The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study

Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy

Change in treatment of narcissistic personality disorder (NPD) has been considered difficult to attain. Aspects of narcissistic pathology, including interpersonal enhancement, avoidance, aggressivity, and control, have contributed to challenges in forming a therapeutic alliance and pursuing treatment towards attainable goals for change and remission. This study, based on a qualitative review of therapists' case reports of individual psychotherapy with eight patients diagnosed with NPD, is the first to identify and explore patterns, processes, and indicators of change in pathological narcissism. All patients showed significant improvement in personality and life functioning, including engagement in work or education and long-term close relationships, with remission of the NPD diagnosis. The process of change was gradual, with some noticeable changes occurring in specific life contexts. Additional factors indicating and contributing to change included patients' motivation and commitment to psychotherapy, reflective ability, emotion regulation, sense of agency, and interpersonal and social engagement.

Childhood emotional neglect and depressive and anxiety symptoms among mental health outpatients: the mediating roles of narcissistic vulnerability and shame

BACKGROUND

Theorized to stem from experiences of childhood emotional neglect, narcissistic vulnerability has been identified as contributing to expressions of psychiatric distress such as depressive and anxiety symptoms, particularly due to shame-proneness.

AIMS

To investigate narcissistic vulnerability and shame as mediators between perceived childhood emotional neglect and depressive and generalized anxiety symptoms among psychiatric outpatients.

METHODS

Adults (N = 137) attending community mental health services completed self-report measures at intake. Mediation analyses tested the indirect effect of perceived emotional neglect on depressive and generalized anxiety symptom severity through narcissistic vulnerability; shame was added to subsequent models to examine narcissistic vulnerability and shame as sequential mediators.

RESULTS

Perceived emotional neglect was significantly associated with narcissistic vulnerability, which in turn was linked with depressive and generalized anxiety symptoms as separate dependent variables. Indirect effects were significant in each model, indicating narcissistic vulnerability as a significant mediator. With the inclusion of shame, narcissistic vulnerability and shame were significant as sequential mediators.

CONCLUSION

Narcissistic vulnerability and shame may operate as mechanisms in conferring affective symptom severity from perceived childhood emotional neglect. Narcissistic vulnerability and susceptibility to shame may thus be important treatment targets when addressing psychological distress in the context of childhood adversity.

Change processes in psychotherapy for patients presenting with histrionic personality disorder

OBJECTIVE

Histrionic personality disorder (HPD) with a lifetime prevalence rate of 1.8% is an under-researched psychiatric diagnosis. The present study therefore aimed to investigate both the processes and outcomes of psychotherapy for HPD in a non-controlled study.

METHODS

A total of 159 patients diagnosed with HPD were recruited and received clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video-recorded and analysed using the Process-Content-Relationship Scale. Therapy outcome was assessed with symptom measures at intake and discharge. Hierarchical linear modelling was applied to estimate the changes in the psychotherapeutic outcome and associations with patient and therapist process developments.

RESULTS

Improvements in relationship processes of patients and therapists were systematically related to outcome while only partial relationships were found on the levels of process and content.

CONCLUSION

The present study represents the first systematic insight into core changes in patients with HPD undergoing psychotherapy.

Diabetes-related shame among people with type 2 diabetes: an internet-based cross-sectional study

INTRODUCTION

Emerging evidence suggests that diabetes stigma and negative emotions associated with it may impair the quality of life of people with diabetes. Among these psychological distresses, shame is considered the most distressing of all human emotional experiences and may be a condition to which diabetes clinicians should pay attention. This epidemiological study focused on diabetes-related shame and aimed to determine the prevalence of diabetes-related shame, its factors, and its association with psychological indicators.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey was conducted among people with type 2 diabetes preregistered with a research firm. The questionnaire included experience of diabetes-related shame and demographic data such as age, clinical characteristic measures such as hemoglobin A1c (HbA1c), and psychological indicators, including the WHO Five Well-Being Index (WHO-5) and Problem Areas In Diabetes-5 (PAID-5). Differences in each indicator between people with diabetes who experienced shame and those who did not were analyzed with the unpaired t-test. As supplemental analysis, binomial logistic regression analysis was used to identify factors associated with the prevalence of diabetes-related shame.

RESULTS

Of the 510 participants, 32.9% experienced diabetes-related shame and 17.5% concealed their disease from colleagues or friends. Those who had experienced diabetes-related shame showed significantly lower WHO-5 and higher PAID-5 scores (p<0.001). However, no significant difference was found in HbA1c (p=0.36). Binomial logistic regression revealed that women, young adults, those without a college degree, those with low self-efficacy, and those with a strong sense of financial burden or external pressure were at higher risk of experiencing diabetes-related shame.

CONCLUSIONS

Among people with type 2 diabetes mellitus, diabetes-related shame was associated with diabetes-specific emotional distress and low psychological well-being. Further research and care development are needed to address diabetes-related shame and improve the quality of life of people with diabetes.

