Object Relations-Focused Psychoanalytic Psychotherapy in the Treatment of Narcissistic Personality Disorder

1 Theoretical and Research Basis for Treatment

Psychoanalytic theorists conceptualize personality disorders in myriad ways based on distinct theoretical models. From a Kleinian object relations perspective, failure to integrate good and bad parts of the self, holding all good/all bad characterizations of others, the use of primitive defenses to manage anxiety (e.g., splitting, denial, and isolation; these defenses are characteristic of early and immature developmental stages), and inadequate reality testing form the core of personality disorders (Kernberg, 1967). Kleinian theorists posit that, in healthy development, infants move from experiencing relationships based solely on their prevailing emotional state to a more complex and integrated perception of others. Individuals whose understanding of the world is less obscured by unconscious impulses and desires (termed phantasies) become better able to make conscious choices. As a result, their perceptions of the world (and those in it) become more closely aligned with external reality (Freud, 1958; Klein, 1923).

Healthy development involves incorporating aspects of other people into the self to form internal objects, a process known in Kleinian terms as introjection. As we gain the capacity to recognize that both “good” and “bad” feelings relate to the same person (rather than two separate, split objects), we create a more nuanced understanding of ourselves and others. This developmental achievement also allows us to distinguish between experiences originating in the self and those originating in others (Bion, 1962; Kernberg, 1975; Klein, 1957). A more nuanced understanding of self and others allows us to develop healthier relationships and reduces the likelihood of developing personality psychopathology. Melanie Klein described this as a movement from the “paranoid-schizoid position” to the “depressive position” (Klein, 1946).

An essential characteristic of paranoid-schizoid position functioning is an unstable boundary between inside and outside and between self and others. Early in development, infants see no distinction between what they experience within themselves and what is outside. As a result, all object relationships are extensions of themselves and are subject to their will, desires, and impulses.

Paranoid-schizoid position functioning in adulthood is typified by an overreliance on primitive defense mechanisms such as splitting (wherein individuals are unable to integrate the positive and negative aspects of others and therefore tend to see those around them as either “all good” or “all bad”) and projective identification (a process by which individuals cannot tolerate parts of themselves that they find unacceptable and project those characteristics onto other people). Individuals who operate from the paranoid-schizoid position do not develop the ability to recognize boundaries between self and other, leading them to project onto others the parts of themselves they find intolerable while clinging to the fragments of experience they can bear to hold within them (Klein, 1946). Splitting off and projecting the intolerable parts of the self into another is inherently damaging to relationships because putting that which is intolerable into an external object makes that object intolerable to the individual (Caper, 1999). Those who find themselves the recipients of the “bad” projections are often the subjects of intense hatred or disdain, which they cannot understand or predict.

Paranoid-schizoid position functioning fosters separations among internal part objects (as opposed to whole objects), characterized by their corresponding affective tone (i.e., “good” or “bad”). Part objects are either pleasurable and associated with what is good inside the infant or persecutory and associated with unpleasant feelings and badness. These representations tend to be unstable and shift with the subject’s emotional states. They are black-and-white representations of reality; there are no shades of gray.

Recognizing that “good” and “bad” experiences may involve the same person represents an important developmental milestone. Children learn to integrate good and bad part objects into more nuanced whole objects in healthy development. This achievement is mirrored in the child’s inner world, as integrating good and bad external objects results in concomitant integration of the self. Internal object representations thus become a more accurate reflection of external reality. Klein termed this achievement the depressive position. Movement from the paranoid-schizoid to the depressive position typically occurs when infants receive responsive caregiving in safe, supportive environments. An awareness of the “wholeness” of objects facilitates the use of more mature defenses, leading to more fulfilling relationships with less risk for severe psychopathology.

While achieving depressive position functioning is an important developmental milestone, individuals who operate from the depressive position remain capable of slipping back into paranoid-schizoid position functioning. When faced with significant distress, the nature of our object relationships may change, such that we see others as temporarily “all good” or “all bad” (an example is deciding that a once highly valued romantic partner who ends the relationship now has no redeeming qualities). Klein’s use of the term “position” implied dynamic movement between the two domains of functioning throughout development and into adulthood (Steiner, 1991).

Those who experience childhoods in which physical and emotional needs are often unmet and who, as a result, experience chronic frustration, cannot sustain depressive position functioning, and therefore spend most of their time functioning in the paranoid-schizoid position (Kernberg, 1967; Klein, 1957). Those who operate primarily in the paranoid-schizoid position rely more heavily on splitting and projection and experience relationships fraught with conflict, inappropriate boundary setting, and emotional instability. This pattern is seen most noticeably among individuals diagnosed with personality disorders. One such manifestation, wherein the subject projects their good and bad part objects so that they may punish those who hold “bad” traits while using those who hold the “good” projected parts to sustain a positive self-perception, typifies narcissistic personality disorder. Individuals with this pattern of functioning often display a grandiose sense of self-importance and a belief that they have control over others, which fosters relational and emotional instability.

