Experts Describe Psychotherapy for Narcissistic Personality Disorder

In their session on treating narcissistic personality disorder (NPD) today at APA’s 2014 annual meeting, Frank Yeomans, M.D., Ph.D., Otto F. Kernberg, M.D., Eve Caligor, M.D., and Diana Diamond, Ph.D., emphasized that psychotherapy is an ever-evolving field with increasing specialization with regard to matching specific techniques to specific disorders. They proposed transference-focused psychotherapy (TFP) as an approach to diagnosing and treating narcissistic patients that can offer hope to therapists who work with this challenging population.

The speakers discussed obstacles to adequately defining the nature and range of narcissistic disorders, pointing out that the DSM system emphasizes overt symptoms and characteristics, while clinicians often find multiple manifestations of underlying narcissistic dynamics. The surface grandiosity, arrogance, and entitlement characteristic of many narcissistic individuals often defend against a painful sense of inadequacy and emptiness. So, paradoxically, some narcissistic patients present with self-effacement, inhibition, and chronic, extreme vulnerability. In addition, narcissistic disorders can present with increasing levels of aggression and antisocial features at the most serious end of the spectrum.

The speakers presented a framework based on psychodynamic object relations theory for conceptualizing, identifying, and treating NPD. They argued that, while individuals benefit from a “healthy narcissism,” in pathological narcissism, self-experience is organized in relation to a rigid but hollow “pathological grandiose self.” This self-structure provides some degree of stability, creating a situation in which patients with NPD may seem to function well superficially while leaving them clinging to a way of viewing themselves that can border on impaired reality testing and that interferes with establishing meaningful relations and integrating fully into the world.

With this framework in mind, the speakers explained the basics of TFP, a manualized psychodynamic psychotherapy that has been modified to treat patients with severe narcissistic disorders. The contract and frame of treatment encourage intense interpersonal experiences in vivo during which the therapist can help the patient observe the anxieties behind distorted images of self and others as they are experienced. The faculty reviewed techniques of intervention and interpretation geared to address the NPD patient’s brittle fragility. In addition, they addressed the frequent countertransference problems that therapists experience with narcissistic patients who can engender powerful feelings of being incompetent, bored, disparaged, and dismissed, or alternatively massively and unnervingly idealized.

The final message was that specialized techniques, combined with patience, can lead to change in this challenging population.

Yeomans and Kernberg are coauthors with John F. Clarkin, Ph.D., of Psychotherapy for Borderline Personality: Focusing on Object Relations by American Psychiatric Publishing. APA members may order the book at a discount here.