Experiential Techniques and Therapeutic Relationship in The Treatment of Narcissistic Personality Disorder: The Case of Laura

Received: 6 October 2022 | Accepted: 9 March 2023
DOI: 10.1002/jclp.23514
CASE REPORT
Experiential techniques and therapeutic

relationship in the treatment of narcissistic
personality disorder: The case of Laura
Antonella Centonze1 | Raffaele Popolo1 | Corinna Panagou2 |

Angus MacBeth2 | Giancarlo Dimaggio1
1
Center for Metacognitive Interpersonal
Therapy, Rome, Italy Abstract
2
Department of Clinical and Health Experiential techniques can be used to address maladaptive
Psychology, School of Health in Social
Science, School of Health in Social Science,
interpersonal patterns in patients with personality disor-
University of Edinburgh, Edinburgh, UK ders (PDs) as long as they are delivered minding about the
Correspondence
therapeutic relationship. We present the case study of
Antonella Centonze, Center for Laura, a 38‐year‐old woman presenting with covert
Metacognitive Interpersonal Therapy, Via
narcissism, generalized anxiety disorder, depression, and
Orazio 3 Rome, Italy.
Email: antonella100nze@icloud.com complicated grief treated with metacognitive interpersonal
therapy. Laura initially refused to engage in any experiential
work out of fear of being judged and abandoned by her
therapist. To navigate this therapeutic obstacle, the
therapist focused on exploring and eventually repairing
early alliance ruptures. Thereafter, Laura engaged in
experiential work, which helped her address her narcissistic
interpersonal patterns. After 2 years, Laura's symptoms and
narcissistic problematic behaviors decreased. This case
study can help us understand how experiential techniques
can be successfully used in PD psychotherapy as long as
attention to the therapy relationship is paid.
KEYWORDS
alliance/therapeutic alliance, grief, mental imagery, narcissistic
personality disorder, personality disorders
1656 | © 2023 Wiley Periodicals LLC. wileyonlinelibrary.com/journal/jclp J Clin Psychol. 2023;79:1656–1669.

