Narcissistic personality disorder (NPD) subtype is largely understudied, in spite of clinicians' warnings that this is the most frequent presentation in patients.
Here we offer psychotherapy tips for working with this population.
• It is risky to challenge self-serving grandiose representations prematurely because self-esteem is unstable; patients may thus shift into derogatory states or drop out from therapy that "hurts"
• Promote a sense of existential agency based on motives other than struggling for grandiosity; suggest to patients that the very pleasure of a craftsman is to sense clay taking shap under his hands, above and beyond the triumph of seeing the final product admired by others
• Promote self-awareness, accurate appraisal of one's own wishes, and understanding of the impact relationships have on the self
• Avoid attempts at improving empathy unless self-desires have been accessed and supported; improved self-awareness will likely automatically free formerly gagged theory-of-mind skills and a certain degree of empathic attunement
• Management of the therapeutic relationship and countertransference is mandatory because of hyperactivation of antagonism and social rank motives
• Avoid hastily promoting awareness of the vulnerable self because this is likely to make patients withdraw, resort to the ivory tower, and drop out; narcissistic personality disorder therapy may often terminate with partial success, even before patients access the weakest parts of their souls
• Tactful confrontation of dysfunctional patterns is needed once the therapeutic relationship is solid; discussing the negative impact that one's behavior has on others and promoting alternatives are nevertheless necessary in later stages of therapy
For more on this topic, see Narcissistic Personality Disorder: Rethinking What We Know, from which this Tipsheet is adapted.