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\begin{document}

\title{Building hope for treatment of narcissistic personality disorder}



\author[1]{Igor Weinberg}%
\affil[1]{McLean Hospital Gunderson Personality Disorders Institute}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Historically, patients suffering from pathological narcissism, including
narcissistic personality disorder (NPD), were considered challenging and
hard to treat. Since the second half of the 20th century new treatments
have been developing heralding a growing hope that transformative
treatment of patients with pathological narcissism is possible. Recent
developments of phenomenology, childhood antecedents, longitudinal
course, and putative mechanisms inspired a greater hope as well. This
invites clinicians and researchers to take an approach that is
evidence-based, destigmatizing, and collaborative that considers that at
least some of the treatment challenges as co-created by both the
therapist and the patient. Further, new treatments add hope by
ameliorating such challenges of patients with pathological narcissism as
fragile alliance, limitations of reflectiveness and grieving. Novel
treatments are evidence- and principles-based and different approaches
to effective treatment development are described. Inspired by these
developments in the field, this Issue of the Journal of Clinical
Psychology: In Session was conceived as an opportunity for clinicians
from different treatment approaches to come together and share their
experiences in treating patients with pathological narcissism. The hope
is to find common language to understand these patients and their
treatment, understand what contributes to change, as well as learn from
commonalities and differences among these treatments. In doing so, this
Issue is hoping to promote destigmatizing, pragmatic approach that
prioritizes evidence-based efforts to understand the patient and
collaborative approach to promoting change.%
\end{abstract}%



\sloppy


\textbf{Abstract}

Historically, patients suffering from pathological narcissism, including
narcissistic personality disorder (NPD), were considered challenging and
hard to treat. Since the second half of the
20\textsuperscript{th}century new treatments have been developing
heralding a growing hope that transformative treatment of patients with
pathological narcissism is possible. Recent developments of
phenomenology, childhood antecedents, longitudinal course, and putative
mechanisms inspired a greater hope as well. This invites clinicians and
researchers to take an approach that is evidence-based, destigmatizing,
and collaborative that considers that at least some of the treatment
challenges as co-created by both the therapist and the patient. Further,
new treatments add hope by ameliorating such challenges of patients with
pathological narcissism as fragile alliance, limitations of
reflectiveness and grieving. Novel treatments are evidence- and
principles-based and different approaches to effective treatment
development are described. Inspired by these developments in the field,
this Issue of the Journal of Clinical Psychology: In Session was
conceived as an opportunity for clinicians from different treatment
approaches to come together and share their experiences in treating
patients with pathological narcissism. The hope is to find common
language to understand these patients and their treatment, understand
what contributes to change, as well as learn from commonalities and
differences among these treatments. In doing so, this Issue is hoping to
promote destigmatizing, pragmatic approach that prioritizes
evidence-based efforts to understand the patient and collaborative
approach to promoting change.

\textbf{Key words:} Narcissistic personality disorder, pathological
narcissism, psychotherapy, evidence-based treatment, principles of
change

\emph{} Building hope for treatment of narcissistic personality disorder

\emph{``Matthew, a single man in his early twenties came to therapy due
to chronic unhappiness, poor self-esteem, isolation, and a difficulty
getting along with others. He was seemingly engaged in therapy, actively
exploring his fantasies of success and what seemed like a perfect life
scheme -- graduate school in a promising field, making ``all the right
connections with all the right people'' that would eventually catapult
him to the top of the professional hierarchy, resulting in wealth,
recognition, and power. He expressed pervasive devaluation of others who
he experienced as `irredeemably stupid and incompetent.' He repeatedly
recognized an exploitative attitude toward others, when he would fake
close relationships only to elicit some benefits from the other person.
These patterns were acknowledged, though Matthew continued to excuse
them in the context of past trauma. Alienating colleagues and friends
through haughty and critical behaviors, he was left in total isolation
and was enraged and humiliated when nobody showed up for his graduation
party. Blaming his therapist and feeling hopeless about the possibility
of changing the cycles of mutual rejections, Matthew stopped therapy and
refused to pay the balance.''}

