NARCISSISTIC PERSONALITY DISORDER: PATTERNS, PROCESSES, AND INDICATORS OF CHANGE IN LONG-TERM PSYCHOTHERAPY

Abstract

Key Aspects

• Challenge of Change in NPD Treatment: The study addresses the long-standing clinical challenge that achieving meaningful change in individuals diagnosed with Narcissistic Personality Disorder (NPD) through psychotherapy is often difficult. Specific pathological traits associated with NPD, such as interpersonal strategies focused on self-enhancement, avoidance of vulnerability, aggression, and excessive need for control, frequently impede the development of a strong therapeutic alliance and hinder progress towards treatment goals, including symptom remission. This establishes the critical need for research into how change occurs in this population.
• Qualitative Study Design and Novelty: This research employed a qualitative methodology, analyzing detailed case reports provided by therapists for eight patients diagnosed with NPD who underwent long-term individual psychotherapy. It represents the first systematic effort to identify and describe the specific patterns, underlying processes, and observable indicators associated with positive change in pathological narcissism within a therapeutic context. This approach allows for an in-depth exploration of the nuances of change beyond quantitative metrics.
• Significant Improvement and Remission: The study yielded significant positive findings, indicating that substantial improvement is possible for individuals with NPD undergoing long-term psychotherapy. All eight patients in the sample demonstrated marked enhancements in overall personality functioning and key life domains, such as successfully engaging in work or educational pursuits and establishing long-term close relationships. Crucially, these improvements culminated in the remission of the NPD diagnosis itself by the end of treatment.
• Gradual Change Process and Contributing Factors: The process of change observed in the patients was typically gradual rather than abrupt, although noticeable shifts sometimes occurred within specific life contexts or following particular events. Beyond the therapeutic relationship itself, several patient-related factors were identified as indicating and potentially contributing to positive change. These included the patient's motivation and commitment to the therapeutic process, development of reflective ability (understanding mental states), improved emotion regulation skills, an enhanced sense of personal agency, and increased engagement in interpersonal and social activities.

Strengths

• Clear Problem Statement

  The abstract clearly articulates the central problem addressed by the study – the difficulty in achieving change in NPD treatment – and highlights the specific aspects of narcissistic pathology that contribute to these challenges. This effectively establishes the context and significance of the research.

  "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." (Page 1)
• Concise Methodology and Novelty

  The abstract concisely summarizes the study's methodology, specifying the qualitative review approach and the sample size (eight patient case reports). It also clearly states the study's novel contribution as the first to explore patterns, processes, and indicators of change in this manner.

  "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." (Page 1)
• Highlights Key Positive Findings

  The abstract effectively highlights the significant positive outcomes observed in the study sample, including improvements in functioning, engagement in work/education and relationships, and importantly, remission of the NPD diagnosis. This provides a compelling overview of the study's main findings.

  "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." (Page 1)
• Identifies Contributing Factors

  The abstract successfully identifies several key factors that appeared to contribute to the observed changes, such as motivation, reflective ability, and emotion regulation. This adds depth to the findings by suggesting potential mechanisms underlying the positive outcomes.

  "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." (Page 1)

Suggestions for Improvement

• Specify Basis for NPD Remission

  This low-impact improvement would enhance the precision of the reported findings. The Abstract is the most concise summary of the study, and clarifying the basis for a key outcome like remission strengthens its informative value. Adding that remission was based on diagnostic criteria provides crucial context for interpreting the significance of this finding, directly addressing how the primary outcome was measured without adding excessive length.

  "All patients showed significant improvement in personality and life functioning... with remission of the NPD diagnosis." (Page 1)

  Implementation: Modify the sentence discussing remission to explicitly state it was based on diagnostic criteria. For example, change "...with remission of the NPD diagnosis" to "...with remission of the NPD diagnosis based on standard diagnostic criteria." or similar phrasing.

INTRODUCTION

Key Aspects

• Limitations of Traditional Change Research for NPD: The introduction critiques traditional psychotherapy change research, which often sought direct cause-effect links between interventions and outcomes. It argues this approach is insufficient for understanding the complexities of change in personality disorders like NPD, where multiple interacting factors are at play. This establishes the need for more sophisticated models that move beyond identifying isolated mechanisms or mediators.
• Multifactorial Integrative Perspective on Change: The paper advocates for understanding change in NPD through a multifactorial, integrative lens, acknowledging that it's a complex process influenced by numerous interacting elements. This perspective considers patient variables (e.g., readiness, motivation, specific pathology), internal processes (e.g., reflective ability, agency), external factors (e.g., life events), and the therapeutic relationship, suggesting change arises from their dynamic interplay rather than solely from specific interventions. This necessitates a transtherapeutic view, looking for common principles across different treatment approaches.
• Complexity and Heterogeneity of NPD: NPD is presented as inherently complex and heterogeneous, characterized by a wide spectrum of functioning, fluidity between states (e.g., grandiosity and vulnerability), and the co-occurrence of healthy and pathological traits. This internal variability, along with differences in severity and comorbidity, leads to multifaceted interactions between internal experience, interpersonal behavior, and life functioning. Recognizing this complexity is fundamental to understanding the diverse ways change can manifest or be hindered in individuals with NPD.
• Proposed Framework for Assessing Change: Drawing from diagnostic frameworks like the DSM-5 Alternative Model and existing research, the study proposes evaluating change across four key domains: 1) Identity and sense of self, 2) Self-functioning (encompassing self-esteem regulation, self-regulation, and sense of agency), 3) Emotion regulation, and 4) Interpersonal relationships. This framework provides a structured method for operationalizing and tracking meaningful shifts in core narcissistic difficulties throughout therapy.
• Challenges in NPD Treatment: The introduction thoroughly outlines the significant clinical challenges in treating NPD, which often stem from the disorder's core features. These include establishing and maintaining a therapeutic alliance (hindered by mistrust, control needs, vulnerability avoidance), managing resistance (e.g., avoidance, intellectualization, rejection of feedback), addressing compromised capacities (like empathy and emotion tolerance), and navigating defensive interpersonal patterns that frequently lead to stalemates or premature treatment termination.
• Emerging Hope and Rationale for the Study: Despite historical pessimism and persistent difficulties, the paper acknowledges recent progress, highlighting the development of specialized treatment models (e.g., TFP, MBT, DBT) and clinical guidelines that offer increased hope for effective intervention. However, it identifies a critical gap: a lack of systematic research into the actual processes, patterns, and indicators of how change occurs in NPD therapy. This gap provides the central justification for the current qualitative study, which aims to fill this void by analyzing successful long-term cases.

