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Narcissistic Personality Disorder

Narcissistic disorder of personality is a personality disorder characterized by a belief in one’s own uniqueness, special position, superiority over other people; high opinion of own talents and achievements; preoccupation with fantasies about self-successes; expectation of an unconditionally good attitude and obedience from others; the search for admiration from others to confirm his/her uniqueness and significance; inability to show sympathy; ideas about imagined freedom from any rules, as well as about the fact that others around envy. It is also characterized by a pervasive model of grandeur, a need for flattery, and a lack of empathy (Geoffreys, 2015). Diagnosis is based on clinical criteria, and treatment is carried out using psychodynamic psychotherapy. Empirical studies have proven the effectiveness of cognitive psychotherapy, which is based on the technology of revealing narcissistic beliefs. Some approaches developed for the treatment of borderline personality disorder can be effectively adapted for use in patients with narcissistic personality disorder (Geoffreys, 2015). There are other forms of psychotherapy, but studies have not yet shown that they are effective. However, new approaches are being developed, in particular, Kramer et al. (2018) explore the role of shame and self-compassion in psychotherapy for narcissistic personality disorder.

Literature Review

The study of Kramer et al. (2018) is aimed at exploring the role of shame, self-compassion, and specific therapeutic interventions in psychotherapy for patients suffering from narcissistic personality disorder (NPD). Based on solid a literature review, the authors consider core characteristics of narcissistic patients, making special emphasis on a “deficit in self‐definition and affect regulation, a brittle sense of self and a lack of empathy” (Kramer et al., 2018, p. 272). Referring to the works of many experts, Kramer et al. (2018) point out opposition of Self and Other, inherent in narcissistic personalities. At the same time, it is shown that such patients not only manifest significant and obvious deficit of emotional empathy but also experience difficulties in describing inner emotional state, and are characterized with low level of emotional awareness (Kramer et al., 2018). At the same time, interestingly, while such patients are not able to identify fear, shame, and anger in others properly, this spectrum of emotions plays one of the crucial roles in their own subjective experience.

The literature review conducted by the authors is well organized and, to some extent, resembles a systematic review. They attempt to give evidence about higher levels of experienced feeling of shame and proneness to shame in narcissistic personalities. Despite a broad range of the aspects of shame manifestation derived from the studies concerned in frames of literature review, Kramer et al. (2018) do not describe in details the works of the authors they referred to. They do not provide the reader with the sample size, research design, and other important parameters of studies, which are determinants of the scientific quality of the results. Moreover, the summarizing paragraph of the literature review consists of only one sentence, which rarely can be met in peer-reviewed articles.

Valuable feature of the study is conceptualizing shame as a dynamically changing emotion. Shame is described as a reaction to the threat of breaking social ties. Since any person needs companions, community, society, emotions or feelings associated with shame affect the life of each individual person and form a social structure as a whole. Shame is a marker of many processes on an individual and social level. Narcissistic shame has its own characteristics, correctly noted by the authors of the article under consideration. The theme of one’s own insignificance is very clearly represented in the life of the narcissist. However, a psyche of such a person can carefully hide this information from itself, splitting and projecting this insignificance on other people. That is why the narcissists are called smug, selfish, since they are trying in this way to defend themselves against the feeling of their own non-ideality.

The subjective experience of narcissistic personalities is imbued with a sense of shame and, most importantly, fear of shame (but not guilt, as in a neurotic organization of psyche). Shame is the feeling that a narcissist is seen as bad or worthless; the observer in this case is outside his own Self (Geoffreys, 2015). Guilt is formed by the feeling of the active possibility of evil, while shame has an additional (and perhaps the most differentiating) meaning of helplessness and powerlessness. The subject of shame seems to be one of the most popular in the clinical descriptions of narcissist and involves a wide variety of approaches to own non-ideality. However, Kramer et al. (2018) do not mention and all the more so analyze these approaches in the literature review part. Instead, they speak about the so called “core shame” and suggest to apply self-compassion techniques as adaptive way, filling a deficit in the sense of Self in narcissistic patients.

It should be noted that the section named Literature Review does not exist in the article written by Kramer et al. (2018). The review is presented in the Introduction having two subsections. Despite the fact that the first subsection gives only brief data, the second one is more detailed, coherent, and practically oriented. It is devoted to clarification‐oriented psychotherapy (COP) for core shame in narcissistic personality disorder. The authors suggest mechanism to access and transform shame, with the aim to minimize its intensity (Kramer et al., 2018). Here, the concept and mechanism, that is, the strategy and tactics of therapy are described in a practically applicable manner. In fact, the authors mean formation of the sense of self as a deficit mental resource in patients with NPD.

