Journal of Personality Disorders, 34, Special Issue, 80–103, 2020 © 2020 The Guilford Press INTERNAL PROCESSING IN PATIENTS WITH PATHOLOGICAL NARCISSISM OR NARCISSISTIC PERSONALITY DISORDER: IMPLICATIONS FOR ALLIANCE BUILDING AND THERAPEUTIC STRATEGIES Elsa Ronningstam, PhD Pathological narcissism (PN) and narcissistic personality disorder (NPD) have primarily been identified by striking external features, such as superiority, attention seeking and a critical or condescending attitude, and less attention has been paid to the internal processing contributing to this particular personality functioning. High dropout from treatment and challenges in building a therapeutic alliance with these patients call for further understanding of the complexity of disordered narcissism. Recent research on neuropsychological underpinnings to narcissistic pathology have provided valuable information that can inform therapeutic interventions for patients with this personality pathology. Internal processing in patients with PN or NPD is specifically influenced by compromised emotion processing and tolerance, identity diffusion, fluctuating sense of agency, reflective ability, perfectionism-related selfesteem, and ability to symbolize. The aim of this article is to review research studies with relevance for internal processing related to disordered narcissism and integrate findings with therapeutic strategies in alliance building with these patients. Keywords: emotion regulation, perfectionism, narcissistic personality disorder, sense of agency, self-esteem, self-reflective ability Patients with pathological narcissism (PN) or narcissistic personality disorder (NPD) present with a wide range of functioning and clinical characteristics. In addition to the standard diagnostic features, subtypes of NPD range from overt and grandiose to covert and vulnerable, and level of function can be exceptionally high with outstanding competence as well as extremely low, accompanied by different comorbid conditions (Caligor, Levy, & Yeomans, 2015; Gabbard & Crisp, 2016; Pincus & Lukowitsky, 2010; Yakeley, 2018). Pathological narcissism and NPD as defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric From Department of Psychiatry, Harvard Medical School, Boston, Massachusetts. Address correspondence to Elsa Ronningstam, McLean Hospital AOPC Mailstop 109, 115 Mill St., Belmont MA 02478. E-mail: ronningstam@email.com INTERNAL PROCESSING IN PATIENTS WITH NPD 81 Association [APA], 2013), sections II and III, and the second edition of the Psychodynamic Diagnostic Manual (PDM-2; Lingiardi & McWilliams, 2017) (see Table 1) are challenging conditions that often can interfere with alliance building and prevent changes in treatment. Patients with NPD tend to drop out early (Ellison, Levy, Cain, Answell, & Pincus, 2013; Hilsenroth, Holdwick, Castlebury, & Blais, 1998), and disagreements, disruptions, and stalemates in treatment are common (Gabbard & Crisp, 2018; Ronningstam, 2014). Therapists’ early interventions—for example, pointing to an observed discrepancy between the patient’s verbal and emotional presentations—can be well intended and solidly anchored in psychoanalytic or psychodynamic theory, or in evidence-based treatment strategies for personality disorders. Nevertheless, they can often evoke patients’ defensive reactions or lead to power struggles. Similarly, interventions influenced by therapists’ direct observations of patients’ immediate interactive or behavioral functioning tend to escalate the patients’ oppositional or defensive reactions. Traits and dimensions that diagnostically define PN and NPD, that is, the official diagnostic criteria (DSM-5, sections II and III; PDM-2) (Table 1) can provide an estimation of narcissistic personality functioning, but they do not fully inform about the underlying subjective internal processing that constitutes the core of narcissistic pathology. The common characteristics of PN—arrogance, critical, condescending attitude, and superiority, which at times can be very striking and provocative—tend to redirect the therapists’ attention away from patients’ subjective experiences and reasoning. In addition, narcissistic aggressivity (O. F. Kernberg, 1992) can remain internalized as well as externally and interpersonally expressed in different ways. This discrepancy between patients’ external presentation and internal processing can easily cause incorrect assessments, misdiagnoses, and ineffective interventions, especially in the early phase of alliance building. The therapist’s efforts to find the optimal strategy to treat a patient’s specific narcissistic character disorder can be derailed by the interpersonal challenges in the emerging alliance between therapist and the individual patient. Correlates and underpinnings of the common expressions of pathological narcissism can be well hidden and difficult to access. Patients’ nondisclosure and compromised ability to identify and verbally convey emotions and subjective internal experiences, combined with their narcissistic defensive stand and interpersonal patterns or reactivity, require specific attention and strategies in the initial assessment and alliance building (Ronningstam, 2012). This also calls for a better integration of therapeutic interventions with understanding of the individual patient’s specific narcissistic functioning and related life circumstances. Complex interactions between mind, brain, and attachment patterns unfold in interpersonal interactions, both in patients’ real life and in treatment, in the relationship to the therapist. In addition, the etiology, comorbidity, and specific life circumstances together form unique and complex patterns in each patient’s narcissistic pathology and functioning. Further awareness of these internal patterns and processes can improve the understanding of patients with PN and NPD, and guide the therapists’ strategies and interventions in the alliance building. 82 RONNINGSTAM TABLE 1. Diagnostic Features for Narcissistic Personality Disorder Diagnostic traits Dimensions Key features 1. Grandiose sense of self-importance 1. Identity Central tension/preoccupation 2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love Excessive reference to others for selfdefinition and self-esteem regulation Inflation and deflation of selfesteem 3. Believes he/she is “special” and unique and can only be understood by, or should associate with other special or high-status people or institutions Exaggerated self-appraisal inflated or deflated,or vacillating between extremes Central affects 4. Requires excessive admiration Emotional regulation mirrors fluctuations in self-esteem. Shame, humiliation, contempt, envy 5. Sense of entitlement, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations 2. Self-direction Pathogenic beliefs about self 6. Interpersonally exploitative, takes advantage of others to achieve his or her own ends Goal setting based on gaining approval from others 7. Lacks empathy, is unwilling to recognize or identify with feelings or needs of others Personal standards unreasonably high in Pathogenic beliefs about others order to see oneself as exceptional, or too low based on sense of entitlement 8. Envious of others, or believes that others are envious of him or her Often unaware of own motivations 9. Arrogant, haughty behavior or attitude 3. Empathy Impaired ability to recognize or identify with the feelings and needs of others “I need to be perfect to feel ok.” “Others enjoy riches, beauty, power, and fame: the more of those I have, the better I will feel.” Central ways of defending Idealization, devaluation Excessively attuned to reactions of others, but only if perceived as relevant to self Over- or underestimate of own effect on others 4. Intimacy Relationships largely superficial and exist to serve self-esteem regulation Mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain Traits 1. Grandiosity Feelings of entitlement, either overt or covert Self-centeredness Firmly holding to the