Assignment: Therapy for Clients With Personality Disorders- Narcissistic Personality Disorder – 1 page

Journal of Psychotherapy Integration Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder Giancarlo Dimaggio Online First Publication, September 2, 2021. http://dx.doi.org/10.1037/int0000263

CITATION Dimaggio, G. (2021, September 2). Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder. Journal of Psychotherapy Integration . Advance online publication. http://dx.doi.org/10.1037/int0000263

Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder

Giancarlo Dimaggio Centro di Terapia Metacognitiva Interpersonale, Rome, Italy

Pathological Narcissism (PN) is a challenge to clinicians, who have difficulties dealing with clients relationally and forming and agreeing on a therapy contract. PN sufferers easily fuel relational conflict or withdraw from relationships. In spite of its severity and prevalence, there is no empirically supported treatment for this condition. Given this, integrative therapists need to be offered a series of principles of good clinical practice, that they can adopt irrespective of their preferred orientation. This article focuses on 5 domains of PN, that is: (a) maladaptive self–other schemas, (b) poor self-reflection and intellectualizing, (c) disturbed agency, (d) maladaptive coping and defenses, and (e) poor theory of mind and empathy. With this background, I offer specific treatment suggestions that can be applied in an integrative spirit and are formulated in a way that lends them to empirical investigation. With this and other recent efforts, the hope is to increase clinicians’ and researchers’ awareness of how PN can be treated and possibly increase the amount of empirical studies aimed at showing what principles of change are actually effective. Pathological Narcissism and narcissistic personality disorder are prevalent and present with significant comorbidity and create problems to self and others, but there is no empirically supported treatment to date for these conditions. This article presents treatment suggestions that may pave the way for addressing them and paving the way for empirical studies.

Keywords: Pathological Narcissism, narcissistic personality disorders, maladaptive interpersonal schemas, metacognition, integrative psychotherapy

Clinicians facing clients with Pathological Nar- cissism (PN) or narcissistic personality disorder (NPD) need empirically supported treatments. Suchclientspresentwithcharacteristics,bothatthe level of inner experience and interpersonal func- tioning, that make psychotherapy complicated. ThroughoutthepaperIwillmostlyrefertoPN(Pin- cus & Lukowitsky, 2010), as it describes a broader range of phenomena than NPD as categorized in the DSM–5 (American Psychiatric Association, 2013). The latter refers to persons who feature self- enhancement and grandiosity, seek admiration, harbor fantasies of success and ideal love, exploit

the others, and lack empathy. These features are typical of the so-called overt type (Gabbard, 1989). Instead, the literature has consistently noted that many patientsfeature the different picture of covert or vulnerable narcissism (Gabbard, 1989). This personality type’s inner life is quite different from that depicted in DSM–5. Persons are consumed by shame, guilt, inferiority and envy (Ritter et al., 2014), experience emptiness, loneliness, separate- ness and alienation, and have little trust that others can help instead of exploiting them (Kealy et al., 2015). PN,withitsbroaderspectrum,embracespersons

with a combination of both overt and covert aspects. The very same individual may present as arrogant and boastful at one moment, and at others conceals himself because of his deep-seated feel- ings of guilt, shame and inferiority (Caligor & Stern, 2020; Crisp & Gabbard, 2020; Dimaggio et al., 2002; Kealy et al., 2015; Kohut, 1977). Evi- dence shows that grandiose narcissism tends to

Giancarlo Dimaggio https://orcid.org/0000-0002-9289- 8756

Correspondence concerning this article should be addressed to Giancarlo Dimaggio, Centro di Terapia Metacognitiva Interpersonale, Piazza dei Martiri di Belfiore 4, 00151 Rome, Italy. Email: [email protected]

1

Journal of Psychotherapy Integration © 2021 American Psychological Association ISSN: 1573-3696 https://doi.org/10.1037/int0000263

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

swing between grandiose and vulnerable states, while the vulnerable type has more stable levels of negative experiences and rarely expresses grandi- osity(Edershile&Wright,2020). PN is highly comorbid with symptom and

behavioral disorders, for example, anxiety and depression (Kealy et al., 2020; Pincus et al., 2014), alcoholanddrugabuse(Stinsonetal.,2008),eating disorders(Gordon&Dombeck,2010)andrisk-tak- ing behaviors, especially if these are socially disap- proved (Leder et al., 2020). Thinking in terms of PN helps make sense of why patients with more prominent global suffering and personality dys- functions and poorer real-world functioning are associated with a suboptimal psychotherapy pro- cess, while patients with higher levels of narcissis- tic traits, low sense of control over action, and higher real-world functioning have better therapy responses(Krameretal.,2020). In sum, these persons’ livesare filled with symp-

toms and loneliness but are difficult to deal with interpersonally. There is therefore a need for per- sonalized and empirically validated treatments. The problem is that, as of today, there are none, in spite of NPD’s wide prevalence, for example, 8.5%-20% in outpatient independent practice (Weinberg&Ronningstam,2020). As noted by Yakeley (2018) and Weinberg and

Ronningstam (2020), some approaches have been tailored or adapted to PN and offer promises of effectiveness. These include psychoanalytic psy- chotherapy (Kernberg, 1975; Kohut, 1971; Ron- ningstam & Maltsberger, 2007), Mentalization Based Treatment (Drozek & Unruh, 2020), Trans- ference Focused Therapy (Diamond & Hersh, 2020), CBT (Beck et al., 2015), Schema-Therapy (Young et al., 2003), Metacognitive Interpersonal Therapy (Dimaggio & Attinà, 2012), and dialecti- cal behavior therapy (Reed-Knight & Fisher, 2011),andanotherapproachadaptedtotreatingPN is Clarification Oriented Psychotherapy (COP; Sachse,2020).Theproblemisthatasoftoday,nota single one has been tested in a randomized con- trolledtrial(Ronningstam,2019;Weinberg&Ron- ningstam, 2020). So, in an era where delivering validated treatments is necessary, what does a ther- apist do when treating PN? And, more specifically, what does the integrative therapist, who cares more about being effective than being faithful to a spe- cific orientation, do? Should they give up their ambitionsofdeliveringsomethingempiricallysup- ported and resort to generic principles of change? Orcantheyroottheiractioninstableground?

PN poses serious challenges to the treating clini- cian. Clients may involve therapists in different maladaptive relational patterns, pushing them to feel angry, devalued, helpless and inadequate and to disengage from the therapy process (Colli et al., 2014;Tanzillietal.,2020).Inthecaseofadolescent PN,therapiststendtoreactwithangerandcriticism or disengagement when facing the grandiose type or with worry and feeling overwhelmed when fac- ingthevulnerabletype(Tanzilli&Gualco,2020). Compliance with tasks may be limited: Very of-

ten patients barely accept they are in treatment to dealwiththeirveryownpersonalityissuesandonly ask for symptom relief. This is one source of impo- tence and frustration in therapists, who eventually ask themselves: “Is this person really suffering? Andifhedoes,ishewillingtobehelped?” Therapists would better avoid being overconfi-

dent about their own generic therapeutic skills and insteadadjusttothe specificneedsofthesepersons. Clearly integrative therapists facing such a difficult condition need to be guided, so not to remain either prey to disturbing feelings or get trapped in rela- tional problems, which end up in conflict, stale- mates, and dropout (Crisp & Gabbard, 2020; Ronningstam, 2020). In absence of empirically supported solutions,one strategy isto offerintegra- tive therapists a series of pragmatic ideas on how to handlePN,irrespectiveoftheirorientation. In the next section of the paper, I will summarize

some aspects of PN pathology and describe what challenges they pose to the clinician. I will exclude patients with antisocial features and malignant nar- cissism,astheyrequirea differentapproach(Yake- ley, 2018) beyond the scope of this work. After this section, I will provide a series of therapeutic sug- gestions on how to handle these problems and illustrate them with clinical vignettes. These sug- gestions are a working-out of principles identified in two recent papers selecting the most suitable approaches to treating PN and NPD (Yakeley, 2018; Weinberg & Ronningstam, 2020). My effort is in line with the pragmatic “dos” and “don’ts” for treating NPD offered by Weinberg and Ronning- stam (2020). The main difference is that these authors’ “principles were derived from clinical ex- perience, not from a theory of NPD” (p. 138). My workinsteadtriestoofferaseriesoftechniquesand strategies tailored around a theoretical and empiri- cal model of PN. Another specific aspect is the inclusionofexperientialtechniques,suchasguided imagery and rescripting, role-play, two-chairs, and body work. This is necessary because among

2 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

current models for treating PN only Schema Ther- apy (Young et al., 2003), Metacognitive Inter- personal Therapy (Dimaggio et al., 2020), and Clarification Oriented Psychotherapy (Sachse, 2020)includethemintheirrepertoire.Experiential practices were not mentioned in the two recent papers offering a perspective on current treatments for narcissism (Yakeley, 2018; Weinberg & Ron- ningstam,2020),whiletheycanaddasharperedge topsychotherapyforthiscondition.

Narcissistic Psychopathology

Clearly there is a gap between current diagnostic manuals of mental disorders and existing knowl- edge about PN and NPD. In order to be clinically useful, a diagnosis needs to be grounded on a con- sistent model of psychopathology, which is hardly provided by listing a set of mostly behavioral crite- ria as in past editions of the DSM (see Sachse, 2020). The DSM–5 (American Psychiatric Associ- ation, 2013) has made a step forward when adopt- ing the level of personality functioning model, which aims at describing personality disorders in terms of their self and interpersonal functioning, assessing aspects such as identity and capacity for self-reflection—self-direction that is clearly con- nected to a core PN problem, that is agency; empa- thy, and capacityfor intimacy.The following list of aspects may provide a comprehensive picture of PN which could then be mapped on a formal, clini- cally useful diagnosis of NPD in future editions of DSM and also of ICD, which currently does not allow for a diagnosis of NPD (see Sachse, 2020 for similarobservations). On the basis of such a rationale I will now (a) list

the core aspects of PN and NPD, then I will (b) describe in details each of them and finally (c) describe how the therapist can work in order to tacklewiththeseelements.

PN and NPD Psychopathology

The aspects of PN and NPD psychopathology I willanalyzeanddiscussare: a) maladaptive representations of self and

others; b) impaired self-reflective capacities and tend-

encytointellectualize; c)agencydisturbances; d)maladaptivecopingstrategiesanddefenses; e)poortheoryofmindandempathy.

Maladaptive Representations of Self and Others

Persons with PN are guided by crystallized and maladaptive ideas of self and others (Caligor et al., 2015; Diamond & Meehan, 2013; Dimaggio et al., 2015; Young et al., 2003), which means that they endorse: disturbed self-representations and dis- turbed representations of others in the context of trying to fulfill core wishes or needs. In simple words,apersonwantstobeappreciatedandharbors ideas of being inferior, which are, however, con- cealed by explicit ideas of being superior; he imag- ines others as either admiring or spiteful and, according to how his ideas about the self and others are combined, different affects emerge. For exam- ple, if he thinks he is inferior and the other spiteful, he will experience either anticipatory anxiety when waiting for judgment or shame after receiving criticism. Maladaptive schemas in PN revolve around

some core wishes or needs. When driven by social rank, as they often are, patients’ self-concept swings from inferior to superior, and a dissociation between explicit self-esteem (high) and an implicit one (low) is present (Gregg & Sedikides, 2010; Kunstetal.,2020). In the attachment domain many problems arise.

PN patients usually adopt a dismissing attachment style (Diamond et al., 2014), avoiding expressing attachment needs because they anticipate others will neglect them and being cold and controlling. They can also display unresolved attachment, anticipatingtheothermightbeverbally,physically, and emotionally abusive (Drozek & Unruh, 2020; Johnson et al., 2001). Resorting to self-soothing as a means to avoid attachment was also observed (Bamelisetal.,2011). When driven by the wish for group inclusion,

PNs swing between the desire to belong to ideal communities where they share special qualities, to derogating groups and experiencing themselves as different and superior (Dimaggio et al., 2007) or to experiencing anxiety at the idea of being rejected (De Panfilis et al., 2019) or pain when feeling excluded and angry, even if at times they may deny it (Cascio et al., 2015; Dimaggio et al., 2008; Twenge&Campbell,2003).Thismeansthatwhat- evertheirconsciousexpectationsare,patientsover- reacttocriticism.Overall,whenthey,experienceor anticipate negative reactions from others they eas- ily resort to fight/flight strategies. They may first attack, devaluate, or blame the others, but in the

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 3

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

long run they resort to withdrawal, shutting them- selves in an ivory tower or a in cocoon, entering states of emptiness and emotional detachment, and self-soothing (Dimaggio et al., 2007; Kohut, 1977; Modell,1984;Youngetal.,2003). Based on these schemas, PNs experience mental

states such as angerat being hurt or rejected, empti- ness and alienation, guilt, envy, fear, anxiety, and a sense of annihilation. Only at times do they enter grandiosestatesofmindfilledwithglory,pride,sat- isfaction, and self-fulfillment, but these states are short-lived (Dimaggio et al., 2002; Kohut, 1977; Kernberg, 1975; Modell, 1984; Ronningstam, 2009).

Impaired Self-Reflective Capacities and Tendency to Intellectualize

PNs are poor at describing their inner experien- ces (Dimaggio et al., 2002; 2007; Krystal, 1998; Pincus, 2020). They have difficulties labeling their affects, in particular ones related to vulnerability and fragility (Lowen, 1983). They can easily say they are angry or refer to emotions related to self- enhancement (Dimaggio et al., 2002; Drozek & Unruh, 2020) but are much less likely to recognize they feel sad (Bouizegarene & Lecours, 2017), guilty, ashamed, or scared (Dimaggio et al., 2002). As previously noted, they actually experience pain due to feeling rejected but consciously deny it (Cascio et al., 2015). Unaware as they are of their vulnerabilities, they are not able to integrate these aspects in their self-concept. This is a likely reason for their liability to symptoms such as anxiety or health-anxiety, that is they, when experiencing a sense of fragility and fear, can hardly name it or communicate it to others, so that they remain prey to negative emotional arousal they then interpret as asignalofimpendingdanger. The other side of the coin of their diminished

capacity to report inner experiences is their tendency to intellectualize (Dimaggio et al., 2002). When trying to convey their inner life to a listener, they resort to abstract theories and intellectualizing; in other words, they pseudo- mentalize (Ronningstam, 2020). It is as if they were on stage delivering a TED talk, which pre- vents listeners from promptly understanding they are talking about something personal and, most importantly, what it is about. These per- sons often resort to intellectualizing more when they have just experienced failure or rejection,

something clinicians discover later in therapy (Dimaggio et al., 2002).

Agency Disturbances

In spite of the layperson idea that persons with PN are goal-oriented and behave like bulldozers when driven by a goal, their agency is frequently impaired, ranging from the expected hyperagentiv- ity to loss of agency (Ronningstam, 2009). When these persons are neither pursuing grandiosity nor fighting against someone they perceive as an obsta- cle, they lack an inner source for goal-oriented, self-initiatedaction(Dimaggioetal.,2007;Dimag- gio & Attinà, 2012; Kohut, 1977; Modell, 1984). Lack of agency is considered a central aspect of all DSM–5 personality disorders (American Psychiat- ric Association, 2013; see Dimaggio et al., 2009; Links, 2015). In recent years, laboratory findings have backed up clinical observations of agency problemsinPN.Asregardsinflatedagency,partici- pants in a laboratory study with moderate to high (but not extreme) narcissistic traits had greater agency than controls, meaning they were overcon- fident of being in control of their actions (Hascalo- vitz & Obhi, 2015). Commenting on the results of Hascalovitz and Obhi, Dimaggio and Lysaker (2015) speculated that sense of agency should be weaker in vulnerable narcissism and stronger in the grandiose type. Render and Jansen (2019) investi- gated this hypothesis in a nonclinical sample and found the vulnerable type was correlated with diminished agency, while the grandiose type did not display any increase in agency. The plausible link with inflated sense of agency and grandiose narcissism requires further exploration in samples withclinicalPNlevels. Indirect support for the presence of agency dys-

functions in PN comes from findings that depres- sion (Obhi et al., 2013) and social exclusion (Malik & Obhi, 2019), both present in many PNs, have a detrimental effect on agency. This means that poor agency in PN may have both trait-like (Hascalovitz & Obhi, 2015; Render & Jansen, 2019) and state-like properties, that is it dimin- ishes when these persons experience specific states of mind such as depression or social rejec- tion. Other indirect evidence for the agency prob- lem is that narcissistic traits are related to reduced entrepreneurship and self-efficacy (Wu et al., 2019) and disengagement from academic activ- ities(Robins& Beer,2001).Thesemaysignalthat

4 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

PNs feel they have less influence on the world, which gets manifested in not sustaining long-term activitiesrequiringprolongedeffort.

Poor Theory of Mind and Empathy

Poor capacity to understand the others and lack of empathy are part of the core definition of NPD (American Psychiatric Association, 2013; Kern- berg, 1975). Many studies support the observation that PNs are poor at understanding the others and resonating with their inner experience (De Panfilis, et al., 2019; Dimaggio et al., 2009; Leunissen et al., 2017; Marissen et al., 2012; Ritter et al., 2011). Poor empathy affects behavior, for example less ability to take others’ perspective predicted lower generosity in narcissism (Böckler et al., 2017). Using a specific interview to assess mentalistic capacities, NDs displayed significantly less capacitythanpersonswithoutanyPDtounderstand what passed through others’ minds and to see the world from their perspective instead of an egocen- tric one (Bilotta et al., 2018). There is debate about whether PNs are poor mentalizers either because they are unwilling to for self-serving purposes or because they have context-dependent issues (Bas- kin-Sommers et al., 2014). A meta-analysis by Urbonaviciute and Hepper (2020) found that both grandiose and vulnerable narcissism were associ- ated with decreased empathy, assessed both with self-reporting and behavioral measures, but it appeared that their problem was motivational, that is, they had the cognitive capacities to understand othersbutwerenotmotivatedto. This leads to the question: under what condi-

tions do PNs lose motivation to understand the others? The hypotheses are that, for the most part, failures in the capacity to understand the others happen under the influence of either attachment (Drozek & Unruh,2020) orsocial rank, in particu- lar when persons experience defeat (Colle et al., 2020) or the need to belong when facing social rejection (Dimaggio et al., 2007). Analyzing the first treatment sessions of 3 NPD patients, Dimag- gio and colleagues (2009) found that during treat- ment all 3 improved in their capacity to both understand others and to reason about their inten- tionsfrom a decentered perspective. This suggests that this capacity is more state-like than trait-like and depends on relational conditions. In light of these observations, consistent with those of Bas- kin-Sommers and colleagues (2014), therapists

need to pay attention to creating the conditions for theory of mind and empathy to flourish, rather than stigmatizing patients for something they are thoughttobejustunwillingtodo.

Maladaptive Coping and Defenses

PNs do not just suffer because of their maladap- tive schemas but also because of the consequences of how they deal with their symptoms and frustra- tion.The strategiespatientsuse forthispurpose,of- ten automatically and unconsciously, are variously termed maladaptive coping (Kealy et al., 2017) or defenses (Caligor et al., 2015; Kernberg, 1975). Beside differences in theory, both concepts refer to behavioral and cognitive/affective strategies aimed at minimizing or preventing psychological pain a person thinks or feels he is unable to bear. Coping anddefensesareenactedforself-protectivereasons and stem from schemas, that is PNs think the other will not give the desired responses to their wishes and needs and so they automatically react in order to prevent,reduce, orkeep at bay the negative emo- tionsthatwouldfollow(Dimaggioetal.,2015). PN has been described as a constant sense of

threat to the self (Westen, 1990). According to this idea, narcissistic strategies can be conceived as grounded in the most archaic defense system in front of threat: fight/flight. Tendencies such as attacking, blaming, belittling and dominating others, and passive-aggression are aspects of the fight system and have been consistently found in PN (Mielimaka et al., 2018; Twenge & Cambpell, 2003).Conversely,similarwell-knownPNtenden- cies toward isolation, withdrawal, emotional dis- tancing, finding shelter in an ivory tower or cocoon (Modell, 1984), disengaging from relationships, and avoiding displaying vulnerabilities (Kohut, 1977) are aspects of the activation of the flight sys- tem. More in general, the most typical narcissistic coping strategy is self-enhancement (John & Rob- ins, 1994), that is an ongoing effort to boost a vul- nerable self-esteem by both striving for the maintenance of an idealized self-image and pre- senting oneself to others as grandiose. It is the most investigated PN cognitive mechanism and is sup- ported by a plethora of studies (Grijalva & Zhang, 2016). It mostly serves to protect from contact with covertfragileself-esteem. I offer now an example of the role of the malad-

aptive consequences of self-enhancement aimed at protectingtheunderlyingvulnerableself-esteem.

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 5

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Michele is a musician from Puglia in his early 40’s and came to therapy in desperation. He said he had lost meaning in all aspects of his life, after the ending of his marriage with a rich and beautiful woman with whom he had travelled the world and led a grand life. The ending also involved a financial disaster for him, as during his married years he spent all his money to adjust his lifestyle to that of his wife. He realized that he was always searching for something bigger, better, and more beautiful and never had a sense of reaching it. At the beginning of the therapy, he did not see any way to restart his quest for grandiosity and felt his des- tiny was just delivering music lessons to earn a few bucks, a condition he wholeheartedly despised. It was not difficult to get him to see that his aspiration to gran- diosity was simply a mechanism. After a few sessions, when he was dating a new woman and enjoying it, he said: “Yes, things are fine but, well . . . you know. . . she’s not Charlize Theron.” I answered that I was pretty sure that if he had had a relationship with the real Charlize Theron, he would have longed for a more beautiful woman. He agreed that he would then have desired to be with Scarlet Johansson or Nicole Kidman. We laughed about this, and he realized that he was prey to a relentless mechanism he now wanted to stop.