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CENTONZE ET AL. | 1657
1 | INTRODUCTION
Treatment for personality disorders (PD), and more specifically narcissistic PD (NPD), requires a number of
specialized considerations due to symptom complexity and relationship patterns. Therapy for narcissism can be a
long‐term endeavor and focuses both on symptom reduction and relational pattern improvement. Accordingly,
support from a skilled clinician who has experience working with patients with PD is required.
Research has linked two dimensions of pathological narcissism: grandiose/overt and vulnerable/covert (Miller
et al., 2011; Pincus & Lukowitsky, 2010). However, individuals may present concurrently with outward grandiosity
and hidden vulnerabilities (Gore & Widiger, 2016; Pincus & Lukowitsky, 2010). Here, we focus only on covert
narcissism, a presentation characterized by hypersensitivity to criticism, lack of self‐confidence, and a tendency for
social withdrawal. Individuals with covert narcissism may be preoccupied with grandiose phantasies and may tend
to blame others for their own mistakes. Alternatively, they may be silently angry at those who may fail to recognize
their special qualities and give them admiration (Wink, 1991). In terms of internal processes, NPD involves
maladaptive self‐regulation, poor awareness of self‐states, and a lack of empathy (Ronningstam, 2020).
When treating the patient described in the current case study, our conceptualization of pathological narcissism
involved the following features: (a) problematic ideas about self and others; (b) limited awareness of one's own
beliefs and emotions; (c) tendency to intellectualize; (d) poor agency in acting according to goals and desires felt to
be one's own; (e) maladaptive cognitive and behavioral coping strategies; and (f) poor theory of mind and lack of
empathy (Dimaggio, 2022). These elements are at the root of impaired interpersonal functioning and pave the way
for comorbidity with anxiety and mood disorders. Several authors (Dimaggio, 2022; Ronningstam, 2020; Weinberg
& Ronningstam 2022) have identified core aspects of treatment that therapists need to remain mindful of to foster
engagement and prevent dropout. They argue, for example, that therapists should avoid engaging in power
struggles with their patients, overindulging in or, conversely, challenging grandiosity, and finally, never ignore
treatment‐interfering behaviors. Finally, NPD is often comorbid with symptoms, such as anxiety and mood
disorders (Weinberg & Ronningstam, 2022).
Metacognitive interpersonal therapy (MIT) utilizes experiential techniques that can be effectively used to target
interpersonal difficulties and other symptoms associated with Narcissism and other PDs. Techniques such as guided
imagery, chair‐work, role‐play, bodily exercises, and behavioral experiments can be used to help patients with PDs
better understand their relational patterns and eventually adopt more adaptive perspectives toward themselves and
others. Of note, growing evidence has shown that experiential techniques are both safe and effective (Dimaggio
et al., 2020; Hoppen et al., 2022). Indeed, empirically supported approaches incorporating experiential techniques
include emotion‐focused therapy (Greenberg, 2002), compassion‐focused therapy (Gilbert, 2010; Matos &
Steindl, 2020), schema therapy (Arntz & Jacob, 2013), EMDR (Shapiro, 2001), dialectical behavior therapy for
complex posttraumatic stress disorder (Bohus et al., 2020), and MIT (Dimaggio et al., 2020; Popolo et al., 2021).
The use of experiential techniques can be linked to significant psychotherapeutic change via multiple
mechanisms. First, individuals with PDs often have limited awareness of the beliefs and emotions that drive their
maladaptive behaviors. For example, a young man with NPD avoided meeting his friends to prevent exposure to a
shame‐arousing situation. Rather than admitting to feeling uncomfortable, the patient stated that “I prefer to spend
my time doing useful and interesting things instead of wasting my time on silly conversations.” Themes, such as
shame and fear of ridicule and judgment would appear only later on in therapy. Therefore, experiential techniques
can help patients increase their capacity for self‐observation. For example, guided imagery could help the
aforementioned patient explore and reflect on aspects of his experience and realize that he was actually “ashamed”
and not just “emotionally unavailable.”
Second, narcissism has been characterized by emotion regulation deficits which appear to be a transdiagnostic
feature across all PDs and may affect individuals' ability to engage in therapy (Dimaggio et al., 2017). For example, a
young man with NPD may experience intense shame when socially exposed and then lose control due to feelings
of shame. He may then resort to self‐regulatory strategies focusing on self‐protection such as contempt or
1658 | CENTONZE ET AL.
self‐enhancement with a view to reducing shame: “I felt uncomfortable because they were awful people and I cut
off all communication with them. I thought I was casting pearls before swine.” Experiential techniques, such as
grounding exercises (Lowen, 1958), guided imagery, or rescripting can be used in the treatment of PDs as they can
enhance individuals' ability to understand and regulate their emotions.
Third, individuals presenting with PDs, have maladaptive schemas indicative of negative beliefs about self and
others (Dimaggio et al., 2015, 2020). These beliefs can be associated with the way people predict that others will
react when their core emotional needs are expressed. For example, individuals with PDs and insecure attachment
styles may predict that their needs for care and safety will not be met or responded to if they seek out help.
Alternatively, driven by a dominant status motive, they may seek approval and admiration to validate their
grandiose self‐image and predict that they will be rejected or ridiculed. Early maladaptive schemas form as a result
of repeated experiences in childhood that become linked with negative beliefs about the self, thus governing
predictions about other people's reactions. For instance, individuals may have core self‐ideas such as “I am
unlovable” or “I am unworthy” following exposure to repeated adverse experiences, such as neglect or
hypercriticism.
Of note, patients with PDs may have positive ideas about their selves and others, but they are characterized by
the tendency to be volatile and affected by their negative mental representations of themselves and others due to
early adverse psychologically challenging experiences.
Experiential techniques can be utilized in therapy as a tool for changing dysfunctional interpersonal schemas.
They can help patients reflect on their inner world and realize that their self‐images represent subjective beliefs
about themselves without necessarily reflecting reality. Experiential techniques offer an opportunity to test their
ideas about themselves and others by acting differently. Moreover, these techniques can enable patients to
experience healthier aspects of the self, such as “I as capable,” “I as curious,” and then behave accordingly in real life.
While acting according to these different ideas about the self they often become able to recognize that others can
be supportive, benevolent, and caring.
Fourth, experiential techniques can be used to counteract maladaptive cognitive and behavioral coping
strategies which characterize PDs. Commonly, patients with PDs resort to maladaptive strategies to regulate their
emotions and fulfill their desires. Typical examples of maladaptive coping strategies employed to reduce suffering
but still with counterproductive effects include avoidance, perfectionism, submissive behavior, and cognitive