belief that one is better than others Condescending toward others 2. Attention seeking Excessive attempts to attract and be belief the focus of others’ attention Admiration seeking Source: American Psychiatric Association. Source: American Psychiatric Association. (2013). Diagnostic and statistical manual (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, of mental disorders (5th ed.). Washington, DC: Author. Section III. Reproduced with DC: Author. Section II. Reproduced with permission. permission. Source: Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). New York, NY: Guilford. p. 48. Reproduced with permission. INTERNAL PROCESSING IN PATIENTS WITH NPD 83 The first aim of this article is to define and outline different aspects of the internal processing in patients with PN or NPD, as they are influenced both by temporary pathological narcissistic reactivity and by deeply engrained characterological and neuropsychological patterns. Of specific importance is the connection between internal processing and identifiable diagnostic features, so that the second aim of this article is to connect these two aspects of pathological narcissism. EXTERNAL CHARACTERISTICS VERSUS INTERNAL EXPERIENCES The discrepancy between the external presentation and the internal processing in patients with PN or NPD has long been confusing, especially since the content and intensity of their internal experiences can remain hidden. Obvious narcissistic interpersonal patterns, often enacted in relationship to the therapist, include self-enhancement, critical devaluation, dismissiveness, avoidance, aggressivity, and various manipulative maneuvers to preserve control, distance, and self-esteem. In different moments, the patient is also accessing his or her own thoughts, images, and visceral as well as emotional reactions that are activated within the alliance to the therapist. Those can be well hidden or inaccessible behind the facade of typical narcissistic features, especially escalated self-enhancement (Ronningstam, 2017). Usually referred to as resistance or negative transference, this has contributed to a blaming and unhelpful attitude towards patients with PN or NPD. However, an alternative view suggested by Eaton and colleagues (2017) and influenced by transdiagnostic research, identified internalized distress and fear in NPD, and the authors concluded that NPD could be conceptualized as a distress disorder. Another study by Kealy and colleagues (Kealy, Ogrodniczuk, Joyce, Steinberg, & Piper, 2015) found anxious attachment and vulnerable self-experience of inadequacy, fearfulness, and sensitivity to rejection to be associated with narcissistic grandiosity. They also identified lower quality of object relations, with intolerance of separation and dependent or controlling relationship patterns. The authors conclude that narcissistic grandiosity co-occurs with insecure self-representations and sensitivity to rejection. This supports the need for further exploration and identification of context and underpinnings of narcissistic pathology that contribute to these patients’ specific internal struggle in contrast to their typical external presentation. INTERNAL PROCESSING Internal mental processing has primarily been attended to in cognitive psychology as a mediational process between stimulus and response, including imagination, memory, attention, and perception. For the purposes of this article, internal processing is used as an umbrella concept referring to cognitive and emotional as well as relational mental activities that can contribute to the individual’s self-regulation, degree of reactivity, and ability for awareness and 84 RONNINGSTAM assessment of self and others. Several factors can influence the nature of internal processing in NPD: fragmented and fluctuating sense of identity; automatic or intentional efforts to avoid or hide specific aspects of self; compartmentalized attachment patterns, in particular avoidant and dismissive (Diamond & Meehan, 2013); and internalized object relations, shifting between idealized and devalued (O. F. Kernberg, 1976). In addition, overwhelming hypersensitivity and reactivity (visceral, psychosomatic, or affective) tend to supersede or overpower actual awareness of and ability to verbalize internal experiences. Internal processing is also affected by considerable underpinnings, such as inheritance and temperament, including hypervigilance, aggressivity, frustration intolerance, and high novelty seeking (Cloninger, 2000; Torgersen et al., 2012). Attachment patterns, in particular dismissive, avoidant, and anxiouspreoccupied patterns (Diamond et al., 2014), and gaze—that is, implications of being seen and seeing associated with shame, humiliation, and retreat (Steiner, 2006)—are also significant developmental components that affect narcissistic functioning. Internalized unintegrated self-object relations play a major role in experiences of and reactions to self and others in social and interpersonal contexts (O. F. Kernberg, 1976). In addition, age-inappropriate role assignments and childhood psychological trauma (P. F. Kernberg, 1998; Maldonado, 2006; Simon, 2002) can have employed significant subjective meaning but remained compartmentalized and unverbalized. Such experiences can continue to have a major impact on the individuals’ perception of self and others, with accompanying reactions in different situations. Exploration of patients’ developmental history is particularly important especially in the phase of alliance building. Recent studies focusing on neuropsychological aspects of emotion and interpersonal processing have identified several significant components and functions related to NPD and PN. One study using MRI scans to assess gray matter deficits in patients diagnosed with DSM-IV NPD suggests a neurological core for noticeable emotion dysregulation and fluctuations in internal control and control of emotions in NPD (Nenadic et al., 2015). Another study measured respiratory sinus arrhythmia and the cardiac pre-ejection period, and identified a psychophysiological base for emotional reactions in NPD (Sylvers, Brubaker, Alden, Brennan, & Lilienfeld, 2008). An additional study of facial expressions confirmed deficits in recognition of emotions in NPD patients, indicating possible underpinnings to narcissistically based interpersonal insensitivity (Marissen, Deen, & Franken, 2012). Noticeable self-centeredness and tendencies to disengage were verified in two fMRI studies that suggested an internal predisposition for self-preoccupation in individuals with PN, and an automatic shift from inter- to intra-subjective focus when facing own and others’ emotions (Fan et al., 2011; Scalabrini et al., 2017). Marcoux and colleagues (2014) found stronger somato-sensory resonance combined with deficits in affective and empathic responses towards others’ pain in patients with NPD using EEG measurement. The authors identified a cerebral reactivity to painful stimuli with a sensory-cognitive approach to assess others’ pain. This suggests an ability to feel but compromised incentive for caring responses. Further studies have provided evidence for compromised empathic function in NPD, that is, intact cognitive but neural-deficient emotional empathy, and INTERNAL PROCESSING IN PATIENTS WITH NPD 85 impact of emotion intolerance and processing on ability to empathize (Ritter et al., 2011). Taken together, these studies provide evidence for a neuropsychological core deficit in emotion processing in individuals with PN or NPD, which affects their ability to access, tolerate, identify, and verbalize emotions. Studies vary with regard to sensitivity and reactivity, but point towards a hyper-reactivity but not necessarily an accompanying interpersonal responsiveness in NPD. One study of facial emotion recognition confirmed that subjects with high NPD traits showed increased sensitivity for subtle cues of non-acceptance in negative or neutral facial expressions, which contributed to their