TREATING NARCISSISTIC PERSONALITY DISORDER WITH SCHEMA THERAPY – A CASE STUDY

DOI: https://doi.org/10.26758/14.1.15

Address correspondence to: Maria Cristina STERIE, PhD Student, School of Advanced Studies of the Romanian Academy, “Constantin Rădulescu-Motru” Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania, E-mail: csterie@yahoo.com; Phone: +40724218088

Abstract

Objectives. This case study endeavors to provide an in-depth understanding of the schema and mode structure of narcissistic personality disorder (NPD) and to illustrate a possible therapeutic approach using schema therapy (ST).

Material and methods. The recorded material from a 2-year therapeutic journey of a 38-year-old female client diagnosed with NPD was transcribed and systematically analyzed, together with the results of questionnaires that were given to the client at the start of therapy and at the end of the process.

Results. The Millon Clinical Multiaxial Inventory (MCMI-III) was initially used to confirm the presence of NPD in the client. Concurrently, the Young Schema Questionnaire (YSQ) and Schema Mode Inventory (SMI) were employed to measure changes across the course of treatment. The MCMI-III confirmed the existence of NPD. The YSQ revealed a high presence of schemas in the domains of disconnection and rejection, as well as schemas of subjugation, entitlement, and approval seeking. The SMI indicated elevated scores on Vulnerable and Angry Child Modes, Detached Self-Soother and Self-Aggrandizer, Punitive and Demanding Parent. The scores for Happy Child and Healthy Adult were medium.  Upon completion of therapy, a reevaluation of the questionnaire’s scores demonstrated a reduction in narcissism on MCMI-III from 89 to 78, indicating that the client no longer met the criteria for NPD but only for narcissistic personality traits. The scores for YSQ and SMI also decreased significantly.

Conclusions. The use of schema therapy was an adaptive and successful approach to addressing the narcissistic personality pathology of the client. The utilization of a limited reparenting stance allowed empathic confrontation of the main narcissistic modes. The utilization of mode conceptualization and schema understanding reduced feelings of shame and promoted participation of the client’s Healthy Adult Mode in the therapeutic process.

 Keywords: personality disorders, narcissistic personality disorder, schema therapy, coping modes.

Introduction

Treating narcissistic personality disorder (NPD) is a difficult endeavor (Behary, 2022, p. 25), demanding a deep understanding of narcissistic pathology and efficient clinical interventions in these cases (Dimaggio & Attinà, 2012, p. 922). NPD is notoriously resistant to therapy, primarily due to the limited self-awareness and avoidance of NPD individuals (Malkin, 2016, p. 43). Typically, clients seek therapy when confronted with the imminence of losing something important to them, often due to co-morbidities (Behary & Dieckmann, 2012, p. 449). Individuals with NPD have an increased tendency to minimize their problems so that they do not lose the allure of the greatness they surround themselves with.

Schema therapy (ST) is an integrative psychotherapeutic approach that was developed by Jeffrey Young (Young, Klosko, & Weishaar, 2006) to address individuals with personality disorders, especially borderline personality disorder, and other populations who did not respond well to cognitive-behavioral therapy.

Various studies have shown that ST can be of great value in working with challenging clinical presentations such as personality disorders of moderate to severe intensity, eating disorders, and complex trauma (Giesen-Bloo et al., 2006; Jacob & Arntz, 2013; Bamelis, Evers, Spinhoven & Arntz, 2014; Talbot, Smith, Tomkins, Brockman & Simpson, 2015; Keulen-de Vos et al., 2017; Peled, Bar-Kalifa & Rafaeli, 2017; Huntjens, Rijkeboer & Arntz, 2019; Simpson & Smith, 2020; Yakın, Grasman & Arntz, 2020; Bernstein et al., 2021).

Schema therapy posits that the inappropriate fulfillment of emotional core needs will lead to the development of early maladaptive schemas (EMS). An EMS can be defined as a broad, pervasive theme or pattern comprised of cognitions, emotions, bodily sensations, and memories (Young et al., 2006, p. 7), which influence the ways we view ourselves and our relationships with others. EMS forms in childhood or adolescence and can be reinforced throughout our lifetime, maintaining various degrees of dysfunctionality and self-defeating patterns (Rafaeli, Bernstein, & Young, 2010, p. 13). When these schemas are activated, a person will also display different schema modes.

