Metacognitive Interpersonal Therapy for Narcissistic Personality Disorder and Associated Perfectionism

` Giancarlo Dimaggio and Giovanna Attina

Center for Metacognitive Interpersonal Therapy, Rome
Treating narcissistic personality disorder (NPD) successfully is possible but requires a thorough understanding of the pathology and appropriate clinical procedures. Perfectionism is one prominent feature often associated with narcissistic difculties. Metacognitive Interpersonal Therapy (MIT) for NPD adopts manualized step-by-step procedures aimed at progressively dismantling narcissistic processes by rst stimulating an autobiographical mode of thinking and then improving access to inner states and awareness of dysfunctional patterns. Finally, adaptive patterns of thinking, feeling, and acting are promoted, together with a sense of autonomy and agency and a reduction of perfectionistic regulatory strategies. Throughout, there needs to be constant attention to regulation of the therapy relationship to avoid ruptures and maximize cooperation. We describe here a successful case of MIT applied to a man in his early 20s with narcissism, perfectionism, and signicant co-occurrence of Axis I and Axis II disorders. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 68:922934, 2012. Keywords: narcissistic personality disorders; psychotherapy; perfectionism; metacognition; therapy relationship

Narcissistic personality disorder (NPD) is a debilitating and hard-to-treat condition. Interpersonal relationships can be severely disturbed, both socially and occupationally, which makes it very difcult for sufferers to experience a fullling life and realize their ambitions. Levels of subjective suffering are described as lower than as in other personality disorders, but this is probably because of the tendency of persons with NPD to minimize their suffering when answering self-report questionnaires. In fact, mood disorders often co-occur, especially beginning in adulthood. Comorbid substance and alcohol abuse and eating disorders are also frequent. Overall, when narcissistic needs are unmet, these individuals become quite distressed and often suicidal (Ronningstam, 2009). Whereas their behavior can hurt others, their inner experience is lled with negative feelings and problems that make life feel meager, to the point, in extreme cases, of meaninglessness. Such individuals conceal their feelings of unworthiness and anticipate a lack of support by others; they imagine they will be rejected, criticized, or ostracized, so that, as a consequence, they feel alone. Underneath the surface lies a sense of fraudulence and the apprehension that sooner or later others will detect the charade, perceptions that lead these individuals to sometimes avoid social contact. When not striving for grandiosity or when sensing their goals are far from being achieved, they lose hope, feel unable to commit themselves to whatever action is required, and eventually feel devitalized and empty. Although often overlooked in the clinical literature, perfectionism is one prominent regulatory strategy for NPD self-esteem. Individuals with NPD have unrelenting standards for maintaining a sense of self-worth. People with narcissistic problems typically raise the bar after each accomplishment, which results in never-ending dissatisfaction. Their experience could therefore be described as looking towards heaven but anticipating a fall into the abyss when perfection is unmet (Dimaggio et al., 2002). Perfectionistic standards are also set for others, who are then derogated when they fail to meet these expectations. Perfection is almost the sole measure used by individuals with NPD to gauge their value and the only goal they consider worth reaching. In order to feel vital, they assign value to one selected accomplishment, for example, being

Please address correspondence to: Giancarlo Dimaggio Piazza Martiri di Belore 4, 00195 Rome, Italy. E-mail: gdimaje@libero.it
C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(8), 922934 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21896

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the next Gordon Gekko, perfectly t, or a Don Juan. If and when this is accomplished, for one sparkling moment they feel they have achieved their ideal self-image, but this feeling does not last. Shortly after, usually after feeling wounded by a signicant gure in their life (e.g., a spouse or a colleague), they feel that the accomplishment was not of sufcient value, and they self-denigrate accordingly. They then raise the bar and, either in their imagination or in reality, set a new higher and perfect standard, for example, losing more weight, making more money, or further surpassing colleagues on the same career path. This is an endless pursuit, with every recently achieved goal soon being perceived as inferior to the new ideal. A second perfectionistic regulatory strategy in NPD is setting a series of high standards for a whole range of goals, termed The decathlon athlete illusion by Dimaggio et al. (2002). To feel perfect, NPD individuals need to feel that their performance is among the highest ranking (not necessarily the very top) for all the goals they set themselves. When they perceive their self-enhanced evaluation to be threatened by others critical feedback, they feel not worthy enough and start using compensatory strategies for promoting self-esteem, such as blaming others for failures, or fantasizing that they could reach their targeted performance goals if only ` obstacles were removed or they just had the time to try (Dimaggio, Semerari, Carcione, Nicolo, & Procacci, 2007). Some empirical evidence is also starting to emerge regarding cosmetic surgery as a regulatory strategy: persons with narcissism and perfectionism tend to seek it, although it can lead to dissatisfaction about the results (Fitzpatrick et al., 2011). In a related vein, we found NPD traits strongly linked to measures of perfectionism in both clinical and community samples, in particular regarding high personal standards, high parental expectations, and excessive concern about mistakes. Our sense is that these individuals are afraid of making mistakes, which would show they have not met the high standards others have set for them (Dimaggio et al., 2012). Primarily as a result of their behavioral presentation, being in the therapy room with a patient with NPD is challenging. The therapy relationship is problematic; patient and therapist often enter into cycles in which they ght to protect their self-esteem against each others perceived attacks, enter into power struggles, or withdraw from each other. These interpersonal patterns put treatment at risk and make success hard to achieve. Treating NPD therefore requires an accurate understanding of the underlying pathology mechanisms, so that treatment procedures can be tailored to precise needs. Nevertheless, if the therapist is aware of the typical problems of this clinical population and able to tactfully handle relational issues, then treatment can be cooperative and successful and these persons can be helped to lead a more fullling life. Once pitfalls in the relationship have been avoided or managed well, these patients can often display humor, recognize their therapists skills and human qualities, and feel grateful for being helped. Metacognitive interpersonal therapy (MIT; Dimaggio et al., 2007), adopted in the case study that follows, focuses on the various narcissistic processes, including perfectionism, and incorporates manualized steps for tackling them. The majority of the processes and symptoms targeted by MIT are included in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) draft prototype for NPD.