When describing coping and defenses at a be- havioral level, many manifestations appear. PNs adopt perfectionism with the goal of fixing the intolerable flaws they see in themselves (Dimaggio et al., 2018), procrastinating (Weinberg & Ron- ningstam, 2020) or lying in order to maintain a grandiose and spotless presentation. Resorting to omnipotence and denial of vulnerable aspects can be the origin of risky behaviors such as having con- domless sex, which has been found in women stu- dents with grandiose narcissism (Coleman et al., 2020), and gambling (Leder et al., 2020). In order to avoid pain or boost self-esteem, PNs resort to alcohol and drug abuse (Stinson et al., 2008)—for example, cocaine—to restore their sense of grandi- osity, problematic videogaming, which is typical of vulnerable narcissism (Di Blasi et al., 2020), dis- ordered eating in both grandiose and vulnerable types (Gordon & Dombeck, 2010), cosmetic sur- gery (Fitzpatrick et al., 2011), and overexercising (Spano, 2001). Repetitive thinking, in the form of rumination and worry, is a cognitive coping strat- egy whose goal is to reduce suffering but with counterproductive effects. Rumination has been observed in PN (Dimaggio et al., 2020). It is corre- lated with vulnerable narcissism and a predictor of its comorbid depression (Kealy et al., 2020). Vul- nerable narcissism is also associated with jealousy, which triggers worry about a partner’s emotional infidelity (Tortoriello & Hart, 2019). Repetitive thoughts filled with anger and suspiciousness are

significant in PN and an important route toward aggression (Krizan & Johar, 2015). Similarly, Fat- fouta and colleagues (2015) found that a combina- tion of anger and rumination is a path between narcissisticrivalryandlackofforgiveness.

Principles for an Integrated Therapy Based on Narcissistic Psychopathology

In light of the above-described aspects of psy- chopathology, to be successful, therapy should aim at: a) increasing self-reflection and reducing

intellectualizing; b) reducing the impact of maladaptive schemas

andforminghealthierandmoreflexibleideasabout selfandothers; c)supportingagency; d) counteracting maladaptive coping and pro-

moting healthier ways of dealing with suffering; e)promotingtheoryofmindandempathy. Thesegoalscanbereachedbydifferentavenues,

including: working through the therapy relation- ship—for example, psychodynamic therapies (Kohut, 1971; Kernberg, 1975), Mentalization Based Treatment (Drozek & Unruh, 2020), Trans- ference Focused Therapy (Diamond & Hersh, 2020), Metacognitive Interpersonal Therapy (Dimaggio et al., 2020), agreeing upon a therapy contract (Diamond & Hersh, 2020), focusing on affects instead of accepting intellectualizing, and using behavioral experiments and experiential techniques (CBT, Schema Therapy, DBT, Meta- cognitiveInterpersonalTherapy).Thisproposalfor an integrated treatment is built around a model of PN; I will therefore organize the treatment sec- tion by aspects of psychopathology and describe how different instruments, for example, working through therapy relationships and assigning behav- ioralexperiments,cantackleanyspecificaspect. These elements of psychopathology obviously

present themselves at the same time, so the order of presentation of the areas of interventions does not correspond to that in which they are dealt with in therapy. For the most part, therapists have to work in parallel on the different aspects. For example, when a therapy starts, clinicians struggle to under- stand what the patient’s self-experience is because of her poor self-reflection and intellectualizing. At the same time, the influence of maladaptive sche- masandpooragencycreateproblemsinthetherapy relationship and in agreeing upon a therapy

6 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

contract. I will propose that it is better to deal with the different aspects of pathology sequentially; for example, it is better for promoting self-reflection to come before promoting theory of mind and empathy.

Promoting Self-Reflection and Reducing Intellectualizing

Listening to narcissistic speech is challenging. Therapists become easily lost, confused, or kept at bay because PNs scarcely report specific auto- biographic memories and, if they do, barely name the emotions they felt. They do not convey the type of information therapists need most: reports of significant problematic interpersonal events filled with negative emotions and prob- lems a patient could not solve. Improving self- reflection and reducing intellectualizing is likely one the first goals a therapist needs achieving, as there is preliminary evidence that an increase in capacities to recognize own affects and self- stateswithmore clarityandnuances isa predictor of good outcome in psychotherapy for personal- itydisorders(Krameret al.,2020). Therapists are better to adopt a curious stance

and not fear presenting themselves as puzzled or confused.Listeningtopatientswithnarcissismdur- ing their early sessions is one of the moments in which adopting a not-knowing stance is necessary. Therapists need to continuously repeat they do not understand and want to know more about specific episodes and to probe for the related affects and cognitions. If patients have difficulties reporting past epi-

sodes with the related affects, I ask them to concen- trate on specific moments in the week to come where there are interactions involving any prob- lems and focus on what happens and try to report it to me in the next session. Then the next session is devotedtoajointscanningoftheepisode,untilspe- cific emotions and thoughts, ones that patients moreeasilyrecognize,emerge. Experiential techniques may be helpful in order

to increase awareness of self-states and reduce PN tendencies toward intellectualizing and ascribing the roots for their distress to the others and the soci- etyatlarge.Experientialtechniqueshaveanexquis- ite capacity to help persons become more aware of their inner processes(Pascual-Leone & Greenberg, 2007). Practices such as chair-work or guided im- agery actually help a person observing their inner

world and the emotions they experience while reliving episodes where clearly “real” others are absent (Dimaggio et al., 2020; Greenberg, 2002; Sachse,2020). As regards intellectualizing, therapists can still

engage in a conversation about the ideas expressed, possibly remaining curious and playful and avoid- ing conflict when views differ. They should focus on common interests, for example, TV series, music, social issues, and so forth. This helps create a sense of intellectual connection, especially if some interests are genuinely shared, and then this can provide the ground for probing for episodes. For example when a patient says society is filled with idiots and incompetents, their therapist may agree that they have come across many of these too but then ask for an episode in which the patient had to face someone they considered an idiot and explore the impact this had on their goals and feelings. In my experience, telling these persons that I

am curious about their opinions but that they do not help me in forming a picture of their inner world is easy and safe. When I say that I am puzzled and do not understand and without spe- cific information have no chance of getting in touch with who they really are and forming a 3-D portrait of their mind, these persons usually grasp that I am interested and not playing the all-know- ing wiseman. I add that with information about what specifically passed through their mind inside specific episodes, I can obtain ideas about their inner world that we can share, so that I do not have to resort to inferences and interpreta- tions based on my books, which would divert me away from my understanding them as unique human beings. There is one minor side effect in these operations, thatis patientsmay becomeirri- tated when the therapist insists on probing for their feelings or battle in order to continue expos- ing their “fancy” theories. These are minor alli- ance ruptureswhich a therapist hasto explore and repair, but in my experience not major ones with a dropoutrisk.

Dealing with Maladaptive Schemas

OnereasonmakingtherapyofPNdifficultliesin their schemas for self and others. First and fore- most, they have a toxic impact on the therapy relationship.

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 7

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Pragmatic Suggestions: Working Through the Therapy Relationship

ProbablythisistheaspectofNPDtherapywhich is most widely covered by the literature (e.g., Gab- bard, 1989; Kohut, 1977; Weinberg & Ronning- stam,2020),anditiscoretomanyofthe treatments tailored to Pathological Narcissism, such as Men- talization Based Treatment (Drozek & Unruh, 2020), Transference Focused Therapy (Diamond & Hersh, 2020), Schema Therapy (Young et al., 2003), and Metacognitive Interpersonal Therapy (Dimaggio et al., 2020). The first idea is that in order to avoid making these persons feel further invalidated, therapists need to provide validation and support while at the same time carefully avoid- ing criticism of them for their interpersonal behav- iors, no matter how disturbing they sound (Kohut, 1977; Weinberg & Ronningstam, 2020). Valida- tion and support can be focused on patients’ actual qualities and actions, capacities for communica- tion, displaying of painful feelings when done spontaneously, and most importantly, non-narcis- sisticaspectswhichtheyareunawareof.

An example of this validating stance comes from my therapy with Arthur, a man in his 40s who sought ther- apy because he self-diagnosed as a “narcissist” and was afraid his personality and his constant fighting with his wife were ruining his pre-teen son. He could be diagnosed as having NPD as he admitted to his ther- apist that on the one hand, he felt superior to others, but on the other hand, he concealed feelings of inferiority. He added that had always used manipulation and dero- gation as conscious strategies to let his romantic part- ners feel inferior so to not let them discover his flaws or realize they were better than him and abandon him for a better man. He also said he had always worn a mask, concealing any difficulties. When he told me episodes about his marital problems and his childrear- ing style, I pointed out that his fights with his wife in front of their son were certainly not useful. But I added that he was very focused on his son’s psychological well-being, in terms of getting him to study, not spend- ing hours on videogames, communicate his feelings, and have a regular sleep pattern. Moreover, Arthur did not display any signs of trying to rear his son as a future narcissist: he was not overly critical, nor did he set unrealistically high expectations. He reacted to my observations with a mixture of surprise and, most of all, relief from his underlying deep guilt. After 2 years of therapy, he divorced after his wife being unfaithful, and his relationship with his son is very good.

Ruptures easily arise when therapists are caught in the activation of the social rank system and try to reestablish their status by taking a dominant stance pushing the person with narcissism into an underdog position, something these persons fight

fiercely against. This is evident when therapists statethey“wanttomakepatients’self-esteemmore realistic,” which just means they are telling the cli- entheisawindbag. The reverse needs to be avoided as well: Thera-

pists should not let patients belittle them or insult them. This has to be done skillfully and tactfully, avoiding counterattacking, and for as long as possi- ble. With the majority of these persons, criticism and spite toward the therapist are expressed with subtle irony, which may err toward sarcasm. Avoiding dealing explicitly with this attitude is a problemforaseriesofreasons.First, itcorresponds to the “confrontation” type of alliance rupture (Safran & Muran, 2000; Muran et al., 2021), which the clinician must readily recognize and deal with. Second, when patients belittle their therapist, they are probably conducting a passive-into-active test, that is acting like whoever mistreated them during development (Weiss, 1993). If therapists let patients belittle them, they confirm the idea that spitefulness is acceptable in the relationship, thus justifying the actions taken by the caregivers, school teachers, or trainers of the person who will endupsufferingfromPathologicalNarcissism.Itis as if the clinician is confirming the idea that we deservetobemistreatedanddonothavetherightto stand up for ourselves. Clinicians would better gently, but continuously, point out that patients are being sarcastic or spiteful and inquire about the underlying reasons. They should acknowledge they can and do make mistakes but receiving con- temptdoesnothelptherapy.Whenapatientharshly insults her therapist, the latter has to set limits (Kernberg,1975). Conversely, in order to prevent ruptures, thera-

pist might validate their clients, noting that compe- tition is one of the most important human drivers (Gilbert,2005)andthatambitionhasasilverlining. Therapists would do better to acknowledge these same attitudes in themselves, not pretend they do not find themselves engaged in power struggles with their partners, colleagues, and friends, and, if appropriate, self-disclose them. Once patients feel understood, therapists can gently ask something sounding like: “What for?” This way they do not question that competition is important, but make patientsnoticethattheirsisanever-endingstruggle, whichhasnothelpedthemreachasenseofsatisfac- tionandfulfillment,norwillitdosointhefuture. Therapists should also pay attention to prevent-

ing overactivation of the attachment system. Given that narcissistic attachment-related schemas are

8 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

filled with predictions that others will neglect, con- trol or react with criticism and rejection of patients’ displaysofvulnerability,itislikelythatiftherapists present with an excess of warmth and concern for patients’ states, the latter immediately shift into the social rank system. They tend to withdraw, react withprideordisdain,anddenytheirvulnerabilities. Inmyearlyyearswhentreatingthesepatients,Ihad dropouts soon after I disclosed my feelings of warmth or tenderness for their pain. I learned the lesson and now advocate therapists carefully moni- tortheactivationoftheircaregivingsystem. This is an area of debate, as schema-therapy, for

example, suggests the contrary; that is that thera- pists need to let PNs contact their vulnerable selves (Youngetal.,2003).Moreover,whenusingexperi- ential techniques, schema-therapy adopts the concept of limited reparenting, while other mod- els such as Metacognitive Interpersonal Therapy (Dimaggio et al., 2020) and Clarification Oriented Psychotherapy (Sachse, 2020) do not. These latter models consider the concept of “reparenting” as a risk to create a power difference between therapist (seen as parent) and patient (seen as child), a differ- ence to which, in my opinion, persons with PN would likely react with feeling belittled. This is a matter for future process-outcome study, but my suggestion would be to carefully avoid treating these persons as if they have an inner vulnerable child. Therapists need to improve access to nega- tive feelings, such as guilt, sadness, anxiety or shame, but this is better done while adopting a stance of curious exploration and not that of a benevolentparent. Problems in the therapy relationship also affect

the shared drafting of the therapy contract, a prob- lemIdealwithinthenextsection.

Pragmatic Suggestions: Bearing in Mind the Therapy Contract and the Goal and Task Components of the Alliance

Maladaptiveschemasalsoexerttheirtoxiceffect by making the formation of a shared, reasonable, and goal-oriented therapeutic contract difficult (Clarkin et al., 2015; Weinberg & Ronningstam, 2020). When therapists figure out where patients needtoheadtoinordertoreducesymptomsorhave a more rewarding social life, they encounter prob- lems. Very often their proposals on how to move forward with therapy are read under the lenses of the schemas, with PNs constructing their therapists

as dominant, tyrannical, or belittling. This easily creates maladaptive patterns in the therapy room, wherebothpatientandtherapistbecomedominated by their own schemas or internalized object rela- tions. Typical narcissist enactments range from: devaluingthegoals,sayingthatthey makeno sense to them, despising their therapists for their nonsen- sical proposals, saying that the outer world offers them no chances to fulfill their wishes, or insisting that what is lost can never be retrieved. They may also react with passive-aggression, agreeing with tasks that they then do not comply with by, for example, persisting in maladaptive coping such as passivity, drug and alcohol abuse, perfectionism, verbal aggression, or disordered eating, without any effort to counteract them. All these reactions first need to be dealt with by handling counter- transference and avoiding fueling maladaptive interpersonal cycles (Safran & Muran, 2000). Once therapists have achieved good self-regula- tion, they must shift to the therapy contract (Wein- berg & Ronningstam, 2020; Yakeley, 2018). Being explicit about this dimension is somethinga therapist cannot avoid and at times is the only way nottoremaintrappedinmaladaptive interpersonal cycles. Therapists need to be crystal clear about thepossibilitiesandlimitsofpsychotherapy. One key aspect of the contract is portraying a

clear path between clients’ expectations and task compliance. Therapists need to be adamantine that change depends on task commitment, and they havenopowertomaketheirpatients’livesgobetter if they do not, for example, take a shot at giving up spendingcountlesshoursontheircomputerwithout searching for a job, trying to abstain from rumina- tion and worry, and engaging in some form of healthybehaviorandsoon.Tobeclear,thecontract is not necessarily about change, but is about what therapy is for. If clients simply want to spend their therapy time saying their life has been and will be miserable and that they are frustrated because others do not understand and admire them as much as they deserve, therapists can still accept this, remaining in the position of an empathic listener. What matters is they make explicit that this will only serve to let the patients perhaps feel under- stood and to alleviate their loneliness but will not yield any change in their life nor dramatically reducetheirpain.Thiswaytherapistspreventfuture complaintsoraccusationsaboutnotdoinganything to help. I will provide an example of how to form a therapeutic contract in the section devoted to pro- motingagency.

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 9

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Promoting Agency

Lack of agency and passivity over one’s own inner experiences and behaviors lie at the core of PN.Addressingthisintreatmentcanhelptheseper- sonsovercomeproblemstheyhave faced overtheir entirelife.Therapistsandpatientsfirstagreethat,in order to make treatment work, they need to focus on this problem and then negotiate ongoingly how to deal with it. As Weinberg and Ronningstam (2020)noted,therearemanywaystofosteragency, including behavioral tasks, emotion regulation practices, and trying to find different ways to deal with suffering. These elements are part of many of the abovementioned treatments for PN, such as CBT, Schema Therapy, Metacognitive Interperso- nalTherapy,andTransferenceFocusedTherapy. AsInoted earlier, the differentaspectsofpathol-

ogy interact with each other (Dimaggio et al., 2002), and I will also therefore, in the section on coping, describe some of the agency-reinforcing practices,astheyareabouttryingtoregaineffortful control of automatisms such as problem behaviors andrepetitivethinking.

Pragmatic Suggestions: Negotiating the Contract

One necessary way of promoting agency is through a patient, but firm, contract negotiation. Actually, as noted by Weinberg and Ronningstam (2020), some approaches for NPD do mind about the therapy contract, asit is a fundamental aspect of therapy with these persons. The term “contract” may have slightly different meanings in the various approaches. For example, Diamond and Hersh (2020) note how in TFP the contract includes ele- mentssuchasexplicitlyaddressingsecondarygain, requiring clients to engage themselves in some formofactiveorproductiveactivityviapaidorvol- unteer work or study, be honest within session, and soforth.Thisisatlargeconsistentwiththeperspec- tive on the therapy contract I adopt here. More ex- plicitly, I refer here to operations aimed at getting the therapist and client on the same page in terms of:agreeingontherapygoals;realizingthatwithout committing themselves to some therapy tasks, some goals will remain out of reach; ensuring that clients purposefully decides to commit themselves to a task and if they do not, reframe therapy goalsin a more realistic way. Of note, this is not an

operation that is performed at therapy onset only, butitispartoftheongoingtherapyprocess. The following example illustrates how focusing

on problems in the contract helped to face the agencyproblem.

Carmelo was a man from Sicily in his 30’s with NPD with borderline features, working as a social media manager—something requiring time and effort to define, as he said he had no working identity. He entered therapy because of a combination of anxiety about his future, self-loathing, and self-directed rage for having failed at everything in his life, not having a job up to his skills, not being economically independ- ent, and not having a stable romantic relationship. He was angry and spiteful of others, whether they ham- pered his goals or appreciated him: “Why say I’m clever? What do they want from me? It pisses me off when they say I could do much more”. He also suffered from nervous enuresis, which he was deeply ashamed of, and binge-eating which he used to regulate distress, together with flirting and casual sex”. During the first months of therapy he reacted with anger to anything I said that did not provide empathic understanding that he had reasons to complain. But when I tried to engage him in any form of therapy action he reacted with an- ger, contempt, and more pain. I spent time regulating the therapy relationship, which was fortunately filled with humor. At a certain point, I realized I had to focus on the therapy contract, as we had no agreement on therapy goals and tasks, and I did not offer him any re- alistic idea of how therapy could help him and under what conditions.

As a consequence of my new awareness that a contract was lacking, I told him I could find no way to help him if he spent all the time in angry rumination or attacking everything I said. I said that I could help him, but I needed him to offer me a viable path, otherwise I would remain impotent in the face of his combination of suffering and an- ger. After another bout of rage and spitefulness, he agreed that he was not offering any solution. But he then became aware that the problem I spotted made sense, that is his never learning how to build a bridge between wishes and means. We recon- structed how he was brought up by an idealizing mother, who also inhibited any spontaneous behavior and manipulated him in order to make him stay close to her, and by an emotionally absent father. We agreed that, though difficult, therapy was about trying to build a bridge, that is committing himself to actions that could have the chance of bringing him closer to his aspirations. This increased his anxiety at that moment but made sense to him. After 1 and a half years of ther- apy, he has his first stable romantic relationship

10 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

ever and is making significant steps in pursuing a career.

Pragmatic Suggestions: Use Tailored Behavioral Assignments

Given that subjective sense of agency is strongly connected with motor control (Moore et al., 2010), experiential practices where motor and premotor areasareactivated(Dimaggioetal.,2020)arewell- suited to reinforcing it. Therapists can adopt a com- bination of techniques, such as guided imagery and rescripting, role-play, or two-chairs (Dimaggio et al., 2020), with the inclusion of sensorimotor work (Lowen, 1983). Patients can then learn that, wheninthemiddleoftheinteractionstheyarereex- periencing, they have power over their physical reactions by adopting a different posture or tone of voice, or acting differently. They then discover that theirmentalstatechangesaccordingtothenewpos- tureoractiontheyundertake.

An example comes from the second year of Carmelo’s therapy. He had made significant steps in the work do- main but still complained he was not active enough in pursuing a career. He had realized that a central prob- lem was his historically rooted passivity. We evoked an episode when he was 22. He had planned to move to Milan to finish university and asked his mother for both emotional and economical support. She replied that it would cost a lot of money, which made Carmelo resentful as the family finances were good, so there was no real reason to deny him support. More impor- tantly, she was skeptical about his capacity to complete his course and get his degree, and so she said she would give him some money but on an exam-by-exam basis. I asked Carmelo how he reacted, and he said he felt deprived of energy and physically weak and had two different thoughts: on the one hand he thought he deserved confidence in his skills so he felt hurt and an- gry, on the other he doubted his qualities and felt infe- rior and incapable. I suggested to him that guided imagery and rescripting could help. With his eyes closed he retorted to his mother: “I need your support and I deserve it. You treating me this way hurts so much.” But he only felt minor relief and said that he was not so convinced he really deserved support. I then asked him to change his posture and adopt one of his choice, to give himself more energy and steadiness. He decided to stand up, still with his eyes closed. He soon felt better and again replied to his mother, while I asked him to raise his voice’s volume more and more. This time he felt more convinced about his skills and his face relaxed. A few days later he texted me that he had sent a CV to a firm, a task assignment which we agreed upon more than a year before but he had never been able to undertake until then.