Modes are defined as transitory states that manifest in the here and now and comprise emotions, thoughts, and behaviors (Farrell, Reiss, & Shaw, 2014, p. 7). There are four main categories of modes: Child modes, Critic/Parent modes, Maladaptive Coping modes, and Healthy modes. There are around eighty modes described in the literature, and the number is expanding (Edwards, 2021). The number of modes can be endless (Roediger, Stevens, & Brockman, 2018, p. 42), but the preservation of simplicity can help with conceptualization and client communication.

Upon a client’s arrival in therapy, their initial presentation will be the result of the manifestation of their Coping modes. Hence, the first phase of the therapy will imply the identification and awareness of the modes, acquiring the skills for their management, and bypassing them. The goal is to unveil and unravel the underlying dynamics of Parent and Child Modes (Farrell et al., 2014, p. 10). Within this dyadic dynamic, the initial hurt that led to the formation of schemas can be discerned, granting the opportunity to address those emotional wounds by teaching the client to meet their emotional core needs in the present moment. The strategies used encompass a blend of cognitive, emotional-focused, and behavioral techniques.

For clients with narcissistic features, the main coping modes, according to the literature, are: overcompensation modes: Self-Aggrandizer, Perfectionistic Over-controller; Avoidant modes: Detached Self-soother. Usually, these clients have a very strong Demanding Parent mode and a very lonely and deprived Vulnerable Child (Arntz & Jacob, 2012; Behary, 2012). The Healthy Adult in NPD clients can be confused with the overcompensation modes, especially when there is a Perfectionistic Over-controller which is very efficient and effective. Those with NPD do have access to healthy features, but these need to get decontaminated from the overcompensation coping modes.

The goal of schema therapy with NPD clients is to strengthen the Healthy Adult mode by using limited reparenting in the therapeutic relationship. The phases of treatment always start with assessment and case conceptualization, which helps the client become aware of their own schemas and modes while drawing the links between current life problems and early unmet needs and EMS emerging from these experiences. In the next phases of therapy, empathic confrontation and limit setting are often used to bypass the maladaptive coping modes and facilitate emotionally focused experiences (imagery and chair work exercises). This work leads to uncovering the Parent/Critic modes that need to be addressed by combating them at times or changing their toxic messages and converting them into a healthier dialogue with the self. Uncovering and healing the Vulnerable Child follows within this process, an endeavor first taken by the therapist but ultimately taken on by the Healthy Adult of the client. The therapeutic process also follows phases of awareness of the modes, management of the modes, and the final phase of Mode change.

The therapeutic relationship with NPD clients may face considerable strain due to the specific activation of therapists’ schemas. Schemas of subjugation and self-sacrifice, defectiveness and unrelenting standards, emotional deprivation, and abandonment can be especially triggered when working with narcissists (Behary, 2022). The typical interpersonal cycles that can emerge in therapeutic relationships involve idealization, competition, and attachment/caregiving (Dimaggio, Semerari, Carcione, Nicolo, & Pocacci, 2007). Therapists working with this population might feel anger, resentment, and dread at always being questioned by the client and might end up avoiding, distracting themselves, or fantasizing about ending therapy (Betan, Heim, Zittel Conklin, & Westen, 2005). When the therapists feel the client is criticizing and hostile, they might react with criticism and disapproval. (Tanzilli, Colli, Muzi, & Lingiardi, 2015). Translated to ST terms, it is considered that in interacting with narcissistic clients, the therapists might tend to activate their Detached Protector mode or a Hopeless Surrender, or, at times, overcompensating modes such as Scolding Over-controller or Self-Aggrandizer can come to compete and set the client in their place. Addressing this in personal therapy or supervision and working with one’s schemas and modes to remain in the Healthy Adult is crucial to the therapeutic process with NPD clients. It is only in HA mode that the therapist can maintain the role of limited reparenting, set healthy boundaries, and use leverage and empathic confrontation.