Strengths

• Comprehensive Problem Framing

  The introduction effectively establishes the context by outlining the historical difficulties and complexities associated with achieving therapeutic change in Narcissistic Personality Disorder (NPD), thereby clearly justifying the need for novel research perspectives and approaches.

  "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." (Page 1)
• Thorough Literature Review

  The section provides a thorough review of pertinent literature, integrating findings on general psychotherapy change processes, specific NPD characteristics (including diagnostic frameworks like the DSM-5 Alternative Model), known treatment challenges, and factors potentially influencing change (e.g., agency, life events, natural remission).

  "Consequently, changes in personality pathology and functioning must be assessed and understood as a multifactorial integrative process (Kramer, 2018) with open attention to the different factors, characteristics, and contexts that can stimulate and enable as well as prevent the individual patient to change." (Page 2)
• Clear Conceptual Framework and Definitions

  The authors clearly define key terms central to their investigation ('indicators,' 'process,' and 'pattern' of change) and propose a specific, multi-dimensional framework (identity, self-functioning, emotion regulation, interpersonal relationships) for conceptualizing and evaluating shifts in narcissistic functioning, enhancing the study's clarity and operationalization.

  "For the purpose of clarity, indicators of change refer to areas or elements of personality functioning in which observed or reported changes occurred as documented in the case reports. Process of change denotes how and when the changes in personality functioning evolve... The pattern of change refers to the sequence or progression in which noticeable changes occur." (Page 7)
• Strong Rationale for Study

  The introduction successfully articulates a significant gap in the existing literature – the lack of systematic studies examining the nuanced processes and patterns of how change unfolds in NPD treatment – thereby providing a compelling justification for the chosen qualitative case study methodology.

  "Although there are several studies and case documentations of treatment, there are still no systematic studies of conditions and processes of change in patients with NPD in treatment." (Page 7)
• Balanced Perspective on Treatment Challenges and Hope

  The text effectively balances the acknowledgment of persistent and significant challenges in treating NPD with the emerging optimism stemming from newly developed specialized treatment modalities and guidelines, setting a realistic foundation for the study.

  "Despite the complexity of narcissism and its pathology there is by now significantly more hope for engaging patients with pathological narcissism or NPD in treatment. Several treatment modalities have recently been developed or adjusted specifically for narcissistic pathology..." (Page 6)

Suggestions for Improvement

• Strengthen Connection Between Literature Review and Specific Study Aims

  This medium-impact improvement would enhance the logical flow and persuasive power of the introduction. While the literature review is comprehensive, explicitly weaving threads from the reviewed studies (e.g., specific findings on agency, emotion regulation, corrective experiences) directly into the justification for the study's focus on indicators, patterns, and processes would create a tighter argument. This belongs in the introduction as it strengthens the foundation and rationale presented to the reader before the methods are detailed. Clarifying these connections would bolster the study's conceptual grounding, making the transition to the specific aims in 'The Present Study' subsection feel more inevitable and directly derived from the established knowledge base, thereby improving reader comprehension of the study's specific contribution.

  "The aim of the study is to identify indicators, patterns, and processes of change in patients with NPD that can inform about actual and possible factors and conditions that facilitate as well as avert change in patients with NPD in treatment." (Page 7)

  Implementation: In the paragraphs leading into 'The Present Study' (page 7), add sentences that explicitly synthesize key findings from the literature review (e.g., importance of agency from Castonguay & Hill, 2012; role of emotion processing from Kramer et al., 2016) and state how these specific findings necessitate an investigation into the patterns and processes (as defined by the authors) through which such changes manifest in long-term therapy. For example: 'Given the identified importance of factors like agency, reflective ability, and corrective life events in prior research, a deeper understanding of the process by which these factors interact and the specific patterns of change they produce over time in NPD treatment is crucial, motivating the present investigation.'

• Define "Transtherapeutic Perspective" for Clarity

  This low-impact improvement enhances clarity for readers less familiar with psychotherapy integration literature. The term 'transtherapeutic perspective' is introduced on page 2 but not explicitly defined. Providing a brief parenthetical definition or a short explanatory phrase would ensure all readers understand this key concept underpinning the authors' approach to studying change. This clarification fits best within the introduction where the theoretical stance is established. Defining this term improves accessibility and ensures the reader fully grasps the authors' viewpoint that common change principles operate across different therapy models, which is central to their rationale for looking beyond specific techniques.

  "A more integrative and transtherapeutic perspective is called for, which can inspire research that attends to heterogeneity and multiplicity in identifying and understanding change processes in personality functioning (Aafjes-van Doorn & Barber, 2018; Kramer, 2018)." (Page 2)

  Implementation: When the term 'transtherapeutic perspective' is first used on page 2, add a brief definition within parentheses or as an appositive phrase. For example: '...A more integrative and transtherapeutic perspective (i.e., one focusing on common change factors across different therapy models) is called for...' or '...A more integrative and transtherapeutic perspective, which focuses on common principles of change operating across various therapeutic modalities, is called for...'

METHOD

Key Aspects

• Experienced Therapist Sample: The study recruited eight experienced therapists (average 22 years) with diverse, high-level training (MD, PhD, MSW) in established psychotherapy modalities for personality disorders (PDs), including MBT, DBT, TFP, and psychodynamic approaches. This selection aimed to ensure that the case reports reflected treatment delivered by qualified clinicians skilled in managing complex PD presentations, enhancing the credibility of the reported therapeutic processes and outcomes.
• Patient Diagnostic Criteria and Change: Patient selection focused on individuals initially diagnosed with NPD according to DSM-5 Section II criteria (meeting an average of 7.75 criteria), whose diagnoses were retroactively assessed by their therapists and independently confirmed by the study authors. Crucially, these patients no longer met NPD criteria upon treatment termination (average 2.31 criteria), indicating significant clinical change within the sample selected for qualitative analysis. This rigorous diagnostic procedure ensures the study focuses on verified cases of NPD remission.
• Standardized Case Report Data Collection: Data were collected through detailed, 20-page case reports solicited from the therapists, following highly structured guidelines provided by the researchers. These guidelines mandated specific content across distinct sections, covering patient background, initial presentation, therapist assessment, and a longitudinal account of the therapy process divided into standardized timeframes (first 6 months, 7-24 months, third year to termination). This standardized format aimed to ensure comprehensive and comparable qualitative data across all eight cases.
• Focused Areas of Change Documentation: Therapists were specifically instructed to document changes across multiple domains throughout the treatment course, providing rich qualitative data on the study's core interests. Key areas included therapeutic alliance development, challenges, interventions, patient resistance and progress, shifts in work/study engagement and interpersonal relationships (family, friends, romantic), significant life events, comorbidity changes (especially sobriety), and core narcissistic functioning (self-esteem, agency, emotion regulation, empathy, identity, reflection). This targeted data collection focused directly on the indicators, processes, and patterns of change.
• Patient Sample Characteristics and Comorbidity: The study provides demographic and clinical characteristics of the patient sample (N=8), including a wide age range (20-58 years, average 30.9), varied educational backgrounds, and significant psychiatric comorbidity. Common co-occurring conditions included borderline personality disorder traits/diagnosis, depressive disorders, eating disorders, and substance use disorders, highlighting the clinical complexity typical of individuals seeking treatment for NPD. This contextual information is vital for interpreting the findings and considering their applicability.