Is there hope of helping Matthew? Can treatment help him address
patterns related to pathological narcissism? What interventions are
likely to invite his curiosity and reflection and help him open to the
process of change? These questions are at the heart of this Issue of the
Journal of Clinical Psychology: In Session, and they have a long history
in psychotherapy. Narcissistic personality disorder (NPD), associated
with the concept of pathological narcissism, historically has been
related to limits of treatability. Originally, Sigmund Freud (1914)
theorized that pathological narcissism limits the ability of patients to
benefit from treatment. The predominant opinion among his followers was
that pathological narcissism was one of the major negative prognostic
predictors (Etchegoyen, 1991; Greenson, 1967). ``Narcissistically
oriented\ldots{}patients are generally not suitable for
psychoanalysis'', Greenson authoritatively wrote in the 1960s (Greenson,
1967).

Earlier pessimism gradually gave way to more hopeful clinical
observations that treatment of pathological narcissism was possible.
This has been related to discussions of the ``scope of analyzability''
-- or treatability (for a review see Etchegoyen, 1991) -- and spurred
developments of new theories and modifications of intervention
techniques to better understand and treat pathological narcissism. This
led to seminal contributions of Heinz Kohut (1971) and Otto Kernberg
(1975) both of whom reformulated earlier understanding of pathological
narcissism. These developments inspired original contributions of James
Masterson (1983), Gerald Adler (1985), Herbert Rosenfeld (1987), John
Steiner (1993), John Fiscalini (1993), Andre Green (2001), Arnold
Rothstein (1984), Arnold Model (1975), and Andrew Morrison (1993), to
name just a few. These contributions proposed novel theoretical
formulations of pathological narcissism and suggested modifications of
treatment technique. In doing so, they introduced a notion,
revolutionary at that time, that treatment of pathological narcissism
was possible and that meaningful changes can occur in the lives of these
patients as a result of psychotherapy.

\emph{Challenges in treatment of NPD}

Was this budding optimism supported by the experiences of other
clinicians treating patients suffering from pathological narcissism?
Unfortunately, patients with NPD were generally viewed by treating
clinicians as challenging (Table 1). Changes in NPD patients, while
possible, required a lengthy and difficult process. How real was the
initial optimism? What made these changes possible? Were those new
theories and techniques generalizable to other patients or were they the
elusive skills of especially gifted therapists who became enthusiastic
following their treatment successes?

To explain frequent difficulties in such treatments, empirical and
clinical reports continued to document specific challenges in treatments
of NPD that undercut effectiveness of these treatments (for reviews see
Weinberg \& Ronningstam 2020, 2022). Initially, the literature
emphasized \emph{individual challenging characteristics} of NPD
patients. For instance, such characteristics of NPD patients as
dismissive attachment (e.g., the tendency to dismiss reliance on others
in times of distress), perfectionism, shame, and devaluation worsen the
outcome (Black et al., 2013; Blatt et al., 1998; Dozier et al., 2001;
Guile et al., 2004). NPD patients tend to provoke negative feelings in
their therapists (Tanzilli et al., 2017). Typically, therapists of NPD
patients struggle with such powerful reactions as feeling annoyed, used,
close to losing one's temper, mistreated, resentful, and walking on
eggshells. They experience sexual tension or feel dread or dislike of
the patient, feel criticized, dismissed, competitive and envious, bored,
hopeless, and cruel or mean toward the patient. Clinical literature
documented the following difficulties that NPD patients bring into
therapy (for a review see Weinberg \& Ronningstam, 2020): (i) NPD
patients' motivation to come treatment is commonly related to crises and
external circumstances, rather than internal and durable reasons for
change. Furthermore, it is not uncommon for their motivation to be
further undercut by overreliance on the financial support of family and
the misuse of status or money. (ii) NPD patients present challenges due
to intolerance of alternative points of view, lack of curiosity,
pathological certainty about their conclusions, and poor recognition of
inner states. (iii) Emotional challenges include difficulty naming and
recognizing emotions, persistent boredom as well as excitement seeking,
and a sense of meaninglessness and fear. (iv) Interpersonal challenges
include impoverished relationships, competitiveness, fear of reliance on
the therapist, and paranoid reactions toward the therapist. Some
patients report superficially stable relationships with others. However,
once the patient faces inevitable disillusionments or the relationship
invites deeper commitment and intimacy, their dream-like interest
evaporates and they plunge into a state of meaninglessness, until they
repeat this cycle all over again. (v) Challenges related to self-esteem
regulation consist of seeking self-affirmation as opposed to
self-understanding, externalization of responsibility, chronic
self-criticism, and perfectionism. (vi) Lastly, compromised moral
functioning -- another treatment challenging factor -- includes lack of
responsibility or commitment, dishonesty, lack of capacity for remorse,
and exploitation of others.

