Clinician Stigma Toward Narcissistic Personality Disorder: Implications for Assessment, Treatment, and Clinical Practice

Introduction

Narcissistic personality disorder (NPD), as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association, 2022), is characterized by patterns of grandiosity, a need for admiration, and a lack of empathy. However, this definition limits the full representation of the disorder, primarily omitting the essential component of vulnerability (Crisp & Gabbard, 2020; Pincus & Lukowski, 2010; Ronningstam, 2016; Weinberg & Ronningstam, 2022). Across a growing body of literature, NPD is recognized as a widely heterogeneous personality disorder represented by two phenotypic presentations of vulnerability and grandiosity that exist simultaneously, expressed in either overt or covert ways (Pincus & Lukowitsky, 2009). It is a disorder of dysfunctional self-esteem regulation and identity disturbance. Despite the field’s movement towards de-stigmatizing mental health, NPD and related traits remain highly stigmatized by both clinicians and the public (Finch & Mellen, 2025; Penney et al., 2017). This stigma has significant implications for the engagement, assessment, and treatment of those with narcissistic pathology. In this context, narcissistic pathology refers to enduring patterns of identity disturbance, maladaptive self-esteem regulation, and relational dysfunction that may or may not meet full DSM-5-TR criteria for narcissistic personality disorder. By some estimates, pathological narcissism occurs in as much as 20% of the clinical population (Weinberg & Ronningstam, 2022). Clinician stigma toward pathological narcissism and NPD is a common, measurable experience amongst clinicians that significantly impacts engagement, assessment, and treatment. However, clinical countertransference can be effectively utilized to improve assessment and treatment outcomes through reflective practice, training, and evidence-based approaches.

Defining NPD Stigma

Generally, people believe that NPD is untreatable and dangerous, and that the behaviors/symptoms are enacted by conscious will. Finch and Mellen (2025) note that this stigma is interesting as it posits that NPD is both uncontrollable (unchangeable) and controllable (by choice). This research explored NPD stigma through narrative interviews with clinicians who treat this population and they found that people with NPD have internalized stigma around their diagnosis, which often exacerbates intense feelings of shame. Clinicians also report that people with NPD face stigma from both the public and from healthcare providers. As a result, those with NPD tend to hide their diagnosis from loved ones and providers as they often anticipate future experiences of stigma and continued shame. Interpersonally, people with NPD are often stereotyped and labeled based on caricatures represented in the media. Even when clients agree with the traits and symptoms represented by NPD, they struggle to accept the label as they may feel they don’t fit this caricature of someone who is manipulative, aggressive, and dangerous (Finch & Mellen, 2025).

Clinician Attitudes and the Construct of Narcissism

Recent studies exploring clinician attitudes toward NPD demonstrate widely held misunderstandings about the disorder. Many clinicians believe that NPD is untreatable and dangerous due to perceptions that those with NPD are inherently prone to aggression, manipulative tendencies, and victimizing others. They tend to wonder how other clinicians have the capacity to work with such a troubling, dangerous disorder (Day et al., 2025; Finch & Mellen, 2025). Indeed, NPD is documented to be challenging to work with, not due to the danger these patients pose, but due to the extended feelings of boredom and demoralization experienced by clinicians within the countertransference (McWilliams, 2025). Nevertheless, such beliefs lead clinicians towards an aversion of treating or understanding narcissistic pathology, despite its relative frequency in clinical populations (Finch & Mellen, 2025; Weinberg & Ronningstam, 2022). Indeed, vulnerable presentations of the disorder are less recognized in the literature and typically misdiagnosed by clinicians as depression, trauma, or borderline personality disorder (BPD; Day et al., 2025).

Depictions of NPD in the media can be highly misinformed and skew both clinician and lay understanding of the disorder, including promising developments in engagement, assessment, and treatment. One explanation for this may be due to how the construct of NPD is defined in the DSM itself. The DSM captures only the grandiose aspects of the disorder, which leads clinicians and the public to understand it as a unidimensional construct of entitlement, arrogance, vanity, and low or absent empathy. The DSM construct of NPD has been criticized on this basis almost since its inception in the mid-1980s (Cooper & Michels, 1988). Further investigations of the DSM diagnostic criteria for NPD have shown that they are overly narrow, poorly differentiated from other personality disorders, and of limited clinical utility, as they emphasize externally observable grandiosity while failing to capture the vulnerable self-states central to clinical presentations (Cain et al., 2008; Gabbard, 1989; Gunderson et al., 1995). These limitations contribute to low diagnostic stability and prevalence as individuals may meet criteria during periods of grandiosity but fall below threshold when shame and self-collapse predominate (Ronningstam, 2009; Vater et al., 2014).

