Discussion: Scholarly article review guideline

R E S E A R C H A R T I C L E

The role of shame and self‐compassion in psychotherapy for narcissistic personality disorder: An exploratory study

Ueli Kramer1,2 | Antonio Pascual‐Leone2 | Kristina B. Rohde3 | Rainer Sachse4

1 Institute of Psychotherapy and General

Psychiatry Services, Department of Psychiatry,

Lausanne University Hospital and University

of Lausanne, Lausanne, Switzerland

2 Department of Psychology, University of

Windsor, Windsor, ON, Canada

3 Bern University Hospital and University of

Bern, Bern, Switzerland

4 Institute for Psychological Psychotherapy,

Bochum, Germany

Correspondence

PD Dr Ueli Kramer, IUP‐Dpt Psychiatry‐ CHUV, University of Lausanne, Place

Chauderon 18, CH‐1003 Lausanne, Switzerland.

Email: [email protected]

Abstract This process‐outcome study aims at exploring the role of shame, self‐compassion, and specific

therapeutic interventions in psychotherapy for patients with narcissistic personality disorder

(NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long‐term

clarification‐oriented psychotherapy. Their mean age was 39 years, and 10 were male. On aver-

age, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated

using the Classification of Affective Meaning States and the Process‐Content‐Relationship Scale.

Outcome was assessed using the Symptom Check List‐90 and Beck Depression Inventory‐II.

Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30).

In Session 36, the presence of self‐compassion was linked with a set of specific therapist inter-

ventions (process‐guidance and treatment of behaviour‐underlying assumptions; 51% of variance

explained and adjusted). This study points to the possible central role of shame in the therapeutic

process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to

access underlying self‐compassion.

KEYWORDS

clarification‐oriented psychotherapy, emotion processing, interaction process, narcissistic

personality disorder, self‐compassion, shame

1 | INTRODUCTION

Patients with narcissistic personality disorder (NPD), or pathological

narcissism, may present at times with self‐enhancing grandiosity,

whereas at other times with a brittle or fragile sense of self. Such con-

trasting self‐presentation of patients with the same underlying prob-

lems should be integrated in a comprehensive understanding of the

disorder (Caligor, Levy, & Yeomans, 2015; Levy, Ellison, & Reynoso,

2011; Ogrodniczuk & Kealy, 2013; Pincus & Lukowitsky, 2010; Pincus

& Roche, 2011; Roepke & Vater, 2014; Ronningstam & Weinberg,

2013). Core psychological features of NPD encompass a deficit in

self‐definition and affect regulation, a brittle sense of self and a lack

of empathy which foster biased conceptualizations of Self and Other.

Self‐enhancement, in particular a sense of grandiosity, exaggerated

entitlement, or arrogance may help maintain a stable self‐image. Often

more implicitly, fluctuating self‐esteem, self‐criticism, and affect dys-

regulation persist.

The quality of emotional processing underlying these core fea-

tures of NPD is of key interest. Deficits in emotional processing as

found on several dimensions which may be linked with the underlying

subjective experience of shame. Emotional processing with regard to

the Self lacks depth, that is, low levels of emotional self‐awareness,

and with regard to the others, that is, deficient emotion recognition

and lack of empathy (Dimaggio & Attina, 2012; Marcoux et al., 2014;

Pincus & Lukowitsky, 2010; Ritter et al., 2011; Ronningstam, 2016;

Sylvers, Brubaker, Alden, Brennan, & Lilienfeld, 2008). Lack of emo-

tional empathy may explain the interpersonal difficulties reported as

part of the NPD diagnosis (Ogrodniczuk, 2013). This lack of empathy

in NPD has been discussed as a prerequisite for the self‐referential

processing bias related to self‐enhancement and grandiosity: It

becomes key to focus on the underlying emotional issues related with

the understanding of the Self as shameful.

Patients with NPD tend to present with low levels of emotional

awareness (Joyce, Fujiwara, Cristall, Ruddy, & Ogrodniczuk, 2013;

Lecours, Briand‐Malenfant, & Descheneaux, 2013; Mizen, 2014;

Ronningstam, 2016). Difficulty in describing one's inner emotional

states has also been associated with grandiose and entitlement traits

(Lawson, Waller, Sines, & Meyer, 2008). These results might indicate

that these patients lack the capacity to be aware of their emotional

life and of its deeper meanings. In her conceptual and clinical account

Received: 3 July 2017 Revised: 26 October 2017 Accepted: 30 October 2017

DOI: 10.1002/cpp.2160

272 Copyright © 2017 John Wiley & Sons, Ltd. Clin Psychol Psychother. 2018;25:272–282.wileyonlinelibrary.com/journal/cpp

of the perceptual recognition of emotion in individuals with NPD,

Ronningstam (2005) put forward a triad of emotions to which

patients with NPD respond with less accuracy: These patients seem

to have difficulties to identify fear, shame, and anger in others (see

also Lewis, 1971; Morrison, 1983). At the same time, these emotions

play an important role in the subjective experience of patients with

NPD: It was shown that they present with higher levels of explicitly

reported shame and an implicit proneness to shame (Ritter et al.,

2014). Implicit self‐related shame may be a trigger for developing high

standards, an excessive drive for success, and perfectionism (Dimag-

gio & Attina, 2012; Sagar & Stoeber, 2009). Ronningstam (2016)

added to this elaboration that other‐related shame, for example, attri-

butions of the other people as unworthy or defective, may result in

the expression of aggression and hatred, along with blaming, dismis-

sive, or overly critical attitudes (Caligor et al., 2015; Kernberg, 1992;

