As therapists, we’ve treated people with narcissistic personality disorder. We have a more hopeful story to tell about them
If you judge by posts on social media, a new band of villains – ‘narcissists’ – has arrived in town. They gaslight, bully, manipulate, abuse, love-bomb and then abandon. The media will be quick to warn you that narcissists do not care and do not change; they are hopeless, and it’s better to avoid them. You may further think that people who suffer from narcissistic personality disorder (NPD) never enter the therapy room, as they consider themselves superior. So why would they humiliate themselves by asking for help?
This popular, vilifying narrative is not helpful for people who actually have NPD. And although their attitudes and behaviours can indeed cause harm to those who are close to them – their partners, children, colleagues – these are tragic side effects of their maladaptive ways of managing their self-esteem. Vilifying them is not helpful for those individuals, either. The alternative is to take an open-minded approach, and to be curious about what is happening in the mind of someone who has narcissistic tendencies. This is the approach we have taken as therapists with decades of experience working with patients who have NPD. In presenting a humanising view, we invite you to better understand the person behind this diagnosis.
Before we challenge some of the common myths about NPD – what is it? NPD is characterised by a pervasive pattern of grandiosity, either in one’s behaviour or in one’s fantasies, as well as a need for admiration and difficulty empathising with others. NPD is the most extreme expression of what is called pathological narcissism – difficulty regulating self-esteem and maintaining a realistic and positive view of oneself. People with pathological narcissism resort to maladaptive strategies to compensate for deep-seated shame, self-criticism or feelings of inadequacy or humiliation. These strategies, such as perfectionism, aggressive competition, or dismissiveness, usually backfire, only to escalate the feelings of defectiveness, thus perpetuating the vicious cycle of self-esteem dysregulation.
Studies indicate that NPD is found in 1 per cent of the general population. The condition is associated not only with an elevated risk of other psychiatric disorders (including mood disorders, anxiety disorders and substance use disorders), but also with greater risk of suicide, legal problems and marital issues. Contrary to the common assumption that people with NPD never seek professional help, it has been estimated that among patients in outpatient and private therapy practices, between 8.5 and 20 per cent suffer from NPD or pathological narcissism. A personal crisis, an ultimatum presented by family members or work supervisors, or a history of disappointments and losses might eventually lead them to knock on therapists’ doors. That being said, their treatment experiences are often prolonged. Sometimes this has to do with a pattern of starting and stopping treatments, sometimes with the fact that changing narcissistic tendencies takes time.
Some fictionalised examples from our work with people who have NPD not only show different features of the disorder in action, but also illustrate how dissimilar these individuals are. There are many ways of having NPD, and we need to understand the person beyond specific symptoms of the disorder:
- Richard, an aging writer, liked to boast about his success in helping many famous celebrities write their autobiographies. Age brought new challenges, including the loss of his youthful looks and energy. Rebelling against these changes, he started an affair and his drinking escalated. Consequently, he missed deadlines at work, and his wife announced a divorce.
- Mark, a secretary in his late 30s, felt depressed, lifeless and saw no future. He said others did ‘silly, meaningless’ things, but it took no more than a few therapy sessions to discover these words were spoken out of envy, as he had a ‘boring’ job, no friends and no romantic partner.
- Joan was plagued by a persistent sense of inadequacy and shame. Unable to feel good about herself, she frantically pursued perfection in her work at a prestigious magazine. She developed a tendency to hold others to the same high expectations and rapidly alienated them. Lonely and disappointed, she came to treatment.
the person is concealing signs of inner suffering, emptiness or meaninglessness to act as if they do not need others
To address these differences between patients, clinicians distinguish between two types of pathological narcissism, grandiose and vulnerable, though some individuals fluctuate between them. Both types involve those deep-seated feelings of defectiveness, humiliation and defeat that make one’s self-esteem unstable.
Grandiose narcissism is the type that overlaps most obviously with the definition of NPD – someone who is arrogant and overly self-confident, who lacks empathy and takes advantage of others. People with predominantly grandiose narcissism regulate their self-esteem by elevating themselves above and devaluing other people. They accomplish that in different ways: they criticise and humiliate others, strive for achievement, status or success, or engage in destructive competition. It may appear that people exhibiting this type of narcissism do not suffer. However, this typically stems from an illusion the person is trying to project; the person is concealing signs of inner suffering, emptiness or meaninglessness to act as if they do not need others.
By contrast, those with vulnerable narcissism can appear humble and controlled, but they also harbour grandiose fantasies and await the admiration they think they deserve but which never arrives. As a result, their resentment and anger grow, they are prone to feeling slighted and envious, and they might lash out when disappointed or rejected. Someone with this type of narcissism regulates their self-esteem by investing in external markers of worth, such as their appearance and material possessions. They hold on to these as if they provide their self-worth with oxygen. Their self-esteem fluctuates more frequently, edging on the negative pole, and they tend to be passive.
As you can see from the cases of Richard, Mark and Joan, the inner experience of someone with NPD frequently includes unabating pain, disappointment, self-shaming and fear. Some of these experiences can be traced to hard-to-meet expectations about oneself and others. They might also be linked to disappointments, unmet needs and other types of adversity that are prevalent in the lives of people with narcissistic personalities. Since many of these individuals have difficulty grieving and moving on, past adversities often inhabit their inner worlds as if they have just occurred, without any change. There are an infinite number of ways of experiencing the pain behind the NPD diagnosis.