intense angry feelings and accompanying self-focus (De Panfilis et al., 2019). This can further explain the often-contradictory presentations of narcissistic individuals as either or both hyper-vigilant and reactive or insensitive and dismissive. In other words, automatic autonomic reactions can be ingrained or compartmentalized, and readily triggered in specific interpersonal contexts. Similarly, self-centeredness and a need for internal control with fear of losing control also influence narcissistic interpersonal interactions. Internal processing can be context dependent and obvious, and activate severe pathological narcissism in patients even in the absence of a full diagnosis of NPD. Internal processing can also fluctuate and be noticeable, but nevertheless remain out of reach for verbal exploration and diagnostic assessment. Patients with PN or NPD are known for making intentional efforts to present in certain ways to evoke explicit impressions on others. However, they can also be totally unaware of the impact they have on others in general or on the therapist in particular. Sometimes they present with sudden intense dismissive, critical, or aggressive reactivity, but the clear underlying reasoning may be inaccessible for a collaborative exploration in therapy. At other times, they can demonstrate a remarkable capacity for identifying and relating to others’ states and intentions, but they may use this primarily for self-enhancing or avoiding purposes, without reflecting on or understanding the underlying motives. Nevertheless, a compromised or even a lack of emotional self-knowledge (Kramer & Pascale-Leone, 2018)—an awareness and understanding of one’s own emotions and feelings, and their expressions and meanings in interpersonal and social contexts—is predominant in patients with PN and NPD. Patients’ internal processing may be activated and or challenged by external life experiences that all of a sudden stir up intolerable reactions that may be difficult to process. An unexpected question or comment from the therapist may evoke reactions that are grounded in deeply compartmentalized emotional experiences and thought patterns. The therapist, in such situations, is facing various discrepancies or disconnects between the external and the internal facets of the patient’s mental functioning. These individual differences and fluctuations in functioning in patients with PN or NPD further point to multifactorial underpinnings that in various ways can contribute to individual expressions and variations of narcissistic pathology. An important aspect of interpersonal functioning in patients with PN or NPD relates to the balance and interaction between deficits, defensiveness, and motivation (Mizen, 2014). In addition to the deficits mentioned above, psychogenic defenses have long been considered a major challenge for engaging 86 RONNINGSTAM NPD patients in psychotherapy and psychoanalysis (O. F. Kernberg, 2015). On the other hand, these patients can also be driven by clear and intentional motivation to avoid or pursue, to compete or protect, and to manipulate or maneuver (Baskin-Somers, Krusemark, & Ronningstam, 2014). Self-esteem regulation, with consistent self-enhancement or oscillations between grandiosity with grandeur control and vulnerability with inferior insecurity (Pincus, Cain, & Wright, 2014), is affected by the patients’ internal processing as well as by their external life context and experiences. Given this background, internal processing in patients with PN or NPD is suggested to be specifically influenced by compromised affect tolerance and processing, identity diffusion, reflective ability and mentalization, sense of agency with competence and control, self-esteem and perfectionism, and ability to symbolize. The aim of the following sections is to highlight and discuss both the separateness and the links between the internal processing and the external features and patterns in interpersonal relating. Clinical case vignettes will demonstrate the unfolding connections between the internal processing and external presentations and interactions. LIMITED AFFECT TOLERANCE AND COMPROMISED EMOTION PROCESSING Patients with PN or NPD have difficulties connecting their own affects and compatible emotions to verbal formulation and interpersonal/social relatedness and interactions. In a recent study of processing and verbal elaboration of affects in patients with NPD features, Bouizegarene and Lecours (2017) used observer-rated measures and identified a lesser ability to tolerate, verbalize, and mentalize sadness, which causes an inability to experience grief (O. F. Kernberg, 2010). This study not only indicates the presence of emotional suffering in patients with PN, but also points to the importance of attending to the complexity of underlying affect processing in assessment and treatment. Clinical observations have indicated that patients with PN or NPD can demonstrate outstanding intellectual capacity and elaborative verbal plasticity, with accompanying ability to provide seemingly rich and detailed, even emotional descriptions of situations and experiences. This can readily shield compromised access to more genuine emotions and leave the therapist with the impression that the patient is more insightful or reflective then he/ she really is. Efforts to empirically conceptualize these differences were first focusing on the “masking” of inferiority by maintaining a grandiose selfview (Morf & Rhodewalt, 2001). This mask model was later connected with fragile self-esteem and the interaction between implicit automatic, uncontrollable self-esteem and high overt levels of explicit self-esteem (Marissen, Brouwer, Hiemstra, & Deen, 2016). Evolving evidence of the co-occurrence of and fluctuations between grandiosity and vulnerability (Pincus et al., 2014) gradually connected with theoretical and clinical psychodynamic accounts on overt and covert narcissism, oscillation between superiority, and control versus inferiority and powerlessness, and between anger and shame (Akhtar, 1989; Ritter et al., 2014; Ronningstam, 2012). INTERNAL PROCESSING IN PATIENTS WITH NPD 87 Patients’ underlying compromised emotional regulation with hidden affect and drastic discrepancies between external interaction and internal processing tend to unfold in the therapeutic alliance. Facing the contrasts between these patients’ presentation and the rapidly or gradually evolving countertransference can be challenging but nevertheless very informative for therapists (Gabbard, 2013; Tanzilli, Colli, Muzi, & Lingiardi, 2015). Patients’ tolerance for mutual interactions and collaborative sharing within the therapeutic alliance depend upon the degree of their compromised emotion processing as well as on intensity of the emerging internalized object relations. Sudden disruptions or dropout from treatment can follow. CASE VIGNETTE Dora, a woman in her late 20s, had after years of procrastination finally graduated with top grades from a master’s program. She needed to take a licensing exam in order to be ready for the next major step in her professional career. She had gradually benefitted from a few years of individual psychotherapy that focused on her enhanced self-esteem, perfectionism, fear of failure, entitlement, and ostentatious aspirations. In the middle of this process, the therapist received a message from Dora that she had decided to end the therapy. The therapist’s efforts to encourage her to come back or to find out the reasons for this sudden unexpected ending remained unanswered, and the therapist was left to her own speculations. A year later, the therapist received a letter from Dora describing her present successful career track in the profession she’d aspired to and explaining her earlier need to abruptly stop therapy in order to pursue her career in finance. She had suddenly found the two commitments— psychotherapy and her professional career-focused work—totally conflicting and incompatible, and had felt it necessary to