As the field shifted toward understanding that stalemates in treatment
are jointly co-created by the patient and the therapist (Bromberg,
1992), there was a growing recognition that some of the difficulties in
treatments of NPD patients are \emph{jointly co-created} as well. They
stem from specific relational configurations that develop in treatments
of NPD patients that lead to non-treatment treatments -- therapies that
continue even though they do not accomplish treatment goals (Weinberg \&
Ronningstam, 2022). Such relational configurations form obstacles to the
productive use of therapy and process of change, and they tend to
develop with mutual contributions of the therapist and the patient.
Usually, such contributions occur outside of awareness of both parties
as they develop interlocking patterns in terms of styles of managing
self-esteem, processing emotions, relating to each other, or their
cognitive processes. (i) Lack of goals. Some therapies proceed without
measurable realistic goals. In these cases, therapies turn into a form
of a psychic retreat (Steiner, 1993) in which the patient is invested in
perpetuating the \emph{status quo} , avoiding emotional experiences and
the pursuit of reality-based goals. With some patients, this challenge
appears gradually. They attend the sessions and always have something to
discuss. However, after a while one start having a sense of \emph{de je
vu} : there is no change in what is being talked about, no change in
problems that brought them into therapy in the first place, and they
sessions feel devoid of distress. In some cases, this is related to an
assumption that the patient will develop inner ability and desire to
change as a result of psychotherapy. (ii) Joint collusion with
protracted states of mutual idealization. In these cases, both the
patient and the therapist co-create a form of mutual idealization as a
form of avoidance of discussion of meaningful experiences or pursuit of
treatment goals and focus on ``how great they are'' (Slochower, 2006).
(iii) Collusion with protracted devaluation, competitiveness, or envy.
At other times treatment stalls when the patient is developing a pattern
of devaluation, competition, or envy in relationship to the therapist
who is contributing to these dynamics or colluding with them. For
instance, mutual enactment of devaluation, competitiveness, or envy due
to underlying narcissistic vulnerability in both therapist and patient
can gradually escalate these dynamics to treatment interfering
proportions. In other words, the patient and therapist continuously
provoke each other and escalate the dynamic as a result. For instance,
the patient might be dismissing therapist's interventions, deeming them
stupid. At first, the therapist might be channeling feelings of
frustration and hurt into efforts to impress the patient by increasingly
complex interventions, trying to ``prove'' his or her worthiness. Later,
losing patience, the same therapist might lapse into chronically
critical tone in interventions. (iv) Allowing the patient to control the
treatment. While patients need to feel and be in control of their
therapies, once they start dictating major treatment decisions, their
treatment is at risk of a stalemate. Sometimes, this is related to
refusal to participate in additional components of treatment (e.g.,
homework, self-help meetings, pharmacotherapy), or refusal to provide
consent to communicate with other treatment providers or significant
others, or at times direct suggestions of how their therapy needs to be
conducted. In one way or another these patterns interfere with effective
treatment (Hendin et al., 2006). It is not uncommon for the same
patients to later blame the resultant lack of progress on the therapist
as if they have no part in that outcome. (v) Use of treatment for
secondary motives. All patients participate in therapy for a host of
reasons, ranging from change-motivated and those driven by less adaptive
motives. For some patients, their ability to effectively participate and
benefit from treatment is limited by the predominance of maladaptive
motives and agendas. For instance, some patients participate in
treatment to appease worried family members or work supervisors, without
having an actual interest in change. Others come to treatment only to
prove that they are beyond help and therefore either are unable to
change as they can now externalize responsibility on treatment or
celebrate triumph as they demonstrate superiority over their therapist
(Kernberg, 2007). (vi) Pseudo-engagement. In such cases there is an
appearance of effective psychotherapy, but the real engagement is
lacking. In some cases, it stems from an overly intellectual focus of
treatment (Dimaggio, 2022), a mutual avoidance of painful emergence of
emotions by both patient and therapist that a deeper engagement entails
(Cooper, 2016), or the development of misalliance around the power
differential. For instance, the patient creates a fa\selectlanguage{ngerman}çade of engagement
to keep the therapist at bay. Sometimes, this pattern reflects a
repetition of power dynamics from the patient's past and lack of trust
in the therapist. (vii) Some treatments persist beyond the productive
stage and turn into non-treatment treatments, or the patient avoids
termination and attends treatment to maintain patient role or because of
avoidance of grieving by either or both parties. The avoidance of
termination helps them avoid mourning losses, including accepting that
therapy could not solve all of their difficulties. This is not to be
confused with ``lifers'' -- patients that stay in treatment for life but
use treatment productively (Wallerstein, 2000).