Strengths

• Detailed Therapist Qualifications

  The method clearly specifies the professional background, extensive experience (average 22 years), and relevant training (MBT, DBT, TFP, psychodynamic/analytic) of the participating therapists. This detail enhances confidence in the quality of the therapeutic interventions and the subsequent case reporting.

  "The therapists were professionally educated (MD, PhD, and MSW) with an average of 22 years of experience. All had training in well-established or evidence-based treatment modalities for personality disorders..." (Page 8)
• Clear Diagnostic Criteria and Confirmation

  The diagnostic process is explicitly described, including the use of standardized DSM-5 Section II criteria for NPD, retroactive assessment by therapists, and independent confirmation by the authors. Reporting the average number of criteria met at start (7.75) and end (2.31) provides quantitative support for the significant change observed.

  "The patients’ diagnoses at the start and end of the treatment were assessed retroactively by the therapists using the nine diagnostic criteria for NPD (DSM-5 Section II; APA, 2013). Each patient’s diagnosis was confirmed by the authors’ independent evaluation of each case report." (Page 8)
• Standardized Case Report Instructions

  The paper outlines highly specific instructions given to therapists for structuring the 20-page case reports, including distinct sections and detailed content requirements covering patient history, initial presentation, standardized timeframes, alliance building, interventions, and specific areas of change (e.g., personality functioning, life domains, comorbidity). This structured approach promotes consistency and comprehensiveness in data collection across cases.

  "The therapists were instructed to outline a 20-page case report and include the following background information... The second section described... The third section was divided into standardized timeframes... Specific focus was on..." (Page 8)
• Explicit Treatment Duration and Frequency

  The method clearly states the range (2.5-5 years) and average (3.5 years) duration of treatment, as well as the frequency (1-4 sessions/week). This information is crucial for contextualizing the findings within a long-term psychotherapy framework.

  "The length of treatment ranged between 2½ and 5 years (average 3½ years) with one to four sessions/week." (Page 8)
• Comprehensive Patient Sample Description

  The inclusion of Table 1 and the accompanying text provides valuable demographic and clinical context for the patient sample, detailing age range, common comorbidities (BPD, depression, SUD, eating disorders), educational background, and treatment modalities utilized. This transparency aids in understanding the characteristics of the patients who demonstrated change.

  "The patients’ demographics, psychiatric conditions, treatment modalities... are displayed in Tables 1 and 2. The patients’ age range was between 20 and 58 years, and their most common comorbidities were borderline personality disorder, depressive disorder, eating disorder, and substance use disorder." (Page 9)

Suggestions for Improvement

• Specify Therapist Selection/Invitation Process

  This medium-impact improvement would enhance the study's transparency regarding potential selection bias. The Method section is the appropriate place to detail participant recruitment. Explicitly describing how the eight therapists were identified and invited (e.g., professional networks, specific clinics, response to an open call) would allow readers to better assess the representativeness of the therapist sample and, consequently, the generalizability of the findings derived from their case reports. Clarifying the selection process strengthens the methodological rigor by addressing potential biases in who provided the case data.

  "Eight therapists accepted an invitation to provide a case report documenting the treatment of a patient with NPD who had shown significant improvement..." (Page 8)

  Implementation: Add 1-2 sentences describing the therapist recruitment process. For example: 'Therapists known to the authors through professional networks/affiliated with [Institution]/who responded to a call circulated via [Mechanism] and known to specialize in long-term PD treatment were invited to participate.'

• Detail Qualitative Data Analysis Method

  This high-impact improvement is crucial for the study's scientific rigor and reproducibility. The Method section must detail how the collected data were analyzed. While the structure for collecting case report data is detailed, the process for analyzing this rich qualitative information (20 pages per patient) is absent. Specifying the qualitative analysis approach (e.g., thematic analysis, content analysis, narrative analysis, specific coding procedures, use of software, inter-rater reliability checks if applicable) is essential for readers to understand how the reported patterns, processes, and indicators of change were systematically derived from the raw case material. This omission significantly limits the ability to evaluate the validity and reliability of the qualitative findings.

  "The therapists were instructed to outline a 20-page case report..." (Page 8)

  Implementation: Add a paragraph detailing the qualitative data analysis method. Specify the approach used (e.g., 'Thematic analysis was conducted following the procedures outlined by Braun & Clarke (2006)...'), how themes/patterns were identified, whether coding software was used, and any steps taken to ensure analytic rigor (e.g., multiple coders, consensus meetings).

• Operationally Define Initial 'Significant Improvement' Criterion

  This medium-impact improvement would enhance clarity regarding the study's inclusion criteria. The Method section should precisely define key selection parameters. While the text states therapists were invited to report on patients showing 'significant improvement,' this term lacks operationalization. Defining how 'significant improvement' was determined at the point of therapist invitation (e.g., therapist judgment based on global functioning, specific symptom reduction thresholds, meeting remission criteria preliminarily) would clarify the initial selection criteria for the cases included in the study, distinct from the final outcome assessment using DSM criteria. This specification helps readers understand the nature of the sample selected for in-depth analysis.

  "Eight therapists accepted an invitation to provide a case report documenting the treatment of a patient with NPD who had shown significant improvement in symptoms and functioning..." (Page 8)

  Implementation: Add a sentence clarifying the basis for the initial determination of 'significant improvement' used for therapist invitation. For example: 'Therapists were asked to select a case based on their clinical judgment of significant overall improvement in psychosocial functioning and symptom reduction by the end of therapy.' or 'Significant improvement was initially defined as the therapist's assessment that the patient no longer met full criteria for NPD.'