Ogrodniczuk, 2013; Sachse, Sachse, & Fasbender, 2011). As such,

malignant forms of narcissism may be characterized by the intentional

destructiveness of the significant other (Kernberg, 2004). If this

aggressiveness is turned inwards, it may result in suicidal thoughts

and actions, which may—paradoxically—have an important function

in maintaining the individual's belief system (Maltsberger,

Ronningstam, Weinberg, Schechter, & Goldblatt, 2010; Ronningstam,

2016). Additionally, fear may be an important emotion tendency in

NPD (Kernberg, 2004, 2008). These patients may fear of “losing face”

in social interactions, again a shame‐based emotion (Kramer,

Berthoud, Keller, & Caspar, 2014; Lecours et al., 2013), or their self‐

control; they may experience fear of social exposure, to be humiliated

and to experience shame in the future. Because of the shame‐based

organization of the latter, authors have also called this emotion

“shame‐anxiety” (Pascual‐Leone & Greenberg, 2005). Because these

shame‐based emotional states are difficult to bear for most persons;

hostile anger is a common defensive interactional manoeuver

(Pascual‐Leone, Gillis, Singh, & Andreescu, 2013). Patients with NPD

have often developed a host of other agency‐enhancing interactional

manoeuvers as well, like boasting, using imagery of grandiosity, set-

ting exaggeratedly ambitious work goals, engaging in competitiveness,

or, also, using harsh self‐criticism, self‐hatred, and self‐contempt.

Patients with NPD have often developed explicit and implicit strate-

gies for avoiding the hurtful experience of shame (Lecours et al.,

2013).

In sum, effective therapy for core shame in patients with NPD

needs to take into account the interactional consequences of the

shame‐based organization as a first step, and then in a second step

deepen and transform the experience of shame.

1.1 | Shame: A dynamically changing emotion

According to emotion‐focused theory, shame may be defined

(Greenberg & Iwakabe, 2011) as an affective‐meaning state (or self‐

organization) composed by the internalized evaluative process of

self‐despising or self‐loathing information. As immediate consequence

of such an implicit (or explicit), self‐organization is the tendency to hide

or to make himself or herself “invisible” to the outer world. Clinical

observation of cases—including patients with NPD—has it that patients

may present with maladaptive shame (Greenberg, 2015; Greenberg &

Iwakabe, 2011). Maladaptive shame may involve the individual's

understanding of his or her person as fundamentally flawed, unworthy,

or despicable: despite explicit messages from other people expressing

the opposite, the person continues to feel, at the core and often implic-

itly, fundamentally flawed.

When it is part of the patient's presentation, engaging this mal-

adaptive form of shame is an essential passageway in the process of

transforming emotion (Kramer, 2017; Pascual‐Leone, 2009; Pascual‐

Leone, 2017; Pascual‐Leone & Kramer, 2017), which may be particu-

larly important in psychotherapy of NPD. The process of emotional

transformation describes how patients' maladaptive emotion is

changed by emotion, that is, how patients move from non‐differenti-

ated and poorly integrated to adaptive and integrated emotional

experiences (Pascual‐Leone, 2009). Engaging in and transforming

shame seem essential for change in patients with NPD, because we

assume that maladaptive shame is strongly connected with negative

evaluations about the self which may contribute to a brittle sense

of self, to an unstable self‐image, and to other identity‐related prob-

lems in NPD. Early components of the emotion transformation pro-

cess (Pascual‐Leone, 2009), also called early expressions of distress

(see Figure1; global distress and rejecting anger), may be secondary

reactions to maladaptive shame and a more fundamentally fragile

sense of self. This conception assumes that rejecting anger involves

the person expressing strong resentment by rejecting or blaming the

other, generally in an intensive and non‐agentic way. Later compo-

nents of the emotion transformation process (Pascual‐Leone, 2009)

—also called primary adaptive emotions (see Figure1)—are assumed

to be underpinned by a new construction of meaning or insight. The

most important emotional states identified in this group are assertive

anger, grief, and self‐compassion; and they involve an individual's

experientially accessing, developing, and articulating an unmet exis-

tential need or wish. For patients with strong shame‐based organiza-

tions, the transformational process might involve an individual's

development of self‐compassion. According to this dynamic concep-

tion (Pascual‐Leone, 2009), self‐compassion is an elaborated

affective‐meaning state where the person actively gives himself or

herself what was ultimately needed at the core in his/her

Key Practitioner Message

• An active therapeutic focus on shame may be useful in

patients presenting with narcissistic personality

disorder, in particular in the working phase (after

Session 20) of the therapy process.

• The emergence of self‐compassion may be fostered by a

process guiding intervention, in advanced working phase

sessions (after Session 35) with patients with narcissistic

personality disorder.

• Once patients with narcissistic personality disorder

experientially access shame in session, its decrease

over the course of the working phase of therapy might

serve as an indicator of productive therapy process.

KRAMER U. ET AL. 273

development. Self‐compassion is therefore an adaptive way of expe-

rientially accessing one's own core needs, requiring a representation

of these needs and of one's sense of self, which is deficient in

patients with NPD, but might be formed through psychotherapy.

The patient's experiential access of self‐compassion can hence be

seen as a marker of good progress in emotional transformation of

core shame in NPD.

1.2 | Clarification‐oriented psychotherapy (COP) for core shame in NPD

COP is an integrative form of psychotherapy, based on humanistic

and interpersonal concepts, that was specifically developed for

patients with personality disorders, and NPD in particular. COP

assumes that patients with NPD present with two action systems:

(a) an authentic action system and (b) a strategic action system

(Sachse et al., 2011). The authentic action system includes a person's

direct access to information related to his or her healthy need satis-

faction which helps the person to adaptively respond to the interac-

tion partners. These authentic actions are based on motives and

involve a direct experiential access and expression of the underlying

need to the interaction partner. In contrast, the strategic action system

describes the interactional manoeuvres, by using indirect expressions

of the underlying need. The use of interactional manoeuvers by the

person might leave him or her dissatisfied with the actual interac-

tions—sometimes without one being fully aware of it. According

to Sachse et al. (2011), this process explains the presenting interper-

sonal problems of NPD. Such interpersonal manoeuvers involve an

external—interpersonal—focus and explain the occurrence of what

the typical compensatory manoeuvers of NPD (Ronningstam, 2016).