strategies such as perseveration or rumination. Experiential techniques can help patients learn strategies that can
promote more adaptive and healthier ways of regulating emotions and fulfilling goals. For example, by using therapy
to model the challenge of asking for a date, rather than using avoidance individuals can regulate their anticipatory
anxiety using mindfulness‐based strategies or can reduce self‐criticism via engaging in chair‐work. Therefore,
experiential techniques can be key features of any successful management plan in therapy for PDs and can lead to
positive outcomes.
Nevertheless, for experiential techniques to be effective, clinicians need to be attuned to the patients'
emotional experience and ensure both therapist and patient understand the rationale for the use of these
techniques. This understanding appears to be a prerequisite for the clients' acceptance of to use of experiential
techniques. Moreover, clinicians need to monitor what is happening in the therapeutic process, for example, what a
patient is experiencing during an imagery exercise; on the one hand, negative effects can surface, and in that case,
the therapist needs to help the patient regulate them; often positive effects and ideas about the self come to the
fore and the therapist needs to help patients recognize their presence and savor them, instead of letting them vane
as usual.
Following from this in‐session monitoring and regulation of the therapeutic relationship is crucial to maximize
the effects of experiential techniques and prevent problems from occurring. This is particularly important in the
treatment of PDs, as the way patients perceive their therapist is guided by their maladaptive representations of and
beliefs about self and others. For example, if a patient has the belief that she or he is weak and vulnerable, and
predicts that the therapist will subjugate her, the use of experiential techniques will be unlikely to have a positive
outcome.
A positive therapeutic relationship is essential in helping the patient connect with the therapist and trust the
therapeutic process. Of note, the use of therapeutic techniques may affect patient–therapist relationships in many
different ways. For instance, a patient may see the therapist as being warm, supportive, and trustworthy: “She is
able to connect with my pain and help me process it without fear.” However, the power of experiential techniques
to strengthen the therapeutic alliance is rarely discussed in the literature. The use of experiential techniques can
indeed, foster a deeper sense of connection and trust, as patients realize that they are not alone in the process of
facing painful or traumatic scenes (e.g., during imagery rescripting).
On the other hand, a patient may have a belief about the therapist which is consistent with their dysfunctional
schemas and negative beliefs about the self and others. This patient may think for example: “I am too vulnerable to
go through this,” “My therapist is taking control of the process and I feel powerless,” “If I don't manage to perform
this exercise, my therapist will criticize me and be disappointed.” This kind of internal process may lead to a
therapeutic alliance rupture that needs to be recognized and resolved.
Therapists employing experiential techniques need to monitor and be constantly mindful of the therapeutic
relationship (Centonze et al., 2021). Given that patients with PD may have multiple maladaptive schemas, even if a
therapist may attempt to use experiential techniques once a positive therapeutic alliance has been established, they
may still trigger the patient's maladaptive schemas. For example, patients may think that the therapist is judgmental
and patronizing and that they are vulnerable and inadequate while a minute ago they were feeling appreciated and
understood (Centonze et al., 2021; Dimaggio et al., 2020). If the therapist is not mindful of the potential for ruptures
in the therapeutic relationship then experiential techniques may be suboptimal or even detrimental to therapy.
Therefore, therapists adopting experiential techniques need to focus on any potential alliance ruptures and repair
them (Muran et al., 2021; Safran & Muran, 2000).
1.1 | The alliance/experiential techniques interface
The use of experiential techniques may impact the therapeutic relationship in two ways: (a) it can cause an alliance
rupture, and (b) it can strengthen the therapeutic alliance.
Alliance ruptures can be defined as disagreements on therapy goals and tasks or as relational difficulties
between the patients and the therapists (Bordin, 1979; Safran & Muran, 2000). Markers signaling the presence of
an alliance rupture are usually divided into two types: withdrawal and confrontation (Muran et al., 2021; Safran &
Muran, 2000). Withdrawal markers include increasing emotional distancing, prolonged silence, coming late to the
session without realistic motives, abruptly shifting topics, and refusing to engage in in vivo exposure or to perform
homework. Confrontation markers are actions or attitudes against the therapist. For example, they can appear as
overt criticism, such as questioning the treatment rationale, complaining about the therapist's actions or attitudes,
and sarcasm, as well as nonverbal signs of criticism and so forth.
Take the example of a therapist who has asked a patient if they were willing to perform an exposure task in
between sessions. This has been agreed upon when drafting the therapy contract, but now the patient refuses to
comply with the task and looks irritated. There is the chance that the patient has viewed the therapist as being
domineering and bossy and so they react by defying what they perceive to be an act of dominance in a
confrontational way, that is either by criticizing the task itself, or the therapist. Alternatively, the patient may display
withdrawal markers. They may overtly comply with the task but experience resentment which they do not reveal.
Consequently, they perform the homework task but with no real involvement while appearing distant, passive, and
devitalized in the next session.
On the other hand, when the patient agrees on a task, such as chairwork or behavioral experiments, this can
strengthen the bond element of the therapeutic alliance. Once a task has been successfully completed, patients may
experience feelings of trust, as well as gratitude and appreciation toward their therapist. For example, after an
imagery rescripting exercise a patient said: “This imagery work has given me a new perspective and helped me see
things differently. I feel this has been very helpful. I managed to experience emotions. I feared they would be
overwhelming. It is true that they were intense, but I could tolerate them much more than I previously thought.”
We tentatively suggest a classification of five potential patterns of therapeutic alliance that can be used to
explore alliance challenges in the context of psychotherapy, and identified in the case example.
1. The suggestion to use or the actual application of a technique may lead to an alliance rupture that the therapist
will need to explore and resolve.” For instance, the patient may be reluctant to engage in a specific experiential
technique such as chairwork, behavioral experiments, and role‐play, because they feel vulnerable following the
therapist's attempt to use a technique (or even suggestion to use it). Discomfort may prompt the patient to say
that they are not keen to use specific techniques or that they do not feel that the therapist respects them, as
they do not prioritize talking about their painful emotions during the session. The patient may also feel
embarrassed to participate in role‐playing and may express anger (triggered by the fact that they have been
asked to do something that they do not want to).
In parallel, the therapist may feel guilty, ashamed, worried, or inadequate at the idea of having hurt the