OBSERVATIONS

Key Aspects

• Patient Sample Characteristics and Treatment Context: The patient sample (N=8) presented with significant clinical complexity at baseline, characterized by a wide age range (20-58), varied educational attainment, and substantial psychiatric comorbidity alongside NPD. Commonly co-occurring conditions included borderline personality disorder (traits or diagnosis), depressive disorders, eating disorders, and substance use disorders. Patients received diverse individual psychotherapies (psychodynamic/analytic, MBT, DBT, TFP, eclectic) often supplemented with multimodal treatments (residential, group, family therapy) in earlier stages.
• Significant Improvement in External Functioning: Across the sample, long-term psychotherapy was associated with marked improvements in external functioning, substantiated by quantitative and qualitative data comparing baseline to endpoint. Significant gains were observed in vocational/educational engagement (from none to all active), financial independence (from 1 to 8 self-sufficient), and the capacity for stable relationships (from 1 to 7 involved). This was mirrored by a substantial increase in average Global Assessment of Functioning (GAF) scores, from 40 (major impairment) to 70 (generally functioning well with mild symptoms).
• Varied Initial Therapeutic Engagement and Resistance: Initial patient engagement in therapy varied considerably; while two patients were committed from the outset, the majority (six) displayed initial opposition, skepticism, or avoidance regarding the therapeutic process, diagnosis, or treatment goals (especially work/sobriety). This highlights the common challenge of establishing a working alliance and motivating change in this population, setting the stage for the gradual shifts observed later in treatment.
• Gradual Change Process and Sequence: The process of change was predominantly characterized as a gradual, stepwise progression rather than abrupt shifts, although specific life events (e.g., losses, new relationships, work/school transitions) catalyzed noticeable changes for half the sample. Change typically unfolded in a sequence, often beginning with increased commitment to work/studies and enhanced reflective/mentalizing ability, followed by improvements in relationships, with changes in core self-esteem regulation (e.g., reduced grandiosity, increased tolerance of vulnerability) emerging more slowly.
• Role of Therapy Frame, Alliance, and Life Experiences: Both the structure and requirements of the therapeutic frame (even when initially resisted) and the therapeutic alliance itself, alongside impactful external life experiences (work, relationships, sobriety, losses), were identified as contributing factors to the change process. These elements interacted dynamically, with therapy providing a context to process life events and life events sometimes prompting deeper engagement in therapy, gradually fostering shifts in personality functioning.
• Specific Changes in Narcissistic Symptoms/Functioning: Beyond broad functional improvements, specific changes indicative of shifts in underlying narcissistic pathology were observed by therapists. These included reported decreases in procrastination, avoidance, argumentativeness, self-criticism, and grandiose fantasies. Concurrently, increases were noted in authenticity, tolerance of limitations, self-worth, capacity for mutuality, empathy, and improved balance between extremes like perfectionism/self-criticism or self-enhancement/devaluation.
• Connection to Core Mechanisms of Change: The observed improvements were linked to several core transtherapeutic mechanisms of change commonly cited in personality disorder treatment. The therapeutic alliance was deemed essential across all cases. Emotional processing (awareness and tolerance of feelings) was highlighted, particularly in psychodynamic and DBT cases. Enhanced sociocognitive capabilities (reflective ability, mentalization) were noted as key components, especially in MBT and TFP cases, suggesting common pathways to change despite differing techniques.

Strengths

• Clear Data Presentation via Tables

  The section effectively utilizes tables (Tables 1, 2, and 3) to concisely summarize complex information regarding patient demographics, comorbidities, treatment modalities, baseline and endpoint functioning (GAF, work, relationships, finances), and observed patterns of change. This enhances clarity and allows for quick comprehension of key quantitative and qualitative observations.

  "The patients’ demographics, psychiatric conditions, treatment modalities, level of functioning at the beginning and end of treatment... are displayed in Tables 1 and 2." (Page 9)
• Quantification of Functional Improvement

  The authors clearly quantify the significant improvements observed in the patient sample, contrasting baseline and endpoint data. Specifically citing the average GAF score increase (40 to 70) and the shifts in employment, relationships, and financial independence provides concrete evidence supporting the claim of positive change.

  "Their average GAF score had risen from 40... to 70... None of the patients were occupationally or educationally engaged in the beginning... but all were actively working or studying at the end. Seven were financially dependent... but at the end of the treatment all eight were financially responsible and independent..." (Page 10)
• Detailed Description of Initial Patient Presentation

  The section effectively describes the variability in patients' initial engagement with therapy, noting that while some were committed, a majority exhibited resistance or skepticism towards the therapeutic frame and goals. This provides crucial context for understanding the subsequent process of change.

  "The reports indicated that the patients’ initial interactive patterns... varied significantly. Two of the patients were at the start committed... Most of the patients (n = 6), however, were initially, in various ways and degrees, oppositional, unmotivated, critical, or dismissive of the therapeutic frame..." (Page 11)
• Identification of Change Patterns and Sequences

  The observations successfully identify and categorize distinct patterns and sequences related to the change process, such as the gradual nature of change, the role of specific life events, the typical order in which improvements were noted (e.g., work/studies, reflective ability first), and key patient-related indicators (e.g., agency, emotion regulation). This structured presentation (summarized in Table 3) moves beyond simple outcome reporting to describe the dynamics of change.

  "There were several identifiable change-related patterns and sequences (see Table 3). All patients demonstrated a gradual stepwise process of change." (Page 11)
• Integration with Theoretical Mechanisms of Change

  The section appropriately connects the observed improvements to established theoretical mechanisms of change in psychotherapy (e.g., therapeutic alliance, emotional processing, reflective ability/mentalization), linking the findings back to broader clinical theory and specific modalities like psychodynamic therapy, DBT, MBT, and TFP.

  "In sum, the improvements mentioned above relate to several mechanisms of change... the therapeutic alliance... Emotional processing... sociocognitive capability and associated reflective ability and mentalization..." (Page 12)

Suggestions for Improvement

• Explicitly Link Findings to Qualitative Analysis Method

  This high-impact improvement would enhance the methodological transparency and trustworthiness of the presented findings. The Observations section reports patterns and indicators derived from qualitative data, but lacks an explicit statement connecting these findings back to the (absent in Method) qualitative analysis process. Stating how these patterns were synthesized (e.g., through thematic analysis, consensus coding) is crucial for readers to understand the basis of the reported observations, particularly those summarized in Table 3. This clarification belongs here as it directly pertains to the origin and interpretation of the presented results.

