Narcissistic Personality Disorder: The Treatment Challenge

This is part 2 of a two-part series.

There are different treatment approaches for narcissistic personality disorder (NPD). We will describe in this column the approach of transference-focused psychotherapy.

From a psychodynamic point of view, the particular challenge of NPD has to do with the psychological structure described in our last column (Psychiatric News, April 1). The “grandiose self” provides a facsimile of identity but one that is not based in reality and that covers over intense feelings of insecurity and/or aggressive affects directed toward others and toward the self. The particular mix of these underlying states (insecurity/aggression) is related to the varied clinical presentations of NPD, which can be roughly divided into the “thick-skinned” type (overtly arrogant) and “thin-skinned” type (prone to bouts of insecurity). A particular diagnostic challenge is to identify the depressive-masochistic type of NPD that can underlie treatment-resistant depression (the patient feels his or her suffering is unique and exceeds that of others, with a conviction of moral superiority that does not allow the compromises that help “lesser” people get through life.)

The “grandiose self” is a narrative that shores up self-esteem but that does not correspond to objective reality. Take, for example, a young man, unemployed and supported by his father for four years since graduating from college, who, when asked what career plans he had, said that when it came time, he wanted to be the head of a major movie studio. This narrative fantasy covered over a life with no achievement in work or relationships. This type of fantasy is the “narcissistic bubble” that the person with NPD uses to avoid despair. The challenge for the therapist is to create a therapeutic alliance with the patient that will allow for the dismantling of the grandiose self without the person decompensating.

Creating an alliance with the NPD patient requires special skill because the main internal relationship pattern (dyad) embedded in the patient’s mind is that of a superior person in relation to an inferior one—in more technical terms, the grandiose self and the devalued other. The narcissistic patient needs to devalue the other to fend off his or her underlying sense of worthlessness. The patient is always at risk of the devaluing attack turning against the self (a manifestation of the aggressive mental elements involved in NPD).

If the therapy frame is properly set up to allow the patient’s “internal world” (internalized sense of self in relation to others) to unfold in the therapy, the patient will eventually devalue the therapist (“I can’t believe you just said such a trite thing; don’t you have an M.D.?” or “At first I thought you were good, but now I see you’re as useless as my other therapists.”)

The alliance at this point is based on the therapist’s decision not to challenge the devaluing remarks: the therapist must avoid both the temptation to defend oneself or even retaliate and the urge to distance oneself mentally from the interaction. The alliance is built on the therapist’s ability to tolerate and contain intense negative affects of being defective, inferior, worthless, and, in the most extreme cases, hateful (NPD often includes intense envy of others who are perceived as having/being more than the patient). This is very different from the therapeutic alliance with higher functioning patients, which feels from the start like a “helping alliance” with the two parties have mutually positive feelings.

The therapist’s ability to be present in the face of the devaluing onslaught offers the patient a relationship based on authentic interest and curiosity about who the patient is. This relationship model is radically different from the patient’s “superior/inferior” paradigm. The ongoing experience of this other relationship model will likely not be enough to help the patient explore and change his personality structure (the grandiose self). The therapist must also use the technical triad of clarification, confrontation of contradictions, and interpretation to help the patient see the obstacles that keep him from perceiving a relationship that is not based on devaluing the other. This generally entails working with a phase of “paranoid” transference. If the therapist does not defend himself against the patient’s devaluation and continues with his authentic interest, the patient often becomes unsettled and puzzled. What is this new phenomenon? There is a phase of suspiciousness (“What are your motives? Are you trying to trick me?”). It is essential to explore these questions with the patient.

An additional crucial element to treating patients with NPD consists of interventions that focus on the patient’s view of the therapist as defective and flawed. In these “therapist-centered interventions” the therapist explores the patient’s critiques of him, accepting imperfections and shortcomings. This acknowledgement of imperfection, while at the same time being able to continue functioning without falling into a sense of worthlessness and despair, can open the eyes of NPD patients to a sense of internal richness complexity as an alternative to their rigid “perfect or worthless” view of self and others. Then they are more likely to choose the “grit” of real relations, including with oneself, over the retreat into a defensive grandiosity. ■