Therapist responses and therapeutic alliance when treating adolescent patients with narcissistic personality disorder

Introduction: Although the clinical literature on countertransference reactions and the therapeutic alliance with adolescent patients with personality pathology is rich, the corresponding empirical literature is limited. This study examined these relational variables in psychotherapy with adolescent patients presenting with three specific subtypes of the narcissistic personality disorder (NPD). Method: Fifty-eight clinicians completed the Psychodiagnostic Chart—Adolescent, the Therapist Response Questionnaire for Adolescents, the Working Alliance Inventory, and the Shedler-Westen Assessment Procedure-II for Adolescents to assess, respectively, countertransference patterns, the quality of alliance, and the personality pathology of a patient in their care. Results: The results showed that the grandiose narcissistic subtype was negatively associated with warm/attuned response and positively associated with angry/criticized and disengaged/hopeless therapist responses. The fragile subtype was positively associated with overinvolved/worried therapist response. The high-functioning/exhibitionistic subtype was negatively associated with angry/criticized response. Moreover, the grandiose subtype was positively related to lower quality of therapeutic alliance, that was negatively related to the high functioning/exhibitionistic subtypes. No significant association was found between therapeutic alliance and the fragile subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resembles theoretical-clinical accounts. Conclusions: The study provides a nuanced view of countertransference reactions evoked by adolescent patients with specific NPD subtypes, and extends knowledge on therapeutic alliance in their treatment. Therapists could use the information derived from the therapeutic relationship to generate clinically meaningful diagnosis of and promote therapies tailored on their core psychological features.