  "There were several identifiable change-related patterns and sequences (see Table 3)." (Page 11)

  Implementation: Add a sentence or phrase clarifying the analytic process used to derive the patterns and indicators from the case reports. For example, before presenting Table 3 or its description, state: 'Through qualitative analysis [specify method, e.g., thematic analysis] of the therapist reports, several identifiable change-related patterns and sequences emerged:' or similar wording that links the findings to the analysis method.

• Clarify Distinction Between Constructs in Table 3

  This medium-impact improvement would enhance the clarity and precision of the reported findings within the Observations section. Table 3 presents two related but distinct lists: 'Sequence of changes / Areas of personality functioning' and 'Patient-related indicators of change (first 2 years)'. While related, the conceptual distinction and relationship between these lists could be clearer. Explicitly defining or differentiating these categories (e.g., are 'indicators' the internal capacities enabling changes in 'areas of functioning'?) would prevent potential reader confusion and allow for a more nuanced understanding of the change process as observed.

  "TABLE 3. Patterns and Indicators of Change" (Page 12)

  Implementation: In the text discussing Table 3 (page 11 or 12), add a sentence clarifying the relationship between the 'Areas of personality functioning' where change was sequenced and the 'Patient-related indicators' observed. For example: 'These observable changes in functional areas appeared related to underlying shifts in patient capacities, termed patient-related indicators of change, such as...' or explicitly define how 'indicators' differ from 'areas'. Alternatively, refine the table subheadings for greater clarity.

• Acknowledge Limitation on Modality-Specific Outcome Links

  This medium-impact improvement enhances the precision of reporting within the Observations section. While the end of the section links observed changes to general mechanisms associated with different therapy types (psychodynamic, DBT, MBT, TFP), it doesn't explicitly state whether the qualitative review attempted to link specific outcomes in individual patients to their specific treatment modality, or if this was beyond the scope of the observational analysis. Adding a brief clarifying statement about the limitations in drawing direct patient-specific modality-outcome links from the case reports at this stage would manage reader expectations and accurately reflect the nature of the observational data presented.

  "Although not specifically measured, each case report points to core processes of change within the reported treatment modality. In line with those mechanisms outlined by Kramer (2018)..." (Page 12)

  Implementation: Towards the end of the section (page 12), after linking changes to general mechanisms and modalities, add a sentence acknowledging the limitation. For example: 'However, the qualitative review did not systematically analyze or establish direct causal links between specific treatment modalities and the observed changes for individual patients within this case series.'

Non-Text Elements

TABLE 1. Patients' Demographics, Comorbid Psychiatric Conditions, and Treatment...

Full Caption

TABLE 1. Patients' Demographics, Comorbid Psychiatric Conditions, and Treatment Modalities at Start of Treatment

Figure/Table Image (Page 9)

First Reference in Text

The patients' demographics, psychiatric conditions, treatment modalities, level of functioning at the beginning and end of treatment, including Global Assessment of Functioning (GAF) scores, vocational and educational commitment, close relationships, and financial dependency versus self-sufficiency are displayed in Tables 1 and 2.

Description

• Table Overview: This table provides a snapshot of the characteristics of the eight individuals who participated in the study before their long-term psychotherapy began. It details their age, other mental health conditions they had alongside Narcissistic Personality Disorder (NPD), their educational background, and the types of therapy they were receiving at the study's start.
• Age Distribution: The patients' ages ranged from 20 to 58 years old, with the average age being approximately 31 years (30.9). This indicates a mix of younger and middle-aged adults.
• Comorbid Psychiatric Conditions: The table lists several other psychiatric conditions, known as comorbidities, present in the patients. 'Comorbidity' simply means having more than one medical condition at the same time. The most common were Borderline Personality Disorder (BPD, affecting 4 patients) - a condition often characterized by unstable relationships, self-image, and emotions - and Depressive disorder (also affecting 4 patients). Other conditions included Substance use disorder (3 patients), Eating disorder (3 patients), Bipolar II disorder (1 patient) - marked by depressive and hypomanic episodes, Antisocial Personality Disorder (ASPD) traits (1 patient) - ASPD involves disregard for others' rights, and Obsessive-compulsive disorder (1 patient).
• Educational Background: Regarding education, all 8 patients had completed high school. Beyond that, educational attainment varied: 2 were college graduates, 4 had attended college but dropped out, and 2 had obtained graduate school degrees.
• Primary Individual Treatment Modalities: The table outlines the therapeutic approaches used at the start. For primary individual therapy, the most common was Psychodynamic/psychoanalytic psychotherapy (3 patients), which focuses on unconscious processes and past experiences. Other therapies included Mentalization-Based Treatment (MBT, 1 patient), which helps patients understand their own and others' mental states; Dialectical Behavior Therapy (DBT, 1 patient), often used for BPD, focusing on skills like mindfulness and emotion regulation; Transference-Focused Psychotherapy (TFP, 1 patient), another psychodynamic approach emphasizing the patient-therapist relationship; and Eclectic therapy (2 patients), which combines techniques from different therapeutic schools.
• Multimodal Treatments: In addition to individual therapy, many patients were involved in other forms of treatment (multimodal treatment). Four patients participated in residential treatment (living in a therapeutic facility), five received family therapy, and three attended DBT group therapy sessions.

Scientific Validity

• Relevance of Data: The table appropriately presents baseline characteristics essential for understanding the study sample. Demographics, comorbidities, and prior/concurrent treatments are crucial covariates in psychotherapy research.
• Sample Size Limitation: The primary limitation is the small sample size (n=8). While typical for qualitative case series, this significantly limits the generalizability of any findings derived from this group to the broader population of individuals with NPD.
• Consistency in Comorbidity Reporting: Reporting 'ASPD (traits)' for one patient versus diagnoses for others introduces slight inconsistency. Clarifying the threshold used for reporting traits versus a full disorder would enhance precision.
• Diagnostic Ascertainment Method: The method for ascertaining diagnoses (retroactive therapist reports confirmed by authors, as per page 344) should be kept in mind when interpreting these baseline data, as it relies on recall and potentially variable diagnostic practices, though confirmation adds rigor.
• Treatment Modality Categorization: The categorization of treatment modalities appears sound, distinguishing primary individual therapy from adjunctive multimodal treatments, which accurately reflects complex care scenarios.

