CLINICAL PRACTICE AND SUMMARY
Treatment of Alec illustrated that change is possible in treatment of patients suffering from pathological narcissism. His treatment was structured around Dos and Don’ts treatment principles that promoted change (Weinberg & Ronningstam, 2020). His treatment goals included improvement of first his academic and then his professional functioning and romantic life. The stance of validation and curiosity invited him to explore his inner world, his capabilities, and difficulties. The treatment addressed attachment patterns of avoidance and introduced the new experience of helpful reliance on others. Attention to life events, such as navigation of work challenges and a new romantic relationship, invited further opportunities for growth. The awareness of my own reactions to Alec promoted constructive relatedness and flexibility. Following these treatment principles also allowed a measure of flexibility, such as deciding to continue treatment despite Alec’s difficulty in following the recommendation to find a job. In doing so, the treatment took a strategic risk to follow the lead of the patient and his life context rather than following a “one size fits all” approach.
Such flexibility was especially important in other aspects of Alec’s treatment. His treatment had to navigate a constantly changing balance between the processes occurring within therapy, his challenges and capabilities, and life-events. Sometimes, processes in therapy, such as working through his childhood experiences, allowed him greater openness and capacity to learn, which led him to embark on his own career. At other times, life experiences, such as a new romantic relationship, invited him to accept imperfections and adopt a problem-solving, pragmatic attitude. His ability to engage in treatment and life grew as a result of his life experiences (e.g., a new partner) as well as his experiences in treatment (e.g., processing fears that others are not available to him when he needs them). Such an interaction between life and therapy is not uncommon in processes of change in people with pathological narcissism (Ronningstam & Weinberg, 2023) and it is one of the reasons that the process of change in patients with pathological narcissism takes a long time (Weinberg & Ronningstam, 2022).
Treatment principles, not theories, are close to what guides individual clinicians in conducting psychotherapy (Castonguay et al., 2019), including with patients suffering from pathological narcissism (Kealy et al., 2017). The Dos and Don’ts treatment principles are friendly to most if not all theoretical approaches and, therefore, can be incorporated into practices of clinicians from all theoretical orientations. Thus, it invites appreciation of the complexity of individual patients and avoids a “one size fits all” approach. They are relativelyeasy to learn , as opposed to theory-based approaches that require mastery of theory and lengthy supervision to ensure adherence in treatment. Finally, the Dos and Don’ts treatment principles have the advantage of clinical flexibility (Castonguay et al., 2019), which what is required of the clinician working with complex and fluidly changing clinical presentations – such as patients with pathological narcissism (Weinberg & Ronningstam, 2022). Finally, this approach is suitable for patients that might not be meeting treatability criteria of other approaches (e.g., not following through with the job recommendation). Accordingly, an individual patient suffering from pathological narcissism might be first evaluated for fit for any of the established approaches, such as TFP, MBT or MIT, and referred. Those patients that do not meet the treatability criteria, or do not improve in those approaches, can be referred to the Do’s and Don’ts principle-based approach.