Reducing Maladaptive Coping and Promoting Healthy Behaviors

Counteracting PN tendencies to adopt problem- aticbehaviorsisbothnecessaryanddifficult.These persons are often convinced that their strategies to dealwithproblemsaregoodorjustified.Theythink theyresorttoperfectionism,isolation,verbalaggres- sion, drug use, disordered eating, overexercising, cosmetic surgery, and so forth with good reasons. Agreeingupontryingtoabstainfromthesestrategies has to be done carefully and is part of the therapy contract. The contract is necessary because if patients do not agree to tasks, therapists should be ready to accept that they are consciously deciding topersistintheirhabits.WhatIsayinthesecasesis thatIwillaccompanythemforaslongastheywant but cannot grant progress and relief if they prefer stickingtotheirbehaviors.Thisisusuallyfollowed byarenegotiationofgoalsandtasks.

Pragmatic Suggestions

Asking to restrain from coping may sound mor- alistic and tyrannical to patients with narcissism. In the case of the most prominent coping, that is, self- enhancement, early attempts at dismantling it are counterproductive (Kohut, 1971; Weinberg & Ronningstam, 2020) as they risk forcing PN to face theideaofselfasinferior. Of note, therapists must make explicit that when

theyaskforsomebehavioraltasks,theydonotcon- sider that patients succeed if they perform the task and fail if they do not. Clinicians would better note thatwhatmattersis(a)theeffortclientsputintotry- ing and (b) focusing on the inner experience’s flow at the moment of trying to abstain from the target behavior. The very first goal of these tasks is improving self-reflection, that is discovering ele- ments of inner experience while trying to steer own behavior in a different direction (Dimaggio et al., 2020). Task assignments are somewhat easier whentheyfocusonadoptingbehaviorsmoreinline withaperson’sdeep-seatedwishes.

Elena, a lawyer in her late 30’s with NPD, used seductive behaviour in order to boost her self-esteem. After having casual sex, she experienced a mixture of contempt for the man she had slept with, self-loathing, and emptiness. We agreed she should try to avoid responding to requests on Tinder when she felt more of the urge to do it, that is, late evening after returning home from work. She tried and discovered that the driver for her seductive behaviors was not so much repairing self-esteem, as we previously thought, but more a sense of numbness. After

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 11

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

reconstructing together that this came from family issues or origins, we searched for something she might to do to counteract this numbness. She realized that a run by the lakeside was what she wanted. She tried, and the next ses- sion she reported she had felt ok and mindfully appreci- ated the sunset, the people walking, and the atmosphere of the restaurants and cafés.

Focusing on Strength, Resources and the Healthy Self

Another problem area in PN regards autonomy and freedom to explore one’s deep-seated wishes not related to ambition and status, which corre- sponds to living in accordance with a false self (Kohut, 1977; Lowen, 1983). Therapists should seek areas patients want to pursue, or wanted in the past, and help them focus on how they feel when being in touch with this desire instead of remaining stuck in feelings of bitterness, desperation, envy, andangerrelatedtosocialrank. Experiential techniques are useful here. For

example, I asked Michele to bring his guitar to my consulting room as I wanted to explore the bodily andemotionalsensationshehadwhileplayingwith him. This helped him realize that, while playing, he swung from pleasure and enjoying music for its own sake to rumination about his past failures. A combination of attention training and body scan- ning (Ottavi et al., 2019) then helped him discover he was able to both interrupt his repetitive thinking and anchor himself to the playfulness he experi- enced in music. I did similar exercises with many PN clients, and these often helped them shut out socialrank,enterstatesofcuriosityandexploration, and connect with wishes they felt deeply their own. This is connected to the promotion of agency, so I willdealwithitinthenextsection. Overall, with a combination of working though

the therapy relationship, behavioral assignments and rescripting exercises (e.g., guided imagery, two-chairs,role-play),clinicianscanhelptheseper- sonsformmorebenevolentideasaboutthemselves, even when failing to meet their unrelenting perfec- tionistic standards. Moreover, contacting deep- seated wishes helps them ground their identity not only on status and social rank but on creativity and playfulness.

Promoting Theory of Mind and Empathy

This is an area where many therapies fail. Given narcissistic tendencies to disregard the opinion of

the others and often be manipulative or spiteful, some therapists feel the urge to correct this attitude. This sounds judgmental and moralistic to PNs, and the result is not an increased capacity to understand othersandbeempathicbutanalliancerupture.Cer- tainly, if PNs do not discover that others have thoughts, feelings, and agendas that are complex, nuanced,and differentfrom theirown,it isunlikely their relationships will improve, but this has to be promotedattheopportunetime. There are two treatments, among the ones rec-

ommended for PN (Weinberg & Ronningstam, 2020; Yakeley, 2018) explicitly focusing on increasing reflective capacities, that is Mentaliza- tion Based Treatment (MBT, Drozek & Unruh, 2020) and Metacognitive Interpersonal Therapy (MIT; Dimaggio & Attinà, 2012). The two approaches follow different strategies: MBT fos- ters curiosity about the mind of the others early in therapy, while MIT adopts a rigid structure (Dimaggioetal.,2020).MITfirstencouragesasus- tainedfocusonself-reflectiontogetherwithpromo- tion of the healthy self, for example, overcoming guilt and shame, focusing on inner-most desires instead of remaining stuck in the quest for the ideal self.Atthismomentdevelopingtheoryofmindand empathy is forbidden. Only once PNs have better self-awareness and are more in touch with the healthy self does MIT focus on promoting a richer awareness of the others. I do advocate the second approach, in line with Mitchell (1986), that is first mentalizing the self and only later the other, but to date there is no evidence that one approach is better suited than the other to PN’s needs. Research is needed to solve the issue. Technically speaking, in advancedstagesoftherapy,experientialtechniques may help promote these capacities, as persons are asked to enact the “other” and so have a different graspofwhatmaypassthroughhermind.

Conclusions

Treating persons with PN or with NPD is a chal- lengetoanyclinician,andempiricalevidenceabout how to treat them is lacking. Suggestions on how to deal with problems any clinician may face when treating these persons come from different schools but, in absence of any outcome study, none of them clearly stands out. At the same time, the integrative therapist needs to find her or his own way to deal with these persons. Against the background of two recent efforts to systematize what we currently

12 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

know about treatment of these persons (Weinberg & Ronningstam, 2020; Yakeley, 2018), I have sug- gested some principles for an integrative therapy of PN and NPD grounded on core aspects of pathol- ogy. The idea is that clinicians need to tackle 5 ele- ments: maladaptive interpersonal schemas, poor self-reflection and intellectualizing, disturbed agency,maladaptivecopinganddefenses,andpoor theory of mind and empathy. A combination of working through the therapy relationship, constant negotiation, and monitoring of the contract and of the goal and task components of the alliance, be- havioral experiments and, when possible, expe- riential practices such as guided-imagery and rescripting, role-play, and bodily work is neces- sary to tackle these different elements. Such an effort has indeed many limitations, the

main one being the point this paper started with: lackofempiricallysupportedtreatments.Byoutlin- ing specific therapyprinciples,based on pathology, this paper may be a further step, together with efforts by Yakeley (2018) and Weinberg & Ron- ningstam(2020),towardprovidingsomeprinciples ofgoodclinicalpracticethatanytherapist,irrespec- tive of her or his own orientation, can use as a road- map to tackle the challenges PN poses. In parallel, there is a chance that, with growing interest in PN and NPD, clinicians’ and researchers’ interest in studying this population will grow, and these ideas passunderempiricalscrutiny.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM–5). American Psychiatric Association Publishing.

Bamelis, L. L. M., Renner, F., Heidkamp, D., & Arntz, A. (2011). Extended Schema Mode concep- tualizations for specific personality disorders: An empirical study. Journal of Personality Disorders, 25(1), 41–58. https://doi.org/10.1521/pedi.2011.25 .1.41

Baskin-Sommers, A., Krusemark, E., & Ronningstam, E. (2014). Empathy in narcissistic personality disor- der: From clinical and empirical perspectives. Per- sonality Disorders, 5(3), 323–333. https://doi.org/10 .1037/per0000061

Beck, A. T., Davis, D. D., & Freeman, A. (Eds.). (2015). Cognitive therapy of personality disorders. Guilford.

Bilotta, E., Carcione, A., Fera, T., Moroni, F., Nicolò, G., Pedone, R., Pellecchia, G., Semerari, A., & Colle, L. (2018). Symptom severity and mindreading in narcissistic personality disorder. PLoS ONE,

13(8), e0201216. https://doi.org/10.1371/journal.po ne.0201216

Böckler, A., Sharifi, M., Kanske, P., Dziobek, I., & Singer, T. (2017). Social decision making in narcis- sism: Reduced generosity and increased retaliation are driven by alterations in perspective-taking and anger. Personality and Individual Differences, 104, 1–7. https://doi.org/10.1016/j.paid.2016.07.020

Bouizegarene, N., & Lecours, S. (2017). Verbal elab- oration of distinct affect categories and narcissistic personality disorder features. Psychoanalytic Psy- chology, 34(3), 279–289. https://doi.org/10.1037/ pap0000066

Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. The American Journal of Psy- chiatry, 172(5), 415–422. https://doi.org/10.1176/ appi.ajp.2014.14060723

Caligor, E., & Stern, B. L. (2020). Diagnosis, classi- fication, and assessment of narcissistic personality disorder within the framework of object relations theory. Journal of Personality Disorders, 34(Suppl.), 104–121. https://doi.org/10.1521/pedi.2020.34.supp .104

Cascio, C. N., Konrath, S. H., & Falk, E. B. (2015). Narcissists’ social pain seen only in the brain. Social Cognitive and Affective Neuroscience, 10(3), 335– 341. https://doi.org/10.1093/scan/nsu072

Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2015). Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing.

Coleman, S. R. M., Bernstein, M. J., Benfield, J. A., & Smyth, J. M. (2020). Narcissistic grandiosity and risky health behaviors in college students. Journal of American College Health. Advance online publica- tion. https://doi.org/10.1080/07448481.2020.1762606

Colle, L., Dimaggio, G., Carcione, A., Nicolò, G., Semerari, A., & Chiavarino, C. (2020). Do competi- tive contexts affect mindreading performance? Frontiers in Psychology, 11, Article 1284. https://doi.org/10.3389/fpsyg.2020.01284

Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. The American Journal of Psychiatry, 171(1), 102–108. https://doi.org/10 .1176/appi.ajp.2013.13020224

Crisp, H., & Gabbard, G. O. (2020). Principles of psychodynamic treatment for patients with narcis- sistic personality disorder. Journal of Personality Disorders, 34(Suppl.), 143–158. https://doi.org/10 .1521/pedi.2020.34.supp.143

De Panfilis, C., Antonucci, C., Meehan, K. B., Cain, N. M., Soliani, A., Marchesi, C., Clarkin, J. F., & Sambataro, F. (2019). Facial emotion recognition and social-cognitive correlates of narcissistic fea- tures. Journal of Personality Disorders, 33(4), 433–449. https://doi.org/10.1521/pedi_2018_32_350

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 13

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Di Blasi, M., Giardina, A., Lo Coco, G., Giordano, C., Billieux, J., & Schimmenti, A. (2020). A com- pensatory model to understand dysfunctional per- sonality traits in problematic gaming: The role of vulnerable narcissism. Personality and Individual Differences, 160, Article 109921. https://doi.org/ 10.1016/j.paid.2020.109921

Diamond, D., & Hersh, R. G. (2020). Transference- focused psychotherapy for narcissistic personality disorder: An object relations approach. Journal of Personality Disorders, 34(Suppl.), 159–176. https:// doi.org/10.1521/pedi.2020.34.supp.159

Diamond, D., & Meehan, K. B. (2013). Attachment and object relations in patients with narcissistic personality disorder: Implications for therapeutic process and outcome. Journal of Clinical Psychol- ogy, 69(11), 1148–1159. https://doi.org/10.1002/ jclp.22042

Diamond, D., Levy, K. N., Clarkin, J. F., Fischer- Kern, M., Cain, N. M., Doering, S., Hörz, S., & Buchheim, A. (2014). Attachment and mentaliza- tion in female patients with comorbid narcissistic and borderline personality disorder. Personality Disorders, 5, 428–433. https://doi.org/10.1037/ per0000065

Dimaggio, G., & Attinà, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology, 68, 922–934. https://doi.org/ 10.1002/jclp.21896

Dimaggio, G., Carcione, A., Conti, M.L., Nicolò, G., Fiore, D., Pedone, R., Popolo, R., Procacci, M., & Semerari, A. (2009). Impaired decentration in Per- sonality Disorder: An analysis with the Metacog- nition Assessment Scale. Clinical Psychology & Psychotherapy, 16, 450–462. https://doi.org/10 .1002/cpp.619

Dimaggio, G., & Lysaker, P. H. (2015). Commen- tary: “Personality and intentional binding: An ex- ploratory study using the narcissistic personality inventory.” Frontiers in Human Neuroscience, 9, Article 325. https://doi.org/10.3389/fnhum.2015 .00325

Dimaggio, G., MacBeth, A., Popolo, R., Salvatore, G., Perrini, F., Raouna, A., Osam, C. S., Buonocore, L., Bandiera, A., & Montano, A. (2018). The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders. Comprehensive Psychia- try, 83, 71–78. https://doi.org/10.1016/j.comppsych .2018.03.005

Dimaggio, G., Montano, A., Popolo, R., & Salvatore, G. (2015). Metacognitive interpersonal therapy for personality disorders: A treatment manual. Rout- ledge. https://doi.org/10.4324/9781315744124

Dimaggio, G., Nicolò, G., Fiore, D., Centenero, E., Semerari, A., Carcione, A., & Pedone, R. (2008). States of minds in narcissistic personality disorder: Three psychotherapies analyzed using the grid of

problematic states. Psychotherapy Research, 18(4), 466–480. https://doi.org/10.1080/105033007018 81877

Dimaggio, G., Ottavi, P., Popolo, R., & Salvatore, G. (2020). Metacognitive interpersonal therapy body, imagery and change. Routledge. https://doi.org/10 .4324/9780429350894

Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G., & Procacci, M. (2007). Psychotherapy of per- sonality disorders: Metacognition, states of mind and interpersonal cycles. Routledge. https://doi .org/10.4324/9780203939536

Dimaggio, G., Semerari, A., Falcone, M., Nicolò, G., Carcione, A., & Procacci, M. (2002). Metacogni- tion, states of mind, cognitive biases and interperso- nal cycles. Proposal for an integrated narcissism model. Journal of Psychotherapy Integration, 12(4), 421–451. https://doi.org/10.1037/1053-0479 .12.4.421

Drozek, R. P., & Unruh, B. T. (2020). Mentalization- based treatment for pathological narcissism. Journal of Personality Disorders, 34(Suppl.), 177–203. https://doi.org/10.1521/pedi.2020.34.supp.177

Edershile, E. A., & Wright, A. G. C. (2020). Fluctua- tions in grandiose and vulnerable narcissistic states: A momentary perspective. Journal of Per- sonality and Social Psychology. Advance online publication, https://doi.org/10.1037/pspp0000370

Fatfouta, R., Gerlach, T. M., Schröder-Abé, M., & Merkl, A. (2015). Narcissism and lack of interperso- nal forgiveness: The mediating role of state anger, state rumination, and state empathy. Personality and Individual Differences, 75, 36–40. https://doi.org/10 .1016/j.paid.2014.10.051

Fitzpatrick, S., Sherry, S., Hartling, N., Hewitt, P., Flett, G., & Sherry, D. (2011). Narcissism, perfec- tionism, and interest in cosmetic surgery. Plastic and Reconstructive Surgery, 127(6), 176e–177e. https://doi.org/10.1097/PRS.0b013e3182131ec9

Gabbard, G. O. (1989). Two subtypes of narcissistic personality disorder. Bulletin of the Menninger Clinic, 53(6), 527–532.

Gilbert, P. (Ed.). (2005). Compassion and cruelty: A biopsychosocial approach. Compassion: Conceptu- alisations, Research and Use in Psychotherapy (pp. 21–74). Routledge. https://doi.org/10.4324/978020 3003459-6

Gordon, K. H., & Dombeck, J. J. (2010). The associ- ations between two facets of narcissism and eating disorder symptoms. Eating Behaviors, 11(4), 288–292. https://doi.org/10.1016/j.eatbeh.2010.08 .004

Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work with their feelings. American Psychological Association. https://doi .org/10.1037/10447-000

Gregg, A. P., & Sedikides, C. (2010). Narcissistic fra- gility: Rethinking its links to explicit and implicit

14 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

self-esteem. Self and Identity, 9(2), 142–161. https://doi.org/10.1080/15298860902815451

Grijalva, E., & Zhang, L. (2016). Narcissism and self-insight: A review and meta-analysis of narcis- sists’ self-enhancement tendencies. Personality and Social Psychology Bulletin, 42, 3–24. https:// doi.org/10.1177/0146167215611636

Hascalovitz, A. C., & Obhi, S. S. (2015). Personality and intentional binding: An exploratory study using the narcissistic personality inventory. Fron- tiers in Human Neuroscience, 9, Article 13. https://doi.org/10.3389/fnhum.2015.00013

John, O. P., & Robins, R. W. (1994). Accuracy and bias in self-perception: Individual differences in self-enhancement and the role of narcissism. Jour- nal of Personality and Social Psychology, 66(1), 206–219. https://doi.org/10.1037/0022-3514.66.1 .206

Johnson, J. G., Cohen, P., Smailes, E. M., Skodol, A. E., Brown, J., & Oldham, J. M. (2001). Child- hood verbal abuse and risk for personality disor- ders during adolescence and early adulthood. Comprehensive Psychiatry, 42(1), 16–23. https:// doi.org/10.1053/comp.2001.19755

Kealy, D., Laverdière, O., & Pincus, A. L. (2020). Pathological narcissism and symptoms of major depressive disorder among psychiatric outpatients: The mediating role of impaired emotional process- ing. The Journal of Nervous and Mental Disease, 208, 161–164. https://doi.org/10.1097/NMD.000 0000000001114

Kealy, D., Ogrodniczuk, J. S., Joyce, A. S., Steinberg, P. I., & Piper, W. E. (2015). Narcissism and relational representations among psychiatric outpatients. Journal of Personality Disorders, 29(3), 393–407. https://doi.org/10.1521/pedi_2013 _27_084

Kealy, D., Ogrodniczuk, J. S., Rice, S. M., & Oliffe, J. L. (2017). Pathological narcissism and maladap- tive self-regulatory behaviours in a nationally rep- resentative sample of Canadian men. Psychiatry Research, 256, 156–161. https://doi.org/10.1016/j .psychres.2017.06.009

Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Jason Aronson, Inc.

Kohut, H. (1971). The analysis of the self. Interna- tional University Press.

Kohut, H. (1977). The restoration of the self. Interna- tional Universities Press.

Kramer, U., Beuchat, H., Grandjean, L., & Pascual- Leone, A. (2020). How personality disorders change in psychotherapy: A concise review of pro- cess. Current Psychiatry Reports, 22(8), Article 41. https://doi.org/10.1007/s11920-020-01162-3

Kramer, U., Gholam, M., Maillard, P., Kolly, S., Püschel, O., & Sachse, R. (2020). Subtypes of nar- cissistic personality disorder based on psychother- apy process: A longitudinal nonparametric analysis.

Personality Disorders: Theory, Research, and Treatment. Advance online publication. https://doi .org/10.1037/per0000438

Krizan, Z., & Johar, O. (2015). Narcissistic rage revisited. Journal of Personality and Social Psy- chology, 108(5), 784–801. https://doi.org/10.1037/ pspp0000013

Krystal, H. (1998). Affect regulation and narcissism: Trauma, alexithymia and psychosomatic illness in narcissistic patients. In E. F. Ronningstam (Ed.), Disorders of narcissism: Diagnostic, clinical, and empirical implications (pp. 229–325). American Psychiatric.

Kunst, H., Lobbestael, J., Candel, I., & Batink, T. (2020). Early maladaptive schemas and their rela- tion to personality disorders: A correlational ex- amination in a clinical population. Clinical Psychology & Psychotherapy, 27(6), 837–846. https://doi.org/10.1002/cpp.2467

Leder, J., Foster, J. D., & Schütz, A. (2020). Willing to do what others won’t: Narcissism, risk-taking, and social approval. Personality and Individual Differences, 153, Article 109672. https://doi.org/ 10.1016/j.paid.2019.109672

Leunissen, J. M., Sedikides, C., Wildschut, T., & Back, M. (2017). Why narcissists are unwilling to apologize: The role of empathy and guilt. Euro- pean Journal of Personality, 31(4), 385–403. https://doi.org/10.1002/per.2110

Links, P. S. (2015). Advancing psychotherapy inte- gration for treatment of personality disorders. Journal of Psychotherapy Integration, 25(1), 45–48. https://doi.org/10.1037/a0038777

Lowen, A. (1983). On narcissism. Denial of the true self. Mac Millan.