2 Case Introduction

“Holden” is a 22-year-old, white, cisgender, heterosexual male who presented for psychotherapy in September 2020 for weekly therapy services in a southeastern university psychological clinic to address frequent anger outbursts. He is enrolled as a full-time undergraduate student at a four-year university majoring in engineering, and until recently, worked the night shift as a stock person at a major retail chain. He currently lives with his girlfriend, whom he has been dating for over five years. He initially sought therapy under the advice of his girlfriend and his family members. The patient’s name and all identifying information have been changed to maintain his confidentiality.

3 Presenting Complaints

Holden’s difficulties with anger have been present for as long as he can remember and have affected his relationships with family members, friends, and romantic partners, as well as his success in school and at work. Holden reported that his anger presents most strongly when he feels unappreciated or disrespected, with his most acute outbursts occurring when his loved ones fail to meet his needs. Holden described getting “tunnel vision” when he becomes angry, unable to recognize reason. His anger was often expressed through “fits” in which he would yell and, on some occasions, break objects around him. However, following an incident in high school in which he became so angry with his ex-girlfriend that he punched through a glass door (which led his ex-girlfriend to leave him), he learned to suppress these violent reactions. Still, he experiences thoughts that he is being disrespected and hurt and that others should be hurt in the same ways they are hurting him. Holden has experienced passive homicidal ideation but has never had an intent or plan to hurt someone else, nor has he gotten into a physical altercation. Prior to starting treatment, Holden experienced occasional passive suicidal ideation without plan or intent, nor has he tried to harm himself or end his life. He denied history of drug or alcohol abuse and does not take any prescription medications. Holden was raised in a Southern Baptist religious tradition and continues to hold these beliefs, attending church services on major holidays.

4 History

Holden was born in a rural area of the Southeastern United States to married parents and is the eldest of three siblings: he has a sixteen-year-old sister and a fourteen-year-old brother. He had a typical developmental trajectory with no complications during his mother’s pregnancy, birth, or with his early developmental milestones. This was his first experience receiving psychological treatment, and he had never been prescribed any psychiatric medications.

Throughout his childhood, Holden’s anger outbursts took place mostly with his father, with whom he had a contentious relationship growing up. When Holden was in middle school and high school, he and his father got into screaming verbal fights that would last for two or 3 hours. These fights would occur approximately two to three times per year until Holden was 17 years old. Holden and his father mainly fought about responsibility. When Holden asked for his father’s help with a problem, his father would respond by telling Holden that he would not get far in life by relying on others and that he must learn to be self-sufficient. These arguments escalated when both Holden and his father would get uncontrollably angry with one another. The last fight that Holden and his father had of this nature occurred when Holden was a senior in high school; the police were called to resolve this fight, and Holden and his father had to appear in court to resolve allegations that Holden’s father was verbally abusive toward Holden. Holden reported that he had no further legal involvement after his court appearance.

Holden’s relationship with his mother is also contentious. When he was 13 years old, his mother was diagnosed with breast cancer and underwent a double mastectomy surgery; Holden described being at the hospital and caring for his mother when she first received her diagnosis. She no longer has cancer, but Holden remarked that she now drinks heavily and refuses to engage with her children, often refusing to leave the house for weeks. Holden has felt consistently neglected by his mother, receiving attention from her only when he assumes a parentified role. In addition to taking care of his mother, Holden feels a parental duty toward his younger siblings; he often gives them advice, attempts to guide their life decisions, and often offers to pay for new clothing or other items that they need to establish himself as an important figure in their lives.

Holden’s descriptions of his previous and current romantic relationships made it clear that he can only maintain relationships in which he feels enmeshed with his partners. He has been in a relationship with his current partner for 5 years and expressed feeling extremely satisfied with his relationship and the close connection he and his girlfriend share. Holden demonstrated an idealized view of his current partner to the point that he could not share any sources of relational dissatisfaction. Holden related that he and his girlfriend work at the same job, attend school together, live together, and have very few friendships outside of their relationship; Holden stated that he enjoys “doing everything together” with his partner. Holden reported that he had one serious relationship prior to his current relationship, which took place in high school, and about which Holden now has a negative, “all bad” view. When Holden’s previous girlfriend accidentally broke a ceramic figurine that he had made, he became so upset that he punched through a glass door, shattering it. After this incident, Holden’s girlfriend left him for one of his best friends, citing Holden’s anger as her reason for leaving him. Holden believed that she used her fear as an excuse to justify her betrayal of him.

Holden has difficulty maintaining lasting and meaningful friendships. He frequently cites feeling different from his peers because he performs better than they do in almost all categories (i.e., he was more intelligent than all his classmates and teachers in academic settings and was the best player on his football and baseball teams in high school). Holden believes that these differences led peers to ostracize him and coaches and teachers to penalize him because they were intimidated by his abilities.