Narcissistic Personality Disorder: Key Pathological Processes

We focus on the following target aspects of narcissism.

Self-States and Self-Other Schemas

While grandiosity and fantasies of power and success are often very recognizable aspects of narcissistic individuals difculties, they are only manifestations of what are actually the core themes in their stream of consciousness. MIT focuses mostly on how self-appraisal swings from hyper-valuing to self-derogation. In addition, those with NPD often experience anger, triggered by feelings of being slighted, socially rejected, or hampered when pursuing their goals; their tendency is to derogate others who give them negative feedback or impede their actions

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(Ronningstam, 2009; Twenge & Campbell, 2003). Others are therefore seen as incompetent or ` 2008). hostile and are blamed for setbacks (Dimaggio, Semerari, Carcione, Procacci, & Nicolo, Nevertheless, anger is not a primary target of MIT, which focuses instead on the vulnerability felt by persons with narcissism, including their lack of condence and their wavering belief that their actions will be supported. The aim of this therapy is to increase individuals condence that their efforts are meaningful, regardless of whether they help them reach perfection or not. Usually, when persons with narcissism see they have the right to pursue their goals, they are less vulnerable to others negative feedback, resulting in a reduction in their anger. States in which the self-image is extremely negative are important to focus on in our model, though they are so hard for the individual to bear that ghting with others and blaming them for any personal aws are frequent defensive maneuvers. Inevitable setbacks, such as failing in a work task or being rejected by a lover, often lead to depression or shame (Tracy, Cheng, Martens, & Robins, 2011). When others are perceived as unwilling to provide attentiona common occurrenceor seen as domineering or spiteful, the self tends to react by ghting or resorting to a cocoon-like state (Modell, 1984). When attachment needs are activated, the other is expected to be rejecting, which, in turn, steers the self to compulsive self-soothing and denial of attachment needs. In general, the experience of an individual with NPD focuses on social rank, with attachment needs overlooked. The vulnerable self is usually concealed. Emptiness, emotional numbing, and devitalization are also key targets of NPD treatment (Kohut, 1971), consequences of the agency decit that we describe below.

Diminished Agency and Goal Setting

The drive to act is diminished in individuals with NPD, counterintuitive as it may seem, when considering persons described as arrogant and self-centered. When persistence is required, performance tends to, after some initial sparkling moments, decline over time (Robins & Beer, 2001). Patients with narcissism, when not struggling for grandiosity or ghting against the oppressor, lack access to those innermost wishes that could make them feel alive and vital; they lack a sense of existential agency (Kohut, 1971; Modell, 1984; Dimaggio et al., 2007, 2008). As a consequence, they are other-directed and their striving for admiration is a coping strategy for avoiding the awful, impending feeling of absence of purpose.

Impaired Metacognition and Empathy

Metacognition is the ability to recognize and reect on mental states, both of oneself and others, as well as the ability to use this knowledge to tackle the difculties of social life (Dimaggio & Lysaker, 2010). The absence of metacognitive abilities is a core feature of NPD (Dimaggio et al., 2002). These patients usually lack awareness of the interpersonal triggers for their emotional reactions; for example, they miss the connection between a no from a girl they are interested in and the depression of the next day. Emotional language is impoverished and emotions are overlooked in favor of theorizing. Sufferers also have difculty questioning their own rigid and schema-driven representations of self and other, which we call poor metacognitive differentiation. Their ability to put themselves in others shoes and react empathically is hampered, though they are not aware of their poor empathy (Fan et al., 2011; Ritter et al., 2011). MIT considers poor self-awareness the core NPD metacognitive dysfunction and, therefore, the key treatment target in this domain. Helping patients access their motives and desiresother than striving for grandiositymay help them live more satisfying lives.

