Assignment: Therapy for Clients With Personality Disorders- Narcissistic Personality Disorder - 1 page

Journal of Psychotherapy Integration Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder Giancarlo Dimaggio Online First Publication, September 2, 2021. http://dx.doi.org/10.1037/int0000263

CITATION Dimaggio, G. (2021, September 2). Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder. Journal of Psychotherapy Integration . Advance online publication. http://dx.doi.org/10.1037/int0000263

Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder

Giancarlo Dimaggio Centro di Terapia Metacognitiva Interpersonale, Rome, Italy

Pathological Narcissism (PN) is a challenge to clinicians, who have difficulties dealing with clients relationally and forming and agreeing on a therapy contract. PN sufferers easily fuel relational conflict or withdraw from relationships. In spite of its severity and prevalence, there is no empirically supported treatment for this condition. Given this, integrative therapists need to be offered a series of principles of good clinical practice, that they can adopt irrespective of their preferred orientation. This article focuses on 5 domains of PN, that is: (a) maladaptive self–other schemas, (b) poor self-reflection and intellectualizing, (c) disturbed agency, (d) maladaptive coping and defenses, and (e) poor theory of mind and empathy. With this background, I offer specific treatment suggestions that can be applied in an integrative spirit and are formulated in a way that lends them to empirical investigation. With this and other recent efforts, the hope is to increase clinicians’ and researchers’ awareness of how PN can be treated and possibly increase the amount of empirical studies aimed at showing what principles of change are actually effective. Pathological Narcissism and narcissistic personality disorder are prevalent and present with significant comorbidity and create problems to self and others, but there is no empirically supported treatment to date for these conditions. This article presents treatment suggestions that may pave the way for addressing them and paving the way for empirical studies.

Keywords: Pathological Narcissism, narcissistic personality disorders, maladaptive interpersonal schemas, metacognition, integrative psychotherapy

Clinicians facing clients with Pathological Nar- cissism (PN) or narcissistic personality disorder (NPD) need empirically supported treatments. Suchclientspresentwithcharacteristics,bothatthe level of inner experience and interpersonal func- tioning, that make psychotherapy complicated. ThroughoutthepaperIwillmostlyrefertoPN(Pin- cus & Lukowitsky, 2010), as it describes a broader range of phenomena than NPD as categorized in the DSM–5 (American Psychiatric Association, 2013). The latter refers to persons who feature self- enhancement and grandiosity, seek admiration, harbor fantasies of success and ideal love, exploit

the others, and lack empathy. These features are typical of the so-called overt type (Gabbard, 1989). Instead, the literature has consistently noted that many patientsfeature the different picture of covert or vulnerable narcissism (Gabbard, 1989). This personality type’s inner life is quite different from that depicted in DSM–5. Persons are consumed by shame, guilt, inferiority and envy (Ritter et al., 2014), experience emptiness, loneliness, separate- ness and alienation, and have little trust that others can help instead of exploiting them (Kealy et al., 2015). PN,withitsbroaderspectrum,embracespersons

with a combination of both overt and covert aspects. The very same individual may present as arrogant and boastful at one moment, and at others conceals himself because of his deep-seated feel- ings of guilt, shame and inferiority (Caligor & Stern, 2020; Crisp & Gabbard, 2020; Dimaggio et al., 2002; Kealy et al., 2015; Kohut, 1977). Evi- dence shows that grandiose narcissism tends to

Giancarlo Dimaggio https://orcid.org/0000-0002-9289- 8756

Correspondence concerning this article should be addressed to Giancarlo Dimaggio, Centro di Terapia Metacognitiva Interpersonale, Piazza dei Martiri di Belfiore 4, 00151 Rome, Italy. Email: gdimaje@gmail.com

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Journal of Psychotherapy Integration © 2021 American Psychological Association ISSN: 1573-3696 https://doi.org/10.1037/int0000263

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swing between grandiose and vulnerable states, while the vulnerable type has more stable levels of negative experiences and rarely expresses grandi- osity(Edershile&Wright,2020). PN is highly comorbid with symptom and

behavioral disorders, for example, anxiety and depression (Kealy et al., 2020; Pincus et al., 2014), alcoholanddrugabuse(Stinsonetal.,2008),eating disorders(Gordon&Dombeck,2010)andrisk-tak- ing behaviors, especially if these are socially disap- proved (Leder et al., 2020). Thinking in terms of PN helps make sense of why patients with more prominent global suffering and personality dys- functions and poorer real-world functioning are associated with a suboptimal psychotherapy pro- cess, while patients with higher levels of narcissis- tic traits, low sense of control over action, and higher real-world functioning have better therapy responses(Krameretal.,2020). In sum, these persons’ livesare filled with symp-

toms and loneliness but are difficult to deal with interpersonally. There is therefore a need for per- sonalized and empirically validated treatments. The problem is that, as of today, there are none, in spite of NPD’s wide prevalence, for example, 8.5%-20% in outpatient independent practice (Weinberg&Ronningstam,2020). As noted by Yakeley (2018) and Weinberg and

Ronningstam (2020), some approaches have been tailored or adapted to PN and offer promises of effectiveness. These include psychoanalytic psy- chotherapy (Kernberg, 1975; Kohut, 1971; Ron- ningstam & Maltsberger, 2007), Mentalization Based Treatment (Drozek & Unruh, 2020), Trans- ference Focused Therapy (Diamond & Hersh, 2020), CBT (Beck et al., 2015), Schema-Therapy (Young et al., 2003), Metacognitive Interpersonal Therapy (Dimaggio & Attinà, 2012), and dialecti- cal behavior therapy (Reed-Knight & Fisher, 2011),andanotherapproachadaptedtotreatingPN is Clarification Oriented Psychotherapy (COP; Sachse,2020).Theproblemisthatasoftoday,nota single one has been tested in a randomized con- trolledtrial(Ronningstam,2019;Weinberg&Ron- ningstam, 2020). So, in an era where delivering validated treatments is necessary, what does a ther- apist do when treating PN? And, more specifically, what does the integrative therapist, who cares more about being effective than being faithful to a spe- cific orientation, do? Should they give up their ambitionsofdeliveringsomethingempiricallysup- ported and resort to generic principles of change? Orcantheyroottheiractioninstableground?

