Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder

Abstract

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self‐image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self‐reflection and foster change in patients with PD.

Between‐session homework and processes of change

“…); In-session practice (e.g., in-vivo, visualization) to help therapists assess clients' understanding of the BSH (rationale); writing down BSH or using a portfolio; use of skills card as a reminder of key BSH features; identifying potential negative and unhelpful beliefs and practical and emotional barriers to engaging with BSH; and confidence-ratings related to specific homeworktask. There are always different levels of specificity, and a somewhat more nondirective approach was also proposed (Magistrale et al, 2023), and the case studies also demonstrate how client engagement with BSH may be assessed in a structured fashion (as within CBT and EFT) or a somewhat more informal way (Magistrale et al, 2023;Warwar, 2023). Also, there was substantial agreement among authors that BSH should not only evaluated according to the amount (quantity) of BSH completed, but also the quality (what was learned?)…”

“…For example, lack of engagement could be due to limited socialization to the treatment model and frustration, especially in the early phase of treatment (e.g., Hammersmark et al, 2023;Murphy et al, 2023), which highlight the need to have a continuous emphasis on the rationale for the treatment and BSH specifically (Callan et al, 2019). Emotional barriers, such as worry and distress (Hammersmark et al, 2023;Magistrale et al, 2023;Warwar, 2023), or difficulties with identifying emotions and anxiety levels (Church et al, 2023) were other potential barriers. Again, authors recommended devoting sufficient time to ensure that clients had understood the rational underlying a specific BSH, by asking for feedback, in-session practice, discussing potential barriers and difficulties to BSH, and writing down specific tasks and rationale.…”

“…Some authors commented on the interplay between techniques and the therapeutic relationship. Magistrale et al (2023), for example, noted how BSH may sometimes evoke strong submissive-or rebelling behaviors in clients, that may be related to needs for dominance or attachment in the context of giving and receiving help and care (Safran & Muran, 2000), and suggested exploring clients' reactions to the use of BSH when challenges arise. Warwar (2023), on the other hand, noted how the therapeutic relationship always has priority over the achievement of specific therapeutic task (e.g., BSH), consistent with the notion that the therapeutic relationship is a facilitative curative factor within humanistic-experiential approaches.…”

“…Specifically, all authors noted how BSH may help clients (1) build awareness or insight (a stance of curiosity toward inner mental life; new perspective on thoughts and though processes, etc.) through specific task such as psychoeducation and sharing of rationale (Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;Wachen, 2023;Warwar, 2023), writing about unresolved feelings toward a significant other (Warwar, 2023), writing an impact statement (Wachen, 2023), using work-/task sheets (McEvoy et al, 2023;Murphy et al, 2023;Wachen, 2023), experimenting with new behaviors (e.g., Magistrale et al, 2023), or experiential tasks (e.g., Hammersmark et al, 2023); as well as (2) change behaviors by extending in-session work and (new) behaviors into clients' daily lives through the practice of new skills (e.g., exposure, activity scheduling, trying out new ways of relating, thought worksheet, etc. ; Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;.…”

“…Finally, Magistrale et al (2023) presented a case exploring the use of BSH within relational psychoanalysis (RP), with a male client presenting with narcissistic personality disorder (PD). The authors note the long-standing "resistance" toward adopting more directive and behavioral interventions in psychoanalysis, but argue for the need to invite clients to experiment with new ways of relating as part of BSH when treating PDs.…”