Scholarly Article Review Guideline Discussion ESSAY

Scholarly Article Review Guideline Discussion

R E S E A R C H A R T I C L E

The role of shame and self‐compassion in psychotherapy for narcissistic personality disorder: An exploratory study

Ueli Kramer1,2 | Antonio Pascual‐Leone2 | Kristina B. Rohde3 | Rainer Sachse4

1 Institute of Psychotherapy and General

Psychiatry Services, Department of Psychiatry,

Lausanne University Hospital and University

of Lausanne, Lausanne, Switzerland

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2 Department of Psychology, University of

Windsor, Windsor, ON, Canada

3 Bern University Hospital and University of

Bern, Bern, Switzerland

4 Institute for Psychological Psychotherapy,

Bochum, Germany

Correspondence

PD Dr Ueli Kramer, IUP‐Dpt Psychiatry‐ CHUV, University of Lausanne, Place

Chauderon 18, CH‐1003 Lausanne, Switzerland.

Email: ueli.kramer@chuv.ch

Abstract This process‐outcome study aims at exploring the role of shame, self‐compassion, and specific

therapeutic interventions in psychotherapy for patients with narcissistic personality disorder

(NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long‐term

clarification‐oriented psychotherapy. Their mean age was 39 years, and 10 were male. On aver-

age, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated

using the Classification of Affective Meaning States and the Process‐Content‐Relationship Scale.

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Outcome was assessed using the Symptom Check List‐90 and Beck Depression Inventory‐II.

Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30).

In Session 36, the presence of self‐compassion was linked with a set of specific therapist inter-

ventions (process‐guidance and treatment of behaviour‐underlying assumptions; 51% of variance

explained and adjusted). This study points to the possible central role of shame in the therapeutic

process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to

access underlying self‐compassion.

KEYWORDS

clarification‐oriented psychotherapy, emotion processing, interaction process, narcissistic

personality disorder, self‐compassion, shame

1 | INTRODUCTION

Patients with narcissistic personality disorder (NPD), or pathological

narcissism, may present at times with self‐enhancing grandiosity,

whereas at other times with a brittle or fragile sense of self. Such con-

trasting self‐presentation of patients with the same underlying prob-

lems should be integrated in a comprehensive understanding of the

disorder (Caligor, Levy, & Yeomans, 2015; Levy, Ellison, & Reynoso,

2011; Ogrodniczuk & Kealy, 2013; Pincus & Lukowitsky, 2010; Pincus

& Roche, 2011; Roepke & Vater, 2014; Ronningstam & Weinberg,

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2013). Core psychological features of NPD encompass a deficit in

self‐definition and affect regulation, a brittle sense of self and a lack

of empathy which foster biased conceptualizations of Self and Other.

Self‐enhancement, in particular a sense of grandiosity, exaggerated

entitlement, or arrogance may help maintain a stable self‐image. Often

more implicitly, fluctuating self‐esteem, self‐criticism, and affect dys-

regulation persist.

The quality of emotional processing underlying these core fea-

tures of NPD is of key interest. Deficits in emotional processing as

found on several dimensions which may be linked with the underlying

subjective experience of shame. Emotional processing with regard to

the Self lacks depth, that is, low levels of emotional self‐awareness,

and with regard to the others, that is, deficient emotion recognition

and lack of empathy (Dimaggio & Attina, 2012; Marcoux et al., 2014;

Pincus & Lukowitsky, 2010; Ritter et al., 2011; Ronningstam, 2016;

Sylvers, Brubaker, Alden, Brennan, & Lilienfeld, 2008). Lack of emo-

tional empathy may explain the interpersonal difficulties reported as

part of the NPD diagnosis (Ogrodniczuk, 2013). This lack of empathy

in NPD has been discussed as a prerequisite for the self‐referential

processing bias related to self‐enhancement and grandiosity: It

becomes key to focus on the underlying emotional issues related with

the understanding of the Self as shameful.

Patients with NPD tend to present with low levels of emotional

awareness (Joyce, Fujiwara, Cristall, Ruddy, & Ogrodniczuk, 2013;

Lecours, Briand‐Malenfant, & Descheneaux, 2013; Mizen, 2014;

Ronningstam, 2016). Difficulty in describing one’s inner emotional

states has also been associated with grandiose and entitlement traits

(Lawson, Waller, Sines, & Meyer, 2008). These results might indicate

that these patients lack the capacity to be aware of their emotional

life and of its deeper meanings. In her conceptual and clinical account

Received: 3 July 2017 Revised: 26 October 2017 Accepted: 30 October 2017

DOI: 10.1002/cpp.2160

272 Copyright © 2017 John Wiley & Sons, Ltd. Clin Psychol Psychother. 2018;25:272–282.wileyonlinelibrary.com/journal/cpp

http://orcid.org/0000-0002-5603-0394
mailto:ueli.kramer@chuv.ch
https://doi.org/10.1002/cpp.2160
http://wileyonlinelibrary.com/journal/cpp
of the perceptual recognition of emotion in individuals with NPD,

Ronningstam (2005) put forward a triad of emotions to which

patients with NPD respond with less accuracy: These patients seem

to have difficulties to identify fear, shame, and anger in others (see

also Lewis, 1971; Morrison, 1983). At the same time, these emotions

play an important role in the subjective experience of patients with

NPD: It was shown that they present with higher levels of explicitly

reported shame and an implicit proneness to shame (Ritter et al.,

2014). Implicit self‐related shame may be a trigger for developing high

standards, an excessive drive for success, and perfectionism (Dimag-

gio & Attina, 2012; Sagar & Stoeber, 2009). Ronningstam (2016)

added to this elaboration that other‐related shame, for example, attri-

butions of the other people as unworthy or defective, may result in

the expression of aggression and hatred, along with blaming, dismis-

sive, or overly critical attitudes (Caligor et al., 2015; Kernberg, 1992;

Ogrodniczuk, 2013; Sachse, Sachse, & Fasbender, 2011). As such,

malignant forms of narcissism may be characterized by the intentional

destructiveness of the significant other (Kernberg, 2004). If this

aggressiveness is turned inwards, it may result in suicidal thoughts

and actions, which may—paradoxically—have an important function

in maintaining the individual’s belief system (Maltsberger,

Ronningstam, Weinberg, Schechter, & Goldblatt, 2010; Ronningstam,

2016). Additionally, fear may be an important emotion tendency in

NPD (Kernberg, 2004, 2008). These patients may fear of “losing face”

in social interactions, again a shame‐based emotion (Kramer,

Berthoud, Keller, & Caspar, 2014; Lecours et al., 2013), or their self‐

control; they may experience fear of social exposure, to be humiliated

and to experience shame in the future. Because of the shame‐based

organization of the latter, authors have also called this emotion

“shame‐anxiety” (Pascual‐Leone & Greenberg, 2005). Because these

shame‐based emotional states are difficult to bear for most persons;

hostile anger is a common defensive interactional manoeuver

(Pascual‐Leone, Gillis, Singh, & Andreescu, 2013). Patients with NPD

have often developed a host of other agency‐enhancing interactional

manoeuvers as well, like boasting, using imagery of grandiosity, set-

ting exaggeratedly ambitious work goals, engaging in competitiveness,

or, also, using harsh self‐criticism, self‐hatred, and self‐contempt.

Patients with NPD have often developed explicit and implicit strate-

gies for avoiding the hurtful experience of shame (Lecours et al.,

2013).

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