Malik, R. A., & Obhi, S. S. (2019). Social exclusion reduces the sense of agency: Evidence from inten- tional binding. Consciousness and Cognition, 71, 30–38. https://doi.org/10.1016/j.concog.2019.03.004

Marissen, M. A. E., Deen, M. L., & Franken, I. H. A. (2012). Disturbed emotion recognition in patients with narcissistic personality disorder. Psychiatry Research, 198(2), 269–273. https://doi.org/10 .1016/j.psychres.2011.12.042

Mielimaka, M., Ogrodniczuk, J.S., Kealy, D., Cheek, J., & Joyce, A.S. (2018). Narcissism and interper- sonal problems among psychiatric outpatients. The Journal of Nervous and Mental Disease, 206(9), 711–715. https://doi.org/10.1097/NMD.00000000 00000871

Mitchell, S. A. (1986). The wings of Icarus—Illusion and the problem of narcissism. Contemporary Psy- choanalysis, 22, 107–132. https://doi.org/10.1080/ 00107530.1986.10746118

Modell, A. H. (1984). Psychoanalysis in a new con- text. International Universities Press.

Moore, J. W., Ruge, D., Wenke, D., Rothwell, J., & Haggard, P. (2010). Disrupting the experience

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 15

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

of control in the human brain: Pre-supplementary motor area contributes to the sense of agency. Pro- ceedings of the Royal Society B: Biological Sciences, 277(1693), 2503–2509. https://doi.org/10.1098/rspb .2010.0404

Muran, J. C., Eubanks, C. F., & Samstag, L. W. (2021). One more time with less jargon: An intro- duction to “Rupture Repair in Practice”. Journal of Clinical Psychology: In-Session, 77, 361–368. https://doi.org/10.1002/jclp.23105

Obhi, S. S., Swiderski, K. M., & Farquhar, R. (2013). Activating memories of depression alters the experience of voluntary action. Experimental Brain Research, 229(3), 497–506. https://doi.org/ 10.1007/s00221-012-3372-5

Ottavi, P., Passarella, T., Pasinetti, M., MacBeth, A., Velotti, P., Velotti, A., Bandiera, A., Popolo, R., Salvatore, G., & Dimaggio, G. (2019). Metacogni- tive interpersonal mindfulness-based training for worry about interpersonal events: A pilot feasibil- ity and acceptability study. The Journal of Nerv- ous and Mental Disease, 207, 944–950. https://doi .org/10.1097/NMD.0000000000001054

Pascual-Leone, A., & Greenberg, L. S. (2007). Emo- tional processing in experiential therapy: Why “the only way out is through. Journal of Consult- ing and Clinical Psychology, 75(6), 875–887. https://doi.org/10.1037/0022-006X.75.6.875

Pincus, A. L. (2020). Commentary on the special issue: Complexity, pleomorphism, and dynamic processes in narcissistic personality disorder. Jour- nal of Personality Disorders, 34(Suppl.), 204–206. https://doi.org/10.1521/pedi.2020.34.supp.204

Pincus, A. L., & Lukowitsky, M. R. (2010). Patho- logical narcissism and narcissistic personality dis- order. Annual Review of Clinical Psychology, 6, 421–446. https://doi.org/10.1146/annurev.clinpsy .121208.131215

Pincus, A. L., Cain, N. M., & Wright, A. G. C. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disor- ders: Theory, Research, and Treatment, 5(4), 439–443. https://doi.org/10.1037/per0000031

Reed-Knight, B., & Fischer, S. (2011). Treatment of narcissistic personality disorder symptoms in a dialectical behaviour therapy framework: A dis- cussion and case example. In W. K. Campbell & J. D. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments (pp. 466–475). John Wiley & Sons.

Render, A., & Jansen, P. (2019). Dopamine and sense of agency: Determinants in personality and substance use. PLoS ONE, 14(3), e0214069. https:// doi.org/10.1371/journal.pone.0214069

Ritter, K., Dziobek, I., Preißler, S., Rüter, A., Vater, A., Fydrich, T., Lammers, C-H., Heekeren, H.R., & Roepke, S. (2011). Lack of empathy in patients

with narcissistic personality disorder. Psychiatry Research, 187(1–2), 241–247. https://doi.org/10 .1016/j.psychres.2010.09.013.

Ritter, K., Vater, A., Rüsch, N., Schröder-Abé, M., Schütz, A., Fydrich, T., Lammers, C.-H., & Roepke, S. (2014). Shame in patients with narcissis- tic personality disorder. Psychiatry Research, 215(2), 429–437. https://doi.org/10.1016/j.psychres .2013.11.019

Robins, R. W., & Beer, J. S. (2001). Positive illu- sions about the self: Short-term benefits and long- term costs. Journal of Personality and Social Psy- chology, 80(2), 340–352. https://doi.org/10.1037/ 0022-3514.80.2.340

Ronningstam, E. (2009). Narcissism personality disor- der: Facing DSM–V. Psychiatric Annals, 39(3), 111–121. https://doi.org/10.3928/00485713-200903 01-09

Ronningstam, E. (2019). Narcissism and its discon- tents: Diagnostic dilemmas and treatment strat- egies with narcissistic patients. Journal of Psychiatric Practice, 25(3), 239–240. https://doi .org/10.1097/PRA.0000000000000379

Ronningstam, E. (2020). Internal processing in patients with pathological narcissism or narcissis- tic personality disorder: Implications for alliance building and therapeutic strategies. Journal of Per- sonality Disorders, 34(Suppl.), 80–103. https://doi .org/10.1521/pedi.2020.34.supp.80

Ronningstam, E., & Maltsberger, J. (2007). Treat- ment of narcissistic personality disorder. In G. Gabbard (Ed.), Gabbard’s treatments of psychiatric disorders (4th ed., pp. 791–804). American Psychi- atric Press.

Sachse, R. (2020). Personality disorders: A clarifica- tion-oriented psychotherapy treatment model. Hogrefe.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. A relational treatment guide. Guilford Press.

Spano, L. (2001). The relationship between exercise and anxiety, obsessive-compulsiveness, and narcis- sism. Personality and Individual Differences, 30(1), 87–93. https://doi.org/10.1016/S0191-8869 (00)00012-X

Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., Ruan, W. J., Pulay, A. J., Saha, T. D., Pickering, R. P., & Grant, B. F. (2008). Prevalence, correlates, dis- ability, and comorbidity of DSM–IV narcissistic personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 69(7), 1033–1045. https://doi.org/10 .4088/JCP.v69n0701

Tanzilli, A., & Gualco, I. (2020). Clinician emotional responses and therapeutic alliance when treating adolescent patients with narcissistic personality

16 DIMAGGIO

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

disorder subtypes: A clinically meaningful empiri- cal investigation. Journal of Personality Disor- ders, 34(Suppl.), 42–62. https://doi.org/10.1521/ pedi.2020.34.supp.42

Tanzilli, A., Gualco, I., Baiocco, R., & Lingiardi, V. (2020). Clinician reactions when working with ad- olescent patients: The Therapist Response Ques- tionnaire for adolescents. Journal of Personality Assessment, 102(5), 616–627. https://doi.org/10 .1080/00223891.2019.1674318

Tortoriello, G. K., & Hart, W. (2019). Modeling the interplay between narcissism, relational motives, and jealousy-induced responses to infidelity threat. Journal of Social and Personal Relationships, 36(7), 2156–2179. https://doi.org/10.1177/026540 7518783096

Twenge, J. M., & Campbell, W. K. (2003). Isn’t it fun to get the respect that we’re going to deserve?” Nar- cissism, social rejection, and aggression. Personal- ity and Social Psychology Bulletin, 29(2), 261– 272. https://doi.org/10.1177/0146167202239051

Urbonaviciute, G., & Hepper, E. G. (2020). When is narcissism associated with low empathy? A meta- analytic review. Journal of Research in Personal- ity, 89, Article 104036. https://doi.org/10.1016/j .jrp.2020.104036

Weinberg, I., & Ronningstam, E. (2020). Dos and don’ts in treatments of patients with narcissistic

personality disorder. Journal of Personality Disor- ders, 34(Suppl.), 122–142. https://doi.org/10.1521/ pedi.2020.34.supp.122

Weiss, J. (1993). How psychotherapy works: Process and technique. Guilford Press.

Westen, D. (1990). The relations among narcissism, egocentrism, self-concept, and self-esteem: Experi- mental, clinical, and theoretical considerations. Psy- choanalysis & Contemporary Thought, 13, 183–239.

Wu, W., Wang, H., Zheng, C., & Wu, Y. J. (2019). Effect of narcissism, psychopathy, and Machiavel- lianism on entrepreneurial intention-the mediating of entrepreneurial self-efficacy. Frontiers in Psy- chology, 10, Article 360. https://doi.org/10.3389/ fpsyg.2019.00360

Yakeley, J. (2018). Current understanding of narcis- sism and narcissistic personality disorder. BJPsych Advances, 24(5), 305–315. https://doi.org/10.1192/ bja.2018.20

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.

ReceivedJanuary17,2021 RevisionreceivedApril3,2021

AcceptedApril23,2021 n

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 17

T hi s do cu m en ti s co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Personality Disorders: Theory, Research, and Treatment Delay Discounting and Narcissism: A Meta-Analysis With Implications for Narcissistic Personality Disorder Sulamunn R. M. Coleman, Anthony C. Oliver, Elias M. Klemperer, Michael J. DeSarno, Gary S. Atwood, and Stephen T. Higgins Online First Publication, January 6, 2022. http://dx.doi.org/10.1037/per0000528

CITATION Coleman, S. R. M., Oliver, A. C., Klemperer, E. M., DeSarno, M. J., Atwood, G. S., & Higgins, S. T. (2022, January 6). Delay Discounting and Narcissism: A Meta-Analysis With Implications for Narcissistic Personality Disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication. http://dx.doi.org/10.1037/per0000528

Delay Discounting and Narcissism: A Meta-Analysis With Implications for Narcissistic Personality Disorder

Sulamunn R. M. Coleman1, 2, Anthony C. Oliver1, 2, Elias M. Klemperer1, 2, Michael J. DeSarno3, Gary S. Atwood4, and Stephen T. Higgins1, 2

1 Vermont Center on Behavior and Health, University of Vermont 2 Department of Psychiatry, University of Vermont

3 Department of Medical Biostatistics, University of Vermont 4 Dana Medical Library, University of Vermont

Several psychiatric conditions (e.g., substance use, mood, and personality disorders) are characterized, in part, by greater delay discounting (DD)—a decision-making bias in the direction of preferring smaller, more immediate over larger, delayed rewards. Narcissistic personality disorder (NPD) is highly comorbid with substance use, mood, and other personality disorders, suggesting that DD may be a process underpinning risk for NPD as well. This meta-analysis examined associations between DD and theoretically distinct, clini- cally relevant dimensions of narcissism (i.e., grandiosity, entitlement, and vulnerability). Literature searches were conducted and articles were included if they were written in English, published in a peer-reviewed journal, contained measures of DD and narcissism and reported their association, and used an adult sample. Narcissism measures had to be systematically categorized according to clinically relevant dimensions (Grijalva et al., 2015; Wright & Edershile, 2018). Seven studies met inclusion criteria (N = 2,705). DD was positively associated with narcissism (r = .21; 95% confidence interval [.10, .32]), with this association being largely attributable to measures of trait grandiosity that were used in each study (r = .24; 95% confi- dence interval [.11, .37]). No studies included diagnostic NPD assessments. These findings provide empiri- cal evidence that DD is related to trait narcissism and perhaps risk for NPD (e.g., grandiosity listed in Criterion B of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, alternative model of personality disorders). Considering the positive evidence from this review, and the dearth of research examining DD in individuals with NPD, investigators studying NPD may consider incorporating DD meas- ures in future studies to potentially inform clinical theory and novel adjunctive treatment options.

Keywords: delay discounting, narcissism, grandiosity, entitlement, vulnerability

Supplemental materials: https://doi.org/10.1037/per0000528.supp

Delay discounting (DD) is an aspect of decision-making wherein the rewarding value of a commodity decreases as a

function of temporal delay to its availability (Bickel et al., 1999; Madden et al., 1997). Individuals with greater than aver- age DD are said to exhibit a decision-making bias in the direc- tion of preferring smaller, more immediate over larger, delayed rewards (Bickel et al., 1999; Madden et al., 1997). Greater DD is associated with a variety of psychiatric conditions, including substance use disorders, affective disorders, schizophrenia, bulimia nervosa, binge-eating disorder, and borderline person- ality disorder (Amlung et al., 2019; Bickel & Mueller, 2009, Bickel et al., 2019; MacKillop et al., 2011). As such, DD has been proposed to constitute a “transdiagnostic process” under- pinning a wide range of psychiatric conditions (Bickel & Muel- ler, 2009; Bickel et al., 2019). This insight aligns with the U.S. National Institute of Mental Health’s Research Domain Criteria initiative, which advocates characterizing psychiatric condi- tions in terms of underlying biological and psychological proc- esses rather than groups of symptoms (Cuthbert & Insel, 2013; Insel et al., 2010).

Narcissistic personality disorder (NPD) is highly comorbid with psychiatric conditions associated with greater DD, including substance

Sulamunn R. M. Coleman https://orcid.org/0000-0002-0460-4632 This study was supported by the National Institute of General Medical

Sciences (NIGMS) Center of Biomedical Research Excellence award P20GM103644 (Elias M. Klemperer, Stephen T. Higgins); National Institute on Drug Abuse (National Institute on Drug Abuse) and Food and Drug Administration (FDA) Tobacco Centers of Regulatory Science (TCORS) Award U54DA036114 (Anthony C. Oliver, Stephen T. Higgins); National Institute on Drug Abuse Institutional Training Award T32DA007242 (Sulamunn R. M. Coleman, Stephen T. Higgins). The authors have no conflicts of interest to disclose. Drs. Coleman, Oliver, Klemperer, and Higgins have research support from the National Institute of General Medical Sciences, National Institute on Drug Abuse, and Food and Drug Administration. Correspondence concerning this article should be addressed to Sulamunn

R. M. Coleman, Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect Street, Burlington, VT 05401, United States. Email: [email protected]

1

Personality Disorders: Theory, Research, and Treatment

© 2022 American Psychological Association ISSN: 1949-2715 https://doi.org/10.1037/per0000528

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

use, mood, and other personality disorders (Stinson et al., 2008). There is an ongoing debate over the factor structure and operationalization of narcissism (Crowe et al., 2019; Krizan & Herlache, 2018; Miller et al., 2017; Pincus & Lukowitsky, 2010; Wright & Edershile, 2018). How- ever, narcissism is generally thought to encompass three clinically rele- vant dimensions of personality: grandiosity, characterized by an overriding need for recognition and admiration to maintain and enhance an inflated sense of self-importance; entitlement, characterized by a prioritization of self-interests and expectations for especially favorable treatment; and vulnerability, which involves an inability to regulate affect, self-concept, and behavior when needs or self-interests are threatened. As Wright and Edershile (2018) discussed, the Diag- nostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5), Section III alternative model of personality disorders (AMPD) NPD diagnostic criteria reflect each of these dimensions. For example, Criterion A contains content related to vulnerability (e.g., “exaggerated self-appraisal may be inflated or deflated or vacillate between extremes”), Criterion B encompasses grandiosity (e.g., “firmly holding to the belief that one is better than others”), and fea- tures of entitlement are found in both Criterion A (e.g., “personal standards are [.. .] too low based on a sense of entitlement”) and Crite- rion B (e.g., “Feelings of entitlement, either overt or covert”; American Psychiatric Association, 2013). Importantly, evidence suggests DD may differentially relate to nar-

cissism dimensions. For example, research linking narcissism to the be- havioral activation and inhibition systems has shown that individuals high in grandiosity appear to have greater than average motivation to pursue rewards but only weak motivation to avoid punishments (i.e., “approach-orientation”; Foster & Trimm, 2008). Consistent with such evidence, those high in grandiosity may be more likely to engage in risky patterns of substance use (e.g., problematic alcohol consumption) and sexual behavior (e.g., having unprotected sex and multiple sex part- ners; Coleman et al., 2020), suggesting such individuals may have greater than average preferences for smaller, more immediate rewards (e.g., intoxication, sexual gratification), even when obtaining them could mean forgoing larger, delayed rewards (e.g., better long-term health). By contrast, individuals high in vulnerability appear to have no more or less motivation to pursue rewards but stronger than average motivation to avoid punishments (i.e., avoidance-orientation”; Foster & Trimm, 2008), which suggests that DD and vulnerability may be unrelated. Clinical perspectives posit that individuals with NPD can vacillate

between grandiose (e.g., extraverted/approach-oriented) and vulnera- ble states (e.g., neurotic/avoidance-oriented; Giacomin & Jordan, 2016; Gore & Widiger, 2016; Pincus et al., 2015; Wright & Eder- shile, 2018) and that both grandiosity and vulnerability may be anch- ored by core expressions of entitlement (Crowe et al., 2019; Krizan & Herlache, 2018; Wright & Edershile, 2018). Therefore, an exami- nation of how DD relates to all three narcissism dimensions is war- ranted and may help inform future psychiatric studies (e.g., efforts to account for comorbidity between NPD and other psychiatric condi- tions or to identify feasible points of intervention). More importantly, others have called for research to identify processes to help better understand NPD (Eaton et al., 2017). To our knowledge, there have been no prior reviews examining potential associations between DD and narcissism. Thus, the purpose of this meta-analysis is to examine potential associations between DD and theoretically distinct, clini- cally relevant dimensions of narcissism.

Method

Search Strategy and Study Selection

This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Figure 1).1 Articles were identified through searches of the PubMed, PsycINFO, and Web of Science databases from inception through January 31, 2021. Search terms included (delay discounting OR temporal discount- ing OR future discounting OR delayed gratification OR deferred gratification OR delayed reward OR intertemporal choice OR intertemporal preference OR impulsivity OR risk-taking) AND (narcissism OR grandiosity OR entitlement OR exhibitionism OR psychopathy OR machiavellianism OR dark triad). The functional search term narciss* was included to produce studies on NPD and trait narcissism. Although the term vulnerability is associated with a specific narcissism dimension, it was not included in the search, as it was expected to produce excessive literature on irrelevant topics (e.g., socioeconomic vulnerability, childhood vulnerability). Search results were limited to full-text journal articles in the Eng- lish language and reporting studies conducted with humans. After removing duplicates, the search identified 1,985 articles for title and abstract screening. Reference sections of relevant articles and reviews were also searched, yielding no additional articles.

Sulamunn R. M. Coleman and Anthony C. Oliver screened titles and abstracts of these 1,985 articles using the following inclusion cri- teria: (a) written in English, (b) published in a peer-reviewed journal, (c) contained an assessment of DD, (d) contained a validated assess- ment of narcissism systematically categorized according to a clini- cally relevant dimension of narcissism (Grijalva et al., 2015; Wright & Edershile, 2018), (e) reported an association between DD and nar- cissism, and (f) used an adult sample. This meta-analysis focused on adults because narcissism (e.g., symptoms of NPD) may be highly prevalent during childhood and adolescence but generally decreases over time (Cohen et al., 2005; Hamlat et al., 2020). Articles that both authors recommended were advanced to full-text review (interob- server agreement = 99.7%). Disagreements were discussed until con- sensus was reached. Seventeen articles advanced to full-text review. Following full-text review, seven articles were selected for inclusion. Finally, authors using the Narcissistic Personality Inventory (NPI; Raskin & Hall, 1979) were contacted for additional data on associa- tions between DD and three NPI subscales, including Leadership/ Authority, Grandiose Exhibitionism, and Entitlement/Exploitative- ness (Ackerman et al., 2011). Dr. Buelow provided means and stand- ard deviations for the three NPI subscales as well as correlations between DD and the three NPI subscales (Buelow & Brunell, 2014; Table 1). No other authors provided additional data.

Data Extraction

Sulamunn R. M. Coleman and Anthony C. Oliver independently read the full texts of the seven articles that met inclusion criteria and extracted the data presented in Table 1. The primary outcome of in- terest was the association between DD and clinically relevant dimen- sions of narcissism. To interpret associations between DD and

1 This meta-analysis was not preregistered. Access to the data set and

codebook associated with the previously unpublished data provided by Buelow and Brunell (2014) was not provided by the authors.

2 COLEMAN ET AL.

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

narcissism dimensions, it is important to understand that the direction of associations may change depending on the index used to quantify DD (Smith & Hantula, 2008). For example, DD measures involve hypothetical choice tasks that require choosing between a smaller, sooner reward and a larger, later reward over different delay intervals (e.g., Would you prefer: (a) $100 today or (b) $1,000 in 1 month? Would you prefer: (a) $100 today or (b) $1,000 in 1 year?). The term “delay interval” refers to the amount of time an individual would have to wait to receive a larger reward (e.g., one month, one year). One way to index DD is to simply count the number of times respondents choose a smaller, sooner reward over a larger, later reward (Griskevicius et al., 2011). Greater count scores correspond to greater DD (i.e., greater preference for smaller, sooner reward). More commonly, data obtained from hypothetical choice tasks are used to generate DD curves (Richards et al., 1999). Once a curve is produced, the data are fit according to quantitative discounting mod- els in which the parameter k is used to index DD (for a detailed ex- planation of discounting models, see Madden & Johnson, 2010).

Larger k values correspond to greater DD. In studies using count scores or k values to index DD, positive associations between DD and narcissism indicate that greater narcissism is associated with a greater preference for a smaller, sooner reward.

An alternative method of calculating DD is to calculate the area under the curve (AUC), which does not require that assumptions be met about the various discounting functions and parameter estimates (Myerson et al., 2001). AUC values range from 0.0 to 1.0. Thus, smaller AUC values indicate greater DD, as they correspond to more rapid devaluation of reward as a function of delay. In studies using AUC to index DD, negative associations between DD and narcissism indicate that greater narcissism is associated with a greater preference for a smaller, sooner reward. To facilitate the interpretation of results in the current meta-analysis, r values derived from AUC values were reverse coded so that all effects faced the same direction (i.e., positive r corresponds to a greater preference for a smaller, sooner reward).