patient. The therapist may also feel frustrated and annoyed viewing the patient as unwilling to engage,
unmotivated, uncooperative, and unfair.
If these kinds of rupture are not dealt with, there is a risk for further deterioration, therapeutic stalemate, or
even dropout. Overall, a maladaptive interpersonal cycle (Safran & Muran, 2000) in which the patient and
therapist reinforce each other negative views of the other is created and maintained. In these instances, we
advise the therapist to take a step back and avoid using or suggesting the use of experiential techniques,
focusing instead on the therapeutic relationship. At the same time, the therapist can renegotiate the therapy
contract and work with the patient on the cocreation of alternative routes to the desired goals.
2. The patient is willing to engage with and starts using the technique recommended by the therapist. However,
they may experience distressing feelings or thoughts, and memories. This may result in alliance rupture as the
patient's trust in the therapist diminishes.
3. The therapist's suggestion to use the technique and its enactment may generate transient negative feelings,
such as anxiety or shame; and the patient may start forming negative appraisals about their therapist. The
patient may view their therapist as being judgemental, domineering, and harmful. However, distressing emotions
and thoughts may be tolerable. Accordingly, the patient does not disengage and uses the techniques suggested
by the therapist. They may discover then that these techniques albeit emotionally intense can be positive as
well, and that the therapist is supportive, validates their affective experience, and helps them regulate their
emotions. Therefore, after a momentary rupture, the therapeutic alliance is resolved.
4. The application of experiential techniques can also boost the therapeutic relationship. This element is often
neglected in the literature and in therapy conversations among colleagues, as clinicians tend to be more focused
on alliance challenges and potential ruptures due to the use of experiential techniques. However, the opposite
may happen. For example, a patient with a maladaptive attachment may be reluctant to seek help for their
difficult emotions as they predict that others will respond with anxiety. The therapist may use bodily‐based
emotion regulation techniques, remaining calm when the patient displays distressing emotions. Modeling
calmness and help is contrary to the patient's predictions and can be a powerful corrective experience
(Alexander & French, 1946).
5. Experiential techniques can also help build trust in the therapist as well as the therapeutic process. This differs
from the previous point as, in the first instance, it is the therapist's attitude and the use of the technique at the
moment that may strengthen the therapeutic alliance or create a rupture due to patients' maladaptive
interpersonal patterns. In this situation, what happens during the application of the technique is less relevant. A
patient may be skeptical about the technique, but they then realize that the technique enhances coping skills
and leads to symptom reduction. This awareness leads to also seeing the therapist in a more positive light, as
someone who is trustworthy and supportive.
The following case study illustrates how technique and therapeutic relationship interact in the treatment of a
patient suffering from covert narcissism generalized anxiety disorder (GAD), depression, and complicated grief.
The patient has been treated with MIT (Dimaggio et al., 2015, 2020), a therapeutic modality where the
interplay between using experiential techniques and paying attention to the therapeutic relationship is crucial. The
intervention was tailored to NPD according to Dimaggio (2022). MIT for NPD aims to increase self‐reflection and
reduce intellectualizing; counteract the impact of negative ideas about self and others by forming healthier and
more flexible beliefs; support the ability to act according to one's own goals and desires and promote healthier ways
of dealing with suffering. Later in therapy, there is also the goal of developing a deeper understanding of others.
To reach these goals, MIT aims to address each one of these different elements. Therapeutic components
include the following: (1) working through the therapeutic relationship; (2) constantly negotiating and monitoring
the therapeutic contract, in particular making sure that therapy goals and tasks are shared and agreed upon; (3)
fostering a sense of curiosity, playfulness, and agency about the patient's own goals; (4) using behavioral
experiments to address maladaptive behavioral coping strategies and promote the use of more adaptive ones; and
(5) applying a set of experiential techniques, such as guided‐imagery and rescripting, role‐play, and bodily work
(Dimaggio et al., 2020).
2 | C ASE ILLUSTRATIO N
Here, we present the case of Laura, focusing on the interplay of working through the therapeutic relationship and
using experiential techniques. Laura is a 38‐year‐old physician, presenting with GAD, complicated grief, and covert
pathological narcissism. During therapy the suggestion to use experiential techniques generated two ruptures,
corresponding to point 1 (above) of the therapeutic relationship/experiential technique interplay. Working through
the therapeutic relationship and repairing alliance ruptures facilitated the understanding of Laura's inner states and
helped her become more aware of her maladaptive coping strategies. As we will see, especially in the second
vignette, the technique strengthened the therapeutic relationship. Therapy was delivered by the first author (A.C.)
who is also an MIT trainer.
2.1 | Presenting problem and client description
Laura presented with GAD, depression, and complicated grief. She decided to start therapy to get support for her
anxiety and low mood following the loss of her husband, a successful businessman, who died from cancer. They had
a very strong relationship and the pain of loss felt overwhelming. Laura's partner died about 10 months after
diagnosis. A month after his death Laura was diagnosed with colon cancer and underwent surgery and
chemotherapy. The cancer treatment Laura received had a positive outcome. However, Laura developed severe
anxiety after the treatments ended which made her seek support from a therapist.
She described flashbacks related to the death of her husband, insomnia, and frequent nightmares. She was
frequently angry, but as her anger was egosyntonic she did not consider it to be a problem to be addressed. Laura
believed that others were wrong, shallow, and disrespectful while she habitually indulged in self‐victimization. She
was hypersensitive to criticism, lacked self‐confidence, and had the tendency to socially withdraw. Furthermore,
Laura displayed a grandiose sense of self and experienced herself as superior. For example, she would judge or
criticize others when noticing their mistakes, whilst experiencing a silent rage whenever she felt that people did not
recognize her special qualities or accomplishments/these aspects were evident early on in therapy, precipitating a
diagnosis of vulnerable narcissism (Pincus & Lukowitsky, 2010). The above personality traits affected alliance
dynamics, making it difficult to focus on her therapy goals.
Laura experienced anxiety but found it hard to verbally articulate her feelings. More specifically she
experienced a sense of agitation and alertness which was more intense in the morning. She also experienced muscle
tension, tachycardia, and difficulty concentrating as well as tension headaches. Following an anxiety episode Laura
would experience feelings of sadness and despair, and she had the tendency to cry a lot. In terms of her