PN poses serious challenges to the treating clini- cian. Clients may involve therapists in different maladaptive relational patterns, pushing them to feel angry, devalued, helpless and inadequate and to disengage from the therapy process (Colli et al., 2014;Tanzillietal.,2020).Inthecaseofadolescent PN,therapiststendtoreactwithangerandcriticism or disengagement when facing the grandiose type or with worry and feeling overwhelmed when fac- ingthevulnerabletype(Tanzilli&Gualco,2020). Compliance with tasks may be limited: Very of-

ten patients barely accept they are in treatment to dealwiththeirveryownpersonalityissuesandonly ask for symptom relief. This is one source of impo- tence and frustration in therapists, who eventually ask themselves: “Is this person really suffering? Andifhedoes,ishewillingtobehelped?” Therapists would better avoid being overconfi-

dent about their own generic therapeutic skills and insteadadjusttothe specificneedsofthesepersons. Clearly integrative therapists facing such a difficult condition need to be guided, so not to remain either prey to disturbing feelings or get trapped in rela- tional problems, which end up in conflict, stale- mates, and dropout (Crisp & Gabbard, 2020; Ronningstam, 2020). In absence of empirically supported solutions,one strategy isto offerintegra- tive therapists a series of pragmatic ideas on how to handlePN,irrespectiveoftheirorientation. In the next section of the paper, I will summarize

some aspects of PN pathology and describe what challenges they pose to the clinician. I will exclude patients with antisocial features and malignant nar- cissism,astheyrequirea differentapproach(Yake- ley, 2018) beyond the scope of this work. After this section, I will provide a series of therapeutic sug- gestions on how to handle these problems and illustrate them with clinical vignettes. These sug- gestions are a working-out of principles identified in two recent papers selecting the most suitable approaches to treating PN and NPD (Yakeley, 2018; Weinberg & Ronningstam, 2020). My effort is in line with the pragmatic “dos” and “don’ts” for treating NPD offered by Weinberg and Ronning- stam (2020). The main difference is that these authors’ “principles were derived from clinical ex- perience, not from a theory of NPD” (p. 138). My workinsteadtriestoofferaseriesoftechniquesand strategies tailored around a theoretical and empiri- cal model of PN. Another specific aspect is the inclusionofexperientialtechniques,suchasguided imagery and rescripting, role-play, two-chairs, and body work. This is necessary because among

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current models for treating PN only Schema Ther- apy (Young et al., 2003), Metacognitive Inter- personal Therapy (Dimaggio et al., 2020), and Clarification Oriented Psychotherapy (Sachse, 2020)includethemintheirrepertoire.Experiential practices were not mentioned in the two recent papers offering a perspective on current treatments for narcissism (Yakeley, 2018; Weinberg & Ron- ningstam,2020),whiletheycanaddasharperedge topsychotherapyforthiscondition.

Narcissistic Psychopathology

Clearly there is a gap between current diagnostic manuals of mental disorders and existing knowl- edge about PN and NPD. In order to be clinically useful, a diagnosis needs to be grounded on a con- sistent model of psychopathology, which is hardly provided by listing a set of mostly behavioral crite- ria as in past editions of the DSM (see Sachse, 2020). The DSM–5 (American Psychiatric Associ- ation, 2013) has made a step forward when adopt- ing the level of personality functioning model, which aims at describing personality disorders in terms of their self and interpersonal functioning, assessing aspects such as identity and capacity for self-reflection—self-direction that is clearly con- nected to a core PN problem, that is agency; empa- thy, and capacityfor intimacy.The following list of aspects may provide a comprehensive picture of PN which could then be mapped on a formal, clini- cally useful diagnosis of NPD in future editions of DSM and also of ICD, which currently does not allow for a diagnosis of NPD (see Sachse, 2020 for similarobservations). On the basis of such a rationale I will now (a) list

the core aspects of PN and NPD, then I will (b) describe in details each of them and finally (c) describe how the therapist can work in order to tacklewiththeseelements.

PN and NPD Psychopathology

The aspects of PN and NPD psychopathology I willanalyzeanddiscussare: a) maladaptive representations of self and

others; b) impaired self-reflective capacities and tend-

encytointellectualize; c)agencydisturbances; d)maladaptivecopingstrategiesanddefenses; e)poortheoryofmindandempathy.

Maladaptive Representations of Self and Others

Persons with PN are guided by crystallized and maladaptive ideas of self and others (Caligor et al., 2015; Diamond & Meehan, 2013; Dimaggio et al., 2015; Young et al., 2003), which means that they endorse: disturbed self-representations and dis- turbed representations of others in the context of trying to fulfill core wishes or needs. In simple words,apersonwantstobeappreciatedandharbors ideas of being inferior, which are, however, con- cealed by explicit ideas of being superior; he imag- ines others as either admiring or spiteful and, according to how his ideas about the self and others are combined, different affects emerge. For exam- ple, if he thinks he is inferior and the other spiteful, he will experience either anticipatory anxiety when waiting for judgment or shame after receiving criticism. Maladaptive schemas in PN revolve around

some core wishes or needs. When driven by social rank, as they often are, patients’ self-concept swings from inferior to superior, and a dissociation between explicit self-esteem (high) and an implicit one (low) is present (Gregg & Sedikides, 2010; Kunstetal.,2020). In the attachment domain many problems arise.

PN patients usually adopt a dismissing attachment style (Diamond et al., 2014), avoiding expressing attachment needs because they anticipate others will neglect them and being cold and controlling. They can also display unresolved attachment, anticipatingtheothermightbeverbally,physically, and emotionally abusive (Drozek & Unruh, 2020; Johnson et al., 2001). Resorting to self-soothing as a means to avoid attachment was also observed (Bamelisetal.,2011). When driven by the wish for group inclusion,

PNs swing between the desire to belong to ideal communities where they share special qualities, to derogating groups and experiencing themselves as different and superior (Dimaggio et al., 2007) or to experiencing anxiety at the idea of being rejected (De Panfilis et al., 2019) or pain when feeling excluded and angry, even if at times they may deny it (Cascio et al., 2015; Dimaggio et al., 2008; Twenge&Campbell,2003).Thismeansthatwhat- evertheirconsciousexpectationsare,patientsover- reacttocriticism.Overall,whenthey,experienceor anticipate negative reactions from others they eas- ily resort to fight/flight strategies. They may first attack, devaluate, or blame the others, but in the

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 3

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long run they resort to withdrawal, shutting them- selves in an ivory tower or a in cocoon, entering states of emptiness and emotional detachment, and self-soothing (Dimaggio et al., 2007; Kohut, 1977; Modell,1984;Youngetal.,2003). Based on these schemas, PNs experience mental

states such as angerat being hurt or rejected, empti- ness and alienation, guilt, envy, fear, anxiety, and a sense of annihilation. Only at times do they enter grandiosestatesofmindfilledwithglory,pride,sat- isfaction, and self-fulfillment, but these states are short-lived (Dimaggio et al., 2002; Kohut, 1977; Kernberg, 1975; Modell, 1984; Ronningstam, 2009).