MIT for NPD

MIT for personality disorders adopts formalized step-by-step procedures (Dimaggio, Salvatore, ` Fiore, & Procacci, 2010; 2012). These have been customized for treating NPD based Nicolo, on the analysis of a series of single cases (Dimaggio et al., 2007, 2010, 2012). These procedures address the structure of narcissistic pathology by attempting a near-optimal regulation of the ` 2010). The initial therapy relationship (Dimaggio, Carcione, Salvatore, Semerari, & Nicolo,

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step, which should continue throughout the therapy, is regulation of the therapy relationship to minimize ruptures, misunderstanding, and disengagement. MIT therapists are alert to any signs of alliance deterioration and ready to prevent or repair ruptures; they use the therapy relationship as a source of information for adaptive ways of relating (Dimaggio, Carcione et al., 2010; Safran & Muran, 2000; Semerari, 2010). Therapists should adopt a constantly validating stance, monitor any tendency to be domineering, be ready to detect any negative relational signals, and always assume that they may be contributing to emerging problems. A tactful use of self-disclosure to promote a sense of we-ness is also fundamental. The rst goal of the procedures is to form a shared understanding of problems with patients and progressively promote their awareness of mental states. Once patients have acquired a model of their functioning, then change becomes possible. MIT procedures comprise a rst set of steps called stage setting and a second series of steps called change promoting that can be enacted once stage setting has been fullled. The stage setting part is made of the following steps:

r r r

Eliciting detailed autobiographical episodes instead of accepting the broad, generalized theories provided by the patient; these episodes should convey clear descriptions of where and when they took place, who the actors were, what kind of dialogue unfolded, what the topic was, and why the patient is describing this specic episode (the underlying wish). Therapists and patients should repeatedly go over the details of an episode until previously unnoticed aspects of subjective experience appear. Promoting patients abilities to recognize their own mental states nesting in the narratives; in particular, patients should be helped to identify and name feelings and then understand the underlying emotional triggers. Collecting a sufcient set of associated autobiographical memories to provide evidence of rigid interpersonal relationship schemas. Promoting a shared awareness of recurrent patterns of interpersonal relationships. Patients with NPD need to understand how they over-resort to antagonism and status seeking and how much they strive for admiration and recognition to feel good enough. They also need to realize how expectations that others will be hostile or hamper their goals are largely schemadriven and use this knowledge to form strategies for changing. As long as psychological information is inaccessible, therapy remains in the stage-setting area. Showing that difculties in acting according to deeply experienced inner wishes, that is, poor agency, are a key problem. A therapist, therefore, should promote autonomous actions driven by those wishes and, at the same time, tactfully discourage actions based on perfectionistic standards and/or aimed at achieving others admiration and approval. Patients need to understand that their inability to enjoy life is due primarily to their passivity and lack of goal-directed action and not others negative reactions. The change promoting parts is made of the following steps:

r r

r r

Showing patients that their ideas do not necessarily mirror reality and that situations can be understood differently when seen from another angle. Fostering access to healthy self-aspects and promoting new behaviors that are in accord with patients innermost wishes. This should happen after creating a shared sense that striving for grandeur and status is a normal human need, common to all, including therapists. Patients should then be encouraged to leave this motivation on the fringes of their consciousness and instead build new and healthier thinking, feeling, and behaving patterns. Stimulating a critical distance from old schemas while constructing different ways to think about problems and a broader repertoire of interpersonal representations; Promoting (in the later phases of therapy) a more nuanced understanding of how people think, feel, and behave. Awareness of how thinking styles and dysfunctional interpersonal behavior patterns create problems and conicts should also be promoted, together with a sense of empathy towards others.

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Case Illustration Client Description and Presenting Problem

Lucian sought therapy in 2009 because of difculties with his studies and in relating to peers, which led him to quit his studies at his university. His presentation was typical of NPD. He described himself as a man of special talents and interests, whose ambitions had been thwarted by his sanctimonious parents: If my parents hadnt clipped my wings, I could have become a great actor. He would have preferred to lived during the era of the Roman Empire; he was sure he would have led an army at that time (he knows every scene by heart of a movie about Alexander the Great). He was contemptuous of his peers: They dont possess my own healthy principles or ambitions . . . . These assholes with their eyebrows shaved who do they think they are? If they could see how horrible they look . . . for me theyre low class. He had isolated himself socially and had only a few, longstanding friends, whom he saw as inferior and treated arrogantly. He was the youngest of four siblings, the son of a 74-year-old father, a retired white-collar worker with a history of depression, and a 70-year-old mother, a retired school teacher. His mother was his sole condant, the only person whom he felt understood and listened, but she was also a person he saw as anxious and controlling. Lucian described his father as a strict, authoritarian man, dissatised with his children and complaining continuously about how they were not up to his level: When I was a child he frightened me a lot. Hed easily get angry even for trivial reasons. Now I hate him . . . . He doesnt deserve anything. I despise him. Lucian felt despised by his father as well as his siblings. He found studying distressing and had morose doubts about whether he was talented enough to succeed. He spent his time at home playing sports and taking care of his dogs. Everything was ruled by perfectionistic standards. He strived for perfect physical tness and, if his training routine got interfered with, he started worrying: Im going to get less t. Im not a serious guy because I dont do my duty and if I dont do that, I cant enjoy anything. He was unable to access pleasant states even while playing soccer or watching a movie. He was socially inhibited and had poor social skills. His romantic and sexual life was poor; he had had only one girlfriend and had not dated for 3 years. He felt inadequate and incapable of living like others. He was poor at describing his internal states and only managed to pinpoint strong negative emotions like anger and anxiety.

