Arts, Faculty of
Psychology, Department of
DSpace
UBCV
Ge, Sabrina Yue Jia
Master of Arts - MA
University of British Columbia
Background: Several decades of theory suggest that pathological narcissism may limit psychotherapy success, but empirical evidence for such theories is limited and mixed. In addition, despite theoretical and empirical associations between pathological narcissism and perfectionism, no studies thus far have investigated the impact of pathological narcissism on psychotherapy outcome for patients with perfectionism. Thus, this study aimed to extend past research by investigating whether pre-treatment pathological narcissism led to smaller pre- to post-treatment reductions in 1) symptom severity, 2) life satisfaction and, 3) work and social functioning in a sample of patients with perfectionism undergoing group psychodynamic psychotherapy. Method: This sample was drawn from the UBC Perfectionism Treatment Study (Hewitt et al., 2023) and consisted of 80 treatment-seeking adults with elevated perfectionism. Patients underwent 12 sessions of psychodynamic group psychotherapy for perfectionism and completed self-report measures of pathological narcissism at pre-treatment and of symptom severity, life satisfaction, and work and social impairment at pre- and post-treatment. Results: Contrary to expectations, multilevel and multiple regression analyses indicated that pre-treatment pathological narcissism did not significantly predict post-treatment changes in symptom severity, life satisfaction or work and social impairment. Additional analyses showed that these findings held even when vulnerable and grandiose dimensions of pathological narcissism were analyzed separately. Conclusions: Despite longstanding theoretical and clinical accounts on the perniciousness of pathological narcissism in the clinical context, these results, taken together with past findings, suggest that pathological narcissism may not be associated with poorer psychotherapy outcomes in certain contexts, such as in the case of psychodynamic group psychotherapy for perfectionism. Future research should investigate whether certain variables may moderate the relationship between pathological narcissism and treatment outcome.
THE IMPACT OF PATHOLOGICAL NARCISSISM ON CHANGE IN SYMPTOMS, LIFE SATISFACTION, AND WORK AND SOCIAL IMPAIRMENT IN PSYCHODYNAMIC GROUP THERAPY FOR PERFECTIONISM by SABRINA YUE JIA GE B.Sc., The University of British Columbia, 2020 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2023 © Sabrina Yue Jia Ge, 2023 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: The impact of pathological narcissism on change in symptoms, life satisfaction, and work and social impairment in psychodynamic group therapy for perfectionism submitted by Sabrina Yue Jia Ge in partial fulfilment of the requirements for the degree of Master of Arts in Psychology Examining Committee: Paul L. Hewitt, Professor, Psychology, UBC Supervisor Frances Chen, Associate Professor, Psychology, UBC Supervisory Committee Member David Kealy, Associate Professor, Psychiatry, UBC Supervisory Committee Member iii Abstract Background: Several decades of theory suggest that pathological narcissism may limit psychotherapy success, but empirical evidence for such theories is limited and mixed. In addition, despite theoretical and empirical associations between pathological narcissism and perfectionism, no studies thus far have investigated the impact of pathological narcissism on psychotherapy outcome for patients with perfectionism. Thus, this study aimed to extend past research by investigating whether pre-treatment pathological narcissism led to smaller pre- to post-treatment reductions in 1) symptom severity, 2) life satisfaction and, 3) work and social impairment in a sample of patients with perfectionism undergoing group psychodynamic psychotherapy. Method: This sample was drawn from the UBC Perfectionism Treatment Study (Hewitt et al., 2023) and consisted of 80 treatment-seeking adults with elevated perfectionism. Patients underwent 12 sessions of psychodynamic group psychotherapy for perfectionism and completed self-report measures of pathological narcissism at pre-treatment and of symptom severity, life satisfaction, and work and social impairment at pre- and post-treatment. Results: Contrary to expectations, multilevel and multiple regression analyses indicated that pre-treatment pathological narcissism did not significantly predict post-treatment changes in symptom severity, life satisfaction or work and social impairment. Additional analyses showed that these findings held even when vulnerable and grandiose dimensions of pathological narcissism were analyzed separately. Conclusions: iv Despite longstanding theoretical and clinical accounts on the perniciousness of pathological narcissism in the clinical context, these results, taken together with past findings, suggest that pathological narcissism may not be associated with poorer psychotherapy outcomes in certain contexts, such as in the case of psychodynamic group psychotherapy for perfectionism. Future research should investigate whether certain variables may moderate the relationship between pathological narcissism and treatment outcome. v Lay Summary People with pathological narcissism tend to engage in problematic interpersonal behaviours that can interfere with their likelihood of benefiting from psychotherapy. For example, patients with pathological narcissism can be manipulative, dismissive, and rude toward their therapists and, in the case of group therapy, towards other group members. These behaviours may negatively impact the patient’s relationships with their therapists and group members, which are important predictors and drivers of positive change in psychotherapy. In this study, I investigated whether more pathologically narcissistic patients were less likely to improve on mental health and relationship outcomes following group psychotherapy. Unexpectedly, I did not find any association between patients’ pathological narcissism and their likelihood of benefiting from treatment. This study may help to destigmatize therapists’ views on pathological narcissism by highlighting that people with pathological narcissism can benefit from certain therapies. vi Preface The project that formed the basis of this thesis is titled, “A Randomized Control Trial for Dynamic-Relational Group Treatment of Perfectionism”, designed by Dr. Paul L. Hewitt, with co-investigators Dr. David Kealy and Dr. Ingrid Sochting, and has been approved by the University of British Columbia’s Behavioural Research Ethics Board [certificate #H16-02815]. My involvement in the research project involved updating the ethics application and data collection. I identified the research question, designed the analytic approach, and performed all data analyses and writing for this thesis. vii Table of Contents Abstract .......................................................................................................................................... iii Lay Summary .................................................................................................................................. v Preface ............................................................................................................................................ vi Table of Contents .......................................................................................................................... vii List of Tables ................................................................................................................................. ix Acknowledgements ......................................................................................................................... x Introduction ..................................................................................................................................... 1 Conceptualizing Pathological Narcissism ................................................................................... 1 Theoretical Perspectives on Pathological Narcissism in the Clinical Context ........................... 2 Research on Pathological Narcissism and Psychotherapy Process ............................................. 4 Research on Pathological Narcissism and Psychotherapy Outcome .......................................... 6 Pathological Narcissism in Patients with Perfectionism ............................................................. 8 The Present Study ..................................................................................................................... 10 Method .......................................................................................................................................... 12 Participants ................................................................................................................................ 12 Measures ................................................................................................................................... 12 Pathological Narcissism ........................................................................................................ 12 Symptom Severity ................................................................................................................. 13 Life Satisfaction .................................................................................................................... 14 Work and Social Impairment ................................................................................................ 14 Procedure .................................................................................................................................. 15 Group Psychodynamic Psychotherapy Format ......................................................................... 16 Data Analytic Strategy .............................................................................................................. 16 Preliminary Analyses ............................................................................................................ 16 Descriptive Statistics & Bivariate Correlations .................................................................... 18 Main Analyses ...................................................................................................................... 18 Exploratory Analyses ............................................................................................................ 20 Results ........................................................................................................................................... 21 Participant Characteristics ........................................................................................................ 21 viii Descriptive Statistics ................................................................................................................. 21 Bivariate Correlations ............................................................................................................... 22 Main Analyses .......................................................................................................................... 23 Exploratory Analyses ................................................................................................................ 23 Post-Hoc Exploratory Analyses ................................................................................................ 24 Discussion ..................................................................................................................................... 25 An Improved Understanding Perfectionism and Pathological Narcissism in the Clinical Context ...................................................................................................................................... 25 An Improved Understanding of Pathological Narcissism in the Clinical Context ................... 27 Strengths, Limitations and Future Directions ........................................................................... 30 Clinical implications ................................................................................................................. 32 Concluding Remarks ................................................................................................................. 33 Tables ............................................................................................................................................ 34 References ..................................................................................................................................... 39 Appendices .................................................................................................................................... 52 Appendix A: Skewness and Kurtosis ........................................................................................ 52 Appendix B. Impact of Grandiose and Vulnerable Narcissism on Treatment Outcome .......... 53 Appendix C. Spearman’s Correlations between Grandiosity and Vulnerability with Outcome Variables ................................................................................................................................... 56 Appendix D. Impact of Grandiose and Vulnerable Narcissism on Likelihood of Dropout ..... 57 Appendix E. Measures .............................................................................................................. 58 ix List of Tables Table 1: Demographic Characteristics .......................................................................................... 34 Table 2: Spearman’s Correlations of Pathological Narcissism with Outcome Variables ............ 35 Table 3: Multiple Regression Model with Post-Treatment Global Severity Index as the Outcome Variable ......................................................................................................................................... 36 Table 4: Multilevel Random Intercept Model with Post-Treatment Satisfaction with Life as the Outcome Variable ......................................................................................................................... 