John Ogrodniczuk

Pathological narcissism is a syndrome involving distorted self-image and identity dysregulation. Narcissistic pathology is associated with emotional and interpersonal difficulties, functional impairment, and mental disorder; such patients are seen frequently in mental health settings, and tend to be regarded by clinicians as having complex treatment issues. Despite a vast conceptual literature on pathological narcissism, empirical research regarding treatment is extremely limited. This study was designed to explore clinicians’ perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism. A Q-methodological approach was used to obtain detailed accounts of therapists’ opinions in a manner that would allow for systematic examination. Participants were 34 psychotherapists of various disciplines who responded to email and listserv postings of the recruitment notice. Participants reviewed three clinical vignettes portraying hypothetical patients suffering from grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q-set (PQS), a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. Analysis of therapists’ mean PQS responses using ANOVA found several differences in prospective interventions, according to the different psychopathologies featured in the vignettes. Principal components analysis with varimax rotation was conducted on all 102 Q-sorts and revealed four factors. Detailed descriptions of these ideal therapy processes were interpreted. The factors were also analyzed regarding their relationship to established therapy models. The first factor was endorsed across all three patient types, and represented an introspective, relationally-oriented therapy process. This factor was strongly correlated with established psychodynamic treatments. The second factor, most frequently endorsed for the panic disorder vignette, consisted of a cognitive and alliance-building approach that correlated strongly with expert-rated cognitive-behavioural therapy. The third and fourth factors involved therapy processes focused on the challenging interpersonal behaviours associated with narcissistic vulnerability and grandiosity, respectively, and were endorsed for vignettes presenting these narcissistic subtypes. These factors had fewer and smaller correlations with established treatments. The findings are discussed with respect to implications for the study and treatment of pathological narcissism.

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