Narcissistic Personality Disorder: Progress in Understanding and Treatment

This review summarizes current knowledge about narcissistic personality disorder (NPD). Each section brings the reader up to date on advances in our knowledge during the last decade. In terms of NPD diagnosis, this review describes the addition of the dimensional model to the categorical model. The accumulating knowledge has led to the description of grandiose and vulnerable narcissism as well as their complex interrelationship. Strong support exists for co-occurrence of these presentations among people with high levels of grandiose narcissism. Studies have identified mechanisms, in domains such as self-esteem dysregulation, emotion dysregulation, cognitive style, interpersonal relations, and empathy, and possible developmental and temperamental antecedents of the disorder. Thus, it appears that NPD has a multifactorial etiology and pathogenesis, with numerous mechanisms associated with each area of dysfunction. Longitudinal studies support the view that these patients can improve, but such improvement is gradual and slow. Several treatments have been developed for the disorder, and a majority share commonalities, including clear goals, attention to treatment frame, attention to relationships and self-esteem, alliance building, and monitoring of countertransference.

Shame: Does It Fit in the Workplace? Examining Supervisor Negative Feedback Effect on Task Performance

Purpose

One of the most exciting aspects of organisational psychology is the study of shame and the factors that lead up to it. The purpose of this study was to examine the relation between supervisor negative feedback and task performance. Further, we examined the mediating role of shame between supervisor negative feedback and task performance and the moderating role of self-esteem.

Methods

Employees working full-time in educational institutions across Pakistan were selected to collect data from the respondents. By using a convenience sampling technique, 258 employees participated in the study. The data were collected in three phases to reduce the problem of the common variance bias. Direct paths were tested by using simple linear regression (SPSS V.25). Hayes (2017) PROCESS macro model 4 was used for mediation and model 1 for moderation.

Results

The findings revealed that negative feedback from supervisors is linked positively with employees' task performance. Further, shame partially mediates the relation between supervisor negative feedback and tas performance. When self-esteem is high, negative feedback and task performance were more strongly associated than low.

Discussion

This study has theoretical and practical implications and is based on the well-known theory of psychology ie affective events theory (AET), which states that workplace events cause emotions, influencing work attitudes and actions. This study fills the gap which is unknown to the scholars and practitioners in understanding that supervisor negative feedback is helpful to enhance employee task performance via feeling shame.

Personality Organization and Depressive Symptoms Among Psychiatric Outpatients: The Mediating Role of Shame

ABSTRACT

Previous research has demonstrated relations between lower level of personality organization (PO) and multiple indices of mental health disturbances. The goal of this research was to examine whether experience of shame would mediate the relationship between PO and depressive symptoms in a sample of 321 Croatian psychiatric outpatients (64% female; mean age, 38.67 years). The total PO level exhibited positive associations with depressive symptoms and with all three subscales of shame ( p < 0.01). Characterological, behavioral, and bodily shame showed significant mediating effects in the PO-depression relationship, while controlling for the influence of age and sex. PO level seems to be strongly related to depressive disturbances, with the experience of shame representing one of the underlying mechanisms of this relationship. Given that patients with personality disorders ( i.e. , low PO level) suffer from poorer treatment outcomes for major mental disorders, more emphasis should be placed on psychotherapeutic management of shame-proneness.

"Effectiveness of Emotion Focused Training for Self-Compassion and Self-Protection in Individuals with Increased Narcissism"

"Objective: The goal of the study was to map out the effectiveness of a 14-day online intervention (EFT-SCP) focused on self-compassion and self-protection in people with an increased level of narcissism. Method: The research sample consisted of 63 participants, 19 men and 44 women, aged 21 to 70 years (M = 32.49; SD = 15.73). Participants were randomly assigned to intervention group (N = 32) or to the passive control group (N = 31). Results: The results indicate that the self-compassion level in the experimental group did not increase following the intervention. However, the same group scored significantly lower on self-criticism after taking part in the intervention. Conclusion: Short term online intervention was able to decrease self-criticism in subclinical population with increased traits of narcissism but was not effective in increasing self-compassion. It seems that in individuals with increased narcissism, it could take longer to develop kind and warm feelings towards self, connected to self-compassion. The process of decreasing self-criticism was effective and could be the starting point for further cultivating of self."

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis

OBJECTIVE

Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns.

METHODS

A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied.

RESULTS

We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns.

CONCLUSION

The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.

