Assignment: Therapy for Clients With Personality Disorders- Narcissistic Personality Disorder

Briefly describe narcissistic personality disorder, including the DSM-5 diagnostic criteria.
Explain a therapeutic approach and a modality to treat a client presenting with this disorder. Explain why the approach and modality was selected, justifying their appropriateness.
Next, briefly explain what a therapeutic relationship is in psychiatry. Explain how to share your diagnosis of this disorder with the client in order to avoid damaging the therapeutic relationship. Compare the differences in how to share this diagnosis with an individual, a family, and in a group session.

APA FormatNo Plagiarism

Journal of Psychotherapy Integration

Treatment Principles for Pathological Narcissism and Narcissistic
Personality Disorder

Giancarlo Dimaggio
Online First Publication, September 2, 2021. http://dx.doi.org/10.1037/int0000263

CITATION
Dimaggio, G. (2021, September 2).

Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder

.
Journal of Psychotherapy Integration . Advance online publication. http://dx.doi.org/10.1037/int0000263

Treatment Principles for Pathological Narcissism and Narcissistic
Personality Disorder

Giancarlo Dimaggio
Centro di Terapia Metacognitiva Interpersonale, Rome, Italy

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

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

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

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

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

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

Correspondence concerning this article should be
addressed to Giancarlo Dimaggio, Centro di Terapia
Metacognitiva Interpersonale, Piazza dei Martiri di Belfiore
4, 00151 Rome, Italy. Email: gdimaje@gmail.com

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

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

mailto:gdimaje@gmail.com

https://doi.org/10.1037/int0000263

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

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

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

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

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

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

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

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

2 DIMAGGIO

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

Narcissistic Psychopathology

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

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

PN and NPD Psychopathology

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

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

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

Maladaptive Representations of Self
and Others

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

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 3

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

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

Impaired Self-Reflective Capacities and
Tendency to Intellectualize

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

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

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

Agency Disturbances

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

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

4 DIMAGGIO

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

Poor Theory of Mind and Empathy

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

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

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

Maladaptive Coping and Defenses

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 5

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

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

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

Principles for an Integrated Therapy Based
on Narcissistic Psychopathology

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

intellectualizing;
b) reducing the impact of maladaptive schemas

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

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

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

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

6 DIMAGGIO

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

Promoting Self-Reflection and Reducing
Intellectualizing

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

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

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

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

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

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

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

Dealing with Maladaptive Schemas

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 7

Pragmatic Suggestions: Working Through
the Therapy Relationship

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

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

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

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

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

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

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

8 DIMAGGIO

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

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

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

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

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 9

Promoting Agency

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

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

Pragmatic Suggestions: Negotiating the
Contract

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

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

on problems in the contract helped to face the
agencyproblem.

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

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

10 DIMAGGIO

ever and is making significant steps in pursuing a
career.

