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\begin{document}

\title{Treatment of Alec: ``History does not have to repeat itself''}



\author[1]{Igor Weinberg}%
\affil[1]{McLean Hospital Gunderson Personality Disorders Institute}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Treatment of patients with pathological narcissism presents several
challenges and there is paucity of published case reports that document
meaningful and durable change in patients suffering from this condition.
Using descriptive and atheoretical language, this paper presents a
treatment of a young adult in his transition from young adulthood to
middle adulthood while he was negotiating complex residues of his
experiences of growing up along with developmental challenges related to
work and love. Against the backdrop of these transitions, the patient
was working through various aspects of functioning related to
pathological narcissism. Initially, given academic pressures and past
romantic disappointments, he was confronting issues related to
perfectionism, self-criticism, and avoidance. While he was able to move
past some of these dynamics and function academically, later challenges
related to becoming an independent adult led to a retreat into an
avoidant state of futility and pessimism. Working through painful family
dynamics related to not being seen and controlled, along with a
deepening attachment in therapy as well as confrontation with realities
of his life, led him to take steps towards greater independence.
Thereafter, his treatment focused on learning from life experiences such
as a newly developed career and romantic life, accepting the complexity
of self and others, and tolerating disillusionments.%
\end{abstract}%



\sloppy


Treatment of Alec: ``History does not have to repeat itself''

Treatment of patients with pathological narcissism presents several
challenges and there is paucity of published case reports that document
meaningful and durable change in patients suffering from this condition.
Using descriptive and atheoretical language, this paper presents a
treatment of a young adult in his transition from young adulthood to
middle adulthood while he was negotiating complex residues of his
experiences of growing up along with developmental challenges related to
work and love. Against the backdrop of these transitions, the patient
was working through various aspects of functioning related to
pathological narcissism. Initially, given academic pressures and past
romantic disappointments, he was confronting issues related to
perfectionism, self-criticism, and avoidance. While he was able to move
past some of these dynamics and function academically, later challenges
related to becoming an independent adult led to a retreat into an
avoidant state of futility and pessimism. Working through painful family
dynamics related to not being seen and controlled, along with a
deepening attachment in therapy as well as confrontation with realities
of his life, led him to take steps towards greater independence.
Thereafter, his treatment focused on learning from life experiences such
as a newly developed career and romantic life, accepting the complexity
of self and others, and tolerating disillusionments.

\textbf{Key words:} Pathological narcissism, psychotherapy, adult
development

Patients suffering from pathological narcissism are troubled by a
pervasive and painful difficulty maintaining a positive and realistic
self-perception as well as a tendency to regulate self-esteem through
maladaptive mechanisms (Miller et al., 2017). The most extreme
expression of pathological narcissism is regarded as narcissistic
personality disorder (NPD), characterized by unrealistic self-perception
along with a feeling of superiority over others, a feeling of deserving
special treatment or exceptions, the tendency to take advantage of
others, and a difficulty putting oneself into others' shoes (American
Psychiatric Association, 2013). NPD is associated with an increased risk
of suffering from comorbid disorders, such as mood disorders, anxiety
disorders and substance use disorders (Stinton et al., 2008). Many NPD
patients are troubled by legal, vocational, and relational/marital
difficulties (Ronningstam \& Weinberg, 2013). They are more likely to
attempt or die by suicide (Ronningstam \& Weinberg, 2013) and they tend
to evoke distress in people close to them (Day et al., 2020). NPD is
associated with the persistence and treatment resistance of comorbid
disorders (Weinberg \& Ronningstam, 2020). Typically, comorbid
conditions do not improve until the treatment includes an additional
focus on the pathological narcissism that is contributing to the
diathesis for these conditions. Another reason for such treatment
resistance is related to the misdiagnosis of difficulties related to
pathological narcissism as solely stemming from anxiety or mood
disorders. In such cases, clarifying the differential diagnosis helps
reframe the treatment and make the co-occurring NPD a treatment priority
(Weinberg \& Ronningstam, 2022).

The subject of the possibility of treatment of patients suffering from
pathological narcissism has invited several controversies since the
concept of narcissism has been introduced into clinical literature. This
led to numerous debates regarding treatability and the possibility of
meaningful change, adaptation in treatment techniques, and the specific
strengths and limitations that these patients present within treatment
(Diamond et al., 2021; Weinberg \& Ronningstam, 2020). Increased
hopefulness about treatability of patients suffering from borderline
personality disorder evoked greater hopefulness that treatment of
patients with NPD could bear fruit as well (Choi-Kain, 2020).
Preliminary reports suggested that patients with NPD can indeed improve
in therapy (for a review see Weinberg \& Ronningstam, 2022). In this
atmosphere of renewed enthusiasm, several approaches to treatment of NPD
and pathological narcissism have been developed, including Transference
Focused Psychotherapy (TFP; Diamond et al., 2021), Mentalization Based
Treatment (MBT; Bateman et al., 2023) and Metacognitive Interpersonal
Psychotherapy (MIT; Dimaggio et al., 2020).

