Alliance Building and Narcissistic Personality Disorder

Elsa Ronningstam
Harvard Medical School, McLean Hospital
Building a therapeutic alliance with a patient with pathological narcissism or narcissistic personality disorder is a challenging process. A combined alliance building and diagnostic strategy is outlined that promotes patients motivation and active engagement in identifying their own problems. The main focus is on identifying grandiosity, self-regulatory patterns, and behavioral uctuations in their social and interpersonal contexts while engaging the patient in meaningful clarications and collaborative inquiry. A denition of grandiosity as a diagnostic characterological trait is suggested, one that captures self-criticism, inferiority, and fragility in addition to superiority, assertiveness, perfectionism, high ideals, and self-enhancing and self-serving interpersonal behavior. These reformulations serve to expand the spectrum of grandiosity-promoting strivings and activities, capture their uctuations, and help clinicians attend to narcissistic individuals internal experiences and motivation as well as to their external presentation and interpersonal self-enhancing, self-serving, controlling, and aggressive behavior. A case example illustrates this process. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 68:943953, 2012. Keywords: narcissistic personality disorder; grandiosity; therapeutic alliance; self-esteem regulation

For a psychiatric diagnosis to be clinically meaningful and consistent with the medical model, the criteria describing traits or symptoms must be informative and guiding for both clinicians and patients. Optimally, the diagnosis will align with the patients own observations and subjective experiences, so that the patient can recognize himself or herself in a way that promotes acceptance and understanding of the condition, as well as motivation for treatment. For most psychiatric conditions it is usually possible to reach a diagnostic agreement that corresponds to the patients experiences and to the clinicians and family members observations. However, attaining such a consensus about the diagnosis of narcissistic personality disorder (NPD) as presently outlined in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) is often problematic. Individuals with pathological narcissism and NPD who seek treatment tend to nd that the diagnostic characteristics of NPD do not match their own perceptions and understanding of their problems. Although informing about Axis II diagnosis, especially NPD, is not required, some patients do raise the question about a possible NPD diagnosis, especially if others have told them that they are narcissistic or have NPD. With other narcissistic patients, clinicians may nd themselves drawn into a one-sided and usually unproductive effort to impose observations of overt signs of pathological narcissism, provoking the patients aggressive protests or shameful withdrawal. As the patients subjective experiences and accounts of problems and symptoms often do not concur with the assigned traits or criteria for NPD, telling the patient he or she has a diagnosis of NPD may be neither productive nor indicated. The aim of this article is to outline a strategy for building a therapeutic alliance with patients with pathological narcissism or NPD that over time integrates patients internal experiences with their external reactive or interpersonal narcissistic traits and patterns.

Please address correspondence to: McLean Hospital, AOPC Mailstop 109, 115 Mill Street, Belmont MA 024781617. E-mail: ronningstam@email.com
C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(8), 943953 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21898

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Identifying and Diagnosing NPD

