When taking on a patient with Narcissistic Personality Disorder (NPD), the therapist must be aware that NPD is a hard-to-treat condition. The question then becomes what makes this personality disorder “hard” to treat? According to some research, patients with NPD do not believe that they have a problem. Even if one does come to terms with having a problem, it is most likely always the fault of someone else, because the ego will not allow him/her to admit it. Generally speaking, it is hard for narcissists to see themselves as a contributor to their troubles.

It is reported that 63% of people with high-level NPD drop out of treatment. the grandiose narcissist will only utilize the therapy as a sounding board, seeing no true value in the therapist other than to listen and enhance/cosign the patient’s self-esteem. the grandiose type pays little attention to cues and fails to connect with the therapist in a meaningful way, and therefore may leave, feeling that the therapist is not good enough. Meanwhile, the vulnerable narcissist may be acutely over-sensitive and feel wounded to any critique by the therapist, and thus move to discredit or devalue the work. These patients may be suspicious due to their deep self-esteem issues and see the therapist as someone out to hurt them.

One thing worth noting, regarding past treatment of NPD, is that society did not always know how to handle it. Up until the late 1800’s, people considered narcissistic behavior a curse, a form of sorcery, and/or evil spirit. Therefore, “treatment” consisted of exorcism, restraints, madhouses, confinement, and even stoning. Fast forward to today, treatment has definitely changed. There are three different NPD treatment approaches that will be discussed; the Mitchell Integrated treatment model, Metacognitive Interpersonal Therapy, and Transference-Focused Psychotherapy.

Because perfectionism is highly valued to an NPD client, metacognitive interpersonal therapy, MIT, is useful in that it challenges a person’s desire to be perfect, and slowly dismantles narcissistic thought processes. One early technique with this model is to break down the patient’s autobiographical episodes, instead of accepting general versions of the story. By asking for concrete details, the therapist breaks down the story to get to the root of the emotion behind client’s actions. The hope is for the patient to see a pattern of behavior. The next step is for the therapist to promote new behaviors that work in accord with patient’s inner-most desires while recognizing other peoples’ desires and needs. The goal of this model is for the therapist to promote empathy of others and understanding of others’ feelings.

Transference-Focused Psychotherapy (TFP) was once used exclusively for borderline personality disorder but now is found useful in treating NPD. It is intense treatment, requiring two sessions per week. A person who has NPD has contradictory and conflicted internal views of themselves, and others around them. These perceptions are distorted and it affects their behavior, which then becomes the focus of therapy. The goal of this model is to facilitate better behavior control, more gratifying relationships, and modify defense mechanisms from feeling vulnerable.

The Mitchell Integrated Treatment model was founded by Stephen Mitchell and integrates theories that narcissism is both, a social defense mechanism and a yearning for social interpersonal growth. The Mitchell model is unique in that, unlike the previous models, there are no specialized strategies/steps for NPD patients. Treatment relies heavily on the therapeutic relationship. Robert Riordan is now a clinician who treats NPD patients but was once a patient himself. He describes the simple-most important factor that helped him change his narcissism, was the result of the relationship that he formed with his therapist. Riordan goes on to list three things to remember when forming this relationship. First, never assume all narcissists have the same stories.

It is easy to paint Narcissistic Personality Disorder patients with a broad brush. Secondly, the therapist must consider their own personality when challenged by a narcissist patient. The therapist must be able to tolerate devaluation. Finally, the therapist must respect the effort made by the narcissist, and understand that respect can still be present, even when challenging or confronting a patient.

By Delmar Devers, Painted Brain intern. You can visit his blog at SingingSocialWorkerBlog

This will close in 0 seconds