Holden currently studies aerospace engineering at a large public university. He tends to earn Bs and Cs in his classes, except for two classes he had to retake after failing. Holden states that his performance in school is negatively affected because he also works full-time and that his fellow students are at an unfair advantage because they do not have the same responsibilities he does. He frequently feels frustrated by his classes and his professors, stating that he often is not given a fair shot at doing well on tests and assignments because of the ways his professors structure their courses. Holden takes great pride in his career choice, often expressing that he believes he is helping people more than a medical doctor or psychologist would because his engineering projects will have broader impacts on society, thus benefitting more peoples' lives.

Until recently, Holden worked 40 hours per week stocking shelves at a major retail chain during the night shift in addition to attending school full-time. While working, Holden found it challenging to balance his demanding course load with his work schedule and experienced conflict with his work managers over missing shifts during demanding academic periods. Holden once expressed to his boss that he valued his schoolwork far more than his job and that he believed the work he does is more complex and more important than the work that his bosses do, including parenting their children. Because of this, Holden’s managers were especially hard on him, penalizing him while he worked even though he did nothing wrong. After a particularly challenging academic semester in which Holden came close to failing two classes, he quit his job, relying on his partner’s income to support him.

5 Assessment

As part of his initial consent to treatment, Holden provided written and verbal approval for his treatment details to be shared for academic purposes. After the initial intake session, Holden completed several self-report assessment measures, which informed his diagnostic conceptualization and treatment goals. Holden completed the Clinical Anger Scale (CAS; Snell et al., 1995), the Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006, the Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001), and the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004).

The Clinical Anger Scale (CAS) is designed to assess the affective, cognitive, physiological, and behavioral symptoms of anger. It is a 21-item self-report questionnaire that asks individuals to choose which item of a four-point Likert-type scale is most descriptive of their typical experience. Higher scores on this measure indicate higher levels of clinical anger. Holden obtained a score of 12 on the CAS, which indicated a sub-clinical level of anger.

The Generalized Anxiety Disorder Scale (GAD-7) is a seven-item measure designed to assess for Generalized Anxiety Disorder symptoms in adults according to DSM-IV diagnostic criteria. It asks individuals to rate the frequency of their anxious experiences on a four-point Likert-type scale from “Not at all” to “Nearly every day.” Holden’s initial score on the GAD-7 was 13, which placed him in the moderate range for clinical anxiety.

The Patient Health Questionnaire (PHQ-9) is a nine-item self-report measure used to assess the severity of Major Depression Disorder symptoms according to DSM-IV diagnostic criteria. It asks individuals to rate the frequency with which they experience depressive symptoms on a four-point Likert-type scale from “Not at all” to “Nearly every day.” Holden scored a seven on the PHQ-9, indicating mild depression.

The Difficulties in Emotion Regulation Scale (DERS) is a 36-item self-report questionnaire that assesses emotion dysregulation across six domains on a five-point Likert-type scale from 1 (“Almost never”) to 5 (“Almost always”): nonacceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties when experiencing negative emotions, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. These scores combine to create a total score representing overall emotion dysregulation. At the beginning of treatment, Holden’s total score on the DERS was 80, suggesting moderate difficulty with emotion regulation.

Given his presentation in-session, his accounts of his experiences, and data from multiple assessment sources, it is likely that Holden endorsed assessment items in accordance with what he believes to be socially desirable rather than what is true to his experience. This may have contributed to his low and sometimes sub-clinical scores. Further, Holden’s initial outcome measure responses reflect the ways in which he initially presented in-session: Holden was well-defended and spent his first months in therapy demonstrating his grandiosity and importance to me, disavowing any traits or experiences which he thought reflected badly on him. I believe that the depressive and anxious symptoms that Holden initially endorsed are better explained by ego-syntonic personality pathology (i.e., patterns of being which do not cause him emotional distress) rather than dystonic mood disorder diagnoses. The relational instability brought on Holden’s narcissistic pathology may have given rise to anxious and depressive symptoms, but those problems alone did not seem to impede his treatment, nor were they severe enough to bring Holden into therapy in the first place; further, these symptoms attenuated as his NPD treatment progressed.

6 Case Conceptualization

While Holden has been reticent to share aspects of his childhood with me due to his belief that they are irrelevant to his current treatment, what he has shared has clarified that Holden’s upbringing was characterized by frequent and intense familial conflict. His experience of early object relationships demonstrated that he felt neither important nor lovable; he only received attention by acting like a third parent in his household, taking on responsibilities beyond his years. On the rare occasion that Holden expressed a need to his parents, he was usually rejected: a pattern that provoked extreme emotional and behavioral outbursts.