Impaired Self-Reflective Capacities and Tendency to Intellectualize

PNs are poor at describing their inner experien- ces (Dimaggio et al., 2002; 2007; Krystal, 1998; Pincus, 2020). They have difficulties labeling their affects, in particular ones related to vulnerability and fragility (Lowen, 1983). They can easily say they are angry or refer to emotions related to self- enhancement (Dimaggio et al., 2002; Drozek & Unruh, 2020) but are much less likely to recognize they feel sad (Bouizegarene & Lecours, 2017), guilty, ashamed, or scared (Dimaggio et al., 2002). As previously noted, they actually experience pain due to feeling rejected but consciously deny it (Cascio et al., 2015). Unaware as they are of their vulnerabilities, they are not able to integrate these aspects in their self-concept. This is a likely reason for their liability to symptoms such as anxiety or health-anxiety, that is they, when experiencing a sense of fragility and fear, can hardly name it or communicate it to others, so that they remain prey to negative emotional arousal they then interpret as asignalofimpendingdanger. The other side of the coin of their diminished

capacity to report inner experiences is their tendency to intellectualize (Dimaggio et al., 2002). When trying to convey their inner life to a listener, they resort to abstract theories and intellectualizing; in other words, they pseudo- mentalize (Ronningstam, 2020). It is as if they were on stage delivering a TED talk, which pre- vents listeners from promptly understanding they are talking about something personal and, most importantly, what it is about. These per- sons often resort to intellectualizing more when they have just experienced failure or rejection,

something clinicians discover later in therapy (Dimaggio et al., 2002).

Agency Disturbances

In spite of the layperson idea that persons with PN are goal-oriented and behave like bulldozers when driven by a goal, their agency is frequently impaired, ranging from the expected hyperagentiv- ity to loss of agency (Ronningstam, 2009). When these persons are neither pursuing grandiosity nor fighting against someone they perceive as an obsta- cle, they lack an inner source for goal-oriented, self-initiatedaction(Dimaggioetal.,2007;Dimag- gio & Attinà, 2012; Kohut, 1977; Modell, 1984). Lack of agency is considered a central aspect of all DSM–5 personality disorders (American Psychiat- ric Association, 2013; see Dimaggio et al., 2009; Links, 2015). In recent years, laboratory findings have backed up clinical observations of agency problemsinPN.Asregardsinflatedagency,partici- pants in a laboratory study with moderate to high (but not extreme) narcissistic traits had greater agency than controls, meaning they were overcon- fident of being in control of their actions (Hascalo- vitz & Obhi, 2015). Commenting on the results of Hascalovitz and Obhi, Dimaggio and Lysaker (2015) speculated that sense of agency should be weaker in vulnerable narcissism and stronger in the grandiose type. Render and Jansen (2019) investi- gated this hypothesis in a nonclinical sample and found the vulnerable type was correlated with diminished agency, while the grandiose type did not display any increase in agency. The plausible link with inflated sense of agency and grandiose narcissism requires further exploration in samples withclinicalPNlevels. Indirect support for the presence of agency dys-

functions in PN comes from findings that depres- sion (Obhi et al., 2013) and social exclusion (Malik & Obhi, 2019), both present in many PNs, have a detrimental effect on agency. This means that poor agency in PN may have both trait-like (Hascalovitz & Obhi, 2015; Render & Jansen, 2019) and state-like properties, that is it dimin- ishes when these persons experience specific states of mind such as depression or social rejec- tion. Other indirect evidence for the agency prob- lem is that narcissistic traits are related to reduced entrepreneurship and self-efficacy (Wu et al., 2019) and disengagement from academic activ- ities(Robins& Beer,2001).Thesemaysignalthat

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PNs feel they have less influence on the world, which gets manifested in not sustaining long-term activitiesrequiringprolongedeffort.

Poor Theory of Mind and Empathy

Poor capacity to understand the others and lack of empathy are part of the core definition of NPD (American Psychiatric Association, 2013; Kern- berg, 1975). Many studies support the observation that PNs are poor at understanding the others and resonating with their inner experience (De Panfilis, et al., 2019; Dimaggio et al., 2009; Leunissen et al., 2017; Marissen et al., 2012; Ritter et al., 2011). Poor empathy affects behavior, for example less ability to take others’ perspective predicted lower generosity in narcissism (Böckler et al., 2017). Using a specific interview to assess mentalistic capacities, NDs displayed significantly less capacitythanpersonswithoutanyPDtounderstand what passed through others’ minds and to see the world from their perspective instead of an egocen- tric one (Bilotta et al., 2018). There is debate about whether PNs are poor mentalizers either because they are unwilling to for self-serving purposes or because they have context-dependent issues (Bas- kin-Sommers et al., 2014). A meta-analysis by Urbonaviciute and Hepper (2020) found that both grandiose and vulnerable narcissism were associ- ated with decreased empathy, assessed both with self-reporting and behavioral measures, but it appeared that their problem was motivational, that is, they had the cognitive capacities to understand othersbutwerenotmotivatedto. This leads to the question: under what condi-

tions do PNs lose motivation to understand the others? The hypotheses are that, for the most part, failures in the capacity to understand the others happen under the influence of either attachment (Drozek & Unruh,2020) orsocial rank, in particu- lar when persons experience defeat (Colle et al., 2020) or the need to belong when facing social rejection (Dimaggio et al., 2007). Analyzing the first treatment sessions of 3 NPD patients, Dimag- gio and colleagues (2009) found that during treat- ment all 3 improved in their capacity to both understand others and to reason about their inten- tionsfrom a decentered perspective. This suggests that this capacity is more state-like than trait-like and depends on relational conditions. In light of these observations, consistent with those of Bas- kin-Sommers and colleagues (2014), therapists

need to pay attention to creating the conditions for theory of mind and empathy to flourish, rather than stigmatizing patients for something they are thoughttobejustunwillingtodo.

