Dialogical Relationship Patterns in Narcissistic Personalities: Session Analysis and Treatment Implications

Patients with narcissistic features are difficult to treat in psychotherapy, in particular because of problems in building sound therapeutic relationships with them. Therapists can get easily involved in dysfunctional relationship patterns that have a negative impact on the therapeutic alliance. Tracing the typical patterns that can recur in persons with narcissistic features should, therefore, prove useful in helping therapists to recognize their involvement in them at an early treatment stage and to deal with them effectively. A dialogical theory of the self offers a promising perspective from which to recognize and describe these patterns. From this vantage point, we discuss the treatment of a client diagnosed as having a narcissistic personality. What occurred during this therapy lends support to the idea that there are typical dialogical relationship patterns in patients with narcissistic features and that knowing them might help therapists to make treatment effective, avoid early dropouts, and successfully manage the therapeutic relationship. In addition, we put forward the hypothesis that some of the therapeutic techniques described here also can be applied to other patients displaying similar narcissistic features.     

The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with relatively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psychotherapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjectivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersubjective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.     

When REBT Goes Difficult: Applying ABC-DEF to Personality Disorders

ABC-DEF framework is at the core of rational emotive behavior therapy. It is a highly flexible framework and has proven to be applicable to many emotional disorders. We cannot take for granted, however, that this framework can be used successfully with all clients, particularly with those suffering from severe disorders or personality disorders. In fact, the difficulties of these clients in recognizing, naming and reflecting upon states of mind, their dysregulated emotions and self-defeating behavior, and their difficulty in establishing a strong working alliance with a therapist may hamper the correct implementation of the ABC-DEF framework and the disputing of their irrational beliefs. This paper aims to describe in detail the challenges that clients with personality disorders may pose during treatment and offer possible technical suggestions, derived from either REBT or non-REBT literature, that can help REBT and CBT practitioners adapting their interventions to resistant clients.     

Reauthoring One's Own Life in the Face of Being HIV+: Promoting Healthier Narratives with Metacognitive Interpersonal Therapy

We describe here a narrative-based psychotherapy for a woman in her 40s who had been HIV+ since the age of 21 and who suffered from posttraumatic symptoms related to having received the diagnosis. She had also suffered from self-stigma and had lost the capacity to envision a future filled with hope. Treating individuals with HIV who face posttraumatic symptoms and stigma can be challenging for the clinician. A narrative approach to therapy can be helpful for these persons, in order to overcome symptoms, build a more benevolent self-image, feel accepted by society, and promote posttraumatic growth. Current evidence indicates that such an approach is mostly lacking. We describe how we applied metacognitive interpersonal therapy—an approach rooted in narrative constructivism. By using this treatment, the patient could overcome posttraumatic symptoms, participate in social activities after years of avoidance and isolation, and recover her sense of being a person able to make plans for the future with strength and dignity. Discussion includes ideas of how to generalize some of the mechanisms that have likely been effective in this therapy to other individuals with HIV.     

Impoverished Self-Narrative and Impaired Self-Reflection as Targets for the Psychotherapy of Personality Disorders

Recent years have seen theory and research in psychiatry and psychotherapy identifying which facets of the psychopathology of personality disorders (PD) should be treatment targets. This paper focuses on four elements: a) impoverished autobiographical narrative/use of generalized memory; b) lack of conscious sense of agency; c) poor awareness of emotions and their triggers; d) loss of fantasy/reality distinction. These all impact PD sufferers’ well-being and social functioning. I first describe the four elements and provide some empirical evidence for them and then propose technical processes for tackling the dysfunctions both directly and through therapy relationship work. I will provide examples of the pathology and treatment from the cases of two patients suffering from wide-ranging and severe PD.     

Know yourself and you shall know the other... to a certain extent: multiple paths of influence of self-reflection on mindreading

Social and neurocognitive research suggests that thinking about one's own thinking and thinking about the thinking of others-termed 'mindreading', 'metacognition', 'social cognition' or 'mentalizing' are not identical activities. The ability though to think about thinking in the first person is nevertheless related to the ability to think about other's thoughts in the third person. Unclear is how these phenomena influence one another. In this review, we explore how self-reflection and autobiographical memory influence the capacity to think about the thoughts and emotions of others. We review studies suggesting that the more individuals are able to reflect on and retrieve episodes from their life narratives, the more they are likely to grasp others' thoughts and emotions. We discuss evidence supporting this possibility including studies of the neurocognitive bases of empathy and self-awareness and how different aspects of self-reflection may impact on mindreading. We also draw from clinical reports how improved self-reflection may result in a more nuanced mindreading, namely persons suffering from schizophrenia and narcissistic personality disorder. We finally discuss the implications for research and practice and consider whether there are conditions in which the reverse is true, where self-reflection might impair mindreading or in which mindreading may facilitate self-reflection.     

Some Historical Conditions of Narrative Work

Written to honor the immense contribution of Michael White as a leader in the development of narrative therapy, this historical essay contrasts the origins of psychoanalysis, family therapy and narrative therapy. Changes in the understanding of therapeutic strategies, methods of training and supervision, styles of leadership, the involvement of audiences in the therapeutic and training processes, and conceptions of the nature of the mind are described. A style of direct demonstration of methods, especially of the formulation of questions, is important in narrative work. The central master-role of the therapist in analysis and family therapy is replaced in narrative work by eliciting local knowledge, and the recruitment of audiences to the work. This is consistent with narrative therapy's "de-centered" image of the therapist.     

The application of prospective strategies to family therapy

Among the most frequently used theoretical orientations for administering family therapy are the systems, interactional, structuralist, problem-centered, and attachment approaches. Each of these methods proposes a theory concerning the etiology and resolution of conflict, a protocol of assessment, and a view on the therapist's role in advocating intervention techniques. Despite the success of these methods, however, families often leave treatment lacking the interpersonal skills for predicting potential conflict and for overcoming episodes of transition. This paper explores how the prospective approach may rectify this problem by enhancing the family members' use of intuition for experiencing transition and predicting upcoming change. As such, the application of the prospective technique may be beneficial for strengthening family relationships.     

Projective identification: Pros and cons. An essay review of Samuel Slipp,the technique and practice of Object Relations Family Therapy

This paper is a critical appraisal of Samuel Slipp's book on Object Relations Family Therapy (ORFT), which uses the concept of projective identification as a central thesis in explaining interpersonal influence. Slipp's book is praised for its excellent review of the literature of object relations theory and the major schools of family therapy, classification of families according to complementary projections, and revealing case material. Interpersonal-Systemic (I-S) theory and methodology with its use of the concepts of empathy, interpersonal influences, search for intimacy, maintenance of self-esteem, selective inattention, and reflected appraisals is offered as an alternative view to projective identification.