The diagnosis of NPD has remained descriptive, with a set of incongruent criteria that fall short of being integrative and psychologically meaningful for the individual patient; moreover, these criteria do not provide an adequate basis for guiding treatment. The categorical criteria approach to the diagnosis of NPD used in the DSM-IV-TR is insufcient for identifying the complex and multifaceted personality functioning that forms this specic syndrome. Clinicians focus on external and provocative narcissistic personality traits typically diverts their attention away from patients less obvious internal conicts and suffering, or from other subjectively relevant life experiences that can spur narcissistic functioning. NPD is especially challenging to identify because of the following reasons: (a) it often cooccurs with occasional or consistent high functioning that come with a sense of agency and competence or, alternatively, with real special qualities, capabilities, or social skills; (b) it represents a fragility in self-regulation and functioning accompanied by strong self-protective reactivity and a range of self-enhancing and self-serving behaviors and attitudes; (c) it takes a variety of phenotypic presentations ranging from overt and interpersonal pretentiousness, arrogance, and assertiveness to covert and internal insecurity, shyness, and hypersensitivity; (d) it can contribute to compromised or lost working capacity, hostility and detachment in relationships, bitterness for unmet needs and expectations, deceptive and deceitful behavior, and occasional criminal or violent acts; (e) it can co-occur with depressivity (e.g., self-criticism, low self-esteem, and hypersensitivity) and posttraumatic stress disorder (PTSD); and (f) it can be either enhanced or concealed by comorbid substance use, mood disorder, or suicidality (Huprich 1998; Ronningstam, 2009, 2011). There have been several recent attempts to broaden the conceptualization of pathological narcissism and the diagnosis of NPD. A self-regulatory approach aims at integrating the multiple aspects of pathological narcissism noted above (Morf & Rhodewalt, 2001; Ronningstam, 2009, 2011). A phenotypic dimensional approach captures both self-enhancement and impaired self-regulation, and it identies needs and motives, self-regulatory capabilities, and interpersonal patterns through scores on the Pathological Narcissism Inventory (PNI; Pincus, Ansell, Pimentel, Cain, Wright, & Levy, 2009). High PNI scores indicate low self-esteem, with signicant interpersonal distress, shame, aggression, and compromised empathy. Recently, other researchers (Westen, Shedler, Bradley, & Defe, 2012) have outlined a diagnosis based on prototype matching. This method ensures that essential narcissistic self-regulatory patterns, such as seeing or portraying oneself as strong and in control despite indications of underlying distress and insecurity, or being self-critical and intolerant while holding on to perfectionist standards, are captured in a comprehensive NPD diagnosis.

Internal Experience Versus External Expressions of Pathological Narcissism

The subjective experiences of patients suffering from pathological narcissism and NPD are usually quite distinct from their external presentation. They use various more-or-less effective ways to sustain and enhance their self-esteem, achieve perfectionist ideals, and avoid embarrassing exposure of failure. Doubts, shame and insecurity, confused self-identity, and self-criticism are common. Consequently, the patient is guarded, hypervigilant, and easily provoked when meeting with the therapist. In addition, biased or impaired ability for self-evaluation, unawareness of or difculties assessing interpersonal interactions and ones own impact on others, limited self-disclosure, and compromised or impaired empathic capability are ongoing difculties when forming the therapeutic alliance with a therapist. While some people with pathological narcissism can sustain a positive albeit exaggerated self-experience over long periods, others may struggle with sudden or gradual uctuations in self-esteem and self-agency. Those in the former category may be able to intermittently access self-reective and empathic capabilities while those in the latter group usually are less able or unwilling to do so. For some, however, acknowledging their own difculties may help them attend to and empathize with others. A diagnostic process that promotes a coherent descriptive narrative of the patients functional and experiential range of pathological narcissism is critically important. This paper outlines a

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process whereby the therapist aims at identifying and clarifying NPD based on patients descriptions of their own experiences of their problems, in the context of exploratory collaborative alliance building. This strategy is intended to promote patients motivations and active engagement in identifying their own problems and pursuing a treatment plan that is meaningful and potentially helpful to them. The main initial therapeutic focus is on identifying grandiosity, the core trait and most outstanding feature for NPD (Kernberg, 1975; Perry & Perry, 2004; Ronningstam & Gunderson, 1990), through clarication and collaborative inquiry.