Case Formulation and Diagnosis

According to the DSM-IV, Lucian suffered from NPD, avoidant personality disorder (PD), and PD not otherwise specied (NOS; depressive type); he also had obsessive-compulsive PD traits and some symptoms of social phobia and depression. According to the DSM-5 current draft, he was a good-to-excellent match with the NPD prototype, with prominent perfectionism and antagonism traits. On the Levels of Personality Functioning Scale (Bender, Morey, & Skodol, 2011) he would likely be rated a 3: he had a weak sense of autonomy/agency, his self-esteem was vulnerable, and when criticized or opposed, he reacted with rage or shame; he was unrealistically self-aggrandizing; he struggled to reach personal goals; his self-reection was hampered; his ability to appreciate others emotions and perspectives was severely impaired; and he easily felt threatened by others viewpoints. He was unaware of and lacked consideration for the impact his behavior had on others. He desired a bond with the community but was incapable of attaining this. Mutuality was virtually absent. During early sessions, Lucian disclosed his negative ideas about himself. Aspects of his selfportrait included weakness, incapability, inadequacy, and timidity. Consistent with the MIT principle of avoiding evoking access to the vulnerable aspects of NPD too soon, the therapist did not actively elicit them. In fact, when describing himself as weak and vulnerable, Lucian experienced depression, emptiness, and shame. In terms of interpersonal patterns, his main desire was to be recognized as special and superior. While in the negative state, his representations of others when reacting to this desire included the terms strong, domineering, rejecting, and

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contemptuous. His reaction to the expected rejections and criticisms swung between shame, isolation, and anger towards enemies to be fought. The only way to cope with the distressful state of feeling rejected and despised was to resort to perfectionistic standards: If I look perfect and sure, nobodys going to see Im incapable and cowardly . . . . They wont criticize me or attack me, but theyll make me feel capable and included in the group. Lucian had difculty identifying his inner states, including desires and emotions, and understanding the triggers for his emotions. The consequences of these selfreection problems were confusion and inability to choose. His narrative style was abstract and intellectualizing and he had difculty recalling specic autobiographical memories.

Course of Treatment
Therapy was weekly. The therapist (GA) was a woman psychologist, a licensed psychotherapist with 4 years of experience in MIT; she was supervised on a monthly basis by one of the founders of MIT (GD). No medication was used.

Early regulation of the therapy relationship and identication of themes. The regulation of the therapeutic alliance was facilitated by the patients cooperative and trusting attitude. The therapist felt tested, challenged, or criticized only a few times. This was probably because of the position she adopted. In fact, to prevent ruptures she avoided casting doubt on the contemptuous image Lucian had of others and resisted the tendency to defend them from his criticisms. On the contrary, she appeared curious and nonjudgmental. According to MIT, rapport and a sense of cooperation are more easily established when the therapist enters into the patients grandiose fantasies without challenging them; therapists need to be aware that the ambition and grandiose aspirations that dwell deeply inside each human being are perfectly normal. Lucians desires to be an actor or Alexander the Great were thus validated at an emotional level with interventions such as I realize you have ambitions and pride which you feel are currently being unmet. When Lucian described himself as inept or inferior, the therapist self-disclosed and told him an episode in which she herself felt incapable, stressing not how she overcame the sensation, but how she found the sensation itself to be similar to his. Lucian did not feel embarrassed by what she said and, feeling safe, revealed his own vulnerable parts. A major problem in the early phase was Lucians intellectualizing style, which MIT suggests be addressed as a primary target: patients need to be encouraged to switch to the autobiographical narrative mode. Stage setting: Eliciting autobiographical memories and accessing inner states. Although in MIT, eliciting episodes and searching for inner states nested in them are separate steps in the procedure, in Lucians case the telling of each episode was accompanied by a rapid surfacing of associated emotions and thoughts and so we will describe them. To elicit autobiographical episodes, the therapist explained the rationale for requesting specic narrative episodes, letting him know that raw material based on lived experiences helped her know the nuances of his mind better. In addition, she used the themes in his theorizing as anchor points for eliciting narratives located precisely in space and time. Moreover, when Lucians intellectualizing about the faults of present day society was excessive, she avoided displaying any signs of boredom, noninterest, or detachment. When, for example, Lucian repeated he would like to be like Alexander the Great, the therapist rst asked him to put himself imaginarily in the scene: How would he have felt being an army leader? How would he have found it enjoyable? Had there been precise moments in his life when he had really experienced emotions and thoughts similar to when he imagined he was a great army leader? In fact, the memories emerging were not about the positive state of grandiosity, but, on the contrary, about the mismatch between his expectations of being recognized as special and superior and the actual reactions of others he perceived as rejecting and spiteful. Lucian felt that achieving his ambitions was impossible.

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A key episode emerged in the second session when he described a visit to the Post Ofce to pay a bill. Before entering, he felt an anxiety connected to his perfectionistic standards and fear of humiliation: Am I going to be up to carrying out this task well? Am I going to gain respect and not be treated rudely? I mustnt appear indifferent to the other; otherwise Im a useless loser. When he got to the clerk, he immediately perceived him to be distracted and impolite and so started thinking: This asshole at the counter hasnt even looked me in the eyes, with that supercilious air of his. Who does he think he is treating me like this? Who does he think hes dealing with? This haughty reaction was short-lived and was soon followed by a shift into a state of vulnerability and inferiority: Im unable to gain respect and make others see what I am and what Im worth . . . . Hes treating me rudely because he thinks Im an idiot. Thinking further together about the episode, the patient and therapist accessed details of Lucians cognitions: he was driven by the social rank motive, needing to be accepted and considered capable, smart, and appreciated. The condition for gaining appreciation and status was carrying out tasks faultlessly. His expectation about the others response was that anyone who is not fearless and exceptional will be considered a loser and worthless.

