Ronningstam, E., & Weinberg, I. (2023) | References

Core Concept

The Question That Haunts Both Clinicians and Survivors

Few questions in personality disorder research carry as much weight as whether narcissists can change. For clinicians, it determines whether intensive treatment is worthwhile. For survivors, it shapes the agonising decision of whether to stay or leave, whether to hope or grieve. Ronningstam and Weinberg's 2023 paper addresses this question with the nuance it deserves, drawing on decades of clinical experience at McLean Hospital and emerging research on personality change processes.

The authors' answer is neither the therapeutic nihilism that long dominated the field nor the naive optimism that enables prolonged abuse. Genuine personality change in narcissistic personality disorder is possible, they argue, but it is rare, difficult, and requires very specific conditions that most narcissists never meet. Understanding what change actually looks like, what it requires, and how to recognise it provides a framework far more useful than simple optimism or despair.

Distinguishing Genuine Change from Strategic Adaptation

A critical contribution of this paper is the distinction between genuine personality change and the superficial modifications narcissists readily display. Narcissists are skilled at strategic adaptation when facing consequences. They can apologise without remorse, promise change they do not intend, and temporarily modify behaviour when necessary to preserve narcissistic supply. Partners and family members often mistake these adaptations for evidence of growth, only to experience devastation when old patterns reassert themselves once the crisis passes.

Ronningstam and Weinberg identify specific markers that distinguish genuine change. In self-experience, real change involves increased capacity to recognise and tolerate painful emotions, particularly shame, without defensive collapse or externalisation. The grandiose self-image begins to be experienced as discrepant from actual feelings rather than as reality. Reliance on external validation decreases as internal resources for self-esteem regulation develop. These changes manifest in the therapeutic relationship before generalising to other contexts, making the therapy itself a testing ground for transformation.

The Phases of Treatment

The paper describes treatment as unfolding through recognisable phases, each presenting distinct challenges and opportunities. The initial phase focuses on establishing a therapeutic alliance that can survive the narcissist's characteristic patterns of idealisation and devaluation. The therapist must engage genuinely while maintaining appropriate boundaries, neither colluding with grandiosity nor triggering defensive rage through premature confrontation.

As alliance strengthens, the middle phase involves gradual development of the patient's capacity to observe their own patterns with some objectivity. This self-reflective capacity, often called mentalisation, is typically impaired in NPD. The narcissist has difficulty holding in mind that they have a mind, that their perspectives are perspectives rather than reality, that others have valid internal experiences. Therapy cultivates this capacity through consistent attention to the patient's moment-to-moment experience, particularly when narcissistic injury is triggered.

Later phases involve working through the grief and shame beneath grandiosity. This is often the most painful part of treatment, as the patient begins to recognise the costs of their patterns: relationships destroyed, children damaged, decades spent defending against rather than living life. Clinicians must hold space for this grief while preventing collapse into despair. New relational capacities are tested first in the therapeutic relationship, then gradually extended to other contexts.

The Central Role of the Therapeutic Alliance

Ronningstam and Weinberg emphasise the therapeutic alliance as both the vehicle for change and its testing ground. The narcissistic patient will inevitably attempt to recreate familiar patterns in therapy: idealising the therapist initially, then devaluing when expectations are not met; demanding special treatment; treating the therapist as an extension of their needs rather than a separate person; responding to perceived slights with rage or withdrawal. These are not obstacles to treatment but its primary material.

The therapist's task is to survive these enactments without retaliation or collapse, demonstrating that relationships can withstand conflict and disappointment. When the therapist can acknowledge mistakes without defensive collapse, the patient encounters something new: a relationship partner who can tolerate imperfection. When the therapist maintains care despite devaluation, the patient begins to question the inevitability of the cycle. These repeated experiences, accumulated over years, gradually modify the internal templates that organise the narcissist's relationships.

Original Context

The Empirical Challenge of Studying NPD Treatment

Research on narcissistic personality disorder treatment faces formidable methodological challenges that Ronningstam and Weinberg acknowledge directly. Narcissists rarely volunteer for research studies, and those who do may differ systematically from the broader population with NPD. Dropout rates are high, often exceeding fifty percent, making longitudinal follow-up difficult. The patients most likely to complete treatment may be those with less severe presentations or more vulnerable features, biasing outcome data toward optimism.

