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Optimal Psychotherapy Process for Pathological Narcissism: an Exploration of Clinicians’ Perspectives

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Optimal Psychotherapy Process for Pathological Narcissism: an Exploration of Clinicians’ Perspectives OPTIMAL PSYCHOTHERAPY PROCESS FOR PATHOLOGICAL NARCISSISM: AN EXPLORATION OF CLINICIANS’ PERSPECTIVES by DAVID KEALY MSW, The University of British Columbia, 2002 BSW, The University of Victoria, 1998 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2015 © David Kealy, 2015 ABSTRACT Pathological narcissism is a syndrome involving distorted self-image and identity dysregulation. Narcissistic pathology is associated with emotional and interpersonal difficulties, functional impairment, and mental disorder; such patients are seen frequently in mental health settings, and tend to be regarded by clinicians as having complex treatment issues. Despite a vast conceptual literature on pathological narcissism, empirical research regarding treatment is extremely limited. This study was designed to explore clinicians’ perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism. A Q-methodological approach was used to obtain detailed accounts of therapists’ opinions in a manner that would allow for systematic examination. Participants were 34 psychotherapists of various disciplines who responded to email and listserv postings of the recruitment notice. Participants reviewed three clinical vignettes portraying hypothetical patients suffering from grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q-set (PQS), a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. Analysis of therapists’ mean PQS responses using ANOVA found several differences in prospective interventions, according to the different psychopathologies featured in the vignettes. Principal components analysis with varimax rotation was conducted on all 102 Q-sorts and revealed four factors. Detailed descriptions of these ideal therapy processes were interpreted. The factors were also analyzed regarding their relationship to established therapy models. The first factor was endorsed across all three patient types, and represented an introspective, relationally-oriented therapy process. This factor was strongly correlated with established psychodynamic treatments. The second factor, most frequently endorsed for the panic disorder vignette, consisted of a ii cognitive and alliance-building approach that correlated strongly with expert-rated cognitive- behavioural therapy. The third and fourth factors involved therapy processes focused on the challenging interpersonal behaviours associated with narcissistic vulnerability and grandiosity, respectively, and were endorsed for vignettes presenting these narcissistic subtypes. These factors had fewer and smaller correlations with established treatments. The findings are discussed with respect to implications for the study and treatment of pathological narcissism. iii PREFACE This dissertation is an original, unpublished work. I designed the research project, collected and analyzed the data, and interpreted the results. The research project was approved by the University of British Columbia’s Behavioural Research Ethics Board (certificate #: H12- 01821). Dr. John Ogrodniczuk (University of British Columbia, Vancouver) supervised the development and conduct of the research project. The research was supported by a University of British Columbia Humanities and Social Sciences Research Grant (FAS #: F13-01357) awarded to Dr. Ogrodniczuk. Dr. Geoff Goodman (Long Island University, Brookville, NY) provided statistical consultation, and provided the expert-rated PQS psychotherapy prototypes used for comparison analyses in section 5.8. iv TABLE OF CONTENTS ABSTRACT ................................................................................................................................... ii PREFACE ..................................................................................................................................... iv TABLE OF CONTENTS ..............................................................................................................v LIST OF TABLES ...................................................................................................................... vii LIST OF FIGURES ................................................................................................................... viii ACKNOWLEDGEMENTS ........................................................................................................ ix 1 INTRODUCTION ......................................................................................................................1 1.1 Narcissism in clinical practice ...............................................................................................1 1.2 Normal narcissism .................................................................................................................2 1.3 Pathological narcissism ..........................................................................................................3 1.4 Epidemiology and associated features ...................................................................................4 1.5 Narcissism and self-enhancement ..........................................................................................5 1.6 Narcissistic personality disorder ............................................................................................8 1.7 Presentations of pathological narcissism ...............................................................................9 1.8 Etiology and contributing factors .........................................................................................13 2 THEORIES OF PATHOGENESIS AND TREATMENT ....................................................16 2.1 The nuances of narcissism theorizing ..................................................................................16 2.2 Drive theory and ego psychology ........................................................................................16 2.3 Kleinian object relations theory ...........................................................................................19 2.4 Interpersonal theory .............................................................................................................21 2.5 Object relations: Fairbairn and Winnicott ............................................................................24 2.6 Self psychology ....................................................................................................................28 2.7 Attachment theory ................................................................................................................31 2.8 Transference-focused psychotherapy ...................................................................................34 2.9 Cognitive behavioural models .............................................................................................37 3 EXAMINING PSYCHOTHERAPY FOR PATHOLOGICAL NARCISSISM .................42 3.1 Empirical investigations of treatments for pathological narcissism ....................................42 3.2 Psychotherapy research from the ground up ........................................................................43 3.3 Research questions ...............................................................................................................43 3.4 Q-methodology ....................................................................................................................45 4 METHOD ..................................................................................................................................50 4.1 Participants ...........................................................................................................................50 4.2 Materials ..............................................................................................................................50 4.2.1 Clinical case vignettes ...................................................................................................50 4.2.2 Clinician demographic questionnaire ...........................................................................51 4.2.3 Psychotherapy Process Q-Set .......................................................................................51 4.3 Procedure .............................................................................................................................54 v 5 RESULTS ..................................................................................................................................56 5.1 Demographic information ....................................................................................................56 5.2 Initial examination of Q-sorts ..............................................................................................56 5.3 Comparison between patient types: Mean PQS scores ........................................................57 5.4 Core factors of ideal therapy process: PQS factor extraction and rotation ..........................60 5.5 Factor composition and description .....................................................................................61 5.6 Most and least characteristic aspects of ideal process .........................................................66 5.7 Distribution of factors ..........................................................................................................71
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