Abstract
Ronningstam’s compelling description of a patient with severe co-occurrent narcissistic personality disorder and alcohol abuse is effective at proposing hypotheses about how to handle such patients’ tendency to leave treatment prematurely. I suggest here that in order to have a more effective therapy and reduce the high drop-out risk typical of these patients, (1) a careful assessment of internalized relational patterns is needed, in particular in order to detect any problem they have as regards intimacy with the therapist; (2) it is likely that fostering a premature sense of interpersonal connection with the therapist and of the need to be cured may trigger patients’ tendency to withdraw from therapy; and (3) targeting an impaired sense of agency could be a first-line therapy with such patients. Copyright © 2011 John Wiley & Sons, Ltd.