What treatment principles contribute to change and productive engagement
in treatment? To answer this question, such principles were formulated
as Dos and Don'ts in treatments with NPD patients (Weinberg \&
Ronningstam, 2020). The list of Dos includes: (i) collaboratively
identify realistic measurable treatment goals; (ii) help the patient
develop a sense of agency; (iii) help the patient to shift toward
exploration of real vulnerability; (iv) develop collaborative alliance
through exploration, validation, and confrontation of dismissive and
avoidant behaviors in sessions; (v) use treatment contract to anticipate
treatment-interfering behaviors. The list of Don'ts emphasize the
following: (i) don't ignore personal reactions to the patient; (ii)
avoid power struggle; (iii) don't directly challenge grandiosity or
self-criticism; (iv) don't indulge grandiosity or self-criticism; (v)
avoid overly empathic or overly expressive interventions; (vi) don't
ignore self-esteem-relevant life events (Weinberg \& Ronningstam, 2020).

This approach has not been tested empirically, though the individual
principles are based on empirical studies (e.g., don't ignore
self-esteem-relevant life events; Wetzel et al., 2020), overlap with
other empirically based approaches (e.g., use of treatment contract to
anticipate treatment-interfering behaviors; Yeomans et al., 2015), or
stem from clinical experience (e.g., develop alliance through
exploration, validation, and challenging dismissive behaviors in
session; Wallin, 2007).

The case presented below illustrates this principles-based approach. It
outlines a twice-a-week individual psychotherapy that unfolded over a
period of more than 5 years. The case highlights the complexity and the
multifactorial nature of change in treatment and discusses possible
pathways and mechanisms of change.

\emph{CASE ILLUSTRATION}

\emph{Presenting problem and clinical description}

Alec was 24 years old when he arrived at our first meeting. He explained
that he had relocated to Boston for graduate school and was looking for
``support for depression and anxiety.'' He was very interested in my
background and told me that he searched the internet about me before our
first appointment. Puzzled, I wondered whether his desire to know things
about me was related to anxiety and uncertainty of beginning treatment.
I also wondered if this indicated problems with intrusiveness and
boundaries. As I was not able to have clarity about any of these
hypotheses, I shelved them, hoping to gain more clarity in the future.

Alec grew up in a privileged family. His family owned a consulting
company that was passing from one generation to the next. However, Alec
was uninterested in the company and was dedicated to the field of his
studies, history. His father ran the company, though in his younger
years pursued an academic career in archeology. It was truncated upon
the death of his first wife, who died from cancer. Alec's father became
depressed, quit his academic job, and was quite literally rescued by his
own father who offered him a new career in the family business. Around
that time, Alec's father met his second wife -- Alec's mother -- and
married her soon thereafter. Alec recalled that his childhood was sad
and lonely. His father worked long hours and his mother, who was
depressed for months at a time, was often unavailable. Alec's younger
brother, Mark, sustained a serious sports injury during the summer
before Alec started high school. The injury left Mark paralyzed, and
Alec de facto lost both of his parents who became preoccupied with
extensive medical care for Mark. Alec would escape into reading fantasy
novels, spending long hours reading at the expense of schoolwork or
spending time with friends. His parents arranged for him to start
treatment. Gradually, he was able to limit his reading and finished high
school.

Hoping for a much needed sense of independence, accomplishment, and
romantic fulfillment -- a new beginning -- Alec started college. He was
busy studying, daydreaming about having a girlfriend, and attending the
occasional party. He thought that his dreams had come true when he met
Mary at one of the parties and both felt a strong connection to each
other. He saw the relationship in idealized terms: two soulmates who
fell completely in love with each other. As the two became closer, Mary
shared with Alec a devastating history of abuse by one of her family
members. Alec became preoccupied with Mary's anguished childhood. He was
enraged that Mary was hurt, especially by a family member. Initially,
Mary felt that Alec was very understanding and sympathetic and her trust
in him increased. However, as he became more and more preoccupied with
``justice'' and became interested in suing her family, she became
increasingly worried. The tension between them grew as Mary experienced
Alec as aggressive and feared that he might harm her family.

Alec felt that the abuse tainted the perfect relationship he and Mary
could have had. In his mind he hoped to reinstate the perfection of
their relationship, while refusing to realize that he was causing
enormous distress to Mary. Mary repeatedly requested him to stop
pursuing justice because she wanted to move on. Eventually, as Alec's
behavior had not changed, she broke up with him, asking him to never
contact her again. Alec felt devastated that he destroyed the
relationship with the woman he loved and wished to protect.