37 Table 5: Multiple Regression Model with Post-Treatment Work and Social Impairment as the Outcome Variable ......................................................................................................................... 38 x Acknowledgements First and foremost, I would like to thank my supervisor and mentor, Dr. Paul L. Hewitt, for showing me the power of psychodynamic thinking and the value of integrating both clinical experience and research in understanding people as individuals. I would also like to thank Dr. Frances Chen and Dr. David Kealy for their time and invaluable guidance on this project. In addition, I would like to extend my gratitude to Yoonseok Choi for his expertise and consultation on my multilevel analyses. Next, I would like to thank Dr. Paul Hewitt and Dr. David Kealy for allowing me to use the data from their project, “A Randomized Control Trial for Dynamic-Relational Group Treatment of Perfectionism”, for my thesis. In addition, I would like to thank the patients and therapists who participated in the study, and the research assistants who made running the study possible. Finally, I would like to thank my friends and classmates for making me laugh, inspiring me through passionate discussions about psychology and for providing me with comfort during challenging times. Most importantly, I would like to extend my deepest gratitude to Katherine Cui, Michael Ge, Darren Ge, Jorge Holguín, Claire Lloyd, and Bita Zareian for their unwavering love and support. 1 Introduction Conceptualizing Pathological Narcissism Individuals with pathological narcissism have long been characterized by clinicians as self-aggrandizing, arrogant, and exploitative individuals who continually devalue and diminish others as a means of warding off their own profound sense of fragility, inadequacy, emptiness, and shame (Diamond et al, 2021; Kealy & Rasmussen, 2012; Kohut, 1971; Pincus, 2013). In research, efforts to capture the complexity and heterogeneity of this personality dysfunction have led to the identification of two broad dimensions of the pathological narcissism construct: narcissistic vulnerability (or vulnerable narcissism), reflecting pathological narcissism’s fragile core, and narcissistic grandiosity (or grandiose narcissism), reflecting the grandiose defence against the fragile core (Diamond et al, 2021; Kealy & Rasmussen, 2012; Kohut, 1971; Pincus, 2013). Narcissistic vulnerability and grandiosity tend to manifest in both overt and covert ways (Diamond et al., 2021; Pincus, 2013). For instance, individuals with pathological narcissism might absorb themselves in covert, grandiose fantasies about their own specialness and superiority as well as engage in overt exploitative and antisocial interpersonal behaviours. Narcissistic vulnerability can manifest covertly as profound experiences of shame and social withdrawal, whereas overt expressions of vulnerability, including depression and rage, may come to the fore when grandiose defences inevitably fail in the face of life’s disappointments and failures (Kealy & Rasmussen, 2012; Kohut, 1971). This conceptualization of pathological narcissism has been supported by past research demonstrating that pathological narcissism is associated with greater loneliness (Kealy et al., 2022), subjective experiences of stress (La Marca et al., 2022) and psychopathology as well as 2 lower self-esteem (Kaufman et al., 2020). Moreover, the grandiose dimension of pathological narcissism has been negatively associated with empathy and positively associated with antisocial, delinquent, dominant, and vindictive interpersonal behaviours (Dickinson & Pincus, 2003; Miller et al., 2007; Ogrodniczuk et al., 2009; Pincus et al., 2009). Meanwhile narcissistic vulnerability has been associated with a weak sense of self and self-alienation (Kaufman et al., 2020), cold and socially avoidant interpersonal behaviours (Dickinson & Pincus, 2003; Pincus et al., 2009), as well as having a more negative view of the future (Kaufman et al., 2020; Kealy et al., 2017). Consequently, based on clinical theory and past research, this study conceptualized and measured pathological narcissism as a multifaceted and dimensional personality construct that consists of both overt and covert manifestations of narcissistic vulnerability and narcissistic grandiosity (Pincus et al., 2009; Schoenleber et al., 2015). Theoretical Perspectives on Pathological Narcissism in the Clinical Context Several decades of theory suggest that pathological narcissism can interfere with psychotherapy outcome through disruptions in the therapeutic alliance and resistance to psychotherapy interventions (Fairbairn, 1952; Gabbard, 2009; Kealy & Ogrodniczuk, 2011; Kealy & Rasmussen, 2012; Kernberg, 2007; Kohut, 1971; Ogrodniczuk & Kealy, 2013). According to Fairbairn (1952), one of the greatest obstacles therapists must navigate when treating patients with pathological narcissism is their inability to form genuine and close relationships. For instance, Kohut (1971) suggested that patients with pathological narcissism create distance and impede the establishment of a therapeutic alliance through idealization and mirror transferences. That is, patients with pathological narcissism oscillate between idealizing their therapists (idealization transference) and expecting therapists to mirror their grandiose self 3 through attention and admiration (mirror transference). Consequently, therapists may find themselves pulled to respond to these transferences in unhelpful ways. For example, therapists might be compelled to challenge their patient’s idealization through correcting, interpreting, or dismissing them. These responses may be perceived by patients as rejection or criticism and thus lead to early ruptures in the therapeutic relationship. Moreover, the mirror transference can evoke various negative countertransference reactions in therapists, including boredom, defensiveness, irritation, as well as an overall devaluing of the patient (Gabbard, 2009; Kernberg, 2007). Interestingly, Kealy and Rasmussen (2012) suggested that patients with pathological narcissism may be unconsciously engaging in behaviours designed to evoke aversive reactions within their therapist as a way to protect their vulnerability and keep therapists at a distance. Taken together, these various transference and countertransference reactions create distance between a therapist and their patient, thus limiting the extent to which a strong therapeutic alliance can be formed. Another way in which individuals with pathological narcissism are theorized to impede treatment outcome is through their resistance to the therapeutic interventions themselves. For instance, patients with pathological narcissism tend to experience their dependence on the therapist as humiliating (Kernberg, 2007; Rosenfeld, 1964). As such, they may attempt to uphold their sense of superiority and defend against feelings of dependency by competing with the therapist (e.g., rejecting, dismissing, or attempting to upstage the therapists’ interpretations) and/or by taking control of therapy sessions (e.g., engaging in lengthy self-analysis; Kernberg, 2007; Rosenfeld, 1964), thus delaying or impeding progress over the course of psychotherapy. Pathological narcissism may also present additional difficulties in the group psychotherapy context. Distinct from individual therapy, group psychotherapy involves patient- 4 therapist interactions as well as patient-group interactions. While research suggests that the therapeutic alliance is important in group therapy (e.g., Joyce et al., 2007), studies have also shown that the quality of the relationship a patient has with other group members (also known as group cohesion) is an important predictor of group psychotherapy success (Burlingame et al., 2011; 2018). As such, problematic interpersonal behaviours that individuals with pathological narcissism tend to engage in may lead to disconnection from other group members and interfere with group treatment progress. For instance, Ogrodniczuk & Kealy (2013) described ways in which patients with pathological narcissism may create distance and disconnection from other group members, by seeking personal exemption from group norms and rules, offering dismissive or devaluing comments toward other group members and/or dominating group conversations and bringing attention to themselves when other group members are speaking. Research on Pathological Narcissism and Psychotherapy Process In line with past theories, there is accumulating empirical evidence pointing to pathological narcissism’s deleterious impact on psychotherapy processes. For example, several studies have found that therapists tend to find their patients with pathological narcissism challenging and difficult to work with. Muir et al. (2021) surveyed nearly 200 American mental health practitioners on their attitudes towards individuals with Narcissistic Personality Disorder (NPD), a construct that primarily captures the overt grandiose characteristics of pathological narcissism (Diamond et al., 2021). The authors found that over 66% of clinicians reported neutral or dissatisfied feelings toward treating patients with NPD. Additional studies have also found that patients with NPD and narcissistic pathology evoke various negative countertransference responses from their therapists, including feelings of anger, frustration, and resentment, feelings of inadequacy, of being criticized and devalued, as well as feelings of 5 disengagement and distraction (Betan et al., 2005; Colli et al., 2014; Tanzilli et al., 2017). These findings are important, as several case studies have illustrated how negative countertransference reactions can impact not only the quality of the therapeutic relationship, but also therapists’ abilities to respond to patients in a helpful manner (Ulberg et al., 2014; Zalman et al., 2019). Moreover, additional research suggests that therapists’ experiences of being “on guard” and feeling inadequate during group treatment are associated with poorer improvement on patients’ psychiatric symptoms (Rossberg et al., 2007; 2010). Furthermore, evidence suggests that patients who drop out of treatment are more likely to have evoked feelings of inadequacy and overwhelm in their therapists early on in group treatment (Rossberg, 2007). Given these findings and evidence pointing to the negative emotional reactions that therapists tend to experience with their patients with pathological narcissism, it is unsurprising that numerous studies have found that higher levels of narcissistic pathology are associated with early termination of treatment (Campbell et al., 2009; Ellison et al., 2013; Goldman & Gelso, 1997; Hilsenroth et al., 1998; Ogrodniczuk et al., 2009). Research also suggests that narcissistic grandiosity is associated with greater patient-rated dominance in psychotherapy sessions (Di Sarno et al., 2023). These findings, taken together with case illustrations of pathological narcissists’ resistance psychotherapeutic interventions (Kacel et al., 2017; Zalman et al., 2019), corroborate theoretical descriptions that patients with pathological narcissism tend to dominate and control sessions as a defensive response to the power differential between the therapist and patient. Finally, studies have found that narcissistic vulnerability is associated with lower motivation for personal growth and diminished expectations for improvement in one’s mental health difficulties (Kealy et al., 2017) as well as greater patient-rated hostility in psychotherapy sessions (Di Sarno et al., 2023). 6 Research on Pathological Narcissism and Psychotherapy Outcome While growing evidence suggests that pathological narcissism may interfere with therapeutic processes important for treatment success, research on pathological narcissism’s association with treatment outcome itself are limited and mixed. In the largest study to date, Daig et al. (2009) found in a heterogeneous sample of 1442 psychosomatic inpatients undergoing group and individual psychodynamic psychotherapy that greater levels of narcissistic vulnerability at baseline (as measured by the “threatened self” subscale of the Narcissism Inventory, Schoeneich et al., 2000) were associated with smaller improvements in mood and interpersonal functioning from admission to discharge. Specifically, cross lagged path models revealed that vulnerable narcissism was associated with poorer social functioning at post-treatment, as well as higher levels of post-treatment anger and anxious depressive mood. This study is one of the first to establish empirically that, in line with past theories, pathological narcissism can impede treatment outcome. Similarly, Euler et al. (2022) found, in 205 psychosomatic inpatients undergoing psychodynamic-based group and individual psychotherapy, that patients with higher levels of narcissistic grandiosity and vulnerability at pre-treatment (as measured by the “classic narcissistic self” and “narcissistic furor” subscales of the Narcissism Inventory) experienced poorer treatment outcome from baseline to discharge, through their lower capacity for mentalization (i.e., one’s ability to understand one’s own and others’ states of mind). That is, the authors found that degree of narcissistic grandiosity and vulnerability predicted lower reductions in psychological and somatoform symptoms through impairments in patients’ capacity to mentalize the state of minds of others. However, the authors did not find a direct association between pathological narcissism and treatment outcome. In contrast to Daig et al. (2009) and Euler et al. (2022), one study found that higher levels of vulnerable narcissism at 7 baseline (as assessed by the Pathological Narcissism Inventory; Pincus et al., 2009) led to improved treatment outcome in a sample of 36 inpatients with stress-related depressive or adjustment disorders (La Marca et al., 2022). Specifically, inpatients with greater narcissistic vulnerability at pre-treatment experienced greater reductions in depressive symptom severity from pre- to