Therapists’ perspectives on optimal treatment for pathological narcissism.

Abstract

This study used Q methodology to explore clinicians' perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism, a syndrome of impaired self-regulation. Participants were 34 psychotherapists of various disciplines and theoretical orientations who reviewed 3 clinical vignettes portraying hypothetical cases of grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q set, a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. By-person principal components analysis with varimax rotation was conducted on all 102 Q-sorts, revealing 4 components representing clinicians' perspectives on ideal therapy processes for narcissistic and non-narcissistic patients. These perspectives were then analyzed regarding their relationship to established therapy models. The first component represented an introspective, relationally oriented therapy process and was strongly correlated with established psychodynamic treatments. The second component, most frequently endorsed for the panic disorder vignette, consisted of a cognitive and alliance-building approach that correlated strongly with expert-rated cognitive-behavioral therapy. The third and fourth components involved therapy processes focused on the challenging interpersonal behaviors associated with narcissistic vulnerability and grandiosity, respectively. The perspectives on therapy processes that emerged in this study reflect different points of emphasis in the treatment of pathological narcissism, and may serve as prototypes of therapist-generated approaches to patients suffering from this issue. The findings suggest several areas for further empirical inquiry regarding psychotherapy with this population.

Grandiose and Vulnerable Narcissism in Borderline Personality Disorder

“…This might in part contribute to the biased higher prevalence of females with BPD in clinical populations, which does not reflect the balanced gender distribution in epidemiological cohorts [66]. Further, our results underline that the high frequency of narcissistic pathologies seen in clinical practice does not correspond to the low prevalence of diagnosed NPD [22, 67]. Fully identifying vulnerable narcissism in a diagnostic assessment might be crucial due to its inherent induction of fragile self-states.…”

“…Uncovering pathological narcissism and differentiating between vulnerable and grandiose traits has been described as crucial for psychotherapy [67]. Depression, anxiety, and suicidality appear distinct in vulnerable and grandiose narcissism [37].…”

Clinical decision‐making and intuition: A task analysis of 44 experienced counsellors

“…Qualitative findings from a stratified sample of counsellors concluded that as counsellors move through developmental stages over time, they rely more on external expertise (notable theoreticians, supervisors or counselling models) in the earlier stages of their development and more on an internalised expertise or accumulated wisdom during the later stages of their development (Skovholt & Rønnestad, ). As a recent example of this phenomenon, a similarly constructed Q‐Methodology study (see Kealy et al., ) examined how psychotherapists viewed the effective treatment for narcissistic personality disorder. The researchers found that experience (a) was negatively correlated with adherence to established theory for treating narcissism (CBT and DBT) and (b) was nonsignificantly associated with other treatment theories (psychodynamic and interpersonal), thus suggesting that more experienced psychotherapists were less likely to adhere to an established theory.…”

“…Q-Methodology therefore allows the researcher to study the responses of participants to a particular stimulus and develop an explanation for why participants responded in the manner they did (Watts & Stenner, 2012). Q-Methodology has a successful track-record in psychological inquiry, including studies of counsellors' perception of gender norms (Trepal, Wester & Shuler, 2008), professional and family caregivers' beliefs and perceptions of sex education for the mentally disabled (Brown & Pirtle, 2008), how women view the use of female body types in advertising (Gustafson, Hanley & Popovich, 2008), young adults' views towards healthy lifestyles after receiving a renal graft transplant (Tielen, van Staa, Jedeloo, van Exel & Weimar, 2008), the therapeutic factors of group counselling (Yalom & Leszcz, 2005) and how expert psychotherapists view effective treatment for narcissism (Kealy, Goodman, Rasmussen, Weideman & Ogrodniczuk, 2015). Therefore, Q-Methodology was an ideal strategy to create a context for eliciting and analysing clinical decision-making.…”

Psychotherapists' ideals in the treatment of panic disorder: An exploratory study

“… Part of a larger project investigating clinicians' therapy process ideals (Kealy, Goodman, Rasmussen, Weideman & Ogrodniczuk, ). …”