Fearing his own destructiveness, he concentrated on his studies. He
graduated a few years later and started graduate studies in history,
hoping to pursue an academic career. He had a few brief relationships
that invariably ended after Alec would get annoyed at the
``imperfections'' of his partners. He was a good student, though his
professors were not aware that his perfectionism was affecting his
ability to do and enjoy the schoolwork. Everything needed to be done
perfectly -- not only did Alec need to meet the expectations of his
professors, but also he had to meet his own standards. That quadrupled
his work, slowed him down, and colored his experience with incessant
fear of inevitable failure. After all, these were impossible
expectations to meet.

\emph{Case formulation}

In terms of his diagnoses, I was initially impressed by the presence of
chronic depressive disorder and generalized anxiety disorder. However,
as I listened deeply to his struggles, I realized that his central
issues could be better explained through the lenses of pathological
narcissism. From how he described his experiences, I learned that what
was at stake was his fragile self-esteem. He was preoccupied with
fantasies of perfect and ideal love while trying to maintain a superior,
though fragile and easily injured, sense of self. Shame, humiliation,
and embarrassment were unwelcome companions of his schoolwork and he
feared that every mistake would catastrophically and permanently taint
his reputation. I also thought that Alec's self-esteem was contingent on
external indices of worth: the positive evaluation of professors, and
academic success. His perfectionism was shame-based, rather guilt-based
(Sorozkin, 1985), differentiating his personality functioning from an
obsessive compulsive personality disorder. At a deeper level, I thought
that Alec was torn between the wish to pursue his own academic career
versus succumbing to tacit expectations to stay in the family business.
The latter decision must have felt difficult given his father's history.
It was as if the gravity of the family history was pulling him back to
the familiar -- and familial -- orbit. This formulation helped me see
his mood and anxiety symptoms as stemming from difficulty regulating
self-esteem. Formulating his treatment around his difficulty regulating
self-esteem, I imagined that a helpful treatment approach for Alec would
likely include helping him examine his strategies of self-esteem
regulation (e.g., self-esteem being contingent on evaluation of
professors or fulfillment of ideal love), develop adaptive alternatives
(including a capacity for a less black-and-white self-evaluation), and
develop his own sense of self independent of his family narrative. I
imagined that such a process would require an emphasis on stability in
my relationship with him and responsivity to his bids for attachment in
efforts to connect in a new way. Overall, the positive prognostic signs
were younger age, intelligence, interest in self-understanding,
engagement with school, absence of antisocial traits, and lack of
substance use.

\emph{Course of treatment}

In therapy Alec described his desolate life and his preoccupation with
Mary and how he wronged her, with an acute awareness that given how the
relationship ended he could not try to work things out with her, try to
have a relationship with her again, or even offer an apology. I wondered
whether he was trying to find something perfect in his life to undo the
devastating events of his childhood. Was his aggressive pursuit of
justice in fact a displaced feeling of being wronged when his brother
Mark got injured and ``stole'' his parents from him? These were some of
the possible explanations of the dynamics, but Alec was not able to
access any of these possibilities in his narrative. He was preoccupied
with extreme perfectionism and catastrophic expectations which came to a
head when he started working on his master's thesis. He wanted to
impress his professors and submit an outstanding piece of research. At
the same time, he feared that even the smallest mistake would lead to
failure. He hoped that by writing such an impressive thesis, he would
solidify his reputation in the department and thus would secure the most
glowing recommendations for possible future jobs. Consequently, his
master's thesis was exceeding in length, scope, and the research methods
required for a master's thesis, and existed only in his mind. His lofty
aspirations paralyzed him and made him feel panicky and his writing was
limited to disjointed paragraphs written in a state of anxious frenzy.
To cope with the anxiety, he reassured himself that he would organize
his thoughts ``at some later point in time,'' only to generate a few
more disjointed paragraphs and escalate his humiliating expectations of
failure.

I worried about him. His high expectations were interfering with the
completion of the thesis and he was not willing to compromise. He
requested multiple extensions, each time fearing rejection and, also,
ruining his reputation in the eyes of his professors. Consciously, he
was pursuing perfection. However, I wondered whether, at the same time,
Alec was also fearing graduation, fearing growing up, fearing taking on
the responsibilities of adulthood and of a professional and personal
life. He grew up with very sad examples of what it meant to be an adult.
His mother was disengaged due to depression. His father sacrificed his
happiness in service of taking care of others. His brother was full of
aspirations and hopes but was paralyzed. With these role models in front
of him, how could Alec feel hopeful about his own adulthood?