Grandiosity
Contrary to grandiosity in bipolar disorder, which is a one-dimensional, self-exaggeration accompanying a hypomanic or manic episode that subsides in the euthymic phase, narcissistic grandiosity occurs in a characterological and self-regulatory context. As a trait of pathological narcissism and NPD, grandiosity represents an exaggeration beyond real assets and capabilities, and is closely tied to underlying fragility and various self-esteem regulatory and enhancing strategies. This stems from narcissistic challenges in early development combined with biopsychological aspects of attunement and attachment that affect self-regulation (Schore, 1994; P. Kernberg, 1998). Grandiosity is a complex trait expressed in beliefs and self-attributions, fantasies and aspirations, and interpersonal behaviors and reactions. It is affected by a sense of self-agency (Knox, 2011) and by the individuals self-esteem, self-control, self-appraisal, and self-criticism. For example, someone who is identied as a competent, ambitious, and successful student in high school and suddenly nds herself unable to meet standards in college may feel confused and devastated internally while presenting with aspirations and holding on to a fantasy that one day under the right circumstances, she will be successful and recognized again. Grandiosity is associated with ego ideals and perfectionism, and with subjectively dened afliations and roles that are accompanied by exaggerated or unrealistic aspirations and fantasies. For some, grandiosity is based mainly on a subjective conviction of ones own ideal state or value, an attribution that in one way or other (acquired or inherited) contributes to the individuals sense of being special, superior, or accomplished, a feeling that I was born to succeed. For these individuals, self-sufciency, aloneness, and interpersonal distance may serve as a self-sustaining protection. For others, grandiosity may be more externally and interpersonally dened, driven by comparisons and competition, or supported by status-supporting connections or admiration, such as, I am superior because I am accepted and belong to this very special organization. Their grandiosity is often dened in interpersonal relational patterns and expectations or in terms of recognition, status, fame, or possibilities. When alone, these individuals may struggle with an internal state that spirals downhill in the absence of interpersonal and social evidence of their self-worth. The balance between aspects of grandiosity that rely on protective, internally based selfassurance and fantasies accessible in splendid isolation versus those that depend on selfesteem supportive afliations and others approval can vary from individual to individual. In other words, some are more interpersonally or socially dependent while others are more selfsufcient and independent. Yet another important subgroup of individuals with pathological narcissism comprises those for whom grandiosity is associated with suffering and victimization (Cooper, 1988). These individuals tend to regulate self-esteem and self-worth, and master and control their own humiliations by means of self-righteousness, entitlement, and martyrdom. Grandiosity tends to uctuate and be state dependent (Ronningstam, Gunderson, & Lyons, 1995). In some situations, it can be defensive and function mainly as a protection against underlying fragility and insecurity, for example, when someone is emphasizing or bragging about achievements to steer the clinicians attention away from embarrassing shortcomings or insecurity. In other situations, grandiosity can be reactive and spur outlandish or aggressive responses, as when a patient blows up at a clinician who unassumingly asked a question that threatened the patients self-esteem or sense of control. In some severe cases, threats to grandiosity can evoke destructive compensatory behavior with devastating consequences, like suicide or homicide. Sudden threats to self-esteem can increase grandiosity (Rhodewalt & Morf, 1998),

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while corrective life events, such as achievements, truly mutual relationships, and manageable disillusionments or even losses or injuries can contribute to a more realistic alignment of selfesteem (Ronningstam, Gunderson, & Lyons, 1995). Grandiosity is also affected by the presence of depressivity and by mood disorders such as major depression, substance use, and bipolar spectrum disorder. Clinically, grandiosity is most noticeable in the patients perception and experience of himself or herself as important, privileged, special, superior, limitless, or self-sufcient. The degree of reality in such grandiose self-perceptions is an important indicator of the severity of narcissistic psychopathology. For example, fantasizing or bragging about qualifying for a national research award after receiving a rst research grant can serve as a proactive albeit provocative selfenhancement and spur ambition and motivation anchored in a real accomplishment. The same persistent fantasies in somebody who failed to complete graduate school may represent a more defensive, exaggerated, illusionary endeavor. In other words, it is important to evaluate and compare indicators of grandiosity (bragging, exaggerations, fantasies, or illusions) to the patients real competence, accomplishments, and afliations, and for young patients, to their potential and ambitions. Given this complexity of features and functions, I argue that grandiosity has to be identied and understood in the context of co-occurring self-devaluing dimensions and evaluated in terms of actual personality assets and capabilities (see Figure 1). In sum, I suggest that grandiosity is not only a personality trait but it also represents one side of self-esteem regulation and an essential aspect of narcissistic personality functioning as well. Grandiosity entails not only a sense of superiority and fantasies but also high ideals and self-enhancing and self-serving behaviors. The nature and functions of grandiosity are also closely related to the individuals actual skills, agency, competence, and personal assets, as well as to their counterparts: insecurity, fragility, and hypersensitivity. This reformulation serves to expand the spectrum of grandiosity-promoting strivings and activities and capture its uctuations. It may also help clinicians attend to narcissistic individuals internal experiences and motivations as well as to their external presentation (e.g., self-enhancing, controlling, and aggressive behavior) and their actual capabilities.