maintain her self-control and do this transition on her own. At a couple of scheduled follow-up therapy sessions, Dora explained further how facing a career with job interviews had escalated extreme internal anxiety and unusual images of her father who had passed away a few years earlier. Of the opinion that women should not advance, he had criticized and undermined her intellectual ability since she was a child, despite the fact that she was intelligent and got good grades. Dora had been convinced that she would fail to engage in her professional career if she stayed in therapy. When the therapist asked, “How come?,” Dora began to cry, saying that she was not supposed to surpass her father. In her mind, that created a significant conflict as she, on the one hand, was convinced that she was superior to her father and knew what she wanted to do, but on the other that she would be punished for her aspirations. She even associated his passing away with her advancements. She had felt undeserving of the potential support of her therapist, and had also at the time felt unable to process this in therapy, given its immediacy in the context of her job applications and interviews. She described the experience: Just thinking about you made me feel overwhelmed by shame and fear—I understand that you are caring and competent, but in my mind you became either 88 RONNINGSTAM somebody who wanted to hold my hand which would have been deeply embarrassing for me! Why should I have somebody to hold my hand when I am about to enter a competitive business world? Alternatively, I envisioned that you would have scorned me for my fear and like my father try to convince me that my feelings were evidence of my incompetence and potential for failure. This patient needed to reach a sense of independence and competence, with stabilized internal and self-regulatory balance, in order to be able to access her self-reflective processing. This encouraged her to reconnect with her therapist and process the earlier emerging transference and residual psychological trauma (Maldonado, 2006; Simon, 2002) that was activated when she was beginning to pursue her professional advancement. At that point, she was able to form a narrative (Ribeiro et al., 2011) and relate to the therapist, who was the source and activator of her internalized object relations (O. F. Kernberg, 1976), which a year earlier had resulted in an overwhelmingly intense transference reaction with accompanying immediate avoidance and withdrawal. This example raises the question of how and when internal processing as opposed to external presentation and interpersonal relating can depart and remain separated or, alternatively, be integrated and processed in the therapeutic alliance. In other words, how do these contexts interact with and affect the patient’s ability to reflect and progress? One way is through realizations based in real life experiences (Ronningstam, Gunderson, & Lyons, 1995). Another is through realizations gained in the exploratory relational interactions or emerging transference within the therapeutic alliance. A third way involves unfolding narratives based on realizations of internal patterns related to attachment, psychological trauma, and self-regulatory strategies within the individual him/herself. IDENTITY DIFFUSION As mentioned earlier, internal processing can be separated and remain hidden, or even be inaccessible in patients with PN or NPD. As such, it can contribute to or reflect identity diffusion, with some intermittent underlying awareness of counterintuitive or perplexing sense of self with fear of being exposed or rejected. Focus on self-enhancing achievement and “other orientation” with the aim of generating specific reactions in others may for a while sustain such character function. CASE VIGNETTE Carl, an outstanding pianist in his early 20s, managed to get his audience’s attention both through his choice of music and his way of performing. His parents, especially his mother, were very proud of him and invested a lot in supporting his education and engagements. He was confident, arrogant, and self-assertive, and he readily got his peers to feel inferior, especially as he seemed to have an unquestionable and exceptional musical career in front INTERNAL PROCESSING IN PATIENTS WITH NPD 89 of him. When moving to a top conservatory, he suddenly began to feel lost, stopped rehearsing, stayed in bed, started using cocaine, and began losing his temper in front of his parents and teachers. Starting treatment, he told his therapist that for a long time he had felt increasingly conflictual, empty, and misplaced in his pianist career, despite being very gifted and capable. Since his early teens, he had also sensed that he really did not know who he was, what he truly wanted in life, or what he indeed liked to do and was good at doing. It had felt easy and natural to adhere to his parents’ expectations and to embrace his ability to please them as well as his teachers, and impress his peers. He had also really liked receiving the audiences’ acclamations, which had spurred his self-esteem and steered his attention away from underlying insecurity and self-doubts. However, at the same time, he was not sure whether he was the one really playing the piano at the concerts or whether it was somebody he just felt he should be. He also conveyed that he had secretly discovered he liked and was good at cooking and that one of his teachers in high school had actually suggested he should apply to restaurant school. He had found the idea both appealing and totally impossible, as he foresaw that such a decision would upset and even rupture his relationship to his parents. The psychotherapy focused on Carl’s identity and self-esteem, encouraging his self-exploration, with attention to experiences, reactions, and feelings in his relationships, as well as in his efforts to explore and decide on a new alternative life track. In addition, he joined a DBT (dialectical behavior training) group to learn more about emotion regulation, and his parents attended a parent psychoeducational support group. For this young man, facing a new stage in life drastically unraveled his identity diffusion and the underlying processes that had held up one aspect of himself but ignored other important sides of his developing personality. This can be challenging to face, especially when actual competence can spur self-esteem and a sense of superiority. Admiration and rivalry with peers further added to this process. Realizing this internal reality and vulnerability motivated him to begin therapy and search for the more genuine sense of self and options for his future. SELF-REFLECTIVE ABILITY AND MENTALIZATION Reflective ability and mentalization (Fonagy, Gergely, Jurist, & Target, 2002) in patients with PN or NPD are compromised or fluctuating and can remain out of reach in treatment (Diamond et al., 2014). Self-reflection encompasses abilities to identify and connect internal experiences with type and level of visceral and bodily arousal; to connect thought and feelings in daily life; and to realize that one’s own perception of interpersonal relationships is subjective and may differ from external reality (Dimaggio & Lysaker, 2018). All this influences the patients’ ability to make a direct connection between their range of internal experiences and their efforts to verbally describe and interactively communicate with the therapist. In addition, it influences the capacity 90 RONNINGSTAM for mentalization, that is, attending to interactions between self and others and understanding oneself and others in terms of intentional mental states with needs, desires, motivations, and goals (Bateman & Fonagy, 2016; Fonagy et al., 2002). In a recent study, Nazzaro and colleagues (2017) also verified that impaired reflective functioning (the operationalization of mentalization assessed with the Reflective Functioning Scale; Fonagy, Target, Steele, & Steele, 1998) was strongly associated with cluster B personality