Self-report measures are particularly problematic with this population. Narcissists are skilled at impression management and may report improvement strategically rather than reflecting genuine internal change. They may lack insight into their own patterns, reporting positive self-regard that reflects grandiosity rather than healthy self-esteem. Clinician-rated measures help but introduce their own biases, particularly regarding countertransference. Ronningstam and Weinberg note that the field needs better outcome measures specifically designed for personality change processes, not just symptom reduction.

Clinical Wisdom and Systematic Observation

Given these empirical limitations, the paper draws heavily on accumulated clinical wisdom from decades of specialised practice. McLean Hospital's Gunderson Residence has treated personality disorder patients since the 1980s, providing a unique vantage point for observing change over years and decades. This is not the same as controlled trial evidence, and the authors do not claim otherwise. But careful clinical observation of hundreds of patients over time generates pattern recognition that randomised trials cannot yet provide.

Ronningstam and Weinberg integrate this clinical wisdom with emerging research on specific mechanisms: emotion regulation development, mentalisation capacity, attachment pattern modification, and the neuroscience of personality change. While full empirical validation remains elusive, the convergence of clinical observation and mechanism research suggests their framework captures something real about how change occurs when it occurs.

The Influence of Treatment Modality

The paper does not advocate for a single therapeutic approach but examines common elements across different modalities that show promise with narcissistic patients. Transference-Focused Psychotherapy (TFP), developed from Kernberg's work, addresses narcissism through systematic interpretation of defensive patterns as they emerge in the therapeutic relationship. Self-psychology approaches, following Kohut, emphasise empathic attunement to the narcissist's fragile self-esteem. Schema Therapy applies cognitive-behavioural methods to the early maladaptive schemas underlying narcissistic patterns. Modified Mentalisation-Based Treatment focuses on developing reflective capacity.

Ronningstam and Weinberg observe that successful treatment across modalities shares certain features: prioritisation of the therapeutic alliance, careful attention to shame sensitivity, balance of validation and challenge, focus on the here-and-now therapeutic relationship as the primary arena for change, and acceptance of the long time horizon required. Theoretical orientation matters less than the therapist's capacity to implement these principles consistently over years of difficult work.

The Spectrum of Narcissistic Presentation

The paper distinguishes between grandiose narcissism and vulnerable narcissism in discussing treatment prognosis. Grandiose narcissists present with overt superiority, open demands for admiration, and dismissal or rage in response to challenge. They rarely seek treatment because they perceive no internal problem; any difficulties are attributed to others' inadequacy or malice. When they do enter therapy, often due to external pressure or crisis, they are prone to treating it as another arena for self-display rather than genuine engagement.

Vulnerable narcissists hide grandiosity behind apparent insecurity, seeking validation through victimhood or special suffering. They experience their patterns as distressing, presenting with depression, anxiety, or relationship pain that motivates treatment-seeking. Their acknowledgment of suffering provides a therapeutic opening absent in purely grandiose presentations. However, their sensitivity to shame makes the therapeutic process intensely painful, with constant risk that narcissistic injury will trigger dropout.

Many patients show mixed presentations, with grandiose surfaces concealing vulnerable depths that emerge as trust develops in treatment. The therapeutic task is to access the vulnerability beneath grandiosity without triggering defensive collapse, a delicate balance that requires considerable clinical skill.

For Survivors

What This Research Tells You About the Narcissist in Your Life

If you are reading this hoping to understand whether the narcissist who harmed you could change, Ronningstam and Weinberg's research offers a framework for thinking through this question honestly. The answer is not simple, but it can guide your decisions.

First, understand that change requires conditions entirely outside your control. The narcissist must recognise internally, not just say, that their patterns cause problems. They must voluntarily commit to specialised, intensive psychotherapy, typically twice weekly for years. They must maintain this commitment through inevitable periods when therapy feels unbearable, when their defenses are challenged, when they want to flee. They must find a therapist skilled in personality disorder work, which remains relatively rare. None of these conditions depends on you. No amount of love, patience, explanation, or sacrifice on your part creates these conditions. The narcissist either does this work or does not.

Second, recognise what genuine change looks like according to this research. If the narcissist in your life claims to have changed, evaluate against these markers: Can they acknowledge their behaviour caused harm without defensive justification or blame-shifting? Do they show genuine empathy for your experience, not just intellectual understanding but actual emotional resonance with your pain? Can they hear feedback without narcissistic rage or collapse? Have these capacities remained stable over time, through stress and conflict, or do they appear only during honeymoon periods? Does their relationship with a therapist show the characteristics described here, including weathering difficult periods without premature termination?