post-treatment. The contrasting findings from this study may be attributable to the unique multimodal therapy provided to the participants in this study as well as its relatively small sample size. Overall, most of these studies suggest that vulnerable narcissism is a particularly important for predicting treatment outcome in inpatient samples. Three studies thus far have investigated the impact of pathological narcissism on treatment outcome in outpatient samples (Cheek et al., 2018; Ellison et al., 2013; Ogrodniczuk et al., 2009). Ogrodniczuk et al. (2009) and Cheek et al. (2018) did not find that baseline levels of narcissistic grandiosity, assessed dimensionally according to the DSM-IV definition, impacted change in interpersonal functioning in outpatients undergoing a Day Treatment Program for personality disorders. However, given the extensive criticisms of the DSM’s inadequate definition of pathological narcissism (e.g., Cain et al., 2008; Diamond et al., 2021; Gabbard, 2009; Kealy & Rasmussen, 2012; Miller et al., 2010; Russ et al., 2008), further research using a more comprehensive measure of pathological narcissism is needed. Finally, Ellison et al. (2013) investigated the impact of pathological narcissism (using the Pathological Narcissism Inventory) in a sample of 41 outpatients from a university-based psychology clinic. The authors found that pre-treatment pathological narcissism did not significantly predict change in symptoms during the early stages of psychotherapy (i.e., the first 7 sessions). However, the authors did not assess whether pathological narcissism predicted outcome once treatment was complete. As such, the 8 question remains of whether or not pathological narcissism impacts psychotherapy outcome from pre- to post-treatment in outpatient populations. Pathological Narcissism in Patients with Perfectionism Perfectionism is a multidimensional personality style reflecting the need to be or appear perfect (Hewitt et al., 2017). This pernicious personality style has long been associated with pathological narcissism in clinical and theoretical accounts (e.g., Freud, 1957; Horney, 1950; Pincus et al., 2009; Ronningstam, 2011; Sorotzkin, 1985). For instance, Hamachek (1978) described two types of individuals with perfectionism: those with higher levels of pathological narcissism (“narcissistic perfectionists”) and those with lower levels of pathological narcissism (“neurotic perfectionists”). Narcissistic perfectionists possess an idealized and grandiose sense that they, unlike others, can attain perfection (Sorotzkin, 1985), while neurotic perfectionists possess a need to perfect themselves without ever believing that they could attain perfection (Flett et al., 2014). In line with past theory, emerging research suggests that narcissistic perfectionism is characterized by grandiosity, entitlement, and the view of oneself as perfect and superior to others (Nealis et al., 2015). Additionally, a meta-analysis of 30 studies (Smith et al., 2016) found that grandiose narcissism was associated with perfectionistic self-promotion (i.e., promoting one’s perfections), other-oriented perfectionism (i.e., the requirement of perfection from others) and self-oriented perfectionism (i.e., the requirement of perfection from the self), while vulnerable narcissism was linked with perfectionistic self-promotion, perfectionistic non-disclosure (i.e., not disclosing any imperfections) and socially prescribed perfectionism (i.e., the perception that others require perfection of the self). 9 Despite longstanding theoretical and empirical links between perfectionism and pathological narcissism, few studies have investigated these two together in a clinical context. Moreover, past research suggests that perfectionism, like pathological narcissism, interferes with various psychotherapy processes and outcomes (see Hewitt et al., 2020). Thus, given the difficulties that perfectionism and pathological narcissism both present in the clinical context, it is plausible that the combination of the two might be particularly pernicious. As such, further research is necessary to understand how the presence of pathological narcissism in patients with perfectionism may impact their likelihood of benefiting from psychotherapy. Gaps in the Current Literature The aim of the present study is to address several gaps and limitations in the current literature. First, no research thus far has investigated the impact of pathological narcissism on treatment outcome for patients with perfectionism. Second, all the extant research investigating the impact of pathological narcissism on treatment outcome have been done in naturalistic contexts. Thus, many of the studies do not account for differences in duration of treatment (Daig et al., 2009; Euler et al., 2022; La Marca et al., 2022) and/or differences in treatment types (Cheek et al., 2018; Daig et al., 2009; Ellison et al, 2013; Euler et al., 2022; La Marca et al., 2022; Ogrodniczuk et al., 2009). This is problematic, given that duration of treatment may impact the amount of change an individual undergoes throughout treatment. Moreover, patients from these studies underwent multimodal forms of treatment, which included combinations of psychological medications (Ellison et al., 2013); non-psychological therapies (Cheek et al., 2018; Daig et al., 2009; Euler et al., 2022; La Marca et al., 2022; Ogrodniczuk et al., 2009); as well as nutrition and sports training (Cheek et al., 2018; Daig et al., 2009; La Marca et al., 2022; Ogrodniczuk et al., 2009). This limitation makes it difficult to tease apart the impact of 10 pathological narcissism on psychological treatments specifically and thus may not adequately test the theory that this personality style impedes psychotherapy. Third, none of the past studies that investigated the impact of pathological narcissism in group psychotherapy have accounted for the possibility of dependence within their data (Cheek et al., 2018; Daig et al., 2009; Ellison et al., 2013; Euler et al., 2022; Ogrodniczuk et al., 2009). That is, no studies have accounted for the possibility that observations from the same group might be more similar than observations from different groups. This is problematic, given that best practice guidelines for group psychotherapy research indicate that accounting for potential between-group variance is important for avoiding inflated Type I error and inaccurate model parameter estimates (Tasca et al., 2009). Finally, past studies have focussed on treatment outcome in terms of change in symptoms and/or interpersonal functioning (Cheek et al., 2018; Daig et al., 2009; Ellison et al., 2013; Euler et al., 2022; La Marca et al., 2022; Ogrodniczuk et al., 2009). However, several studies have shown that individuals with pathological narcissism experience lower life satisfaction (e.g., Kaufman et al., 2020; Kealy et al., 2022; Rohmann et al., 2019) as well as problems in occupational functioning (e.g., Jang & Lee, 2022; Moon & Morais, 2022; Meier & Semmer, 2013). As such, it is also important to assess whether individuals with pathological narcissism are less likely to experience improvements in their life satisfaction and occupational functioning over the course of psychotherapy. The Present Study Past theory and research suggest that patients’ pathological narcissism present various challenges in the clinical context. While emerging studies on pathological narcissism provide some evidence for the negative impact of pathological narcissism on treatment outcome, further 11 research is needed to address the current limitations and gaps in the literature. As such, my study aims to assess the impact of pre-treatment pathological narcissism on pre- to post-treatment changes in symptom severity, life satisfaction, and work and social impairment, in patients undergoing psychodynamic group therapy for perfectionism. Consistent with current theories and emerging research on the perniciousness of pathological narcissism in the clinical context, I expect that higher levels of pre-treatment pathological narcissism will predict smaller improvements in patient-reported symptom severity, life satisfaction and work and social impairment. Finally, given that past research suggests that pre-treatment narcissistic vulnerability and grandiosity may relate differently to treatment outcome, I conducted exploratory analyses to assess whether different levels of narcissistic vulnerability and grandiosity differentially impact treatment outcome. 12 Method Participants This sample is shared with Hewitt et al. (2023) and consisted of 80 treatment-seeking adults (72.5% women) recruited from Vancouver, Canada. Inclusion criteria for participants were: 1) absence of active psychotic symptoms or current suicidality as measured by the Personality Assessment Inventory (Morey, 1991), 2) fluency in English, 3) ability to commit to 12 weekly group therapy sessions, and 4) presence of elevated perfectionism (defined as a perfectionism score at least one standard deviation above the normative means for community adults; Hewitt & Flett, 2004). In addition, participants were included if they were willing to disclose personal information during the initial interview and had had at least one close relationship in their lifetime. Inclusion and exclusion criteria were chosen based on past research (Hewitt et al., 2015). Measures Pathological Narcissism The Brief – Pathological Narcissism Inventory (B-PNI; Schoenleber et al., 2015) is a 28-item measure of pathological narcissism that assesses overt and covert vulnerable and grandiose narcissism characteristics. Using a 6-point Likert scale from 0 (not at all like me) to 5 (very much like me), patients indicate the degree to which each statement describes them. Scores on the B-PNI range from 0 to 5, with higher scores reflecting greater levels of pathological narcissism. The B-PNI consists of 2 major subscales: Grandiosity and Vulnerability. The Grandiosity subscale is composed of 3 additional facets: Exploitativeness (e.g., “I can usually talk my way out of anything”), Self-Sacrificing Self-Enhancement (e.g., “Sacrificing for others makes me the better person”), and Grandiose Fantasy (e.g., “I often fantasize about accomplishing things that 13 are probably beyond my means”). In addition, the Vulnerability subscale is composed of 4 facets: Contingent Self-Esteem (e.g., “When people don’t notice me, I start to feel bad about myself”), Hiding the Self (e.g., “I often hide my needs for fear that others will see me as needy and dependent”), Devaluing (e.g., “When others don’t meet my expectations, I often feel ashamed about what I wanted”) and Entitlement Rage (e.g., “I get annoyed by people who are not interested in what I say or do”). The B-PNI has shown adequate internal consistency and validity (Schoenleber et al., 2015) as well as high test-retest reliability (Hassanzadeh et al., 2020). In this study, I used the B-PNI total score as well as its 2 major subscales: Grandiosity and Vulnerability. The Cronbach’s alphas for the B-PNI total score, Grandiosity and Vulnerability are .89, .80 and .85, respectively. Symptom Severity The Brief Symptom Inventory (BSI; Derogatis, 1993) is a 53-item self-report measure that that assesses symptom severity across nine symptom dimensions (i.e., somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) as well as overall symptom severity (i.e. the global severity index, GSI). Participants rate the degree to which they experienced each item over the past 7 days (e.g., “nervousness or shakiness inside”, “trouble remembering things”) on a 5-point scale from 0 (not at all) to 4 (extremely). For this study, I used the Global Severity Index (GSI) as a global measure of symptom severity (Derogatis & Melisaratos, 1983), where higher scores reflect greater overall symptom severity. Scores on the GSI range from 0 – 4. The GSI is considered a sensitive measure of change in distress and has established clinical norms (Derogatis & Melisaratos, 1983). The Cronbach’s alphas for the GSI in this sample were .94 at pre-treatment and .95 at post-treatment. 