\emph{Alec: ``I tried to write yesterday. I slept late because I was up
all night. I woke up at 11am and told myself `OK, today is the day -- I
am going to put all these paragraphs together and I want to be done by
the end of the month.' I want to go for a trip to Florida with my
friends. It would be great to feel that I have finished and enjoy a good
time with them.''}

\emph{Therapist: ``You sound motivated to get it done.''}

\emph{Alec: ``I was -- but then I got up as I wanted to work on
integrating these pieces. I looked at all my files -- I did not know
where to start. I wanted to figure it all out first in my head and only
then put these pieces together. I started going through all these
sections and paragraphs I had written and started feeling panicky as I
did not know how to do it! I freaked out and ordered fast food.''}

\emph{Therapist: ``What do you think you were trying to accomplish?''}

\emph{Alec: ``Clearly, I wanted to make it all go away -- I did not want
to feel panicky any longer. If I feel anxious -- I cannot work or write.
What's wrong with me? I should be able to control all this anxiety --
it's humiliating. I feel too anxious. What am I, a child?''}

\emph{Therapist: ``You sound angry with yourself.''}

\emph{Alec: ``I am -- I should be able to figure things out on my own. I
should be able to write and put all these pieces together.''}

\emph{Therapist: ``So, when something is hard to do, you get angry with
yourself and start kicking yourself as hard as you can?''}

\emph{Alec: ``Exactly!''}

\emph{Therapist: ``What do you think you are trying to accomplish by
getting angry with yourself?''}

\emph{Alec: ``I don't know -- I think I am trying to get myself to do
it. If I get angry with myself, maybe I can force myself to do it.''}

\emph{Therapist: ``You treat yourself as if the harder you hit yourself,
the more likely you will start doing your work.''}

\emph{Alec: ``I do that a lot! I feel like this is my way of holding
myself to a high standard. If I fail at something -- like when I cannot
do my thesis writing -- I feel like by kicking myself I can actually
hold myself to a higher standard -- like I can do better.''}

\emph{Therapist: ``So it is sort of a reassurance that you can do
better?''}

\emph{Alec: ``Exactly -- I can do better, and I can write and put all
these pieces of my thesis together.''}

\emph{Therapist: ``So in a way, you motivate yourself to work hard by
kicking yourself and in doing so you hold yourself to very high
standards.''}

\emph{Alec: ``Totally -- it makes me feel that my failing is only
temporary and not real -- the stronger I kick myself -- the higher are
the standards that I hold myself to.''}

\emph{Therapist: ``What does that imply that you hold yourself to high
standards?''}

\emph{Alec: ``I am not sure.''}

\emph{Therapist: ``Could it be that by holding yourself to high
standards you remind yourself of having actually high self-esteem?''
Alec: ``I guess so -- you are right! By setting unrealistic standards of
getting all my work done in one day I tell myself that I can do it. It
reassures me in the moment, but only makes me feel more panicky later
because I don't get any work done.''}

Confronting cycles of self-criticism and paradoxical efforts of
regulating self-esteem through self-attacks allowed Alec to see how his
efforts to regulate self-esteem pulled him further and further away from
writing. Realizing that pattern, he hired a tutor who suggested how to
organize his multiple disjointed paragraphs. Initially, these
recommendations challenged his expectations and he considered hiring a
different tutor. Gradually though, he was able to reconsider his
reactions in light of his perfectionism, accepted the recommendations,
completed the thesis, and graduated.

Graduation brought a short-lived sense of accomplishment. Alec was
facing a new chapter in his life: becoming a young professional and
launching his own life. On a practical level, he knew that if he wanted
to go forward with his independent life he needed to look for a job.
However, he took a different approach. He moved back into his parents'
home. Initially, he thought of it as some well-deserved time to
recuperate and put his thoughts together about his future. However, soon
it looked as if he was living his life as a perpetual adolescent on a
permanent summer break. He slept late, fed the cat, read books on
history, and occasionally got together with old friends from high
school. Underneath a care-free fa\selectlanguage{ngerman}çade, he was plagued by self-doubt,
pessimism, and avoidance.

The possibility of applying for jobs terrified him. Hopeless and
fearful, he was hiding behind walls of negativity and futility,
portraying his future as bleak and full of failures. He imagined that he
had no control or power and that I had no ability to help him either. My
repeated reflections on his very real capabilities, as well as his prior
academic achievements, were invariably rebuffed by his arguments that
everything was futile, hopeless, and pointless. His capabilities were
skillfully recruited to prove his point: everything was hopeless,
including efforts to help him. He imagined that even if he found a job
he would find himself paralyzed again, the same way he was paralyzed
writing his thesis. Hence, he thought, there was no need to apply for
jobs.

At times he felt increasingly desperate, and yet unmovable about his
career. The occasional get-together with friends provoked mixed feelings
in him. He enjoyed spending time with them, though each time he felt
trepidatious, comparing himself to their careers. Feeling panicky and
hopeless, he would try to justify the delays and find reasonable excuses
for the growing gap in his resume: ``I think it is not unreasonable to
take time off after graduation. I also think I can explain during
interviews that the pandemic froze the hiring process for many jobs.''
Once he felt comfortable with his justifications, he would fall back
into familiar avoidance. A few adjunct treatments followed. Those
included medication changes, a day treatment, TMS and ketamine
infusions. His depression did not change very much, and Alec started to
recognize that ``maybe this is not a biological condition,'' but part of
his personality.