However, yet another reason for these challenges in treating NPD
patients may have to do with the status of our understanding of NPD. Is
it the NPD or, maybe, our own expectations, biases and narratives about
NPD patients that affect treatability? Similarly,\emph{destigmatization}
of other personality disorders improved treatment outcomes (Ferguson,
2016; Sheehan et al., 2016). Looking at social media and popular
culture, one cannot help to notice that it is an unfortunate
\emph{zeitgeist} to vilify anyone suffering from pathological
narcissism. In that narrative narcissism is associated with exclusively
negative attributes and adjectives, that inviting blaming and negative
mindset. Not only does this demotivates patient to seek professional
help, but also interferes with therapists' ability to learn from each
patient from \emph{his or her} internal point of view. Could better
understanding of NPD patients through empirical research and the
development of novel treatments decrease stigma and improve treatment
outcomes?

\emph{Possibility of change in NPD}

Empirical studies of the longitudinal course of NPD are especially
informative regarding the question of possibility of change. The
conclusions from the studies of longitudinal course of patients
suffering from NPD are the following: (i) NPD improves over time, (ii)
changes are slow and gradual and sudden improvements were not
documented, and (iii) symptomatic improvements occur faster than
improvements in pathological narcissism as a dimension. No studies in
clinical samples focused on vulnerable narcissism (Weinberg \&
Ronningstam, 2022). Studies of pathological narcissism in non-clinical
samples complement and extend the findings from the studies of NPD in
clinical samples. The findings from these studies highlight that
different facets of pathological narcissism improve at a different pace.
The facet of hypersensitivity, that includes such characteristics as
resentment, depletion, sense of entitlement, and roughly corresponds to
vulnerable narcissism, continues to improve throughout the person's
life, while the facet of willfulness that includes external grandiosity
and exhibitionism, and roughly corresponds to grandiose narcissism,
improves until middle age and tends to plateau thereafter (Cramer 2011;
Edelstein et al., 2012). Taken together these studies show that
pathological narcissism is associated with a slow pace of change and
that compared to vulnerable narcissism traits, traits associated with
grandiose narcissism are more persistent.

While longitudinal studies demonstrated that NPD patients change, the
question remains what processes are responsible for change. So far,
research has documented that some of these changes occur as a result of
life events (Ronningstam et al., 1995; Wenzel et al., 2020). Improvement
in pathological narcissism has been associated with new relationships,
achievements, or disillusionments, especially if those are being
processed in a sympathetic context, including therapy (Ronningstam et
al., 1995). Realistic jobs (e.g., engineering, medicine) are more likely
to be associated with improvements in pathological narcissism compared
to leadership positions or enterprising jobs (Wenzel et al., 2020).