For example, it may involve a patient presenting to others as free of

any problems or of someone who denies any need for treatment,

invincible, and grandiose. At other times, the patient with NPD pre-

sents as someone with a particular “gift” for which the interlocutor

should admire him or her or, finally, as someone who is so fragile

that he or she requires special care and attention by the interaction

partner. The therapy process in COP undergoes several phases.

The initial 10 to 20 sessions encompass the in‐session resolution

(i.e., reduction) of such interpersonal manoeuvers by offering a par-

ticularly responsive therapeutic relationship tailored to the underly-

ing motivational system. Sachse et al. (2011) propose to use the

complementary or motive‐oriented therapeutic relationship (for a

clinical example of this intervention type with a patient suffering

from NPD, see Kramer et al., 2014). As part of the initial sessions

and only when the interactional manoeuvres are significantly

reduced in‐session, the patient defines the therapeutic goal, which

includes the definition of the actual problem, which will then serve

as the vector for all further clarification and deepening work.

The core working phase of COP for NPD—typically after sessions

15–20—involves the patient's exploration of momentary experi-

ences and constructing relevant personal meaning, with the aim of

broadening and deepening the patient's scope of self‐understanding

(self‐processes related to the identified problem). COP increases the

patient's awareness with regard to the central functions underlying

his or her interpersonal manoeuvers. Internal determinants, such as

core affects, needs, assumptions, and motives related to shame, are

deepened during the working phase of this treatment which is only

feasible when the patient can reliably use internal information

(without reusing an external focus, as in the earlier sessions of

therapy). In a final treatment phase of COP, the therapist fosters

change in the internal determinants by using various techniques,

including a version of a two‐chair dialogue for fostering change.

In a recent effectiveness study on 29 patients with NPD undergo-

ing COP, pre‐post effect sizes were found to be large (d's varying

between 1.2 and 2.3; Sachse & Sachse, 2016).

From a psychotherapy process perspective, Kramer, Pascual‐

Leone, Rohde, and Sachse (2016) demonstrated for 39 patients with

a variety of personality disorders (including NPD), that good outcome

cases—defined as a reliable clinical change index greater than 1.96

(Jacobson & Truax, 1991) on outcome measures—were characterized

by more self‐compassion and rejecting anger in early working phase

sessions—session 25—than poor outcome cases. This result points

H ig

h gnis secor

P lanoito

m E

fo eerge

D L

o w

Primary Adaptive Emotions

Early Expressions of Distress

Rejecting Anger

Acceptance and Agency

Grief / Hurt

Assertive Anger or

Self-Compassion

Need

Start

Global Distress

Shame / (Fear)

Negative Evaluation

FIGURE 1 Sequential model of emotional processing (adapted with permission from Pascual‐Leone & Greenberg, 2007)

274 KRAMER U. ET AL.

to the potential centrality of self‐compassion in psychotherapeutic

change of NPD, however, it is unclear whether the patient's experien-

tial access to self‐compassion increases over the course of the work-

ing phase in COP. Access to rejecting anger was interpreted as an

important stepping stone towards such deeper and more meaningful

emotional processing (Pascual‐Leone, 2009; Figure1). One further

stepping stone towards deeper processing may be the access of

shame (see Figure1) which we expect should be accessed and

transformed (i.e., diminished in intensity) throughout the working

phase of COP for NPD. We expect that such between‐session change

of shame in the working phase of therapy would depend on the

degree of the patient's initial functioning and would be linked with

outcome in COP. Kramer et al. (2016) showed that a therapist's pro-

cess‐guiding towards patient's core issues in the first part of early

working phase sessions was linked with the engagement in shame

(or fear) in the second part of the same session. It remains unclear

what the role of self‐compassion is in later working phase sessions

for patients with NPD. From an emotion‐focused perspective

(Greenberg, 2015; Pascual‐Leone, 2009), self‐compassion may

emerge in the context of a trustful patient‐therapist interaction,

allowing the patient to experientially access and acknowledge his/

her inner motives and needs. This exploratory study aims at address-

ing these issues for a subsample of the cited study, by more closely

examining patients who presented with NPD over the course of the

working phase of COP.

1.3 | Study hypotheses

This process‐outcome study focuses on the early and late working

phase of COP for NPD. By doing so, we will focus on the standard def-

inition of NPD by Diagnostic and Statistical Manual of Mental Disorders‐

IV (DSM‐IV; American Psychiatric Association, 1994). During working

phase, the patient's (less productive) interactional manoeuvers are

reduced in session, and the patient is able to attend to the current

inner experience in a potentially productive way; these processes

may occur after the initial 20 sessions of COP. For this reason, we for-

mulate hypotheses on emotional processing after Session 20.

H1a Shame decreases from early working phase session

(25) to late working phase session (36).

H1b Change in shame is negatively related with symp-

tom intensity in patients with NPD; the greater the symp-

tom load at intake, the smaller the change in shame in the

working phase of therapy.

H2a Late‐working phase sessions (36) present with more

in‐session self‐compassion than earlier working phase ses-

sions (25).

H2b The presence of self‐compassion in the second part

of late working phase sessions (i.e., after minute 20 into

the session) is linked with the quality of the patient‐ther-

apist interaction in the first part of the same sessions (i.e.,

between minutes 10 and 20).

H3 In‐session shame is related to symptom change post‐

treatment.

2 | METHOD

2.1 | Participants

2.1.1 | Patients

Seventeen patients participated in this naturalistic trial. These patients

were self‐referred and consulted at a German‐speaking Consultation

Center specialized in the treatment of Personality Disorders (PDs).

