Treating Narcissists: Expert Interview on the Psychology of Narcissistic Personality Disorder

Spotting Narcissistic Traits in Clients

Zoe says that she can sometimes spot signs that her clients may have narcissistic traits before she has had a real conversation with them.

“One thing that can jump out at me before I’ve even met the client is a sense of entitlement: an expectation that you will (and should), do more than is reasonable for the person,” she says. 

This could present itself when the client cancels the first session at the very last minute or when (s)he doesn’t show up and then expects not to pay for it.

“I send out a few basic questions for my clients to answer before we first meet and ask them to email their answers back at least 24 hours before-hand to give me time to read them. They are usually a page or two long at most. Someone once sent me answers that were 14 pages long, at about 10:30 at night, and expected me to read them all before our 9:00 a.m. session,” she says.

Another red flag that can present itself is a need to control the sessions: “This might mean someone continually interrupts or talks non-stop, and raises their voice when they see that I’m about to speak. They can try to use me as a sounding board while encouraging me to praise and admire them. They might boast about their work achievements every time we meet. One client wanted me to watch a video of her receiving an award at a work conference. Or they might tell me in every session about the successful and accomplished people they know.

“Another way these clients try to control the sessions is to refuse to do any of the exercises I suggest or try to postpone doing them, giving excuses every time they are given one until it becomes clear they are sabotaging our work together,” Zoe says.

“Other red flags are an obvious lack of empathy,” she continues. “They might only be able to see the pain of someone close to them as something inconvenient for them, not show any interest in it or be repulsed by it and talk about that person with contempt.”

The Challenge of Treating NPD

While making a correct diagnosis and administering therapy can be challenging, it’s not impossible if the patient can stay committed to the process and allow themselves to be vulnerable.

“These are the biggest challenges and the reason why many are unable to change. Narcissists wear masks to protect themselves from being hurt. So, this means they tend to not be themselves much of the time. This can make treating a narcissist very difficult because it’s hard to get to the real person inside who you want to help. Their masks are born out of a belief that people won’t accept them for who they are, so they can find it hard to accept empathy from a therapist beyond seeing it as a cue to try to manipulate them. This makes it hard to form a therapeutic alliance.”

Also, to be committed, “they need to have a reason to want to change,” Zoe explains. “By its very nature, NPD means only thinking of yourself and your own needs, so narcissists don’t tend to want to change for anyone else’s benefit. For some, they can hit a period of depression and want to change at that time, but then lose motivation when they are feeling better again. 

“Long-term psychotherapy can be useful, but it’s important for people with NPD to find one that suits them. For example, someone with NPD might find Psychodynamic Therapy too intrusive and this could feel threatening. So, they might end up intellectualizing about their behavior without ever trusting the therapist enough to be vulnerable.”

Person-centered counseling might not be useful for every patient, as it could be too gentle. “They could end up using the counselor as a sounding board and not getting anywhere,” Zoe says.

Schema Therapy is considered helpful for people who have personality disorders and don’t respond to other therapies. It’s an integrated therapeutic approach that emphasizes lifelong patterns, affective change techniques, and the therapeutic relationship, integrating all of these strategies together to best help the patient.

“It’s a practical way to work that encourages clients to go beyond intellectual talk and hypothesizing,” Zoe says. “The ‘reparenting’ aspect of Schema Therapy can help people to re-experience past events in a different way, undoing some of the trauma associated with their memories.”

“Reparenting” refers to the therapist establishing a secure attachment with the patient to meet the patient’s early childhood needs that were not met in the past.

“This can be a good way to get around some of the things narcissists can do that block therapy from working,” Zoe says.

According to Psychology Today, there are not enough psychotherapists available who are properly trained in the diagnosis and treatment of narcissistic personality disorder.