In the case of MC, there were two main challenges in the therapeutic relationship. Firstly, the Self-Aggrandizer coping mode would appear every time the therapist tried to contact the Vulnerable Child. It presented itself as very strong, tougher than others, and self-sufficient. Secondly, confrontation with the Guilt-Inducing Critic/Parent Mode was very much opposed by the client. The client feared that working with this mode in therapy would lead to her losing the relationship with her mother, who was the only being she felt ever loved her. There was a big pull for the therapist to go into an Overcompensator Mode and contradict the client or convince her otherwise, but chair work was used instead to reflect back on the coping modes present in the room and the subsequent mode cycles. The emphasis was placed on the fact that activation in the therapy room can offer an opportunity to observe similar dynamics outside of the office. This allowed the client to reframe her perspective and become more cooperative in noticing how her coping modes interfered with meeting the needs and goals of therapy.

Methodology

The qualitative method of systematic case study (Edwards, 2019) was chosen for this paper, as it can better demonstrate the effectiveness of schema therapy in the work with NPD and also the challenges that appear in the therapeutic relationship. The therapeutic journey with an NPD client was recorded, transcribed, and analyzed for this paper, together with the results from the questionnaires that were administered at the beginning and end of therapy.

Case presentation

This case study examines MC, a 38-year-old female client presenting symptoms of depression (anhedonia, feeling of hopelessness, low self-esteem, feelings of sadness, suicidal ideation), work-related stress, and difficulties in forming romantic relationships. At the moment of her arrival in therapy, MC was single, with no children, and living alone in a rented apartment. The client presented herself as a strong, independent woman, perfectly dressed, and always in charge. She did not want to let anyone see her as vulnerable, including colleagues at work, prospective romantic interests, friends, and her therapist. Throughout our interactions, she consistently projected an image of comprehensive knowledge, but this did not contribute to the therapeutic process of change.  She utilized an overintellectualizing coping strategy to keep herself away from emotional material. In her home, she used food for self-soothing, along with the consumption of drugs and alcohol, in an attempt to cultivate an image of self-sufficiency and an absence of relying on others. Paradoxically, this attitude was the opposite of what she really wanted and what motivated her to seek therapeutic help.

History of the problem

MC considers that she always had a low mood, but her symptoms were accentuated around a year ago, when her boss made some harassing remarks. She realized she had no one to protect her, and for many years, her aspiration has been for this perception to be held by others regarding her. Aging has resulted in her thinking more about the future and all the failures in her life, especially not having children, but she was afraid to show this to others.

Assessment

For assessment, the following instruments were used: the Millon Clinical Multiaxial Inventory (MCMI-III), the Young Schema Questionnaire (YSQ), the Schema Mode Inventory (SMI), the Adverse Childhood Experiences Questionnaire (ACEQ) and the Beck Depression Inventory (BDI) at the beginning and at the end of the therapeutic process. As part of the assessment process, the life history of the client and variations of imagery for assessment (Van der Wijngaart, 2021, p. 33) were used.

MC scored 74 on depressive personality and 89 on Narcissistic personality (MCMI-III), meeting the criteria for a narcissistic personality disorder with depressive elements. A BDI score of 20 represents severe depression.  For the YSQ, MC scored very high for the following schemas: emotional deprivation, abandonment/instability, mistrust/abuse, social isolation, defectiveness/shame, subjugation, entitlement/grandiosity, and approval and recognition seeking. For the SMI, very high scores were obtained on the following modes: vulnerable child, angry child, detached self-soother, self-aggrandizer, bully and attack, punitive parent. The Demanding Parent mode has a moderate score, as well as the Healthy Adult mode.  The ACE score was 5 out of 10, which increases the risk of suicide attempts by 37.5% and the development of somatic and mental diseases (Nelson, Bhutta, Burke Harris, Danese, & Samara, 2020).

Retrieving the life history of the client was also used in the assessment phase to assess the unmet needs and the formation of early maladaptive schemas. From this, several focal points resulted, summarized in the table below (Table 1).

Table 1

Core memories, formation of EMS and modes (to see Table 1, please click here).

The client was the only child of an alcoholic and very influential father and a very submissive and manipulative mother. She was severely abused both physically and emotionally by her father until the age of 16. Her mother showed her warmth and love but also asked her to grow up and study in order to save her from her abusive husband. In addition, her mother used to blackmail her emotionally and threaten to leave every time MC would try to oppose her and disobey her. MC was a very good student and dreamed that she could use her intelligence to escape her home.

She started earning money from modeling and managed to pay for her own rented apartment. She eventually resumed contact with her mother, hiding where she lived out of fear that her father might follow.