Pragmatic Suggestions: Use Tailored
Behavioral Assignments

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

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

Reducing Maladaptive Coping and
Promoting Healthy Behaviors

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

Pragmatic Suggestions

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 11

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

Focusing on Strength, Resources and the
Healthy Self

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

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

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

Promoting Theory of Mind and Empathy

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

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

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

Conclusions

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

12 DIMAGGIO

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 13

https://doi.org/10.1521/pedi.2011.25.1.41

https://doi.org/10.1037/per0000061

https://doi.org/10.1371/journal.pone.0201216

https://doi.org/10.1016/j.paid.2016.07.020

https://doi.org/10.1037/pap0000066

https://doi.org/10.1176/appi.ajp.2014.14060723

https://doi.org/10.1521/pedi.2020.34.supp.104

https://doi.org/10.1093/scan/nsu072

https://doi.org/10.1080/07448481.2020.1762606

https://doi.org/10.3389/fpsyg.2020.01284

https://doi.org/10.1176/appi.ajp.2013.13020224

https://doi.org/10.1521/pedi.2020.34.supp.143

https://doi.org/10.1521/pedi_2018_32_350

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

14 DIMAGGIO

https://doi.org/10.1016/j.paid.2020.109921

https://doi.org/10.1521/pedi.2020.34.supp.159

https://doi.org/10.1002/jclp.22042

https://doi.org/10.1037/per0000065

https://doi.org/10.1002/jclp.21896

https://doi.org/10.1002/cpp.619

https://doi.org/10.3389/fnhum.2015.00325

https://doi.org/10.1016/j.comppsych.2018.03.005

https://doi.org/10.4324/9781315744124

https://doi.org/10.1080/10503300701881877

https://doi.org/10.4324/9780429350894

https://doi.org/10.4324/9780203939536

https://doi.org/10.1037/1053-0479.12.4.421

https://doi.org/10.1521/pedi.2020.34.supp.177

https://doi.org/10.1037/pspp0000370

https://doi.org/10.1016/j.paid.2014.10.051

https://doi.org/10.1097/PRS.0b013e3182131ec9

https://doi.org/10.4324/9780203003459-6

https://doi.org/10.1016/j.eatbeh.2010.08.004

https://doi.org/10.1037/10447-000

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 15

https://doi.org/10.1080/15298860902815451

https://doi.org/10.1177/0146167215611636

https://doi.org/10.3389/fnhum.2015.00013

https://doi.org/10.1037/0022-3514.66.1.206

https://doi.org/10.1053/comp.2001.19755

https://doi.org/10.1097/NMD.0000000000001114

https://doi.org/10.1521/pedi_2013_27_084

https://doi.org/10.1016/j.psychres.2017.06.009

https://doi.org/10.1007/s11920-020-01162-3

https://doi.org/10.1037/per0000438

https://doi.org/10.1037/pspp0000013

https://doi.org/10.1002/cpp.2467

https://doi.org/10.1016/j.paid.2019.109672

https://doi.org/10.1002/per.2110

https://doi.org/10.1037/a0038777

https://doi.org/10.1016/j.concog.2019.03.004

https://doi.org/10.1016/j.psychres.2011.12.042

https://doi.org/10.1097/NMD.0000000000000871

https://doi.org/10.1080/00107530.1986.10746118

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

16 DIMAGGIO

https://doi.org/10.1098/rspb.2010.0404

https://doi.org/10.1002/jclp.23105

https://doi.org/10.1007/s00221-012-3372-5

https://doi.org/10.1097/NMD.0000000000001054

https://doi.org/10.1037/0022-006X.75.6.875

https://doi.org/10.1521/pedi.2020.34.supp.204

https://doi.org/10.1146/annurev.clinpsy.121208.131215

https://doi.org/10.1037/per0000031

https://doi.org/10.1371/journal.pone.0214069

https://doi.org/10.1016/j.psychres.2010.09.013.

https://doi.org/10.1016/j.psychres.2013.11.019

https://doi.org/10.1037/0022-3514.80.2.340

https://doi.org/10.3928/00485713-20090301-09

https://doi.org/10.1097/PRA.0000000000000379

https://doi.org/10.1521/pedi.2020.34.supp.80

https://doi.org/10.1016/S0191-8869(00)00012-X

https://doi.org/10.4088/JCP.v69n0701

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

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

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

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

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

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

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

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

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

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

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

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

ReceivedJanuary17,2021
RevisionreceivedApril3,2021

AcceptedApril23,2021 n

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 17

https://doi.org/10.1521/pedi.2020.34.supp.42

https://doi.org/10.1080/00223891.2019.1674318

https://doi.org/10.1177/0265407518783096

https://doi.org/10.1177/0146167202239051

https://doi.org/10.1016/j.jrp.2020.104036

https://doi.org/10.1521/pedi.2020.34.supp.122

https://doi.org/10.3389/fpsyg.2019.00360

https://doi.org/10.1192/bja.2018.20

Personality Disorders: Theory, Research, and
Treatment

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

Sulamunn R. M. Coleman, Anthony C. Oliver, Elias M. Klemperer, Michael J. DeSarno, Gary S. Atwood, and Stephen T.
Higgins
Online First Publication, January 6, 2022. http://dx.doi.org/10.1037/per0000528