professional life, Laura was a workaholic, with perfectionism and procrastination forming a further source of
anxiety. She had the tendency to worry about being inept and unworthy, as well as feeling embarrassed or
humiliated because of her unworthiness. In terms of her personal life, Laura reported having a good relationship
with the few friends that she liked. More generally, she had a tendency to blame people for being incompetent,
shallow, inept, or immoral. As a consequence, she preferred to spend time alone, stating “It's better to live in a world
where I can keep jackasses and jerks at bay.” Laura also reported that she often argued with her managers at work.
She described them as being incompetent and reported feeling compelled to take the responsibility for their
mistakes.
Laura was the eldest of two daughters. She described her parents as incapable, immature, self‐absorbed, and
problematic. Her father suffered from lifetime hypochondriasis. Laura described him as selfish and domineering.
Laura's mother was reportedly chronically depressed, cold, and judgmental. Laura's sister never managed to become
independent and live on her own. At the age of 35, she was not working and still lived with her parents. Laura
reported being protective toward her sister and feeling sorry for her. She described feeling compelled to take care
of her sister and parents as she deemed them unable to look after themselves. Laura described often getting angry
because of feeling obliged to intervene and solve family problems. Furthermore, she described her relatives as being
superficial and had the tendency to blame them for their shallowness. Moreover, she believed that her family
members would suffer “because of their own stupidity.” Therefore she felt she could not ignore family problems and
had to be involved, leading to a sense of overwhelm.
2.2 | The therapeutic relationship
From the very first sessions, Laura presented as emotionally detached, cold, and cynical. The therapist sometimes
observed that Laura was not engaging in therapy, and was reluctant to collaborate with the therapist, despite self‐
referring to treatment, leaving the therapist feeling frustrated. The therapist noticed that Laura often appeared
dismissive and made sarcastic remarks about her therapist's interventions. She would change her attitude saying,
for instance, “… Doctor, I do respect you. I know that you are smart, very smart actually. Please do not take it
personally, but you know how things are… I have little faith in therapy in general.” At these moments the therapist
would feel useless and helpless, struggling not to disengage.
Laura could appear to be sincerely cooperative and compliant. However, when Laura became sarcastic or
appeared to be overly compliant, the therapist would try metacommunication to reflect on the therapist–patient
interaction. The therapist's attempts to reflect generally failed as Laura blushed and became withdrawn. On one
occasion, the therapist noted: “Laura, it seems to me that my intervention made you blush, and you seem to have
experienced some emotion. Am I right to be thinking this way? Would you like to talk about it?”
These remarks would trigger a response such as: “No Doctor, I'm not blushing, it's just hot flashes. Nothing is
happening. I don't feel anything.” Laura would come across as angry when she made these remarks.
The therapist would suggest that it would have been better if they postponed any discussion about what was
happening in their relationship until the next session. Laura would agree with this. The therapist noted that part of
her seemed to rely on her therapist. The therapist and Laura agreed to reflect on what was happening in the here
and now, and discuss aspects of their therapeutic relationship, while also considering the initial therapy goals.
2.3 | Case formulation
Laura experienced painful emotions when she thought that others were not responsive toward her need to be
looked after. Since her childhood, her parents reportedly have always been absent when she needed help and
attention. She noted that even during her recent chemotherapy her parents did not visit her. She shared with the
therapist that they told her: “We can't come to see you. It's a shame that we live far away but there is nothing we
can do about it.”
Consequently, Laura would feel angry and had the tendency to ruminate about her parents' lack of caring
attitude. Only later in the therapy did loneliness and sadness surface, together with the idea of being unlovable.
Laura felt that her husband was the only person who really cared for her, so she depended on him for support.
Laura struggled profoundly with his loss which triggered feelings of helplessness and loneliness.
Laura's sense of being unlovable also led her to crave approval from others. She sought high social status, as
well as her parents' validation and praise, setting exceedingly high standards for her performance and developing
perfectionistic tendencies. She stated, “If I can't receive love and care from others, I will get the best grades at
school so that people will notice me and praise me.” Sometimes she would feel indeed acknowledged and
appreciated for her efforts and achievements which strengthened her belief in excellence. Nevertheless, she often
did not feel appreciated. Laura also described her parents as being judgmental. This must have led to the formation
of negative core beliefs about herself, such as being unlovable and worthless. Her insatiable quest for self‐worth
and approval led to her feeling unworthy, having a negative self‐image, and believing in being unlovable and alone.
Laura could be quite judgmental when she felt unappreciated. She would often say: “They don't give me what I
need because they are stupid.” Furthermore, Laura tended to avoid having close relationships to protect herself
from experiencing a lack of appreciation and acknowledgment. Of note, all these patterns are typical of NPD
presentations (Dimaggio, 2022).
The presence of the two opposite self‐images, that is, being excellent and being unworthy, was one of the
reasons for her interpersonal problems at work. Having spent her teenage years trying to be “the good girl”, as an
adult she tried to gain scientific recognition. However, every time she has to write a paper, her beliefs of inferiority
were triggered and she feared people's negative judgment, leading to procrastination and avoidance. The more she
avoids, the more she became afraid of not being able to accomplish the task. The resulting cycle of worry about the
way her paper will be perceived and evaluated diminished her ability to concentrate and affected her performance.
2.4 | Course of treatment
During the first sessions, at Laura's request, the main focus of therapy was the loss of her husband. Laura did not
consider her own cancer diagnosis a problem stating “I am not concerned about myself. Being sick does not cause
any emotional suffering to me. I only have painful feelings about the loss of my husband.”
Laura described the relationship with her partner as unique and unprecedented. She spoke about him as the
person who had come into her life at the right time after a series of failures. However, she was unable to
comprehend the finality of her husband's loss and experienced the same painful emotions, depression, and anxiety
2 years after his death.
During the day Laura would ruminate about how the world was unfair and how her life was ruined. She had
frequent flashbacks to the last days before her husband died, and the funeral. She would feel agitated, tearful, and
unable to describe her feelings and thoughts. Therefore, therapy initially focused on increasing her capacity to
identify and describe her inner states, decreasing rumination, and promoting better emotion regulation strategies.
The therapist encouraged Laura to focus on painful images surrounding her husband's death, with a view to