Case conceptualization in terms of schemas and modes

In collaboration with the client, a mode map was constructed, serving as a mutual framework for case conceptualization and the basis for later therapeutic work. The act of sharing the case conceptualization with the client is customary practice in schema therapy, as it sets the premises for a good therapeutic alliance, building trust and motivation for active participation in the therapeutic endeavor. Some of the schemas and modes listed in the mode map do not correspond with those revealed by the questionnaire, as they were discovered during the exploration in therapy with the client. (Figure 1.)

Figure 1

Mode map of the client (to see Figure 1, please click here).

Phases of treatment

Creating the therapeutic relationship and establishing working goals constituted the first phase of therapy. Initially, the client’s Surrender Mode facilitated an easy rapport while avoiding abandonment or abuse. Confrontation was avoided at this stage, and internal dynamics were presented and discussed, in terms of modes and schemas. The Compliant Surrender mode interfered with the process of change, giving way to over-compensatory modes during emotional distress. The following goals for therapy were agreed upon:

1. Reducing suicidal ideation by addressing the Vulnerable Child Mode, who sought relief from overwhelm and suffering.
2. Develop healthy boundaries by confronting the Over-compensator modes who thought she was the only one who could save her mother and was stronger than others.
3. Counteract the negative influence of the Parent Modes.
4. Foster a healthy romantic relationship by bypassing the Coping Modes and learning to meet the needs of the Vulnerable Child in the present.

In the second phase, bypassing coping modes proved difficult and time-consuming. Each attempt to venture outside the comfort zone triggered a shift from Compliant Surrender mode to Over-controller mode, which resisted change and tried to show me the proper way therapy is done. Many sessions felt like a battleground, requiring efforts to remain in my Healthy Adult mode and refrain from using Coping Modes. Empathic confrontation, metaphors, story-telling, and chair-dialogue were used to raise the client’s awareness of the dynamic present in the room and the parallels between the therapeutic process and external relationships.

“Th.: So, let’s have a look at what is going on in the therapy room and in our relationship at this very moment.

Cl.: I suppose you would say I am defending myself, but I am not (looking in my eyes and preparing to say more)

Th.: (I raise my eyebrow and smile) – but you did stop yourself from continuing…

Cl.: Well… I am not stupid…

Th.: I don’t think that was even in question, but I am wondering how you would name the way you were talking just earlier

Cl.: Passion?

Th.: Passion for what?

Cl.: (Starts smiling) – for arguing… look, I know you want to help me and you are not telling me these things to criticize me… it is hard to let go.

Th.: And what do you do when the other person acts like you and you want to help them so they can feel better?

Cl.: I argue with them too!

Th.: And does it work?

Cl.: No, it doesn’t.

Th.: So what part of you does that?

Cl.: I would say is my Self-aggrandizer who is trying to show you I know things.

Th.: And what would happen if you didn’t know?

Cl.: I would need to fade away, to disappear…

Th.: Just like…

Cl.:  yes, just like when I was little. This part of me helped me stay alive.”

Employing humor, metaphors, and storytelling contributed to preserving a strong therapeutic alliance while confronting the maladaptive coping modes and negotiating with them for the welfare of the Vulnerable Child. This kind of empathic confrontation was helpful in contacting the Vulnerable Child and offering them comfort and care, which many times led to the activation of the Parent/Critic Modes.

The third phase involved addressing toxic messages from Parent/Critic modes. Implementation of imagery rescripting and chair-based mode dialogues posed difficulties due to the intense fear of the client that nobody could confront her father and come out alive from the confrontation, even at a symbolic level.

In a powerful session of imagery rescripting and using the resources of imaginary rescripting and the endless possibilities it offers (Van der Wijngaart, 2021), I reframed first her perception regarding the invincibility of her father by emphasizing how alcohol reduces his strengths and sense of coherence. In order to be able to address both her fear of the father and also her mistrust in men, I constructed the rescripting around the idea that 10 powerful men, the kind you see playing with their daughters and wearing lipstick and hair clips, would also come with me to help take her and mom out of the house and put them in a safe house, far away from him, where he could never find them. This was a very important moment in therapy and helped her gain more trust in men and also connect for the first time with little MC.

