This study aimed to address the long-standing challenge of facilitating change in individuals with Narcissistic Personality Disorder (NPD), a condition often resistant to treatment. Moving beyond simply asking if change is possible, the researchers sought to understand how positive change unfolds by identifying specific patterns, processes, and indicators associated with improvement during long-term psychotherapy. The research fills a gap, as systematic studies exploring the nuances of the change process itself in NPD treatment have been lacking.
To investigate this, the authors employed a qualitative methodology, analyzing detailed case reports provided by eight experienced therapists (average 22 years experience). These reports documented the treatment of eight patients (aged 20-58) initially diagnosed with NPD according to standard DSM-5 criteria, who underwent individual psychotherapy (often supplemented with other treatments like group or family therapy) for an average of 3.5 years (range 2.5-5 years) and were judged by their therapists to have shown significant improvement. Therapists retroactively assessed diagnostic criteria at the start and end of treatment, with the authors independently confirming the initial diagnoses based on the reports.
The findings were notably positive for this selected group. All eight patients demonstrated significant improvements in personality and life functioning, achieving remission from the NPD diagnosis based on DSM-5 criteria (average criteria met decreased from 7.75 to 2.31). Functionally, average Global Assessment of Functioning (GAF) scores rose substantially from 40 (indicating major impairment) to 70 (generally functioning well). All patients became engaged in work or education (compared to none initially), achieved financial independence (compared to only one initially), and most (7 out of 8) established stable relationships (compared to one initially). The change process was typically gradual, often catalyzed by life events, and frequently began with enhanced commitment to work/study and increased reflective ability (the capacity to understand mental states), followed later by improvements in relationships and self-esteem regulation. Key patient factors identified as indicators and potential contributors to change included motivation, reflective ability, emotion regulation, sense of agency (feeling in control and responsible), and interpersonal engagement.
The study concludes that meaningful change and remission are attainable for individuals with NPD through long-term, often multimodal, psychotherapy. It emphasizes that change is a complex, gradual, and multifactorial process influenced by the interplay of therapy, patient characteristics (like motivation and developing internal capacities), and significant life events. Improvements in external functioning (work, relationships) and internal capacities (reflection, agency, emotion regulation) serve as important markers, suggesting potential targets for intervention and monitoring in clinical practice, while acknowledging that core narcissistic vulnerabilities require sustained therapeutic attention within this dynamic context.
This qualitative study provides valuable, albeit preliminary, insights into the complex process of change for individuals diagnosed with Narcissistic Personality Disorder (NPD) undergoing long-term psychotherapy. Its primary contribution lies in offering a hopeful perspective, demonstrating that significant functional improvement and even diagnostic remission are achievable outcomes within this often challenging-to-treat population. The identification of specific patterns (e.g., gradual change, sequence starting with external functioning/reflection), indicators (e.g., agency, emotion regulation), and influencing factors (e.g., motivation, life events, multimodal treatment) offers potential avenues for future research and clinical focus.
However, the study's conclusions must be interpreted with significant caution due to major methodological limitations. The reliance on a small sample (N=8) of successful cases, documented through retrospective therapist reports without independent verification or systematic qualitative analysis procedures described, severely limits generalizability and introduces potential bias. We observe an association between long-term therapy and positive outcomes in this select group, but cannot definitively conclude causation or assume these findings apply broadly. The absence of the patient perspective is a critical omission, leaving a gap in understanding the subjective experience of change.
Practically, the findings suggest clinicians might monitor improvements in work/study and relationships as potential early indicators of change, alongside developing internal capacities like reflective ability and a sense of agency. The study underscores the likely necessity of long-term commitment and potentially integrated (multimodal) treatment approaches. Future research should prioritize prospective designs with larger, more diverse samples, incorporate patient self-report and independent assessments, employ rigorous, clearly defined qualitative analysis methods, and investigate factors contributing to treatment failure or dropout to provide a more complete picture.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.'
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.
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...'
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 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 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 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 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.
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.
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.'
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.
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).
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.
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.'
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 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.
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 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.
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.
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.
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.
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.
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.
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.
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.'
TABLE 1. Patients' Demographics, Comorbid Psychiatric Conditions, and Treatment Modalities at Start of Treatment
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.
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.
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.
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.
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.
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.
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.
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.
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.'
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.
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.