The Therapeutic Alliance

Accepting that building a therapeutic alliance is a gradual process has helped clinicians work with the inevitable difculties of certain patients, especially those with pathological narcissism and NPD (Bender, 2005; Gabbard, 1998). Alliance building involves working with ruptures and uctuations, and is affected by numerous internal, intersubjective, and external factors, such as harmful substance use (Tatarsky & Kellog, 2010), perfectionism (Hewett, Habke, LeeBaggley, Sherry, & Flett, 2008), co-morbid borderline personality disorder (Gunderson, 2000), and suicidality (Weinberg, Ronningstam, Goldblatt, & Maltsberger, 2011). The initial alliance building with patients with pathological narcissism or NPD is usually challenged by their reluctance or unclear motivation for treatment, a situation that is often caused by requests from others for them to seek treatment. Their tendency to provoke, control, or disengage the therapist and their high dropout rate early in treatment are by now wellestablished facts. The therapist may also face a most confusing contradiction between these patients assetstheir intellectual, social and verbal competence, psychological interest, curiosity, and other-directed mindfulness and responsiveness and their anxiety and avoidance or their critical, aggressive, or derogatory attitude. As mentioned above, several factors related to pathological narcissism contribute to the patients initial caution and guarded or even deceptive presentation. Those include: perfectionism, superiority, and other exaggerated strivings; limited ability or willingness to self-disclose and self-reect; shame and dread of facing intimidating or deating exposure; and expectations of being accused, blamed, and devalued. Perhaps most critically, these patients often have great difculty in acknowledging and verbalizing internal subjective experiences related to their narcissistic functioning. Those experiences include not only a sense of worthlessness and incompetence but also fear of loss of status, afliation, support, and sense of control.

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Figure 1. Grandiosity: Context and range.

Narcissistic patients can come across as circumstantial with difculties identifying meaningful specic problems. They may not know why they come for treatment and what they want to work on, or they may see a discrepancy between their own and others perceptions of their problems and what they need to change. They may feel blamed, threatened, and unfairly treated, and/or they readily oppose and criticize the therapists comments and interventions while pursuing their own point of view. In contrast to an initial meeting with a depressed patient wherein a clinicians conrmation of signs and appearance indicating a depressive disorder can be validating and even encouraging, noting external narcissistic traits to a patient may have a provocative or disruptive effect on the alliance. Similarly, the therapists observational feedback, and seemingly empathic and well-meaning interventions, can be perceived as intrusive and controlling. Understanding the nature of pathological narcissism and narcissistic personality functioning can help the clinician implement proactive strategies and focus on relevant issues from the start of treatment (See

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Table 1
Alliance Building With Patients With Pathological Narcissism or NPD
Therapeutic Attitude: Respectful Consistent Attentive Task focused Therapeutic Interventions: Validation Psycho education Clarication Exploration Interpretation (require sufcient foundation in the alliance). Note that empathic comments and observational feedback may be experienced as intrusive efforts to control and mind read. Strategic Steps in Alliance Building: Identify the patients descriptive understanding of problems and motivation to seek treatment. Encourage the patients coherent narrative of internal experiences. Build mutually agreed upon perspectives and understanding between patient and therapist. Focus attention on the patients divergent and opposite or incompatible experiences of self and others. Encourage meaningful formulations of range of self and self-esteem regulatory problems including superiority and self-enhancing strategies, inferiority and factors causing loss of self-esteem, and actual competence/assets. Gradually attend to the patients criticism and transference reactions of anger, disappointment, and retaliation.

Table 1). Thus, it is essential to handle the initial contact with narcissistic patients in ways that encourage their exploration of relevant problems and their willingness to address these problems in a meaningful way with the therapist. This process can require many sessions over several months, especially if the patient feels forced to come or is deeply unaware of or uninterested in addressing problems.

Case illustration
Mr. A, a married man in his mid-30s with 3 children between 2 and 6 years old, had recently lost his job and been forced to le for bankruptcy. He was referred by his psychiatrist to psychotherapy to address symptoms of depression and anxiety. He and his family were temporarily living in his grandfathers house.