14 Life Satisfaction The Satisfaction with Life Scale (SWLS; Diener et al., 1985) is a 5-item self-report measure of subjective life satisfaction. Participants indicate the extent to which they agree with each statement (e.g., “I am satisfied with my life.”) on a 7-point Likert scale from 1 (strongly disagree) to 7 (strongly agree). Scores on the SWLS can range from 5 – 35, where scores between 5 – 9 indicate extreme dissatisfaction with life, 10 – 14 indicate dissatisfaction with life, 15 – 19 indicate slight dissatisfaction with life, 20 indicates an equal amount of satisfaction and dissatisfaction, 21 – 25 indicate slight satisfaction with life, 26 – 30 indicate satisfaction with life and 31 – 35 indicate extreme satisfaction with life (Pavot & Diener, 1993; 2008). The SWLS is a widely used measure of life satisfaction and has demonstrated good psychometric properties, including high internal consistency, test-retest reliability, and construct validity (Diener et al., 1985; Pavot & Diener, 1993). In addition, this measure has been shown to be sensitive to changes in life satisfaction over the course of treatment (Pavot & Diener, 1993). The Cronbach’s alphas for the SWLS in this sample were .88 at pre-treatment and .84 at post-treatment. Work and Social Impairment The Work and Social Adjustment Scale (WSAS; Mundt et al, 2002) is a 5-item self-report measure assessing the extent to which participants’ difficulties with perfectionism impact their wok and social activities, including their ability to: work, manage their home, engage in social and private leisure activities, and form and maintain close relationships (e.g., “because of my perfectionism, my ability to form and maintain close relationships with others, including those I live with, is impaired”). Participants rate this measure on a 9-point scale from 0 (not at all) to 8 (very severely). WSAS scores can range from 0 – 40, with scores ranging from 0 – 10 indicating subclinical functional impairment, 10 – 20 as significant functional impairment with 15 less severe clinical symptomatology, and 20 and above severe psychopathology (Mundt et al., 2002). The WSAS has shown satisfactory psychometric properties, including good internal consistency, test-retest reliability, and convergent validity (Mundt et al., 2002; Zahra et al., 2014). The WSAS measure has been used in past clinical samples and demonstrates sensitivity to change in work and social impairment over the course of treatment (Zahra et al., 2014). The Cronbach’s alphas for the WSAS in this sample were .79 at pre-treatment and .85 at post-treatment. Procedure This study involves a re-analysis of a larger, randomized control trial study (Hewitt et al., 2023). Treatment-seeking community members who self-identified as dealing with difficulties with perfectionism contacted the research lab via advertisements posted across Vancouver, British Columbia. During the initial phone call, participants were asked to provide a brief description of their difficulties and given the chance to ask any questions they had about the study. Participants whose difficulties were related to perfectionism were then invited to the lab to complete an assessment. During this assessment, participants completed an intake interview and a battery of measures to assess their eligibility for the study (see Participants section for full list of eligibility criteria). Eligible participants provided informed consent and were randomly assigned to one of two psychodynamic group psychotherapies (i.e., supportive psychodynamic and dynamic-relational psychodynamic). In addition, all participants agreed to suspend other psychotherapy treatments during their participation in the study. Each participant underwent 12 weekly sessions of group psychotherapy. The final sample consisted of 10 groups, each comprising 7 to 10 members (Mean group size = 8) and 2 co-therapists. The therapists in this study (n = 9) were clinical psychology 16 doctoral students who had, on average, 5.4 years of supervised clinical experience, and had previously completed a psychodynamic clinical practicum. All therapists were trained and supervised by clinical psychologists who were experts in dynamic-relational and supportive psychodynamic psychotherapy. For the purposes of this study, I used pre-treatment measures of B-PNI, BSI’s GSI subscale, SWLS and WSAS (administered during the assessment), in addition to post-treatment measures of BSI’s GSI subscale, SWLS, and WSAS (administered at session 12). Group Psychodynamic Psychotherapy Format Supportive group psychotherapy and dynamic-relational group psychotherapy both draw upon psychodynamic principles (Hewitt et al., 2017; Rockland, 2003). In this study, supportive group therapy included providing patients with an empathic climate where they could share their experiences and feelings and receive support and validation for their efforts at coping with their perfectionism (Rockland, 2003). Dynamic-relational therapy involved addressing relational and developmental underpinnings of perfectionism through interpretations of here-and-now group interactions and relationships (Hewitt et al., 2017). Research has demonstrated that both psychodynamic group psychotherapies are effective in improving symptom severity, life satisfaction and work and social impairment (Hewitt et al., 2015; 2019; 2023). Data Analytic Strategy Preliminary Analyses A total of 80 participants were included in the treatment. No data was missing at Level 2 (i.e., group). At Level 1, 66 participants completed every measure at pre- and post-treatment (full response rate = 82.5%, Newman, 2014). A total of 10 participants dropped out of treatment and thus did not complete any measures at post-treatment. Treatment dropouts and completers were 17 compared using independent-samples t-tests (for normally distributed variables) or independent-samples Mann-Whitney U tests (for non-normally distributed variables). No significant differences were found between dropouts and treatment completers on all study variables and most demographic variables. Specifically, dropouts did not differ from treatment completers on pre-treatment pathological narcissism, t(78) = -.51, p = .61, work and social impairment, t(76) = .16, p = .23, symptom severity, Z = .13, p = .72, life satisfaction, Z = .46, p = .50, age, Z = 3.78, p = .05, or years of education, Z = 2.45, p =.12. Moreover, Chi-squared tests revealed that dropouts did not differ from completers in terms of ethnicity, χ2(4) = 3.48, p = .48, marital status, χ2(6) = 4.56, p = .60, gender, χ2(2) = 4.33, p = .11, or group number, χ2 = 9.12, p = .43. However, results did reveal that a greater proportion of dropouts were unemployed, students or retired, compared to treatment completers, χ2(4) = 19.02, p < .001. Of the treatment completers (n = 70), four additional participants were missing at least one measure at pre- and/or post-treatment1. Three partial respondents were retired or choosing not to work (for reasons unrelated to their perfectionism) and thus did not complete WSAS questionnaires at pre- and/or post-treatment. One participant did not complete their BSI questionnaire at pre-treatment due to an administrative error. No other participants were missing more than 50% of items on any given measure. Specifically, a total of 23 items (out of 12,012 possible items of interest) were missing across all 66 participants (0.19%). Accordingly, construct scores for these 66 participants were calculated based on available items (Graham, 2009; Newman, 2014; Tabachnick & Fidell, 2007). Finally, Little’s MCAR test was nonsignificant (Chi-Square = 1675.00, DF = 3693, p = 1.00), 1I compared partial respondents (n = 4) with full respondents (n = 66) using independent-samples t-tests or independent-samples Mann-Whitney U tests on all study and demographic variables. The results mirrored those comparing dropouts and completers. That is, the partial and full respondents did not differ on study and demographic variables, except for employment whereby partial respondents were more likely than full respondents to be retired or a student and full respondents were more likely than partial respondents to be employed, χ2(4) = 15.02, p = .005. 18 suggesting that the data (n = 80) is missing completely at random. Handling of missing data is discussed in the sections below. Three outliers were identified using 3xIQR in SPSS Statistics Version 27. One participant scored above the 95th percentile on the B-PNI at pre-treatment and on the GSI at pre- and post-treatment. Two other outlying participants scored above the 95th percentile on GSI at post-treatment. I conducted main analyses with and without these three outliers, and the results did not differ meaningfully. Accordingly, did not remove these three outliers. I assessed normality of all my variables by conducting a Shapiro-Wilk’s normality test and inspecting skewness and kurtosis in SPSS Statistics Version 27 (See Appendix A). Results showed that GSI and SWLS at pre- and post-treatment were positively skewed. As such, these non-normal distributions were accounted for by using Spearman correlations to assess associations between all study variables. Descriptive Statistics & Bivariate Correlations The means, standard deviations, and Cronbach’s alphas as well as Spearman’s correlations of all measures were conducted in SPSS Statistics Version 27. Results are reported in Table 2. In line with past studies (Hewitt et al., 2020), correlational analyses were conducted using pairwise deletion. The sample size used for each bivariate correlation is reported in Table 2. Main Analyses Following Tasca et al.’s (2009) recommendations for group treatment research, I conducted three two-level2 random intercept models (Level 1: patients, Level 2: group) to 2 I also considered a three-level multilevel model (Level 1: patients, Level 2 groups, Level 3: treatment condition). However, ICC calculations showed that < 0.00% of the variance in outcome measures were attributable to treatment condition and multilevel moderation analyses showed that treatment condition did not moderate the impact of pathological narcissism on treatment outcome measures. Accordingly, I opted for a two-level model. 19 determine the extent to which pathological narcissism at pre-treatment predicted changes in symptom severity, life satisfaction and work and social impairment, respectively.3 For symptom severity and work and social impairment, tests of near singularity for the random intercept models suggested that they were overfitted, which could signal inaccurate model parameter estimates (Bates et al., 2015). Upon further investigation, I found that the intraclass correlation coefficient (ICC) for symptom severity was 0.002 and for work and social impairment, 0.001, suggesting that only 0.2% of the variance in post-treatment symptom severity and 0.1% of the variance in post-treatment work and social impairment, respectively, were attributable to between-group variability. Thus, I removed the random effect and ran single-level multiple regression models for symptom severity and work and social impairment. Findings between random intercept and multiple regression analyses did not differ meaningfully4. As such, given that the random intercept models showed singularity, indicating potentially inaccurate model parameter estimates (Bates et al., 2015), I chose to report the multiple regression results. For each multilevel or multiple regression analysis, total pathological narcissism was entered as the predictor; post-treatment symptom severity, life satisfaction or work and social impairment was entered as the dependent variable; and pre-treatment symptom severity, life satisfaction or work and social impairment was entered as a covariate. All predictor variables were grand mean centered. 3 I also ran random slope and intercept models to incorporate a maximum random structure (Barr et al., 2013; Tasca et al., 2009), but all models showed singularity. Accordingly, I removed the random slope from the model (Barr et al., 2013; Bates et al., 2015). 4 The significance of pathological narcissism’s impact on post-treatment symptom severity was marginally significant for the random intercept model (p=.04) but not for the multiple regression model. However, this effect did not meet significance at the adjusted significance level of p < .008 (using a Bonferroni correction). 20 Finally, consistent with recommendations for handling missing data with multilevel and multiple regression analyses, all analyses were conducted using multiple imputation with R’s “pan” and “mice” packages, respectively (Grund et al., 2016; Newman, 2014). Multilevel analyses were conducted using R’s lme4 package with full information maximum likelihood estimation (Grund et al., 2016). The results for each analysis are reported in Tables 3 (symptom severity), 4 (life satisfaction) and 5 (work and social impairment). Exploratory Analyses To assess whether different levels of vulnerability and grandiosity predicted treatment outcome, I conducted each two-level random-intercept model again, but this time with vulnerable narcissism or grandiose narcissism as the predictor. Random intercept models for symptom severity and work and social impairment showed singularity again (Bates et al., 2015). Thus, I removed the random effect and ran single-level multiple regression models for symptom severity, and work and social impairment. Findings between random intercept and multiple regression analyses did not differ meaningfully. As such, I chose to report the results from the multiple regression models. For each multilevel or multiple regression analysis, pre-treatment vulnerable and grandiose narcissism were entered as predictors; post-treatment symptom severity, life satisfaction or work and social impairment was entered as the dependent variable; and pre-treatment symptom severity, life satisfaction or work and social impairment was entered as a covariate. Missing data were dealt with using multiple imputation with R’s “mice” and “pan” packages and all multilevel analyses were conducted using R’s lme4 package with full information maximum likelihood estimation (Grund et al., 2016; Newman, 2014). The results for each analysis are reported in the results section and in Appendix B. 21 Results Participant Characteristics Demographic characteristics are presented in Table 1. On average, participants were 36.85 years of age (SD =13.01; Range = 19 – 73) and had 16.74 years of education (SD = 3.75; range = 0 – 23). A total of 72.5% of participants identified as a woman, 26.3% identified as a man and 1.3% identified as nonbinary. Overall, 65.0% identified as Caucasian/European descent, 15% identified as Asian/Pacific Islander, 1.3% identified as Hispanic/Latino and 12.5% identified as another ethnicity. At pre-treatment, 52.5% of participants were single, 37.6% were married or in a relationship, and 6.3% were separated or divorced. Finally, with respect to employment status at pre-treatment, 58.8% of participants were employed, 22.5% were students, 6.3% were retired, and 5.0% were unemployed. Descriptive Statistics Descriptive statistics are reported in Table 2. At pre-treatment, patients’ mean scores on the Satisfaction with Life scale suggested that patients were on average dissatisfied with life (Pavot & Diener, 2008). In addition, the mean and standard deviation of satisfaction with life in this sample were similar to those of other outpatient samples (Pavot & Diener, 2008; Zeitler et al., 2020). With respect to work and social impairment, patients in this sample scored within the “significant impairment” range indicating that they have significant functional impairment but less severe clinical symptomatology (Mundt et al., 2002). Moreover, patients’ mean and standard deviation on work and social impairment were comparable to that of patients with mild to moderate depression (Mundt et al., 2002) and patients without severe personality pathology (Pedersen et al., 2017). Next, this sample’s mean and standard deviation for symptom severity were comparable to that of past adult psychiatric outpatient samples (Derogatis, 1993). 