Therapist responses and therapeutic alliance in the psychotherapy of adolescent patients with narcissistic personality disorder: An empirical investigation

Aim: Although the clinical literature on countertransference reactions and therapeutic alliance with adolescent patients with personality pathology is quite extensive, the corresponding empirical literature is limited. This study examined these relational variables in psychotherapy with adolescent patients with three subtypes of the narcissistic personality disorder (NPD). Methods: Fifty-eight clinicians completed the Psychodiagnostic Chart–Adolescent (PDC-A) of the Psychodynamic Diagnostic Manual (PDM-2), the Shedler-Westen Assessment Procedure-II for Adolescents (SWAP-II-A), the Therapist Response Questionnaire for Adolescents (TRQ-A), and the Working Alliance Inventory (WAI), to provide a comprehensive diagnostic assessment of adolescent patients in their care as well as to evaluate countertransference patterns and quality of alliance in their treatment. Results: The grandiose narcissistic subtype was negatively associated with warm/attuned therapist response and positively associated with angry/criticized and disengaged/hopeless responses. The fragile subtype was positively associated with overinvolved/worried 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. Discussion: This 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 adolescent patients and promote therapies tailored on their core psychological features.