Understanding psychological causalities. To understand better the cognitive-affective processes underlying Lucians suffering and avoidant behavior, other episodes were evoked and analyzed in detail. In a recent episode, Lucian struggled to deal with a sense of emptiness, boredom, and lack of purpose by searching for a job. He was offered a job as a secretary by his brother-in-law in the latters ofce. His duties involved going to clients to deliver les, making appointments, organizing meetings, and so on.
Lucian : Im not sure if Im going to accept this offer. Its not what Im looking for in my life. Therapist : In the last session, you told me it was better than staying at home doing nothing . . . that you wanted to give it a try. L : Hum . . . . Yes, but its not what I want in my life . . . Id be wasting . . . . T : You talk about it as if you were choosing a job for life. You told me instead that you were doing it just as a part-time job to earn some money and see a few people. Whats changed since last week? L : I didnt like my brother-in-laws behavior when we were in an ofce. (Lucian pauses and has difculty describing his inner state. The therapist recognizes the emergence of the typical narcissistic difculty in accessing emotions and works at trying to help Lucian describe his feelings.) T : What didnt you like? L : Im not sure. We walked down these corridors full of people who didnt even look at you. They all knew each other. I didnt know where to go, how to behave. My brother-in-law hurriedly explaining to me what I had to do, the lines . . . the counters where the les were to be handed over. I mean it was horrible. Thats not the life I want! The therapist now understood that Lucian felt socially rejected and frustrated and therefore validated his stance to facilitate a feeling of being accepted. This created the conditions for a further search for inner states. Lucian felt readily understood and he and the therapist explored cause-effect chains between events and his thoughts and feelings. T : I can see. It cant have been an easy morning. Finding yourself somewhere you dont know and having to try and grasp how it works. Plus, were talking about an enormous ofce . . . . I can imagine the tremendous confusion. L : Yes, it was frightful. T : Sure, and while you were with your brother-in-law, what did you think about what you were experiencing, the place and the things you had to learn to do? L : That Id never have managed (pause), that Id never have understood anything (pause), that Id have failed and that my brother-in-law and parents would think I couldnt do even piss easy things.

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At this point the therapist attempted to help Lucian differentiate between expectations and reality. This is something that MIT suggests be typically done later in the treatment. Nevertheless, when there is a prominent negative state, the principle of adopting a validating stance allows a therapist to try and encourage a more benevolent self-image. There is no expectation at this point of stable change, which will be achieved later; rather, the goal is to help the patient exit from the negative state during the current session, which is what happened as the conversation continued. T : But why do you call them piss easy? They arent at all. You were right in nding the ofce chaotic. To get to know it, you need time and patience. You might ask your brother-in-law how long it took him to learn things before displaying the nonchalance you saw yesterday. L : I hadnt thought of that. T : You thought you wouldnt be up to learning your way around the law courts and imagined youd be mocked by everyone. What did you feel at the moment when you pictured this scene to yourself? While you were telling me about it, you seemed anxious. L : Yes, anxiety. I started to sweat. I wanted to get out of there. I thought Id been a fool to say yes. The therapist encouraged Lucian to clarify what he felt and thought about his experience in the ofce. Thanks to the exploration of this narrative episode, Lucian grasped that his isolation was caused not so much by the fact that his narcissistic expectations would not be satised by a society that did not understand him and was not up to his level, but by his avoidant behavior, an action he chose to protect himself from the criticism he expected from others. The core problem was therefore that he felt ashamed because he was not up to his own perfectionistic standards. In their analysis of the episode, the patient and therapist dwelled on the fact that Lucian had failed before even starting: He was going to be considered incapable and inadequate for sure. The cause-effect chain underlying his negative interpersonal schema was therefore: I want to be appreciated and considered highly but Im anxious about the idea of being judged negatively. I dont do things to perfection and Im confused. And so others see me as incapable and clumsy and I, too, think the same about myself. For this reason, I get depressed and ashamed, and isolate myself.

Eliciting associated memories. The next step in this clinical procedure is to collect associated memories to be used as evidence for oneself and the patient to show that the latters mind contains stable ways of thinking about the self and others. The therapist therefore asked Lucian to think of any memories he felt in some way connected to the ones just described: You were in the ofce with your brother-in-law and you felt incapable and anxious, and were frightened about criticism. Have you felt something similar in other situations? Lucian was able to recognize that he often felt like this when faced with things to tackle, even if they were activities on his own. Lucian recalled other episodes from his childhood, in particular an occasion during which he had felt totally incapable, weak, and clumsy vis-` a-vis his parents and older brothers, all seen as superior and humiliating. During a party game his brothers ridiculed him because they deemed him incapable of miming a lm. Further episodes surfaced: some were consistent with this narrative structure, while others reected memories of a successful performance contaminated by thoughts that the task performed was too simple. Promoting awareness of perfectionistic schemas. After reviewing the narrative episodes and discussing them during supervision, the therapist proposed the following reformulation to Lucian:
Lucian, you live for success and think youre going to fail and that others will ridicule you. When, instead, youre successful, thus disconrming your hypothesis about being incapable, clumsy, and inadequate; you ascribe this to the things youve done being easy. If you manage to approach a person youre interested in, you

