Despite the expression of ‘a narcissist’ being prevalent in the cultural lexicon, often thrown around in the media, online, at ex’s and even friends, relatively little is known about the condition in terms of treatment and research. Pathological narcissism is more (or less!) common than you might expect, estimated to affect around 6% of the population over the life-course (Stinson et al., 2008). It is characterised by two distinct types: the archetypal grandiose kind we associate with the disorder, encompassing a sense of entitlement, lack of empathy and arrogance; and the lesser-known vulnerable narcissism, typified by conditional self-esteem, hypersensitivity and insecurity (Drozek and Unruh, 2020). It is a serious and debilitating condition associated with instability, substance abuse, violence and suicidal tendencies.
Yet, there are currently no effective treatment guidelines for pathological narcissism, with no randomised controlled trials that test the effectiveness of treatments, completed to date (Dimaggio et al., 2008). Further, the psychotherapy literature is limited to case reviews and evaluations of clinical reports, creating a real problem for clinicians treating these patients. Thus, there is a pressing need for an investigation into promising treatments. Drozek and Unruh (2020), propose the use of mentalisation-based treatment (MBT), which works to strengthen patients’ capabilities to understand their thoughts, feelings and beliefs, and is used to treat related conditions such as borderline personality disorder (BPD), as a worthwhile treatment for pathological narcissism.
In the paper, the authors create a developmental model of pathological narcissism based upon Bateman and Fonagy’s (2016) theory of personality disorders, conceptualising it as an impairment in mentalising; the ability to make sense of the mental states of ourselves and others. They suggest that similar to BPD, narcissism develops when caregivers do not sufficiently validate a child’s emotions. In this case, the caregiver does not mirror the child’s internal feelings, due to abuse, neglect or conversely parental overvaluation; thinking their child is more entitled than other children. This leads to the child feeling empty and the development of the narcissistic alien self. Narcissism is outlined as a combination of factors:
- Insecure attachment related to lack of mentalisation
- Lack of ability to mentalise their own and other’s emotional states
- Narcissistic self-enhancement through the alien self.
This theory is supported by research into parenting styles and narcissism (Capron, 2004). Thus, the authors propose mentalisation-based treatment (MBT) as a worthwhile treatment to explore.
The authors suggest that the purpose of mentalisation-based treatment (MBT) for narcissism is to increase mentalisation through reflection and curiosity about experiences in oneself and others (Bateman & Fonagy, 2016). They suggest the following:
Foundational MBT interventions
Empathy and validation
Patients need to feel like the therapist sees them as a person, through marked (refers to the patient’s mind, not the therapist’s), contingent (the patient’s experience of what they are feeling) and supportive validation of the patient’s experience. In the clinical example, the therapist empathetically validates the patient’s insecurities and anxieties, allowing the patient to further reflect on her emotional states.
As patient’s descriptions of events is often limited to experiences of anger, entitlement and separateness from others, asking them for more details about a situation can give the therapist a better understanding of what is triggering the patient emotionally. They can then make the patient aware of this, enabling them to be more in touch with and reflective about their emotions. In the clinical example, this allows the patient to share her feelings of humiliation and shame when in touch with her insecurities.
The therapist directly asks about how a situation affects the patient’s sense of identity and self-esteem. Narcissistic patients are often unable to reflect on their emotional responses. However, by probing patients about why certain situations upset their sense of self, the patient can become more aware of this in the future. Additionally, questioning them about vulnerable emotional states such as sadness and about what other’s may be thinking, helps to broaden their range of emotional states. In the clinical example, this allows the patient to explore her feelings and enables greater flexibility in her thinking.
Specific MBT interventions for narcissism
Throughout the process of a patient becoming more emotionally aware, moments will occur where the patient’s thinking is rigid, disconnected and externally focused. When this happens, MBT recommends the therapist validate the patient’s present state of mind and ask them to elaborate. The therapist should also share their viewpoint, not to change the patient’s view, but so they can compare it to their own temporarily making them reflective of other perspectives. It is also recommended the therapist praise the patient to reinforce positive mentalising and position themselves in a non-expert position, relying on inquisitiveness to allow for reflection.