Some studies documented changes in NPD patients in therapy, reporting
symptom reduction and improvement of functioning (Callaghan et al.,
2003; Riordan, 2012; Kramer et al., 2018; Weinberg et al., under
review). While conclusions from these reports are limited by small
sample sizes, pre-post designs, and lack of uniformity in the use of
measurement, they provide hope that treatments can help NPD patients
change.

Research has been lagging in identifying mechanisms of change in
psychotherapy. From a theoretical standpoint, some of the candidates for
such mechanisms are treatment alliance, development of reflective
ability, and mourning. How do these concepts apply to treatments of NPD?

(i) Alliance. Treatment alliance has been identified as the most
powerful predictor of change in treatment (Muran \& Barber, 2010).
Alliance provides a leverage for change but also provides patients with
a lived experience of a collaborative, respectful, and emotionally
attuned relationship that on its own is conducive to emotional growth
and self-exploration, and the discovery of new forms of relating
(Lowald, 1980). In fact, numerous meta-analyses estimated that treatment
alliance is the most significant predictor of treatment outcome,
contributing moderately to its prediction (Barber et al., 2010; Baier et
al., 2020; Fluckiger et al., 2018), including behavioral treatments
(Sauer-Zavala et al., 2018; Ovenstad et al., 2020).

However, alliance in NPD is undercut by several factors, including
dismissive and avoidant attachment styles (Diamond et al., 2014) as well
as such characteristics as avoidance of reliance on the therapist,
competitive relationship with the therapist, envy, and attribution of
malintent to the therapist (for a review see Weinberg \& Ronningstam,
2020). This limits the ability of the patients to benefit from therapy.
One approach suggests that treatment alliance can be built through
curiosity about the patient's experiences, an exploratory approach,
helping the patient understand and develop a sense of agency about their
behaviors (Ronningstam 2012). These interventions encourage the patient
to take ownership of their capabilities, and not only their maladaptive
behaviors. Alliance develops based on these interventions as well as a
conveyed understanding that the patient's experiences can be understood
in context of complex interactions between limitations, capabilities,
motivations, and fears. Another approach, transference-focused
psychotherapy (Diamond et al., 2022), is viewing alliance development as
both a treatment goal in its own right and a mediator of change. This
approach consists of developing a treatment contract to contain
treatment interfering behaviors and careful exploration and
interpretation of negative projections that undermine more positive
reliance on the therapist. Others have suggested that the use of
autonomous motivation that is based on investment in treatment goals
(Zuroff et al., 2007) is an alternative to the fragile alliance of NPD
patients (Weinberg \& Ronningstam, 2020). These interventions suggest
that while treatment alliance is fragile in patients with pathological
narcissism, certain treatment modifications can help these patients
engage in treatment and develop alliance as one of the treatment
outcomes.

(ii) Reflective function. Reflective ability -- thinking about one's own
psychological processes, such as thoughts, feelings, and motivations --
overlaps with metacognition -- thinking about thinking (Dimaggio et al.,
2007). Many treatments encourage the development of reflective
capacities and view such developments as instrumental in the process of
change (Fonagy et al., 2002). Many treatment interventions are designed
to promote such capacity in patients -- exploration of antecedents of
problem-behaviors as well as of progress, exploration of functions of
different behaviors, exploration of thoughts, feelings, and behaviors to
promote pattern recognition and insight into their functions,
motivations, and developmental antecedents (Castonguay \& Hill, 2007).
However, research has shown that patients with NPD have decreased
reflective function (Diamond et al, 2014), and clinical observations
describe propensity for detached, intellectual - pseudo-mentalizing
(Drozek \& Unruh, 2020), intellectualized reflectiveness (Dimaggio,
2022), and the difficulty to think in a meaningful and reflective way
(Shoshani \& Shoshani, 2016). This has led to development of treatments
that promote the development of reflective and mentalizing capabilities
(Choi-Kain et al., 2022; Drozek \& Unruh, 2020), thus increasing the
potential of NPD patients to benefit from treatments that rely on
reflective capacities. In fact, preliminary observations confirm that
reflectiveness can improve at least in some therapies, such as
transference focused psychotherapy (Diamond et al., 2014).