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immediately think they arent worth it. The idea you have of your relations with others seems to be, If the other holds me in esteem, its because hes in turn stupid or damaged, or else because he hasnt had time to evaluate me properly. Lucian agreed with this reformulation and understood it was his typical perfectionistic way of appraising events. During the following sessions he and his therapist reviewed recent episodes for further evidence for the existence of this pattern. Lucian readily saw he was deeply insecure. When he realized he had done a task well, he did not enjoy the success because he tended to raise the bar, that is, he considered that what he was doing was nothing that should especially make him feel satised. In addition, he then put himself to the test by pursuing a more difcult goal, as in the following example. Initially, he described himself as satised with his job in the ofce. Later that same day he was expecting that a girl that he had met the day before would go out with him when he proposed a rst date. Faced with her refusal, which for him meant failure, he thought angrily: This girls an idiot who thinks she knows everything. Shes underestimating who I am . . . . Ive been too interested in her . . . . Immediately afterwards, he got depressed: I deluded myself, thinking I was smart and capable, but at the end of the day Im not getting anywhere. Im a failure. What I did at the ofce was nothing! Overall, Lucian displays a fragile and uctuating self-esteem, dependent on external feedback. The stage setting was considered to be mostly accomplished, though, of course, there were moments in sessions when Lucian lost awareness of being schema-driven. In these instances, the therapy returned to analyzing narrative episodes in detail and reconstructing the underlying mental processes.

Change promoting: Differentiating between fantasy and reality. The therapist reformulated the problem: It seems youre seeking conrmations that havent the slightest effect on the negative ideas you have of yourself. How much do you believe this idea to be true? You seem to listen to the part testifying to your nonvalue. Why do you need to be so strict with yourself ? The patient and therapist now had a shared understanding of the formers schema and Lucian could see how his self-representations were inexible. The therapist now helped him consider his ideas as hypotheses rather than the absolute truth and to see himself from a different perspective. Lucian arrived at one session looking shaken and gloomy. He was demoralized, thinking he wasnt worth anything and everyone would reject him. Then a facial expression of anger surfaced. The therapist explored an episode at a party where there were a few of Lucians friends, two guys he had met for the rst time, and a girl who seemed interested in him:
L : Im really pissed off and demoralized. This is not what I want in life. T : Explain better. What is it you dont want in life? L : This idea of studying archaeology, these new friends. I feel Im wasting time I could be using for other goals. T : What other goals? Has some other wish you want to achieve come to mind? L : No! I dont know! However, its what Im doing. I dont know whether I like it. I feel dissatised, as if I thought there was something else for me and that Im wasting my life away. Yesterday evening I went to a dinner at a colleagues place. There was the usual little group but there were also some friends of this girl that I didnt know. T : You met them that evening? L : I didnt really take any notice of them. They kept to themselves and didnt look at anyone. They looked like two assholes. At a certain point I wanted to leave . . . . T : But why did you want to leave? Werent you having a good time with your friends? . . . Manuela was there too. Wasnt she? (Manuela was the colleague who was courting him) L : Yes, but it didnt matter. Those two assholes werent doing anything to create a group. They kept to themselves and at a certain point I asked them something and they gave me a curt reply. They were cold. T : What did you think at that moment? L : That they didnt want to accept me. They were giving themselves airs . . . .

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The therapist rst gave Lucian her approval for his ability to relate the details of the episode clearly. Then she pointed out that an old schemahe felt inferior, others were viewed as harsh judges, and he felt contemptuous towards themhad gotten reactivated. She also remarked how the idea of being excluded from groups was pervasive in his thinking. Lucian agreed and the therapist continued by pointing out that his attention had been selective: While he was focusing on those moments in the evening at which he felt excluded, he was virtually ignoring the attention Manuela was paying to him. She also pointed out how rapidly two expectations became activated for him: the expectation of being recognized as special and the subsequent expectation of being considered a loser. She asked Lucian if he considered it possible to be immediately regarded highly by people who do not know us and he acknowledged that this was unlikely. At this point, the therapist invited Lucian to consider alternative interpretations of the event. He thought again about the episode and realized that he had spent the evening thinking about how others were appraising him as if he was the center of their thoughts. He also realized how much he had been driven a priori by deance, hoping to nd some faults in them in order to feel superior and win. T : When the atmosphere turns competitive, what you think becomes the universal reality: They want to exclude me! Shall we think for a moment of what other possible explanations there could have been behind those two guys cold and detached behavior? L : I didnt think about it at that moment. Thinking about it now, perhaps it was they who felt uncomfortable. There were more of us and we were more familiar with each other. And to tell the truth, we werent paying them much attention . . . . Thanks to this intervention, Lucians depression and anger diminished. He realized that the problem was not the external obstacle, but his propensity, rooted in his history, to feel inadequate and incapable when others fail to show interest in him or pay him attention. Thanks to this exploration of alternative hypotheses, his theory of others minds grew (Perhaps it was they who felt uncomfortable)