Research Questions

This study under consideration attempts to assess the “possible central role of shame in the therapeutic process of patients with NPD” (Kramer et al., 2018, p. 272). Psychological and psychocorrectional assistance in these cases is preferable and possible, but there are some difficulties. Since the concept of a narcissistic personality is largely built around a distorted self-perception of these individuals, studying the specificity of the self-concept of narcissistic personalities can become an important tool in psychological counseling, psychodiagnostics, and psycho-correctional work. The study described in the article of Kramer et al. (2018) has precisely this focus.

Hypothesis and Research Methodology

According to the authors, in hypothetic sense, one way of resolving the issue of shame for the patient is access accompanying self‐compassion (Kramer et al., 2018). In general, three hypotheses are formulated, despite the fact that the principle of their deriving is not described. Moreover, they are given in the article prior to the description of the study design and thus unlikely can be comprehended by the reader at this stage. The first hypothesis implies a decrease in shame from early working phase session to late working phase session (Kramer et al., 2018). The second hypothesis states modifications in shame are negatively related with the symptom intensity in narcissistic patients, and the third one states that “in‐session shame is related to symptom change post‐treatment” (Kramer et al., 2018, p. 276). All hypotheses seem to be insulated from the context because the ground for their formulation was not provided in previous sections; thus, it significantly decreases the quality of the article. Although the ideas presented by the authors are valuable and rather innovative, the way of their presentation deteriorates their potential to be an effective contribution to understanding, conceptualization, and treatment of NPD.

The study included long-term clarification-oriented psychotherapy with 17 participants. Treatments included on average 64 sessions of client-centered psychotherapy, adapted to the specific problems of patients with NPD. The treatment provided patterns of emotional transformation regarding shame and “associated negative self-evaluations” (Kramer et al., 2018, p. 276). Such an expanded personality-oriented theory of therapy should illustrate how a psychotherapist can recognize this type of experience (diagnostic moment), and demonstrate how a “defective” experience can be transformed into an effective congruent experience. It is also necessary to emphasize exactly what professionally important qualities a psychotherapist should possess, what he/she should know to be able to help or enable such changes to be implemented in practice. The authors mention the use of specially designed manual for therapist – thus, it can be said that the declared methods are applied on a solid scientific base. Among the tools applied, there are such widely accepted and well-known ones as Symptom Check List SCL‐90‐R, Beck Depression Inventory‐II, Classification of Affective‐Meaning States, Processing‐Content‐Relationship Scale.

However, despite solid organization of research, the sample size is extremely small for such kinds of studies and, thus, it does not allow speaking about any representativeness of the results obtained. It is surprising fact that, spending so much effort on the preparation and conducting of empirical research, the authors did not pay necessary attention to formation of an appropriate sample. Sample size in this case is of crucial importance, as narcissism in the form described in the classifications is quite rare. In private practice, in a psychiatric hospital and crisis departments, specialists are confronted with mixed forms of narcissism. In addition, narcissism is often combined with other personality disorders.

Results and Interpretation

Exploratory Pearson’s correlation analysis showed that change in shame was correspondent to intake measures, although a significant decrease in shame was not revealed. At the same time, a decrease in depression in participants was obtained. It can be considered as a valuable result, as some researchers have noted an increase in atypical depressions, which they believe are low-curable (Geoffreys, 2015). By too vague and specific symptoms, such atypical depressive disorders include specific depression characteristic of people with narcissistic features, or narcissistic depression. The first hypothesis was not proven – according to the results, “the greater the intake (general) symptom load, the smaller the decrease in shame” (Kramer et al., 2018, p. 278). In addition, significant extent (45%) of patient contributions was revealed in the increase of participants’ self‐compassion. At the same time, the contribution of the therapist was much larger (78%) later in frames of the same session. This fact can be considered as a source of doubt in the validity of the results obtained. The authors provide small pieces of dialogues with participants during sessions, but they seem to be torn from the context. It would be much more useful for raising validity of the study if to arrange these dialogues based on the application of grounded theory or, at least, content analysis.

In the conclusion, speaking about the overall results and trying to combine literature review implications with the results of empirical studies, Kramer et al. (2018) claim that “working through shame may be a central task for patients with pathological narcissism” (p. 279). They propose such a design of sessions that implies patient’s participation as an agent of change, and a therapist, in this case, plays a role of a facilitator. Although these conclusions represent an innovative approach, the empirical study declared as a base for such formulations cannot be considered appropriate and representative. However, further studies are evidently needed based on preliminary results obtained by Kramer et al. Their study can be called a pilot one, and namely in this kind it can be considered scientifically and theoretically valuable.

References

Geoffreys, C. (2015). Narcissistic Personality Disorder: The ultimate guide to symptoms, treatment, and prevention. CreateSpace Independent Publishing Platform.

Kramer, U., Pascual-Leone, A., Rohde, K., & Sachse, R. (2018). The role of shame and self‐compassion in psychotherapy for narcissistic personality disorder: An exploratory study. Clinical Psychology & Psychotherapy, 25(2), 272-282. Web.

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