For example, Holden explained that early in his life, his paternal uncle got into a physical altercation with his paternal aunt, hitting her head repeatedly, which resulted in Holden’s aunt dying from an aneurism. When Holden was 12 years old, he and his mother got into an argument in which she compared him to this violent uncle. Holden became so upset after this comment that he took a kitchen knife into his room and held it up to his stomach to “teach her a lesson.” Holden stated he felt that his mother was not “grateful for his life.” Another incident of note occurred when Holden was a senior in high school. Holden reported having an argument with his father that lasted over 3 hours, during which his father came into his room with a small iron shovel designed for fireplace maintenance with the intention of smashing Holden’s television. Holden reported that when he saw his father enter his room, he pushed him to the ground, at which point his mother stepped between them, and they separated. Holden often expresses that when others hurt him, he feels entitled to make them hurt in that same way.

Holden tends to engage in binary thinking in all domains of his life. He often expresses that he knows the “right way” to handle any situation and sees others' disagreements as indicators of their incompetence or desire to hurt him. Once someone has expressed an opinion different from his, he finds it difficult to recover his relationships with them. He defends against the pain he feels from these losses by categorizing everyone around him as either “good” or “bad,” often expressing that if someone did not care about him enough not to hurt him by doing the wrong thing, then he did not want them in his life. This rigidity allows Holden to uphold a sense of control over his relationships, although it limits him in the quality of relationships that he can maintain in his life. This view seems to have originated with Holden’s perceptions of his mother and his father. Holden idealized his father as a hard-working, intelligent, and masculine figure to whom he looked for guidance, while he viewed his mother as a lazy, neglectful alcoholic who did not care for him as she should have. Through Holden’s therapy, it became clear that from an early age, Holden was placed in a parentified role in which he felt responsible for “holding his family together,” a pressure that continues to weigh on Holden’s sense of self, as well as his sense of belonging in his family.

Holden cannot incorporate disparate elements of his internal world to develop a nuanced, integrated sense of himself. Specifically, it is difficult for Holden to acknowledge any parts of himself that he considers undesirable; he goes to great lengths to ensure that others view him as necessary, heroic, and intelligent. When his efforts go unacknowledged, or he believes others are thinking badly of him, he reacts with severe anger and frustration, which often exacerbates his desire to control those around him.

An event that occurred during the summer of 2020, while Holden was on a family outing with his partner, his two younger siblings, and his partner’s younger siblings, demonstrates this process. Holden described taking his family to a mini-golf course, an event which he explained he paid for and took great care in planning. Partway into the outing, Holden’s sister began complaining about the heat, stating that she was not having a good time. His brother and his partner’s siblings soon began to echo her complaints, drawing attention from others and walking to sit down on nearby benches instead of participating.

Feeling that his efforts for his family were unappreciated, Holden became irate. He began yelling and cursing at his and his partner’s siblings, scaring and embarrassing them to the extent that they decided to end the trip early and go home. Holden felt intensely hurt by this decision—what had started as a minor schism had now widened to form a crevasse—a profound narcissistic injury. During these times when he feels hurt or abandoned by others, he tries to control others' actions and thoughts. Holden hopes that his success in manipulating others will make it less likely for them to leave him or hurt him further. Holden would accept nothing other than his family repairing their “mistake” by assuring him that they appreciated his effort, that they cared about him, and that they understood his importance. In the absence of these affirmations, he was faced with his inability to control his external objects—to control himself—leading him to become acutely and uncontrollably upset.

In describing his emotional reaction, Holden used the metaphor of fire, illustrating that he believes his anger destroys connections with others to the point that they cannot be revived. He stormed away from his family and walked nearly a mile to a convenience store, where he roamed the aisles, fuming, for about an hour while his family did not know where he was. His initial outburst of anger was followed by deep despair; he thought that his fire had destroyed the most important relationships in his life and that, as a result, his family members were abandoning him. Holden returned to his family and became hysterical, sobbing and thrashing his body like a young child having a tantrum, inconsolable. His partner got in the car with their siblings and started to back out of their parking spot without him, and he became even more upset, banging on the car window and holding on to the bumper of the moving car so that she could not drive away. When he finally agreed to go home, Holden was shepherded into the trunk of the car, where he continued to thrash, hitting his head against the borders of what felt like a cage. With hot tears streaming down his face, Holden pulled the trunk cover over his body like a blanket and fell into what he described as a coma-like sleep. When he awoke, his girlfriend was dragging him out of the trunk and into the parking lot of their apartment complex. Holden told her that nothing mattered anymore because she did not care about him and that he might as well die. At this point, his girlfriend contacted the police to assess him for suicidal intent. Holden revealed when recalling this story that he did not feel suicidal, but that he said that to his partner to test her love for him, just as he had with his mother when he was a child.