His romantic life fueled an equal measure of rejection and defeat.
Contemplating dating, he initially worried about a repetition of the
relationship with Mary: falling in love and not being able to accept a
partner's ``imperfections.'' After talking about it in therapy helped
him assuage his worries, he joined a couple of dating sites. He started
talking to a few women, but soon faced a lack of progression: sometimes
women did not want to talk again after what he thought were good
conversations, and sometimes they did not want to go out on second or
third dates. Sure, sometimes a lack of chemistry was mutual, but many
times he felt rejected after feeling excited and liking the women he
went out with. He started to consider the possibility -- a very real one
-- that these rejections had something to do with his life situation. He
realized that he was approaching dating without consideration of
developmental context and life stage: many women wanted to get married
and were looking for a partner to build a family with. However, he was
unmovable.

Both he and I were defeated: he felt that his chances of having a
successful job were next to none, I felt my efforts were falling flat. I
worried that the time was passing by and that eventually not only would
Alec have an unexplainable gap on his resume, but also that he would
miss out on developmental milestones, such as an independent life, a
career, and romantic relationships. I felt that I needed to do something
and, in line with Good Psychiatric Management (Gunderson, 2014) and
Transference Focused Psychotherapy (Yeomans et al., 2015), discussed
with him the recommendation of taking a job. The rationale for such a
recommendation was to help him engage in ``real life'' to address
avoidance, start confronting his well-defended grandiosity, learn to
deal with disappointments, and start accepting himself and others with
all the complexities of strengths and limitations. I also hoped that by
doing so he would start moving forward with his life plans. However,
Alec avoided following through on the recommendation. Consequently, I
faced the dilemma of whether to stop treatment or not. In thinking about
this further, I decided to continue treatment because I realized that
stopping treatment would convey my collusion with his futility and
hopelessness and repeat the abandonment by his parents. I hoped that I
could help him address avoidance through greater engagement in treatment
and exploration of his emotional avoidance and his preservation of
grandiosity through avoidance of life, pervasive futility and pessimism,
and disconnect from his internal world.

This brought him to talk about his earlier times when such experiences
of futility, entrapment, and self-doubt dominated his life, bringing up
vivid and palpably anguished memories from his teenage years. He talked
about his dilemmas growing up with real feelings of rage, abandonment,
neglect, loneliness and despair. He felt unseen and abandoned by his
parents in the middle of his own identity crisis during his adolescence.
He had nobody to turn to, except fantasy novels. He spoke with
hopelessness about his fears of growing up: Would he become like his
work-obsessed father, his disengaged mother or his paralyzed brother?
None of that was appealing, though he was starting to recognize that he
was effectively becoming all of them at once. He was struck by the
parallels between their ways of being and his own ways of dealing with
emotional pain: to escape his feelings through work, to disengage from
others and reality, or becoming paralyzed and unable to move forward.
These realizations were scary and uncanny. Our relationship became even
more important as he relied on me to understand his feelings, his
avoidance, and the ``damned if you do, damned if you don't'' dilemma. He
felt he was destined to fail either way, whether he was trying to get a
job or a personal life.

During that time his interest in my background became of greater
significance. Initially, I thought of his questions, such as ``do you
have any plans for this weekend?'' or ``what was it like to come to the
U.S.?'' as being either defensive or a projection of his own feelings. I
thought that he was avoiding his feelings about himself by being
preoccupied with me. I also thought that these questions might reflect
his feelings of not belonging and disconnection, or maybe he worried
that I could not understand him fully because I did not grow up in this
country. I thought this also could reflect feelings of superiority over
his ``foreigner therapist,'' though I could also see how he might have
been idealizing my multicultural background and devaluing his own. As I
entertained different possibilities, my thoughts on the matter started
to shift. I started to consider that my initial interpretations of his
questions as being defensive were partially correct at best if not
simply wrong.

As I became more curious about our exchanges, I started listening to
them from a different vantage point. Gradually, Alec brought up a
totally new area into treatment. He grew up with a younger brother who
became paralyzed and parents who became unavailable. What he always
wanted was to have an older brother. He wanted this brother to keep him
company in his difficult family -- misery loves company, as they say. He
also wanted to have an older brother who could teach him things. Life
stuff -- how things work in life. Alec felt that he was finally having
these experiences in therapy with me. I was there for him through these
changes and transitions, and I had not abandoned him even though there
were multiple periods that felt stagnant, futile, and hopeless. I also
never bought into the idea that therapy was futile and continued to help
him understand himself better.