pathology and vulnerability in personality functioning. Failure in reflective ability and mentalization invites personality pathology, and a focus on mentalization in treatment can lessen rigidity, promote understanding, and adjust behavior and actions. It is important to keep in mind that self-reflection with gain of internal control usually precedes the ability for genuine mentalizing in patients with NPD. Their tendency for pseudo-mentalizing—demonstrating and pretending a primarily intellectual capacity to assign intentions and beliefs in others based on their cognitive empathic ability (Ritter et al., 2011)—can contribute to misevaluation of their actual internal processing and reflective ability. Other underpinnings to reflective ability in patients with NPD include co-occurring alexithymia, the impaired ability or even inability to tolerate, feel, and experience own emotions (Krystal, 1998) and self-centeredness (Fan et al., 2011). In addition, patients can fluctuate between preoccupation and distancing, sometimes being totally immersed and preoccupied with a specific issue, other times remaining ignorant, distant, or dismissive. Intense reactivity and difficulties integrating and verbalizing emotional experiences also contribute to lack of reflective ability. As a result, the therapist is facing an unusually complex task of discerning the obscured and hidden internal processing from the obvious external reflective and mentalizing interactive patterns. Attending to experiences in external life context or within multimodal treatment—combined group and individual therapy focused on improving patient’s reflective ability—can help reveal such complexities and discrepancies in internal and interpersonal functioning. CASE VIGNETTE Laura stormed out of a group therapy session after a heated interaction with the group leader who had suggested that her critical view of others may reflect her own self-negativity and insecurity. In her individual session a couple of days later, Laura described in detail her intense and overwhelming reactions to the group therapist’s comment: “It felt as if my brain caught fire and my stomach cramped. . . . I don’t understand why I react so strongly.” The therapist invited further explorations of how Laura perceived and experienced the group leader’s comment and after a long pause she said: I felt invaded, as if somebody was trying to overpower and take control over me. . . . I am embarrassed for reacting so strongly . . . but I just get sooo angry and scared!! I was not prepared and I felt exposed in front of everybody. It happens to me at work too. When I presented a project plan in front of my department, one of the managers began questioning my choice of methods and its impact on the INTERNAL PROCESSING IN PATIENTS WITH NPD 91 potential results, and suggested a totally different strategy. It felt as if I was hit by a bomb. I thought my project plan was perfect. This is why I got fired from my previous job and it is one of the major reasons I am in treatment! A couple of months later, in the context of another intense group interaction, Laura had gained some more reflective ability for emotion processing and self-reflection and said: I can see that I exaggerate what others say to me and how I tend to misperceive their intentions. I think that is why I react so intensely. As I sit here, I can realize for instance, that my manager at work actually tried to improve my project proposal when he questioned my choice of methods. And the same with my group leader. I have been thinking about what she said about my harsh self-criticism. Maybe if I can be somewhat more accepting and understanding of myself, I may not have to be so critical of others, and easily get so suspicious of their intentions and get ready to attack. This example demonstrates some of the underpinnings of interpersonal reactivity in patients with PN or NPD that both echo and influence their impaired reflective ability—that is, compromised emotional processing, with visceral internal reactivity, shame-based or shame-covered interpersonal aggressivity, lack of differentiation of self and others, and need for internal and interpersonal control. Attending two different treatment modalities, one that exposes the patient interpersonally and activates narcissistic patterns (group therapy) and another that provides an alliance that encourages exploration of internal processing with verbalizing, narration, and self-reflection (individual psychotherapy) can be very useful for NPD patients. SENSE OF AGENCY, COMPETENCE, AND CONTROL Self-agency or sense of an own agential core conceptualizes the awareness and ownership of goal setting and direction, and of planning, initiating, executing, and controlling one’s own thoughts, intentions, actions, and motivations (APA, 2013, section III; Fonagy et al., 2002; Gallagher, 2012; DSM-5). As a central aspect of narcissistic functioning, sense of agency influences both selfregulatory and interpersonal strategies, such as attention seeking, competitiveness, and achievements (Campbell & Foster, 2007). The subjective experiences of fluctuations or loss of agency are especially frightening for narcissistic individuals whose sense of self-worth is fragile and whose ability for interpersonal relationships is compromised (Ronningstam & Baskin-Sommers, 2013). Capacity for experience of agency in therapy depends on several factors. Knox (2011) highlighted affect regulation (the ability to experience strong emotions without fearing them as destructive), self-reflective ability (the awareness of the mental and emotional separateness of self and others), and regression in the service of development (the need to create a reaction in the other to be able to work through and move on). 92 RONNINGSTAM CASE VIGNETTE Amy, a married woman in her mid 30s and mother of two, started therapy as she considered resuming work after having been a stay-at-home-mom for a several years. Despite several opportunities, she felt hesitant and found herself procrastinating. Amy came across as a woman who belonged to the top class in society. She was extraordinarily well articulated and readily engaged in long, seemingly convincing descriptive elaborations about herself and her family, which differed from session to session. Initially, Amy praised her husband and identified with his career, adored her children, and adamantly repeated how much she loved her mother. The therapist found this rather incompatible with her unfolding description of her problems as she expressed increasing frustration and rage outbursts with regard to her children, and feelings of envy and inferiority in relation to her successful husband. In addition, she had vivid images as to what her own success could have been had she not gotten married and had children. All this furthered her feelings of resentment and regret. Her efforts to reenter a career had always been postponed as it evoked increasing self-doubt and insecurity, and she repeatedly asked herself “Why am I feeling like this?” A sudden decline in her husband’s health required Amy to take on more financial responsibility for her family. She began to struggle with intense confusion, self-hatred, and a sense of not knowing who she was and what she wanted to do with herself. In contrast to while she was growing up, when she was a top student and athlete, often feeling that she took care of and protected her parents who had intermittent alcohol problems, she now found herself in an incomprehensible trap. Further exploration of Amy’s internal experiences revealed that she also felt dismissed and degraded by her mother. She had always sensed that she lost in competition with her younger sister for her mother’s attention, but she consoled herself by believing that she was admired for her achievements by her father. By perceiving herself as “taking charge” in her family of origin, she had also been able to justify or ignore their distancing from her, especially after she got married and