Clinical and Developmental History

Mr. A reported a long history of panic attacks, insomnia, undereating or overeating, periodic substance use, and depressive episodes, including suicidal ideation. Since his teenage years he had seen a few counselors and psychiatrists, usually for brief periods, who foremost had attended to his symptoms of depression and anxiety. The possibility of an Axis II personality disorder diagnosis had never been raised until most recently when a consulting psychiatrist told Mr. A that he was narcissistic and suggested a diagnosis of NPD. Mr. A grew up with his parents and two older sisters. He described a relatively normal childhood but had since early years anticipated that his father would leave and that his parents would get divorced, which they did when he was in his early teens. He stayed with his mother, who now was remarried and lived abroad, and he got close to his maternal grandfather, with whom he and his family now stayed temporarily. Despite his struggle with various symptoms, Mr. A had been reasonably well functioning and active, with professional success. He had a graduate degree in business administration and several years of work in corporate managerial

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positions. Despite actual capability, Mr. A had struggled with a deep fear of failing and a vague sense of insecurity and uncertainty about his identity and competence. Mr. A started intensive psychotherapy two times per week.

Course of Alliance Building First session.

T : What brought you here today? P : I really dont know. I wish the world was a better place to live in, and that I would not need to be here. T : Well, we can always wish for a better world, but we cant change that here. However, you are here now, and the question is what you see as challenging and problematic in your life. Another question is in what ways we can work here together to help you to understand and deal with your problems differently, and to be able to change and move on in your life. P : I dont know if I can change, or even want to change, and I do not think anybody can help me either. Dont feel personally offended, but nobody has so far. I was even accused of having a narcissistic personality disorder, which we all know is untreatable. But my wife is threatening to leave me, and my grandfather wants to see me out of his house in 3 months, so I suppose I have to do something. T : So, your wife threatens to leave you and your grandfather wants you out of the house; why is that do you think? P : They are just assholes; they have ganged up on me. T : Hmmm, are you sure that those are the only reasons? P : (laughs) Well I suppose I may have contributed too, but not in the way they see it. T : So, how do you see the problems from your perspective? P : You really want to know that? T : Yes, I believe that is why you are here and where we need to start. By focusing on the patients own experiences and perspective, the therapist invited the patients narrative and understanding of his problems, deliberately shifting attention from the patients self-enhancing other-oriented speculation of vindictiveness and maliciousness. What followed over the next few sessions was Mr. As elaborated description of his internal state of pain and confusion, which made it difcult for him to attend to his children and follow through with chores and responsibilities assigned to him. Facing what he saw as overwhelming expectations and demands from his family, he felt decient and constantly criticized and misunderstood. He described hating family gatherings at dinnertime and early evening, and lashing out, shutting down, and withdrawing to his room, only to come out late at night when he could embrace the solitude in the house and a good movie. He described frequent ghts with his wife and grandfather about anything from house cleaning and nances to job searches and interactions with the children. He escaped to his friends homes where he watched movies, drank beer, and engaged in elaborative philosophical and political discussions. With them he felt relaxed, appreciated, and admired for his extensive knowledge and outstanding ability to state his ideas and opinions. Despite occasionally being driven by what he described as his ambitions, enthusiasm, and wishes to show off, Mr. A struggled with deep nihilism. He conveyed a sense of himself as worthless, believing that everything was going to end and that he would lose everything he had built up. Nevertheless, Mr. A also came across as an impressive man. He was good-looking, spoke loudly and eloquently, had a sense of sarcastic humor, and lled the room with his presence. But mostly he harbored a contemptuous attitude towards others, complaining about their incompetence and maliciousness and their lack of trustworthiness, genuine interest, and concern. Mr. A described himself as a martyr, a victim of others stupidity and malevolence. But he also experienced himself as a charismatic guru, admired and listened to by others. His sense of victimization and feeling blamed stood in stark contrast to his past history of competence, including his ability to engage in studies and relatively challenging and interactive professional

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work. It also contrasted to his experiences of nightly solitude and to socializing with his friends. He described a range of interpersonal interactions from impulsive hostility to friendliness, with intermittent periods of withdrawal, especially when feeling pressured. Mr. As descriptions of himself were noticeably incongruent and disconnected; each session was devoted to a different aspect of himself and his life. The therapist noticed her own anxiety as Mr. A described his life experiences, and she raised the question to herself whether Mr. A was actually struggling with a deeper sense of inferiority and compromised sense of self-agency, in addition to his sense of victimization and present losses. She wondered about Mr. As ability to reect, at any given time, on the entire range of his experiences, including his real past and present competence, his perceived sense of superiority, and his fears of inferiority.