Third, understand the timeline. If the narcissist claims transformation after weeks or months, what you are witnessing is almost certainly strategic adaptation rather than personality change. Genuine change, as Ronningstam and Weinberg describe it, unfolds over years and is marked by ongoing struggle rather than sudden resolution. The person who claims complete transformation quickly is demonstrating not change but the familiar pattern of grandiose self-presentation.

Why Your Love Could Not Fix Them

Many survivors carry profound guilt, wondering if they could have prevented the damage by loving better, explaining more clearly, or staying longer. Ronningstam and Weinberg's research addresses this directly: the change process, when it occurs, requires internal motivation that comes from the narcissist's own suffering, not external love from others. Partners and family members can provide context in which change might occur, but they cannot cause it. This is not failure on your part. It is the structure of personality disorder.

The narcissist's core difficulty is their relationship with themselves: the false self constructed to ward off unbearable shame, the inability to access authentic emotional experience, the terror of vulnerability that makes genuine intimacy impossible. These internal structures cannot be reached by external love, no matter how genuine. The therapist reaches them not through loving more but through creating a specific kind of relationship, one with clear boundaries, professional structure, and interpretive skill, that allows the patient's patterns to emerge safely for examination. This is not a role partners or family members can play, however much they might wish to.

Making Decisions Without Waiting for Change

Perhaps the most important implication of this research is that survivors should make decisions based on current reality, not hypothetical future change. Ronningstam and Weinberg's framework can help you assess whether change is occurring, but if there are no signs of the conditions and processes they describe, change is almost certainly not occurring. Waiting for something that shows no signs of beginning is waiting for something that will likely never come.

This does not mean change is impossible. But if the narcissist in your life has not sought specialised treatment voluntarily, has not maintained engagement over years, has not demonstrated the specific markers of change described here, then their current patterns are your best predictor of their future patterns. You can hold space for the possibility of change while making decisions that protect yourself based on what actually is.

If you are the adult child of a narcissistic parent, this research may help you understand why your parent did not change despite your best efforts throughout childhood. You could not have caused their change. Their failure to change was not your failure. Understanding this can release the guilt that often accompanies recognition that no amount of accommodation or achievement ever produced the loving parent you deserved.

For Clinicians

Preparing for Narcissistic Patient Work

Ronningstam and Weinberg offer clinicians a realistic preview of what narcissistic patient work entails. This is not work for everyone, and there is no shame in recognising that it is not suited to your practice. Those who do engage should expect a distinctive experience marked by intense countertransference, repeated ruptures, and progress that is slow, nonlinear, and often invisible until viewed retrospectively.

Initial idealisation is common and seductive. The narcissistic patient may present you as uniquely understanding, finally the right therapist after a series of failures. They may credit you with special qualities, hang on your words, express gratitude that feels genuine. Enjoy this phase with appropriate skepticism, because it will shift. When you inevitably disappoint, fail to provide unlimited admiration, or challenge defensive patterns, devaluation follows. You become incompetent, unhelpful, just like all the others. Your task is to survive this devaluation without retaliating or withdrawing, demonstrating that you remain committed even when not idealised.

Expect to feel used. Narcissistic patients often treat therapists as extensions of their needs rather than separate persons with their own perspectives. Your existence matters only insofar as it serves their self-esteem regulation. Sessions may feel like performances where you are audience, or battles where you are opponent, rather than collaborative work. Expect to feel controlled, as the patient attempts to dictate session content, timing, boundaries. Expect to feel invisible, as your personhood disappears behind the function you serve.

Maintaining Therapeutic Stance

The paper emphasises empathy for the wounded person beneath the grandiosity without colluding with the false self. This balance is difficult to maintain. Too much validation of grandiosity reinforces defensive structure; too much challenge triggers defensive collapse or flight. Ronningstam and Weinberg recommend addressing shame sensitivity carefully, allowing patterns to emerge in the relationship rather than interpreting them prematurely. When you do offer interpretations, frame them as curiosity about the patient's experience rather than pronouncements about their character.

Boundaries require special attention. Narcissistic patients often request or demand special treatment: extended sessions, outside-hours contact, exceptions to standard policies. These demands test whether you can be controlled, and whether you maintain your separate identity under pressure. Consistent boundary maintenance, without punitiveness or rigidity, provides the structure within which genuine relating can eventually develop. When you maintain boundaries and the patient does not terminate, an important learning occurs: relationships can include limits and still continue.