All participants met criteria on the Structured Clinical Interview for

DSM‐IV Axis II Disorders for NPD, although their initial explicit formu-

lation of their problem might be consistent with a different psycholog-

ical disorder. All patients participated in an earlier process‐outcome

analysis (Kramer et al., 2016) which used a mixed sample of N = 39

patients suffering from various personality disorders, of which

N = 20 presented with NPD. In order to be included in the primary pro-

cess‐outcome analysis, the patients must present with PD, have pro-

cess and outcome data available, and must not present with

schizophrenia nor bipolar disorder. In order to be selected for the cur-

rent specialized analysis, patients must present with NPD and have

one additional audio‐ or video tape from session 36 (or, if not available,

37). For n = 3 individuals from the sample of the primary analysis, these

tapes did not exist or were not available. Therefore, the present sample

is composed of a total of N = 17 patients. In addition to the NPD diag-

nosis, seven (41%) presented with comorbid major depression, four

(24%) with substance abuse, two (12%) with somatoform disorder,

and one (6%) with generalized anxiety disorder. On axis II, four patients

(24%) presented with an additional comorbid personality disorders:

two (12%) with histrionic, one (6%) with dependent, and another

(6%) with avoidant personality disorders. DSM‐IV‐diagnoses (APA,

1994) were established by trained researcher‐clinicians using the

Structured Clinical Interview for DSM‐IV (First, Spitzer, Williams, &

Gibbons, 2004) for axes I and II of the DSM‐IV. The mean age of the

sample was 39.4 years (SD = 9.9) and ranged between 22 and 60;

seven patients were female (41%). All patients gave written informed

consent for their data to be used for research. The study was approved

by the institute's internal board.

2.2 | Treatment

COP represents an adaptation of client‐centred psychotherapy to the

specific problems related with personality disorders, and in particular

NPD (Sachse et al., 2011). This treatment involves the step‐by‐step

working through of specific interpersonal manoeuvres, such as pre-

senting oneself as being invincible or particularly vulnerable in order

to justify demands for assistance in specific domains. After the focus

on the interpersonal manoeuvers, the core task of the COP therapist

is to clarify and render explicit the network of assumptions, emotions,

and motives underlying a patient's clinical presentation (Sachse et al.,

2011) where it is assumed that, particularly for NPD, a fragile sense

of self together with self‐evaluations about oneself as worthless and

flawed underlie the presence of shame. Therefore, the treatment pro-

motes certain types of emotional transformation related to shame and

associated negative self‐evaluations. A manual describes the stages

and techniques involved in COP for NPD (Sachse et al., 2011), which

was used to train all therapists who were also supervised by the

KRAMER U. ET AL. 275

model's developers. Treatments lasted between 45 and 99 weekly ses-

sions with a mean of 64 sessions (SD = 10).

2.3 | Instruments

2.3.1 | Symptom Check List SCL‐90‐R (Derogatis, 1994)

This questionnaire consists of 90 items addressing various signs of dis-

tress. Our study used the Global Severity Index (GSI; score ranging

from 0 to 4), which is a mean rated over all symptoms. Clinical cut‐

off score is .80. The German version was used in this study and previ-

ously yielded satisfactory validation coefficients (Franke, 1995). Inter-

nal consistency (Cronbach's alpha) for this sample was .94.

2.3.2 | Beck Depression Inventory‐II (BDI‐II; Beck, Steer, & Brown, 1996)

The German version of the BDI‐II was used; this version has shown

satisfactory validation coefficients (Hautzinger, Bailer, Worall, & Keller,

1995). This self‐report measure assesses depressive symptoms using

21 items. The intensity of each symptom is rated on a 4‐point Likert‐

type scale (0–3). The sum score of all items is computed, with the clin-

ical cut‐off of 10 for mild depression. Internal consistency for the scale

for this sample was .89.

2.3.3 | Classification of Affective‐Meaning States (CAMS; Pascual‐Leone & Greenberg, 2005)

The CAMS is an observer‐based rating system for the assessment of

distinct affective meaning states that emerge during the course of

therapy sessions and that can be reliably categorized according to pre-

cisely defined criteria involving para‐verbal and verbal markers. It has

been developed based on emotion‐focused theory (i.e., Greenberg,

2015). In this study, the CAMS assesses two affective‐meaning states

which are the central subjective emotion categories: (a) shame

(and fear) and (b) self‐compassion. A manual (Pascual‐Leone &

Greenberg, 2005) guides the rater for the task of the moment‐by‐

moment analysis of audio‐/video‐recordings. Several studies have

demonstrated excellent reliabilities and validity of the CAMS (e.g.,

Kramer et al., 2015; Pascual‐Leone, 2009). Raters in this study were

blind to one another's coding on the CAMS, to treatment outcomes

of cases they were coding, and to research hypotheses. Reliability

was demonstrated in the parent study on a subsample of n = 10 ses-

sions out of 34 sessions (29%) of cases with NPD. The results for

inter‐rater reliability on the distinct emotion categories were excellent

(Mean Cohn's κ = .91; SD = .11, ranging between .71 and 1.00).

2.3.4 | Processing‐Content‐Relationship Scale (Bearbeitungs‐, Inhalts‐ Beziehungsskalen [BIBS; Sachse, Schirm, & Kramer, 2015])

Processing‐Content‐Relationship Scale is an observer‐rated instru-

ment assessing the quality of the therapeutic interaction according to

COP. Each of the 54 items is rated on a Likert‐type scale, ranging from

0 to 6. Global ratings are made for both patient's and therapist's contri-

butions to the therapy process using segments lasting 10 min of the

middle of the video‐/audio‐recorded session (between Minutes 10

and 20). On this scale, higher scores reflect better interaction quality.