Communication

• Organization and Clarity: The table is well-organized with clear headings and categories (Age, Comorbidity, Level of education, Treatment modalities). The use of 'n' to denote the number of patients within each category is appropriate and standard.
• Caption Accuracy: The caption accurately reflects the content presented in the table, clearly stating it covers baseline demographics, comorbidities, and treatment modalities.
• Use of Abbreviations and Notes: The inclusion of a note defining abbreviations (BPD, ASPD) enhances clarity, although expanding this to include less common therapy acronyms (MBT, TFP) might benefit readers less familiar with specific psychotherapy modalities.
• Ambiguity in Comorbidity Counts: It is slightly ambiguous whether the comorbidity counts represent unique patients having at least that disorder, or if patients could be counted in multiple categories, summing to more than 8. Clarifying this (e.g., stating the total number of patients with any comorbidity) could improve precision.
• Clarity of Treatment Categories: The distinction between 'Prime individual treatment' and 'Multimodal treatment' is clear and effectively communicates the different therapeutic contexts.

TABLE 2. Patients' Level of Functioning at Start and End of Treatment

Figure/Table Image (Page 10)

First Reference in Text

All eight patients showed significant improvement in external personality and life functioning as measured by their engagement in work or studies, long-term relationships, and degree of financial responsibility and independence (Table 2) (Weinberg & Ronningstam, 2023).

Description

• Table Overview: This table compares how the eight patients were functioning in key life areas at the beginning of their long-term psychotherapy versus at the end. It looks at their overall functioning, work or study engagement, relationships, and financial independence.
• Global Assessment of Functioning (GAF) Change: A significant change is shown in the average Global Assessment of Functioning (GAF) score. The GAF scale is a numerical rating (0-100) used by clinicians to assess a person's overall level of psychological, social, and occupational functioning; higher scores indicate better functioning. The average score increased substantially from 40 at the start (indicating major impairment in several areas like work, relationships, or mood) to 70 at the end (indicating mild symptoms or some difficulty in social/occupational functioning, but generally functioning pretty well).
• Work Status Change: Regarding work, there was a dramatic shift. At the start, 6 patients were unemployed and 2 had never worked. By the end, 5 were employed, with 3 in professional careers, 1 in skilled work, and 1 in temporary work. None remained unemployed or had never worked.
• Study Status Change: Similarly, in education ('Studies'), no patients were engaged in studies at the start, whereas by the end, 3 patients were attending college or graduate school.
• Relationship Status Change: In terms of relationships, only 1 patient was married at the start, with 7 having no relationship. By the end, 6 patients were in stable long-term relationships or married, 1 was dating, and only 1 reported no relationship.
• Financial Situation Change: Financially, 7 out of 8 patients were dependent on parents or relatives at the start, with only 1 being self-sufficient (fully or partly). At the end of treatment, all 8 patients were reported as fully or partly self-sufficient, and none were dependent.

Scientific Validity

• Focus on Functional Outcomes: Presenting functional outcomes (work, relationships, finances, GAF) is crucial in treatment studies, as symptom reduction doesn't always equate to improved life functioning. This table addresses that important dimension.
• Use of GAF Score: The GAF score provides a global metric, but its reliability and validity have been debated, and it's known to be subjective. Its removal from the main DSM-5 criteria section reflects these concerns, although it remains a widely understood historical measure. The substantial change reported (40 to 70) is clinically significant.
• Magnitude of Reported Change: The improvements shown across all domains (work/study, relationships, finances) are striking, suggesting substantial positive change. However, the data are categorical counts based on retroactive therapist reports.
• Sample Size Limitation: The small sample size (n=8) severely limits the ability to generalize these findings. While indicative of potential change within this specific group, these results cannot be assumed to apply broadly to all NPD patients in long-term therapy.
• Assessment Method (Retroactive): The reliance on retroactive therapist assessment introduces potential recall bias and lacks the rigor of prospective, standardized assessments by independent raters.
• Lack of Statistical Testing within Table: The table presents descriptive counts ('n='). While the reference text claims 'significant improvement', the table itself doesn't include statistical tests (e.g., McNemar tests for paired categorical data, paired t-test for GAF) to formally assess the statistical significance of these changes from start to end.
• Ambiguity in Financial Category: The definition of 'Self-sufficient (fully or partly)' could be more precise. Does 'partly' still involve some dependence?

Communication

• Layout and Comparability: The table effectively uses a side-by-side layout to contrast patient functioning at the start versus the end of treatment, facilitating easy comparison across different domains (Work/Studies, Relationships/Finances).
• Categorization: Categorization of functioning into distinct areas (Work, Studies, Relationships, Finances) is logical and clearly presented.
• GAF Score Presentation: The presentation of GAF scores provides a concise summary measure of overall functioning change. Including the note defining GAF is crucial for readers unfamiliar with this scale.
• Detail in Employment Status: The breakdown of employment status at the end of treatment (Professional, Skilled, Temp) adds useful granularity beyond simply stating 'Employed'.
• Clarity of Counts: The use of 'n = x' clearly indicates the number of patients in each category, which is standard and effective.
• Caption Accuracy: The caption accurately reflects the table's content, focusing on the change in functioning levels over the course of treatment.

TABLE 3. Patterns and Indicators of Change

Figure/Table Image (Page 12)

First Reference in Text

There were several identifiable change-related patterns and sequences (see Table 3).