In the myth that gives the condition its name, Narcissus dies of starvation because he is unable to stop contemplating his reflection in the stream. Is the future of people with narcissistic personalities so bleak?
At the end of the treatment, the patients no longer met diagnostic criteria for NPD
In fact, research shows that pathological narcissism can slowly but naturally change over time, thanks to emotional growth and learning from life experiences. Some changes have to do with attenuation of the symptoms of NPD. Other changes are related to broader changes in personality – better ability to regulate self-esteem, tolerate disappointments and relate more constructively to others – as well as improved vocational functioning. Certain characteristics and circumstances seem to facilitate this positive change. These include a capacity for inner discipline and goal-commitment and some ability to form sincere affective bonds, as well as events such as new relationships, achievements or corrective disappointments (eg, the breakdown of a relationship or professional setbacks) – as long as these events are coupled with a capacity to make sense of them. Overall, grandiose narcissism diminishes more slowly than vulnerable narcissism; it appears that dismissiveness and the tendency to devalue others places limits on the pace of change.
As for the role that therapy can play in encouraging such changes, the scientific investigation is still in its infancy. However, one of us, Igor Weinberg, and his colleagues from McLean Hospital are in the process of having a case series on this subject published – the first step when studying the effectiveness of a treatment for any condition. Statistical analyses of these cases have shown that all of the patients – who attended treatment for 2.5 to 5 years – demonstrated a significant improvement in their NPD symptoms, and all improved their vocational and social functioning. The changes observed included a decrease in dismissiveness regarding therapists’ interventions, improvements in friendships, and increases in the ability to regulate emotions. Gradually, patients coped better with insecurity, self-criticism and self-esteem fluctuations. At the end of the treatment, the patients no longer met diagnostic criteria for NPD. They worked or attended school and all but one were in a serious relationship. While this research did not have a comparison group and was conducted retrospectively, the analysis suggested at least some of the changes observed occurred with the help of the treatment.
Our clinical experiences more generally indicate that it is possible to treat people with NPD or pathological narcissism; difficult, for sure, but possible. In our experience, a few strategies help to promote change.
People with NPD challenge the clinician: they can be defiant, spiteful, passive, seductive or just reject any effort to help them, which they might deem impossible or nonsensical. We have found that, instead of counterattacking or becoming submissive to the patient, a therapist can gain momentum in treatment if they invite the patient to reflect on their interaction with curiosity. This is an arduous task for the therapist, but such an approach promotes an atmosphere of mutual respect and cooperation.
In time, Joan began to see that she tended to use criticism as a misguided way to motivate herself
Richard initially expressed doubt that therapy would help him and dismissed his therapist’s questions about his feelings. But after one occasion when Richard rolled his eyes and criticised a question, the therapist calmly asked him about his dismissiveness and critical tone, and he became very ashamed. He then became curious about what made him act that way – and started relating this critical pattern to other areas of his life.
At the beginning of treatment, people with NPD usually have difficulty describing their inner experience. They have trouble naming their emotions and tend to indulge in intellectualising, speaking about theories and how the world should work, about art or human behaviour, without providing insights into their real life. A therapist can help them focus on their inner life instead, inviting them to explore their emotional experience, always being mindful of possible negative reactions. Such ongoing attention slowly opens windows into these people’s souls.
As Joan started to reflect on her own dismissiveness, she recognised that she can be critical towards colleagues and her partner. She started to explore the reasons why she engaged in this behaviour. In time, she began to see that she tended to use criticism as a misguided way to motivate herself. She remembered that, when she was growing up, her parents were too focused on their divorce to provide her with guidance. Left to her own devices, she started using self-criticism as a way to get herself to do schoolwork. She realised that over time she had become strict, harsh and critical toward both herself and others, and that this approach was misfiring in her current life.
Finally, we think it is important to help patients with NPD to identify realistic treatment goals. People with narcissistic tendencies often attribute their suffering to the external world, whether in the guise of spouses, lovers, colleagues or society at large preventing them from realising their potential. What they do not do is figure out a specific goal – something they want to change about themselves, about their thinking or behaviours. So, another route to successful change involves a clinician inviting the person into a discussion about what their goal in therapy is. They have to set goals that are realistic and pragmatic. The next step is asking the patient: ‘Are you willing to do something outside the therapy session in order to meet this goal?’ Therapy with NPD patients needs an explicit, continuously updated therapeutic contract.
The contract was fundamental for creating a turning point in therapy with Mark. He was spiteful and often derogated his therapist. The therapist helped him realise that he was overly focused on other people and had no access to any healthy wishes, nor had he realised that therapy is about doing something in order to feel better. Then Mark was asked whether he would agree to focus on changing his inner states, to try to access some wish of his own and act in order to pursue it. After some struggle in the therapy relationship, Mark realised that such a commitment was the only way to move towards a richer social life. Instead of remaining home harbouring resentment and envy, he set new goals and started going to the gym, playing tennis and dating.
What our experience with people who’ve had NPD shows is that you should not listen to messages that depict these individuals as pure evil, as people who never suffer or, if they do, never seek help. Sure, their interpersonal style can at times be abrasive, cause suffering and make it difficult for others to stay curious about why they would act or think that way. However, they almost never do it for pleasure, but more commonly as part of a self-protective process. And remember, let he who is without sin cast the first stone; are these the only ‘difficult’ personalities or tendencies that people exhibit in everyday life? The reality is that people suffering from pathological narcissism do come to treatment and, with competent guidance and an understanding of what’s really happening, they can be helped.