Consultation is not optional for this work. The intensity of countertransference, including temptations to rescue, retaliate, or give up, requires regular processing with colleagues. The isolation that narcissistic patients can induce in therapists mirrors the isolation they create in other relationships. Consultation prevents acting out, provides perspective on subtle dynamics, and maintains the clinician's wellbeing through difficult cases.

Assessing Change Over Time

Ronningstam and Weinberg's framework provides specific markers for assessing therapeutic progress. Early changes may be visible only in session: the patient tolerates a challenging interpretation without rage, acknowledges uncertainty about their own motivations, expresses curiosity about your perspective. These micro-moments accumulate over months and years into recognisable shifts. The patient who once experienced feedback as attack begins to consider it. The patient who treated you as extension begins to acknowledge your separateness.

Changes in the patient's life outside therapy follow changes in the therapeutic relationship. Improved capacity for empathy, tested first in sessions, may eventually manifest in family relationships. Reduced reliance on narcissistic supply, observed first in decreased need for therapist admiration, may gradually extend to other contexts. The therapeutic relationship serves as laboratory for new relational capacities, which then generalise imperfectly and gradually to the wider world.

Setbacks are expected and do not necessarily indicate treatment failure. The patient who seemed to progress may regress under stress, when old patterns feel safer than new ones. Narcissistic injury from life events can trigger defensive grandiosity that temporarily obscures gains. The key question is whether the relationship survives, whether the patient returns to therapeutic work after regression, whether patterns of rupture and repair are themselves changing over time. Treatment that ends well may include many periods that felt like failure.

Broader Implications

The Limits of Current Mental Health Systems

Ronningstam and Weinberg's framework has sobering implications for mental health policy and service delivery. The treatment they describe, twice-weekly intensive psychotherapy for years with a specialist clinician, exceeds what most healthcare systems provide. Insurance typically limits session frequency and duration. Community mental health systems prioritise acute crisis over long-term personality work. Wait times for personality disorder specialists can extend for months. The treatment most likely to help narcissistic patients is the treatment least likely to be available.

This creates a stark access divide. Patients with resources, financial stability, flexibility in their schedules, proximity to academic medical centres, can access specialised treatment. Patients without these resources encounter systems designed for acute symptom relief rather than personality change. The narcissistic patients most likely to harm others, those in low-resource contexts without treatment access, are also least likely to receive intervention.

Policy solutions might include training more clinicians in personality disorder work, developing stepped-care models that match intensity to severity, and advocating for insurance coverage that reflects the actual timeline of personality change. Until such changes occur, the treatment evidence base applies to a narrower population than the full range of people with NPD.

Implications for Family Court and Custody Evaluation

Family courts regularly encounter narcissistic parents in high-conflict custody disputes. Ronningstam and Weinberg's framework has implications for how these cases should be assessed and decided. Narcissistic parents often present well in evaluation settings, using impression management skills to appear reasonable and caring. Short-term compliance with parenting plans may reflect strategic adaptation rather than genuine change. Courts should be skeptical of claims of transformation without evidence of the specific treatment process described here.

Custody evaluators trained in personality disorder assessment can look for the markers Ronningstam and Weinberg identify. Has the parent engaged in appropriate treatment voluntarily? Has treatment continued for sufficient duration? Does the parent show genuine empathy for the child's experience, including the child's relationship with the other parent? Can the parent acknowledge their own contribution to conflict without defensive projection? These questions, informed by the research on what change actually requires, can distinguish genuine progress from strategic performance.

Parenting plans should reflect realistic expectations about the narcissistic parent's capacity for child-focused decision-making. Joint custody arrangements that require high cooperation may be inappropriate when one parent cannot perceive the child as a separate person with their own needs. Protection of children may require accepting that treatment recommendations, even if ordered, may not produce the change that would make flexible arrangements safe.

Workplace Implications

Narcissistic leaders are increasingly recognised as destructive to organisations, yet they often rise to positions of authority because their grandiosity impresses superiors and their willingness to take credit advances their careers. Ronningstam and Weinberg's framework suggests what organisations can expect from leadership coaching or mandated therapy for narcissistic executives: strategic compliance without genuine change unless the specific conditions for change are present.