One and a half months later.

T : You describe yourself as attended to and admired by your friends, and misunderstood, criticized, and devalued by your wife and grandfather, and a year ago as a working professional man. These are very different experiences. How do you understand this? P : Well, I dont!!! T : In one setting you describe feeling competent, in another you feel admired, and at home you feel criticized, devalued, and incompetent. What happens do you think? P : I just get lost. I was out playing with my son. We had a great time. He was building a sand castle and he was very engaged and happy. I watched him, helped him occasionally, and made some suggestions for various ways to decorate the towers. It came out great and he was very pleased. Then I came home and my wife was furious because I had not washed the car and paid the utility bills. T : So, you had a good time and did enjoy being a father together with your son. [The therapist deliberately chose to focus on a moment of Mr. As competence and responsibility as a father, which contrasted dramatically to his descriptions of incompetence and nihilism that he so eloquently had described]. P : Yes, sometimes I get tired and disconnect from my children, but yesterday I had a very good time with my son. I really like to see him grow. I feel proud of him and of being his father. T : What do you think makes it possible for you to feel competent and proud and act with condence? P : That is actually a good question. I dont know. I did well in school. I know I am a good sailor; I used to race and I won a few times. When I worked as a manager in the company I always heard from others that I did a good job and I was promoted to become the vice president. I never really liked the job, but the rst year went OK. Then we started to have production and nancial problems and my coworkers acted really strange. I could not trust anybody. I was totally alone and began to feel paralyzed. T : So, something changed. P : Yes, I stopped sleeping and could not go in to work, and I lost my job and my house, and now I am about to lose my family and my grandfathers support. T : That is a very tough and drastic turn of events. [Mr. A started to cry] In the following sessions Mr. A was furious, stating emphatically that the treatment was useless, that nothing and nobody could help him, that everything was bullshit, and that nobody could be trusted. He accused the therapist of being incompetent, just out to prove herself and promote her own interests. Intermittently he cried, stating that he felt hopeless and worthless and that he was going to lose everything, including his children who would be better off without him. The therapist listened carefully. Facing Mr. As rage and devaluing and provocative accusations, she acknowledged Mr. As genuine pain and his extremely negative and potentially destructive apprehensions. At this stage in the alliance building, 4 months into treatment, Mr. A made the rst candid acknowledgement of his own experiences of failure, describing his self-exaggerations and martyrlike sense of victimization, his areas and moments of actual competence, and his fragility and

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fears. The therapist wondered whether Mr. As intense aggressive reactions could be shame based, or protective efforts that reected a deeper fragility. The therapist felt nonexistent while Mr. A was engulfed in his own internal experiences. She sensed that Mr. A struggled with problems with self-esteem and self-worth that were yet to be explored.

One month later.