Maladaptive Coping and Defenses

PNs do not just suffer because of their maladap- tive schemas but also because of the consequences of how they deal with their symptoms and frustra- tion.The strategiespatientsuse forthispurpose,of- ten automatically and unconsciously, are variously termed maladaptive coping (Kealy et al., 2017) or defenses (Caligor et al., 2015; Kernberg, 1975). Beside differences in theory, both concepts refer to behavioral and cognitive/affective strategies aimed at minimizing or preventing psychological pain a person thinks or feels he is unable to bear. Coping anddefensesareenactedforself-protectivereasons and stem from schemas, that is PNs think the other will not give the desired responses to their wishes and needs and so they automatically react in order to prevent,reduce, orkeep at bay the negative emo- tionsthatwouldfollow(Dimaggioetal.,2015). PN has been described as a constant sense of

threat to the self (Westen, 1990). According to this idea, narcissistic strategies can be conceived as grounded in the most archaic defense system in front of threat: fight/flight. Tendencies such as attacking, blaming, belittling and dominating others, and passive-aggression are aspects of the fight system and have been consistently found in PN (Mielimaka et al., 2018; Twenge & Cambpell, 2003).Conversely,similarwell-knownPNtenden- cies toward isolation, withdrawal, emotional dis- tancing, finding shelter in an ivory tower or cocoon (Modell, 1984), disengaging from relationships, and avoiding displaying vulnerabilities (Kohut, 1977) are aspects of the activation of the flight sys- tem. More in general, the most typical narcissistic coping strategy is self-enhancement (John & Rob- ins, 1994), that is an ongoing effort to boost a vul- nerable self-esteem by both striving for the maintenance of an idealized self-image and pre- senting oneself to others as grandiose. It is the most investigated PN cognitive mechanism and is sup- ported by a plethora of studies (Grijalva & Zhang, 2016). It mostly serves to protect from contact with covertfragileself-esteem. I offer now an example of the role of the malad-

aptive consequences of self-enhancement aimed at protectingtheunderlyingvulnerableself-esteem.

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Michele is a musician from Puglia in his early 40’s and came to therapy in desperation. He said he had lost meaning in all aspects of his life, after the ending of his marriage with a rich and beautiful woman with whom he had travelled the world and led a grand life. The ending also involved a financial disaster for him, as during his married years he spent all his money to adjust his lifestyle to that of his wife. He realized that he was always searching for something bigger, better, and more beautiful and never had a sense of reaching it. At the beginning of the therapy, he did not see any way to restart his quest for grandiosity and felt his des- tiny was just delivering music lessons to earn a few bucks, a condition he wholeheartedly despised. It was not difficult to get him to see that his aspiration to gran- diosity was simply a mechanism. After a few sessions, when he was dating a new woman and enjoying it, he said: “Yes, things are fine but, well . . . you know. . . she’s not Charlize Theron.” I answered that I was pretty sure that if he had had a relationship with the real Charlize Theron, he would have longed for a more beautiful woman. He agreed that he would then have desired to be with Scarlet Johansson or Nicole Kidman. We laughed about this, and he realized that he was prey to a relentless mechanism he now wanted to stop.

When describing coping and defenses at a be- havioral level, many manifestations appear. PNs adopt perfectionism with the goal of fixing the intolerable flaws they see in themselves (Dimaggio et al., 2018), procrastinating (Weinberg & Ron- ningstam, 2020) or lying in order to maintain a grandiose and spotless presentation. Resorting to omnipotence and denial of vulnerable aspects can be the origin of risky behaviors such as having con- domless sex, which has been found in women stu- dents with grandiose narcissism (Coleman et al., 2020), and gambling (Leder et al., 2020). In order to avoid pain or boost self-esteem, PNs resort to alcohol and drug abuse (Stinson et al., 2008)—for example, cocaine—to restore their sense of grandi- osity, problematic videogaming, which is typical of vulnerable narcissism (Di Blasi et al., 2020), dis- ordered eating in both grandiose and vulnerable types (Gordon & Dombeck, 2010), cosmetic sur- gery (Fitzpatrick et al., 2011), and overexercising (Spano, 2001). Repetitive thinking, in the form of rumination and worry, is a cognitive coping strat- egy whose goal is to reduce suffering but with counterproductive effects. Rumination has been observed in PN (Dimaggio et al., 2020). It is corre- lated with vulnerable narcissism and a predictor of its comorbid depression (Kealy et al., 2020). Vul- nerable narcissism is also associated with jealousy, which triggers worry about a partner’s emotional infidelity (Tortoriello & Hart, 2019). Repetitive thoughts filled with anger and suspiciousness are

significant in PN and an important route toward aggression (Krizan & Johar, 2015). Similarly, Fat- fouta and colleagues (2015) found that a combina- tion of anger and rumination is a path between narcissisticrivalryandlackofforgiveness.

Principles for an Integrated Therapy Based on Narcissistic Psychopathology

In light of the above-described aspects of psy- chopathology, to be successful, therapy should aim at: a) increasing self-reflection and reducing

intellectualizing; b) reducing the impact of maladaptive schemas

andforminghealthierandmoreflexibleideasabout selfandothers; c)supportingagency; d) counteracting maladaptive coping and pro-

moting healthier ways of dealing with suffering; e)promotingtheoryofmindandempathy. Thesegoalscanbereachedbydifferentavenues,

including: working through the therapy relation- ship—for example, psychodynamic therapies (Kohut, 1971; Kernberg, 1975), Mentalization Based Treatment (Drozek & Unruh, 2020), Trans- ference Focused Therapy (Diamond & Hersh, 2020), Metacognitive Interpersonal Therapy (Dimaggio et al., 2020), agreeing upon a therapy contract (Diamond & Hersh, 2020), focusing on affects instead of accepting intellectualizing, and using behavioral experiments and experiential techniques (CBT, Schema Therapy, DBT, Meta- cognitiveInterpersonalTherapy).Thisproposalfor an integrated treatment is built around a model of PN; I will therefore organize the treatment sec- tion by aspects of psychopathology and describe how different instruments, for example, working through therapy relationships and assigning behav- ioralexperiments,cantackleanyspecificaspect. These elements of psychopathology obviously

present themselves at the same time, so the order of presentation of the areas of interventions does not correspond to that in which they are dealt with in therapy. For the most part, therapists have to work in parallel on the different aspects. For example, when a therapy starts, clinicians struggle to under- stand what the patient’s self-experience is because of her poor self-reflection and intellectualizing. At the same time, the influence of maladaptive sche- masandpooragencycreateproblemsinthetherapy relationship and in agreeing upon a therapy

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contract. I will propose that it is better to deal with the different aspects of pathology sequentially; for example, it is better for promoting self-reflection to come before promoting theory of mind and empathy.

