What do we need in order to successfully treat persons with pathological narcissism? How does change happen? Treatment principles and mechanisms of change emerging from single cases treated by experts: A commentary
Abstract
Persons with pathological narcissism (PN) or narcissistic personality disorder present with a wide array of symptoms and social problems. They need effective psychotherapies but empirical evidence for what works with them is mostly lacking. In this issue of the Journal and Clinical Psychology: In Session four authors from different orientations described single cases of patients suffering from different manifestations of PN. In this commentary we reviewed in detail the four cases and tried to distill (a) the treatment principles adopted; (b) the actual mechanisms of therapeutic change. We hope that the list of principles and mechanisms and change we identified here can help both clinicians and researchers develop and test effective options for persons with PN who are difficult to treat but do have chances to change in a meaningful way in treatment.
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Narcissistic patients frequently engage in power struggles, assuming dominance and superiority and externalizing blame, to protect self-image and ward off insecurities.
“To protect their self-image and ward off underlying insecurities, narcissistic patients frequently engage in power struggles, assuming a position of dominance and superiority and resorting to the externalization of blame (145, 154).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [154]
Patients with PN frequently misinterpret therapist interventions, perceiving constructive feedback as criticism, leading to oppositional reactions or emotional withdrawal.
“Patients with PN frequently misinterpret therapist interventions, often perceiving constructive feedback as criticism, leading to oppositional reactions or emotional withdrawal (70, 128, 154).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [154]
Narcissistic patients often seek admiration that becomes expectation, idealize the therapist then devalue them when validation goes unmet, and treat the therapist as a passive sounding board, undermining mutuality.
“These dynamics often materialize with narcissistic patients seeking admiration that quickly becomes expectation, idealizing the therapist only to later devalue them when their need for validation goes unmet, and treating the therapist as a passive sounding board, undermining any sense of mutuality (70, 71, 154).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [154]
Transference-countertransference dynamics are central to the treatment of PN.
“Therapists must stay attuned to the transference-countertransference dynamics that are central to treatment of PN (70, 128, 154).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [154]
Therapeutic ruptures and transference dynamics are common challenges in treating PN and can significantly impact engagement in MDMA-AT.
“Therapeutic ruptures and transference dynamics are common challenges in treating PN and can significantly impact engagement in MDMA-AT.”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [154]
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- Authors
- Dimaggio, G., & Weinberg, I.
- Affiliations
- Centro di Terapia Metacognitiva Interpersonale (IT)
- McLean Hospital (US)
- Corresponding author
- Dimaggio, Giancarlo
- Venue
- Journal of Clinical Psychology
- Publisher
- Wiley
- Published
- 2024-02-03
- Volume
- 80
- Issue
- 5
- Pages
- 1079-1097
- ISSN
- 0021-9762 (ISSN-L)
- 1097-4679
- OpenAlex
- W4391507863
- Cited by
- 4
- References
- 26
- Citations by year
- 2026: 2 · 2025: 2
- FWCI
- 2.01
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- Journal of Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
- Keywords
- pathological narcissism, narcissistic personality disorder, psychotherapy, mechanisms of change, treatment principles, single case study, difficult-to-treat patients, therapeutic change
- MeSH terms
- Narcissistic Personality Disorder, Anxiety, Humans, Narcissism, Personality Disorders, Psychotherapy
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