(iii) Mourning. Mourning is related to the ability to grieve losses,
unmet needs, and unfulfilled fantasies or dreams, and accept reality,
personal limitations, and realistic expectations, and give up
maladaptive solutions or unrealistic fantasies -- all important -- if
not critical - aspects of psychotherapy. Traditionally, pathological
narcissism was thought to be associated with a limitation in the ability
to mourn (Kernberg, 1975; Steiner, 1993; Shoshani \& Shoshani, 2016), as
pathological narcissism was seen as a complex form of avoidance of the
process of mourning. In that way, narcissistic functioning can be seen
as antithetical to the mourning process, thus introducing challenges to
treatments that rely on intact capacity to grieve. On the other hand,
our understanding of the grieving process has changed. Traditionally, it
was assumed that grieving involves gradual acceptance of the loss and
redirecting the investment into the lost relationship into new ones
(Freud 1917); current findings demonstrate however that giving up
connection with the lost person does not always occur (Bonnano 2009).
For some people such transformation manifests itself in the feeling that
the lost person is still present in their lives through internal
dialogue or through their commitment to make room in their own lives for
what was important to the lost person. For instance, a bereaved husband
might feel connection to his deceased wife though dedicated care for
their grandchildren, viewing them as extension of her. Rather than
viewing treatment as giving up maladaptive aspects of narcissistic
functioning, it can be seen as transformation of them into more adaptive
ones, echoing Kohut's notion of transformation of narcissism (Kohut,
1966). For instance, a patient might be able to transform aspirations to
become a top scientist in their respective field, into a dedication to
their mentees and students.

\emph{New directions for treatment of NPD}

The burgeoning empirical research on pathological narcissism provided
very much needed information on a wide spectrum of areas related to it
(Table 2; Weinberg \& Ronningstam, 2022). It introduces a new
perspective that views the patient in context of multifactorial etiology
and mutually influencing areas of functioning. This invites the
clinician to be attuned to multilayered and fluctuating experiences and
functioning of the patient, to avoid making assumptions, and recognize
the uniqueness of each patient. This introduces an evidence-based and
more optimistic approach to NPD.

This renewed optimism resulted in novel treatment developments,
including formulation of principles of psychoanalytically-oriented
therapy for NPD (Crisp \& Gabbard, 2020), transference-focused
psychotherapy for NPD (Diamond et al., 2020), mentalization based
treatment for NPD (Drozek \& Unruh, 2020; Choi-Kain et al., 2022),
adaptation of good psychiatric management to NPD (Weinberg et al.,
2019), Metacognitive Interpersonal Therapy (Dimaggio et al., 2020;
Centonze et al., 2023) and formulation of general principles of
treatment for NPD (Weinberg \& Ronningstam, 2020; Dimaggio, 2022).
Guided by a pragmatic focus on change, informed by recent research
developments, while keeping an open mind for revision necessitated by
clinical experience, these treatments herald a new era in the treatment
of pathological narcissism.

Another area of optimism is shifting the perspective from the one that
views the patients as holding all the challenges to effective treatment,
to a transactional approach that views challenges at least in part
co-created. Instead of viewing patients' treatability in context of
their personality factors, the field is moving to the perspective that
treatability is related to patient-therapist match (Kantrowitz, 2020)
and stalemates -- are at least in part co-created (Bromberg, 1992).
Treatability is not only a characteristic of a patient but of a
therapist-patient dyad and their capacity to work together. Certain
experiences and characteristics of therapists make them more likely to
succeed with certain patients that might not be treatable by others.
Destigmatization and evidence-based perspective on pathological
narcissism are another component. One aspect of this is avoiding the
``one size fits all'' approach, imposing theory, our biases or personal
reactions onto the patient, and judging internal experiences based on
external manifestations. Instead, clinicians are invited to recognize
the uniqueness of each person and seek understanding that aspires to
integrate inner experiences of the patients, their overt behaviors, as
well as the reactions they evoke.