had children. As these realizations gradually unfolded, Amy became overwhelmed with rage, sadness, and feelings of loss and betrayal. She felt that a fantasy of her own traction and influence suddenly crumbled, forcing her to face a deep sense of insecurity, shame, envy, longing, and inadequacy. However, as she processed this in therapy, she also noticed less frustration and accompanying rage outbursts vis-a-vis her children, and if they occurred, she had better ability to stop herself and reflect on and assess the situation and see different perspectives. In addition, she had moments when she could appreciate her husband’s family by recognizing their genuine support of her, although that also made her feel uncomfortable and intruded upon. In therapy, she began to integrate her role and identity as a mother with her professional competence and aspirations. She struggled with perceiving her therapist on the one hand as a successful but unattainable and demeaning role model, and on the other hand as an enviable threat. A few months later, Amy had her first job interview. Her insecurity and avoidance, with the fear of exposing herself and failing and the underlying shame, became the new focus in psychotherapy. INTERNAL PROCESSING IN PATIENTS WITH NPD 93 This example demonstrates the unfolding of internal narcissistic processing in the context of a major life change, which specifically challenged the patient’s sense of agency and competence, and evoked intense emotional reactions. Fragile self-enhancement was interrupted by reactive rage, shame, and fear of failure. Actual sense of agency and reality-based competence was shattered in the context of intolerable internalized object relations and accompanying compromised emotion processing and tolerance. As the full range of these experiences was regenerated, the patient’s external life experiences, internal processing, and transference reactions could begin to be integrated and processed within the therapeutic alliance. SELF-ESTEEM AND PERFECTIONISM Perfectionism has long been associated with NPD (Rothstein, 1980). As an integral part of narcissistic self-esteem regulation and self-enhancement, perfectionism can serve as a means for control as well as for interpersonal competition and dismissiveness in individuals with PN or NPD. In a study of the relationship between perfectionism and various aspects of neurocognitive performance, Slade and colleagues (Slade, Coppel, & Townes, 2009) differentiated between positive perfectionism with motivation and focus related to mental and physical efforts versus negative perfectionism motivated by fear of failure with focus on avoidance of making errors, especially related to accuracy and speed. These results are specifically relevant for pathological narcissism where perfectionism usually is less related to morals and ideals, but foremost aiming at achieving grandiose standards, maintaining a sense of self-cohesion, control, and high level of performance, and especially sustaining status and others’ admiration. Often used as a vehicle to avoid humiliation and shame, failure to measure up to perfectionist standards can rapidly evoke shame, rage, and depression (Marčinko et al., 2014; Sorotzkin, 1985). In addition, perfectionist standards can also be more directly associated with an underlying fear of failure. CASE VIGNETTE Maria, a woman in her mid 20s who had been in psychotherapy for several years, outlined training programs and manuals for various sports at work and also taught their contents. She felt very proud of her accomplishments, which gave her a sense of professional authority in line with her perfectionist standards. She had also received significant admiration and acclaim for her organizational and teaching skills. One day, the director asked her to apply the manual to preschool children and perform a series of swimming lessons. She adjusted the manual and entered the first lesson to find seven or eight kids in the pool, splashing, screaming, and laughing. They were all having a super-fun time and did not pay any attention to her entering the pool area. Maria described her reactions in detail: First, she was instantly infuriated and considered just leaving and complaining to her director. Then she panicked, 94 RONNINGSTAM believing that the kids, their parents, and the director were out to prove her incompetent, and after an additional few seconds she felt totally paralyzed and convinced that she was going to fail and be fired. For a moment, she even thought about suicide. However, as she stood there facing these lively, loud, and laughing kids, she noticed her own bodily sensations and realized that the kids actually were enjoying themselves. Because of this awareness, she understood that they were not determined to make her fail. Her paralysis lifted, and she decided to get into the pool, join the kids, and splash around to get their attention. Then she introduced herself and started the lesson. She also realized that she had to put the “perfect” manual and teaching strategies aside and apply a much more creative, playful, spontaneous, and “kid-appealing” approach to reach her goal and accomplish her efforts, which initially felt very uncomfortable and even frightening. However, this realization also enabled her to organize the lessons and teach the kids how to swim. To her psychotherapist, Maria described feeling quite stunned by this experience. For the first time, she sensed she had found a constructive way out of her initial and familiar, infuriated, overwhelming, and panicky reactions when facing a challenging real-life situation. Such situations had usually evoked self-silencing, withdrawal into self-condemnation, and suicidal ideations. This patient apparently struggled with extreme fear of not measuring up to her own perfectionist standards and consequently failing, which externally tended to trigger superior dismissiveness or aggressive outbursts. Her ability to redirect her attention to the kids’ laughing and realize both cognitively and emotionally that they were enjoying themselves made it possible for her to approach the situation in a new and more proactively competent way. Perfectionism focused on accuracy and speed (negative perfectionism) can be useful in certain contexts, such as in individual precision sports like ice-skating and gymnastics or in concert performances for solo piano or violin. When combined with positive perfectionism, such negative exact-focused perfectionism can help optimize performance (Slade et al., 2009). However, in the context of underlying narcissistic pathology, with self-doubts, sensitivity to expectations and excessive concerns about mistakes, or detachment from regular self-criticism, failure to measure up can evoke intense inner agony, feelings of inadequacy, avoidance, and depression. CASE VIGNETTE David was an exceptional gymnast who during high school advanced to compete at the national level; in college, he was considered for the upcoming Olympic Games. However, in one of his final competitions, David fell for the first time, sustaining a concussion and broken bones. Although he recovered medically and resumed physical strength, this event nevertheless led to major mental problems, including a suicide attempt. A psychiatric evaluation revealed rather severe narcissistic pathology, including extraordinary aspirations, need for attention and admiration, feelings of inferiority, extreme self-criticism, and identity diffusion, and David was referred for psychotherapy. He told his therapist that since childhood he had relied on his athletic capabilities to feel worthy, impress his parents, and be accepted by his peers. After the accident, INTERNAL PROCESSING IN PATIENTS WITH NPD 95 however, he had felt increasingly lost, as if he had fallen into a big hole, and could see no future for himself. He had begun to feel afraid of his gymnastic activities, unable to trust his capability, and could not identify anything else that would provide him with a sense of