Exploring new avenues consistent with patients innermost wishes: Promoting agency and autonomy. Apart from his tendency to avoid exposure to feared social events, Lucian could
not fully account for his tendency to quit jobs. This is evident, for example, at the beginning of the session just described: Lucian did not love the work he did but had difculty perceiving alternative desires that could guide him to act. The therapist invited Lucian to put aside his perfectionistic expectations and concentrate on how little he found his job interesting. Some aspects of moral perfectionism emerged: Lucian was convinced he had to stay out of gratitude towards his brother-in-law and that, if he resigned, he would show himself to be unworthy. The therapist joked that Lucian had not signed a contract in blood and the latter, smiling, started to relax and explore the idea of nding his way in life. Two years later he decided to leave the job with his brother-in-law. Lucians initial grandiose fantasies provided a useful starting point in getting him more in touch with his inner feelings and desires. He wanted to become an army leader, but in doing so he had become an expert on ancient history and the subject truly excited him. To one session he brought the start of a story he had written on General Belisario, inspired by a painting depicting an ancient Roman ofcial. The therapist read it during the session and found it wellwritten and enthralling. She asked Lucian to write the next part of it because she felt sincerely interested. He let himself get involved in the writing and felt appreciated by the therapist. His grandiose fantasies got gradually transformed into a realistic project: Ive been thinking I like studying ancient history or writing stories but there are no job prospects. But I feel that studying archaeology unites this passion of mine with the possibility of nding work. Lucian enrolled at the university to study archaeology. He found the therapists support to be particularly important for overcoming the criticism from his parents, who ercely disapproved of the idea. Beginning his studies, one of his old schemas re-emerged: Theyve accepted me

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because they need students. However, unlike previously, he saw very quickly that this was an old schema-driven idea and managed to divert his attention toward how much he was interested in and motivated by the topics he was studying. His fear of social rejection by preexisting groups also got reactivated. In response, the therapist self-disclosed about her experiences when she joined her rst work group. She wanted to be part of it but felt excluded and an outsider; she felt sad because of the absence of people she knew and her solitude. Gradually, however, her face became known to the others, and between one hello and another she managed to get on more-or-less familiar terms with them. She put the emphasis not on her ability to get herself accepted, but on the sense of we-ness that develops almost naturally in social groups with the passing of time together and with the sharing of experiences.

Outcome and Prognosis

At the time of writing this articleafter two and a half years of therapythe outcome has been good in many respects. Lucian no longer meets either NPD or avoidant PD criteria. He still has full-blown PD NOS (depressive type), mostly reecting the remaining issue of critical perfectionism toward self and others, on which therapy is currently concentrating. In terms of overall personality pathology, he meets 10 PD criteria in contrast to the initial 22. Social phobia is subthreshold and he feels less depressed; moreover, his depression alternates with moments of agency and initiative. As regards a DSM-5 diagnosis, he no longer meets criteria for NPD nor for Avoidant PD. He can be classied as PD trait-specied with antagonism features. He has reached a level of functioning between 1 and 2, unlike the 3 at the beginning of therapy. Some recent text messages while the therapist was on maternity leave provide a summary of his current state. He recently spent a night with a woman and, after 4 years of total absence of romantic affairs, kissed her; a few days later he had sex with her. Doctor, good morning! A stupid question but one I have to ask. These butteries, this excitement I feel in my stomach, are they caused by the fact that Im savouring true living or is it fear of all this newness Im experiencing this year? Excuse me for the rather strange question. Have a good day! The therapist answered with: Good morning Lucian, the description is perfect. I can understand what you feel and I really believe that its the savouring of true living and, in particular, feeling involved with a woman you like. Feeling a bit of anxiety in this situation is totally normal. Have a good week-end! He replied: Thanks, doctor. Its that sometimes I almost feel like a child who has to unwrap his presents. Have a good weekend, you too!

Clinical Issues and Summary

Treating NPD successfully is possible. Therapy can be manualized and detailed procedures can be described, as in the case of MIT described here. We advocate that even if the therapy relationship is difcult with these patients, because of their tendencies to attack the therapist or withdraw, a combination of empathy, careful management of the therapy relationship, and appropriate step-by-step therapy procedures can reduce the drop-out risk and improve the chances of success. Finally, here are some quick rules of thumb for therapists treating NPD:

r r r r

Be cautious about challenging self-serving grandiose representations; self-esteem achieved on this basis is not inated but unstable. Patients could shift into self-deprecating states or drop out of therapy if they feel hurt. Work to promote a sense of agency based on motives other than the need for grandiosity. We suggest to patients that the great pleasure of a craftsman is to sense the clay taking shape, an experience that to many is at least as satisfying as the triumph of seeing the nal product emerge. Avoid attempts at improving empathy for others until the patients inner desires have been accessed and supported. Carefully regulate the therapeutic relationship and ones negative reactions. Therapists tend to easily enter into cycles in which they feel attacked or belittled by a narcissistic patient and react

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by defending their own role and status. They may get frustrated and disengage, or they may blame patients for lack of involvement in the relationship. Such reactions must be regulated in sessions, through either supervision or self-disclosure of these concerns. Self-disclosures in which therapists acknowledge their own aws and limitations are highly recommended. These comments serve to counteract the patients narcissistic tendency to feel the therapist is embodying the role of the wise person, which can easily trigger a deant attitude and ignite power struggles. Be cautious about promoting awareness of the vulnerable self because this may cause patients to withdraw or actually terminate treatment. NPD therapy can often terminate with partial success even before patients access the softest parts of their souls. Tactful confrontation of dysfunctional patterns is possible only once the therapy relationship is solid enough to withstand difcult and/or frightening moments.