For instance, many NPD patients discontinue treatment prematurely
(Hilsenroth et al., 1998; Gamache et al., 2018). However, not all early
terminations are the same and not all of them indicate that the
treatment has not been productive. Terminations are related to enactment
of various aspects of narcissistic functioning: dismissive attachment,
need for control, fear of change, superiority, competition, envy, fear
of closeness or reliance on the therapist, withdrawal, devaluation, or
entrapment. Terminations could be related to various treatment
processes: fragile alliance, disagreements about goals or lack of
attention to setting explicit shared goals (Dimaggio \& Valentino, 2023;
Dimaggio, 2023), overstimulation of attachment through overly empathic
or dramatic interventions, retaliation against therapist, exclusive
focus on treatment relationship or insufficient focus on it; use of
interpretations to assert power differential or intrude and control the
patient. For other patients the judgment of the therapist that the
termination is an ``early'' one is a reflection of disagreement between
the patient and the therapist about the continuation of the therapy.
This could stem theoretical biases or unprocessed reactions of the
therapist (e.g., anger or overprotectiveness) and may not necessarily
indicate that the therapy itself was not helpful. With other patients,
early terminations are expression of a pattern that consists of
intermittent engagement in otherwise productive therapy (Paris, 2007).
For others, despite early terminations, such treatments ``plant the
seeds'' for future reflections, insight or change. These processes of
change might occur in future treatments, or as a result of personal
reflections of the patients, or as a result of inner integrations that
might be happening outside of the patients' awareness.

Novel understanding of the disorder and renewed interest in
understanding the patients suffering from it inspired the recognition
that ``NPD is a new BPD'' (Choi-Kain, 2020). In other words, similar to
how BPD became a treatable disorder due to advances in research and
treatment development in the 80s and the 90s, it is now the turn of NPD
to undergo the same transformation. This invites a few approaches to
treatment development for pathological narcissism. Some of those
approaches are listed below.

(i) \emph{Modification of treatments for related conditions} , such as
BPD. For instance, such treatments as TFP and MBT, that were previously
supported for treatment of BPD were subsequently modified to treat a
closely related condition -- NPD (Diamond et al., 2022; Drozek \& Unruh,
2020).

(ii) Eclectic treatments -- \emph{selection of effective principles} and
interventions. Another strategy consists of the development of
treatments that combine effective interventions from existing treatment
modalities. The chosen interventions were identified because of the
clinical utility and their ability to address characteristics of
narcissistic patients (e.g., use of treatment contract to address
difficulty stay in treatment; Weinberg \& Ronningstam, 2020).

(iii) Development of treatments based on empirical understanding
of\emph{mechanisms of NPD} (Dimaggio, 2022). This strategy of treatment
development targets putative mechanisms associated with NPD. For
instance, dismissive attachment, that is the tendency to dismiss
reliance on others during distress, in NPD patients invites the
development of treatments that target dismissive attachment.

(iv) Development of treatments that target \emph{mechanisms of change in
therapies} of NPD. Such treatments address those areas of treatment
undermined by pathological narcissism. For instance, difficulty forming
alliance by NPD patients invites treatment approaches that help target
this area in NPD patients (Ronningstam, 2012; Dimaggio, 2022).

(v) \emph{Development of therapies based on cases of treatments
associated with change} . Such an approach encourages treatment
development based on therapies that went well. Such cases provide
insight into what works with NPD patients and possibly can inform novel
treatment developments (Weinberg \& Ronningstam, in preparation). This
perspective encourages treatment development using an experience driven
approach, as opposed to theory driven approach. This approach is
preferred by clinicians (Kealy et al., 2017) who tend to think in terms
of principles of treatment rather than point by point interventions.
This approach invites development of principle-based treatments. The
tradition of principle-based treatment has a long history in clinical
science (Castonguay et al., 2019). Treatment principles have the
advantage of flexibility in addressing variability, fluidity, and
complexity of cases (Castonguay et al., 2019), such as NPD (Weinberg \&
Ronningstam, 2022). Use of principles as opposed to treatment manuals is
especially relevant to treatments of NPD in which therapists struggle
with fragility of alliance. Research shows that for patients who have
low motivation and form fragile alliance -- typical for NPD -- adherence
to treatment is associated with worse outcome or not related to it at
all; alliance is more predictive of the treatment outcome than adherence
(Webb et al., 2010; Huppert et al., 2006).