Holden’s “black and white” thinking and grandiosity intensify when he is in situations that leave him emotionally vulnerable. When he experiences negative emotions, he feels emphatical that his pain directly results from someone else’s negligence. He attempts to trace back events to their earliest origins, sure that if others had followed the “right way” to act, nothing would have gone wrong. In response to what he sees as apparent “betrayals,” Holden becomes gripped in unconscious phantasy: he is so sure of others’ intentions that he leaves no room for the reality of his relationships. Establishing a rigid idea of others as predominantly dangerous protects Holden against disappointment and injury should his loved ones hurt him or decide to leave. While projecting the “bad” onto others, he clings to as much of the “good” as he can. He will often begin describing how his unique talents might lend themselves to success in careers such as filmmaking, politics, medicine, and athletics. Holden’s lack of understanding of others’ intentions and mental states (also known as mentalization; Bateman & Fonagy, 2008), coupled with his tendency to split between good and bad and subsequent grandiose fantasies, allow him to defend against the painful emotions that he so frequently experiences in his interactions with others.

The narcissistic symptoms that Holden exhibits pervade his inner world to such an extent that his interpersonal relationships and functioning are highly impaired. He has difficulty maintaining close relationships unless they are utterly enmeshed; his sense of entitlement and preoccupation with power often compromises his ability to function in academic and vocational environments. When Holden is denied what he desires, he becomes deeply hurt, which manifests externally as anger outbursts that drive away his loved ones. This anger served as the impetus for Holden’s psychotherapeutic treatment.

7 Course of Treatment and Assessment of Progress

Thus far, Holden has participated in weekly psychotherapy sessions for 14 months with two two-week breaks for a total of 56 sessions. To track symptom changes throughout treatment, Holden submitted measurements of anger, emotion regulation, anxiety, and depression each month via the CAS, the DERS, the GAD-7, and the PHQ-9.

During the first phase of treatment (object relations-focused psychodynamic therapy, sessions 1 through 12), Holden spent much of his time in-session telling stories that he believed would demonstrate his intellectual, physical, and moral prowess. He explained how he was the best player on his high school football team despite receiving no recognition from his coaches, how he was more knowledgeable than his college professors, and how he understood the “right way” to act in all situations when others did not.

Holden often spoke for 40 minutes straight, leaving little space in session for me to interject with questions and interpretations. When I was able to cut in and offer extra-transferential insights, such as the connection between Holden’s feelings of abandonment sparked by his family at the golf course leading to intense anger and a desire for control, Holden would respond by disagreeing, making belittling comments, or proceeding as if I had not spoken at all. At the beginning of his treatment, Holden’s attempts to make me feel diminutive often succeeded. My countertransference toward him was marked by feelings of inadequacy and fear that I may make a mistake with his care—feelings that were difficult to decipher from my own trepidations about being new to clinical work. Despite never having been in therapy before, Holden was steadfast in his belief that his role as the patient was to talk at me and give as much context as possible, and it was my task to listen quietly without interrupting. Holden hoped to encourage my understanding of him as an impressive presence.

During session 11, a therapeutic rupture occurred. I had recently begun making transference comments centered around Holden’s desire to control my understanding of him and, by extension, to control me through his domineering presence in session. When Holden would speak over me, I would note that he had trouble allowing me to voice my thoughts because he did not want me to disagree with or misunderstand him. When he would retort my observations on his emotional processes with stories of his accomplishments and strengths, I would remark on his desire for me to think highly of him, especially when he is feeling vulnerable. These comments were received poorly. By drawing attention to the transference relationship, I not only established myself as a separate person outside of Holden’s control, but I also suggested that his efforts to control me, and others by extension, were unsuccessful and often detrimental to his relationships.

Holden retaliated in session 13 by drinking wine during his 10:00 am session (on Zoom), proclaiming to me that he had had a “tough week” and would be drinking during our conversation. As he raised his glass to the webcam in a defiant “cheers” gesture, I interpreted this aggressive action as an attempt to control me because I had demonstrated my separateness from him in the previous weeks. My interpretation was coupled with a comment on the frame of our work together: I stated the importance of Holden showing up to his therapy unaltered and ready to work. He became embarrassed by my assertions and quickly shifted, using the rest of that session to talk about his unrecognized accomplishments, barely pausing for breaths to ensure that I could not say anything else.

Behavioral indicators of Holden’s narcissistic injury reemerged during sessions 15–20. This time, Holden approached me with aggressive self-pity, showing me how much I had hurt him. Holden drew attention to the fact that I do not take notes during our sessions, which he interpreted as evidence that I leave our sessions each week and forget about his existence—that I do not care about him. When that tactic did not receive its desired reaction, Holden enacted a sexually aggressive role in our dyad, comparing himself to “misunderstood” womanizing and predatory figures such as R. Kelly and Donald Trump, or blaming his younger sister for being “dumb enough” to get raped by a 17-year-old when she was 12. My feelings toward Holden oscillated between fear and anger in synchrony with his own emotional shifts; I became acutely aware of how my presentation as a young, white, female graduate student at a training clinic fed into Holden’s attempts to assume power over me. Recognizing the importance of my own ability to tolerate Holden, I had to process and understand my countertransference, as well as the intolerable parts of Holden’s internal objects that he projected into me at the time. It became clear that fears of abandonment and being unloved pervade Holden’s unconscious phantasies of his relationships, and as a matter of course, they would be equally as present in our therapeutic relationship.