addressing rumination as well as helping her identify and regulate her distress related to these images. At MIT,
therapists adopt a combination of techniques, such as attention retraining to tackle rumination, and guided imagery
and rescripting as well as bodily exercises to help patients regulate somatic arousal (Dimaggio et al., 2020; Ottavi
et al., 2021). The use of these techniques may bring about alliance challenges.
Whilst narrating an incident related to grief, Laura experienced distressing feelings that she could not control.
She described these feelings as “emotional pain”. The therapist asked Laura to stand up to use a grounding exercise
that would help her regulate her emotions, involving deep breathing, focusing the attention on the feet resting on
the floor, and creating a soothing sensation in the body (Lowen, 1958). The therapist asked Laura to take a deep
breath while bringing her attention to the areas of contact that her feet had with the floor. Laura suddenly stopped
and with a forced smile said: “I'm not good at these things. These exercises are not good for me.” The therapist
noticed that Laura appeared to be embarrassed and showed contempt while they were doing the exercise. The
therapist decided to stop the exercise and asked Laura what was going on.
T: “Is this exercise causing you any difficulties? How are you feeling about me now?”
Laura blushed when she heard this, and said:
L: “Doctor, I don't want to do this exercise, it seems pointless.”
Laura found it hard to articulate her thoughts, let alone her feelings. She became emotionally detached, cold,
and hopeless. Laura noted that she was feeling embarrassed and ashamed, and thought that the therapist was
overly demanding and judgmental. She explained that on the one hand, she felt compelled to do the exercise to
please her therapist but on the other hand, she was not keen to do the exercise out of embarrassment. On further
discussion, Laura noted that if she continued doing the exercise despite her will, it felt as if she was repeating a
lifelong pattern of being the good girl to get acknowledgment and appreciation.
T: “Laura, I can see that you feel the urge to comply with people's desires in order to please them. If
this is the case, it is great that you managed to say ‘no’. However, I have the feeling that you are
trying to avoid negative feelings, and we have seen that this is an entrenched habit of yours, isn't it?”
Laura appeared calmer after the therapist stopped the exercise, potentially as she felt heard and understood. At
that point, the therapist asked Laura to reflect on how she felt when she refused to do the exercise. The therapist
speculated that Laura was probably trying to refrain from the tendency to please others by refusing to do the
exercise. Hence, the therapist encouraged Laura to reflect on what had happened and how she had felt.
T: “I am wondering whether we could slow down a bit and think about what happened the moment
you said you did not want to do what I had asked you to?”
Laura nodded but immediately her facial expression changed, again becoming cold and distant. This was a signal
that her maladaptive interpersonal schema was activated creating challenges in the therapeutic alliance.
L: “Well I don't know, it's always the same thing. Well… if I focus on what I felt a few minutes ago. it
will feel like having a kind of contraction in my stomach. I am afraid that I will feel ashamed and
inadequate…. but there is more to this. it's… fear? Yes, it's fear. I am afraid about what may go wrong
if I don't do what people expect from me.”
T: “Good, please focus a bit on your fear… what does it remind you of? Is this something you
experienced in the past?”
L: “Hm… a sense of being alone and abandoned. If I'm not good, people will reject me. It's a loneliness
I'm familiar with. I know it, it is mine.”
T: “So Laura, let me summarize what I think is happening to make sure I got it right. It seems to me
that you need to be acknowledged and appreciated to feel adequate. You have learnt that you have
to be the good girl and please other people. But there seems to me more than that. You noted that
you are afraid that you will be abandoned if you do not do what has been asked from you can you tell
me please if you are afraid that I will abandon you if you do not the right thing, or what is excepted
from you.”
L: “Perhaps… yes, I think that's true.”
As soon as Laura came to this realization she again became emotionally detached, cold, and distant while
objecting to anything the therapist was suggesting.
L: “I don't need anyone. Why don't we forget about these games, it would be better.”
The therapist was surprised because Laura on the one hand acknowledged that she was protecting herself from
her therapist's abandonment, which was a sign of increased awareness and deeper understanding of her
maladaptive patterns. However, despite this realization, she was reacting to protect herself from her therapist's
perceived rejection.
Laura became defensive, which made the therapist feel criticized. At this point, the therapist realized that
Laura's mind had reverted with her well‐entrenched maladaptive patterns starting to take precedence. This would
have contributed to an alliance rupture (Muran et al., 2021). However, Laura managed to self‐regulate and stated
that she would not do the task.
The therapist agreed to stop doing the experiential activity and focus on a new goal: noticing when she really
needed others or when she was pushing them away. The aim of this exercise was to draw her attention to incidents
that would help explore attachment‐related experiences. This exercise still helped Laura become aware of her
loneliness but also gave the signal that it was safe to discuss this in therapy. Laura realized that although feelings of
loneliness were related to the loss of her husband she had them since her childhood. Following this session and a
further 3 months of therapy, a new memory emerged in reference to her relationship with her parents.
Laura was ill and had to undergo treatment. During that time her parents were in the same city but did not
come to help her while a couple of friends were there to support her. On the day Laura was discharged from the
hospital after her surgery, her mother called her whilst Laura was in the car with a friend. The call was brief and
when it ended Laura punched the car's window. The therapist tried to reflect on the incident trying to understand
Laura's feelings. Laura explained that she was feeling angry toward her parents, but she did not want to explore this
further. Her facial expression showed that she was feeling angry and contemptuous.
The therapist then suggested that they use a guided imagery activity that would help Laura identify what her
feelings were before experiencing anger.
L: “Let's talk about it another time doctor! What is there to understand? My parents are idiots! This is
a fact, and I don't see any point in talking about this. Could you help me change them? Obviously not!
I live just fine without them and without anyone else to be honest. I have lost my faith in humanity. I
don't think you can do anything about it.”
Laura blushed and seemed to be very angry. The therapist felt helpless and inadequate but at the same time
realized that every time Laura felt lonely and hurt she would see herself surrounded by stupid and useless people,
including her therapist. Again an alliance rupture had occurred. The therapist suggested using an experiential
technique thinking that it would have been useful. However, this triggered a rupture in the working alliance. The
therapist has had signals of change that made her trust she could apply an experiential technique again, which
triggered a micro alliance rupture. This time the therapist was prepared for the alliance rupture and tried to repair it.