From the patient's perspective, three subscales are defined (process,

content, and relationship), from the therapist's perspective, six sub-

scales are defined (relationship, understanding, process‐directiveness,

therapeutic work with focus on of process, on relationship, and on

content assumptions); this study includes the three patient's subscales

and the theoretically central therapist's subscales of process‐

directiveness, therapeutic work with focus on relationship, and on

basic assumptions. Excellent psychometric properties were reported

for the BIBS (Sachse et al., 2015). In particular, accuracy for patients

with personality disorders was demonstrated, as well as the validity

of coding a midsession segment instead of the entire therapy session.

Cronbach's alpha for the present NPD sample (all items together) was

α = .94. In total, 18 sessions (out of a total of 34 sessions) of the NPD

cases were rated by two raters independently that represents a 53% of

reliability sample, and the reliability was excellent (Mean Intraclass

Correlation Coefficient; ICC (1, 2) = .93; SD = .06; range between .81

and .98; Shrout & Fleiss, 1979).

2.4 | Procedure

2.4.1 | Session selection

Two therapy sessions from the beginning and end of the working

phase (i.e., midtreatment vs. late‐treatment) were chosen and analysed

for this study. Session 25 was selected for analysis and served as the

basis for our earlier process‐outcome analysis (Kramer et al., 2016),

in order to ensure that there is an early working phase session which

is not dealing with interpersonal manoeuvres anymore (see above). In

addition, session 36 was selected for analysis and served as late‐

working phase session. This session was selected as being as much dis-

tant from the early session and not yet being part of the termination

phase of therapy (starting after sessions 38–40 for some cases). This

target late‐working phase session was not available in only one case,

so the closest available session (i.e., 37) was used in this case.

2.4.2 | Raters, training, and coding procedures

A total of five raters were used for both scales (CAMS and BIBS).

Procedures for selecting and training to reliability of all raters were

identical to those used in the parent study (Kramer et al., 2016). Impor-

tantly, all trainings (involving 40 hr per rating scale) in the scales were

completed prior to the ratings included in this study. In order to code

emotions using the CAMS, we used continuous cross‐classification rat-

ings (a code was given at each moment of the material). In a further

step, a minimum of 1 min per code was used as a threshold for coding

emotion using the CAMS except for the categories of negative evalu-

ation and existential need. The entire sessions (in total 34 sessions;

two per patient) were coded with both rating systems.

2.5 | Statistical analyses

In order to assure that both therapy sessions (Sessions 25 and 36)

were comparable on key variables, we compared the number of CAMS

codes and the BIBS ratings by using Paired Sample t‐tests, because

basic assumptions for ANOVAs were not satisfied. H1a (change in

shame) was tested using Paired Sample t‐test and H1b (impact of

intake psychopathology on change in shame) using linear regression

(method enter; adjusted values used for R Square, because of the small

276 KRAMER U. ET AL.

sample size). H2a (change in self‐compassion) was tested using Paired

Sample t‐test and H1b (impact of interaction quality on self‐compas-

sion in Session 36) using linear regression (method enter; adjusted

values used for R Square). H3 (link with outcome) was tested using a

linear regression model (method enter, adjusted values used for

Rsquare). Statistics were computed on spss23.

3 | RESULTS

3.1 | Preliminary analyses

The number of CAMS codes did not differ between the mid‐ (25) and

late‐(36)‐in‐treatment sessions (t(1,16) = 1.12; p = .28; d = .37). From a

total of 134 observed minutes (both sessions taken together) in the

composed category of shame and fear, 80% (107 min) were specifically

shame‐based emotions. Therefore, and because of this study's focus

on shame, we only included those units that were rated as shame

and excluded the 27 instances of maladaptive fear from our subse-

quent analyses.

The overall patient and therapist contributions, using the BIBS, did

not differ between Sessions 25 and 36 (see Table 1), however, there

are medium effect sizes based on the total score of BIBS that suggest

an overall decrease in quality of the interaction (a noteworthy trend

with, p = .06).

Mean GSI at intake was 1.21 (SD = 0.81; ranging from 0.15 to

2.83), at discharge 0.71 (SD = 0.74; ranging from 0.00 to 2.85; prepost

effects: t(1, 16) = 2.97; p = .01; d = .64). In total, n = 11 (65%) of the

patients presented with a reliable clinical change index on the GSI,

according to Jacobson and Truax (1991). Mean BDI at intake was

19.56 (SD = 14.25; ranging from 1 to 46), at discharge 13.00

(SD = 10.57; ranging from 1 to 30; prepost effects: t(1, 16) = 3.39;

p = .00+; d = .52). In total, n = 12 (71%) of the patients presented with

a reliable clinical change index on the BDI, according to Jacobson and

Truax (1991). Taken both outcome indexes together, n = 8 (47%) of the

patients presented with a reliable clinical change index.

Exploratory Pearson's correlation analyses revealed that change in

shame (between Sessions 25 and 36) correlated with intake measures

(BDI: r = −.41; p = .11; GSI: r = −.48; p = .05) and outcome (BDI change:

r = .45; p = .05; GSI change: r = .30; p = .24). Correlation analyses

revealed also that the frequency of self‐compassion after Minute 20

in Session 36 was linked with the interaction quality measured before

this minute mark (patient content: r = .66; p = .00+; patient process:

r = .22; p = .40; patient interactional manoeuvres: r = .33; p = .20; ther-

apist process‐guidance: r = .69; p = .02; therapist treatment of interac-

tional manoeuvres: r = −.55; p = .02; therapist treatment of schemes:

r = .85; p = .00+).

3.2 | The role of shame in psychotherapy for NPD

Contrary to our hypothesis (H1a; Table 1), we did not find a statistically

significant change in the frequency of shame, although there was a

small between‐session effect (d = .30), substantiating a small decrease

in shame over therapy. When linking the difference in shame between

Sessions 25 and 36 with intake predictors (H1b), we found the follow-

ing significant relationship: the greater the intake (general) symptom

load, the smaller the decrease in shame between Sessions 25 and 36

(F(1, 16) = 4.52; p = .049; 23% of variance of change in shame

explained; 18% adjusted). A similar effect was not found for the link

between the intensity of depression at intake and change in shame

(F(1, 16) = 2.90; p = .11; 17% of variance of change in shame explained;

12% adjusted).