Also, the Guilt-inducing Parent/Critic Mode was addressed in chair-work, at first, and then in imagery rescripting. This process was more sinuous as the client strongly defended the mother, who inspired this mode, and affirmed that she preferred dying herself to abandoning the mother. At that point, we could clearly track the appearance of the Self-Aggrandizer early in childhood, as this mode clearly helped the client feel less powerless and overwhelmed. This strong Coping Mode also had the role of protecting the mother and resisting the abuse as proof of toughness.

Limited reparenting of child needs and purposely redirecting the anger of the Angry Child happened in the last stage of therapy. This transformation occurred as the client began accepting that her Vulnerable child mode could receive support and nurturing from external sources, including the therapist, without the expectation of reciprocity. Another pivotal change in this phase of therapy was represented by the client’s spontaneous and healthy expression of needs and recognition of anger as a valuable signal of unmet needs. The client’s Healthy Adult mode was used to reestablish emotional balance.

In a session, the client confessed she was very angry with me, and I took the opportunity to use my Healthy Adult Mode to model a different reaction than she was expecting. Using humor and mode language, I invited her to express her anger, and this helped her discover that the angry part was only around 4 years old. Using chairs, I invited her into her Healthy Adult Mode to draw from the energy of anger and confront her mother. This moment led to a great catharsis and an important realization in terms of why she could not let go of the anger.

Throughout therapy, strengthening the Healthy Adult Mode, while disentangling it from the Over-compensation modes was an important endeavor. The strengthening of the Healthy Adult mode was needed so that the Over-compensators could step back from their role. This allowed the client to make significant life changes, including ending a relationship that was not meeting her needs and successfully confronting her boss to secure a job promotion.

Using the resources from the Happy Child Mode, more fun and enjoyment were brought into the therapy session and made empathic confrontation more tolerable and less shaming: “I really appreciated your sense of humor and the fact that we could laugh together at things, even what I was doing wrong. It helped me not to crawl into a corner and isolate myself. I felt I was not alone, and when we were laughing together, my inner child knew you were not going to abandon us.”

Terminating the therapeutic process was of paramount significance (Tsai, Gustafsson, Kanter, Plummer Loudon, & Kohlenberg, 2017), as it marked the client’s first experience planning a healthy and collaborative relationship ending (Goode, Park, Parkin, Tompkins, & Swift, 2017). During this phase, the therapeutic journey was summarized, addressing benefits, challenges, and areas for improvement.

A chair exercise was organized to invite each mode to reflect on the therapeutic process and discuss future collaboration and potential challenges. Imagery was used to reinforce the collaboration between the modes and to set anchors for safety, confidence, and well-being. “It was very useful to do the exercise and have my healthy part talk to the others. I felt that at the beginning of therapy, none of my parts wanted to talk to each other; they were all feeling comfortable in isolation, but now they are happy to meet and talk, and they are not ashamed of who they are. Each of them has a role.”

Discussions

MC sought therapy for depressive symptoms, including suicidal ideation, difficulties in establishing romantic relationships, and work-related stressors that led to anger outbursts. Assessment revealed the client met the criteria for NPD. This diagnosis fueled a conflict between her desire to feel better and her strong, self-sufficient image (Caligor, Levy, & Yeomans, 2015).

These features inherent to NPD pose challenges in various areas of the client’s life, exacerbating symptoms of depression, feelings of loneliness, and hopelessness, thereby intensifying suicidal ideation (Gabbard, 2022).

In the context of schema therapy conceptualization, it becomes evident that the history of severe deprivation, the traumatic abuse inflicted by her father, and the helpless passivity of her mother played an important role in the formation of schemas from the first domain, which greatly impacted the functioning in many areas of the client’s life. Emotional deprivation and defectiveness/shame were the schemas underlying the Vulnerable Child mode, as highlighted by Young (2006). In this case study, the typical schemas associated with NPD, are complemented by the mistrust/abuse schema, particularly activated in relation to men.

The client oscillated between Surrendering and Overcompensation modes, a dynamic that affected her work and personal relationships. A cycle entailed sequences of overcompensation modes, followed by intense depressive symptoms and feelings of giving up life, which can be translated as a Surrender Coping Mode. Addressing this mode cycle within therapy proved challenging, since bypassing a mode would usually lead to the other one appearing with more intensity and activating the Parent/Critic Modes. These mode sequences were explored, and cognitive and emotional-focused techniques were employed until there was a shift in behavior and symptoms. Mode maps and mode cycles maps were drawn and emphasized through the use of mode dialogues and mode interviews in order to emphasize the role of coping modes in preventing the attainment of the clients’ therapeutic goals and meeting their emotional needs.