22 Specifically, the GSI T scores for both men (GSI T score = 47) and women (GSI T score = 47) scored within the average range for psychiatric outpatients (Derogatis, 1993). Finally, with respect to pathological narcissism, the mean of grandiose narcissism (M = 2.55, SD = 0.88, Range = 0.58 – 5.00) in this sample was comparable to that of college students and half a standard deviation below that of community members, while the mean of vulnerable narcissism (M = 2.43, SD = 0.89, Range = 0.44 – 4.69) in this sample was half a standard deviation higher than college students and comparable to that of community members (Schoenleber et al., 2015; Weiss et al., 2021). No research thus far has reported means for the B-PNI for clinical samples. While further research on the B-PNI is needed to establish clinical norms, this sample appears to be characterized by lower levels of grandiose narcissism, when compared to past research on community members (Schoenleber et al., 2015). Bivariate Correlations Bivariate correlations comparing pathological narcissism with study measures are reported in Table 2. Bivariate correlations comparing grandiose and vulnerable narcissism with study measures are reported in Appendix C. The reported effect sizes are based on Cohen’s (1992) guidelines for small (r = .10), medium (r =.30) and large (r = .50) effects. Pre-treatment pathological narcissism had moderate positive correlations with symptom severity at pre- and post-treatment as well as small positive correlations with work and social impairment at post-treatment. When narcissistic grandiosity and vulnerability were assessed separately, pre-treatment grandiosity showed a small to moderate positive association with pre- and post-treatment symptom severity, and pre-treatment vulnerability showed a moderate positive association with pre- and post-treatment symptom severity. In addition, narcissistic vulnerability had small positive associations with pre- and post-treatment work and social impairment. 23 Main Analyses Contrary to my hypotheses, pre-treatment narcissism did not significantly predict pre-to post-treatment change in symptom severity, life satisfaction, or work and social impairment. First, a multiple regression analysis indicated that pathological narcissism at pre-treatment did not significantly predict post-treatment symptom severity when controlling for pre-treatment symptom severity, B = 0.14, SE = 0.08, p = .10 (see Table 3). Next, a random intercept model indicated that pre-treatment pathological narcissism did not significantly predict post-treatment satisfaction with life when controlling for pre-treatment satisfaction with life, B = 0.56, SE = 0.68, p = .41 (see Table 4). Finally, a multiple regression analysis indicated that pre-treatment pathological narcissism did not significantly predict post-treatment work and social impairment when controlling for pre-treatment work and social impairment, B = 0.91, SE = 1.24, p = .47 (see Table 5). Exploratory Analyses Neither grandiose nor vulnerable narcissism significantly predicted change in symptom severity, satisfaction with life or work and social impairment (see Appendix B). Specifically, a multiple regression analysis showed that neither grandiose, B = 0.13, SE = 0.08, p = .14, nor vulnerable narcissism, B = 0.02, SE = 0.10, p = .87 predicted symptom severity at post-treatment when controlling for symptom severity at pre-treatment. In addition, a random intercept model indicated that neither grandiose, B = 0.15, SE = 0.82, p = .85 nor vulnerable narcissism, B = 0.40, SE = 0.85, p = .64, predicted satisfaction with life at post-treatment when controlling for satisfaction with life at pre-treatment. Finally, a multiple regression analysis showed that neither grandiose, B = 0.78, SE = 1.49, p = .60, nor vulnerable narcissism, B = 0.15, SE = 1.56, p = .93 24 predicted work and social impairment at post-treatment when controlling for work and social impairment at pre-treatment. Post-Hoc Exploratory Analyses Given that past studies have found that pathological narcissism predicted greater likelihood of early treatment termination (e.g., Campbell et al., 2009; Ellison et al., 2013; Ogrodniczuk et al., 2009), I sought to explore whether or not pathological narcissism predicted likelihood of dropout within this sample, as one reason for not finding any association between pathological narcissism and treatment change could be that those who dropped out of the study were the very individuals who would have benefitted less from treatment. As such, I conducted a logistic regression model using R’s stats package, with grandiose and vulnerable narcissism entered as predictors and dropout status (0 = dropped out, 1 = completed study) entered as a dependent variable. Contrary to past studies, I did not find that either grandiose, B = -0.13, SE = 0.50, p = .85 or vulnerable narcissism, B = -0.09, SE = 0.49, p = .80, significantly predicted early termination of treatment in this sample (see Appendix D). 25 Discussion In this study, I sought to address several methodological and conceptual limitations and gaps in the literature in an effort to clarify the relationship between pathological narcissism and psychotherapy outcome. Contrary to my expectations, but consistent with past research (Cheek et al., 2018; Ellison et al., 2013; Euler et al., 2022; Ogrodniczuk et al., 2009), I did not find evidence to support the hypothesis that higher levels of pathological narcissism at baseline led to poorer psychotherapy outcome. Specifically, my study adds to existing theory and research by demonstrating that pre-treatment pathological narcissism did not lead to significantly smaller improvements in symptom severity, life satisfaction or work and social impairment in a sample of patients undergoing psychodynamic group therapy for perfectionism. Furthermore, neither grandiose nor vulnerable dimensions of narcissism significantly predicted treatment outcome in this sample. Finally, contrary to past studies (Campbell et al., 2009; Ellison et al., 2013; Ogrodniczuk et al., 2009), I did not find evidence to suggest that patients with pathological narcissism had an increased likelihood of dropping out of treatment. An Improved Understanding Perfectionism and Pathological Narcissism in the Clinical Context To my knowledge, this study was the first to investigate whether pathological narcissism interfered with treatment outcome in patients with perfectionism. Contrary to my hypotheses, I did not find that pre-treatment pathological narcissism predicted poorer treatment outcome or likelihood of dropout in this sample. These findings are surprising, given that theory and research suggest that both pathological narcissism and perfectionism are particularly pernicious in the clinical context (Daig et al., 2009; Euler et al., 2022; Hewitt et al., 2020). Some explanations for my results are considered below. 26 Research suggests that perfectionism and pathological narcissism share certain problematic interpersonal behaviours, such as overtly promoting one’s purported perfections and concealing one’s perceived flaws and imperfections (see Smith et al., 2016). As such, given that psychodynamic group psychotherapy for perfectionism has been shown to effectively reduce perfectionistic behaviours in this sample (Hewitt et al., 2023), it is possible that these reductions facilitated improvements in therapeutic alliance and group cohesion among patients with higher pathological narcissism, thus removing one of the primary barriers theorized to impede progress in psychotherapy for patients with pathological narcissism. While no research has explicitly tested this within patients with perfectionism, Busmann et al. (2021) did find that baseline narcissistic vulnerability was associated with improvements in therapeutic alliance in patients undergoing individual psychodynamic treatment for Borderline Personality Disorder, thus demonstrating that it is indeed possible for patients with pathological narcissism to improve relationally over the course of psychotherapy for personality dysfunction. My findings may also be explained by empirical and theoretical links between pathological narcissism and perfectionism traits. Both narcissistic grandiosity and perfectionism have been described in the literature as defences against underlying vulnerability (Diamond et al., 2021; Hewitt et al., 2017; Kealy & Rasmussen, 2012). Specifically, pathological narcissism and perfectionism appear to serve similar functions, albeit in different ways. The former may ward off a deeply felt sense of inadequacy and worthlessness through self-aggrandizing defences, while the latter may thwart these painful affects through the relentless pursuit of perfection. Empirically, pathological narcissism has been associated with perfectionism traits (Smith et al., 2016), suggesting that these two personality styles may share similar underlying vulnerabilities that drive both defences. Thus, given that research has shown that psychodynamic 27 group psychotherapy for perfectionism leads to reductions in perfectionism traits (Hewitt et al., 2023), it is possible that improvements in perfectionism-related vulnerabilities may have also led to improvements in pathological narcissism. Taken together with the broader literature, findings from this study suggest that patients presenting with pathological narcissism at pre-treatment do not experience poorer outcome in treatments for perfectionism, potentially due to reductions in interpersonal problems and/or underlying vulnerabilities that pathological narcissism and perfectionism share. An Improved Understanding of Pathological Narcissism in the Clinical Context Findings from this study can advance our current understanding of pathological narcissism’s impact on psychodynamic psychotherapy. Specifically, results from this study add to an accumulating body of research suggesting that pre-treatment pathological narcissism does not negatively impact psychodynamic psychotherapy outcome (Cheek et al., 2018; Euler et al., 2022; Ogrodniczuk et al., 2009). These findings are also in line with past research suggesting that multimodal psychotherapies containing psychodynamic elements are not negatively impacted by pathological narcissism (Ellison et al., 2013). One of the pathways through which pathological narcissism is theorized to impede treatment is through therapists’ negative countertransference (Gabbard, 2009; Kernberg, 2007; Kealy & Rasmussen, 2012). As such, one possible explanation for my findings could be that psychodynamic psychotherapy’s particular emphasis on the importance of managing one’s countertransference (e.g., Cutler, 1958; Freud, 1910; Hewitt et al., 2017; Rockland, 2003; Van Wagoner, 2000) enabled group therapists in this study to avoid inadvertently acting out their countertransference and responding in unhelpful ways. For instance, clinical researchers have illustrated that group therapists’ failure to manage their emotional reactions to difficult 28 interactions with patients can be detrimental for a group’s development and progress over the course of therapy (Bemak & Epp, 2001; Van Wagoner, 2000). In addition, research has found that group therapists’ negative countertransference reactions can lead to poorer treatment outcome and even patient drop out (Rossberg et al., 2007; 2010). Moreover, indirect evidence from meta-analytic research on individual psychotherapy has shown that successful management of countertransference is associated with better therapy outcomes (Hayes et al., 2011). As such, one possible explanation for my findings and those of past studies (Cheek et al., 2018; Ellison et al., 2013; Euler et al., 2022; Ogrodniczuk et al., 2009) could be that psychodynamic psychotherapists are particularly effective at managing their countertransference, thus minimizing the potential negative impacts of pathological narcissism on group psychotherapy outcome. Indeed, some evidence does suggest that psychodynamic therapists are better at anticipating and managing countertransference than therapists from other theoretical orientations (Gordon et al., 2016; Van Wagoner et al., 1991). However, given that one study by Daig et al. (2009) did find a small significant negative relationship between pathological narcissism and change in psychodynamic treatment, more research is needed to assess whether the lack of association between pathological narcissism and treatment outcome are related to psychodynamic-specific elements (e.g., countertransference management) and whether it can be generalized more broadly to other forms of psychotherapy. An alternative explanation for mixed findings regarding pre-treatment pathological narcissism’s influence on treatment outcome may be that certain moderators in this association have yet to be uncovered. Indeed, diverse clinical presentations of pathological narcissism have been proposed in the literature (Diamond et al., 2021; Russ & Shedler, 2013), suggesting the possibility that some types of pathological narcissism may impede or even facilitate 29 psychotherapy more than others. For example, some studies suggest that higher levels of vulnerable narcissism may, in certain contexts, predict better treatment outcomes. In particular, La Marca et al. (2022) found that higher baseline levels of vulnerable narcissism predicted improvements in depressive symptom severity and Busmann et al. (2021) found that higher pre-treatment vulnerable narcissism led to greater improvements in therapeutic alliance over the course of psychotherapy for Borderline Personality Disorder. These findings, when contrasted with reports on the deleterious impacts of pathological narcissism (Daig et al., 2009) point to the possibility that an additional third moderating variable may be at play. Specifically, there might be certain aspects of pathological narcissism that were not captured in this study that moderate the impact it has on treatment outcome. For instance, clinician and researcher Diana Diamond (2021) posited that pathological narcissism can occur at one of three levels of functioning (i.e., high-functioning, borderline