Description

• Table Overview: This table summarizes how change happened and what specific changes were observed in the eight patients undergoing long-term therapy for Narcissistic Personality Disorder (NPD). It breaks down the process into the pace of change, the order in which improvements appeared, and specific internal shifts noticed early on.
• Pace of Change (Gradual/Sudden): Regarding the pace of change, all 8 patients showed a 'stepwise, gradual process of changes over time'. Additionally, 4 patients experienced moments of more sudden change, often linked to specific life events like family events, losses, or starting new jobs or relationships.
• Sequence of Change: Early Improvements: The table outlines the sequence in which improvements in different areas of personality functioning were typically noticed by therapists. The earliest changes noted were often in 'Commitment to work or education' (noticed first in 5 patients) and 'Reflective and mentalizing ability' (noticed first in 5 patients). 'Reflective and mentalizing ability' refers to the capacity to think about one's own and others' thoughts, feelings, and intentions. Improvements in 'Interpersonal relations' (like friendships or close relationships) and 'Self-esteem regulation' (managing feelings of self-worth, reducing grandiosity, tolerating insecurity) were noticed first in fewer patients (3 each).
• Sequence of Change: End of Treatment Status: By the end of treatment, improvements were noted in most patients across these areas, though not universally. Commitment to work/education was seen in all 8 patients. Improved interpersonal relations were noted in 7 patients. Enhanced reflective/mentalizing ability was noted in 6 patients. Better self-esteem regulation was observed in 5 patients, suggesting this area remained challenging for some even at termination.
• Early Patient-Related Indicators: The table also lists key internal changes ('Patient-related indicators') observed within the first two years of treatment. 'Reflective ability, curiosity, forming narratives' (telling coherent stories about their experiences) was seen in 6 patients. A stronger 'Sense of agency, responsibility, initiatives' (feeling in control of their lives, taking ownership) was noted in 5 patients. Better 'Emotion regulation and tolerance' (managing feelings without being overwhelmed) was seen in 5 patients. Increased 'Interpersonal and social engagements' were also noted in 5 patients.

Scientific Validity

• Qualitative Data Synthesis: The table synthesizes qualitative observations from therapist reports into quantifiable counts, providing a structured overview of perceived change patterns and indicators in a hard-to-study population.
• Reliance on Subjective Therapist Reports: The primary limitation stems from the data source: retrospective therapist observations. This introduces potential subjectivity, recall bias, and lack of standardized assessment for the indicators (e.g., 'reflective ability', 'sense of agency'). The counts reflect therapist judgment rather than objective measurement.
• Small Sample Size: The small sample size (n=8) significantly limits the generalizability of these observed patterns and sequences. These findings are suggestive for this cohort but cannot be assumed to represent universal pathways of change in NPD treatment.
• Theoretical Relevance of Indicators: The indicators listed (reflective ability, sense of agency, emotion regulation) are theoretically relevant constructs in personality change, aligning with models of psychotherapeutic process.
• Temporal Dimension: The distinction between 'First noticed' and 'Noticed at end of treatment' provides a useful, albeit potentially approximate, temporal dimension to the observed changes.
• Confounding Treatment Factors: The heterogeneity of treatment modalities (psychodynamic, MBT, DBT, etc.) and the use of multimodal treatments make it difficult to attribute the observed patterns solely to one specific therapeutic factor; they likely reflect a combination of influences.

Communication

• Structure and Organization: The table is logically structured, separating the nature of change (gradual/sudden), the sequence in which different functional areas improved, and specific patient-related indicators observed early in treatment.
• Temporal Clarity: The use of distinct columns for 'First noticed' and 'Noticed at end of treatment' effectively communicates the temporal sequence of observed improvements in different areas.
• Clarity of Indicators: The listed indicators (e.g., 'Commitment to work or education', 'Reflective and mentalizing ability') are relatively clear, although some terms ('reflective ability', 'sense of agency') rely on the reader's familiarity with psychotherapeutic concepts or the main text for full understanding.
• Use of Counts: Presenting the findings as counts ('n' out of 8) is straightforward and appropriate for this type of qualitative summary, clearly indicating how many patients exhibited each pattern or indicator.
• Caption Accuracy: The caption accurately describes the table's focus on patterns and indicators of change.

DISCUSSION

Key Aspects

• Factors Promoting Change in NPD: The discussion synthesizes qualitative findings to identify several key factors that appear to promote positive change in individuals with NPD during long-term psychotherapy. These include the patient's developing openness and motivation for change (often spurred by life events or gradual realization), commitment to external responsibilities like work or study (serving as both an indicator and mechanism of change), the ability to form and maintain meaningful interpersonal relationships, engagement in multimodal treatment approaches tailored to individual needs, the paradoxical facilitating effect of certain comorbidities (e.g., BPD traits increasing accessibility, SUD abstinence revealing underlying issues), and developmental shifts associated with life stages.
• Challenges Inhibiting Change in NPD: Complementing the facilitators, the discussion outlines significant challenges and circumstances that can impede therapeutic progress in NPD. Intense negative reactions to receiving the NPD diagnosis itself, often fueled by stigma and misunderstanding, can hinder alliance building. A profound fear of change, linked to relinquishing familiar identities or facing the unknown, can lead to resistance or termination. The characteristic narcissistic need for control and associated perfectionism often manifests as resistance. Difficulties managing anger and aggression (both self-directed and interpersonal), including defensive projection, pose significant hurdles. Finally, deeply ingrained dysfunctional identities (e.g., 'the sick child') can represent major obstacles to engagement and change.
• Acknowledged Study Limitations: The discussion explicitly addresses the study's methodological limitations, crucial for interpreting the findings appropriately. Key limitations include the reliance on therapists' retrospective case reports (subject to bias and adherence to specific modalities), the potential confounding effects of multimodal treatments, the lack of independent, systematic assessments (including structured diagnostics and change markers), the use of potentially restrictive DSM-5 Section II NPD criteria (limiting generalizability, especially regarding vulnerable presentations), the absence of baseline and follow-up comorbidity symptom measures, and the lack of direct patient perspectives on their experiences and motivations for change.
• Core Conclusions and Possibility of Change: The discussion concludes by reaffirming the central finding that meaningful change and even remission are attainable for individuals with NPD through long-term psychotherapy, particularly when multimodal approaches are employed. It emphasizes that change is a complex, multifactorial process occurring gradually, often influenced by life events alongside therapy. Key indicators of progress include external functioning (work, relationships) and internal capacities (reflective ability, emotion regulation, agency). Importantly, it highlights that core issues like self-esteem dysregulation must be addressed within this complex context, considering the interplay of therapy, patient factors, and life circumstances.
• Interplay of Therapy, Life Events, and Patient Factors: A significant point emphasized in the discussion is the complex interplay between therapeutic interventions, patient characteristics, and external life events in fostering change. Realizations prompting change can emerge both within therapy (e.g., through exploration, interpretation) and from real-life experiences (e.g., losses, achievements), which can, in turn, motivate deeper therapeutic engagement. The study suggests that effective treatment requires attention to this dynamic interaction, recognizing that change in core narcissistic features like self-esteem regulation is influenced by multiple internal and external factors simultaneously.
• Role of Multimodal Treatment: The discussion highlights the potential benefits of multimodal treatment approaches for NPD, where individual psychotherapy is combined with other modalities like group therapy, family therapy, or residential programs. Examples illustrate how such combinations can provide necessary structure, support alliance building, offer skills training (e.g., DBT for emotion regulation), and provide direct opportunities to address interpersonal patterns. This suggests that integrating different therapeutic components may be particularly effective in addressing the multifaceted challenges presented by NPD.