self-worth, attention, and direction. Initially, he frowned at the prospect of becoming a trainer; he dismissed the suggestion to pursue alternative activities or academic studies and chose to isolate himself in his room playing videogames in addition to attending treatment. He remained in intensive multimodal treatment for a year, during which he gradually tried out different types of temporary jobs and finally decided to apply for college in another state. He ended treatment when he started college, but a couple of follow-up sessions indicated that he had continued psychotherapy and was adjusting well to his college studies and environment. These two case examples demonstrate the importance of exploring and identifying the subjective motivation and internal processing related to perfectionism. It also calls for attention to the degree of rigidity and whether and to what degree the patient’s perfectionism is associated with a sense of identity and integrated sense of agency in addition to performance. COMPROMISED ABILITY FOR SYMBOLIZATION Symbolization, the ability to represent one thing with something else and to differentiate the symbolized from the original object, requires both affective and relational competence, the ability to reflect and to access and differentiate between concrete reality and its potential underlying meanings. More recently, attention has been directed to mental concreteness and desymbolizing or non-symbolizing in certain patients, especially those with NPD, and to the impact on alliance building, countertransference, and processing of interpretations (Bonovitz, 2016; Frosch, 2012). Mizen (2014) in particular suggested an integrative model which outlines a pathway for narcissistic functioning that integrates both developmental, neuropsychological, affect, and relational factors. Accordingly, narcissistic pathology represents “failures at specific points on a representational function pathway through which subcortical affect and visceral feelings in a relational context become the basis for abstraction and language” (p. 254). In other words, this implies an interaction between biological and relational factors for generating language as a means of communicating feelings. Biological, relational, or psychogenic factors may disrupt the development of symbolic functioning, resulting in pathological and narcissistic interpersonal patterns of relating. Compromised capacity to symbolize leads to a “concrete” mode of mental functioning with diminished reflective and mentalizing ability. It leads to compromised awareness and understanding of own emotions and feelings (Kramer & Pascale-Leone, 2018). When facing sudden, unexpected, and challenging life circumstances, this can also escalate sudden acute suicidality, with risk for lethal actions (Ronningstam, Weinberg, Goldblatt, Schechter, & Herbstman, 2018). Maldonado (2005) identified the manifestation as a constant verbal acting out in the alliance, that is, a verbal communication that is empty of meaning. This affects alliance building as it can evoke the therapist’s intense negative 96 RONNINGSTAM reactions and countertransference. It also prevents a collaborative therapeutic process from developing, with eminent risk for negative enactments or premature termination. Symbolization, mentalization, and metacognition are all associated with the experiences and verbal elaboration of affect (Bouizegarene & Lecours, 2017; Lecours & Bouchard, 2011). CASE VIGNETTE Betsy: My four previous therapists started to behave just like my mother so I quit immediately. I could not stand it and I could not trust them. And just so you know—if you start to talk or act like my mother, I will fire you too. Immediately!!! Therapist: I don’t intend to deliberately act like your mother, but if you find that I do remind you of your mother, I would suggest that you tell me, because it could be a good opportunity for us to talk about your memories and experiences of your mother that suddenly can be activated in different situations Betsy: Well, that is why I need treatment, because my mother was such an aggressive self-inflated person and I can’t get her out of my mind. I can’t control her, stop her, or get rid of her, and I am afraid that I will become like her! This patient demonstrated concreteness in her thinking and identity diffusion accompanied by aggressivity, blame, and dismissiveness, which automatically were activated when facing her therapists. Difficulties separating the therapist as a person from her internalized experiences of and relationship to her mother readily evoked the impression that the patient was developing a negative transference reaction that calls for the therapist’s transference-focused interpretation. However, using the concept of transitional space (Winnicott, 1971) concreteness can be a defense or a means to avoid the reexperience of intense affects or early developmental trauma (Cancelmo, 2009; Maldonado, 2005, 2006). In addition, alexithymia, which involves a deficit in symbolization of emotional somatic and mental states, can also contribute to concreteness, especially as it relates to an unawareness of or incapacity to distinguish physical and affect states, with a lack of words for emotions. Lemche and colleagues (Lemche, Klann-Delius, Koch, & Joraschky, 2004) identified a connection between insecure and disorganized attachment and deficits in the development of internal state language, which implies that alexithymia can be a consequence of deficits in the developing mentalizing ability. Awareness of and attention to emotions are particularly important in treatment of patients with PN and NPD, given the significant role of emotion dysregulation within this range of pathology. On the other hand, these patients’ hypervigilance and tendencies to readily feel insecure and criticized when facing difficulties or shortcomings— that is, an indication of unawareness of own emotions—call for a gradual collaborative and exploratory therapeutic strategy. When signs of emotions can be attended to, experienced, and reflected upon, a transition from implicit to explicit aspects of emotion can be possible through the psychophysiological activation within the therapeutic alliance, which can link sensory input with INTERNAL PROCESSING IN PATIENTS WITH NPD 97 different memory and symbolizing systems (Baskin-Sommers et al., 2014; Fan et al., 2011; Krystal, 1998; Lane & Garfield, 2005; Mizen, 2014). A therapeutic frame, and the nonverbal general atmosphere and open attitude that the therapist can convey, may enable such a gradual transition from concreteness towards symbolization, gradual verbalization, and interpersonal interaction within the therapeutic alliance. The use of metaphors (Stine, 2005) can pave the way for such a link between affect, impulses, and negative concreteness, towards enhancing the communication and collaboration. EXTERNAL INDICATIONS OF INTERNAL PROCESSING Of importance for assessment of PN and NPD, and especially for connecting to and understanding the patient, is an awareness of how internal processing relates to and influences observable features of narcissistic pathology. Table 2 provides an outline for possible connections between the different components of internal processing and some of the diagnostic features in DSM-5 sections II and III. Limited affect tolerance can result in need for control and interpersonal TABLE 2. Interface Between Internal Processing Components and External Diagnostic NPD Features Indicators of internal processing Diagnostic features from DSM-5 sections II and III Limited affect tolerance Need for control and fear of losing control Avoidant and dismissive interpersonal patterns Identity diffusion Excessive reference to others for self-definition and self-esteem regulation Often unaware of own motivations Self-reflective ability and mentalization Self-centeredness Over- or underestimate of own effect on others Impaired ability to recognize or identify with the feelings and needs of others