Clinical Countertransference in the Treatment of NPD

Clinical countertransference can be a helpful tool in the assessment and treatment of narcissistic pathology if effectively utilized. In commensurate vignettes, Day et al. (2025) found that clinicians were more likely to accurately diagnose NPD in vignettes representing a grandiose presentation (97%) but did not typically do so with the vulnerable presentation (24%). Instead, clinicians diagnosed the vulnerable vignette with depressive disorder (29%), trauma and stressor related disorder (21%), or BPD (21%). Clinicians also reported higher personality impairment in grandiose presentations of NPD while under-pathologizing vulnerable presentations, despite both vignettes having the same level of severity markers between them (Day et al., 2025). Significantly, the authors found that clinician countertransference can be measured and, if accurately assessed, may help to identify and distinguish grandiose and vulnerable presentations.

Disparities in the accurate assessment and severity between grandiose and vulnerable NPD presentations may be due to the measurable countertransference differentials. Day et al. (2025) found common countertransference reactions to grandiose presentations tended to be stigmatizing and included anger, lack of empathy, and hopelessness, while those reactions toward vulnerable presentations tended to be colluding and included sympathy, sadness, and vague discomfort or unease. It was theorized that stigma toward grandiose presentations of NPD impacted the assessment of personality impairment severity, while collusion with vulnerable NPD led to overlooking severity of personality impairment and accuracy of diagnosis. Notably, such collusion was shown to result in stagnant or superficial therapeutic relationships (Day et al., 2025). In another study, Penney et al. (2017) remark that clinicians often meet NPD with their own defensive strategies that include over-compensation (e.g. needing to be an expert) or avoidance (e.g. giving up), which may further impact treatment and engagement outcomes.

Many countertransference reactions to NPD often reflect or echo aspects of the intrapsychic and interpersonal dynamics of the disorder itself. NPD patients often distance themselves from others to avoid shameful or disorganizing attachment anxiety, feelings of humiliating exposure, or intolerable interpersonal dependency. In grandiose presentations, clinicians may subtly or overtly disengage from NPD patients, particularly when the vulnerable dynamics of the disorder are difficult to access or recognize. In response to grandiose vignettes, clinicians stated, “my immediate reaction is anger… my first reaction is a sense of distaste towards [the patient] …” (Day et al., 2025, p. 6). Alternatively, clinicians may overlook the covert grandiosity that often motivates overtly vulnerable presentations. In response to vulnerably presented vignettes, clinician countertransference statements included, “I felt for this man… this is a very sad state of being…,” although some reported a sense of nervousness or subtle frustration towards apparent martyrdom (Day et al., 2025, p. 6). Many people with NPD seek treatment when they are experiencing a vulnerable collapse, which may appear as depression (Ronningstam, 2016). However, depression is episodic, a narcissistic character is global and enduring, identifiable in the client’s history and transferential space (Day et al., 2025; McWilliams, 2011). Effectively engaging NPD patients during vulnerable periods in the disorder is critical, as they are less likely to seek care or be aware of their distress while in grandiose states.

While overt presentations in NPD patients may be confusing or inconsistent, both grandiose and vulnerable dynamics appear organized around the need to protect a fragile internal experience of self (Day et al., 2025). This may run counter to clinician preconceptions that grandiose NPD is essentially without internal distress, or sympathetic countertransference reactions to vulnerable-presenting patients that are contingent on grandiose themes not surfacing in the treatment relationship. However, appearances can be deceiving. Patients with a predominantly vulnerable presentation may present with more suicidal ideation and non-suicidal self-injury, but those with more consistently grandiose presentations are typically at elevated risk for high-intent suicide-related outcomes (Sprio et al., 2024). In such cases, grandiosity can be protective, functioning well as a kind of intrapsychic suit of armor…until it doesn’t. Despite the overtly depressive characteristics vulnerable narcissistic patients display, they can be protected by underlying grandiosity. Conversely, primarily grandiose patients can be at risk when their grandiose defenses collapse.