3.3 | Quality of interaction's role in patient's self‐ compassion in Session 36

In accordance with the assumed centrality of self‐compassion in late

working phase sessions, we tested whether its in‐session frequency

was greater in Session 36, compared to Session 25, which it was not

(H2a; see Table 1).

For Session 36, we examined the role of the interaction quality

early in Session 36 (measured between minutes 10 and 20 into the

session) for the emergence of self‐compassionate stances in the

patient later in the same session (measured after the 20 min mark of

Session 36). The regression analysis showed in Table 2 (H2b) reveals

that patient contributions (i.e., content, process, and interactional

manoeuvers) explained 45% (29% adjusted) of the occurrence of self‐

compassion and that specific therapist contributions (i.e., process‐

TABLE 1 Comparison of in‐session frequencies of emotions and therapist and patient interaction style between Sessions 25 and 36 (N = 17)

Session 25 Session 36

M (SD) M (SD) t (1, 16) p d

Early expression of distress (CAMS)

Shame 5.47 (6.17) 3.94 (3.77) 0.92 .37 0.30

Primary adaptive emotion (CAMS)

Self‐compassion 0.35 (0.61) 0.53 (1.12) −0.51 .62 0.20

Total BIBS 3.45 (0.74) 2.91(0.77) 3.20 .06 0.72

Patient interaction 3.95(1.10) 3.18(1.10) 2.93 .13 0.70

Therapist interaction 2.95(0.74) 2.63(0.80) 1.69 .11 0.42

Note. BIBS = Bearbeitungs‐, Inhalts‐ Beziehungsskalen.

TABLE 2 Early in‐session process predictors of late in‐session pres- ence of self‐compassion (N = 17)

R2 B SE β t p‐value

Patient contributions .45 .04

Content .64 .23 .77 2.83

Process .00 .27 .00 0.00

Interact manoeuvers −.15 .29 −.18 −0.52

Therapist contributions .78 .00+ Process‐guidance .24 .15 .34 1.56 Treatment manoeuver .09 .29 .08 0.32 Treatment assumption .64 .34 .59 1.85

Note. All predictors measured on the Beziehungs‐ Inhalts‐ Bearbeitungsskalen between Minutes 10 and 20 of Session 36. Self‐com- passion measured on a 1‐minute basis using the Classification of Affec- tive‐Meaning States for this particular analysis only started at Minute 20 into Session 36.

Patient contribution corrected R2 = .29; therapist contribution corrected R2 = .51.

KRAMER U. ET AL. 277

guidance and treatment of assumptions) explained 78% (51% adjusted)

of the occurrence of self‐compassion later in the same therapy session.

Interestingly, the treatment of the patient's interactional manoeuvres

correlated negatively with the self‐compassion after Minute 20 (see

the preliminary Pearson's correlations).

3.4 | Prediction of outcome

The small decrease in shame between Sessions 25 and 36 predicted

decreases in depression over the entire psychotherapy (F(1,

16) = 1.56; p = .048) and explained 14% (9% adjusted) of the variance

of decrease in depression (BDI), as predicted by H3.

4 | CLINICAL ILLUSTRATION: “THE SKINNY HERRING”

The following sequence (2300336) illustrates the clarification of the

brittle sense of self (Minutes 8 to 15 of Session 36) in a male patient

with NPD, based on his saying “I am too skinny, like a herring”. (see

below discussion).

“T1: … it sounds like this is a really awful feeling … can you put

words to that? … what does it mean?

P1: yes.

T2: What would you say? what does the feeling tell you right now,

in this moment now …

P2: it's almost as if there's something that I absolutely don't want

to hear about me. And if I hear it then it bothers me a lot. It's

like a mix. It creates a heavy sense of pressure …

T3: mhm

P3: and then I get angry and irritated.

T4: Irritated and something heavy …. I also get the sense that there

is something that hits you, that bothers you in the heart of this.

P4: … yes it does…

T5: Can we look at what is it that hurts you about this …? stay with

that feeling right now, you're doing a good job [gentle process‐

guiding by therapist, focusing on the underlying pain]. What hurts

the most when someone comes up to you and says, “you are

too skinny, you are like a herring”

P5: It feels true.

T6: You think it is true, you think you are too thin …. Ok, you are

doing a good job [encouraging process‐guiding by therapist],

keep with that feeling for now. Try to ask yourself: ‘What does

it mean to me?: to be too skinny, to be like a herring’.

P6: [Pause] It's heavy, like being disabled. [emergence of unclear

negative self‐evaluation; see P10]

T7: it's heavy, like being disabled?

P7: mhm … it's heavy.

T8: I hear yes, this is a big source of suffering for you. What it is

about the impression that makes it so “heavy”, when you say

I am way too skinny? And also it's so heavy like being disabled

for you … what makes it so heavy?

P8: it's like I don't feel comfortable with it, it weighs on me, and I

can't accept it.

T9: Your sense is: it's very bad. To be skinny isn't good for you…?

P9: yeah, absolutely.

T10: what you think what makes it so difficult to be skinny? Why is

it so difficult for you?

P10: …. I just don't like it … it means something might be wrong with

me, with me as a person. [clear representation of negative self‐

evaluation; see P6]

T11: Almost like, it's some uncomfortable sense that I'm not nor-

mal... something is wrong with me. And everybody can see that

something might be wrong with me.

P11: Exactly, yes.

T12: and so there's this conviction, right?, by seeing me as too

skinny, it's obvious to everybody that I'm not “okay.”

P12: mhm …

T13: mhm … What would you say … what does it mean to you not to

be “okay?”, “not normal”? ....

P13: …. it's heavy, it's a lot of negative things … I have to just accept

it all, I have to accept everything, people laughing at me and

things like that.

