Testing and treatment-by-attitude in psychotherapy for pathological narcissism: A clinical illustration

Pathological narcissism is a personality constellation comprising distorted self-image, maladaptive self-esteem regulation, and difficulties in intimate relationships. Patients with elevated pathological narcissism may not necessarily meet criteria for narcissistic personality disorder, and may seek treatment for a range of mental health concerns across various clinical settings. An understanding of key principles of control-mastery theory (CMT) can help clinicians understand the specific goals and challenges of the individual patient with pathological narcissism, and can illuminate ways in which the patient may work in psychotherapy. This paper outlines how patients with pathological narcissism may engage in testing of their pathogenic beliefs, and how therapists can respond in ways that facilitate the patient's sense of safety and foster psychological work. The role of the therapist's attitude is highlighted as a means for countering pathogenic beliefs associated with pathological narcissism. Clinical material from a single case of time-limited supportive psychotherapy will be used to illustrate these principles and associated therapeutic processes. Insights from CMT regarding pathogenic beliefs and the patient's plan for addressing them can help to explain how therapy works or does not work for patients with pathological narcissism.