All studies included self-report measures of trait narcissism; no studies containing diagnostic assessments of NPD were identified.

Figure 1 PRISMA Diagram of Included and Excluded Reports

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; WOS = Web of Science; DD = delay discounting.

DELAY DISCOUNTING AND NARCISSISM 3

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

In general, most measures of trait narcissism are thought to be cap- tured primarily by one clinically relevant dimension of the con- struct but may be captured by other dimensions at secondary or tertiary levels (Crowe et al., 2019; Wright & Edershile, 2018). Measures of trait narcissism in the current meta-analysis were coded according to the dimension they are thought to be captured by at a primary level (i.e., grandiosity, entitlement, or vulnerabil- ity) based on the categorizations of existing reviews (Grijalva et al., 2015; Wright & Edershile, 2018; Table 1). Importantly, dem- onstrating that DD broadly associates with trait measures along one or more clinically relevant dimensions of narcissism could suggest which DSM–5 AMPD NPD criteria are most likely to reflect greater (or lesser) DD. Discrepancies in data extraction were discussed between authors until consensus was reached.

Quality Assessment

Quality of evidence was evaluated using the National Institutes of Health Quality Assessment Tool for Observational Cohort and

Cross-Sectional Studies (Table 2; National Heart, Lung, and Blood Institute, 2021), which contains 14 criteria used to evaluate the risk of bias and the validity for each study contained in the meta- analysis (e.g., “Was the participation rate of eligible persons at least 50%?”). The criteria were rated as “yes,” “no,” or other (i.e., cannot determine [“CD”], not reported [“NR”], or not applicable [“NA”]). Consistent with a recent meta-analysis (Torres-Castro et al., 2021), a total score (i.e., percentage) was provided for each study based on the number of criteria rated as “yes” divided by the number of criteria applicable to the study. Studies with a total score of $75% were assigned a quality rating of “good” (i.e., least risk of bias, results are considered valid), those with a total score of 50%–74% were assigned a quality rating of “fair” (i.e., some bias deemed not sufficient to invalidate the results), and those with a total score of ,50% were assigned a quality rating of “poor” (i. e., significant risk of bias). Sulamunn R. M. Coleman and Elias M. Klemperer independently evaluated the quality of evidence for each study, and discrepancies were discussed between authors and resolved by consensus.

Table 1 Summary of Studies Examining Associations Between Delay Discounting and Self-Report Measures of Trait Narcissism

Authors Year Sample DD measure DD index DD mean (SD)

Narcissism measure

Narcissism dimension

Narcissism mean (SD) Correlation

Buelow and Brunell

2014 194 University students MCQ k CNBD PES Entitlement 29.05 (11.33) .292 (United States; other characteristics not reported)

MCQ k CNBD NGS Grandiosity 50.44 (21.12) .172

630 University students MCQ k CNBD NPI Grandiosity 16.14 (10.15) .099 (United States; Mage = 19.16 [SD = 3.92]; 364 women)

NPI-LA Grandiosity 5.21 (2.95)c c.116 NPI-GE Grandiosity 3.54 (2.66)c c.101 NPI-EE Entitlement 0.97 (1.05)c c.151

Crysel et al. 2013 Study 2: 299 General popula- tion (roughly half from the United States, remaining half from India, Canada, Indonesia, and Pakistan; Mage = 32.60 [SD = 11.10]; 120 women)

Five delay intervalsa

k 0.46 (0.92) Dirty Dozen Grandiosity 2.95 (1.04) .170

Jonason et al. 2020 602 General population (United States; Mage = 37.11 [SD = 12.76]; 319 women)

Seven delay intervalsb

Count 3.87 (2.65) SD3 Grandiosity 2.70 (0.68) .170

Malesza and Kaczmarek

2018 338 University students (Germany; Mage = 23.10 [SD = 1.05]; 191 women)

Seven delay intervalsa

AUC 0.55 (0.14) NPI Grandiosity 121.80 (29.3) .440

Seven delay intervalsa

AUC 0.55 (0.14) HSNS Vulnerability 27.80 (7.15) �.080

Malesza and Kalinowski

2021a 255 University students (Germany; Mage = 23.52 [SD = 3.70]; 172 women)

Five delay intervalsa

AUC 0.53 (0.28) SD3 Grandiosity 33.61 (3.07) .460

Malesza and Kalinowski

2021b 283 University students (Germany; Mage = 22.90 [SD = 3.40]; 148 women)

Five delay intervalsa

AUC 0.52 (0.38) NPI Grandiosity 8.95 (2.06) .340

Malesza and Ostaszewski

2016 298 University students (Germany; Mage = 21.80 [SD = 1.52]; 160 women)

Five delay intervalsa

AUC Men = 0.39 (0.13) Women = 0.56 (0.17)

NPI Grandiosity Men = 8.19 (2.20)

Women = 7.93 (2.54)

�.058

Note. DD = delay discounting; MCQ = Monetary Choice Questionnaire; CNBD = could not be determined; AUC = area under curve; NGS = Narcissistic Grandiosity Scale; NPI = Narcissistic Personality Inventory; NPI-LA = Narcissistic Personality Inventory, Leadership/Authority subscale; NPI-GE = Narcissistic Personality Inventory, Grandiose Exhibitionism subscale; NPI-EE = Narcissistic Personality Inventory, Entitlement/Exploitativeness subscale; PES = Psychological Entitlement Scale; SD3 = Short Dark Triad; HSNS = Hypersensitive Narcissism Scale. Large discrepancies in means and standard deviations on narcissism scales such as the NPI and SD3 are attributable to differences in scale versions and scoring procedures. a Discounting curves were generated accord- ing to procedures outline by Richards et al. (1999). b Count scores were obtained according to procedures outline by Griskevicius et al. (2011). c Unpublished data were provided by authors in the corresponding row.

4 COLEMAN ET AL.

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

Statistical Analysis

Analyses were conducted using the software package Compre- hensive Meta-Analysis Version 3 (Borenstein et al., 2013). The measure of effect size used in this study was r. Consistent with the recommendations of the statistical software, the mean of effect sizes was used for studies reporting more than one effect per sample (Buelow & Brunell, 2014; Malesza & Kaczmarek, 2018). Random- effects, meta-analysis models were selected a priori to calculate the estimated average effect size and the corresponding 95% confi- dence intervals (CI). Random-effects models, in which each study’s effect is weighted inversely proportional to its variance, were used due to the assumption of significant heterogeneity of effect sizes across studies. Finally, possible publication bias was examined using funnel plots and Egger’s regression test (Egger et al., 1997).

Results

Study Characteristics

Included studies were published between 2013 and 2021 (Table 1). Overall sample size was 2,705 across studies (Mage = 26.21, SD = 7.49; 54% women). The median sample size was 299. Ten correlations were extracted from the seven articles. Regarding DD measures and indices (Table 1), a count score was

calculated using delay intervals in one study (Jonason et al., 2020). Two studies calculated k scores (Buelow & Brunell, 2014; Crysel et al., 2013) using either Kirby’s 27-item Monetary Choice Questionnaire (Kirby et al.,1999) or delay intervals. The remaining studies used delay intervals to calculate AUC (Malesza & Kaczmarek, 2018; Malesza & Kalinowski, 2021a, 2021b; Malesza & Ostaszewski, 2016). Regarding measures and dimensions of narcissism (Table 1), all

studies included measures coded as assessing trait grandiosity (Buelow & Brunell, 2014; Crysel et al., 2013; Jonason et al., 2020; Malesza & Kaczmarek, 2018; Malesza & Kalinowski,

2021a, 2021b; Malesza & Ostaszewski, 2016), such as the Narcis- sistic Grandiosity Scale (NGS; Crowe et al., 2016; Rosenthal et al., 2020), Dark Triad Dirty Dozen Narcissism subscale (Dirty Dozen; Jonason & Webster, 2010), Short Dark Triad Narcissism subscale (Jones & Paulhus, 2014), or the NPI (Raskin & Hall, 1979). In addition, Buelow and Brunell (2014) provided data on the NPI Leadership/Authority and Grandiose Exhibitionism sub- scales (Ackerman et al., 2011), both of which were coded as meas- ures of trait grandiosity. One study (Buelow & Brunell, 2014) included the Psychological Entitlement Scale (PES; Campbell et al., 2004) and NPI Entitlement/Exploitativeness subscale (Acker- man et al., 2011), both coded as measures of trait entitlement, and another study (Malesza & Kaczmarek, 2018) included the Hyper- sensitive Narcissism Scale (HSNS; Hendin & Cheek, 1997), which was coded as a measure of trait vulnerability.

Meta-Analyses (DD and Narcissism Overall or Trait Grandiosity)

The estimated average effect calculated from seven effect sizes of DD and narcissism overall (i.e., collapsing across narcissism dimen- sions) was small to moderate (r = .21; 95% CI [.10, .32]) (Figure 2). The mean effect size for the data provided by Buelow and Brunell (2014) was calculated using the correlations between DD and the PES, NGS, and NPI full scale, and the mean effect size for the data provided by Malesza and Kaczmarek (2018) was calculated using the correlations between DD and the NPI and HSNS; r was positive and significant for all but one study (Malesza & Ostaszewski, 2016).

There were seven effect sizes used to calculate the estimated aver- age effect size for trait grandiosity (Figure 3). Similar to narcissism overall, the estimated average effect calculated from seven effect sizes of DD and trait grandiosity was small to moderate (r = .24; 95% CI [.11, .37]). The mean effect size for the data provided by Buelow and Brunell (2014) was calculated using the correlations

Table 2 National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

Authors Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total score Quality rating

Buelow and Brunell 2014 Y Y N NR N NA NA Y Y NA N NA NA N 4/9 (44%) Poor Crysel et al. 2013 Y Y Y N N NA NA Y Y NA Y NA NA N 6/9 (67%) Fair Jonason et al. 2020 Y Y NR N N NA NA Y Y NA Y NA NA N 5/9 (56%) Fair Malesza and Kaczmarek 2018 Y Y Y Y N NA NA Y Y NA Y NA NA N 7/9 (78%) Good Malesza and Kalinowski 2021a Y Y Y Y N NA NA Y Y NA Y NA NA N 7/9 (78%) Good Malesza and Kalinowski 2021b Y Y Y Y N NA NA Y Y NA Y NA NA N 7/9 (78%) Good Malesza and Ostaszewski 2016 Y Y Y Y N NA NA Y Y NA Y NA NA N 7/9 (78%) Good

Note. Rating criteria: 1 = Was the research question or objective in this article clearly stated? 2 = Was the study population clearly specified and defined? 3 = Was the participation rate of eligible persons at least 50%? 4 = Were all subjects selected or recruited from the same or similar populations (including the same time period)? [and] Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? 5 = Was a sample size justification, power description, or variance and effect estimates provided? 6 = For the analyses in this article, were the exposure(s) of interest measured prior to the outcome(s) being measured? 7 = Was the timeframe sufficient so that one could reasonably expect to see an association between ex- posure and outcome if it existed? 8 = For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as a continuous variable)? 9 = Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? 10 = Was the exposure(s) assessed more than once over time? 11 = Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? 12 = Were the outcome assessors blinded to the exposure status of participants? 13 = Was loss to follow-up after baseline 20% or less? 14 = Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? Abbreviations: Y = yes; N = no; NR = not reported; NA = not applicable. Total score: (number of “yes” ratings)/(number of criteria applicable to the study). Quality ratings: poor = ,50%; fair = 50%–74%; good = .75%. Additional guidance for assessing the quality of evidence using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies can be located at https://www.nhlbi.nih.gov/health-topics/study-quality -assessment-tools.

DELAY DISCOUNTING AND NARCISSISM 5

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

between DD and the NGS and NPI Full Scale. Again, r was positive and significant for all but one study (Malesza & Ostaszewski, 2016). Two supplemental meta-analyses were conducted making use of

the NPI subscale data provided by Buelow and Brunell (2014). For the first analysis (narcissism overall), the mean effect size for the data provided by Buelow and Brunell (2014) was calculated using the correlations between DD and the PES, NGS, Narcissistic Per- sonality Inventory—Leadership/Authority subscale, Narcissistic Personality Inventory—Grandiose Exhibitionism subscale, and Narcissistic Personality Inventory—Entitlement/Exploitativeness subscale. The results of this meta-analysis (r = .21; 95% CI [.10, .32]) were identical to those of the main meta-analysis for narcis- sism overall (Figure S1 in the online supplemental materials). For the second analysis (trait grandiosity), we used only the

correlations between DD and the NGS, Narcissistic Personality Inventory—Leadership/Authority subscale, and Narcissistic Personality Inventory—Grandiose Exhibitionism subscale to calculate the mean effect for the data provided by Buelow and Brunell (2014). Again, the results of this meta-analysis (r = .24; 95% CI [.11, .37]) were identical to the results of the main meta-analysis for trait grandiosity (Figure S2 in the online sup- plemental materials).

Associations Between DD and Trait Entitlement or Trait Vulnerability

There were too few effect sizes to conduct separate meta-analy- ses for trait entitlement or vulnerability. DD was positively and significantly associated with trait entitlement measured with the Psychological Entitlement Scale (r = .29, p # .001) and the NPI Entitlement/Exploitativeness subscale (r = .15, p # .001), with small-to-moderate effect sizes comparable with the estimated av- erage effect sizes for DD and narcissism overall and trait grandios- ity. DD was unrelated to trait vulnerability (r =�.08, p = n.s.).

Quality Assessment and Publication Bias

The quality of evidence was rated as “good” for four studies (Malesza & Kaczmarek, 2018; Malesza & Kalinowski, 2021a, 2021b; Malesza & Ostaszewski, 2016), as “fair” for two studies (Crysel et al., 2013; Jonason et al., 2020), and as “poor” for one study (Buelow & Brunell, 2014; Table 2). One study was rated as “fair” (Crysel et al., 2013) rather than “good” because subjects were recruited from very different populations (United States, India, Canada, Indonesia, and Pakistan), but potential group differ- ences by country of origin were not reported, and it was unclear

Figure 2 Meta-Analysis of Associations Between Delay Discounting and Narcissism Overall

Note. The study by Buelow and Brunell (2014) presents the average effect for associations between DD and the Psychological Entitlement Scale, DD and the Narcissistic Grandiosity Scale, and DD and the Narcissistic Personality Inventory Full Scale. The study by Malesza and Kaczmarek (2018) presents the average effect for associations between DD and the Narcissistic Personality Inventory Full Scale and DD and the Hypersensitive Narcissism Scale. DD = delay discounting.

Figure 3 Meta-Analysis of Associations Between Delay Discounting and Grandiosity

Note. The study by Buelow and Brunell (2014) presents the average effect for associations between DD and the Narcissistic Grandiosity Scale and DD and Narcissistic Personality Inventory Full Scale. DD = delay discounting.

6 COLEMAN ET AL.

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

whether eligibility criteria were applied uniformly to all partici- pants. A second study was rated as “fair” (Jonason et al., 2020) because it was unclear whether any participants were missing data that would have excluded them from the analyses. In addition, given the study’s very large age distribution (18–82; Mage = 37.11, SD = 12.76), there may have been important age-related differen- ces between participants that were unaccounted for. One study was rated as “poor” (Buelow & Brunell, 2014) because only 31% of the participants completed all measures of narcissism, and it was unclear why the measures were not implemented consistently across participants and less than 50% of eligible participants com- pleted all assessments. In addition, eligibility criteria were not reported. Overall, six of seven (86%) of the studies included in the meta-analysis were rated as “fair” or better, and four of seven (57%) of the studies were rated as “good.” Finally, we found no evidence of publication bias for narcissism overall (Figure 4) or trait grandiosity (Figure 5).

Discussion

The purpose of this meta-analysis was to evaluate associations between DD and clinically relevant dimensions of narcissism. Although no studies examining DD and diagnostic assessments of NPD were identified, the aggregated effect sizes presented in the main and supplemental meta-analyses provide a modest but consistent body of empirical evidence for a small-to-moderate positive associa- tion between DD and measures of trait narcissism. This association

was mostly examined using various measures of trait grandiosity. A positive association between DD and trait entitlement was also observed in one study (Buelow & Brunell, 2014), but there was no association between DD and trait vulnerability in another study (Mal- esza & Kaczmarek, 2018). Consistent with the DSM–5 Section III AMPD, these findings suggest that greater DD may be reflected in NPD Criterion B (i.e., grandiosity, attention-seeking) but could be more broadly associated with NPD via features of entitlement. In the spirit of the Research Domain Criteria Framework, the current find- ings provide initial support for the position that DD may be a process of relevance to NPD that could help to account, in part, for comorbid- ities between NPD and disorders characterized by greater DD.

In this study, small-to-medium estimated average effect sizes were observed for associations between DD and narcissism overall (i.e., collapsing effect sizes across measures of different narcissism dimensions) and trait grandiosity. In terms of magnitude, the strength of association between DD and trait narcissism is compara- ble with that of DD and major depressive disorder, schizophrenia, obsessive-compulsive disorder, bulimia nervosa, and binge-eating disorder but not as strong compared with associations between DD and borderline personality disorder, bipolar disorder, or substance use disorders (Amlung et al., 2019; Bickel et al., 2019; MacKillop et al., 2011). Thus, the present findings suggest that DD could be an important process for understanding aspects of narcissism (e.g., grandiosity, entitlement), associated behavioral risks (e.g., problem- atic alcohol consumption; Coleman et al., 2020), or comorbidities between NPD and other psychiatric conditions.

Figure 4 Funnel Plot for Meta-Analysis of Associations Between Delay Discounting and Narcissism Overall

Note. Egger’s test: t(5) = 0.62, p = .56.

DELAY DISCOUNTING AND NARCISSISM 7

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

Importantly, although the debate over the number and opera- tionalization of the primary dimensions of narcissism remains ongoing (Crowe et al., 2019; Krizan & Herlache, 2018; Miller et al., 2017; Wright & Edershile, 2018), it is widely accepted that grandiosity and entitlement are pronounced in individuals with NPD. The current findings indicate that trait grandiosity and per- haps entitlement may be indicative of greater DD. Therefore, it is reasonable to suggest that DD may be greater among those who meet diagnostic criteria for NPD. More importantly, this review highlights a dearth of research in the area of DD and NPD, and research focused on clinical samples or using diagnos- tic assessments of narcissism is needed to better contextualize the clinical significance of the association between DD and narcissism. Beyond the clinical literature, a growing body of evidence indi-

cates that trait narcissism, particularly grandiosity, associates with a variety of risky behavior patterns (Buelow & Brunell, 2018), including greater alcohol consumption (Coleman et al., 2020; Hill, 2016; Luhtanen & Crocker, 2005), having unprotected sex and mul- tiple sex partners (Coleman et al., 2020; Martin et al., 2013), mak- ing risky financial decisions (Foster et al., 2011), gambling (Lakey et al., 2008), and even disregarding public health and safety mes- sages during the COVID-19 pandemic (Hardin et al., 2021; Nowak et al., 2020; Venema & Pfattheicher, 2021; Zajenkowski et al., 2020). Because greater DD is associated with many of these same behaviors (Bickel et al., 2019), it may be informative to examine

whether interventions that have been shown to reduce DD (e.g., Ep- isodic Future Thinking; Peters & Büchel, 2010; Snider et al., 2016; Stein et al., 2016) are effective for producing reductions in behav- ioral problems associated with narcissism.

Limitations

This study has several limitations that merit mention. First, as noted earlier, none of the studies in this review included diagnostic assessments of NPD. Although categorizing self-report measures of trait narcissism according to clinically relevant dimensions may provide some insight into how DD could relate to NPD, and meas- ures such as the NPI have been shown to correspond with expert ratings of NPD trait profiles (Miller et al., 2016), this study pro- vides only preliminary evidence that DD may represent a process of relevance to NPD. Second, the topic of interest is relatively understudied, with only seven studies meeting inclusion criteria for this review and only two of those studies examining dimen- sions other than grandiosity. This small number of studies pre- cluded, for example, a moderation analysis of the association between DD and narcissism by dimensions of narcissism. It will be important to further examine associations between DD and nar- cissism after more research by a larger group of investigators emerges on this topic. Third, although the Dirty Dozen (Jonason & Webster, 2010) is thought to represent a measure of grandiosity (Grijalva et al., 2015), some evidence demonstrates that it

Figure 5 Funnel Plot for Meta-Analysis of Associations Between Delay Discounting and Grandiosity

Note. Egger’s test: t(5) = 0.54, p = .61.

8 COLEMAN ET AL.

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

positively correlates with the HSNS (i.e., a measure of vulnerabil- ity), which distinguishes it from other measures of grandiosity that negatively correlate with the HSNS (Maples et al., 2014). Given the evidence presented in the current study that DD may be unre- lated to vulnerability (Malesza & Kaczmarek, 2018), it is possible that the Dirty Dozen underestimates the association between DD and grandiosity. Relatedly, as the NPI and HSNS have been shown to negatively correlate (Maples et al., 2014), calculating a mean effect size for the data provided by Malesza and Kaczmarek (2018) using the association between DD and the NPI and the association between DD and the HSNS likely obscures the effect of DD for both grandiosity and vulnerability. Furthermore, most measures of grandiosity and vulnerability capture aspects of enti- tlement, or “self-centered antagonism” more broadly, which encompasses a lack of empathy and a willingness to exploit others to meet entitled expectations (Crowe et al., 2019); however, it was not possible to factor these aspects out of all measures of grandios- ity or vulnerability contained in this meta-analysis. Together, these limitations underscore the need for additional research on this topic, particularly research examining associations between DD and narcissism dimensions other than grandiosity. Moreover, it would be informative for future studies to report associations between DD and subscales of narcissism measures such as the NPI or use narcissism measures that contain subscales demon- strated to load primarily onto one narcissism dimension (e.g., the Five-Factor Narcissism Inventory Short Form, Agentic Extraver- sion, Antagonism, and Neuroticism subscales; Crowe et al., 2019; Miller et al., 2016; Sherman et al., 2015).