P : I have always since I was a child struggled with insecurity and a sense that things or the world will come to an end. I could suddenly feel anxious and panicky. Although I did very well, I always felt something was missing or wrong. I felt that I did everything I needed to do or that I was supposed to do and it still did not work. What is wrong with me? Do I have narcissistic personality disorder? T : Well, lets look at what you have described so far about your experiences. NPD is as you know about problems with self-esteem and sense of competence and self-worth, the various ways these can uctuate from feeling superior to feeling insecure and inferior, and what you do to protect and exaggerate your self-esteem, how you handle criticism, threats and set-backs, and how you feel towards and relate and come across to others. P : I know I feel devastated when I am criticized and fail. I get very angry but then I feel hopeless. T : Do you think that your retreat into seeing yourself and the world as failing is a reaction to that, like a way to protect yourself? P : Probably, by everything else failing, in some strange way, I feel in charge. As if I have it all thought out and under control. T : In other words and in a paradoxical way you access a sense of power and superiority. P : So that is grandiosity I suppose. But why do I feel so confused and insecure? Why do I always walk around with a sense that I will suddenly lose my ability or my interest or motivation? T : That is a very important question you raise. What do you think happens? Mr. As questions turned the exploration towards his relationships. It was as if this initial clarication of some aspects of the NPD diagnosis encouraged Mr. As further exploration. He described his father as a harsh, demanding, and insensitive man. He recalled being coached by him in sports, but when facing games and competition he always felt nervous. At several occasions he peed in his pants and had to leave the ground. The father got furious, criticized his son for being an unmanly coward, and ceased taking interest in him. Obviously, these were traumatizing experiences. They resulted in major disruptions in Mr. As male identity development and his sense of personal worth, competence, and control. A few weeks later Mr. A was discussing his relationship with his grandfather, a very accomplished executive whom Mr. A had admired, wished to please, and be like since he was a young boy. He had a secret dream that he could become his grandfathers associate, but as he struggled with self-doubts and insecurity, he also felt different from and inferior to the grandfather. He felt great when he engaged in political discussions with his grandfathers colleagues, but he longed for his attention and for being supported in ways that his own father had not. In a family meeting, the grandfathers mutual desires were conrmed; that is, he wished to be a better father for his grandson, Mr. A, than his own father had been for him, and than his son-in-law, Mr. As father, had been. In some way, Mr. As presence and need for help made the grandfather feel strong and valuable, and Mr. A reciprocated by appreciating and even idealizing his grandfather. On the other hand, the grandfather also felt increasingly burdened by his grandsons demands and intrusion in his life, so he had presented an ultimatum, requesting Mr. A to get a new job and move on in his life. Mr. A feared and dreaded the upcoming end of his grandfathers extended generosity. During the following sessions Mr. A elaborated on various professional possibilities, with intermittent sadness and crying. Unrealistic ambitions alternated with efforts to convince the therapist of his functional disability and to prove the treatment useless. The therapist acknowledged Mr. As anger and disappointment at her and the treatment for neither magically making him into the ideal man he wished to be nor supporting his idea of himself as entitled to lifelong

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disability. She consistently acknowledged his actual areas of competence and responsibilities, especially as a father to his children and provider for his family, his desire for an improved relationship with his wife, and his love and longing for his grandfather. She also acknowledged his disappointment and sense of failure to measure up to the grandfathers professional standards and success, a source of a deep sense of inferiority. A gradual process marked Mr. As acceptance of reality: its bleakness as well as its possibilities. Previous grandiose strivings and devastating anticipations were gradually integrated into narratives of real and contrasting life experiences. Therapy became the stage upon which previous dramas and needs were enacted, for example, the patients wish to ofcially be declared incompetent in order to disengage from adult responsibilities and remain victimized and for his demands that others change and adhere totally to his needs. As these and other narratives were explored, Mr. As relationships gradually improved. His wife decided to put the divorce negotiations on hold, he began having more constructive and mutually satisfying interactions with his grandfather, and he enjoyed and engaged more consistently with his children.

Outcome and Prognosis

After 8 months of treatment Mr. A was employed in a managerial position, overseeing production in a small company. He was able to access his working capability and resume his professional afliation. Together with his wife he saw a couples therapist. Mr. A began psychotherapy at a very crucial moment, facing signicant ultimatums while still experiencing a strong attachment to his family and support of his grandfather. In addition to the timing of the treatment, Mr. As ability to gradually mourn, reect, and integrate his divergent experiences of self and others, including his aggression and resentment, suggests cautiously positive prognosis. However, upcoming life changes and challenges may require additional psychotherapy.

Clinical Practices and Summary

This case illustrates how the external presentation of narcissistic traits and patterns, specically grandiosity, can differ quite signicantly from the patients inner world and subjective experiences. To identify and discuss a narcissistic trait in a way that can be meaningful, informative, and agreeable to the patient, the clinician is urged to explore the patients internal experiences and attend carefully to the patients own descriptions and understanding. Focus on a gradual integration of contrasting perceptions and experiences of self and others, including internalized merits and fears, and externalized expectations and faults, is essential. A collaborative, exploratory approach is crucial for gradual alliance building and for introducing interventions that can potentially lead to change. Focusing on clarifying and establishing a shared understanding of the narcissistic patients internal experiences and perceived problems is the central task.

