Historically, patients suffering from pathological narcissism, including narcissistic personality disorder (NPD), were considered challenging and hard to treat. Since the second half of the 20th century new treatments have been developing heralding a growing hope that transformative treatment of patients with pathological narcissism is possible. Recent developments of phenomenology, childhood antecedents, longitudinal course, and putative mechanisms inspired a greater hope as well. This invites clinicians and researchers to take an approach that is evidence-based, destigmatizing, and collaborative that considers that at least some of the treatment challenges as co-created by both the therapist and the patient. Further, new treatments add hope by ameliorating such challenges of patients with pathological narcissism as fragile alliance, limitations of reflectiveness and grieving. Novel treatments are evidence- and principles-based and different approaches to effective treatment development are described. Inspired by these developments in the field, this Issue of the Journal of Clinical Psychology: In Session was conceived as an opportunity for clinicians from different treatment approaches to come together and share their experiences in treating patients with pathological narcissism. The hope is to find common language to understand these patients and their treatment, understand what contributes to change, as well as learn from commonalities and differences among these treatments. In doing so, this Issue is hoping to promote destigmatizing, pragmatic approach that prioritizes evidence-based efforts to understand the patient and collaborative approach to promoting change.

Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalytic principles, while others argue they enhance 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. We present the case of a man diagnosed with narcissistic personality disorder to illustrate this: the patient, wrestling with social relations and control dynamics within therapy, was assigned homework aimed at curbing his compulsive caregiving and exploring its underlying motives. This exercise led him to understand his actions stemmed from avoidance of exposing his vulnerabilities. Subsequently, he was able to engage with relationships from diverse perspectives and discover new meanings. We advocate that homework tasks can be successfully incorporated into the relational psychoanalytic approach, fostering self-reflection and facilitating transformative change in patients with personality disorders.

Objective: Intrusive thoughts are characterized by a sense of intrusiveness of foreign entry into cognition. While not always consisting of negative content, intrusive thoughts are almost solely investigated in that context. Involuntary Musical Imagery (INMI) offers a promising alternative, as it is a type of involuntary cognition that can be used to evaluate intrusiveness without negative content. Methos: In Study 1, 200 participants completed self-report questionnaires to assess several aspects of intrusiveness: meta-awareness, control, repetitiveness, frequency, and subjective experience of INMI. In Study 2, 203 participants completed self-report questionnaires to explore the clinical characteristics (depression, stress, anxiety, and rumination) which might mediate the connection between INMI frequency and INMI negative experience. Results: Study 1 revealed, through exploratory factor analysis, that intrusiveness shares variance with the negative experience of INMI but not with INMI frequency. In study 2, ruminative thinking was found to mediate the relationship between frequent INMI and negative experience of INMI. Conclusion: These results suggest that INMI might be used to investigate intrusiveness in the lab without the potential confound of negative emotions. In addition, the results suggest that neither the content nor the frequency of intrusive thoughts can solely explain why these thoughts are aversive to some but not others. Ruminative style might be the missing link to explain how and why these intrusive thoughts become aversive and obsessive. In other words, we suggest that the cause for intrusiveness lies not in the thought or repetitiveness, but in the thinker.

Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization (WHO)’s International Classification of Diseases (ICD-11). This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of CPTSD. SNT balances interventions that address current day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man. The treatment introduces client tailored coping skills for current minority stress, discrimination and micro-aggressions as well as trauma-focused interventions regarding events from his childhood and the death of his partner and many members of his community due to the AIDS epidemic. Qualitative and quantitative outcomes are summarized. Implications regarding the relevance of SNT for sexual and gender minority (SGM) individuals is discussed.