Promoting Self-Reflection and Reducing Intellectualizing

Listening to narcissistic speech is challenging. Therapists become easily lost, confused, or kept at bay because PNs scarcely report specific auto- biographic memories and, if they do, barely name the emotions they felt. They do not convey the type of information therapists need most: reports of significant problematic interpersonal events filled with negative emotions and prob- lems a patient could not solve. Improving self- reflection and reducing intellectualizing is likely one the first goals a therapist needs achieving, as there is preliminary evidence that an increase in capacities to recognize own affects and self- stateswithmore clarityandnuances isa predictor of good outcome in psychotherapy for personal- itydisorders(Krameret al.,2020). Therapists are better to adopt a curious stance

and not fear presenting themselves as puzzled or confused.Listeningtopatientswithnarcissismdur- ing their early sessions is one of the moments in which adopting a not-knowing stance is necessary. Therapists need to continuously repeat they do not understand and want to know more about specific episodes and to probe for the related affects and cognitions. If patients have difficulties reporting past epi-

sodes with the related affects, I ask them to concen- trate on specific moments in the week to come where there are interactions involving any prob- lems and focus on what happens and try to report it to me in the next session. Then the next session is devotedtoajointscanningoftheepisode,untilspe- cific emotions and thoughts, ones that patients moreeasilyrecognize,emerge. Experiential techniques may be helpful in order

to increase awareness of self-states and reduce PN tendencies toward intellectualizing and ascribing the roots for their distress to the others and the soci- etyatlarge.Experientialtechniqueshaveanexquis- ite capacity to help persons become more aware of their inner processes(Pascual-Leone & Greenberg, 2007). Practices such as chair-work or guided im- agery actually help a person observing their inner

world and the emotions they experience while reliving episodes where clearly “real” others are absent (Dimaggio et al., 2020; Greenberg, 2002; Sachse,2020). As regards intellectualizing, therapists can still

engage in a conversation about the ideas expressed, possibly remaining curious and playful and avoid- ing conflict when views differ. They should focus on common interests, for example, TV series, music, social issues, and so forth. This helps create a sense of intellectual connection, especially if some interests are genuinely shared, and then this can provide the ground for probing for episodes. For example when a patient says society is filled with idiots and incompetents, their therapist may agree that they have come across many of these too but then ask for an episode in which the patient had to face someone they considered an idiot and explore the impact this had on their goals and feelings. In my experience, telling these persons that I

am curious about their opinions but that they do not help me in forming a picture of their inner world is easy and safe. When I say that I am puzzled and do not understand and without spe- cific information have no chance of getting in touch with who they really are and forming a 3-D portrait of their mind, these persons usually grasp that I am interested and not playing the all-know- ing wiseman. I add that with information about what specifically passed through their mind inside specific episodes, I can obtain ideas about their inner world that we can share, so that I do not have to resort to inferences and interpreta- tions based on my books, which would divert me away from my understanding them as unique human beings. There is one minor side effect in these operations, thatis patientsmay becomeirri- tated when the therapist insists on probing for their feelings or battle in order to continue expos- ing their “fancy” theories. These are minor alli- ance ruptureswhich a therapist hasto explore and repair, but in my experience not major ones with a dropoutrisk.

Dealing with Maladaptive Schemas

OnereasonmakingtherapyofPNdifficultliesin their schemas for self and others. First and fore- most, they have a toxic impact on the therapy relationship.

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Pragmatic Suggestions: Working Through the Therapy Relationship

ProbablythisistheaspectofNPDtherapywhich is most widely covered by the literature (e.g., Gab- bard, 1989; Kohut, 1977; Weinberg & Ronning- stam,2020),anditiscoretomanyofthe treatments tailored to Pathological Narcissism, such as Men- talization Based Treatment (Drozek & Unruh, 2020), Transference Focused Therapy (Diamond & Hersh, 2020), Schema Therapy (Young et al., 2003), and Metacognitive Interpersonal Therapy (Dimaggio et al., 2020). The first idea is that in order to avoid making these persons feel further invalidated, therapists need to provide validation and support while at the same time carefully avoid- ing criticism of them for their interpersonal behav- iors, no matter how disturbing they sound (Kohut, 1977; Weinberg & Ronningstam, 2020). Valida- tion and support can be focused on patients’ actual qualities and actions, capacities for communica- tion, displaying of painful feelings when done spontaneously, and most importantly, non-narcis- sisticaspectswhichtheyareunawareof.

An example of this validating stance comes from my therapy with Arthur, a man in his 40s who sought ther- apy because he self-diagnosed as a “narcissist” and was afraid his personality and his constant fighting with his wife were ruining his pre-teen son. He could be diagnosed as having NPD as he admitted to his ther- apist that on the one hand, he felt superior to others, but on the other hand, he concealed feelings of inferiority. He added that had always used manipulation and dero- gation as conscious strategies to let his romantic part- ners feel inferior so to not let them discover his flaws or realize they were better than him and abandon him for a better man. He also said he had always worn a mask, concealing any difficulties. When he told me episodes about his marital problems and his childrear- ing style, I pointed out that his fights with his wife in front of their son were certainly not useful. But I added that he was very focused on his son’s psychological well-being, in terms of getting him to study, not spend- ing hours on videogames, communicate his feelings, and have a regular sleep pattern. Moreover, Arthur did not display any signs of trying to rear his son as a future narcissist: he was not overly critical, nor did he set unrealistically high expectations. He reacted to my observations with a mixture of surprise and, most of all, relief from his underlying deep guilt. After 2 years of therapy, he divorced after his wife being unfaithful, and his relationship with his son is very good.