It's Not That Great Anymore: The Central Role of Defense Mechanisms in Grandiose and Vulnerable Narcissism

Objectives: The concept of narcissism contains a yet unresolved paradox: Its grandiose facet depicts the psychopathological core but is often associated with life-satisfaction and overall functioning, whereas its vulnerable facet is associated with psychological distress, but still not included in the international classification systems. Our goal was to investigate the relationship between the two facets of narcissism expecting underlying defense mechanisms to be core elements. First, we aimed to identify defense mechanisms specific to grandiose and vulnerable narcissism. Second, we explored how both facets are differentially associated with psychological distress, assuming that grandiose narcissism would be associated with less psychological distress than vulnerable narcissism. Third, we investigated the mediating role of defense mechanisms between narcissism and psychological distress. Methods: In a non-clinical sample of N = 254 individuals, the Pathological Narcissism Inventory was used for the assessment of grandiose and vulnerable facets of narcissism, the Defense Style Questionnaire for defense mechanisms, and the Brief Symptom Inventory for psychological distress. Structural equation modeling was employed to identify distinct factors of grandiose and vulnerable narcissism. Associations between specific defense mechanisms and both facets were calculated. Furthermore, the direct association between both facets and psychological distress was examined. We finally explored whether defense mechanisms mediate the association between distress and both grandiose and vulnerable narcissism. Results: A distinct pattern of defense mechanisms for each facet of narcissism could be extracted: Both facets showed significant positive correlations with specific intermediate and all maladaptive defense mechanisms. Only grandiose narcissism showed significant positive correlations with adaptive defenses. Vulnerable narcissism showed negative correlations with all adaptive defenses. Specifically, grandiose narcissism was significantly related to anticipation, pseudo-altruism, rationalization, and dissociation, whereas vulnerable narcissism was negatively related to all these defense mechanisms. While grandiose narcissism was not related to psychological distress, vulnerable narcissism showed high correlations with psychological distress. Intriguingly, mediator analysis found that grandiose narcissism was related to psychological distress when mediated by maladaptive defense mechanisms. Discussion: The role of defense mechanisms is central for a differentiated understanding of the two different faces of narcissism. The relevance of assessing defense mechanisms in clinical settings, and related empirical findings are discussed.

Narcissistic traits in young people and how experiencing shame relates to current attachment challenges

BACKGROUND

Young people with pathological narcissistic traits may have more maladaptive ways of relating to themselves and others. In this study, we investigated how the experience of shame may be a mechanism by which vulnerable and grandiose pathological narcissism relates to negative and positive internalised models of the self and others, manifested as attachment styles.

METHODS

Participants (N = 348) were young people who reported on pathological narcissism, the experience of shame and their model of self and others (secure, dismissive, preoccupied and fearful attachment). Mediation of the experience of shame between vulnerable and grandiose narcissism on the one hand and secure, dismissive, preoccupied and fearful attachment on the other hand, was tested using a path model.

RESULTS

Shame mediated the relationship between vulnerable narcissism and a more negative model of others and self (i.e. less secure, more fearful and more preoccupied in attachment). Higher grandiose narcissism traits were related to a more positive model of others and self (i.e. more secure attachment) and were unrelated to the experience of shame.

CONCLUSIONS

Young people with vulnerable narcissism traits tended to report more shame, and struggled to be close to others. It may be that shame experiences highlight a discrepancy between the ideal and actual self that may contribute to a more insecure attachment style. A good working alliance and fostering self-compassion may counter some negative effects of shame in those most vulnerable, but dismissal in those most grandiose presents a clinical conundrum requiring further research.

Vulnerable narcissism as beneficial factor for the therapeutic alliance in borderline personality disorder

Evidence suggests that narcissism and borderline personality disorder are associated with each other. This naturalistic study investigated the predictive value of grandiose and vulnerable narcissism on the development of the therapeutic alliance in short-term psychodynamic treatment across 12 weeks. The sample consisted of 99 patients with borderline personality disorder. Narcissism was assessed with the Pathological Narcissism Inventory at treatment onset. The therapeutic alliance was rated with the Scale to Assess Therapeutic Relationships by both patient and therapist at four time points during treatment. Results showed a significant predictive value of vulnerable narcissism on the therapeutic alliance, revealing a more beneficial progression for patients with higher vulnerable narcissism. Grandiose narcissism had no predictive value on the therapeutic alliance. The study strengthens the clinical utility of the concept of vulnerable narcissism towards the evaluation of treatment processes in borderline personality disorder.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process

PURPOSE OF REVIEW

The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective.

RECENT FINDINGS

The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

Processes of Change in Psychotherapy for Narcissistic Personality Disorder

The present study aims at determining the role for outcome of potential processes of change in psychotherapy for narcissistic personality disorder (NPD). They were examined on three levels: the content, the process, and the relationship. A total of 161 patients suffering with NPD were recruited in a naturalistic setting as part of the present study. They underwent a long- term clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video- or audio-recorded and analyzed with an observer-rated instrument that measures the quality of the interaction processes from the patient's and therapist's perspectives. Different self-report measures were used to assess therapy outcomes. In-session improvement was observed in both patient and therapist processes across sessions. Patient improvement in the three levels of processes was systematically related with outcome. Only partial relationships were found between therapist improvement and outcome. The present study represents the first systematic insight into core changes in patients with NPD undergoing psychotherapy.