These ruptures signaled that Holden could not tolerate transference-focused work at this point in his treatment; I therefore shifted to a supportive therapeutic framework. It became clear that to withstand further transference interpretations (and to move toward introjecting me as a whole object), Holden first needed to recognize that I was in his corner: that I understood him, that I could weather his aggression, and that I would show up the following week ready to listen again.

Holden began to share more vulnerable experiences with me, explaining his pain at the mini-golf course when he felt as though his family did not care about or appreciate him. During session 25, he came into session and explained that his family was “falling apart” and that he felt like the lynchpin holding his and their lives together (it was revealed three sessions later that Holden’s parents were getting a divorce and that his father, whom Holden had once idealized, was now the subject of Holden’s absolute hatred and disdain). Holden made it clear that he needed to get through the story he wanted to tell and that I was to remain quiet while he did so.

For four consecutive sessions, any interpretations I made or questions I asked were met with aggression and hostility. Holden would raise his voice, interrupt me, and curtly state that he “Needed to get through what [he wants] to say if [I] could just be quiet.” He was terrified that if I derailed him, I would never understand his role or sacrifice in this story.

Holden was cycling between competing, phantastical self-perceptions, catalyzed by our relationship. At times, he was a victim of his parents' poor decisions and wanted me to pity and care for him. Holden needed me to act as a container for his emotional experiences (Bion, 1962). When I would reflect this to him and comment on his desire for me to care for him in the ways in which his parents did not, he defensively inflated into a more heroic persona. He would bluntly reject my attempts to comfort him and instead demonstrate his omnipotence by telling me that he was the only one that could save his mother and siblings from what he saw to be his father’s evil grasp, now requiring my praise to keep the wind in his proverbial Superman cape.

Entry into Holden’s third phase of treatment was signaled in session 30 by his acceptance of and participation in a joke at his expense. He commented on his frustration that the people in his life are disruptive and messy, making them difficult to understand. I remarked that his desire is for his relationships to behave more like machine parts: pieces that he could disassemble, observe, understand, and place to the side, where he knew they would remain clean and stagnant. For the first time in our treatment, I saw a smile spread across Holden’s face as he recognized the impossibility of this scenario. He associated playfully that his sister’s latest troubles were annoying primarily because of their effect on him, and, taking a risk, I chimed in sardonically, “How dare she do this to you!” Holden suddenly erupted with laughter, and I joined him. After a few seconds, his face grew solemn. He sighed and admitted that he did not want his family to think he was a bad person, controlling, or dangerous, but that he feared that was their perception. This shared moment seemed to allow Holden to recognize a critical pathological process that permeates his relationships, and for the first time, he was able to realize and admit its disservice to him.

After that session, Holden began to allow more space for me as a participant in our sessions, rather than insisting that his 50 minutes belong to him alone. Now, my beginning utterances, once ignored and spoken over, led Holden to stop what he was saying and invite me to share my thoughts. Comments I made regarding his transference to me were no longer met with anger or aggression but rather subtle nods of agreement. He began to demonstrate tolerance for the difference between our opinions and thoughts and differences between him and his family members. This understanding was exemplified most by a comment he made in session 42: “I know that what I say or do may not be interpreted by others in the way I intend, and this may lead them to misunderstand me. That always makes me angry – when I feel misunderstood.” In just two sentences, Holden captured a year of hard work. He understood his mind to be separate from others while also acknowledging that this difference often makes him feel hurt and abandoned.

Most recently, Holden’s defensive strategy has taken a new tack, namely, idealizing me and our work together. In-session, he has taken time to explain how helpful he has found therapy and how much he feels he has progressed in his ability to “think through his decisions” and “not become angry when others do not understand him.” Holden also noted that he feels his interactions have become less conflictual overall. Through his projections, I once inhabited the role of an unsupportive, uncaring mother in his internal object world, incapable of ever understanding him. Now, his internalization of me seems to have shifted, although still obscured by phantasy, to projecting onto me all the “good” that he has in himself. Holden’s idealization of me serves as a defense against his unconscious fear that I may fail him in our relationship or leave were he to fail me—a tenuous position given his propensity to feel misunderstood and unappreciated. As Holden’s perception of his importance has diminished, I have become a temporary keeper of his projected goodness.

Holden’s current treatment focuses on further developing his ability to understand the harmful effects of his grandiosity and desire for control over his relationships. Our discussions of the transference between us strengthen his understanding of the difference between himself and others. We work together to link the emotional processes Holden displays in session—specifically those in which he feels misinterpreted and hurt, and then attempts to recover by dominating over me and our relationship—to the experiences he describes from his outside interactions.