Strengths

• Effective Synthesis of Findings

  The Discussion section effectively synthesizes the complex qualitative findings presented in the Observations section, organizing them into coherent categories of factors promoting change and factors challenging change. This structure aids reader comprehension.

  "This study further confirms that change in narcissistic personality functioning is a complex process influenced by a range of factors. The qualitative analysis of the therapists case reports suggests that change in narcissistic pathology can be promoted by the following factors and circumstances." (Page 13)
• Nuanced Exploration of Factors

  The section provides nuanced descriptions of various factors influencing change, such as the dual role of work/study and relationships as both indicators and promoters of change, and the paradoxical role comorbidity can sometimes play.

  "Comorbidity can at times paradoxically facilitate treatment engagement and processing of narcissistic pathology. In the context of co-occurring borderline pathology, for example, traits or diagnosis of borderline personality disorder (BPD) narcissistic personality functioning can become more obvious and accessible..." (Page 14)
• Highlights Key Treatment Challenges

  The discussion appropriately identifies and elaborates on significant challenges specific to treating NPD, including patient reactions to the diagnosis, fear of change, need for control, managing anger/aggression, and dysfunctional identity narratives, grounding these in clinical observation.

  "Fear of Change. Change in personality functioning and life engagement inevitably involves both giving up something familiar and facing the unknown and uncontrollable. In addition, fear of change can also relate to questioning or giving up a deeply familiar sense of identity and self-defining narrative." (Page 15)
• Acknowledges Study Limitations

  The section includes a dedicated 'Limitations' subsection (pages 16-17), acknowledging methodological constraints such as reliance on retrospective therapist reports, lack of independent raters, potential influence of multimodal treatments, restrictive diagnostic criteria (DSM-5 Section II), absence of specific comorbidity measures, and lack of patient perspective. This demonstrates appropriate scientific caution.

  "This study has several limitations. As a qualitative review of therapists case reports, the results and conclusions in this study are highly influenced by the therapists' adherence to their primary treatment modality..." (Page 16)
• Strong Concluding Summary

  The Conclusions subsection effectively summarizes the key takeaways, emphasizing the possibility of change in NPD, the importance of markers like work/relationships, the role of internal capacities (reflection, agency), the multifactorial nature of change, and the influence of multimodal treatment contexts.

  "The final conclusion from this study is that changes in narcissistic personality disorder are possible and attainable in treatment." (Page 18)

Suggestions for Improvement

• Enhance Theoretical Integration and Mechanistic Explanation

  This medium-impact improvement would enhance the theoretical depth and explanatory power of the Discussion. This section is the primary place for interpreting findings within broader theoretical contexts. While factors promoting and inhibiting change are identified, the discussion could more explicitly connect these factors to specific psychodynamic concepts (e.g., defense mechanisms like projection, splitting; object relations; attachment dynamics), cognitive-behavioral frameworks (e.g., schema activation, maladaptive coping), or mentalization theory concepts that were alluded to in the Introduction and Observations. Doing so would provide a richer understanding of how these factors might operate mechanistically to influence change in NPD, moving beyond description towards deeper explanation and strengthening the study's contribution to theory.

  "This study further confirms that change in narcissistic personality functioning is a complex process influenced by a range of factors." (Page 13)

  Implementation: In the subsections discussing 'Factors Promoting Change' and 'Challenges to Change', integrate more explicit links to relevant psychological theories. For instance, when discussing 'Fear of Change' (p. 15), connect it to concepts like identity diffusion or defenses against vulnerability. When discussing 'Anger and Aggression' (p. 16), link it more directly to theories of narcissistic rage or deficits in affect regulation. When discussing 'Openness to Change' (p. 13), relate it to concepts like ego strength or developing mentalization capacity.

• Elaborate on Clinical Applications and Therapeutic Strategies

  This medium-impact improvement would increase the practical utility of the findings for clinicians. The Discussion section should ideally translate research findings into actionable insights for practice. While the study identifies factors associated with change (e.g., commitment to work, interpersonal relationships, managing need for control), it could more explicitly discuss how therapists might leverage these insights. For example, how might awareness of the importance of 'Commitment to Work or Study' influence therapeutic goal-setting or interventions? How might therapists address the 'Need for Control' or 'Fear of Change' therapeutically, based on these observations? Elaborating on these clinical applications would make the research more directly relevant and useful for therapists working with this challenging population.

  "This also opens new perspectives on targets for interventions in treatment of pathological narcissism." (Page 18)

  Implementation: Within the discussions of specific factors (promoting and challenging change), add brief commentary on potential clinical strategies or stances. For example, after discussing 'Commitment to Work or Study' (p. 13), add a sentence like: 'This suggests therapists might actively prioritize and support vocational engagement as both a goal and a facilitator of broader change.' When discussing 'Need for Control' (p. 15), consider adding: 'Clinicians may need to find ways to empathically address the underlying fears driving control needs while collaboratively exploring alternative coping strategies.'

• Integrate Acknowledgement of Limitations More Contextually

  This low-impact improvement would enhance the flow and integration of the Discussion section. While having a dedicated Limitations subsection (pages 16-17) is standard and appropriate, the transition into it feels somewhat abrupt, and the main discussion preceding it could better foreshadow these limitations. The Discussion's primary role involves interpreting findings, and acknowledging relevant constraints during the interpretation process strengthens the argument. Briefly mentioning key limitations (e.g., retrospective data, therapist perspective) when discussing specific findings derived from that data (like therapist-observed 'realizations' or 'reflective ability') would create a more integrated and critically aware narrative before the comprehensive summary in the Limitations subsection.

  "LIMITATIONS" (Page 16)

  Implementation: In the main body of the Discussion (pages 13-16), subtly integrate acknowledgements of relevant limitations where specific interpretations are made. For example, when discussing therapist observations of internal patient changes like 'realizations' (p. 13) or shifts related to 'projection' (p. 16), add brief qualifiers like '...as perceived retrospectively by the therapists...' or '...keeping in mind the reliance on therapist reports...'. This contextualizes the interpretations before the formal Limitations section.