Targeting Narcissistic Vulnerability in a Single-Subject Design: Brief Dynamic Psychotherapy for Major Depressive Disorder

Abstract

Background: While a significant body of research has utilized general clinical manuals, a thorough literature review revealed a notable absence of studies using the Busch et al. (2016) manual — one of the few manuals grounded in the psychoanalytic concept of narcissistic vulnerability as a core mechanism in depression. This study is the first to empirically examine this foundational yet underexplored perspective. Objectives: This study investigates the efficacy of a 24-session manualized short-term dynamic psychotherapy (STDP), adapted from Busch et al.'s (2016) work, in reducing moderate to severe depressive symptoms. The manual identifies narcissistic vulnerability, conflicted anger, and perfectionism as key dynamics in depression. The primary aim of this intervention is to improve problematic relational patterns linked to narcissistic vulnerability, such as insecure attachment, egocentricity, social incompetence, and alienation. It is hypothesized that the intervention's effectiveness stems from targeting narcissistic vulnerability as a central feature of depression. Methods: A single-subject design was employed with five participants diagnosed with major depressive disorder (MDD). Changes in depressive symptoms, daily functioning, and quality of object relations were assessed across baseline, intervention, and follow-up phases using the Hamilton Depression Rating Scale (HDRS), the Sheehan Disability Scale (SDS), and the Bell Object Relations Inventory (BORRI), respectively. The Reliable Change Index (RCI) and visual trend analysis were used to evaluate outcomes. For more nuanced analysis, the intervention phase was divided into two halves. The treatment phase comprised 24 twice-weekly sessions, followed by a 4-week follow-up phase. Results: The intervention demonstrated significant effectiveness in reducing depressive symptoms throughout treatment and follow-up. Scores on the HDRS significantly decreased post-intervention. Mediation analysis supported the intervention’s role in mitigating depression by improving relational patterns, particularly through a significant reduction in insecure attachment. Additionally, scores on the SDS indicated improvements in daily functioning. Conclusions: These findings suggest that brief dynamic psychotherapy targeting narcissistic vulnerability as a core depressive feature holds promise for treating depression and informing the development of novel interventions.