T14: mhm so for you, there are lots of consequences to not being

normal, not being okay, you have to put up with a lot of stuff

… others laugh at you … maybe, then there's a feeling like,

“nobody really wants me”…? “Nobody really likes me”… try to

look into that feeling. What is it? What's it all about?

P14: mhm yeah, I am afraid of losing everything, of losing my friends

….

T15: mhm, I think it's good that you can really take a look at this.

This feeling that, “something is wrong with me,” and that it

comes with these negative consequences, like others laugh

at me, or no one likes me or, I'll lose my friends ….

P15: mhm

T16: … and all that is so horrible, you don't want those things ….

What's the most difficult of these consequences that you just

imagined?

P16: To be excluded from my own life, from my friends, that's the

most difficult, yeah.

T17: … not to be respected, not to be taken seriously … and then

always, again and again, to get the feeling that, something is

really wrong with me as a person.

P17: That's it. It always comes back and hits me in the face, yeah.

T18: So, now I kind of understand a bit better what it means when

you say, “I think I am too skinny,” ‐‐ It means a whole lot more

to you. It's actually a symbol of your feeling that you are not

okay. You look into the mirror and it confirms that something

is wrong with you, as a person.

P18. Yes, that's what always happens, and what makes it so heavy.”

5 | DISCUSSION

This exploratory study examined the role of emotional processing in

two working phase sessions of COP—one in early working phase and

one late working phase—in a small sample of patients diagnosed with

NPD. Whereas no significant between‐session changes were found,

the closer examination of the patient's experiential access of shame

278 KRAMER U. ET AL.

and self‐compassion revealed a specific pattern of results which should

be tested in larger samples.

5.1 | Working through shame may be a central task for patients with pathological narcissism

Clinical and empirical accounts underline the centrality of shame in

NPD (e.g., Lachmann, 2011; Lecours et al., 2013; Lewis, 1971; Morri-

son, 1983; Ogrodniczuk & Kealy, 2013; Ritter et al., 2014;

Ronningstam, 2016). This study is the first to specifically examine

shame in patients with NPD in the actual therapy hour. Even though

our study reported no significant changes in frequency of shame

between Sessions 25 and 36 in psychotherapy, its small decrease

(d = 0.30) was related with clinical features at intake. More symptoms

at intake tended to impede on the reduction of shame throughout the

working phase of psychotherapy. As reported by Sharp et al. (2015), a

general psychopathology factor may impede here on, or moderate, the

process of change, which was observed for several aspects of symp-

tom load in personality disorders. This result seems particularly inter-

esting in the light of the link with outcome: This small decrease in

shame in the working phase predicted 14% (9% adjusted) of the out-

come variance (on the BDI‐II) at the end of treatment. We may specu-

late that the access, awareness, exploration, deepening, and

completion of shame‐based emotions may be productive tasks in psy-

chotherapy for patients with NPD. These results may extend what was

called, from a psychodynamic perspective, “shame tolerance” in treat-

ments for NPD (Lecours et al., 2013; see also Lachmann, 2011),

although shame deepening and completion are additional patient tasks

related specifically to emotion transformation (Pascual‐Leone, 2009).

As shown by Kramer et al. (2016), the in‐session experiential access

of shame (in session 25 into the therapy process) may be fostered by

what was called process‐directivity, the subtle following and encourag-

ing guiding of the patient's attention towards his or her core issues

(Greenberg, 2015; Greenberg, Rice, & Elliott, 1993). In the transcript

excerpt, T5 and T6 are prototypical examples of the combination of

both gentle focusing on the core underlying “hurt” and encouraging

the patient that he is doing a “good job” in this task. More case studies

of this kind should combine the qualitative description of the process

in single cases with the standardized nomothetic assessment of change

(Kramer, 2017).

Implicit shame‐based self‐organizations may be linked with more

explicit negative self‐evaluations. In NPD, negative self‐evaluations

that are underpinned by shame‐based emotions may reflect the brittle

identity, such as “I am fundamentally unworthy,” “I am so unworthy

that I should disappear,” or “I am a flawed person.” As shown in a case

study (Kramer et al., 2014), the emergence in the focus of joint atten-

tion—and patient's emotional self‐awareness—of negative self‐evalua-

tion in the process of therapy can, again, be fostered by a process‐

guiding psychotherapist stance. In this study, T9, T10, and T11 are,

sequentially, therapist process‐guiding interventions that aim at foster-

ing the representation (in the patient) of new aspects of his negative

self‐evaluation. The emergence of representation of the latter in the

patient actually starts at P6 (with the rather imprecise “like being dis-

abled”) and becomes quite clear at P10 (with the mention “something

might be wrong with me, with me as a person”). Again, these observa-

tions should be tested in a controlled design.

5.2 | Self‐compassion: Knowing what is “good” for you

Self‐compassion is a transdiagnostic and therapy‐integrative feature of

a productive stance in psychotherapy, in particular as part of the reso-

lution of shame‐based emotions (Gilbert, 2011). There are several

operational definitions of self‐compassion, in one perspective, it is

based on a behavioural skills conception where generic “compassion

skills” can be taught to patients (Gilbert & Procter, 2006), in a different

definition, self‐compassion may be the result of an empathic process

with the shoring up the Self (Gehrie, 2011; Lachmann, 2011). In this

study, we defined self‐compassion as a dynamically emerging self‐

organization that implies an elaborated and highly idiosyncratic affec-

tive‐meaning state involving the individual's experiential awareness

of otherwise implicit core needs (Greenbeg & Iwakabe, 2011;

Greenberg, 2015).

This study did not find significant between‐session changes in the

raw frequency in self‐compassion: the actual frequency of self‐compas-

sion does not capture the transformative power of emotion in NPD.