The authors conclude that MBT is a much-needed treatment for pathological narcissism. They outline narcissism as an impairment in mentalisation and suggest that MBT allows narcissistic patients to feel understood by the therapist. MBT is suited to their vulnerabilities as the therapist positions themselves as ‘lower’ than the patient so does not trigger a power struggle as other forms of therapy, such as Cognitive Behavioural Therapy (CBT) may. They suggest that MBT is effective in treating narcissistic patients’ specific problems, is easy to learn and a less costly treatment than other forms of therapy for ‘personality disorders’.
Strengths and limitations
- The paper offers a very detailed explanation of MBT techniques and how they can be adapted specifically for pathological narcissism. The authors thoroughly examine the impairments in mentalisation that narcissistic patients may have and give specific examples of how a therapist may address them. This gives a really clear picture of how MBT can be used as an effective treatment.
- As the author’s highlight, MBT positions the therapist as ‘not-knowing’ and encourages them to accept responsibility and validate the patient’s feelings, unlike other forms of therapy where the therapist attempts to ‘knowingly’ describe the internal processes of a patient. Given the vulnerabilities of narcissists and their fragile self-esteem (Choi-Kain, 2020), it is evident MBT would be a more effective treatment than other forms of therapy such as CBT.
- The two types of pathological narcissism, vulnerable and grandiose, are markedly different both in terms of how they develop and how they are expressed in an individual (Horton, 2011). Therefore, it is difficult to say if they will both respond to MBT in the same way. The paper cites only one clinical example of a vulnerable narcissist responding to treatment positively and able to explore mentalisation patterns, a grandiose narcissist may not be so willing to open up or attend therapy in the first place.
- The paper has a limited case study of one patient for which MBT has seemed to be effective. However, it is not evidenced by any reliable measures or data that the patient has actually made an improvement. Also, much of the paper is based on speculation about how a patient could react to MBT and the therapist’s probing to become more self-reflective. There is no telling if this would be the case. Further, only one type of narcissism has been explored and with a limited sample, so it is impossible to tell the effectiveness of MBT on a large scale from this paper.
This paper opens up a discourse about how MBT could be used in the treatment of narcissism, a condition which is currently poorly understood. MBT can be seen to address some of the difficulties therapists face when dealing with narcissistic patients and the paper provides a strong argument for its potential. Other studies also support the use of MBT as an effective treatment for similar disorders like BPD and comorbid BPD and narcissism (Choi-Kain, 2020). However, since this study only uses one case study as an example, further research using a larger sample of patients with pathological narcissism should be carried out to determine the effectiveness of MBT. Additionally, future studies should also explore the long-term effects of using MBT as a treatment for pathological narcissism and use quantifiable measures to determine its success in more concrete ways. The paper emphasises the relative ease and cost of training therapists in MBT, indicating the potential for widespread application of the therapy for narcissism if further research evidences its safety and efficacy.
The techniques explored in the paper, such as the therapist ‘not-knowing’ and validating the patient’s experience, are useful practices to implement. As the authors set out, by using these techniques, patients are less likely to feel threatened by the therapist and drop out (Choi-Kain, 2020). I can see how using these methods may be much more helpful and less threatening to patients, even perhaps for those experiencing depression, which is often co-morbid with narcissism. In my own clinical experience, I have found that patients often feel nervous about seeing a therapist and may see them as an intimidating figure. By positioning themselves in this way, those anxieties are largely eased by the therapist, which particularly for narcissism, I imagine could be beneficial for those with the disorder.
Conflicts of interest
King’s MSc in Mental Health Studies
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Drozek R, Unruh B (2020). Mentalization-Based Treatment for Pathological Narcissism. Journal of Personality Disorders. 2020; 34:177-203.
Bateman A, Fonagy P (2016). Mentalization- based treatment for personality disorders: A practical guide. Oxford, UK: Oxford University Press.
Capron E (2004). Types of pampering and the narcissistic personality trait. Journal of Individual Psychology. 2004; 60:76–93.
Choi-Kain L (2020). Narcissistic personality disorder: a coming of age. Journal of Personality Disorders 2020; 34: 210-213.
DiMaggio G, Nicolo G, Fiore D, Centenero E, Semerari A, Carcione A, & Pedone R (2008). States of minds in narcissistic personality disorder: Three psychotherapies analyzed using the grid of problematic states. Psychotherapy Research. 2008;18:466–480.
Horton R (2011). Parenting as a cause of narcissism: Empirical support for psychodynamic and social learning theories. The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments. Hoboken, NJ: John Wiley & Sons.
Stinson F (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2008; 69:1033–1045.
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