In session 43, Holden expressed a desire for me to recognize his progress thus far in therapy, a request that I understood to indicate his idealization of me and his evolution in our work thus far. Holden has indeed made strides in his understanding of his mind and internal processes. His improved ability to understand himself has made him better able to communicate his emotions, allowing others to understand him as well; he relies less on phantasy-heavy projection in his relationships, and his connections with others are more in line with reality. When I told him this, I saw a second smile begin to form on Holden’s face, this time softer, as he recognized and appreciated a separate other who had, for a moment, made him feel seen and important.

Results

To statistically assess changes in Holden’s symptoms of anger, anxiety, depression, and emotion regulation abilities, I utilized the Reliable Change Index (RCI; Jacobson & Traux, 1991). RCI analyses quantify a patient’s level of functioning relative to a non-clinical sample; they are calculated by dividing the difference of a patient’s clinical scores on a given measure throughout their treatment by the standard deviation of that measure. The RCI must exceed the 97th percentile (values below −1.96 or above 1.96) for a score change to be considered significant (p < .05; Jacobson & Truax, 1991). The current RCI analyses compared Holden’s scores regarding different clinical symptoms across different phases of his treatment. These phases each represent therapeutically distinct and significant moments for Holden’s work in therapy. I compared scores from the beginning of Holden’s treatment (T₁), a time point directly before the therapeutic rupture (T₂), a time point directly after the rupture (T₃), and a time point from the current phase of treatment (T₄).

Holden demonstrated a significant decrease in clinical anger symptoms between the beginning of treatment and the current phase (RCI_T1-T4 = −8.58, p < .05). He also showed a significant reduction in anxiety (RCI_T1-T4 = −5.28, p < .05) and depression (RCI_T1-T4 = −4.62, p < .05) between these two time points.

Interestingly, Holden’s scores prior to the current phase of treatment reflected that his emotion dysregulation increased between the beginning of treatment (T₁) and a time point before the therapeutic rupture (T₂) (RCI_T1-T2 = 6.60, p < .05), as well as between the time point before and the time point after the therapeutic rupture (T₂; T₃) (RCI_T2-T3 = 7.26, p < .05). Holden’s emotion dysregulation between the beginning of treatment (T₁) and the time point after the therapeutic rupture (T₃) demonstrated a large increase (RCI_T1-T3 = 13.85, p < .05), while his scores in depression (RCI_T1-T3 = −3.30, p < .05), anxiety (RCI_T1-T3 = −5.94, p < .05), and anger (RCI_T1-T3 = −5.28, p < .05) each showed steady declines during this time. From the time point directly after the rupture (T₃) to the current phase of treatment (T₄), Holden’s emotion dysregulation score dropped (RCI_T3-T4 = −19.23, p < .05) such that he now demonstrates lower dysregulation compared to the beginning of his treatment (RCI_T1-T4 = −5.28, p < .05).

8 Complicating Factors

Due to the COVID-19 pandemic, the entirety of Holden’s treatment thus far has taken place over telehealth via HIPAA-compliant Zoom. Looking past the obvious technical difficulties inherent with this therapeutic setting, conducting therapy with Holden over video chat has presented unique difficulties because of his clinical presentation. To him, I am a figure on a screen that he owns; he can choose to make me disappear at any moment by pressing the “end call” button.

Virtual therapy has likely allowed Holden’s phantastical sense of control to overtake his understanding of me more than it would have had we been able to do therapy in person. Still, initial engagement with me and with the therapeutic process may have been made easier by the physical and emotional distance inherent in teletherapy. Upon our transition to in-person therapy, our work will attempt to address Holden’s phantasy of his omnipotence over me and others, as well as his narcissistic injury and resulting anger when that omnipotence is challenged—processes which I predict will become re-energized when we are in the room for the first time. I will be curious to explore with Holden how the emotional and transferential processes that have been present over Zoom will manifest and shift once he and I begin working together in-person.

9 Access and Barriers to Care

There were no financial constraints or barriers to care. The university clinic at which Holden received services does not accept insurance; however, patients’ self-pay therapy fees are determined using a sliding scale based on annual income, and insurance co-pays are honored.

10 Follow-Up

Holden is currently in treatment. Given that psychotherapy with him is ongoing, there is no posttreatment data available.

