The ongoing rewriting of the therapeutic contract in Metacognitive
Interpersonal Therapy for narcissistic personality disorder: The case of
Mark
Abstract
In order to treat persons suffering from narcissistic personality
disorder (NPD) it is necessary to agree on therapeutic goals and om
tasks to undertake in order to meet them. This is difficult with NPD, as
they have difficulties finding meaningful goals to strive for, other
than the quest for status. Moreover, in order to change they need to
expose themselves to experience painful feelings such as shame, guilt or
fear, feelings that they automatically tend to keep at bay. Finally,
they have problems forming a benevolent image of their therapists and to
harken to it in order to cooperate towards mutually agreed goals and
tasks. As a consequence, NPD patients ask for change but hardly engage
themselves in the work necessary to achieve it. Therapists therefore
need to pay the uttermost attention to drafting, negotiating and
continuously updating a reasonable and realistic therapeutic contract.
In this paper we describe the story of a man in his thirties with NPD
who was ridden with depression, guilt, envy and anger and did not find
ways to pursue the healthy and adaptive behaviors he would need to
pursue in order to leave a richer social life. The therapist overcame
ruptures in the therapeutic alliance and then involved the patient in a
process where they set the steps to follow, making sure the patient was
convinced they made sense. After a contract was reached progress became
possible. Implications for the role of the therapeutic contract in NPD
treatment are discussed.