2022, Vol. 21, No. 3, 211-227 | International Journal of Forensic Mental Health
The Meaningfulness of Grandiose and Vulnerable Narcissism in Forensic Mental Health Rehabilitation Practice: A Systematic Review
Lobke H. Keune; Erasmus University Medical Centre, Rotterdam, The Netherlands
Vivienne de Vogel; De Forensische Zorgspecialisten, Utrecht, The Netherlands; University of Applied Sciences, Utrecht, The Netherlands
Mara Eisenberg; De Forensische Zorgspecialisten, Utrecht, The Netherlands
Hjalmar J. C. van Marle; Erasmus University Medical Centre, Rotterdam, The Netherlands
Narcissism is a personality construct with grandiose, and vulnerable aspects, that are interconnected through antagonistic characteristics. While antagonism is strongly related to antisocial behavior, the role of narcissism remains underexplored in offender rehabilitation practice. Research in non-forensic samples has already shown promising results in the differential associations for grandiose and vulnerable narcissism in relation to violent and antisocial behavior and treatment responsiveness that could be relevant for offender rehabilitation. To research the meaningfulness of both narcissism aspects for forensic offender rehabilitation practice, we systematically reviewed the electronic literature databases CINAHL EBSCOhost, Cochrane CENTRAL, EMBASE, Medline All Ovid, PsycINFO Ovid, and Web of Science Core Collection. Subsequently, we synthesized the outcome into meaningful data classifications related to the risk of violence in offender populations and treatment responsivity. In total, 14 publications on forensic samples were included. Overall, the findings suggest that grandiose narcissism was strongly related to proactive violence and a low treatment responsiveness. Vulnerable narcissism was associated with reactive aggression, mediated by impulsivity and negative emotions, and with a moderate responsivity level. As such, both narcissism aspects seem relevant for the development of structured and focused treatment plans in offender rehabilitation practice. The implications for offender rehabilitation practice are provided.
Forensic mental health; grandiose narcissism; vulnerable narcissism; risk-need-responsivity; offender rehabilitation practice
Summary of the Research
“…According to the leading offender rehabilitation model of Bonta and Andrews (2017), known as the Risk-Need-Responsivity (RNR) model, treatment should be focused on those factors that are directly related to the risk of re-offending (i.e., criminogenic needs)…pathological narcissism…remains unduly underexplored in offender rehabilitation research…Narcissism is considered a multidimensional personality construct that consists of two distinct dimensions: grandiose narcissism [GN] and vulnerable narcissism [VN] (Wink, 1991)…Despite the lack of basic research in forensic settings on the differential association of these narcissism aspects with the risk of violence, empirical research on communal samples has already shown promising results that further our understanding on various types of violence…Additionally, clinical literature has shown a differential relation with treatment response for both aspects…” (p. 211-213).
“The variable aspects of narcissism might imply variable responsivity, and implications for risk reduction in offender rehabilitation (i.e., forensic samples) that cannot be dismissed. The potential meaningfulness of both aspects of the narcissism construct for the risk assessment, management, and treatment of serious sexual and violent offenders in FMH [forensic mental health] practice was examined by systematically reviewing the existing evidence on GN and VN in FMH. Our research questions were: (1) Which responsivity issues have been identified for GN and VN aspects in forensic samples? (2) Which relationships have been identified in forensic samples between GN and VN aspects and the risk to violently/sexually re-offend?” (p. 214).
“The findings of this review suggest that GN and VN are of relevance in offender rehabilitation practice. Both aspects of narcissism seem relevant for the development of structured and focused treatment plans in offender rehabilitation due to their implied divergent risk management and risk-reducing treatment strategies. With regards to responsivity, we found that both aspects were associated with a general defensive response style but with distinctive response patterns that are consistent with characterizations of each aspect…GN defensive motivational style was characterized by a selective attention bias for positive evaluations, and an attention shift from negative evaluations to protect, maintain, and uphold one’s positive self-image. Any therapeutic intervention that challenged this process was faced with an active maladaptive defense attitude (e.g., manipulation, devaluation, control) that obscured an efficient and effective working alliance…” (p. 221-222).