He agreed to take a job at the family company as an administrative
assistant. He was horrified that the job would become his actual career
and that his career would follow the same trajectory as his father's. He
did not want to give up his dream of pursuing his own career, which led
him to apply for a job in one of the research institutes where his
historical background and interests were of interest. After a series of
interviews, a job offer was extended. On a month's notice, he moved out
of his parents' home and relocated closer to the job. Initially, he was
obsessed with the possibility of failure and considered starting
ketamine infusions.

\emph{Alec: ``I thought about resuming ketamine therapy.''}

\emph{Therapist: ``Could you say more about it?''}

\emph{Alec: ``I found this one local clinic and they offer ketamine
treatments. Here is their website. It says they treat anxiety,
depression, addiction -- everything. And it is close to where I live
now. They offer treatments 5 days a week.''}

\emph{Therapist: ``Seems like they offer a lot of attractive options.
What made you want to resume ketamine treatment?''}

\emph{Alec: ``I am not sure. I am worried that I might feel anxious and
paralyzed again -- the same way I felt in grad school. And the stakes
are higher now -- it is my job, my independence. I feel like I must
prove to my family that I can do it.''}

\emph{Therapist: ``These are serious expectations to meet. You feel like
you have no room for anything going wrong.''}

\emph{Alec: ``Exactly! I must succeed.''}

\emph{Therapist: ``This is a familiar way for you to feel. You must
succeed, it is black and white, no room for errors.''}

\emph{Alec: ``I know. It does feel like that.''}

\emph{Therapist: ``It is as if it is hard for you to trust your own
capabilities. As if you cannot do anything right.''}

\emph{Alec: ``This is true. I do worry that I cannot accomplish anything
on my own.''}

\emph{Therapist: ``However, you seem to forget that you graduated
despite all these difficulties.''}

\emph{Alec: ``Right\ldots{} I seem to always forget that I graduated in
the end. There is always that other side -- there are difficulties and
then there is the actual outcome.''}

\emph{Therapist: ``And back then we were able to work on these
difficulties together, here, in therapy. Do you think we will be able to
resolve these issues together again, if they come up at work?''}

\emph{Alec: ``That's true. I think we can do it again. Talking to you
was helpful and I think if these issues with work paralysis come up
again, I can discuss it with you. I think once I moved out from home, I
sort of expected that I should be able to do everything myself. And then
I think about how I got stuck in college.''}

\emph{Therapist: ``It's a familiar place to be -- to expect to do
everything yourself.''}

\emph{Alec {[}tearing up{]}: ``It is, it is\ldots{}I expect to do it all
myself, when in fact you are here and can help me as you were helping me
all along. It is what I got used to growing up. My parents were so
focused on Mark or were preoccupied with their own struggles, that I was
the last one on their list.''}

\emph{Therapist: ``What a sad place to be in.''}

\emph{Alec: ``It was hard -- sad, lonely. I knew Mark was very ill, and
my parents were really worried about him. He was taking up 1,000\% of
their time. I did not dare to ask for their help. I felt I would be
depriving Mark of their time and effort. I worried about him, too. I
felt it was too much for them to take care of him and asking for their
help would have thrown them over the edge.''}

\emph{Therapist: ``You carried a lot of responsibilities.''}

\emph{Alec: ``I did.'' {[}sobbing{]}}

\emph{Therapist: ``Could you let your tears speak?''}

\emph{Alec: ``I still feel sad and upset they were not there for me.''}

\emph{Therapist: ``But you know what? You don't have to be in such a
lonely place anymore. You have different choices available to you today.
You can reach out for help, and you don't have to rely only on
yourself.''}

Alec was moved by that discussion. He was able to develop a new
perspective and see that not only does he have capabilities and can get
through crises, but also he does not have to rely exclusively on
himself. On the heels of that discussion, Alec started expressing
greater confidence in himself and therapy and decided to postpone
ketamine treatments. He also thought that ketamine treatments would
interfere with his ability to tell whether his success had anything to
do with \emph{his own} capabilities as opposed to the ketamine therapy.
Thus, he wanted to test himself, learn about his capabilities, and
develop self-esteem based on dealing with challenges.

Indeed, as he was no longer living under his parents' roof, life
presented him with several such challenges. First, he discovered the
complexity of departmental politics. Reporting to more than one
supervisor, he negotiated boundaries as both of his bosses placed high
expectations on him. Anxious, he worried about his ability to meet these
multiple deadlines, especially when he discovered that one of his
supervisors tended to be hypercritical. He talked about his fears, his
fluctuating awareness of his capabilities, and a helpless expectation of
failure. Gradually, he came up with a few time management strategies and
discovered that some of the junior faculty members struggled with
similar challenges. He was fearful of being open with them but gradually
decided to take that risk, and to his surprise found solace in sharing
experiences about work stress and hypercritical coworkers. Due to his
reliable productivity, his collaborations within the department
strengthened and he developed a solid reputation.