and malignant) and described how dimensions of grandiosity and vulnerability must be considered in tandem with a patient’s level of functioning in order for clinicians and researchers to adequately understand and capture an individual’s narcissistic pathology. Thus, future research should consider the complexity and heterogeneity of presentations of pathological narcissism and investigate variables that might moderate the impact that pathological narcissism has on treatment outcome (e.g., level of functioning; Diamond et al., 2021). Finally, while this study did not find that pathological narcissism was significantly associated with change in various outcome measures, it is important to note that correlational analyses revealed that elevated grandiose and vulnerable narcissism at pre-treatment were significantly associated with higher levels of pre- and post-treatment symptom severity, and that increased vulnerable narcissism at baseline was associated with greater pre- and post-treatment 30 work and social impairment. Thus, these results add to an accumulating body of research pointing to the various adverse mental health, interpersonal and occupational outcomes associated with pathological narcissism (e.g., Cheek et al., 2018; Ellison et al., 2013; Jang & Lee, 2022; Kaufman et al., 2020; Kealy et al., 2016; Meier & Semmer, 2013; Moon & Morais, 2022; Ogrodniczuk et al., 2009; Pincus et al., 2009). Moreover, consistent with past research, my findings show that pathological narcissism’s perniciousness persists, even after psychological treatment (Cheek et al., 2018; Ogrodniczuk et al., 2009). Taken together, these findings are in line with existing theories and clinical descriptions suggesting that patients with pathological narcissism experience a great deal of intrapsychic and interpersonal distress (Diamond et al., 2021; Kealy & Rasmussen, 2012). Strengths, Limitations and Future Directions This study has some notable strengths. First, contrary to past studies on group therapy, this study used multilevel modeling when appropriate to account for dependency in group therapy data, thus minimizing inflation of Type I error (Tasca et al., 2009). Second, this study provided the same duration and type of treatment (psychodynamic psychotherapy) to all participants, enabling us to control for potential confounds of different treatment types and durations that limited past studies (Cheek et al., 2018; Daig et al., 2009; Ellison et al, 2013; Euler et al., 2022; La Marca et al., 2022; Ogrodniczuk et al., 2009). Finally, this study assessed pathological narcissism more comprehensively than most other studies by using a measure that captured overt and covert elements of both narcissistic vulnerability and grandiosity. Despite the strengths of this study, there are several limitations that are important to consider when interpreting findings. First, as this study relied solely on participants’ self-reports, future research should adopt a multi-method, multi-informant approach to reduce potential biases 31 associated with self-report measures. Importantly, some clinicians have proposed that patients with pathological narcissism may not always be aware of their vulnerability, especially in cases where patients are relatively successful at maintaining their grandiose defence (e.g., in the case of high-achieving individuals with pathological narcissism), thus enabling a continued projection of any sense of vulnerability onto others (Diamond et al., 2021). As such, it will be particularly important for future research to consider additional sources of information (e.g., informant reports, clinician reports) when assessing pathological narcissism. Second, while the pathological narcissism measure used in this study (i.e., B-PNI) has demonstrated good psychometric properties in past research (Schoenleber et al., 2015), the validity of its grandiose narcissism subscale has been challenged by some researchers (e.g., Miller et al., 2014). Specifically, Miller et al. (2014) have suggested that the PNI scale (on which the B-PNI is based) is a strong measure of narcissistic vulnerability but does not adequately assess narcissistic grandiosity. As such, future research should consider using additional measures of pathological narcissism (e.g., Five-Factor Narcissism Inventory; Glover et al., 2012) to ensure a more comprehensive assessment of the construct. Future research should also consider using alternative diagnostic manuals, such as the Psychodynamic Diagnostic Manual (PDM-2), which may provide more comprehensive descriptions of narcissistic pathology (Diamond et al., 2021). Third, in this study’s sample, the average level of grandiose narcissism, as assessed by the B-PNI, was approximately 0.5 standard deviations below the average level of grandiose narcissism reported in Schoenleber et al.’s (2015) community sample. As such, some evidence points to the possibility that lower levels of grandiose narcissism in this sample might have contributed to the lack of association between pathological narcissism and psychotherapy outcome. Fourth, it should be noted that the participants who were recruited for the study were treatment-seeking individuals who had had at 32 least one close relationship with another person in their lifetime. As such, there is a possibility of selection bias, whereby we excluded those who had never had a close relationship, therefore potentially excluding those who are very high on pathological narcissism. Moreover, research suggests that individuals with higher levels of grandiose narcissism are less likely to seek out certain therapeutic services (Ellison et al., 2013), thus potentially explaining why our sample consisted of less narcissistically grandiose individuals than past studies (Schoenleber et al., 2015). Fifth, while our sample size was larger than that of several past studies (i.e., Cheek et al., 2018; Ellison et al., 2013; La Marca et al., 2022), it may not have been large enough to detect a small effect size consistent with previous findings (Daig et al., 2009). As such, future studies should aim to recruit larger sample sizes when evaluating the impact of pathological narcissism on treatment outcome. Sixth, the sample in this study consisted primarily of White, employed, educated women. As such, future research should aim to investigate the impact of pathological narcissism on outcome in a more diverse sample. Finally, this study, in line with past research, investigated the impact of pathological narcissism at one timepoint (pre-treatment) on psychotherapy outcome. However, future studies should investigate whether and how pathological narcissism changes dynamically over multiple timepoints throughout the course of treatment and test whether and how these changes may relate to psychotherapy processes and outcomes. Clinical implications Pathological narcissism has been purported for decades to have a negative impact on psychotherapy processes and outcome. The difficulties that clinicians encounter with their patients with pathological narcissism have been well documented in the literature and are reflected in the stigma and negative attitudes that mental health professionals hold towards 33 individuals with narcissism and personality disorders in general (Penney et al., 2017; Sheehan et al., 2016). This study, taken together with emerging research (Cheek et al., 2018; Ellison et al., 2013; La Marca et al., 2022; Ogrodniczuk et al., 2009), suggests that contrary to past theory and clinical accounts, pathological narcissism may not negatively impact treatment outcome in certain samples and clinical contexts. Specifically, findings from this study suggests that pathological narcissism does not significantly impact treatment outcomes for patients undergoing group psychodynamic psychotherapy for perfectionism. While further research is needed, clinicians should consider, when treating individuals with perfectionism who are elevated in pathological narcissism, using group psychodynamic psychotherapy, as this study suggests that patients’ level of pathological narcissism does not interfere with their likelihood of benefiting from this treatment. Concluding Remarks Decades of theory and clinical accounts have pointed to the negative impacts of pathological narcissism on psychotherapy outcome and processes. This study tested, in a sample of patients receiving short-term group psychodynamic treatment for perfectionism, the hypothesis that higher levels of pathological narcissism would predict poorer treatment outcome. Contrary to my predictions, I did not find that pathological narcissism predicted poorer treatment outcome in terms of symptom severity, life satisfaction or work and social impairment. These findings add to a growing body of literature suggesting that patients with pathological narcissism do not necessarily benefit less from psychotherapy. 34 Tables Table 1 Demographic Characteristics Variables n % Gender Woman 58 72.5 Man 21 26.3 Nonbinary 1 1.3 Ethnicity Caucasian/European Descent 52 65 Asian/Pacific islander 12 15 Hispanic/Latino 1 1.3 Other 10 12.5 Marital Status Single 42 52.5 Married 17 21.3 Common law 7 8.8 In a relationship 6 7.5 Divorced 3 3.8 Separated 2 2.5 Employment status Employed 47 58.8 Student 18 22.5 Retired 5 6.3 Unemployed 4 5 35 Table 2 Spearman’s Correlations of Pathological Narcissism with Outcome Variables Variables 1 2 3 4 5 6 7 8 9 1. Narcissism – pre – 2. Symptom severity – pre .42** n 78 – 3. Symptom severity – post .40** .59** n 70 69 – 4. Satisfaction with life – pre -.10 -.45** -.16 n 80 78 70 – 5. Satisfaction with life – post -.02 -.31** -.23 .74** n 70 69 70 70 – 6. Work and Social Impairment – pre .21 .38** .34** -.34** -.26* n 78 76 68 78 68 – 7. Work and Social Impairment – post .28* .38** .41** -.23 -.26* .70** n 68 67 68 68 68 67 – 8. Gender -.01 .18 .04 .07 .12 .04 .98 n 80 78 70 80 70 79 68 – 9. Age .06 .02 .04 .09 .07 .04 -.08 -.15 n 80 78 70 80 70 78 68 80 – M 2.48 1.09 0.77 17.38 21.21 18.60 15.76 1.75 36.85 SD 0.80 0.60 0.54 7.13 6.81 8.38 8.49 .46 13.01 Minimum .50 .15 .00 5.00 8.00 .00 2.00 0.00 19 Maximum 4.82 2.85 2.87 31.00 35.00 40.00 38.00 3.00 73 α .89 .94 .95 .88 .84 .79 .85 / / Note. * p < .05. ** p < .01 ns for each pairwise correlation are below the correlation coefficient. 36 Table 3 Multiple Regression Model with Post-Treatment Global Severity Index as the Outcome Variable Parameters Estimate (SE) p Intercept 0.79 (0.06) < .001 Symptom severity-pre 0.41 (0.12) .001 Pathological narcissism – pre 0.14 (0.08) .10 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 37 Table 4 Multilevel Random Intercept Model with Post-Treatment Satisfaction with Life as the Outcome Variable Parameters Estimate (SE) p Fixed components Intercept 20.92 (0.70) < .001 Satisfaction with life-pre 0.69 (0.08) < .001 Pathological narcissism – pre 0.56 (0.68) .41 Variance components Residual 18.64 Intercept 2.12 Intraclass Coefficient 0.13 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 38 Table 5 Multiple Regression Model with Post-Treatment Work and Social Impairment as the Outcome Variable Parameters Estimate (SE) p Intercept 16.39 (1.08) < .001 Work and social impairment-pre 0.64 (1.12) < .001 Pathological narcissism – pre 0.91 (1.24) .47 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 39 References Barr, D. J., Levy, R., Scheepers, C., & Tily, H. J. (2013). Random effects structure for confirmatory hypothesis testing: Keep it maximal. Journal of Memory and Language, 68(3), 255-278. https://doi.org/10.1016/j.jml.2012.11.001 Bates, D., Kliegl, R., Vasishth, S., & Baayen, H. (2015). Parsimonious mixed models. https://doi.org/10.48550/arxiv.1506.04967 Bemak, F., & Epp, L. (2001). Countertransference in the development of graduate student group counselors: Recommendations for training. The Journal for Specialists in Group Work, 26(4), 305-318. https://doi.org/10.1080/01933920108413781 Betan, E., Heim, A. K., Zittel Conklin, C., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. The American Journal of Psychiatry, 162(5), 890-898. https://doi.org/10.1176/appi.ajp.162.5.890 Burlingame, G. M., McClendon, D. T., & Alonso, J. (2011). Cohesion in group therapy. Psychotherapy, 48(1), 34–42. https://doi.org/10.1037/a0022063 Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta- analysis. Psychotherapy (Chicago, Ill.), 55(4), 384-398. https://doi.org/10.1037/pst0000173 Busmann, M., Meyer, A. H., Wrege, J., Lang, U. E., Gaab, J., Walter, M., & Euler, S. (2021). Vulnerable narcissism as beneficial factor for the therapeutic alliance in borderline personality disorder. Clinical Psychology and Psychotherapy, 28(5), 1222-1229. https://doi.org/10.1002/cpp.2570 Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: Phenotypic 40 description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical Psychology Review, 28, 638–656. https://doi.org/10.1016/j.cpr.2007.09.006 Campbell, M. A., Waller, G., & Pistrang, N. (2009). The impact of narcissism on drop-out from cognitive-behavioral therapy for the eating disorders: A pilot study. The Journal of Nervous and Mental Disease, 197(4), 278-281. https://doi.org/10.1097/NMD.0b013e31819dc150 Cheek, J., Kealy, D., Joyce, A. S., & Ogrodniczuk, J. S. (2018). Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study. Archives of Psychiatry & Psychotherapy, 20(2). https://doi.org/10.12740/APP/90328 Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. http://dx.doi.org/10.1037/0033-2909.112.1.155 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 Cutler, R. L. (1958). Countertransference effects in psychotherapy. Journal of Consulting Psychology, 22(5), 349-356. https://doi.org/10.1037/h0044815 Daig, I., Klapp, B. F., & Fliege, H. (2009). Narcissism predicts therapy outcome in psychosomatic patients. Journal of Psychopathology and Behavioral Assessment, 31(4), 368-377. https://doi.org/10.1007/s10862-008-9122-0 Derogatis, L. R. (1993). Brief symptom inventory: BSI. Pearson. Derogatis, L. R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological medicine, 13(3), 595–605. 