It is not uncommon for NPD to be misdiagnosed for other mental health conditions or personality disorders (Day et al., 2025). Clinicians’ overreliance on first impressions, while important, may impact diagnosis and treatment outcomes. This diagnostic and conceptual invisibility may recapitulate the very relational trauma thought to contribute to narcissistic pathology in early childhood (e.g., experiences of being overlooked, misunderstood, or unseen by important attachment figures). When reproduced in treatment, such enactments can lead to exacerbation of narcissistic pathology, treatment failure, and treatment burnout despite efforts to engage. For these reasons, clinicians should reflect on their early treatment impressions. For narcissistic patients, the hidden dimensions of grandiosity or vulnerability should be sought to fill out and contextualize countertransference. Through appropriate training, supervision, and education, clinicians can learn to effectively utilize the transferential space and avoid engaging in stigma or collusion that may exacerbate this disorder and thwart opportunities for engagement (Day et al., 2025; Finch & Mellen, 2025).

Lessons from Borderline Personality Disorder

Penney et al. (2017) sought to examine the stigma toward NPD through a comparative exploration of BPD stigma. Historically, people with BPD have been viewed as “manipulative, undeserving of sympathy, in control of destructive behaviors, and undeserving of healthcare resources” (Penney et al., 2017, p. 64). However, over the last twenty years, this diagnosis has been increasingly (though not fully) destigmatized, with many individuals finding access to effective treatment. The authors credit this to the development of dialectical behavioral therapy (DBT), which offered clear skills to ameliorate suffering, emphasized the impact of developmental trauma, and documented that change was possible with accurate treatment application. Despite stigmatized beliefs, NPD also has documented success in treatment and roots in developmental trauma, however, treatment happens over time and countertransference reactions are significant (Penney et al., 2017). 

Penney et al., (2017) state that “[countertransference] can be a useful tool to understanding the inner experience of a patient, who does not yet have the capacity to verbalize their inner world” (p. 66). This quote emphasizes the developmental deficit inherent in NPD which includes deficits in self-regulatory processes, identity, empathy, and intimacy (Ronningstam, 2016). Children rely on the people in their life to develop healthy self-esteem, learn how to get their needs met, and learn healthy interdependence. When their caregivers are rejecting, shaming, absent, or not sufficiently attuned, children fail to develop healthy ways of achieving those needs and relating to others (Ettensohn, 2016).

Across BPD and NPD, patients express pathologies related to absent, unstable, or deficient internal regulation. Countertransference is a valuable source of clinical data that can inform the clinician of implicit mental states that the patient does not have the ability or willingness to articulate. For example, feelings of disengagement on the part of the therapist may reflect important psychodynamics in the patient, including grandiose self-enhancement, inauthenticity, or underlying feelings of shame or inadequacy (Penney et al., 2017). Feelings of inadequacy or admiration in the clinician can be understood to represent the patient’s unwanted feelings.

While there is currently no gold-standard treatment for NPD (Crisp & Gabbard, 2020), psychodynamic and schema-focused therapy can be helpful modalities in treating this diagnosis given their emphasis on understanding developmental impacts on psychological functioning. Penney et al. (2017) and Ronningstam (2016) cite transference-focused psychotherapy (TFP) as an effective treatment for NPD, as it explores defensive structures and improves mentalizing, which is the ability to understand the behaviors of self and others. Supervision, education, and clinical groups focused on normalizing and understanding the transferential space are also helpful in treating NPD (Day et al., 2025; Penney et al., 2017). Overall, de-stigmatizing NPD, understanding its roots in developmental trauma, and increasing effective treatment and engagement strategies can help to improve treatment outcomes and ameliorate suffering for both those with NPD and the relationships it impacts as has been done with BPD populations.

Conclusion

NPD remains one of the most highly stigmatized mental health disorders by both healthcare professionals and the public. Such stigma impacts assessment, treatment, and engagement for those with NPD. Countertransference experiences toward this population among clinicians appears to also be influenced by widespread stigma, negatively impacting assessment and treatment outcomes. BPD is a personality disorder that has similar features and that has faced similar stigma, but due to advancements in treatment and destigmatizing conceptualizations, stigma towards BPD and its effective treatment have been drastically improved. Through a similar approach of understanding the developmental roots of NPD, providing psychoeducation, and working to understand and utilize clinician countertransference, the field can move toward a less stigmatizing approach to NPD. Such efforts would help improve engagement, treatment outcomes, and ameliorate the distress those with NPD and their loved one’s face.