Executive coaching, unlike intensive psychotherapy, typically lacks the duration, frequency, and therapeutic depth that personality change requires. The narcissistic leader in coaching may learn to modulate behaviour in obvious ways while maintaining exploitative patterns underneath. Organisations should not mistake behavioural coaching for personality treatment and should design systems, distributed authority, anonymous feedback, clear accountability, that limit damage regardless of whether individual leaders change.

Educational Implications

Mental health training programmes often provide inadequate preparation for personality disorder work generally and NPD specifically. Many clinicians graduate without exposure to the nuances Ronningstam and Weinberg describe, leading them either to avoid narcissistic patients entirely or to apply inappropriate treatments. Standard psychotherapy techniques, developed for patients who acknowledge problems and engage collaboratively, may be ineffective or harmful with narcissistic presentations.

Training programmes might consider developing specialised tracks for personality disorder treatment, ensuring all trainees have supervised experience with personality-disordered patients, and teaching the specific modifications required for narcissistic presentations. Continuing education opportunities for practicing clinicians could address this gap, though reaching clinicians who avoid personality disorder work presents its own challenges.

Research Directions

The paper points toward needed research that could advance the field. Better outcome measures for personality change, not just symptom reduction, would allow more rigorous study. Dismantling studies identifying which treatment components produce which effects could guide efficiency improvements. Neurobiological research on brain changes during successful treatment could validate clinical observations and perhaps predict treatment response. Prospective studies following patients through treatment, rather than retrospective case series, would provide stronger evidence, though the practical challenges are formidable.

Research on prevention represents perhaps the most promising direction. If we could identify at-risk individuals before narcissistic personality fully consolidates, earlier intervention might be more effective than treatment of established disorder. Understanding the developmental pathways that produce NPD could inform parenting interventions, early childhood programmes, and school-based approaches that reduce transmission to the next generation.

FAQs

Foundational Questions

What specifically did this research study?

Ronningstam and Weinberg synthesised decades of clinical experience treating narcissistic personality disorder patients at McLean Hospital with emerging research on personality change processes. The paper identifies patterns that characterise successful long-term psychotherapy for NPD, distinguishing genuine personality change from superficial behavioural modification. The authors describe the phases of treatment, the critical role of the therapeutic alliance, and specific observable markers that indicate real progress. Rather than a single controlled study, this represents comprehensive clinical wisdom integrated with theoretical and empirical advances in understanding how narcissistic patients change when they change.

How is this research different from previous work on NPD treatment?

Earlier clinical literature on NPD treatment often polarised between nihilism, claiming narcissists cannot change and should not be treated, and naive optimism, applying standard psychotherapy without recognising the special challenges NPD presents. Ronningstam and Weinberg chart a middle path grounded in realistic assessment of what change requires. Their contribution includes specific markers distinguishing genuine change from strategic adaptation, detailed description of treatment phases, and clear articulation of the conditions under which change becomes possible. This practical framework guides clinical decision-making in ways earlier theoretical discussions did not.

What are the key limitations survivors should understand?

Survivors should understand that this research describes change under optimal conditions: specialised treatment, skilled clinicians, patient motivation, and years of commitment. Most narcissists never meet these conditions. The research describes what is possible, not what is probable. Additionally, the evidence base relies substantially on clinical observation rather than controlled trials, meaning specific claims about effectiveness await stronger validation. Survivors should use this framework to assess whether change is occurring, not to maintain hope that change will inevitably occur.

Applied Questions

How can I tell if the narcissist in my life is genuinely changing?

Look for the specific markers Ronningstam and Weinberg identify: Can they acknowledge harm caused without defensive justification? Do they show genuine empathy, not just intellectual understanding, for your experience? Can they hear feedback without rage or collapse? Has treatment continued through difficult periods, including the desire to quit? Have new capacities remained stable over time and stress, not just appearing during honeymoon periods? Strategic adaptation looks like change initially but fails these tests over time. Genuine change unfolds slowly and is marked by struggle, not sudden transformation.

Should I wait for the narcissist to change before making decisions about the relationship?

Ronningstam and Weinberg's framework suggests making decisions based on current reality while remaining open to revising if genuine change occurs. If the narcissist has not engaged in appropriate treatment voluntarily, has not maintained treatment through years of difficult work, and has not demonstrated the specific markers of change, then their current patterns are the best predictor of their future patterns. You can hope for change while making protective decisions based on what actually is. Waiting for change that shows no signs of beginning is waiting for something that may never come.