Conclusion

In conclusion, this meta-analysis provides evidence that DD and trait narcissism are positively associated. Given the relative consis- tency of associations between DD and trait narcissism across dif- ferent samples and measures categorized according to clinically relevant dimensions, these findings have implications for placing NPD among other psychiatric conditions characterized by greater DD. Further research in this domain could help to clarify whether DD represents an important source of transdiagnostic variance underlying NPD and psychiatric comorbidities and whether DD links NPD to risky behaviors and associated downstream func- tional impairments (e.g., health, relationship, legal, or financial problems).

References

Ackerman, R. A., Witt, E. A., Donnellan, M. B., Trzesniewski, K. H., Robins, R. W., & Kashy, D. A. (2011). What does the Narcissistic Per- sonality Inventory really measure? Assessment, 18(1), 67–87. https://doi .org/10.1177/1073191110382845

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

Amlung, M., Marsden, E., Holshausen, K., Morris, V., Patel, H., Vedelago, L., Naish, K. R., Reed, D. D., & McCabe, R. E. (2019). Delay discounting as a transdiagnostic process in psychiatric disorders: A meta-analysis. JAMA Psychiatry, 76(11), 1176–1186. https://doi.org/10 .1001/jamapsychiatry.2019.2102

Bickel, W. K., Athamneh, L. N., Basso, J. C., Mellis, A. M., DeHart, W. B., Craft, W. H., & Pope, D. (2019). Excessive discounting of delayed reinforcers as a trans.-disease process: Update on the state of

the science. Current Opinion in Psychology, 30(1), 59–64. https://doi .org/10.1016/j.copsyc.2019.01.005

Bickel, W. K., & Mueller, E. T. (2009). Toward the study of trans.-disease processes: A novel approach with special reference to the study of co- morbidity. Journal of Dual Diagnosis, 5(2), 131–138. https://doi.org/10 .1080/15504260902869147

Bickel, W. K., Odum, A. L., & Madden, G. J. (1999). Impulsivity and ciga- rette smoking: Delay discounting in current, never, and ex-smokers. Psy- chopharmacology, 146(4), 447–454. https://doi.org/10.1007/PL00005490

Borenstein, M., Hedges, L., Higgins, J., & Rothstein, H. (2013). Compre- hensive meta-analysis software version 3. BioStat.

Buelow, M. T., & Brunell, A. B. (2014). Facets of grandiose narcissism predict involvement in health-risk behaviors. Personality and Individual Differences, 69(1), 193–198. https://doi.org/10.1016/j.paid.2014.05.031

Buelow, M. T., & Brunell, A. B. (2018). Narcissism and involvement in risk-taking behaviors. In A. Hermann, A. Brunell & J. Foster (Eds.), Handbook of trait narcissism (pp. 233–242). Springer. https://doi.org/10 .1007/978-3-319-92171-6_25

Campbell, W. K., Bonacci, A. M., Shelton, J., Exline, J. J., & Bushman, B. J. (2004). Psychological entitlement: Interpersonal consequences and validation of a self-report measure. Journal of Personality Assessment, 83(1), 29–45. https://doi.org/10.1207/s15327752jpa8301_04

Cohen, P., Crawford, T. N., Johnson, J. G., & Kasen, S. (2005). The chil- dren in the community study of developmental course of personality dis- order. Journal of Personality Disorders, 19(5), 466–486. https://doi.org/ 10.1521/pedi.2005.19.5.466

Coleman, S. R. M., Bernstein, M. J., Benfield, J. A., & Smyth, J. M. (2020). Narcissistic grandiosity and risky health behaviors in college students. Journal of American College Health. Advance online publica- tion. https://doi.org/10.1080/07448481.2020.1762606

Crowe, M., Carter, N. T., Campbell, W. K., & Miller, J. D. (2016). Valida- tion of the Narcissistic Grandiosity Scale and creation of reduced item variants. Psychological Assessment, 28(12), 1550–1560. https://doi.org/ 10.1037/pas0000281

Crowe, M. L., Lynam, D. R., Campbell, W. K., & Miller, J. D. (2019). Exploring the structure of narcissism: Toward an integrated solution. Journal of Personality, 87(6), 1151–1169. https://doi.org/10.1111/jopy .12464

Crysel, L. C., Crosier, B. S., & Webster, G. D. (2013). The dark triad and risk behavior. Personality and Individual Differences, 54(1), 35–40. https://doi.org/10.1016/j.paid.2012.07.029

Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric di- agnosis: The seven pillars of RDoC. BMC Medicine, 11(1), Article 126. https://doi.org/10.1186/1741-7015-11-126

Eaton, N. R., Rodriguez-Seijas, C., Krueger, R. F., Campbell, W. K., Grant, B. F., & Hasin, D. S. (2017). Narcissistic personality disorder and the structure of common mental disorders. Journal of Personality Disorders, 31(4), 449–461. https://doi.org/10.1521/pedi_2016_30_260

Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. British Medical Jour- nal , 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629

Foster, J. D., Reidy, D. E., Misra, T. A., & Goff, J. S. (2011). Narcissism and stock market investing: Correlates and consequences of cocksure investing. Personality and Individual Differences, 50(6), 816–821. https://doi.org/10.1016/j.paid.2011.01.002

Foster, J. D., & Trimm IV, R. F. (2008). On being eager and uninhibited: Narcissism and approach–avoidance motivation. Personality and Social Psychology Bulletin, 34(7), 1004–1017.

Giacomin, M., & Jordan, C. H. (2016). The wax and wane of narcissism: Grandiose narcissism as a process or state. Journal of Personality, 84(2), 154–164. https://doi.org/10.1111/jopy.12148

Gore, W. L., & Widiger, T. A. (2016). Fluctuation between grandiose and vulnerable narcissism. Personality Disorders: Theory, Research, and Treatment, 7(4), 363–371. https://doi.org/10.1037/per0000181

DELAY DISCOUNTING AND NARCISSISM 9

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

Grijalva, E., Newman, D. A., Tay, L., Donnellan, M. B., Harms, P. D., Robins, R. W., & Yan, T. (2015). Gender differences in narcissism: A meta-analytic review. Psychological Bulletin, 141(2), 261–310. https:// doi.org/10.1037/a0038231

Griskevicius, V., Tybur, J. M., Delton, A. W., & Robertson, T. E. (2011). The influence of mortality and socioeconomic status on risk and delayed rewards: A life history theory approach. Journal of Personality and Social Psychology, 100(6), 1015–1026.

Hamlat, E. J., Young, J. F., & Hankin, B. L. (2020). Developmental course of personality disorder traits in childhood and adolescence. Journal of Personality Disorders, 34(Supplement B), 25–43. https://doi.org/10 .1521/pedi_2019_33_433

Hardin, B. S., Smith, C. V., & Jordan, L. N. (2021). Is the COVID-19 pan- demic even darker for some? Examining dark personality and affective, cognitive, and behavioral responses to the COVID-19 pandemic. Per- sonality and Individual Differences, 171(1), Article 110504. https://doi .org/10.1016/j.paid.2020.110504

Hendin, H. M., & Cheek, J. M. (1997). Assessing hypersensitive narcis- sism: A reexamination of Murray’s Narcissism Scale. Journal of Research in Personality, 31(4), 588–599. https://doi.org/10.1006/jrpe .1997.2204

Hill, E. M. (2016). The role of narcissism in health-risk and health-protec- tive behaviors. Journal of Health Psychology, 21(9), 2021–2032. https:// doi.org/10.1177/1359105315569858

Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., Sanislow, C., & Wang, P. (2010). Research domain criteria (RDoC): to- ward a new classification framework for research on mental disorders. The American Journal of Psychiatry, 167(7), 748–751. https://doi.org/ 10.1176/appi.ajp.2010.09091379

Jonason, P. K., Talbot, D., Cunningham, M. L., & Chonody, J. (2020). Higher-order coping strategies: Who uses them and what outcomes are linked to them. Personality and Individual Differences, 155(1), Article 109755. https://doi.org/10.1016/j.paid.2019.109755

Jonason, P. K., & Webster, G. D. (2010). The dirty dozen: A concise mea- sure of the dark triad. Psychological Assessment, 22(2), 420–432. https://doi.org/10.1037/a0019265

Jones, D. N., & Paulhus, D. L. (2014). Introducing the short dark triad (SD3): A brief measure of dark personality traits. Assessment, 21(1), 28–41. https://doi.org/10.1177/1073191113514105

Kirby, K. N., Petry, N. M., & Bickel, W. K. (1999). Heroin addicts have higher discount rates for delayed rewards than non-drug-using controls. Journal of Experimental Psychology: General, 128(1), 78–87. https:// doi.org/10.1037/0096-3445.128.1.78

Krizan, Z., & Herlache, A. D. (2018). The narcissism spectrum model: A synthetic view of narcissistic personality. Personality and Social Psychol- ogy Review, 22(1), 3–31. https://doi.org/10.1177/1088868316685018

Lakey, C. E., Rose, P., Campbell, W. K., & Goodie, A. S. (2008). Probing the link between narcissism and gambling: The mediating role of judg- ment and decision-making biases. Journal of Behavioral Decision Mak- ing, 21(2), 113–137. https://doi.org/10.1002/bdm.582

Luhtanen, R. K., & Crocker, J. (2005). Alcohol use in college students: Effects of level of self-esteem, narcissism, and contingencies of self- worth. Psychology of Addictive Behaviors, 19(1), 99–103. https://doi .org/10.1037/0893-164X.19.1.99

MacKillop, J., Amlung, M. T., Few, L. R., Ray, L. A., Sweet, L. H., & Munafò, M. R. (2011). Delayed reward discounting and addictive behavior: A meta-analysis. Psychopharmacology, 216(3), 305–321. https://doi.org/10.1007/s00213-011-2229-0

Madden, G. J., & Johnson, P. S. (2010). A delay-discounting primer. In G. J. Madden & W. K. Bickel (Eds.), Impulsivity: The behavioral and neurological science of discounting (pp. 11–37). American Psychologi- cal Association. https://doi.org/10.1037/12069-001

Madden, G. J., Petry, N. M., Badger, G. J., & Bickel, W. K. (1997). Impul- sive and self-control choices in opioid-dependent patients and non-drug-

using control participants: Drug and monetary rewards. Experimental and Clinical Psychopharmacology, 5(3), 256–262. https://doi.org/10 .1037/1064-1297.5.3.256

Malesza, M., & Kaczmarek, M. C. (2018). Grandiose narcissism versus vulnerable narcissism and impulsivity. Personality and Individual Dif- ferences, 126(1), 61–65. https://doi.org/10.1016/j.paid.2018.01.021

Malesza, M., & Kalinowski, K. (2021a). Dark triad and impulsivity–an ec- ological momentary assessment approach. Current Psychology, 40(8), 3682–3690. https://doi.org/10.1007/s12144-019-00320-y

Malesza, M., & Kalinowski, K. (2021b). Willingness to share, impulsivity and the Dark Triad traits. Current Psychology, 40(8), 3888–3896. https://doi.org/10.1007/s12144-019-00351-5

Malesza, M., & Ostaszewski, P. (2016). Dark side of impulsivity—Associ- ations between the dark triad, self-report and behavioral measures of impulsivity. Personality and Individual Differences, 88(1), 197–201. https://doi.org/10.1016/j.paid.2015.09.016

Maples, J. L., Lamkin, J., & Miller, J. D. (2014). A test of two brief meas- ures of the dark triad: The dirty dozen and short dark triad. Psychologi- cal Assessment, 26(1), 326–331. https://doi.org/10.1037/a0035084

Martin, A. M., Benotsch, E. G., Lance, S. P., & Green, M. (2013). Trans- mission risk behaviors in a subset of HIV-positive individuals: The role of narcissistic personality features. Personality and Individual Differen- ces, 54(2), 256–260. https://doi.org/10.1016/j.paid.2012.09.006

Miller, J. D., Lynam, D. R., & Campbell, W. K. (2016). Measures of narcis- sism and their relations to DSM-5 pathological traits: A critical reappraisal. Assessment, 23(1), 3–9. https://doi.org/10.1177/1073191114522909

Miller, J. D., Lynam, D. R., Hyatt, C. S., & Campbell, W. K. (2017). Con- troversies in Narcissism. Annual Review of Clinical Psychology, 13(1), 291–315. https://doi.org/10.1146/annurev-clinpsy-032816-045244

Miller, J. D., Lynam, D. R., McCain, J. L., Few, L. R., Crego, C., Widiger, T. A., & Campbell, W. K. (2016). Thinking structurally about narcis- sism: An examination of the Five-Factor Narcissism Inventory and its components. Journal of Personality Disorders, 30(1), 1–18. https://doi .org/10.1521/pedi_2015_29_177

Myerson, J., Green, L., & Warusawitharana, M. (2001). Area under the curve as a measure of discounting. Journal of the Experimental Analysis of Behavior, 76(2), 235–243. https://doi.org/10.1901/jeab.2001.76-235

National Heart, Lung, and Blood Institute. (2021). Study quality assessment tools: Quality assessment tool for observational cohort and cross-sectional studies. https://www.nhlbi.nih.gov/health-topics/study -quality-assessment-tools

Nowak, B., Brzóska, P., Piotrowski, J., Sedikides, C., _Zemojtel- Piotrowska, M., & Jonason, P. K. (2020). Adaptive and maladaptive behavior during the COVID-19 pandemic: The roles of Dark Triad traits, collective narcissism, and health beliefs. Personality and Individ- ual Differences, 167(1), Article 110232. https://doi.org/10.1016/j.paid .2020.110232

Peters, J., & Büchel, C. (2010). Episodic future thinking reduces reward delay discounting through an enhancement of prefrontal-mediotemporal interactions. Neuron, 66(1), 138–148. https://doi.org/10.1016/j.neuron .2010.03.026

Pincus, A. L., & Lukowitsky, M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6(1), 421–446. https://doi.org/10.1146/annurev.clinpsy.121208.131215

Pincus, A. L., Roche, M. J., & Good, E. W. (2015). Narcissistic personality disorder and pathological narcissism. In P. H. Blaney, R. F. Krueger, & T. Millon (Eds.), Oxford textbook of psychopathology (3rd ed., pp. 791–813). Oxford University Press.

Raskin, R. N., & Hall, C. S. (1979). A Narcissistic Personality Inventory. Psychological Reports, 45(2), 590–590. https://doi.org/10.2466/pr0 .1979.45.2.590

Richards, J. B., Zhang, L., Mitchell, S. H., & De Wit, H. (1999). Delay or probability discounting in a model of impulsive behavior: Effect of alco- hol. Journal of the Experimental Analysis of Behavior, 71(2), 121–143.

10 COLEMAN ET AL.

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

Rosenthal, S. A., Hooley, J. M., Montoya, R. M., van der Linden, S. L., & Steshenko, Y. (2020). The Narcissistic Grandiosity Scale: A measure to distinguish narcissistic grandiosity from high self-esteem. Assessment, 27(3), 487–507. https://doi.org/10.1177/1073191119858410

Sherman, E. D., Miller, J. D., Few, L. R., Campbell, W. K., Widiger, T. A., Crego, C., & Lynam, D. R. (2015). Development of a Short Form of the Five-Factor Narcissism Inventory: The FFNI-SF. Psychological Assessment, 27(3), 1110–1116. https://doi.org/10.1037/pas0000100

Smith, C. L., & Hantula, D. A. (2008). Methodological considerations in the study of delay discounting in intertemporal choice: A comparison of tasks and modes. Behavior Research Methods, 40(4), 940–953. https:// doi.org/10.3758/BRM.40.4.940

Snider, S. E., LaConte, S. M., & Bickel, W. K. (2016). Episodic future thinking: Expansion of the temporal window in individuals with alcohol dependence. Alcoholism, Clinical and Experimental Research, 40(7), 1558–1566. https://doi.org/10.1111/acer.13112

Stein, J. S., Wilson, A. G., Koffarnus, M. N., Daniel, T. O., Epstein, L. H., & Bickel, W. K. (2016). Unstuck in time: Episodic future thinking reduces delay discounting and cigarette smoking. Psychopharmacology, 233(21–22), 3771–3778. https://doi.org/10.1007/s00213-016-4410-y

Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., Ruan, W. J., Pulay, A. J., Saha, T. D., Pickering, R. P., &

Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM–IV narcissistic personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 69(7), 1033–1045. https://doi.org/10 .4088/JCP.v69n0701

Torres-Castro, R., Vasconcello-Castillo, L., Alsina-Restoy, X., Solis- Navarro, L., Burgos, F., Puppo, H., & Vilaró, J. (2021). Respiratory function in patients post-infection by COVID-19: A systematic review and meta-analysis. Pulmonology, 27(4), 328–337. https://doi.org/10 .1016/j.pulmoe.2020.10.013

Venema, T. A. G., & Pfattheicher, S. (2021). Perceived susceptibility to COVID-19 infection and narcissistic traits. Personality and Individual Dif- ferences, 175(1), Article 110696. https://doi.org/10.1016/j.paid.2021.110696

Wright, A. G., & Edershile, E. A. (2018). Issues resolved and unresolved in pathological narcissism. Current Opinion in Psychology, 21(1), 74–79. https://doi.org/10.1016/j.copsyc.2017.10.001

Zajenkowski, M., Jonason, P. K., Leniarska, M., & Kozakiewicz, Z. (2020). Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Personality and Individual Differences, 166(1), Article 110199. https:// doi.org/10.1016/j.paid.2020.110199

DELAY DISCOUNTING AND NARCISSISM 11

T hi s do cu m en t is co py ri gh te d by

th e A m er ic an

P sy ch ol og ic al A ss oc ia ti on

or on e of

it s al li ed

pu bl is he rs .

T hi s ar ti cl e is in te nd ed

so le ly

fo r th e pe rs on al us e of

th e in di vi du al us er

an d is no t to

be di ss em

in at ed

br oa dl y.

Missouridou et al. BMC Psychiatry (2022) 22:2 https://doi.org/10.1186/s12888-021-03607-2

R E S E A R C H

Containment and therapeutic relationships in acute psychiatric care spaces: the symbolic dimensions of doors Evdokia Missouridou1*, Evangelos C. Fradelos2, Emmanouel Kritsiotakis1,3, Polyxeni Mangoulia1,4, Eirini Segredou5 and Ioanna V. Papathanasiou2

Abstract Background: There is an increasing trend of door locking practices in acute psychiatric care. The aim of the present study was to illuminate the symbolic dimensions of doors in Greek mental health nurses’ experiences of open and locked working spaces.

Results: A sequential mixed-method designexplored the experiences of nurses working in both open and locked psychiatric acute care units. Participants experiences revealed four types of doors related to the quality of recovery- oriented care: (a) the open door, (b) the invisible door, (c) the restraining door, and (d) the revolving door. Open doors and permeable spacesgenerated trust and facilitated the diffusion of tension and the necessary perception of feeling safe in order to be involved in therapeutic engagement. When the locked unit was experienced as a caring environ- ment, the locked doors appeared to be “invisible”. The restraining doors symbolized loss of control, social distance and stigma echoing the consequences of restrictingpeople’s crucial control over spaceduring the COVID-19 pandemicin relation toviolence within families, groups and communities. The revolving door (service users’ abscondence/re- admission) symbolised the rejection of the offered therapeutic environment and was a source of indignation and compassion fatigue in both open and locked spaces attributed to internal structural acute care characteristics (limited staffing levels, support, resources and activities for service users) as well as ‘locked doors’ in the community (limited or no care continuity and stigma).

Conclusions: The impact of COVID-19 restrictions on people’s crucial control of space provides an impetus for erect- ing barriers masked by the veil of habit and reconsidering the impact of the simple act of leaving the door open/ locked to allow both psychiatric acute care unit staff and service users to reach their potential.

Keywords: Acute psychiatric care, Open doors, Door locking practice, Nurses, Greece

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Introduction Persons with mental health problems often experience distressing feelings culminating in a crisis which neither themselves nor their families can contain prior to seek- ing refuge to a bigger system of relationships in acute

psychiatric care spaces. These spaces constitute a tem- porary escape, ‘a third place’ [1] of emotional contain- ment and refuge in varied distance from family (the first system) or community (the second system) and a space apart from the pressures of the latter systems. Physi- cal and emotional containment can be attained through containment measures as well as relationships which are founded in trust and have the capacity to bear feel- ings too difficult for the people to manage on their own [2]. Mental health service users stress that relationships

Open Access

*Correspondence: [email protected] 1 Department of Nursing, Faculty of Health and Caring Professions, University of West Attica, Saint Spiridonos 12243, Egaleo, Athens, Greece Full list of author information is available at the end of the article

Page 2 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

of trust and respect, in which they are listened to, are of great importance to them [3]. Establishing a therapeutic alliance depends on several factors such as the clinician’s ability to have empathy and the patient’s degree of under- lying psychopathology and might be possible within minutes or could take years [4]. Peplau [5] described therapeutic relationships as the foundation of psychi- atric nursing because they create feelings of being held together and of being safe. She also urged nurses to focus on persons rather than patients and ‘give up the notion of a disease, such as schizophrenia and to think exclusively of patients as persons’ [6]. Understanding the person and their experiences, facilitating growth, therapeutic use of self, choosing the right approach and authoritative vs. emotional containment, emerged as the “Principles of Engagement” in acute mental health wards [7]. Positive ward atmosphere increases service users’ satisfaction and strengthens the therapeutic alliance [8, 9]. Moreo- ver, a good therapeutic relationship is associated with better health outcomes for patients, enhances the effec- tiveness of interventions in inpatient mental health care, and improves both patients’ well-being and experience [10]. Cultural norms, subjective ways in which people interpret and use spaces, expectations and narratives can play an important role in shaping people’s experiences of space [11, 12] while physical and built environments, social conditions and human perceptions contribute in combination in promoting healing at given ‘therapeutic landscapes’ [13].