The term Vulnerable Child was not very much used at the beginning of therapy as it triggered the overcompensation mode and a strong reaction from the Parent/Critic Mode. The leverage was set through reminders of the therapeutic objectives and current goals rather than insisting on the Vulnerability.

The client additionally used fantasies about perfect future relationships, creating a perpetual feeling of being disappointed by day-to-day encounters. This can be understood as a blended mode (Edwards, 2021, p. 3) formed by a Self-Soother and a Self-aggrandizer mode, which were cooperating to both avoid emotional pain and loneliness and enhance feelings of strength and being above others.

In this case study, the therapeutic strategies suggested by Jeffrey Young (2006) and Wendy Behary (2012) for addressing the symptoms consistent with those who have NPD were used. Empathic confrontation worked especially well at addressing the coping modes of the client, helping her to become aware of their appearance and understand their role in her psyche. Linking present behaviors to the past and EMS formation was important in reducing the shame and building trust in the therapeutic process.

The utilization of ST case conceptualization proved instrumental in fostering a nuanced understanding of the intricate issues of this client, benefiting both the therapist and the client. Mode language was used to help the client disidentify with the Maladaptive Coping Modes and Critic Modes and build a more balanced and flexible perception of the world from a Healthy Adult stance.

Chair work was used as a powerful technique for MC, as it allowed her to observe, not only at a cognitive level but also at an emotional level, the different perspectives of the various modes. This led to uncovering more subtle facets of the modes, their role, function, and present consequences upon meeting her emotional core needs.

Full imagery rescripting was possible later in therapy; however, its effects lay in facilitating a profound emotional connection between the client and her Vulnerable Child Mode.  The integration of emotional-focused techniques, coupled with the insights derived from the complex case conceptualization, played a central role in sustaining the client’s commitment to therapy and fostering active engagement throughout the therapeutic process, even in the face of encountered challenges.

The findings in this particular case study provide evidence supporting the idea that schemas can be diminished, consequently resulting in a reduction of NPD symptomatology to an extent where the client no longer meets the diagnostic criteria for the disorder.

At the end of therapy, the scores obtained on the MCMI–III were reduced to 71 from 89 on the narcissistic personality scale, which signifies the client did not meet criteria for NPD anymore. Also, her depression score on the BDI lowered to 8, meaning she was no longer clinically depressed. Modifications appeared as well on YSQ and SMI, thus reducing the intensity of schemas and modes  significantly.

Conclusions

Although NPD is characterized by significant interpersonal difficulties and increased risk for suicide, not enough studies are conducted on this type of personality disorder, and many therapists avoid working with clients exhibiting narcissistic traits.

When working with narcissists, it is important that the therapist remains in their Healthy Adult mode and learn to protect their Vulnerable Child mode from the attacks of the narcissistic coping modes of the client.

Cultivating meta-awareness skills, orienting one to the “here and now” and towards the hidden Vulnerable Child mode of the client, necessitates the development of the ability to tolerate frustration while remaining emotionally connected. This can be attained only if the therapist preserves congruent communication, a coherent sense of identity that remains unthreatened by client presentation, and a lot of compassion for the self and others.

Schema therapy proves to be an exemplary framework for addressing narcissistic personality pathology, as evidenced by the outcomes of this case study. The use of a meticulous and thorough case conceptualization and the application of cognitive, emotion-focused, and behavioral techniques, with an emphasis on therapeutic alliance via “limited reparenting” and empathic confrontation, equip the therapist to adeptly navigate the myriad challenges presented by the NPD client.

List of abbreviations:

NPD – Narcissistic Personality Disorder

ST – Schema Therapy

MCMI – III – Millon Clinical Multiaxial inventory

YSQ – Young Schema Questionnaire

SMI – Schema Modes Inventory

EMS – Early Maladaptive Schemas

ACEQ – Adverse Childhood Experiences Questionnaire

BDI – Beck Depression Inventory

Th. – Therapist

Cl. – Client

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