Ruptures easily arise when therapists are caught in the activation of the social rank system and try to reestablish their status by taking a dominant stance pushing the person with narcissism into an underdog position, something these persons fight

fiercely against. This is evident when therapists statethey“wanttomakepatients’self-esteemmore realistic,” which just means they are telling the cli- entheisawindbag. The reverse needs to be avoided as well: Thera-

pists should not let patients belittle them or insult them. This has to be done skillfully and tactfully, avoiding counterattacking, and for as long as possi- ble. With the majority of these persons, criticism and spite toward the therapist are expressed with subtle irony, which may err toward sarcasm. Avoiding dealing explicitly with this attitude is a problemforaseriesofreasons.First, itcorresponds to the “confrontation” type of alliance rupture (Safran & Muran, 2000; Muran et al., 2021), which the clinician must readily recognize and deal with. Second, when patients belittle their therapist, they are probably conducting a passive-into-active test, that is acting like whoever mistreated them during development (Weiss, 1993). If therapists let patients belittle them, they confirm the idea that spitefulness is acceptable in the relationship, thus justifying the actions taken by the caregivers, school teachers, or trainers of the person who will endupsufferingfromPathologicalNarcissism.Itis as if the clinician is confirming the idea that we deservetobemistreatedanddonothavetherightto stand up for ourselves. Clinicians would better gently, but continuously, point out that patients are being sarcastic or spiteful and inquire about the underlying reasons. They should acknowledge they can and do make mistakes but receiving con- temptdoesnothelptherapy.Whenapatientharshly insults her therapist, the latter has to set limits (Kernberg,1975). Conversely, in order to prevent ruptures, thera-

pist might validate their clients, noting that compe- tition is one of the most important human drivers (Gilbert,2005)andthatambitionhasasilverlining. Therapists would do better to acknowledge these same attitudes in themselves, not pretend they do not find themselves engaged in power struggles with their partners, colleagues, and friends, and, if appropriate, self-disclose them. Once patients feel understood, therapists can gently ask something sounding like: “What for?” This way they do not question that competition is important, but make patientsnoticethattheirsisanever-endingstruggle, whichhasnothelpedthemreachasenseofsatisfac- tionandfulfillment,norwillitdosointhefuture. Therapists should also pay attention to prevent-

ing overactivation of the attachment system. Given that narcissistic attachment-related schemas are

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filled with predictions that others will neglect, con- trol or react with criticism and rejection of patients’ displaysofvulnerability,itislikelythatiftherapists present with an excess of warmth and concern for patients’ states, the latter immediately shift into the social rank system. They tend to withdraw, react withprideordisdain,anddenytheirvulnerabilities. Inmyearlyyearswhentreatingthesepatients,Ihad dropouts soon after I disclosed my feelings of warmth or tenderness for their pain. I learned the lesson and now advocate therapists carefully moni- tortheactivationoftheircaregivingsystem. This is an area of debate, as schema-therapy, for

example, suggests the contrary; that is that thera- pists need to let PNs contact their vulnerable selves (Youngetal.,2003).Moreover,whenusingexperi- ential techniques, schema-therapy adopts the concept of limited reparenting, while other mod- els such as Metacognitive Interpersonal Therapy (Dimaggio et al., 2020) and Clarification Oriented Psychotherapy (Sachse, 2020) do not. These latter models consider the concept of “reparenting” as a risk to create a power difference between therapist (seen as parent) and patient (seen as child), a differ- ence to which, in my opinion, persons with PN would likely react with feeling belittled. This is a matter for future process-outcome study, but my suggestion would be to carefully avoid treating these persons as if they have an inner vulnerable child. Therapists need to improve access to nega- tive feelings, such as guilt, sadness, anxiety or shame, but this is better done while adopting a stance of curious exploration and not that of a benevolentparent. Problems in the therapy relationship also affect

the shared drafting of the therapy contract, a prob- lemIdealwithinthenextsection.

Pragmatic Suggestions: Bearing in Mind the Therapy Contract and the Goal and Task Components of the Alliance

Maladaptiveschemasalsoexerttheirtoxiceffect by making the formation of a shared, reasonable, and goal-oriented therapeutic contract difficult (Clarkin et al., 2015; Weinberg & Ronningstam, 2020). When therapists figure out where patients needtoheadtoinordertoreducesymptomsorhave a more rewarding social life, they encounter prob- lems. Very often their proposals on how to move forward with therapy are read under the lenses of the schemas, with PNs constructing their therapists

as dominant, tyrannical, or belittling. This easily creates maladaptive patterns in the therapy room, wherebothpatientandtherapistbecomedominated by their own schemas or internalized object rela- tions. Typical narcissist enactments range from: devaluingthegoals,sayingthatthey makeno sense to them, despising their therapists for their nonsen- sical proposals, saying that the outer world offers them no chances to fulfill their wishes, or insisting that what is lost can never be retrieved. They may also react with passive-aggression, agreeing with tasks that they then do not comply with by, for example, persisting in maladaptive coping such as passivity, drug and alcohol abuse, perfectionism, verbal aggression, or disordered eating, without any effort to counteract them. All these reactions first need to be dealt with by handling counter- transference and avoiding fueling maladaptive interpersonal cycles (Safran & Muran, 2000). Once therapists have achieved good self-regula- tion, they must shift to the therapy contract (Wein- berg & Ronningstam, 2020; Yakeley, 2018). Being explicit about this dimension is somethinga therapist cannot avoid and at times is the only way nottoremaintrappedinmaladaptive interpersonal cycles. Therapists need to be crystal clear about thepossibilitiesandlimitsofpsychotherapy. One key aspect of the contract is portraying a

clear path between clients’ expectations and task compliance. Therapists need to be adamantine that change depends on task commitment, and they havenopowertomaketheirpatients’livesgobetter if they do not, for example, take a shot at giving up spendingcountlesshoursontheircomputerwithout searching for a job, trying to abstain from rumina- tion and worry, and engaging in some form of healthybehaviorandsoon.Tobeclear,thecontract is not necessarily about change, but is about what therapy is for. If clients simply want to spend their therapy time saying their life has been and will be miserable and that they are frustrated because others do not understand and admire them as much as they deserve, therapists can still accept this, remaining in the position of an empathic listener. What matters is they make explicit that this will only serve to let the patients perhaps feel under- stood and to alleviate their loneliness but will not yield any change in their life nor dramatically reducetheirpain.Thiswaytherapistspreventfuture complaintsoraccusationsaboutnotdoinganything to help. I will provide an example of how to form a therapeutic contract in the section devoted to pro- motingagency.

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Promoting Agency

Lack of agency and passivity over one’s own inner experiences and behaviors lie at the core of PN.Addressingthisintreatmentcanhelptheseper- sonsovercomeproblemstheyhave faced overtheir entirelife.Therapistsandpatientsfirstagreethat,in order to make treatment work, they need to focus on this problem and then negotiate ongoingly how to deal with it. As Weinberg and Ronningstam (2020)noted,therearemanywaystofosteragency, including behavioral tasks, emotion regulation practices, and trying to find different ways to deal with suffering. These elements are part of many of the abovementioned treatments for PN, such as CBT, Schema Therapy, Metacognitive Interperso- nalTherapy,andTransferenceFocusedTherapy. AsInoted earlier, the differentaspectsofpathol-

ogy interact with each other (Dimaggio et al., 2002), and I will also therefore, in the section on coping, describe some of the agency-reinforcing practices,astheyareabouttryingtoregaineffortful control of automatisms such as problem behaviors andrepetitivethinking.