What should I expect if I am a clinician beginning work with a narcissistic patient?

Expect initial idealisation that will shift to devaluation. Expect challenges to your competence and boundaries. Expect to feel used, controlled, or invisible at times. Expect intense countertransference requiring regular consultation. Expect negative therapeutic reactions where the patient worsens during progress. Expect a multi-year commitment with many opportunities for the patient to leave. Expect that despite all this, genuine transformation remains possible with patients who sustain the relationship through these challenges. This is demanding work that is not for everyone, and there is wisdom in recognising if it is not suited to your practice.

What predicts whether a narcissistic patient will benefit from treatment?

Several factors influence prognosis. Vulnerable narcissistic presentations, where the patient experiences their patterns as distressing, predict better engagement than purely grandiose presentations where the patient sees no problem. Motivation that comes from internal suffering rather than external pressure predicts better outcomes. Capacity to maintain the therapeutic relationship through narcissistic injuries, rather than terminating when challenged, is essential. History of some capacity for attachment, even if troubled, suggests better prognosis than complete incapacity for connection. Younger age may offer advantage, as personality patterns become more entrenched over time.

How does this research apply to narcissistic parents specifically?

The research has particular relevance for adult children of narcissistic parents wondering whether their parent could change. The framework suggests that parental change would require the parent to seek treatment voluntarily, not because the adult child requests it, to acknowledge that their parenting caused harm, and to maintain years of difficult therapeutic work. Most narcissistic parents never meet these conditions. Adult children can release guilt about their parent's failure to change by understanding that change was never within their control. They can assess whether current relationship with the parent is safe based on observable behaviour rather than hope for future transformation.

What role does the partner or family member play in the narcissist's change process?

Ronningstam and Weinberg's framework suggests that partners and family members cannot cause the narcissist to change, but they can affect the context in which change might occur. Setting clear boundaries, following through on consequences, and refusing to provide unlimited narcissistic supply can contribute to the crisis that sometimes motivates treatment-seeking. However, once treatment begins, the change process occurs between the narcissist and their therapist, not between the narcissist and their family. Family members may be involved in therapy at appropriate points but are not the agents of change. Understanding this can relieve the burden that family members often carry.

Are there alternatives to long-term intensive psychotherapy for NPD?

Ronningstam and Weinberg focus on long-term psychotherapy because that is where evidence for personality change exists. Shorter-term interventions may produce behavioural modification but are unlikely to produce the deeper personality shifts the paper describes. Medication addresses co-occurring symptoms like depression or anxiety but does not treat the personality disorder itself. Group therapy, while potentially helpful, is complicated by the narcissist's tendency to compete for attention and devalue other group members. The honest answer is that there are no quick solutions to NPD, and claims of rapid transformation should be viewed skeptically.

Historical Context

The publication of this paper in 2023 represents a significant moment in the evolution of NPD treatment understanding. For decades, clinical literature oscillated between extremes. The nihilistic view, prominent through much of the twentieth century, held that narcissistic personality disorder was essentially untreatable. Narcissists lacked the capacity for the self-reflection and relationship engagement that therapy requires. The grandiose defenses that defined the disorder prevented the very vulnerability that healing would demand. Many clinicians simply refused to work with narcissistic patients.

The optimistic view, emerging particularly in popularised self-help contexts, suggested that narcissists could change if loved correctly, confronted skillfully, or given the right therapy. This view often underestimated the structural depth of narcissistic pathology and the difference between strategic behavioural adaptation and genuine personality change. It left partners and family members trapped in cycles of hope and disappointment, waiting for transformation that surface changes seemed to promise but that never materialised.

Ronningstam's career has spanned this evolution. Her 2005 book, Identifying and Understanding the Narcissistic Personality, established the clinical framework that continues to dominate the field. Her subsequent work has focused increasingly on treatment, particularly the question of what actually produces change. The 2023 paper with Weinberg represents the culmination of this trajectory, offering the most detailed account yet of how change unfolds when it occurs.

The paper also responds to advances in personality disorder treatment more broadly. The validation of Dialectical Behaviour Therapy for borderline personality disorder, the development of Transference-Focused Psychotherapy and Mentalisation-Based Treatment, and growing research on personality change mechanisms have created context for more hopeful engagement with personality pathology. Ronningstam and Weinberg extend this hope to NPD while maintaining realistic acknowledgment of the disorder's particular challenges.

Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy

APA Citation