Patients with NPD can be helped to understand their lives not in terms of rules and abstractions, but through contact with the details of their raw experience, as evident from autobiographical episodes. Emotional awareness needs to be fostered, together with a more accurate understanding of the triggers for the emotions. A sense of purpose, including goal-directness, needs to be promoted. The case described here is one example of the application of these procedures. We hope that the mounting evidence on how to treat NPD leads to clinical trials that will enable us to more accurately identify the specic interventions that work for this population.

Selected References and Recommended Readings

Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for assessing level of personality functioning in DSM-5, part I: A review of theory and methods. Journal of Personality Assessment, 93, 322346. ` G., Sisto, A., & Semerari, A. (2011). Progressively Dimaggio, G., Carcione, A., Salvatore, G., Nicolo, increasing metacognition through a step-by-step procedure in a case of obsessive-compulsive personality disorder treated with metacognitive interpersonal therapy. Psychology and Psychotherapy: Theory, Research and Practice, 84, 7083. ` G. (2010). A rational model for maximizDimaggio, G., Carcione, A., Salvatore, G., Semerari, A., & Nicolo, ing the effect of regulating therapy relationship in personality disorders. Psychology and Psychotherapy: Theory, Research and Practice, 83, 363384. doi:10.1348/147608310485256 Dimaggio, G., & Lysaker, P. H. (Eds.) (2010). Metacognition and severe adult mental disorders: From basic research to treatment. London, UK: Routledge. ` G., Fiore, R., Pedone, R., Popolo, R., Centenero, E., . . . Carcione, A. (2008). States Dimaggio, G., Nicolo, of minds in narcissistic personality disorder. Three psychotherapy patients analysed through the grid of problematic states. Psychotherapy Research, 18, 466480. ` G., & Semerari, A. (2012). General princiDimaggio, G., Salvatore, G., Fiore, D., Carcione, A., Nicolo, ples for treating personality disorder with a prominent inhibitedness trait: Toward an operationalizing integrated technique. Journal of Personality Disorders, 26, 6383. ` G., Fiore, D., & Procacci, M. (2010). Enhancing mental state underDimaggio, G., Salvatore, G., Nicolo, standing in the over-constricted personality disorder with metacognitive interpersonal therapy. In G. Dimaggio & P.H. Lysaker (Eds.), Metacognition and severe adult mental disorders: From basic research to treatment (pp. 247268). London, UK: Routledge. ` G., & Procacci, M. (2007). Psychotherapy of personality Dimaggio, G., Semerari, A., Carcione, A., Nicolo, disorders: Metacognition, states of mind and interpersonal cycles. London, UK: Routledge. ` G. (2006). Toward a model of self patholDimaggio, G., Semerari, A., Carcione, A., Procacci, M., & Nicolo, ogy underlying personality disorders: Narratives, metacognition, interpersonal cycles and decisionmaking processes. Journal of Personality Disorders, 20, 597617. ` G., Carcione, A., & Procacci, M. (2002). Metacognition, Dimaggio, G., Semerari, A., Falcone, M., Nicolo, states of mind, cognitive biases and interpersonal cycles. Proposal for an integrated model of Narcissism. Journal of Psychotherapy Integration, 12, 421451. Fan, Y., Wonneberger, C., Enzi, B, de Greck, M., Ulrich, C., Tempelmann, C., . . . Northoff, G. (2011). The narcissistic self and its psychological and neuralcorrelates: an exploratory fMRI study. Psychological Medicine, 41, 16411650.

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Fitzpatrick, S., Sherry, S. B., Hartling, N., Hewitt, P. L., Flett, G. L., & Sherry, D. (2011). Narcissism, Perfectionism, and Interest in Cosmetic Surgery. Plastic and Reconstructive Surgery, 127, 176e177e. Kohut, H. (1971). The analysis of the self. New York, NY: International University Press. Modell, A. H. (1984). Psychoanalysis in a new context. New York, NY: International University Press. Ritter, K., Dziobek, I., Preiler, S., Ruter, A., Vater, A., Fydrich, T., . . . Roepke, S. (2011). Lack of empathy in patients with narcissistic personality disorder. Psychiatry Research, 187, 241247. Robins, R. W., & Beer, J. (2001). Positive illusions about the self: Short term benets and long-term costs. Journal of Personality and Social Psychology, 80, 340352. Ronningstam, E. (2009). Narcissism personality disorder: Facing DSM-V. Psychiatric Annals, 39, 111121. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. A relational treatment guide. New York, NY: Guilford. Tracy, J. L., Cheng, J. T., Martens, J. P., & Robins, R. W. (2011). The affective core of narcissism: Inated by pride, deated by shame. In Campbell, K. W. & Miller, J. (Eds.), Handbook of narcissism and narcissistic personality disorder (pp. 330343). New York, NY: Wiley. Twenge, J. M., & Campbell, W. K. (2003). Isnt it fun to get the respect that were going to deserve? Narcissism, social rejection, and aggression. Personality and Social Psychology Bulletin, 29, 261272.

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