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

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

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

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

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

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

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

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

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

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

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

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

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

R. M. Coleman, Vermont Center on Behavior and Health, University of
Vermont, 1 South Prospect Street, Burlington, VT 05401, United States.
Email: sulamunn.coleman@uvm.edu

Personality Disorders: Theory, Research, and Treatment

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

https://orcid.org/0000-0002-0460-4632

mailto:sulamunn.coleman@uvm.edu

https://doi.org/10.1037/per0000528

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

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

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

Method

Search Strategy and Study Selection

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

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

Data Extraction

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

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

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

2 COLEMAN ET AL.

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

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

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

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

Figure 1
PRISMA Diagram of Included and Excluded Reports

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

DELAY DISCOUNTING AND NARCISSISM 3

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

Quality Assessment

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

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

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

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

Narcissism
measure

Narcissism
dimension

Narcissism mean
(SD) Correlation

Buelow and
Brunell

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

MCQ k CNBD NGS Grandiosity 50.44 (21.12) .172

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

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

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

Five delay
intervalsa

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

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

Seven delay
intervalsb

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

Malesza and
Kaczmarek

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

Seven delay
intervalsa

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

Seven delay
intervalsa

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

Malesza and
Kalinowski

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

Five delay
intervalsa

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

Malesza and
Kalinowski

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

Five delay
intervalsa

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

Malesza and
Ostaszewski

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

Five delay
intervalsa

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

NPI Grandiosity Men = 8.19
(2.20)

Women = 7.93
(2.54)

�.058

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

4 COLEMAN ET AL.

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Statistical Analysis

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

Results

Study Characteristics

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

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

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

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

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

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

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

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

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

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

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

DELAY DISCOUNTING AND NARCISSISM 5

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https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

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

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

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

Associations Between DD and Trait Entitlement or Trait
Vulnerability

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

Quality Assessment and Publication Bias

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

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

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

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

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

6 COLEMAN ET AL.

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

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

Discussion

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

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

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

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

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

DELAY DISCOUNTING AND NARCISSISM 7

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

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

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

Limitations

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

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

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

8 COLEMAN ET AL.

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

Conclusion

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DELAY DISCOUNTING AND NARCISSISM 9

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

https://doi.org/10.1177/1073191110382845

https://doi.org/10.1001/jamapsychiatry.2019.2102

https://doi.org/10.1016/j.copsyc.2019.01.005

https://doi.org/10.1080/15504260902869147

https://doi.org/10.1007/PL00005490

https://doi.org/10.1016/j.paid.2014.05.031

https://doi.org/10.1007/978-3-319-92171-6_25

https://doi.org/10.1207/s15327752jpa8301_04

https://doi.org/10.1521/pedi.2005.19.5.466

https://doi.org/10.1080/07448481.2020.1762606

https://doi.org/10.1037/pas0000281

https://doi.org/10.1111/jopy.12464

https://doi.org/10.1016/j.paid.2012.07.029

https://doi.org/10.1186/1741-7015-11-126

https://doi.org/10.1521/pedi_2016_30_260

https://doi.org/10.1136/bmj.315.7109.629

https://doi.org/10.1016/j.paid.2011.01.002

https://doi.org/10.1111/jopy.12148

https://doi.org/10.1037/per0000181

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10 COLEMAN ET AL.

