionism to outcome in brief outpatient
sive disorders. Journal of Personality Disor- treatment of depression. Journal of Consulting
ders, 27, 697–715. and Clinical Psychology, 68, 114–124.
Torgersen, S. (2012). Epidemiology. In T. A. Widiger Zuroff, D. C., Koestner, R., Moskowitz, D. S.,
(Ed.), The Oxford handbook of personality McBride, C., Marshall, M., & Bagby, M. R.
disorders. Oxford, UK: Oxford University (2007). Autonomous motivation for therapy:
Press. A new common factor in brief treatments
Torres, W. J., & Bergner, R. M. (2012). Severe pub- for depression. Psychotherapy Research, 17,
lic humiliation: Its nature, consequences, 137–147.

08_G4784_460.indd
View publication stats 142 3/11/2020 12:36:55 PM