41 https://doi.org/10.1017/S0033291700048017 Di Sarno, M., Frisina, S., Madeddu, F., & Di Pierro, R. (2023). Interpersonal perceptions in treatment sessions: Pathological narcissism predicts self-rater discrepancies. Journal of Clinical Psychology, 79(4), 1002-1020. https://doi.org/10.1002/jclp.23454 Diamond, D., Yeomans, F. E., Stern, B. L., & Kernberg, O. F. (2021). Treating pathological narcissism with transference-focused psychotherapy. Guilford Publications. Dickinson, K. A., & Pincus, A. L. (2003). Interpersonal analysis of grandiose and vulnerable narcissism. Journal of Personality Disorders, 17, 188–207. https://doi.org/10.1521/pedi.17.3.188.22146 Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality Assessment, 49(1), 71–75. https://doi.org/10.1207/s15327752jpa4901_13 Ellison, W. D., Levy, K. N., Cain, N. M., Ansell, E. B., & Pincus, A. L. (2013). The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: A naturalistic investigation. Journal of Personality Assessment, 95(3), 291-300. https://doi.org/10.1080/00223891.2012.742904 Euler, S., Hüwe, L., Gablonski, T. C., Dehoust, M., Schulz, H., Brütt, A. L., & Andreas, S. (2022). Mentalizing Mediates the Association between Narcissism and Psychotherapeutic Treatment Outcome in a Mixed Clinical Sample. Psychopathology, 1-10. https://doi.org/10.1159/000524203 Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. London: Routledge. Flett, G. L., Sherry, S. B., Hewitt, P. L., & Nepon, T. (2014). Understanding the narcissistic 42 perfectionists among us: Grandiosity, vulnerability, and the quest for the perfect self. Handbook of psychology of narcissism: Diverse perspectives, 43-66. Freud, S. (1910). Future prospects of psychoanalytic therapy. In J. Strachey (Ed.), The standard ed. of the complete works of Sigmund Freud (pp. 139–151). London, England: Hogarth Press. Freud, S. (1957). On narcissism: An introduction. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (pp. 73–102). London, England: Hogarth Press. Gabbard, G. O. (2009). Transference and countertransference: Developments in the treatment of Narcissistic Personality Disorder. Psychiatric Annals, 39, 129–136. https://doi.org/10.3928/00485713-20090301-03 Glover, N., Miller, J. D., Lynam, D. R., Crego, C., & Widiger, T. A. (2012). The five-factor narcissism inventory: A five-factor measure of narcissistic personality traits. Journal of Personality Assessment, 94(5), 500-512. https://doi.org/10.1080/00223891.2012.670680 Goldman, G. F., & Gelso, C. J. (1997). Kohut's theory of narcissism and adolescent drug abuse treatment. Psychoanalytic Psychology, 14(1), 81-94. https://doi.org/10.1037/h0079725 Gordon, R. M., Gazzillo, F., Blake, A., Bornstein, R. F., Etzi, J., Lingiardi, V., McWilliams, N., Rothery, C., & Tasso, A. F. (2016). The relationship between theoretical orientation and countertransference expectations: Implications for ethical dilemmas and risk management. Clinical Psychology and Psychotherapy, 23(3), 236-245. https://doi.org/10.1002/cpp.1951 Graham, J. W. (2009). Missing data analysis: Making it work in the real world. Annual 43 Review of Psychology, 60(1), 549-576. https://doi.org/10.1146/annurev.psych.58.110405.085530 Grund, S., Lüdtke, O., & Robitzsch, A. (2016). Multiple imputation of multilevel missing data: An introduction to the R package pan. SAGE Open, 6(4), 1-17. https://doi.org/10.1177/2158244016668220 Hamachek, D. E. (1978). Psychodynamics of normal and neurotic perfectionism. Psychology, 19, 26-33. Hassanzadeh, F., Akhani, A. & Asgharnezhad, A. (2020). Psychometric Properties of Brief Version of the Pathological Narcissism Inventory. Journal of Neyshabur University of Medical Sciencees, 8(1), 77-87. https://sid.ir/paper/414516/en Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy (Chicago, Ill.), 48(1), 88-97. https://doi.org/10.1037/a0022182 Hewitt, P. L., & Flett, G. L. (2004). The Multidimensional Perfectionism Scale: Technical Manual. Toronto: Multi-Health Systems Inc. Hewitt, P. L., Flett, G. L., & Mikail, S. F. (2017). Perfectionism: A relational approach to conceptualization, assessment, and treatment. Guilford Publications. Hewitt, P. L., Kealy, D., Mikail, S. F., Smith, M. M., Ge, S., Chen, C., Sochting, I., Tasca, G. A., Flett, G. L., & Ko, A. (2023). The efficacy of group psychotherapy for adults with perfectionism: A randomized controlled trial of dynamic-relational therapy versus psychodynamic supportive therapy. Journal of Consulting and Clinical Psychology, 91(1), 29-42. https://doi.org/10.1037/ccp0000787 Hewitt, P. L., Mikail, S. F., Flett, G. L., Tasca, G. A., Flynn, C. A., Deng, X., Kaldas, J., & 44 Chen, C. (2015). Psychodynamic/Interpersonal group psychotherapy for perfectionism: Evaluating the effectiveness of a short-term treatment. Psychotherapy (Chicago, Ill.), 52(2), 205-217. https://doi.org/10.1037/pst0000016 Hewitt, P. L., Qiu, T., Flynn, C. A., Flett, G. L., Wiebe, S. A., Tasca, G. A., & Mikail, S. F. (2019). Dynamic-relational group treatment for perfectionism: Informant ratings of patient change. Psychotherapy (Chicago, Ill.), 57(2), 197-205. https://doi.org/10.1037/pst0000229 Hewitt, P. L., Smith, M. M., Deng, X., Chen, C., Ko, A., Flett, G. L., & Paterson, R. J. (2020). The perniciousness of perfectionism in group therapy for depression: A test of the perfectionism social disconnection model. Psychotherapy (Chicago, Ill.), 57(2), 206-218. https://doi.org/10.1037/pst0000281 Hilsenroth, M. J., Holdwick, D. J., Castlebury, F. D., & Blais, M. A. (1998). The effects of DSM-IV cluster B personality disorder symptoms on the termination and continuation of psychotherapy. Psychotherapy (Chicago, Ill.), 35(2), 163-176. https://doi.org/10.1037/h0087845 Horney, K. (1950). Neurosis and human growth: The struggle toward self-realization ([1st]. ed.). Norton. Jang, S. J., & Lee, H. (2022). Pathological narcissism, interpersonal cognitive distortions, and workplace bullying among nurses: A cross‐sectional study. Journal of Nursing Management, 30(7), 3051-3059. https://doi.org/10.1111/jonm.13706 Kacel, E. L., Ennis, N., & Pereira, D. B. (2017). Narcissistic personality disorder in clinical 45 health psychology practice: Case studies of comorbid psychological distress and life-limiting illness. Behavioral Medicine (Washington, D.C.), 43(3), 156-164. https://doi.org/10.1080/08964289.2017.1301875 Kaufman, S. B., Weiss, B., Miller, J. D., & Campbell, W. K. (2020). Clinical correlates of vulnerable and grandiose narcissism: A personality perspective. Journal of Personality Disorders, 34(1), 107-130. https://doi.org/10.1521/pedi_2018_32_384 Kealy, D., & Ogrodniczuk, J. S. (2011). Narcissistic interpersonal problems in clinical practice. Harvard Review of Psychiatry, 19(6), 290-301. https://doi.org/10.3109/10673229.2011.632604 Kealy, D., & Rasmussen, B. (2012). Veiled and vulnerable: The other side of grandiose narcissism. Clinical Social Work Journal, 40(3), 356-365. https://doi.org/10.1007/s10615-011-0370-1 Kealy, D., Sandhu, S., & Ogrodniczuk, J. S. (2017). Looking ahead through a fragile lens: Vulnerable narcissism and the future self. Personality and Mental Health, 11(4), 290-298. https://doi.org/10.1002/pmh.1384 Kealy, D., Tsai, M., & Ogrodniczuk, J. S. (2012). Depressive tendencies and pathological narcissism among psychiatric outpatients. Psychiatry Research, 196, 157–159. https://doi.org/10.1016/j.psychres.2011.08.023 Kealy, D., Tsai, M., & Ogrodniczuk, J. S. (2016). Pathological narcissism and somatic symptoms among men and women attending an outpatient mental health clinic. International journal of psychiatry in clinical practice, 20(3), 175-178. https://doi.org/10.1080/13651501.2016.1199811 Kealy, D., Woolgar, S., & Hewitt, J. M. A. (2022). Investigating pathological narcissism and 46 loneliness, and the link with life satisfaction. Scandinavian Journal of Psychology, 63(1), 32-38. https://doi.org/10.1111/sjop.12773 Kernberg, O. F. (2007). The almost untreatable narcissistic patient. Journal of the American Psychoanalytic Association, 55(2), 503-539. https://doi.org/10.1177/00030651070550020701 Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. International Universities Press. La Marca, R., Scheiwiller, M., Pfaff, M., La Marca-Ghaemmaghami, P., & Böker, H. (2022). The Role of Vulnerable and Grandiose Narcissism in the Inpatient Treatment of Stress-Related Depressive Disorders. Journal of Psychiatry and Psychiatric Disorders, 6(3), 142-161. Meier, L. L., & Semmer, N. K. (2013). Lack of reciprocity, narcissism, anger, and instigated workplace incivility: A moderated mediation model. European Journal of Work and Organizational Psychology, 22(4), 461-475. https://doi.org/10.1080/1359432X.2012.654605 Miller, J. D., Campbell, W. K., & Pilkonis, P. A. (2007). Narcissistic personality disorder: Relations with distress and functional impairment. Comprehensive Psychiatry, 48(2), 170-177. https://doi.org/10.1016/j.comppsych.2006.10.003 Miller, J. D., McCain, J., Lynam, D. R., Few, L. R., Gentile, B., MacKillop, J., & Campbell, W. K. (2014). A comparison of the criterion validity of popular measures of narcissism and narcissistic personality disorder via the use of expert ratings. Psychological Assessment, 26(3), 958-969. http://dx.doi.org/10.1037/a0036613 Miller, J. D., Widiger, T. A., & Campbell, W. K. (2010). Narcissistic personality disorder and 47 the DSM-V. Journal of Abnormal Psychology, 119(4), 640–649. https://doi.org/10.1037/a0019529 Moon, C., & Morais, C. (2022). The effect of covert narcissism on workplace incivility: The mediating role of self-esteem and norms for respect. Current Psychology, 1-15. https://doi.org/10.1007/s12144-022-02968-5 Morey, L. C. (1991). Personality assessment inventory. Psychological Assessment Resources. Muir, O., Weinfeld, J. N., Ruiz, D., Ostrovsky, D., Fiolhais, M., & MacMillan, C. (2021). Mental health clinicians' attitudes toward narcissistic personality disorder. Personality Disorders, 12(5), 389-399. https://doi.org/10.1037/per0000510 Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. M. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. The British Journal of Psychiatry, 180(5), 461–464. https://doi.org/10.1192/bjp.180.5.461 Nealis, L. J., Sherry, S. B., Sherry, D. L., Stewart, S. H., & Macneil, M. A. (2015). Toward a better understanding of narcissistic perfectionism: Evidence of factorial validity, incremental validity, and mediating mechanisms. Journal of Research in Personality, 57, 11-25. https://doi.org/10.1016/j.jrp.2015.02.006 Newman, D. A. (2014). Missing data: Five practical guidelines. Organizational Research Methods, 17(4), 372-411. https://doi.org/10.1177/1094428114548590 Ogrodniczuk, J. S. & Kealy, D. (Ed.). (2013). Interpersonal problems of narcissistic patients. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 113–127). American Psychological Association. https://doi.org/10.1037/14041-007 Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., Steinberg, P. I., & Duggal, S. (2009). Interpersonal problems associated with narcissism among psychiatric outpatients. Journal 48 of Psychiatric Research, 43(9), 837-842. https://doi.org/10.1016/j.jpsychires.2008.12.005 Pavot, W., & Diener, E. (1993). Review of the Satisfaction with Life Scale. Psychological Assessment, 5(2), 164–172. https://doi.org/10.1037/1040-3590.5.2.164 Pavot, W., & Diener, E. (2008). The satisfaction with life scale and the emerging construct of life satisfaction. The Journal of Positive Psychology, 3(2), 137-152. https://doi.org/10.1080/17439760701756946 Pedersen, G., Kvarstein, E. H., & Wilberg, T. (2017). The work and social adjustment scale: Psychometric properties and validity among males and females, and outpatients with and without personality disorders: The work and social adjustment scale: Psychometric properties and validity among males and females. Personality and Mental Health, 11(4), 215-228. https://doi.org/10.1002/pmh.1382 Penney, E., McGill, B., & Witham, C. (2017). Opinion Piece: Therapist Stigma towards Narcissistic Personality Disorder: Lessons Learnt from Borderline Personality Disorder. Australian Clinical Psychologist, 3(1), 1745. Pincus, A. L. (2013). The Pathological Narcissism Inventory. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 93–110). American Psychological Association. https://doi.org/10.1037/14041-006 Pincus, A. L., Ansell, E. B., Pimental, C. A., Cain, N. M., Wright, A. G. C., & Levy, K. N. (2009). Initial construction and validation of the pathological narcissism inventory. Psychological Assessment, 21, 365–379. https://doi.org/10.1037/a0016530 Rockland, L. (2003). Supportive therapy: A psychodynamic approach. Basic Books. Rohmann, E., Hanke, S., & Bierhoff, H. (2019). Grandiose and vulnerable narcissism in relation 49 to life satisfaction, self-esteem, and self-construal. Journal of Individual Differences, 40(4), 194-203. https://doi.org/10.1027/1614-0001/a000292 Ronningstam, E. (2011). Narcissistic personality disorder: A clinical perspective. Journal of Psychiatric Practice, 17(2), 89-99. https://doi.org/10.1097/01.pra.0000396060.67150.40 Rosenfeld, H. (1964). On the psychopathology of narcissism; a clinical approach. International Journal of Psychoanalysis, 45, 332. Rossberg, J. I., Karterud, S., Pedersen, G., & Friis, S. (2007). An empirical study of countertransference reactions toward patients with personality disorders. Comprehensive Psychiatry, 48(3), 225-230. https://doi.org/10.1016/j.comppsych.2007.02.002 Rossberg, J. I., Karterud, S., Pedersen, G., & Friis, S. (2010). Psychiatric symptoms and countertransference feelings: An empirical investigation. Psychiatry Research, 178(1), 191-195. https://doi.org/10.1016/j.psychres.2009.09.019 Russ, E., & Shedler, J. (2013). Defining narcissistic subtypes. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 29–43). American Psychological Association. https://doi.org/10.1037/14041-002 Russ, E., Shedler, J., Bradley, R., & Westen, D. (2008). Refining the construct of narcissistic personality disorder: Diagnostic criteria and subtypes. American Journal of Psychiatry, 165, 1473–1481. https://doi.org/10.1176/appi.ajp.2008.07030376 Schoeneich, F., Rose, M., Danzer, G., Thier, P., Weber, C., & Klapp, B. F. (2000). Narcissism inventory-90 (NI-90). Empirically-based reduction and identification of items sensitive for change – a questionnaire particularly suited for measuring self-regulatory parameters. Psychotherapie, Psychosomatik, Medizinische Psychologie, 50, 396–405. https://doi.org/10.1055/s-2000-9095 50 Schoenleber, M., Roche, M. J., Wetzel, E., Pincus, A. L., & Roberts, B. W. (2015). Development of a brief version of the pathological narcissism inventory. Psychological Assessment, 27(4), 1520-1526. https://doi.org/10.1037/pas0000158 Sheehan, L., Nieweglowski, K., & Corrigan, P. (2016). The stigma of personality disorders. Current Psychiatry Reports, 18(1), 11-11. https://doi.org/10.1007/s11920-015-0654-1 Smith, M. M., Sherry, S. B., Chen, S., Saklofske, D. H., Flett, G. L., & Hewitt, P. L. (2016). Perfectionism and narcissism: A meta-analytic review. Journal of Research in Personality, 64, 90-101. https://doi.org/10.1016/j.jrp.2016.07.012 Sorotzkin, B. (1985). the quest for perfection: Avoiding guilt or avoiding shame? Psychotherapy (Chicago, Ill.), 22(3), 564-571. https://doi.org/10.1037/h0085541 Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Pearson/Allyn & Bacon. Tanzilli, A., Muzi, L., Ronningstam, E., & Lingiardi, V. (2017). Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy (Chicago, Ill.), 54(2), 184-194. https://doi.org/10.1037/pst0000111 Tasca, G. A., Illing, V., Joyce, A. S., & Ogrodniczuk, J. S. (2009). Three-level multilevel growth models for nested change data: A guide for group treatment researchers. Psychotherapy Research, 19(4-5), 453–461. https://doi.org/10.1080/10503300902933188 Ulberg, R., Amlo, S., Hersoug, A. G., Dahl, H. J., & Høglend, P. (2014). The effects of the therapist's disengaged feelings on the in-session process in psychodynamic psychotherapy. Journal of Clinical Psychology, 70(5), 440-451. https://doi.org/10.1002/jclp.22088 Van Wagoner, S. L. (2000). Anger in group therapy, countertransference and the novice group 51 therapist. Journal of Psychotherapy in Independent Practice, 1(2), 63-75. https://doi.org/10.1300/J288v01n02_08 Van Wagoner, S. L., Gelso, C. J., Hayes, J. A., & Diemer, R. A. (1991). Countertransference and the reputedly excellent therapist. Psychotherapy: Theory, research, practice, training, 28(3), 411. https://doi.org/10.1037/0033-3204.28.3.411 Zahra, D., Qureshi, A., Henley, W., Taylor, R., Quinn, C., Pooler, J., Hardy, G., Newbold, A., & Byng, R. (2014). The Work and social impairment Scale: Reliability, sensitivity and value. International Journal of Psychiatry in Clinical Practice, 18(2), 131–138. https://doi.org/10.3109/13651501.2014.894072 Zalman, H., Aafjes-van Doorn, K., & Eubanks, C. F. (2019). Alliance challenges in the treatment of a narcissistic patient: The case of alex. Research in Psychotherapy (Milano)., 22(2), 351-351. https://doi.org/10.4081/ripppo.2019.351 Zeitler, M., Bohus, M., Kleindienst, N., Knies, R., Ostermann, M., Schmahl, C., & Lyssenko, L. (2020). How to assess recovery in borderline personality disorder: Psychosocial functioning and satisfaction with life in a sample of former DBT study patients. Journal of Personality Disorders, 34(3), 1-307. https://doi.org/10.1521/pedi_2018_32_394 52 Appendices Appendix A: Skewness and KurtosisVariables Skewness Kurtosis Shapiro–Wilk Test Narcissism – pre .12 .39 W = .99, p = .83 Symptom severity – pre .16 -.49 W = .96, p = .02 Symptom severity – post 1.13 1.11 W = .89, p < .001 Satisfaction with life – pre .23 -.88 W = .96, p = .02 Satisfaction with life – post -.04 -1.06 W = .96, p = .03 Work and social impairment – pre -.00 -.27 W = .99, p = .93 Work and social impairment – post .41 -.44 W = .97, p = .09 53 Appendix B. Impact of Grandiose and Vulnerable Narcissism on Treatment Outcome B.1 Multiple Regression Model with Post-Treatment Global Severity Index as the Outcome Variable Parameters Estimate (SE) p Intercept 0.79 (0.06) < .001 Symptom-related severity-pre 0.42 (0.12) < .001 Grandiose narcissism – pre 0.13 (0.08) .14 Vulnerable narcissism – pre 0.02 (0.10) .87 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 54 B.2. Multilevel Random Intercept Model with Post-Treatment Satisfaction with Life as the Outcome Variable Parameters Estimate (SE) p Regression coefficients Intercept 20.95 (0.68) < .001 Satisfaction with life-pre 0.69 (0.08) < .001 Grandiose narcissism – pre 0.15 (0.82) .85 Vulnerable narcissism – pre 0.40 (0.85) .64 Variance components Residual 18.80 Intercept 2.04 Intraclass Coefficient 0.13 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 55 B.3 Multiple Regression Model with Post-Treatment Work and Social Impairment as the Outcome Variable Parameters Estimate (SE) p Intercept 16.40 (1.08) < .001 Work and social impairment-pre 0.64 (0.12) < .001 Grandiose narcissism – pre 0.78 (1.49) .60 Vulnerable narcissism – pre 0.15 (1.56) .93 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 56 Appendix C. Spearman’s Correlations between Grandiosity and Vulnerability with Outcome Variables Variables 1 2 3 4 5 6 7 8 1. Narcissistic Grandiosity – pre – 2. Narcissistic Vulnerability – pre .57** – 3. Symptom severity – pre .28* .46** – 4. Symptom severity – post .38** .39** .59** – 5. Satisfaction with life – pre -.00 -.15 -.45** -.16 – 6. Satisfaction with life – post .06 -.06 -.31** -.23 .74** – 7. Work and social impairment – pre .11 .22* .38** .34** -.34** -.26* – 8. Work and social impairment – post .20 .26* .38** .41** -.23 -.26* .70** – Note. * p < .05. ** p < .01 57 Appendix D. Impact of Grandiose and Vulnerable Narcissism on Likelihood of Dropout Parameters Estimate (SE) p Intercept 1.96 (0.34) < .001 Grandiose narcissism – pre -0.13 (0.50) .85 Vulnerable narcissism – pre -0.09 (0.49) .80 Note. Parameter estimate standard errors listed in parentheses. All predictors were grand-mean centered. All estimates are unstandardized. 58 Appendix E. Measures E.1 Brief-Pathological Narcissism Inventory Please indicate how much each of the following statements is typical of you. Use the scale provided. Not at all Very much like me like me 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 1 ________ I can usually talk my way out of anything. 2 ________ When people don't notice me, I start to feel bad about myself. 3 ________ I often hide my needs for fear that others will see me as needy and dependent. 4 ________ I can make anyone believe anything I want them to. 5 ________ I get annoyed by people who are not interested in what I say or do. 6 ________ I find it easy to manipulate people. 7 ________ Sometimes I avoid people because I'm concerned that they'll disappoint me. 8 ________ I typically get very angry when I'm unable to get what I want from others. 9 ________ When others don't meet my expectations, I often feel ashamed about what I wanted. 10 ________ I feel important when others rely on me. 11 ________ I can read people like a book. 12 ________ Sacrificing for others makes me the better person. 13 ________ I often fantasize about accomplishing things that are probably beyond my means. 14 ________ Sometimes I avoid people because I'm afraid they won't do what I want them to. 15 ________ It's hard to show others the weaknesses I feel inside. 16 ________ It's hard to feel good about myself unless I know other people admire me. 17 ________ I often fantasize about being rewarded for my efforts. 18 ________ I am preoccupied with thoughts and concerns that most people are not interested in me. 19 ________ I like to have friends who rely on me because it makes me feel important. 20 ________ Sometimes I avoid people because I'm concerned they won't acknowledge what I do for them. 21 ________ It's hard for me to feel good about myself unless I know other people like me. 22 ________ It irritates me when people don't notice how good a person I am. 23 ________ I will never be satisfied until I get all that I deserve. 24 ________ I try to show what a good person I am through my sacrifices. 25 ________ I often fantasize about performing heroic deeds. 26 ________ I often fantasize about being recognized for my accomplishments. 59 27 ________ I can't stand relying on other people because it makes me feel weak. 28 ________ When others get a glimpse of my needs, I feel anxious and ashamed. 60 E.2 Brief Symptom Inventory Below is a list of problems people sometimes have. Please read each one carefully and choose what best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. 1. Nervousness or shakiness inside ........................................................... 0 1 2 3 4 2. Faintness or dizziness ........................................................................... 0 1 2 3 4 3. The idea that someone else can control your thoughts .......................... 0 1 2 3 4 4. Feeling others are to blame for most of your troubles ............................ 0 1 2 3 4 5. Trouble remembering things .................................................................. 0 1 2 3 4 6. Feeling easily annoyed or irritated.......................................................... 0 1 2 3 4 7. Pains in heart or chest ............................................................................ 0 1 2 3 4 8. Feeling afraid in open spaces or on the streets ...................................... 0 1 2 3 4 9. Thoughts of ending your life ................................................................... 0 1 2 3 4 10. Feeling that most people cannot be trusted ......................................... 0 1 2 3 4 11. Poor appetite ........................................................................................ 0 1 2 3 4 12. Suddenly scared for no reason ............................................................ 0 1 2 3 4 13. Temper outbursts that you could not control ........................................ 0 1 2 3 4 14. Feeling lonely even when you are with people ..................................... 0 1 2 3 4 15. Feeling blocked in getting things done ................................................. 0 1 2 3 4 16. Feeling lonely ....................................................................................... 0 1 2 3 4 17. Feeling blue .......................................................................................... 0 1 2 3 4 18. Feeling no interest in things ................................................................. 0 1 2 3 4 19. Feeling fearful ...................................................................................... 0 1 2 3 4 20. Your feelings being easily hurt ............................................................. 0 1 2 3 4 21. Feeling that people are unfriendly or dislike you .................................. 0 1 2 3 4 22. Feeling inferior to others ....................................................................... 0 1 2 3 4 23. Nausea or upset stomach .................................................................... 0 1 2 3 4 24. Feeling that you are watched or talked about by others ....................... 0 1 2 3 4 25. Trouble falling asleep ........................................................................... 0 1 2 3 4 26. Having to check and double--check what you do .................................. 0 1 2 3 4 27. Difficulty making decisions ................................................................... 0 1 2 3 4 28. Feeling afraid to travel on buses, subways, or trains............................ 0 1 2 3 4 29. Trouble getting your breath .................................................................. 0 1 2 3 4 0 = Not at all 1 = A little bit 2 = Moderately 3 = Quite a bit 4 = Extremely 61 30. Hot or cold spells .................................................................................. 0 1 2 3 4 31. Having to avoid certain things, places, or activities because they frighten you 0 1 2 3 4 32. Your mind going blank .......................................................................... 0 1 2 3 4 33. Numbness or tingling in parts of your body .......................................... 0 1 2 3 4 62 E.3 Satisfaction with Life Scale Instructions: Below are five statements that you may agree or disagree with. Using the 1 - 7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item, Please be open and honest in your responding. • 7 - Strongly agree • 6 - Agree • 5 - Slightly agree • 4 - Neither agree nor disagree • 3 - Slightly disagree • 2 - Disagree • 1 - Strongly disagree _____ In most ways my life is close to my ideal. _____ The conditions of my life are excellent. _____ I am satisfied with my life. _____ So far I have gotten the important things I want in life. _____ If I could live my life over, I would change almost nothing. 63 E.4 Work and Social Impairment Scale Instructions: People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems, look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional If you're retired or choose not to have a job for reasons unrelated to your problems, tick here: 1. Because of my [problem] my ability to work is impaired. '0' means 'not at all impaired' and '8' means very severely impaired to the point I can't work. 0 1 2 3 4 5 6 7 8 Not at all Slightly Definitely Markedly Very severely 2. Because of my [problem] my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired. 0 1 2 3 4 5 6 7 8 Not at all Slightly Definitely Markedly Very severely 3. Because of my [problem] my social leisure activities (with other people e.g., parties, bars, clubs, outings, visits, dating, home entertaining) are impaired. 0 1 2 3 4 5 6 7 8 Not at all Slightly Definitely Markedly Very severely 4. Because of my [problem], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired. 0 1 2 3 4 5 6 7 8 Not at all Slightly Definitely Markedly Very severely 5. Because of my [problem], my ability to form and maintain close relationships with others, including those I live with, is impaired. 0 1 2 3 4 5 6 7 8 Not at all Slightly Definitely Markedly Very severely 64
Thesis/Dissertation
eng
Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Hewitt, Paul L. (Paul Louis)
The impact of pathological narcissism on change in symptoms, life satisfaction, and work and social impairment in psychodynamic group therapy for perfectionism
Text