Transference-focused psychotherapy for pathological narcissism: The hybrid case study of “Daniel”

Pathological narcissism reflects an impaired capacity to maintain and regulate healthy self-esteem. Maladaptive compensatory strategies manifest affectively and interpersonally, compromising functioning across domains (Pincus & Lukowitsy, 2010; Sasso et al., 2021). Transference-Focused Psychotherapy (TFP) is a manualized and empirically supported intervention for personality pathology based on contemporary object relations theory, and it has proven effective in the treatment of pathological narcissism by facilitating identity consolidation and helping patients to integrate split-off aspects of the self (Caligor et al., 2018). This case study provides an overview of narcissistic pathology as it appears in psychodynamic literature, with particular attention paid to the role of shame dynamics. Using the hybrid case example of “Daniel,” a male patient organized at the borderline level of functioning, this study highlights the benefits and challenges of working with shame to address the vulnerable phenotypic expression of narcissistic pathology (Cain et al., 2008; Kernberg, 1967). Daniel’s case is based on the author’s real, deidentified psychotherapy patients as well as clinical illustrations found in relevant literature (Shepherd, 2022). Adhering to the format of a pragmatic case study as outlined by Fishman (1999, 2013, 2017), Daniel’s case explores the role of shame in the etiology and expression of pathological narcissism while also examining these dynamics through the lens of relational and developmental trauma, which is beyond the scope of TFP. The study is intended to serve as a resource for clinicians seeking to more effectively conceptualize and treat pathological narcissism through shame- and trauma-informed practice.