Sense of agency, competence, and control Interpersonally exploitative, takes advantage of others to achieve his/her own ends Excessive attempts to attract and be the focus of others’ attention Admiration seeking Goal setting based on gaining approval from others Self-esteem and perfectionism Grandiose sense of self-importance Firmly holding to the belief that one is better than others Believes he or she is “special” and unique Relationships largely superficial and exist to serve self-esteem regulation Personal standards unreasonably high in order to see oneself as exceptional, or too low based on sense of entitlement Inflation or deflation of self-esteem Compromised ability for symbolization Mutuality constrained by little genuine interest in others Self-centeredness 98 RONNINGSTAM distancing. Identity diffusion causes other orientation and unawareness of own motivation. Self-centeredness and difficulties estimating own effects on others relate to compromised reflective and mentalizing abilities. Sense of agency is evident in the narcissistic efforts to get attention and approval, to exploit, and to take advantage of others. Internal self-esteem is noticeably related to beliefs and expressions of own superiority and to engaging in relationships that support self-esteem. Finally, compromised symbolizing ability can be indicated in patients’ self-centeredness and constrained interpersonal relatedness. THERAPEUTIC IMPLICATIONS Accessing and integrating internal processing is crucial in psychotherapy with patients with PN or NPD. By making internal processing an integral part of the therapeutic focus and alliance, the therapist can promote access to some of the core processes that influence the patients’ way of perceiving and relating to others. Encouraging and stimulating reflective capacity via self-narratives of experiences and reactions, and of memories of experiences that formed internal processing patterns and sense of identity, are essential for the patients’ ability to fully engage in the therapeutic alliance and tolerate its increasing interpersonal intensity with unfolding transference. There are primarily two strategies in the initial alliance building with patients with PN or NPD that can promote such development. The first strategy involves inquiries and explorations, which serve to build a foundation for identifying and understanding the patient’s actual functioning, reactions, and experiences of their problems. The therapist’s interest and curiosity can gradually encourage the patient’s self-exploration and narratives, and promote a collaborative alliance. Highlighting connections and contrasts—for example, between self-enhancement and competence versus vulnerability and failure—can help the patient overcome shame. Nonjudgmental exploration of resentment, envy, and aggressivity can promote self-reflection. Questions can be rejected by the patient without causing a breach in the alliance, and remain unprocessed or avoided until circumstances and/or patient’s mental processing promote reactivation of the specific topic. Questions also tend to activate and engage the patient, and allow dimensions of contrasts, complexities, and contradictions to unfold, which gradually can be integrated in a more solid alliance that promotes the patient’s sense of identity. The second strategy involves narration and forming of self-narratives. Narration can be an emerging, progressive process within the therapeutic alliance that integrates self-knowledge, psychophysiological sensations, and emotional experiences with verbalization and reflective ability. Capacity to narrate, understand, and integrate internal processes or significant life experiences can be key to adaptive identity development and to a more differentiated flexible view of self and ability for self-regulation. Forming a coherent narrative can strengthen affect regulation through emotional awareness and reflectivity. It can incorporate both affects and cognition, and it can highlight the interactional nature of cognitive and emotional processes. By engaging the patient’s reflective ability while at the same time attending to and sustaining INTERNAL PROCESSING IN PATIENTS WITH NPD 99 affective experiences, an integration of emotional and cognitive elements of dysregulated states can be possible (Angus & Kagan, 2013; Pasupathi et al., 2015). The awareness of affective states means that emotions become the focus of real-time reflectivity, which can lead to characterological change. In other words, articulation and consolidation of an emotionally coherent self-narrative becomes an important part of the therapeutic change process. Reflective inquiries in the therapy provide opportunities to deconstruct limiting cultural and social norms, and heighten sense of personal agency for constructing new personal meaning and self-coherent narratives (Angus & Kagan, 2013; Pasupathi et al., 2015). However, in cases of severe narcissistic personality functioning, narration combined with pseudo- or hyper-mentalization can also be used as a way to maintain distance, establish a pseudo-alliance, and preserve internalized grandiosity. Such case narratives can be self-defining, compartmentalized, and remain inaccessible to processing in therapy, and can require a different therapeutic strategy with balancing clarification, exploration, and confrontation over time. An integral part of these strategies is the therapist’s active and engaging listening to the patient. Providing space and attention in the alliance can enable access to and integration of the patient’s internal processing. However, it is important to identify the difference between patient’s tendencies to retreat into avoidant detached monologues and to engage in reflective processing and narration. In the phase of alliance building, the therapist becomes a vehicle for promoting the patient’s self-reflective ability. The therapist takes on a symbolic role in the patient’s processing and correcting of internalized experiences and patterns. In this phase, countertransference may not be a reliable source of information about the patient’s internal processing. Maldonado (2005) points to the failure of interpreting and the risk for distorting or misinterpreting unconscious processes and acts based on countertransference, which can negatively impact curiosity and symbolization in patients with PN or NPD. CONCLUSIONS The aim of this article has been to outline and discuss the complexity of internal processing in PN and NPD and to point to the impact of internal processing on these patients’ interpersonal behavior and relativeness. In addition, internal processing was specifically related to the DSM diagnostic traits and features. Recent research has pointed to a range of complexities and deficits that especially influence emotion processing, reactivity, and selfesteem. Emotion dysregulation including aggression and self-criticism can affect self-esteem and lead to self-enhancing (entitled, admiration seeking) or dismissive interactions. Compromised capacity to feel, identify, tolerate, or process feelings can contribute to intense preoccupation and reactivity, or to an inability to interactively integrate emotions. Emotional experiences in the present can relate to and activate past psychological emotional trauma and contribute to shame, affect intolerance, and psychophysiological reactivity, leading to avoidance and withdrawal. Fear of exposure, failure, and losing 100 RONNINGSTAM control due to feeling emotionally overwhelmed can lead to drastic actions such as substance use or suicide. The internal processing in patients with PN or NPD can remain hidden and out of reach. Consequently, it is increasingly important to adjust alliance building, therapeutic strategies, and interventions to optimally access and integrate the patient’s specific internal processing. Further research and clinical studies are needed to identify indicators of internal processing in NPD. 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