The study of Roviralta-Vilella et  al. [14] shows that the factors associated with higher-quality therapeutic relationship in mental health units are a more favour- able nurse practice environment and, specifically, the presence of more foundations for quality nursing care, together with higher academic qualifications and longer nurse experience. The lack of time is seen as the major obstacle to achieving the therapeutic relationship, both by nurses and by patients. Another limiting factor in the therapeutic relationship is an insecure setting [15]. In some countries spaces have been specially set aside for contact with patients (‘patient-protected time’), never- theless, there continue to be problems, because of per- sonnel shortages or a lack of support of supervisors [16]. Of course this alone will not eliminate the unpredict- ability of the surrounding, given that are acute psychiat- ric units, so nurses have to work hard to ensure that it does not entail insecurity in the hospital unit [15]. The review of Moreno-Poyato et al. [16] points to the need for nurses to have greater organizational support, the impor- tance of promoting effective teamwork and the existence of a nursing model within the units. However, both the organizational climate, culture, safety and physical infra- structure of a ward, alongside nurses’ and patients’ own

personal resources may either positively or negatively influence engagement. Additionally, an individual’s actual or perceived capabilities, opportunities and motivation drive their ability to overcome the influential factors [7].”

On the other hand, doors constitute boundaries of acute psychiatric care environment which limit or enhance control over space [17]. Door locking consti- tutes a measure of containing the psychiatric crisis which regulates the ability of both voluntary and involuntary patients to leave psychiatric units [18]. Research on staff, patient and visitors’ perceptions and experiences of door locking practices has identified both advantages and dis- advantages in relation to locked environments [19–21]. On the other hand, research on open wards is very lim- ited and focuses mostly on the success of treatment in terms of absconding, aggression and coercive measures rates [22–24] or the implementation of open-door poli- cies in wards with a tradition of locked door policy [25]. Efkemann et  al. [8] attempted to illuminate the percep- tions and experiences of patients and staff in a mixed method study of wards traditionally operating in an open or locked policy and concluded that ward atmosphere was associated with the door policy status. Similarly, McKeown et al. [26, 27], in an ethnography of coercion in acute psychiatric care in the UK, observed the profound impact of open doors and less rigid demarcations of ward space on therapeutic and social contacts and identified legitimation as a crucial process in professionals’ justi- fications for door locking practices. In Greece, a recent study of nursing students’ attitudes towards open door policy and restrictive measures concluded that the cul- ture of psychiatry in a locked or open unit with custom restrictive practices socialized students’ views towards the locally dominant pattern of relative evaluations [28]. In contrast, a recent study of Greek nurses’ experiences in open wards [29] and a study of nursing care provid- ers’ experiences in locked wards [30] found that negative and positive feelings about door locking did not appear to match the specific system of practice since participants described how open or locked door practices influenced their professional role. In pursuit of a comparable prox- imity to the results of these two studies, the authors fur- ther examine the symbolic dimensions of doors in mental health nurses’ descriptions of their working environ- ments. Thus, in the study reported here we provide new insights in the descriptive nature of open and locked door practices and the symbolic meanings assigned to doors in acute psychiatric care spaces.

The Greek context In Greece, the debate on the concept of recovery [31] is growing steadily [32] in alignment with many other countries in Europe and the US [33] while emphasis is

Page 3 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

placed on social justice issues [34], the education of men- tal health professionals [28], service users experiences [35–37] and trauma-informed care and education [34, 38, 39]. Positive initiatives include an anti-stigma movement, the development of societies comprising the families of service users, and a Greek Hearing Voices Network [40]. Nonetheless, the percentage of involuntary admissions in both the two public psychiatric hospitals of Athens (i.e. approximately 54%) and the psychiatric inpatient units of general hospitals (i.e. approximately 35%) is alarmingly high [41] in the context of a long-lasting financial crisis [42].

Methods Aim and study design The aim of the present study was to describe the sym- bolic dimensions of doors in mental health nurses’ expe- riences of their working environments (25-bed acute care units). Person-centered care (medication, psychoeduca- tion and social care) in these environments was provided by a multidisciplinary team for approximately six weeks to three months. A sequential mixed method qualita- tive approach was employed to allow for triangulation of methods and a final phase of integration of data [43] as well ensuring methodological integrity evaluated by (a) fidelity to the subject matter and (b) utility in achieving research goals [44] as follows:

• Study one: An inductive content analysis qualitative study [29] conducted between May 2017 – Novem- ber 2017 in six open acute psychiatric care wards. Analysis started immediately after conducting an interview while emerging codes were discussed with the primary researcher prior to conducting another interview. Additionally, saturation issues were dis- cussed with the primary researcher at later stages.

• Study two: A thematic analysis qualitative study [30] in six locked acute psychiatric care wards which began at the completion of study one data collec- tion and was completed on October 2018. Analysis started during the later stages of data collection.

Interviewers were student nurses with a six-month clinical placement in mental health acute care units and were prepared for their research by the first three researchers who were also responsible for their clinical training.

Participants & procedure Purposive sampling aiming to achieve an equal par- ticipation of male and female participants was used to approach nurses who provide services to service users in open and locked wards. The nurse director of each

hospital provided the names of nursing profession- als who were available for an interview. The number of professionals interviewed in a unit was limited to two to ensure equal participation of participants from different units. Eleven out of twenty-two participants were male (50%). Participants’ age ranged from 33 to54 years (mean 43.3 years) while their clinical experience ranged from 4 to 28 years (mean 18.1 years). All participants (100%) had a degree in Nursing. One participant held a MSc degree and four participants had acquired a post-graduate spe- cialization in mental health nursing. Individual inter- views (thirty to sixty minutes duration) were conducted by three female student nurses supervised by the first author in the context of two research projects completed as part of an undergraduate degree course. Interview- ers had a varied support from the second and the third author.

An introductory question (What are the advantages and disadvantages of the open/locked door practices for your nursing care?) generated lively discussions about nurses’ experiences of working in open/locked wards. This was followed by further questions: What are the advantages and disadvantages of the open/locked door practices for the people with mental health problems and your relationship to them? What were your first impressions of working in an open/locked ward when you started working? Have your feelings or the way you think changed since then? A closing question invited par- ticipants to offer description of the impact of their work- ing experience on them (How do you think working in an open/locked ward affected you over time?) as well as recommendations that may support their work in future. Questions were open-ended, with probes facilitating rich accounts.

Ethical approval and conduct Participants were recruited in the study on a voluntary basis and ground rules around disclosures, respect for participants’ privacy and anonymity were discussed with the participants prior to participation. All participants were informed of their rights to refuse or to discontinue their participation, according to the ethical standards of the Helsinki Declaration of 1983 and signed an informed consent form. The study was approved by the Scientific Committees of the Hospitals included in the study.

Analysis In our attempt to understand the richness of the data and to interpret the ‘social reality’ of participants, the process of analysis included open coding, creating categories and abstraction [45]. To ensure the credibility of findings, the first three researchers read independently the transcripts and consensus was reached on the identified themes and

Page 4 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

subthemes. Confirmability of results was enhanced by data (space and person) triangulation [46] and researcher triangulation. Finally, all participants’ quotations aiming at illuminating authentic closeness to the subject matter have been reported solely in the present article.

In the present study the researchers reflected on per- sonal experiences and pre-understanding that may influ- ence the research process. The first four authors, two female and two male, are mental health nurses sharing a varied commitment to trauma informed care and reduc- tion of coercive care. The first and the fifth author have a systemic and group analytic background respectively. The second and the third authors are currently completing their studies on social and political sciences and worked at the time of the study at locked and open acute care wards respectively at the hospitals involved in the study. The last author is a professor of Community Psychiatric Nursing.

Results Nurses’ experiences varied greatly among wards and hos- pitals and participants described several locked doors (e.g. unit entrance, nurses’ room) as well as open doors (e.g. unit entrance, patient room) in the unit space. The type of ‘door’ appeared to be a central organising element of participants’ experiences in locked and open acute care units. Overall, four types of doors were identified in interview transcripts (a. the open door, b. the invisible door, c. the restraining door, and d. the revolving door), while eighteen sub-themes described their working expe- riences and perceptions in relation to the four door types in acute psychiatric care units (Table 1).

Theme 1: the open door This theme comprised five sub-themes: (a) feeling of freedom and therapeutic atmosphere, (b) trust and col- laboration, (c) enhanced socialization, (d) reduced like- lihood for aggression and conflict, and (e) service users’ empowerment and nurses’ increased self-awareness.

Participants described the therapeutic atmosphere created by an open-door emphasizing that the feeling of freedom is therapeutic since having opportunities for choices instils hope in an individual about their future. According to interviewees, people can leave at any time and in essence feel independent and free to decide about their care in collaboration with the nurse.

"The open ward offers more freedom to the patients. They are calmer, it is better for them when they have the opportunity to go out. Patients in open wards have options. This also benefits the nurses because we have the cooperation and participation of the patients. They understand that they do not stay in the clinic by force, they are not forced, they stay because they want to get well." (O9)

"You have to convince the patients and not impose yourself on them when patients have the opportunity to leave. This requires great mental strength and abilities. You learn to listen. All they want is some- one to listen to their pain and traumas … " (O2)

Trust in therapeutic relationships is greatly dependent on the trust being given to people indirectly by an open- door. According to participants, being trusted enhances service users’ self-determination and self-confidence leading to their empowerment. An open-door enhances

Table 1 Themes and sub-themes

THEMES SUB-THEMES

The open door • feeling of freedom and therapeutic atmosphere • trust and collaboration • enhanced socialization • reduced likelihood for aggression and conflict • service users’ empowerment and nurses’ increased self-awareness

The invisible door • limit setting • safety and privacy • meaningful staff-patient interactions

The restrictive door • a strong impression of “prison like” environment • difficulty in building trust and therapeutic alliances • conflict and aggressionincidents • stigma • service users’ disempowerment and nurses’compassion fatigue

The revolving door • service users’ relapse and nurses’compassion fatigue • lack of care continuity • substance misuse • limited resources and containment in the context of multidisciplinary team • guilt and fear of litigation

Page 5 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

their morale since the open door means for them that they are trusted and that they are able to preserve their dignity as much as possible. Recovery involves collabo- ration, listening to, learning from and acting upon com- munications and clarifications on what is important to people. As the latter discuss with nurses their needs and realize the options they have,they feel the nurse close to them, a supporter helping in their recovery rather than an obstacle. Furthermore, they gradually feel confident that the nurse will listen to them, be interested and help.

“The main thing for me is that in the open ward you observe patients and see if they want to stay in treat- ment. They are becoming aware of their illness, you discuss all this with them, they tell you: ‘I do not feel well’, ‘I want to see the doctor’, ‘I want to change my medication’. The main thing is that they stay because they want to. They have the option or the right to put it better, to leave at any time”. (O3)

“Just because of the freedom of movement, I believe that a two-way relationship of trust is created between the patient and the nurse. The patient thinks that the nurse shows me confidence to go out for a walk, I will trust him/her too. It all works ther- apeutically.” (O7)

“In the open wards you offer something more human … Patients are tied to you. They want you. They leave and come to greet you…” (O5)

Participants described that contact with the ‘outside world’ and socialization with people from other units works therapeutically for service users and contributes to their good mental health and faster discharge from the hospital. The latter was likened to a ‘small village’.

“In the open wards, the environment is more beauti- ful, the patients’ energy is channeled. They will go for a walk, they will talk to other patients, they will go out to have a cup of coffee”. (O3)

“In the open wards, the emotional tension is diffused. The patients’ energy is channeled, they get socialized. Even when their conversations do not make sense, for them it is a form of ‘psychotherapy’.” (O4)

Several participants reported that through mental health nursing in open units they gradually gained self-aware- ness within a particular socio-political context. Typically, they believe that they have become better professionals and better parents in their families. Through daily work they understood their needs and their limits. Limits are also necessary in the treatment of people in the land- scape of mental health problems and trauma and require

communication as well as to develop the ability to set limits without becoming distant and authoritarian.

“I gradually got to know my limits. You commu- nicate, you care about the patient, you come to understand his/her world, you listen to him/her. You change as a human being.” (O2)

“Through your contact with the patient you discover yourself, and your limits.” (O8)

Theme 2: the invisible door The therapeutic benefits of locked doors appeared to be the central organising element of participants’ experi- ences in some locked units. When the locked unit was experienced as a caring environment, the locked doors appeared to be ‘invisible’. This theme comprised three sub-themes: (a) limit setting, (b) safety and privacy, and (c) meaningful staff-patient interactions.

Several participants reported that limit setting is one of the most important parts of patients’ treatment as well as being fundamental in a successful collaboration between patients and nurses. The practice of locking the door helps a lot in cultivating limit setting and promoting responsible, sensible and prudent decision making. Some nurses noted that physical boundaries enable the patient to internalize the importance of limit setting and self- control in his/her recovery.

“I see people with mental health problems as my children and treat them with the same compassion or strictness. I want to give them the best I can, to understand them, to help them and to teach them not to exceed certain limits.” (L1)

“I believe there is no locked door. The lock is just a vir- tual constraint and the railings are natural limits which in essence prevent patients from delinquent behavior … The natural limits used in the locked wards constitute the means of teaching patients to internalize ethical limits and help them to reintegrate in society after being dis- charged from a psychiatric hospital.” (L8).

According to participants, patients rarely admit that they feel safe in the locked ward and that they do not suf- focate. However, several patients have shared with par- ticipants that they feel protected and safe behind bars and locked doors for different reasons (the source of threat may be another patient, an unwanted relative, or a symptom of their illness). The gradual attainment of trust within therapeutic relationships contributed to perceiving the environment as primarily caring instead of ‘locked’.

“No matter how much the patients react against the practice of the locked door, both directly and indi-

Page 6 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

rectly, after they get better, they thank us and some- times they apologize for hurting us, for treating us badly or because we just saw them in their worst phase.” (L9).

Theme 3: the restraining door This theme comprised five sub-themes: (a) a strong impression of “prison like” environment, (b) difficulty in building trust and therapeutic alliances, (c) con- flict and aggression incidents, (d) stigma, and (e) ser- vice users’ disempowerment and nurses’ compassion fatigue.

According to some participants, the locked door restrains service users’ freedom to the extent that the lat- ter often liken the locked ward to a ‘prison’. People admit- ted involuntarily are commonly highly negative with the locked ward describing feelings of imprisonment which in combination with their vulnerable psychiatric condi- tion creates tensions and often makes them more aggres- sive. Tension in the atmosphere due to confinement is a common phenomenon according to participants. This tension causes discomfort to patients, who react aggres- sively to others, resulting in increased rates of conflict and violence.

“We do not want the hospital to look like a prison, but unfortunately this is how patients perceive it. Doors locked, railings and nurses-guards.” (L1)

“The tension of confinement is so high that it often results in aggressive behavior which needs to be restrained.” (L9)

Furthermore, several participants stressed that people have less trust in nurses in locked spaces and even when this happens it takes a long time to be established. Apart from the suspicion characteristic of several mental health service users, this situation is aggravated by the practice of door locking that makes “nurses” look “bad” in the eyes of service users.

"Imagine going to a house and suddenly the host locks the door and forces you to stay inside. That’s exactly how patients see it. How easy is it to trust us afterwards? " (L13)

Some of the nurses pointed out that one of the disad- vantages of locked spaces is patients’ resignation, passiv- ity and dependency. They emphasize that when patients have care on a 24-h basis their recovery is hindered. Treatment not founded on cooperation prevents people from taking responsibility for themselves. In this way service users gradually get disempowered. Some of the

nurses underlined the stigma towards people and nurses themselves.

“In the long run, the patients’ stay in the ward for a long time I think negatively affects them because they are comfortable, rested and stop taking initia- tives.” (L11)

Most nurses agreed that symptoms of compassion fatigue are related to the atmosphere of the working environ- ment and the distancing from people who face the dual burden of mental health problems and trauma. Many stressed the importance of the integrity of professional’s personality in order to cope with the difficult situation that he/she often has to face.

“You are very tired mentally. You do not want to talk to for two hours. Many times I come home exhausted, my head is buzzing, I need to calm down or a pill to sleep.” (L13)

“The psychiatric hospital can pressurize you psycho- logically, it can darken your soul as we say. Especially when you spend half your day looking at walls and locked doors. After the end of my shift I always try to forget everything and calm down. During the shift I often distance myself from patients to control my emotions and to protect myself psychologically.” (L15)

Theme 4: the revolving door The interviewees described the revolving door as a source of compassion fatigue for nurses and barrier to recov- ery for service users related to lack of care continuity after discharge and substance misuse during admission and after discharge. Sub-themes were (a) service users’ relapse and nurses’compassion fatigue, (b) lack of care continuity, (c) substance misuse, (d) limited resources and containment in the context of multidisciplinary team, and (e) guilt and fear of litigation.

Participants had the opportunity to describe their life inside and outside the hospital from the moment they first started working to the point of data collection. Frus- tration, tension and compassion fatigue were words that they used during the interviews. The biggest concern of several nurses was the re-admission of patients. Their comments showed their frustration and indignation when they had made a great effort to support a patient and he/she returned after a while. Some nurses stressed that lack of care continuity and collaboration with men- tal health professionals in the community hinders service users’ recovery.

“Sometimes I find myself trying hard for a patient. I feel so proud to see him/her leave and be happy

Page 7 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

and thank me for the care provided by the unit. I cannot explain the frustration I feel when I see him re-admitted. Most of the times my efforts are thwarted. A few times you get satisfaction. My big- gest fear is to see patients who have made progress coming back. I get upset and I feel all our effort are cancelled, especially when the patient is young … I started with dreams and hopes to change a lot but in the process I compromised. With time I realized that no matter how much soul I put in, there are not appropriate structures in community and help from the state. “(O1)

“The community is indifferent to service users’ effort to work on their recovery after being discharged. It does not have the proper infrastructure to receive these people and help them stand on their own feet. When there is no one in the community to care for them, to help them get their medication or support them at some point they will go back to the hospital to get help.” (L12)

Furthermore, the import of psychoactive substance users constitutes a considerable burden on the nursing work and appeared to provoke intense negative reaction to participants.

“I get very angry when I have patients who use and are in the unit just because they are users. We do not help them as long as the department is open and they continue to use.” (O8)

“What makes me tired is the re-admission of users. And they come in again if the department is open; if he/she wants to find his/her dose, he/she will find it, no one is stopping him/her”. (O9)

Inadequate patient activity during hospitalization is reported as a major disadvantage in patient’s recovery. Nurses report that there are not enough activities for patients during their treatment in the unit. Low staff levels and inadequate staff education on working with groups contribute to low levels of patients’ activities. However, in the open wards, the patient has the oppor- tunity to socialize with other patients during the day. Socialization works therapeutically and the contact with other patients covers to some extent the lack of activities and occupational therapy.

“The biggest disadvantage of the locked unit is that it is not fully staffed, it needs more staff, it needs occupational therapists … but also other profession- als so that the patients are involved in some activi- ties. They cannot lie down all day, nor watch TV all the time, it is not good for their mood but also for

their health. This way we will be able to work with patients within a nursing approach and create a therapeutic relationship with them. If this happens there will be less tension … ” (L10)

Several participants mentioned that lack of resources included staffing levels, support from managers, clinical supervision and employment of security personnel so as to ensure that nurses are not burdened with the locking and unlocking demands on unit entrance. Furthermore, they went on to emphasize that they felt exposed by the legal framework because they are considered accountable and burdened with lengthy legal proceedings that affect them in both their professional and personal lives. Par- ticipants often felt guilty during their everyday work life.

“You have a big share of responsibility because you are also locked in here and usually everything is the fault of the nurse on shift.” (L9)

Discussion Overall, in the present study we identified four types of doors in nurses’ experiences of their working environ- ments: the open doors, the invisible doors, the restraining doors and the revolving doors. Open doors symbolised trust, therapeutic opportunity, respect and shared deci- sion making. Leaving the door open appeared to be a simple but symbolic anti-stigma act of social inclusion against ‘othering’ social processes [47] related to archaic fears towards mental illness [48]. Similarly, invisible doors symbolized permeability of spaces in psychiatric care [18, 49] and appeared to satisfy symmetrically safety and care imperatives by collective containment of stress among staff [2]. In contrast, the restraining doors symbolised loss of control, social distance and stigma which seems to be echoed in the recent impact of lock-downs dur- ing the Covid-19 pandemic demonstrating that restric- tion of the crucial control over space [50] is associated with considerable increases in aggressiveness, violence, substance misuse, trauma and social isolation within families, groups and communities [51]. Furthermore, the restraining doors appeared to deprive nurses and ser- vice users of the necessary feeling of safety to engage in therapeutic encounters imposing an atmosphere of fear [52] potentially leading to further restrain of the latters’ crucial control over space, recalcitrance or abscondence [53]. Finally, the revolving doors appeared to symbolise service users’ rejection of the offered therapeutic envi- ronment and mental health professionals’ failure in their professional role sometimes personified, projected or attributed to service users in the expression ‘the revolv- ing door patients’. Furthermore, the revolving door was a source of deep feelings of frustration and indignation

Page 8 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

for nurses in both open and locked wards and was linked to similar attributions in both environments related to internal microsystem acute care aspects (limited staffing levels, support, recourses and activities for service users) as well as ‘locked doors’ in the community (limited care continuity, stigma, organisation of community mental health centres with limited number or no mental health nurses).