Selected References and Recommended Readings

Bender, D. (2005). Therapeutic Alliance. In J. Oldham, A. Skodol, & D. Bender. Textbook of Personality Disorder (pp. 405420). Washington DC: American Psychiatric Publishing. Cooper, A. M. (1988). The narcissistic-masochistic character. In R. A. Glick & I. D. Meyers (Eds.), Masochism: Current psychoanalytic perspectives (pp. 117138). Hillsdale, NJ: American Psychoanalytic Press. Gabbard, G. O. (1998). Transference and countertransference in the treatment of narcissistic patients. In E. Ronningstam (Ed.), Disorders of narcissism: Diagnostic, clinical and empirical implications (pp. 125145). Washington DC: American Psychiatric Press. Gunderson, J. G. (2000). Borderline personality disorder. A clinical guide. Washington DC: American Psychiatric Press. Hewitt, P. L., Habke, A. M., Lee-Baggley, D. L., Sherry, S. B., & Flett, G. L. (2008). The impact of perfectionist self-presentation on the cognitive, affective and physiological experience of a clinical interview, Psychiatry, 71(2), 93- 122.

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Huprich S. K. (1998). Depressive personality disorder: Theoretical issues, clinical ndings, and future research questions. Clinical Psychology Review, 18, 477500. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York, NY: Jason Aronson. Kernberg, O. F. (Guest Editor). (2009). Narcissistic personality disorders: part 1 and part 2. Psychiatric Annals, 39(3,4). Kernberg, P. (1998). Developmental aspects of normal and pathological narcissism. In E. Ronningstam (Ed.), Disorders of narcissism: Diagnostic, clinical and empirical implications (pp. 103120). Washington, DC: American Psychiatric Press. Knox, J. (2011). Self-agency in psychotherapy. New York, NY: W.W. Norton & Company. Morf, C. C., & Rhodewalt, F. (2001). Unraveling the paradoxes of narcissism: A dynamic self-regulatory processing model. Psychological Inquiry, 12, 177196. Perry, J. D. C., & Perry, J. C. (2004). Conicts, defenses and the stability of narcissistic personality features. Psychiatry: Interpersonal and Biological Processes, 27, 310330. Pincus A. L, Ansell, E. B., Pimentel, C. A., Cain, N. M., Wright, A. G. C., & Levy K. N. (2009). Initial construction and validation of the pathological narcissism inventory. Psychological Assessment, 21, 365379. Rhodewalt, F., & Morf, C. C. (1998). On self-aggrandizement and anger: A temporal analysis of narcissism and affective reactions to success and failure. Journal of personality and Social Psychology, 74, 672685. Ronningstam, E. (2005). Identifying and understanding the narcissistic personality. New York, NY: Oxford University Press. Ronningstam, E. (2009). Narcissistic personality disorder: Facing DSM-V. Psychiatric Annals, 39, 194201. Ronningstam, E. (2011). Narcissistic personality disorderA clinical perspective. Journal of Psychiatric Practice, 17, 89. Ronningstam, E., & Gunderson, J. (1990). Identifying criteria for narcissistic personality disorder. American Journal of Psychiatry, 147, 918922. Ronningstam, E., Gunderson, J., & Lyons, M. (1995). Changes in pathological narcissism. American Journal of Psychiatry, 152, 253257. Safron, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. New York, NY: Guilford. Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: Lawrence Erlbaum. Tatarsky, A., & Kellog, S. (2010). Integrate harm reduction psychotherapy: A case of substance use, multiple trauma and suicidality. Journal of Clinical Psychology: In Session, 66, 123135. Weinberg, I., Ronningstam, E., Goldblatt, M., & Maltsberger, J. (2011). Vicissitudes of the therapeutic alliance with suicidal patients. A psychoanalytic perspective. In K. Michel, & D. Jobes (Eds.), The therapeutic alliance with the suicidal patient (p. 293316). The AESCHI Papers. Washington DC: American Psychological Association. Westen, D., Shedler, J., Bradley, B., & DeFife, J. A. (2012). An empirically derived taxonomy for personality diagnosis: Bridging Science and practice in conceptualizing personality. American Journal of Psychiatry, 169, 273284.

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