The therapist remained unaffected by Laura's criticism and invited Laura to explore the alliance rupture.
T: “Laura, let's stop for a moment and think about what has happened just now? I'm very interested
to hear what you are feeling. When I suggested using this exercise what kind of feelings were
triggered in you? How did you feel?”
Laura seemed to be more regulated and remained capable of self‐exploration.
L: “I am angry. I feel your intentions are nice but what can you do? A part of me is angry with you as
well. My loneliness is matter of fact and neither you nor anyone can do anything about it. I don't
even want to discuss this further because then I know that this will make me feel worse.”
T: “So, Laura do you think it is pointless to try? You seem to believe that no one can help you and
that neither can I. This feeling must be painful.”
L: “Well, it seems to me that your tools are useless and that there is nothing you can do for me. This
is my situation. This make me so angry that I would rather change subject. Otherwise I will feel sick.”
Laura seemed to be unable again to access the painful emotions she experiences when she needs support, but
she thinks she cannot have it. Again, the therapist felt helpless, frustrated and inadequate.
T: “Laura I would like to help you, but I don't know how to do this. I feel I can't get close to you.”
L: “I'm sorry but this is not my problem.”
The therapist then admitted to having experienced emotions like loneliness and hopelessness in the past. The
aim of this self‐disclosure was to make Laura feel heard and understood.
T: “I think I know how you feel Laura. It made me angry as well in the past when I felt that others
were not there when I needed them. We can't depend really on anyone, so we have to rely on
ourselves. I feel that anger masks a deeper sense of loneliness and sadness that is really hard to
tolerate. At least this has been my experience.”
The therapist smiled when sharing this with Laura trying to convey a sense of calmness and hope. Laura looked
the therapist in the eyes and appeared to be connected again.
L: “Doctor, what should I do with this sense of loneliness?”
T: “That is a good question. What about setting this as our therapy goal? I mean we could put our
head together and think about what we could do when we feel alone. This may sound difficult, I
know, but shall we give it a try?”
Laura nodded. During this interaction, when the therapist suggested using an experiential technique Laura
became absorbed into her maladaptive interpersonal pattern thinking that no one can help her when she was in
need, thus rupturing the working alliance. The therapist self‐disclosed experiencing similar emotions and thoughts
with a view to resolving the rupture. Laura felt reconnected with her therapist. The therapist's self‐disclosure
facilitated rapport, and strengthened and rendered the therapeutic relationship more egalitarian. In other words, it
reduced the power imbalance between the patient and therapist. This probably helped Laura realize that her
therapist has similar feelings and thoughts and was not going to judge or criticize her.
2.4.1 | Laura
Following this session, Laura was more willing to use experiential techniques such as guided imagery and bodily
work. These techniques were utilized to address Laura's feelings of loneliness and maladaptive interpersonal
schemas.
Laura became more motivated and willing to use experiential techniques to access emotions and memories,
hoping for healing and growth. At the same time, she started viewing her therapist as someone who was genuinely
interested in her and wanted to help. This corresponded to Pattern 4 of the relationship/technique interaction
described earlier. These techniques also helped reduce her distress, further strengthening the bond with the
therapist and the therapeutic process, corresponding to Pattern 5 of the relationship/technique interaction.
The quality of the therapeutic relationship dramatically improved. Laura seemed to feel more connected and
less resistant. She opened up and was more willing to share her experiences in a nondefensive way. Laura would
make jokes or send text messages with funny memes or photos of her dog. Moreover, Laura's thoughts about
people not being there for her shifted. She started to believe that people could be there for her if she needed them.
Alongside this shift, her anger toward her therapist vanished and her faith in the therapeutic process increased.
2.5 | Outcome and prognosis
Laura was in therapy for 2 years. Over the course of treatment, Laura made significant improvements with
decreased anxiety symptoms. At the end of therapy, she did not display intense emotions and preoccupation with
thoughts and memories of her deceased husband. Furthermore, Laura became more aware of her inner states when
she realized that feeling lonely and inadequate was stemming from her developmental history.
Despite this realization, she would still sometimes resort to defensive mechanisms to protect herself from
experiencing emotional pain. For instance, she would still experience anger and contempt when she was feeling that
other people were not there for her.
However, there was a marked improvement in her self‐esteem and confidence as she was able to gain access to
healthier self‐images such as being adequate. She started feeling less lonely while her tendency to see others as
neglectful and judgmental significantly reduced. This in turn helped her to sustain more contact with others and her
tendency to social withdrawal was markedly reduced. Furthermore, she managed to reflect on her overdeveloped
sense of responsibility toward her family and no longer thought she had more responsibilities than her sister. At the
end of therapy, she was not seeking a new romantic partner.
In the work domain, perfectionism and performance anxiety were no longer prominent. Laura stopped
displaying workaholic tendencies and was able to meet deadlines. She started pursuing goals based on her own
personal values rather than status attainment and prestige. She decided to change her job, based on her interests
and spend more time with her dog. These choices were born out of her need to gain a stronger sense of agency.
Laura became aware of her perfectionistic thoughts and tendencies. She learned to recognize what she really
wanted and carry it forward without aiming to please others or holding excessively high personal standards that
were unrealistic or overly demanding.
3 | C L I N I C A L P R A C T I C E S AN D S U M M A R Y
Therapists using experiential techniques for the treatment of pathological narcissism may face challenges and
ruptures in the therapeutic relationship. The current study explored these issues and showed that therapists can
still use these techniques as they are an important vehicle for change as long as they are mindful of possible alliance
ruptures and focus on resolving them. Working through the patient–therapist relationship helped the patient
identify maladaptive interpersonal patterns and beliefs and challenge the view that others would not be there for
her if she needed them. This case study demonstrated that using experiential techniques alongside working through
ruptures in the patient–therapist relationship can help address emotion regulation deficits, whilst also increasing
trust in the therapist. This may eventually strengthen the therapeutic alliance.
Further exploration is recommended to identify how the combination of experiential techniques, such as
guided imagery, bodywork, and behavioral experiments, and working through the relationship can increase the
effectiveness of treatment for NPD and PDs in general. This combination may ultimately help improve the
psychological treatment of narcissism.
CO NFL I CT OF INTERES T S T ATEME NT