Dating was a different story. Initially, Alec was hesitant about the
possibility of being in a romantic relationship. He worried that
romantic relationships would require compromises and the acceptance of
failures as well as the imperfections of a prospective partner. These
were hard for him to imagine, as he anticipated getting annoyed with
prospective partners. He imagined that relationships are ``too much work
and not enough fun''. In sessions, Alec explored these experiences. They
reflected a fear of rejection that was all too familiar to him from his
disappointing dating experiences in the previous phase of his life. To
cope, he hid behind the veil of a pessimistic outlook on his romantic
future. Such a defensive retreat into pessimistic certainty was familiar
to him as he used to rely on such a maneuver in a different area of his
life -- his career. By considering dating, he also was stepping outside
of the comfort zone of the predictability of his own fantasies and
projections. Dealing with real people was far more complex and required
acceptance of the uncontrollable and unpredictable nature of their
feelings and actions. Pessimistic certainty was more predictable and
offered a promise of control, though at a price: missed opportunities. I
thought that dating could invite him to explore his fears, wishes,
expectations, and personal limits, and also help him accept the
unpredictable and uncontrollable complexity of relationships. I thought
that life experiences, coupled with exploration of them in our therapy
together, could help him start seeing himself and his prospective
partners as real people with complex and, at times, contradictory
feelings.

After talking about his hesitations, he started dating and discovered
that women found him desirable. They thought he was good looking and
witty, and his job made him an attractive catch and a viable
relationship prospect. And then he met Kate. Kate had a successful
career, and he liked her vivacious disposition as well as her caring and
patient attitude toward him. He was in love and felt happy to discover
that Kate loved him as well. His hesitation about long-term
relationships gave way to a dedicated interest in making things work
with Kate.

The relationship was progressing and they moved in with each other. That
felt like a natural step in their connection as they had also discussed
long-term commitment and the possibility of getting married. This
brought about more opportunities to deal with disappointments. Kate was
traveling for three weeks -- first, for purposes of her job and
afterward with her girlfriends. She left her three cats with Alec. Alec
felt angry at Kate as he did not want to be taking care of three cats.
He seethed with anger, feeling that he had become a ``glorified cat
sitter'' while Kate was away. This felt infantilizing and humiliating
and brought up memories of his domineering mother who used to make
decisions on his behalf. Close to breaking up with Kate, he mustered the
courage to speak up. Talking about it in therapy allowed him to
entertain the possibility that Kate's intentions were different from the
outcomes of her actions. He respectfully expressed his feelings to her,
negotiated with her, and learned that Kate felt overwhelmed with her job
and hadn't thought through her decision. She acknowledged that she was
very particular about the cats, trusted Alec with their care, and felt
genuinely remorseful that her decision hurt Alec. This was a new
experience of effective negotiation, forgiveness, and reconciliation.
The breakup was averted as Alec learned that he was not powerless and,
Kate, not heartless or controlling. He no longer felt doomed to lose the
woman he loved or destroy the relationship through his angry behaviors.
He was discovering the ability to negotiate and forgive. Accepting his
own imperfections and feeling that he could be accepted despite them
allowed him to feel more engaged in the relationship with Kate. He
started to feel a sense of agency and ability to choose his own future
and make his own choices. He discovered that history does not have to
repeat itself.

Alec started contemplating proposing to Kate. He felt that they had good
chemistry and was reassured by how well they resolved their
disagreements. He shared his plans in therapy and he knew, based on
informal discussion of the matter, that Kate would like to marry him,
too. Work was stirring up disappointments that he was able to tolerate
and learn from. Planning to build his own family, he started exploring
the possibility of getting promoted and increasing his income. However,
he discovered that this was not an option and felt disappointed.
Weighing other courses of action, he started applying for different
jobs, hoping to seek more gainful employment. His pragmatic investment
in the long-term outcome was different from his past tendency to retreat
and give up. He learned from his life and trusted that the future had
something good to offer him.