Trust given to people indirectly by the open doors contributed, according to participants, to therapeu- tic engagement and shared decision-making processes which in turn facilitated containment of mental health crisis and service users’ self-empowerment. In essence open doors were described as compatible with person- centered and recovery-oriented care while emphasis on ward atmosphere is similar to findings of previous research [8]. Furthermore, strenuous discussions were necessary to build communication bridges with people and their families as in the case study of Di Napoli and Andreatta (2014). Nonetheless, Di Napoli and Andreatta [54] described an acute care environment operating on a non-restraint protocol. In the present study, only one open unit operated on a non-restraint protocol [55]. All other open acute care spaces achieved containment of mental health crisis primarily through a multidisciplinary team approach and employed restrictive measures as a last resort.

As containment was embedded in the context of an acute ward, inevitably nurses had to be directive and coercive in some instances [56]. Björkdahl et  al. [57] found containment by control, coercion or force to be a therapeutic act. This may be because it was conducted on a psychiatric intensive care unit, where the most violent and aggressive individuals are cared for, hence control, coercion and force were necessary to maintain the physi- cal safety of some individuals. The rest of the literature spoke of containment by control as a last resort, and on the whole, it was considered non-therapeutic [7]. Tech- nical safety features strongly in measures to reduce risks of absconding or self harm. Nursing practice is influ- enced by ‘expert’ views, imposed at central institutional level, on particular risks to be avoided. These included: escape from the forensic wards of mental health patients subject to Ministry of Justice restrictions, cases of sui- cide involving shower rails or curtains failing to meet prescribed standards, or deliberate or accidental falls from unrestricted windows [58]. An emphasis on techni- cal procedures and rules to enhance security and safety for staff and service users and the general public, may make it difficult to provide recreational, psychothera- peutic, educational, spiritual and occupational therapies [59]. While a ‘safe place’ implies a reasonable degree of ‘technical safety’, it may, as importantly, embrace social,

psychological, and emotional safety, corresponding to the relational, social, and symbolic dimensions of therapeutic landscapes [58].

As regards the theme “invisible doors”, it denotes locked doors in acute care spaces which depict a physi- cal and a spiritual closeness between staff members and people that gives the latter peace [60]. It appears that an overall positive ward atmοsphere in a rich social environ- ment, caring and respectful informal interactions and openness between mental health professionals and peo- ple can cultivate a sense of freedom in an acute psychiat- ric care unit and render it ‘permeable’ [18, 49].

On the other hand, the restraining door descriptions include nurses’ recognition of and concern for people’s negative feelings and reactions such as tension, aggres- sion and physical injury which ultimately result in feeling uncontained and dissatisfied with care. Even when the door locking was considered as a necessary part of the work, discomfort with a time-consuming task blurring their professional role and hindering the building of ther- apeutic alliances was prominent and similar to that of other research [21]. Structural and cultural characteris- tics of the psychiatric hospitals of the present study [61], low staff levels and resources due to the Greek economic crisis of the last decade [42], previous traumatizing expe- riences of involuntary hospitalization [62, 63] may have also impacted the attempts of mental health nurses in the present study who strived to find space for therapeutic engagement.

Finally, according to participants the revolving doors which were mostly attributed to lack of care continuity after treatment, lack of activities and substance misuse during in-patient care appeared to be related to nurses’ feelings of frustration and compassion fatigue. Econo- mou [41] in a study of mental health professionals to severe mental illness in the two Psychiatric Hospitals of Attica reported that unfavourable attitudes to severe mental illness were limited to pessimism about recov- ery, difficulty in viewing people with mental illness as similar to other people and desire to keep distance in intimate encounters. Economou et  al. suggest that their findings, although aligned to international find- ings, may reflect staff burn-out or could be attributed to the chronic and usually revolving-door service users found in the psychiatric hospitals of Attica. Indeed, increased rates of secondary traumatic stress among psychiatric nurses and/or different mental health nurse profiles [14–16] may explain the present study participants’ distancing from people as a means to protect themselves [38].

Curtis et  al. [58] emphasized how responsibility for technical safety was being invested in the physical infra- structure of certain ‘places’ within the hospital where

Page 9 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

risks are seen to be ‘located’. Staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. If carers are to be seen as equal partners in the treatment and recovery of men- tal health service users, then as well as being aesthetically pleasing, safe and secure, it is important that the hospital environment be experienced as ‘permeable’ for them in their caring role [64]. Carers and family members need to have access to a variety of different settings within the hospital where they can spend time with a patient during their visit; private living rooms and garden spaces simi- lar to those enjoyed in the domestic family home [64]. A holistic understanding of the essential components of containment and therapeutic relationships in acute psychiatric care spaces and the symbolic dimensions of doors, may allow both staff and service users to reach their potential.

Limitations As regards the limitations of the present study, the sam- ple was drawn at two psychiatric hospitals only, and therefore may not be representative of nurses in Greece in general. Furthermore, interviews with nurses with sus- tained exposure to psychiatric practice in other hospitals, would allow comparison of perceptions and experiences which would not be influenced by professional socializa- tion processes at a particular hospital. Finally, although the sociodemographic and professional characteristics of nurses in this study were very similar to those of par- ticipants in other studies evaluating attitudes and char- acteristics of the nursing practice environment in other countries, the fact that other characteristics of wards’ culture were not included constitutes another limitation of the present research.

Implications If nurses experience ethical dilemmas related to their practice then there is a clear need to cultivate and retain a critical and analytical attitude towards the system they operate [2]. Clinical supervision may support mental health nurses at an individual and team level in this chal- lenging task. A multidisciplinary approach is of utmost importance in achieving continuity of care and contain- ment of personal suffering. Addiction and trauma educa- tion might also enable mental health nurses to provide care to people who exhibit challenging behaviours. Research into people’s perceptions of treatment and per- sonal recovery might inform service provision in open and locked wards. Finally, an urgent increase in mental health nurse staffing levels is required to avoid an increase in the use of locked doors and rigid demarcated spaces

in acute care wards. In a context of increased demand for services, funding difficulties and staff shortages fur- ther complicated by the recent COVID pandemic and the severe impact of the global financial crisis, open systems and permeability of mental health care spaces is crucial to resist the decline of therapeutic mental health landscapes, contain mental health suffering and instil hope, connec- tivity, meaning and empowerment of persons with mental health problems.

Acknowledgements All participants contributing to the study.

Authors’ contributions We would like to acknowledge that all authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. EM conceived and supervised the study and drafted the manuscript. E.K., E.F., P.M., E. S and I.P. contributed to planning, data collec- tion, preparation or critical review of the manuscript. All the authors read and approved the final manuscript.

Author information Department of Nursing, Faculty of Health and Caring Professions, University of West Attica, Athens, GreeceEvdokiaMissouridou, EmmanouelKritsiotakis, PolyxeniMangoulia. Department of Nursing Department, School of Health Sciences, University of Thessaly, Larissa, Greece.IoannaV. Papathanassiou, EvangelosC. Fradelos. Psychiatric Hospital of Attica, Athens, Greece IreneSegredou.

Funding No funding received for this study.

Availability of data and materials Τhe dataset supporting the conclusions of this article are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate Ethics approval and consent to participate in the study was given by the Psychiatric Hospital of Attica and the Psychiatric Hospital of Attica ‘Dromokaiteion’. All the methods in this study were in accordance to the Declaration of Helsinki. Participants provided informed consent prior to the interviews and their participation was voluntarily, and their information was kept confidential.

Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests.

Author details 1 Department of Nursing, Faculty of Health and Caring Professions, University of West Attica, Saint Spiridonos 12243, Egaleo, Athens, Greece. 2 Community Nursing Lab, Department of Nursing, University of Thessaly, Larissa, Greece. 3 Psychiatric Department, General State Hospital “Sismanoglio”, Marousi, Greece. 4 Psychiatric Liaison Unit, General State Hospital “Evangelismos”, Ath- ens, Greece. 5 Alcohol Treatment Unit, Psychiatric Hospital of Attica, Chaidari, Greece.

Received: 28 July 2021 Accepted: 9 November 2021

Page 10 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

References 1. Glover TD, Parry DC. A third place in the everyday lives of people living

with cancer: functions of Gilda’s club of greater Toronto. Health Place. 2009;15(1):97–106.

2. Bowers L, Alexander J, Bilgin H, Botha M, Dack C, James K, et al. Safewards: the empirical basis of the model and a critical appraisal. J Psychiatr Ment Health Nurs. 2014;21(4):354–64.

3. Moreno-Poyato AR, Rodríguez-Nogueira Ó, MiRTCIME. CAT work- ing group. The association between empathy and the nurse–patient therapeutic relationship in mental health units: a cross-sectional study. J Psychiatr Ment Health Nurs. 2021;28(3):335–43.

4. McWilliams N. Psychoanalytic diagnosis: understanding personality structure in the clinical process: Guilford Press; 2011.

5. Peplau HE. Interpersonal relations in nursing: a conceptual frame of refer- ence for psychodynamic nursing: Springer Publishing Company; 1991.

6. PeplauHE. Another look at schizophrenia from a nursing standpoint. In: Anderson CA, editor. Psychiatric nursing 1974 to 1994: a report on the state of the art St. Louis: Mosby-Year Book; 1995.

7. McAllister S, Robert G, Tsianakas V, McCrae N. Conceptualising nurse- patient therapeutic engagement on acute mental health wards: an integrative review. Int J Nurs Stud. 2019;93:106–18.

8. Efkemann SA, Bernard J, Kalagi J, Otte I, Ueberberg B, Assion HJ, et al. Ward atmosphere and patient satisfaction in psychiatric hospitals with different ward settings and door policies. Results from a mixed methods study. Front Psychiatry. 2019;10:576.

9. Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry. 2014;205(3):171–6.

10. Moreno-Poyato AR, Delgado-Hito P, Suarez-Pérez R, Leyva-Moral JM, Aceña-Domínguez R, Carreras-Salvador R, et al. Implementation of evidence on the nurse-patient raltionship in psychiatric wards through a mixed method design: study protocol. BMC Nurs. 2017;16:1–7.

11. Olausson S, Wijk H, Johansson Berglund I, Pihlgren A, Danielson E. Patients’ experiences of place and space after a relocation to evidence- based designed forensic psychiatric hospitals. Int J Ment Health Nurs. 2021;30(5):1210-20.

12. Edensor T. Illuminated atmospheres: anticipating and reproduc- ing the flow of affective experience in Blackpool. Environ Plann D. 2012;30(6):1103–22.

13. Gesler W. Lourdes: healing in a place of pilgrimage. Health Place. 1996;2(2):95–105.

14. Roviralta-Vilella M, Moreno-Poyato AR, Rodríguez-Nogueira Ó, Duran- Jordà X, Roldán-Merino JF. Relationship between the nursing practice environment and the therapeutic relationship in acute mental health units: a cross-sectional study. Int J Ment Health Nurs. 2019;28:1338–46.

15. Moreno-Poyato AR, Montesó-Curto P, Delgado-Hito P, Suárez-Pérez R, Aceña-Domínguez R, Carreras-Salvador R, et al. The therapeutic relation- ship in inpatient psychiatric care: a narrative review of the perspective of nurses and patients. Arch Psychiatr Nurs. 2016;30:782–7.

16. Moreno-Poyato AR, Roviralta-Vilella MR, El Abidi K, Bordera-Antequera S, Trivino-Briones SR, Ulldemolins-de Olives C, et al. Nursing practice envi- ronment in psychiatric units: a scoping review. J Psychosoc Nurs Ment Health Serv. 2021;1:1–8.

17. Andes M, Shattell MM. An exploration of the meanings of space and place in acute psychiatric care. Issues Mental Health Nurs. 2006;27(6):699–707.

18. van der Merwe M, Bowers L, Jones J, Simpson A, Haglund K. Locked doors in acute inpatient psychiatry: a literature review. J Psychiatr Ment Health Nurs. 2009;16(3):293–9.

19. Muir-Cochrane EC, Baird J, McCann TV. Nurses’ experiences of restraint and seclusion use in short-stay acute old age psychiatry inpatient units: a qualitative study. J Psychiatr Ment Health Nurs. 2015;22(2):109–15.

20. Bowers L, Haglund K, Muir-Cochrane E, Nijman H, Simpson A, Van der Merwe M. Locked doors: a survey of patients, staff and visitors. J Psychiatr Ment Health Nurs. 2010;17(10):873–80.

21. Haglund K, Van Der MEIDENE, von Knorring L, von Essen L. Psychiatric care behind locked doors. A study regarding the frequency of and the reasons for locked psychiatric wards in Sweden. J Psychiatr Ment Health Nurs. 2007;14(1):49–54.

22. Schneeberger AR, Kowalinski E, Fröhlich D, Schröder K, von Felten S, Zinkler M, et al. Aggression and violence in psychiatric hospitals with and

without open door policies: a 15-year naturalistic observational study. J Psychiatr Res. 2017;95:189–95.

23. Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, et al. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016;3(9):842–9.

24. Jungfer HA, Schneeberger AR, Borgwardt S, Walter M, Vogel M, Gairing SK, et al. Reduction of seclusion on a hospital-wide level: successful imple- mentation of a less restrictive policy. J Psychiatr Res. 2014;54:94–9.

25. Kalagi J, Otte I, Vollmann J, Juckel G, Gather J. Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals’ and patients’ view: a qualitative interview study. BMC Psychiatry. 2018;18(1):1–1.

26. Mckeown M, Scholes A, Jones F, Aindow W. Coercive practices in mental health services: stories of recalcitrance, resistance, and legitimation. In: Madness, violence, and Power; 2019. p. 263–85. University of Toronto Press.

27. McKeown M, Thomson G, Scholes A, Jones F, Downe S, Price O, et al. Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study. Sociol Health Illness. 2020;42(3):449–64.

28. Missouridou E, Zartaloudi A, Dafogianni C, Koutelekos J, Dousis E, Vlachou E, et al. Locked versus open ward environments and restrictive measures in acute psychiatry in Greece: nursing students’ attitudes and experi- ences. Perspect Psychiatr Care. 2020;2020:1–11. https:// doi. org/ 10. 1111/ ppc. 12699.

29. Missouridou E, Xiarhou P, Fradelos E, Kritsiotakis E, Mangoulia P, Kasidi E, et al. Nurses’ experiences of psychiatric care in acute care units with an open door policy. Adv Exp Med Biol. 2021;1337. https:// doi. org/ 10. 1007/ 978-3- 030- 78771-4_ 15. (in print).

30. Missouridou E, Resoulai A, Sakavara I, Fradelos E, Kritsiotakis E, Mangoulia P, et al. Psychiatric care in acute care units with locked doors: nursing care providers’ perceptions and experiences. Adv Exp Med Biol. 2021;1337. https:// doi. org/ 10. 1007/ 978-3- 030- 78771-4_ 12. (in print).

31. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual frame- work for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52.

32. Stylianidis S, Lavdas M, Markou K, Belekou P. The recovery model and modern psychiatric care: conceptual perspective, critical approach and practical application. In: Social and community psychiatry; 2016. p. 145–65. Springer, Cham.

33. Slade M, Williams J, Bird V, Leamy M, Le Boutillier C. Recovery grows up. J Ment Health. 2012;21(2):99–103.

34. Stylianidis S, editor. Social and community psychiatry: towards a critical, patient-oriented approach: Springer; 2016.

35. Apostolopoulou A, Stylianidis S, Issari P, Chondros P, Alexiadou A, Belekou P, et al. Experiences of recovery in EPAPSY’s community residential facili- ties and the five CHIME concepts: a qualitative inquiry. Front Psychiatry. 2020;11:24.

36. Kounenou K, Yotsidi V. Experiences of mental health service users on their empowerment and social integration in the community. Eur J Counsel- ling Psychol. 2018;7(1):165–80.

37. Stylianidis S, Peppou LE, Drakonakis N, Iatropoulou G, Nikolaidi S, Tsikou K, et al. Patients’ views and experiences of involuntary hospitalization in Greece: a focus group study. Int J Cult Ment Health. 2018;11(4):425–36.

38. Missouridou E. Secondary posttraumatic stress and nurses’ emo- tional responses to patient’s trauma. Journal of trauma nursing|. JTN. 2017;24(2):110–5.

39. Missouridou E. Cultivating a trauma awareness culture in the addictions. Curr Drug Abuse Rev. 2016;9(2):99–105.

40. MadianosMG. The adventures of psychiatric reform in Greece: 1999–2019. BJPsych Int. 2020;17(2):26–8.

41. Economou M, Lazaratou H, Ploumpidis D. Compulsory admissions in Greece: multifaceted action is required. Lancet. 2018;391(10129):1481.

42. Stylianidis S, Souliotis K. The impact of the long-lasting socioeconomic crisis in Greece. BJPsych Int. 2019;16(1):16–8.

43. Creswell JW, Clark VL. Designing and conducting mixed methods research: Sage publications; 2017.

44. Levitt HM, Motulsky SL, Wertz FJ, Morrow SL, Ponterotto JG. Recommen- dations for designing and reviewing qualitative research in psychology: promoting methodological integrity. Qual Psychol. 2017;4(1):2.

Page 11 of 11Missouridou et al. BMC Psychiatry (2022) 22:2

• fast, convenient online submission

•

thorough peer review by experienced researchers in your field

• rapid publication on acceptance

• support for research data, including large and complex data types

•

gold Open Access which fosters wider collaboration and increased citations

maximum visibility for your research: over 100M website views per year •

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions

Ready to submit your researchReady to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from:

45. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

46. Begley CM. Using triangulation in nursing research. J Adv Nurs. 1996;24(1):122–8.

47. Mannarini T, Salvatore S, Veltri GA. Identity, otherness, and psycho-cultural dynamics. In: Media and social representations of otherness; 2020. p. 1–16. Springer, Cham.

48. Jodelet D. Madness and social representations: living with the mad in one French community: Univ of California press; 1991.

49. Chow WS, Priebe S. Understanding psychiatric institutionalization: a conceptual review. BMC Psychiatry. 2013;13(1):1–4.

50. de Rosa AS, Mannarini T. Covid-19 as an “invisible other” and socio- spatial distancing within a one-metre individual bubble. Urban Des Int. 2021;1:1–21.

51. Mazza M, Marano G, Lai C, Janiri L, Sani G. Danger in danger: interpersonal violence during COVID-19 quarantine. Psychiatry Res. 2020;289:113046.

52. Power T, Baker A, Jackson D. ‘Only ever as a last resort’: mental health nurses’ experiences of restrictive practices. Int J Ment Health Nurs. 2020;29(4):674–84.

53. Voss I, Bartlett R. Seeking freedom: a systematic review and thematic synthesis of the literature on patients’ experience of absconding from hospital. J Psychiatr Ment Health Nurs. 2019;26(9–10):289–300.

54. Di Napoli W, Andreatta O. A" no-restraint" psychiatric department: opera- tive protocols and outcome data from the “opened-doors experience” in Trento. PsychiatriaDanubina. 2014;26(1):138–41.

55. Megaloeconomou T. Franco Basaglia’s influence on the Greek mental health system. Basaglia’s International Legacy: From Asylum to Commu- nity, vol. 28; 2020. p. 161.

56. Mackay I, Paterson B, Cassells C. Constant or special observations of inpatients presenting a risk of aggression or violence: nurses’ per- ceptions of the rules of engagement. J Psychiatr Ment Health Nurs. 2005;12(4):464–71.

57. Björkdahl A, Palmstierna T, Hansebo G. The bulldozer and the ballet dancer: aspects of nurses’ caring approaches in acute psychiatric inten- sive care. J Psychiatr Ment Health Nurs. 2010;17(6):510–8.

58. Curtis S, Gesler W, Wood V, Spencer I, Mason J, Close H, et al. Compas- sionate containment? Balancing technical and therapy in the design of psychiatric wards. Soc Sci Med. 2013;97:201–9.

59. Leader D. What is madness? London: Hamish Hamilton; 2011. 60. Johansson IM, Skärsäter I, Danielson E. The experience of working

on a locked acute psychiatric ward. J Psychiatr Ment Health Nurs. 2013;20(4):321–9.

61. Missouridou E. Exploring the past: mental health nursing in Greece. J Psychiatr Ment Health Nurs. 2009;16(1):18–26.

62. Walker S, Mackay E, Barnett P, Rains LS, Leverton M, Dalton-Locke C, et al. Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narra- tive synthesis. Lancet Psychiatry. 2019;6(12):1039–53.

63. Brophy L, Roper C, Grant K. Risk factors for involuntary psychiatric hospi- talisation. Lancet Psychiatry. 2019;6(12):974–5.

64. Wood VJ, Curtis SE, Gesler W, Spencer IH, Close HJ, Mason J, et al. Creating “therapeutic landscapes” for mental health carers in inpatient settings: a dynamic perspective on permeability and inclusivity. Soc Sci Med. 2013;91:122–9.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations.

BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under the CCAL, authors retain copyright to the article but users are allowed to download, reprint, distribute and /or copy articles in BioMed Central journals, as long as the original work is properly cited.