Alliance challenges in the treatment of a narcissistic patient: the case of Alex

  • Hemrie Zalman Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States.
  • Katie Aafjes-van Doorn | Katie.aafjes@yu.edu Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States.
  • Catherine F. Eubanks Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States.

Abstract

People with pathological narcisism, with their conflicted sense of grandiosity and vulnerability, often pose a variety of therapeutic challenges, which may impede these patients’ ability to benefit from psychotherapy. To offer a case illustration and provide insight into the intrinsic difficulties of working with this patient group, we examined the treatment of a fictional character, Alex, from the TV series In Treatment. Based on the Shedler-Westen Assessment Procedure-200 we diagnosed Alex with pathological narcissism, and evaluated the treatment process (seven sessions) by reporting on measurements of session-by-session change in explicit working alliance, implicit language alliance, and ruptures and repairs. Over the course of treatment, the working alliance (Working Alliance Inventory-Observer scale) fluctuated with a particularly low bond at session five, identified as a rupture (Rupture Resolution Rating System). Language analysis (Linguistic Inquiry and Word Count) showed that the unconscious aspects of the alliance started to deteriorate just before the rupture occurred. The results illustrate how therapists might be pulled to collude with narcissistic patients’ grandiosity, with the risk of neglecting their vulnerability. This fictional portrayal of a treatment with a narcissistic patient may be widely shared with researchers, students and therapists alike, offering a common locus of scholarly attention, and an innovative tool for teaching. Given the lack of empirical treatments for pathological narcissism and the great therapeutic challenges narcissistic patients present, further research and development of clinical guidelines are warranted.

Downloads

Download data is not yet available.
Published
2019-07-30
Section
Special Section: the legacy of Jeremy Safran
Keywords:
Narcissism, Alliance, Rupture, In Treatment
Statistics
Abstract views: 200

PDF: 161
HTML: 7
Share it

PlumX Metrics

PlumX Metrics provide insights into the ways people interact with individual pieces of research output (articles, conference proceedings, book chapters, and many more) in the online environment. Examples include, when research is mentioned in the news or is tweeted about. Collectively known as PlumX Metrics, these metrics are divided into five categories to help make sense of the huge amounts of data involved and to enable analysis by comparing like with like.

How to Cite
Zalman, H., Aafjes-van Doorn, K., & Eubanks, C. (2019). Alliance challenges in the treatment of a narcissistic patient: the case of Alex. Research in Psychotherapy: Psychopathology, Process and Outcome, 22(2). https://doi.org/10.4081/ripppo.2019.351