The Many Complexities in Treating and Studying Narcissism

Abstract

In this commentary I examine conceptual and methodological issues in Dr. Riordan's (2012) presentation of three cases treated using Mitchell's integrative model that combines aspects of Kernberg and Kohut's technical stances in the treatment of narcissism. Riordan proposes that Mitchell's integrative model provides a useful blend of Kernberg's focus on defense and Kohut's focus on empathy. He then provides case material to illustrate the benefits of Mitchell's model. In discussing Riordan's paper, I focus on approaches to the case study method and present technical advances in Kernberg's approach that I believe address the concerns articulated by Riordan. These issues are examined in the current context of evidence-based practice.

The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example

“…Rather than privileging RCTs or naturalistic designs, Levy (Levy, 2012;Levy & Scott, 2007) has argued for a pluralistic approach toward levels of evidence. RCTs are very valuable, in some ways clearly a gold standard, but in some ways confounded, as such they are in no way the lone standard.…”

A Personal Perspective on the Treatment of Three Cases of Narcissistic Vulnerability

“…In contrast to McWilliams, Levy (2012) focuses on conceptual and methodological issues in the design of my case studies and presents technical advances in Kernberg's approach that are designed to meet the concerns that I raised about this model. I welcome Levy's thorough and wide-reaching comments concerning the design of my project and the ways in which such designs could be improved in the future.…”

“…In commenting on my article, Nancy McWilliams (2012) and Kenneth Levy (2012) take different but complementary perspectives in critically evaluating the nature and implications of my work. Below I briefly comment on each commentary and then present some observations to expand the reader's understanding of what I individually brought to the treatment of Alex, Brian, and Candace.…”

Clinical Characteristics of Comorbid Narcissistic Personality Disorder in Patients With Borderline Personality Disorder

“…The comorbidity of narcissistic and borderline pathology has been shown clinically and empirically to be a complicating factor for both an accurate diagnosis and psychotherapy (Diamond & Yeomans, 2008;Ellison et al, 2013;Kernberg, 1984;Levy, 2012). Indeed, clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population poses specific clinical challenges and may be among the more difficult to treat within the personality disorder spectrum (Kernberg, 2007;Stone, 1990).…”

“…Some speculations have been made that the vulnerable narcissistic type is more likely to characterize NPD/BPD patients, since in some presentations narcissism appears to be associated with measures of psychopathology (e.g., neuroticism) and service utilization (Ellison et al, 2013;Pincus et al, 2009;Rathvon & Holmstrom, 1996), and in other positions, it seems most associated with measures of distress (Levy, 2012). These investigations have dovetailed with clinical observations that the dimensions of vulnerability and grandiosity may actually represent not distinct categories or subtypes of NPD, but phenotypic expressions that may provide indices of the level of severity of narcissistic disorders.…”