11 Treatment Implications of the Case

Acute aggression marked the first phase of Holden’s treatment as he attempted to dominate over me and our work together. He had difficulty allowing me to speak at all, let alone offer an interpretation or observation, and did all he could to demonstrate his importance and power; Holden was displaying patterns in the (virtual) therapy room that had brought him into treatment in the first place. During this time, Holden’s symptoms of anger, anxiety, and depression (measured via the CAS, the GAD-7, and the PHQ-9, respectively), each indicated moderate severity, and he demonstrated difficulty regulating his emotions (measured via the DERS). Treatment during this phase focused on sitting through his monologues to show him that I was a trustworthy and reliable resource while slowly reflecting and interpreting his desire that I understand him to be powerful through comments about his transferential beliefs of what I thought about him. This phase of treatment was guided by Kleinian and Bionian theories of containing Holden’s emotional projections and “metabolizing” them into transferential interpretations which he could consciously consider and introject.

My comments regarding Holden’s transference in our relationship soon became too much for him to tolerate, and a therapeutic rupture occurred, resulting in a series of aggressive behavioral outbursts. I quickly pivoted my approach with him to a more supportive framework. I backed away from transferential remarks and acted more as a mirror in which Holden could begin to view himself more truly (Kohut, 1972). It is important to note that a large part of therapeutic recovery during this phase was facilitated simply by my commitment to staying reliable and steady with Holden. Despite his aggression, which had previously driven away loved ones, I continued to show up to our sessions on Mondays at 10:00 am. I remained present and available through ruptures and repairs, through both of our feelings of inadequacy and fear. What seemed like an artless, inconsequential aspect of our work allowed Holden to understand that the parts of himself that he believed to be venomous were not going to make me abandon him.

Interestingly, Holden’s symptoms of anger, depression, and anxiety all decreased throughout these phases of treatment, while his difficulties with emotion regulation increased. I believe that this signals the value of our relationship as an effective container for his negative emotions (Bion, 1962); his anger and aggression were metabolized in session and did not leak out into his other relationships. However, this meant that Holden was experiencing a faltering of the defensive strategies on which he once relied. Insight into his emotional world was an essential step in Holden’s treatment, but he found himself unprepared to handle the onslaught of affect that accompanied this awareness. As a result, his difficulties regulating and understanding his emotions worsened as he attempted to reconstruct his patterns of relating to others. I believe the increase in Holden’s emotion dysregulation, anxiety, and depressive symptoms during this time indicates his progress in therapy rather than a regression to maladaptive tendencies.

As Holden and I moved past this rupture into the third phase of his treatment, he became more aware of different aspects of his emotional experiences. He was better able to tolerate the separateness of himself and others and was more willing to admit how his behavior had negatively affected his relationships. I watched as he tentatively stepped down from the pedestal he once used to bolster his sense of self. Holden became calmer with me, more relational, and allowed me more space in our sessions and our relationship. Reflective of this change, all of Holden’s symptom scores reached the lowest points since he started therapy.

Holden’s current treatment focuses on helping him understand how this new, idealized role in which he has placed me serves to keep the projected good parts of himself protected, yet nonetheless inaccessible. He decided to give me a turn atop the pedestal—an indication of his improvement—but my being there does not facilitate equality within our relationship, which we both strive to achieve. As Holden gains insight into his relational and emotional patterns through the transference between us, he will hopefully move toward the capacity for introjecting integrated whole object representations in his inner world. Doing so will allow him to build more sustained and connected relationships with others.

12 Recommendations to Clinicians and Students

This study examined the effects of object relations-focused psychoanalytic psychotherapy in treating an individual with narcissistic personality disorder. Progress across treatment was evaluated utilizing Reliable Change Index analyses of self-report measures of anxiety, depression, clinical anger, and emotion regulation difficulties. Results provided evidence that psychoanalytic psychotherapy utilizing a Kleinian object relations approach is effective in reducing these symptoms. While the current study demonstrated evidence for the efficacy of this treatment, there are limitations to address.

Holden’s symptoms were measured online via face-valid assessments of anxiety, depression, anger, and emotion regulation symptoms. Therefore, his desire to appear well or unwell to me during specific points in his treatment may have influenced his pattern of responses. In addition, the measures available for Holden to complete assessed symptoms that are secondary to, and likely result from, his NPD diagnosis. Including more robust psychological health and personality functioning measures, such as the Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2; Graham, 1990) or the Rorschach Inkblot Test (Meyer & Eblin, 2012), would strengthen results. If measured at different time points throughout his treatment, these tests would reveal Holden’s personality pathology progression. These personality functioning measures and other process-oriented measures were not included as outcome measures due to the limitations of the training clinic in which treatment was conducted. Despite these limitations, this study supports the efficacy of object relations-focused psychoanalytic psychotherapy in treating narcissistic personality disorder. Few publications to date have demonstrated the efficacy of a combined self-psychology and object relations approach to treating NPD (e.g., Masterson, 1993; Levine & Faust, 2013). The current study offers unique insight into the importance of each of these theories in response to therapeutic relational processes including rupture and repair. It may be helpful for future clinicians to track and publish the effectiveness of this combined treatment method starting with a Kohutian approach to provide the patient with missing selfobject experiences and establishing a supportive therapeutic relationship before attending to internal object insight in a Kleinian vein.