(vi) Identification of \emph{common factors} in different effective
treatments. Such factors are likely putative effective interventions
responsible for change. Building on common factor approach to therapy
(Wampold \& Imel, 2015), research identified such factors in
evidence-based treatments for BPD (Weinberg et al., 2011). The
identification of common interventions in various effective therapies,
including case reports of therapies with NPD patients, will help with
the development of novel effective treatments. This approach can be
applied to case reports published in this Special Issue, thus
formulating new hypotheses as to what interventions are likely effective
in treatment of NPD patients.

The present issue of the \emph{Journal of Clinical Psychology: In
Session} was planned to address some of these urgent questions in the
field. The current approach is based on (i) prioritizing evidence,
including clinical evidence, over theory, (ii) collaborative,
constructive approach, and (iii) pragmatic effort to identify factors
responsible for change. (iv) destigmatization of NPD. Thus, five/six
clinicians were invited to contribute treatments of NPD patients using
descriptive atheoretical language, promoting an understanding of what
allows change in each one of these therapeutic engagements. The goal is
to start a dialogue between different treatments to learn from
convergences and unique interventions and to learn what interventions
worked. This is to inform clinicians and treatment developers regarding
possible helpful interventions, leading to a more hopeful approach to
treatment of NPD patients and spurring new effective treatments. At the
end of the issue Dimaggio and Weinberg will comment the single
case-based papers and try to distill common factors at work, outline
differences and note if they increase our understanding how to best
address the need of a condition like NPD which presents difficulties but
is indeed treatable.

\emph{``Going back to Matthew and the questions regarding the
possibility of him having productive treatment, one might have the
following reverie of an alternative therapy development inspired by this
introduction. Accordingly, his treatment started with a careful
discussion of his past experiences with psychotherapy and significant
others. During that discussion he disclosed that many times he tended to
end relationships when he felt angry or disappointed and, subsequently,
put the blame on others. As a result, his therapist brought up the
possibility that a similar situation might occur in treatment and that
it would be important to work it through so he could have an opportunity
to address this tendency to end relationships. Matthew agreed as he
regretted some of these impulsive endings. As the treatment unfolded, he
indeed voiced his inclination to leave after nobody showed up for his
graduation party. That led to the discussion about the agreement he made
at the outset of the treatment. Initially, Matthew was hesitant to honor
it, but agreed to give it another try after the therapist emphatically
recounted how much Matthew regretted many of his early endings. As they
worked together, therapist noticed his own critical thoughts about
Matthew's intolerant judgmental attitude to others. The therapist had a
consultation with an experienced colleague, and they end up wondering
whether these critical feelings correspond to how Matthew feels about
himself and, also, reflect critical voices of his perfectionistic
parents. That allowed the therapist to listen more closely to the
internal experiences of Matthew, not just to their external
manifestations. He started getting curious about the inner experiences
of Matthew that we hid behind arrogance, condescending criticism of
others and distrust. Gradually, Matthew started describing a profound
sense of insecurity, distrust in himself, and a constant sense of not
being good enough viz-a-viz unremitting self-criticism. He started
noticing parallels between his self-criticism and the criticism of his
parents that made him feel humiliated and inept throughout his unhappy
childhood. Talking about his childhood feelings brought up fear
regarding therapy as he worried that the ``therapy was making him
weak''. Matthew explained that talking about his feelings made him feel
vulnerable, which he equated with being weak. He felt angry at the
therapist who was ``weakening him'' and making him ``less prepared to
deal with the hostile world out there''. Invited to reflect on these
judgments, he saw parallel with the stoic critical culture of his family
that dealt with persecution and discrimination. He was also surprised
that the therapist was not retaliating against him, despite Matthew's
angry criticism. He shared that it made him feel accepted and cared for
and indicated that he wanted to feel like that in his life. As he was
more open to the side of him that wanted to be cared for and accepted,
he started to consider that others might have the same desires as well.
That invited him to consider that ``maybe there is more to life than who
hurts whom'' and started considering building friendship on more genuine
interest and support as his fear of criticism by others started to
subside as well.''}

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