The authors declare no conflict of interest.
ORCID
Antonella Centonze http://orcid.org/0000-0002-8272-8024
Raffaele Popolo http://orcid.org/0000-0003-4903-8977
Giancarlo Dimaggio http://orcid.org/0000-0002-9289-8756
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How to cite this article: Centonze, A., Popolo, R., Panagou, C., MacBeth, A., & Dimaggio, G. (2023).
Experiential techniques and therapeutic relationship in the treatment of narcissistic personality disorder: The
case of Laura. Journal of Clinical Psychology, 79, 1656–1669. https://doi.org/10.1002/jclp.23514

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Received: 6 October 2022 | Accepted: 9 March 2023

Experiential techniques and therapeutic

Antonella Centonze1 | Raffaele Popolo1 | Corinna Panagou2 |

1656 | © 2023 Wiley Periodicals LLC. wileyonlinelibrary.com/journal/jclp J Clin Psychol. 2023;79:1656–1669.

1.1 | The alliance/experiential techniques interface

2.1 | Presenting problem and client description

2.2 | The therapeutic relationship

2.3 | Case formulation

2.4 | Course of treatment

Laura blushed when she heard this, and said:

L: “Doctor, I don't want to do this exercise, it seems pointless.”

L: “Perhaps… yes, I think that's true.”

Laura seemed to be more regulated and remained capable of self‐exploration.

L: “I'm sorry but this is not my problem.”

L: “Doctor, what should I do with this sense of loneliness?”

2.5 | Outcome and prognosis

CO NFL I CT OF INTERES T S T ATEME NT

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