Instead, our results suggest that the timing of patient's access to self‐

compassionate organization could be more critical. Both patients' and

therapists' interactional quality in the first part of the advanced work-

ing phase session—session 36—was linked with the patient's access to

a self‐compassionate stance in the second part of the same session. In

cases where the patient formulated clear and idiographically central

contents (i.e., insights with regard to his/her thoughts, emotions, and

interaction patterns), kept his or her attentional focus on these con-

tents, and refrained from attempts to interpersonally control or manip-

ulate the therapist, we may hypothesize that the patient could then

move forward and access more self‐compassion. In cases where the

therapist used high frequencies of process‐guidance (Greenberg

et al., 1993; Sachse & Elliott, 2002)—when the therapist constructively

and directly addressed the internal determinants of the interaction

manoeuvres, patients accessed more self‐compassion. It is interesting

that for Session 36, the therapist working with the problematic interac-

tional manoeuvres was related negatively with the emergence of self‐

compassion. This might be interpreted in terms of the stage model in

COP, suggesting that productive process in PDs, including the emer-

gence of self‐compassion, should be associated with a constructive

and deeply trustful therapeutic relationship where work on interaction

problems in the Here and Now may be overcome (see also

Ronningstam, 2016).

The observation that the therapeutic modification of internal

determinants of the interaction manoeuvers was linked with self‐com-

passion in an advanced working phase session was in line with our

hypotheses. In such advanced therapy sessions as part of the COP

model, the therapist may be advised to use a version of a two‐chair

dialogue, adapted to problems related with NPD, in order to increase

the internal distance between the Self and the problematic internal

aspects, and in order to bring about change related to the core internal

determinants. In particular, the clinical work with counter‐affects

(Sachse et al., 2011) may be important here, which is when clients

KRAMER U. ET AL. 279

counter the shameful NPD‐specific assumption by saying, for example,

“something might be wrong with me (…) as a person” (P10). Doing this

generally involves fostering self‐compassionate imageries or dialogues

between two components of the Self. It might also involve the emer-

gence of pride in what was actually accomplished and pride in oneself

as a person. For example, a patient with NPD may feel pride when say-

ing: “I realize now that that I have value, not only because I have

accomplished many things, but because I am who I am.” (This verbatim

example is from a male patient in Session 36 during the modification

phase of the clarification‐oriented work). More research is needed to

understand the role of access of pride in the therapeutic process of

NPD, which was not the focus of this study.

5.3 | Limitations and perspectives

This process‐outcome analysis focuses on a small sample of patients

with NPD, as such it is mandatory to consider it as exploratory at best.

The naturalistic design enables greater generalization but is also limited

by the absence of a control group, which would help to delineate ther-

apy‐specific processes from generic changes. The lack of comparison

patients with a non‐PD diagnosis would have been necessary to delin-

eate the role of shame and self‐compassion in NPD, as compared with

other diagnostic categories. It might also be interesting to retest the

same hypotheses on different subtypes of NPD, as described in con-

temporary accounts (Caligor et al., 2015). Most importantly, when

linking in‐session processes (i.e., interactions and patient's emotion

processing), we need to insist that we have to assume simultaneous

association—instead of causality. This is because it might have been

that the third variables (e.g., level of experiencing and therapeutic col-

laboration) or the emotion processing variable (i.e., self‐compassion) in

the very first minutes of the session influenced the therapist's choice

of intervention. Because of lack of power, we decided not to control

for this possible influence but insist that this type of control is neces-

sary in larger studies. Also, the influence of comorbid disorders, medi-

cation use, and sociodemographic level (i.e., education and intelligence)

was not possible in present design. Because certain therapies lasted

much longer than 40 sessions in the current sample, it might have been

interesting to analyze even later sessions, with the hypothesis that the

non‐significant change in shame and self‐compassion observed in this

study might become significant there. Outcome was measured pre‐

and post‐therapy, which prevented from controlling for early change

(i.e., symptom change prior to Session 25) which may have occurred

in the present sample. The secondary analysis of a previously analyzed

dataset may be prone to Type I error. Finally, it is unclear whether the

observed links are relevant for other therapy forms for NPD.

Despite these limitations, we can state that, to our knowledge, this

is the first psychotherapy research study which examines in‐session

shame and self‐compassion in a sample of patients with NPD and with-

out the often observed comorbid borderline personality disorder. As

such, it should be acknowledged that systematic research in this

domain is still lacking and more should be done in order to understand

treatment‐underlying mechanisms of change (Kramer, 2017;

Ogrodniczuk, 2013). This study has opened exploratory avenues to a

more differentiated picture of the role of patient in‐session emotional

processing, in relationship with therapist interventions, symptom

distress, and change. This study has focused on the analyses of two

sessions from the working phase, which implies an optimal design for

analyzing both within‐session and between‐session processes. Future

research should focus on the links between changes in shame and

self‐compassion in NPD, in order to determine possible mediator

effects in relation with final treatment outcome. The role of access

to pride in session may be a promising avenue. As such, we propose

a patient‐focused approach to psychotherapy research, which focuses

on the observation of patient‐related change mechanisms such as emo-

tional processing in the therapy session (Greenberg, 1999). Such

research designs assume that therapist interventions are facilitators

of these patients' in‐session processes who are assumed to function

as agents of change.

ACKNOWLEDGMENTS

Parts of this study were supported by the "Hamburger Preis

Persönlichkeitsstörungen 2016" of the Gesellschaft für Forschung

and Therapie von Persönlichkeitsstörungen (GePs), given to PD Dr.

Kramer.

ORCID

Ueli Kramer http://orcid.org/0000-0002-5603-0394

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How to cite this article: Kramer U, Pascual‐Leone A, Rohde

KB, Sachse R. The role of shame and self‐compassion in psy-

chotherapy for narcissistic personality disorder: An exploratory

study. Clin Psychol Psychother. 2018;25:272–282. https://doi.

org/10.1002/cpp.2160

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