\emph{Case prognosis}

Alec improved during the treatment. Symptomatically he no longer met
criteria for any mood or anxiety disorders, and he was able to manage
occasional bouts of anxiety effectively. His early difficulty in
regulating self-esteem had improved, though occasionally he was
vulnerable to the familiar tendency to think in black and white terms,
judge intentions based on the outcome, and expect that he needs to be
perfect to be accepted. He worked and managed work stress, was
financially self-sufficient, and had a fulfilling relationship with
Kate. He was developing a sense of identity and building his own family.
What allowed these changes to happen? These changes occurred against the
backdrop of the maturation and development of Alec in terms of identity,
career, and intimacy, which were both challenges and opportunities for
his growth (Levenson, 1978). Initially, these areas of his life had
posed challenges and evoked fear of disappointments and failures. Due to
his difficulty regulating his self-esteem and the desire to preserve an
ideal sense of himself, he had retreated into the comfort of his
parents' home. Through processing the difficult experiences of growing
up, gaining greater clarity regarding the self-defeating ways in which
he was protecting himself from disappointments and failures, and
developing a deeper attachment in therapy, he rejoined the developmental
trajectory. The reality of his life became the source of change. His
life had posed an ultimatum: he felt pressed to choose between working
for the family company versus overcoming his fears, developing his own
career, separating from his family, and declaring his own identity.
Moving forward with his own wishes challenged his role identification
with his family members that resulted in paralysis (like his brother),
avoidance (like his mother), and an expectation that life is a joyless
process of sacrificing one's needs (like his father). As he rejoined the
developmental trajectory, he navigated the complexities of work, his
romantic relationship, and his own independent life. Initially, these
evoked fears that were understandable given his difficulties regulating
self-esteem and reintegration into life after a long break. Alec showed
the ability to learn from his experiences, regulate his emotions in
service of pragmatic outcomes, and resolve ambivalent and mixed feelings
in the face of new experiences. He continued to use therapy in a
productive way and developed a new recognition that it is possible to
rely on others. The new experiences of love, commitment, and evolving
intimacy in his relationship with Kate allowed him to see himself and
her as lovable despite imperfections. He also discovered his
professional capabilities as well as his ability to manage conflicts and
stress at work. He was learning from life experiences. Similar to
earlier stages in treatment, the therapy process and life experiences
worked synergistically to promote growth and new learning, and challenge
maladaptive ways of functioning.

\emph{CLINICAL PRACTICE AND SUMMARY}

Treatment of Alec illustrated that change is possible in treatment of
patients suffering from pathological narcissism. His treatment was
structured around Dos and Don'ts treatment principles that promoted
change (Weinberg \& Ronningstam, 2020). His treatment goals included
improvement of first his academic and then his professional functioning
and romantic life. The stance of validation and curiosity invited him to
explore his inner world, his capabilities, and difficulties. The
treatment addressed attachment patterns of avoidance and introduced the
new experience of helpful reliance on others. Attention to life events,
such as navigation of work challenges and a new romantic relationship,
invited further opportunities for growth. The awareness of my own
reactions to Alec promoted constructive relatedness and flexibility.
Following these treatment principles also allowed a measure of
flexibility, such as deciding to continue treatment despite Alec's
difficulty in following the recommendation to find a job. In doing so,
the treatment took a strategic risk to follow the lead of the patient
and his life context rather than following a ``one size fits all''
approach.

Such flexibility was especially important in other aspects of Alec's
treatment. His treatment had to navigate a constantly changing balance
between the processes occurring within therapy, his challenges and
capabilities, and life-events. Sometimes, processes in therapy, such as
working through his childhood experiences, allowed him greater openness
and capacity to learn, which led him to embark on his own career. At
other times, life experiences, such as a new romantic relationship,
invited him to accept imperfections and adopt a problem-solving,
pragmatic attitude. His ability to engage in treatment and life grew as
a result of his life experiences (e.g., a new partner) as well as his
experiences in treatment (e.g., processing fears that others are not
available to him when he needs them). Such an interaction between life
and therapy is not uncommon in processes of change in people with
pathological narcissism (Ronningstam \& Weinberg, 2023) and it is one of
the reasons that the process of change in patients with pathological
narcissism takes a long time (Weinberg \& Ronningstam, 2022).

Treatment principles, not theories, are close to what guides individual
clinicians in conducting psychotherapy (Castonguay et al., 2019),
including with patients suffering from pathological narcissism (Kealy et
al., 2017). The Dos and Don'ts treatment principles are friendly to most
if not all theoretical approaches and, therefore, can be incorporated
into practices of clinicians from \emph{all} theoretical orientations.
Thus, it invites appreciation of the complexity of individual patients
and avoids a ``one size fits all'' approach. They are
relatively\emph{easy to learn} , as opposed to theory-based approaches
that require mastery of theory and lengthy supervision to ensure
adherence in treatment. Finally, the Dos and Don'ts treatment principles
have the advantage of clinical flexibility (Castonguay et al., 2019),
which what is required of the clinician working with complex and fluidly
changing clinical presentations -- such as patients with pathological
narcissism (Weinberg \& Ronningstam, 2022). Finally, this approach is
suitable for patients that might not be meeting treatability criteria of
other approaches (e.g., not following through with the job
recommendation). Accordingly, an individual patient suffering from
pathological narcissism might be first evaluated for fit for any of the
established approaches, such as TFP, MBT or MIT, and referred. Those
patients that do not meet the treatability criteria, or do not improve
in those approaches, can be referred to the Do's and Don'ts
principle-based approach.

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