Pragmatic Suggestions: Negotiating the Contract

One necessary way of promoting agency is through a patient, but firm, contract negotiation. Actually, as noted by Weinberg and Ronningstam (2020), some approaches for NPD do mind about the therapy contract, asit is a fundamental aspect of therapy with these persons. The term “contract” may have slightly different meanings in the various approaches. For example, Diamond and Hersh (2020) note how in TFP the contract includes ele- mentssuchasexplicitlyaddressingsecondarygain, requiring clients to engage themselves in some formofactiveorproductiveactivityviapaidorvol- unteer work or study, be honest within session, and soforth.Thisisatlargeconsistentwiththeperspec- tive on the therapy contract I adopt here. More ex- plicitly, I refer here to operations aimed at getting the therapist and client on the same page in terms of:agreeingontherapygoals;realizingthatwithout committing themselves to some therapy tasks, some goals will remain out of reach; ensuring that clients purposefully decides to commit themselves to a task and if they do not, reframe therapy goalsin a more realistic way. Of note, this is not an

operation that is performed at therapy onset only, butitispartoftheongoingtherapyprocess. The following example illustrates how focusing

on problems in the contract helped to face the agencyproblem.

Carmelo was a man from Sicily in his 30’s with NPD with borderline features, working as a social media manager—something requiring time and effort to define, as he said he had no working identity. He entered therapy because of a combination of anxiety about his future, self-loathing, and self-directed rage for having failed at everything in his life, not having a job up to his skills, not being economically independ- ent, and not having a stable romantic relationship. He was angry and spiteful of others, whether they ham- pered his goals or appreciated him: “Why say I’m clever? What do they want from me? It pisses me off when they say I could do much more”. He also suffered from nervous enuresis, which he was deeply ashamed of, and binge-eating which he used to regulate distress, together with flirting and casual sex”. During the first months of therapy he reacted with anger to anything I said that did not provide empathic understanding that he had reasons to complain. But when I tried to engage him in any form of therapy action he reacted with an- ger, contempt, and more pain. I spent time regulating the therapy relationship, which was fortunately filled with humor. At a certain point, I realized I had to focus on the therapy contract, as we had no agreement on therapy goals and tasks, and I did not offer him any re- alistic idea of how therapy could help him and under what conditions.

As a consequence of my new awareness that a contract was lacking, I told him I could find no way to help him if he spent all the time in angry rumination or attacking everything I said. I said that I could help him, but I needed him to offer me a viable path, otherwise I would remain impotent in the face of his combination of suffering and an- ger. After another bout of rage and spitefulness, he agreed that he was not offering any solution. But he then became aware that the problem I spotted made sense, that is his never learning how to build a bridge between wishes and means. We recon- structed how he was brought up by an idealizing mother, who also inhibited any spontaneous behavior and manipulated him in order to make him stay close to her, and by an emotionally absent father. We agreed that, though difficult, therapy was about trying to build a bridge, that is committing himself to actions that could have the chance of bringing him closer to his aspirations. This increased his anxiety at that moment but made sense to him. After 1 and a half years of ther- apy, he has his first stable romantic relationship

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ever and is making significant steps in pursuing a career.

Pragmatic Suggestions: Use Tailored Behavioral Assignments

Given that subjective sense of agency is strongly connected with motor control (Moore et al., 2010), experiential practices where motor and premotor areasareactivated(Dimaggioetal.,2020)arewell- suited to reinforcing it. Therapists can adopt a com- bination of techniques, such as guided imagery and rescripting, role-play, or two-chairs (Dimaggio et al., 2020), with the inclusion of sensorimotor work (Lowen, 1983). Patients can then learn that, wheninthemiddleoftheinteractionstheyarereex- periencing, they have power over their physical reactions by adopting a different posture or tone of voice, or acting differently. They then discover that theirmentalstatechangesaccordingtothenewpos- tureoractiontheyundertake.

An example comes from the second year of Carmelo’s therapy. He had made significant steps in the work do- main but still complained he was not active enough in pursuing a career. He had realized that a central prob- lem was his historically rooted passivity. We evoked an episode when he was 22. He had planned to move to Milan to finish university and asked his mother for both emotional and economical support. She replied that it would cost a lot of money, which made Carmelo resentful as the family finances were good, so there was no real reason to deny him support. More impor- tantly, she was skeptical about his capacity to complete his course and get his degree, and so she said she would give him some money but on an exam-by-exam basis. I asked Carmelo how he reacted, and he said he felt deprived of energy and physically weak and had two different thoughts: on the one hand he thought he deserved confidence in his skills so he felt hurt and an- gry, on the other he doubted his qualities and felt infe- rior and incapable. I suggested to him that guided imagery and rescripting could help. With his eyes closed he retorted to his mother: “I need your support and I deserve it. You treating me this way hurts so much.” But he only felt minor relief and said that he was not so convinced he really deserved support. I then asked him to change his posture and adopt one of his choice, to give himself more energy and steadiness. He decided to stand up, still with his eyes closed. He soon felt better and again replied to his mother, while I asked him to raise his voice’s volume more and more. This time he felt more convinced about his skills and his face relaxed. A few days later he texted me that he had sent a CV to a firm, a task assignment which we agreed upon more than a year before but he had never been able to undertake until then.

Reducing Maladaptive Coping and Promoting Healthy Behaviors

Counteracting PN tendencies to adopt problem- aticbehaviorsisbothnecessaryanddifficult.These persons are often convinced that their strategies to dealwithproblemsaregoodorjustified.Theythink theyresorttoperfectionism,isolation,verbalaggres- sion, drug use, disordered eating, overexercising, cosmetic surgery, and so forth with good reasons. Agreeingupontryingtoabstainfromthesestrategies has to be done carefully and is part of the therapy contract. The contract is necessary because if patients do not agree to tasks, therapists should be ready to accept that they are consciously deciding topersistintheirhabits.WhatIsayinthesecasesis thatIwillaccompanythemforaslongastheywant but cannot grant progress and relief if they prefer stickingtotheirbehaviors.Thisisusuallyfollowed byarenegotiationofgoalsandtasks.