“…Conversely, VN defensive motivational style was characterized by both a selective attention bias for positive and negative evaluations, showing a hypersensitivity for criticism. The passive defense mechanisms of denial, rationalization, and avoidance did not prevent an efficient and effective working alliance. The level of suffering was more prudent, explicated in the open display of the offender’s vulnerability, with a resultant higher intrinsic motivational level for treatment and behavioral change…The findings suggest that GN was predominately related to proactive violence, intended, unprovoked violence against people, while VN was predominately related to reactive and self-directed violence. GN was modestly related to reactive violence in response to shame, and it functioned as a dysfunctional strategy to cope with this stressor…Overall, GN was strongly related to externalizing behaviors such as unprovoked assaults against persons (e.g. murder, manslaughter). VN showed a divergent association pattern that was predominately associated with reactive aggression, mediated by impulsivity and negative emotions…The association with internalizing psychopathological symptoms was substantial, and it seemed that aggression functioned as a dysfunctional coping style…” (p. 222).
Translating Research into Practice
“…As observed in clinical practice…the treatment of vulnerable characteristics only, can result in an enhancement or manifestation of grandiose characteristics; grandiose characteristics will become visible after stabilization of vulnerable characteristics. If the targeting of VN characteristics could inadvertently enhance GN characteristics, this could reduce the risk for reactive violence but increase the risk for proactive violence…Following this line of thought, we would prefer a combined approach in which the treatment is focused on both aspects of narcissism that are assessed and evaluated alternating during therapy. This would allow for an all-inclusive view on an individual’s narcissistic personality profile, and consequently for the detection of possible shifts in personality profile that require attention for a positive treatment outcome” (p. 223).
“Although it is not yet clear how GN and VN relate to each other, given the results of this review, it seems beneficial to include an instrument in the risk and management assessment that captures both aspects of narcissism. While some researchers make use of the so-called “stack approach” to capture both aspects separately through the use of two different instruments…we would recommend one instrument that captures both aspects together. Currently, there are two such instruments available for adults. The Five Factor Narcissism Inventory (FFNI) (Glover et al., 2012), or the short form, the Five Factor Narcissism Inventory Short Form (FFNI-SF) (Sherman et al., 2015) …Or else, the Pathological Narcissism Inventory (PNI) (Pincus et al., 2009) …The use of an instrument that measures both aspects of narcissism would allow for a finer analysis of personality characteristics. With GN, the intermittent targets of change could pertain to an antagonistic personality style and maladaptive coping mechanisms. With VN, this could pertain to impulsivity, reactive violent impulses, and a dysfunctional coping style” (p. 223-224).
“To maximize treatment efficacy, we would suggest that treatment implementation is conducive to the divergent presentations of both aspects during treatment. With GN…schema therapy could be beneficial. Through alignment with the prosocial/healthy personality aspects of the offender, the maladaptive aspects that interfere with their working alliance could be reduced…Also, by systematically interpreting the divergent manifestations, a more integrated identity, and consequently realistic self-image, could be achieved…With VN, the offender’s hypersensitive nature in relation to others’ reactions, principally seems to indicate an empathic attitude to prevent a ‘shutdown’ of the offender in response to a perceived narcissistic injury…therefore, we would suggest an empathic understanding before gradually moving onto interpretation, as is indicative in treatment of personality disorders and self-directed aggression…” (p. 224).
Other Interesting Tidbits for Researchers and Clinicians
“…the aforementioned shared etiology of both narcissism qualities in the clinical view, is also used to understand the fluctuations between both grandiose and vulnerable narcissism qualities. It involves protecting and preserving an idealized self-image that is impaired due to a cold upbringing. In the case of grandiose narcissism, this may result in self-enhancement strategies that are directed at others to protect an idealized self-image (e.g., acting out). In the case of vulnerable narcissism, this may result in emotional dysregulation when the validation needs are not met (e.g., social withdrawal, depressed affects due to increased sensitivity for ego-threats, and manipulation) …Consequently, these individuals fluctuate between both grandiose and vulnerable qualities as a function of their self-enhancement level…” (p.212). “…GN represents the prototypic manifestation of narcissism, and it is best captured by characteristics related to antagonism (e.g., grandiosity, selfishness, deceitfulness, oppositionality, and callousness) and agentic extraversion (e.g., assertiveness, high activity level, and attention seeking/exhibitionism). VN is best captured by slightly different antagonistic characteristics (e.g., distrust, selfishness, deceitfulness, oppositionality, and callousness) and by characteristics related to negative affect and introversion (e.g., anxiety, depression, self-consciousness, and vulnerability)” (p. 213).