Transference-Focused Psychotherapy for Narcissistic Personality Disorder: An Object Relations Approach

Abstract

Transference-focused psychotherapy (TFP) is an empirically validated psychodynamic psychotherapy for borderline personality disorder (BPD), based on object relations theory, that has clinical utility for individuals with narcissistic personality disorder (NPD). Given the effectiveness of TFP for patients with BPD, including a number of patients with comorbid NPD, we have adapted the tactics and techniques of TFP with specific modifications for patients with NPD or narcissistic traits. TFP for NPD (TFP-N) retains core elements of the treatment, including a contracting phase and an interpretive process designed to identify and modify maladaptive mental representations of self and others that underlie the affect and behavioral dysregulation in those with personality disorders including NPD. The major goal of TFP-N is the focus on disturbed interpersonal patterns of relating in the here-and-now of the therapeutic interaction as a vehicle to effect enduring changes in personality organization and real-world changes in the areas of love and work.

Pathological narcissism: An analysis of interpersonal dysfunction within intimate relationships

“…Regarding the treatment of individuals with pathological narcissism, interventions to promote interpersonal safety may involve the creation of a ‘treatment contract’. The treatment contract establishes clear expectations and consequences that inform treatment progression, such as those described in transference focused psychotherapy (Caligor et al, 2018), which has specific modifications for the treatment of pathological narcissism (Diamond et al, 2021; Diamond & Hersh, 2020; Stern et al, 2017). For instance, a treatment contract may include the fact that treatment progression is contingent on the client not acting out violent urges against intimate partners, or even the therapist, and rather treatment would involve exploring these impulses in therapy in a safe way, with specific consequences (e.g., contacting authorities, therapy termination) if the contract is significantly or repeatedly violated.…”

Treatment principles for pathological narcissism and narcissistic personality disorder.

“…In light of the above-described aspects of psychopathology, to be successful, therapy should aim at: a) increasing self-reflection and reducing intellectualizing; b) reducing the impact of maladaptive schemas and forming healthier and more flexible ideas about self and others; c) supporting agency; d) counteracting maladaptive coping and promoting healthier ways of dealing with suffering; e) promoting theory of mind and empathy. These goals can be reached by different avenues, including: working through the therapy relationship-for example, psychodynamic therapies (Kohut, 1971;Kernberg, 1975), Mentalization Based Treatment (Drozek & Unruh, 2020), Transference Focused Therapy (Diamond & Hersh, 2020), Metacognitive Interpersonal Therapy (Dimaggio et al, 2020), agreeing upon a therapy contract (Diamond & Hersh, 2020), focusing on affects instead of accepting intellectualizing, and using behavioral experiments and experiential techniques (CBT, Schema Therapy, DBT, Metacognitive Interpersonal Therapy). This proposal for an integrated treatment is built around a model of PN; I will therefore organize the treatment section by aspects of psychopathology and describe how different instruments, for example, working through therapy relationships and assigning behavioral experiments, can tackle any specific aspect.…”

“…As noted by Yakeley (2018) and Weinberg and Ronningstam (2020), some approaches have been tailored or adapted to PN and offer promises of effectiveness. These include psychoanalytic psychotherapy (Kernberg, 1975; Kohut, 1971; Ronningstam & Maltsberger, 2007), Mentalization Based Treatment (Drozek & Unruh, 2020), Transference Focused Therapy (Diamond & Hersh, 2020), CBT (Beck et al, 2015), Schema-Therapy (Young et al, 2003), Metacognitive Interpersonal Therapy (Dimaggio & Attinà, 2012), and dialectical behavior therapy (Reed-Knight & Fisher, 2011), and another approach adapted to treating PN is Clarification Oriented Psychotherapy (COP; Sachse, 2020). The problem is that as of today, not a single one has been tested in a randomized controlled trial (Ronningstam, 2019; Weinberg & Ronningstam, 2020).…”

Effectiveness of Transference-focused Psychotherapy and Acceptance and Commitment Therapy in Promoting the Mental Health and Psychological Capital of Staff Working in Hospitals Covered by Social Security in Tehran Province

“…The effectiveness of TFP was demonstrated in reducing disturbance symptoms, although the rate of withdrawal and its effect size were higher and lower than those of the schema therapy, respectively. In another study, although TFP, dialectical behavioral therapy, and supportive psychotherapy were effective in reducing depression and anxiety and improving overall performance, adaptability to stressful conditions, and resilience (symptom changes), it was only the TFP that always significantly reduced aggression and personality (structural changes) in the form of maintaining increased attachment after one year of treatment (Diamond & Hersh, 2020).…”