Pragmatic Suggestions

Asking to restrain from coping may sound mor- alistic and tyrannical to patients with narcissism. In the case of the most prominent coping, that is, self- enhancement, early attempts at dismantling it are counterproductive (Kohut, 1971; Weinberg & Ronningstam, 2020) as they risk forcing PN to face theideaofselfasinferior. Of note, therapists must make explicit that when

theyaskforsomebehavioraltasks,theydonotcon- sider that patients succeed if they perform the task and fail if they do not. Clinicians would better note thatwhatmattersis(a)theeffortclientsputintotry- ing and (b) focusing on the inner experience’s flow at the moment of trying to abstain from the target behavior. The very first goal of these tasks is improving self-reflection, that is discovering ele- ments of inner experience while trying to steer own behavior in a different direction (Dimaggio et al., 2020). Task assignments are somewhat easier whentheyfocusonadoptingbehaviorsmoreinline withaperson’sdeep-seatedwishes.

Elena, a lawyer in her late 30’s with NPD, used seductive behaviour in order to boost her self-esteem. After having casual sex, she experienced a mixture of contempt for the man she had slept with, self-loathing, and emptiness. We agreed she should try to avoid responding to requests on Tinder when she felt more of the urge to do it, that is, late evening after returning home from work. She tried and discovered that the driver for her seductive behaviors was not so much repairing self-esteem, as we previously thought, but more a sense of numbness. After

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reconstructing together that this came from family issues or origins, we searched for something she might to do to counteract this numbness. She realized that a run by the lakeside was what she wanted. She tried, and the next ses- sion she reported she had felt ok and mindfully appreci- ated the sunset, the people walking, and the atmosphere of the restaurants and cafés.

Focusing on Strength, Resources and the Healthy Self

Another problem area in PN regards autonomy and freedom to explore one’s deep-seated wishes not related to ambition and status, which corre- sponds to living in accordance with a false self (Kohut, 1977; Lowen, 1983). Therapists should seek areas patients want to pursue, or wanted in the past, and help them focus on how they feel when being in touch with this desire instead of remaining stuck in feelings of bitterness, desperation, envy, andangerrelatedtosocialrank. Experiential techniques are useful here. For

example, I asked Michele to bring his guitar to my consulting room as I wanted to explore the bodily andemotionalsensationshehadwhileplayingwith him. This helped him realize that, while playing, he swung from pleasure and enjoying music for its own sake to rumination about his past failures. A combination of attention training and body scan- ning (Ottavi et al., 2019) then helped him discover he was able to both interrupt his repetitive thinking and anchor himself to the playfulness he experi- enced in music. I did similar exercises with many PN clients, and these often helped them shut out socialrank,enterstatesofcuriosityandexploration, and connect with wishes they felt deeply their own. This is connected to the promotion of agency, so I willdealwithitinthenextsection. Overall, with a combination of working though

the therapy relationship, behavioral assignments and rescripting exercises (e.g., guided imagery, two-chairs,role-play),clinicianscanhelptheseper- sonsformmorebenevolentideasaboutthemselves, even when failing to meet their unrelenting perfec- tionistic standards. Moreover, contacting deep- seated wishes helps them ground their identity not only on status and social rank but on creativity and playfulness.

Promoting Theory of Mind and Empathy

This is an area where many therapies fail. Given narcissistic tendencies to disregard the opinion of

the others and often be manipulative or spiteful, some therapists feel the urge to correct this attitude. This sounds judgmental and moralistic to PNs, and the result is not an increased capacity to understand othersandbeempathicbutanalliancerupture.Cer- tainly, if PNs do not discover that others have thoughts, feelings, and agendas that are complex, nuanced,and differentfrom theirown,it isunlikely their relationships will improve, but this has to be promotedattheopportunetime. There are two treatments, among the ones rec-

ommended for PN (Weinberg & Ronningstam, 2020; Yakeley, 2018) explicitly focusing on increasing reflective capacities, that is Mentaliza- tion Based Treatment (MBT, Drozek & Unruh, 2020) and Metacognitive Interpersonal Therapy (MIT; Dimaggio & Attinà, 2012). The two approaches follow different strategies: MBT fos- ters curiosity about the mind of the others early in therapy, while MIT adopts a rigid structure (Dimaggioetal.,2020).MITfirstencouragesasus- tainedfocusonself-reflectiontogetherwithpromo- tion of the healthy self, for example, overcoming guilt and shame, focusing on inner-most desires instead of remaining stuck in the quest for the ideal self.Atthismomentdevelopingtheoryofmindand empathy is forbidden. Only once PNs have better self-awareness and are more in touch with the healthy self does MIT focus on promoting a richer awareness of the others. I do advocate the second approach, in line with Mitchell (1986), that is first mentalizing the self and only later the other, but to date there is no evidence that one approach is better suited than the other to PN’s needs. Research is needed to solve the issue. Technically speaking, in advancedstagesoftherapy,experientialtechniques may help promote these capacities, as persons are asked to enact the “other” and so have a different graspofwhatmaypassthroughhermind.

Conclusions

Treating persons with PN or with NPD is a chal- lengetoanyclinician,andempiricalevidenceabout how to treat them is lacking. Suggestions on how to deal with problems any clinician may face when treating these persons come from different schools but, in absence of any outcome study, none of them clearly stands out. At the same time, the integrative therapist needs to find her or his own way to deal with these persons. Against the background of two recent efforts to systematize what we currently

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know about treatment of these persons (Weinberg & Ronningstam, 2020; Yakeley, 2018), I have sug- gested some principles for an integrative therapy of PN and NPD grounded on core aspects of pathol- ogy. The idea is that clinicians need to tackle 5 ele- ments: maladaptive interpersonal schemas, poor self-reflection and intellectualizing, disturbed agency,maladaptivecopinganddefenses,andpoor theory of mind and empathy. A combination of working through the therapy relationship, constant negotiation, and monitoring of the contract and of the goal and task components of the alliance, be- havioral experiments and, when possible, expe- riential practices such as guided-imagery and rescripting, role-play, and bodily work is neces- sary to tackle these different elements. Such an effort has indeed many limitations, the

main one being the point this paper started with: lackofempiricallysupportedtreatments.Byoutlin- ing specific therapyprinciples,based on pathology, this paper may be a further step, together with efforts by Yakeley (2018) and Weinberg & Ron- ningstam(2020),towardprovidingsomeprinciples ofgoodclinicalpracticethatanytherapist,irrespec- tive of her or his own orientation, can use as a road- map to tackle the challenges PN poses. In parallel, there is a chance that, with growing interest in PN and NPD, clinicians’ and researchers’ interest in studying this population will grow, and these ideas passunderempiricalscrutiny.

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ReceivedJanuary17,2021 RevisionreceivedApril3,2021

AcceptedApril23,2021 n

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