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

https://doi.org/10.1037/a0038231

https://doi.org/10.1521/pedi_2019_33_433

https://doi.org/10.1016/j.paid.2020.110504

https://doi.org/10.1006/jrpe.1997.2204

https://doi.org/10.1177/1359105315569858

https://doi.org/10.1176/appi.ajp.2010.09091379

https://doi.org/10.1016/j.paid.2019.109755

https://doi.org/10.1037/a0019265

https://doi.org/10.1177/1073191113514105

https://doi.org/10.1037/0096-3445.128.1.78

https://doi.org/10.1177/1088868316685018

https://doi.org/10.1002/bdm.582

https://doi.org/10.1037/0893-164X.19.1.99

https://doi.org/10.1007/s00213-011-2229-0

https://doi.org/10.1037/12069-001

https://doi.org/10.1037/1064-1297.5.3.256

https://doi.org/10.1016/j.paid.2018.01.021

https://doi.org/10.1007/s12144-019-00320-y

https://doi.org/10.1007/s12144-019-00351-5

https://doi.org/10.1016/j.paid.2015.09.016

https://doi.org/10.1037/a0035084

https://doi.org/10.1016/j.paid.2012.09.006

https://doi.org/10.1177/1073191114522909

https://doi.org/10.1146/annurev-clinpsy-032816-045244

https://doi.org/10.1521/pedi_2015_29_177

https://doi.org/10.1901/jeab.2001.76-235

https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

https://doi.org/10.1016/j.paid.2020.110232

https://doi.org/10.1016/j.neuron.2010.03.026

https://doi.org/10.1146/annurev.clinpsy.121208.131215

https://doi.org/10.2466/pr0.1979.45.2.590

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

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

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

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

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

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

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

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

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

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

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

DELAY DISCOUNTING AND NARCISSISM 11

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s
do
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an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
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li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
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cl
e
is
in
te
nd
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le
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fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

https://doi.org/10.1177/1073191119858410

https://doi.org/10.1037/pas0000100

https://doi.org/10.3758/BRM.40.4.940

https://doi.org/10.1111/acer.13112

https://doi.org/10.1007/s00213-016-4410-y

https://doi.org/10.4088/JCP.v69n0701

https://doi.org/10.1016/j.pulmoe.2020.10.013

https://doi.org/10.1016/j.paid.2021.110696

https://doi.org/10.1016/j.copsyc.2017.10.001

https://doi.org/10.1016/j.paid.2020.110199

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

Method
Search Strategy and Study Selection
Data Extraction
Quality Assessment
Statistical Analysis
Results
Study Characteristics
Meta-Analyses (DD and Narcissism Overall or Trait Grandiosity)
Associations Between DD and Trait Entitlement or Trait Vulnerability
Quality Assessment and Publication Bias
Discussion
Limitations
Conclusion
References

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

R E S E A R C H

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

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

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

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

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

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

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

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

Open Access

*Correspondence: emis@uniwa.gr
1 Department of Nursing, Faculty of Health and Caring Professions,
University of West Attica, Saint Spiridonos 12243, Egaleo, Athens, Greece
Full list of author information is available at the end of the article

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Table 1 Themes and sub-themes

THEMES SUB-THEMES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

nurses underlined the stigma towards people and nurses
themselves.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Acknowledgements
All participants contributing to the study.

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

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

Funding
No funding received for this study.

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

Declarations

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

Consent for publication
Not applicable.

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

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

Received: 28 July 2021 Accepted: 9 November 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://doi.org/10.1111/ppc.12699

https://doi.org/10.1007/978-3-030-78771-4_15

https://doi.org/10.1007/978-3-030-78771-4_12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Containment and therapeutic relationships in acute psychiatric care spaces: the symbolic dimensions of doors

Abstract
Background:
Results:
Conclusions:
Introduction
The Greek context
Methods
Aim and study design
Participants & procedure
Ethical approval and conduct
Analysis
Results
Theme 1: the open door
Theme 2: the invisible door
Theme 3: the restraining door
Theme 4: the revolving door
Discussion
Limitations
Implications

Acknowledgements
References

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