Narcissistic Personality Disorder Across Types of Therapy: Individual, Couple, and Group

Why is there so much talk about narcissism lately? Is it a trend, baseless hysteria, or even a problem at all? Narcissism itself is a singular personality trait; it can be protective and even beneficial, especially in Western society (Ronningstam, 2005). This may be due to the individualistic virtues and increased achievement-dependent self-esteem rates in Western cultures as compared to those from more collectivistic societies (Vater et al., 2018). Narcissistic personality disorder (NPD), on the other hand, can be much more insidious and harmful. People with NPD are not simply arrogant, vain, selfish, or empathy-impaired, as mainstream media may portray. Diagnostic criteria, ranging from entitlement to exploitation, imply destructive interactions with other people in their proximity.

NPD is comprised of an antagonistic personality structure, meaning relational disruption, exploitativeness, callousness, and vengefulness are standard characteristics of this presentation (Day et al., 2020). Both grandiose and vulnerable NPD variants show a preoccupation with satisfying personal needs at the expense of others (Yakeley, 2018). The prevalence of those meeting diagnostic criteria for NPD is estimated to be up to 2% of the population (Weinberg & Ronningstam, 2022), or over 6.5 million people in the United States (U.S. Census Bureau, n.d.). Moreover, rates in clinical and outpatient therapy populations may be up to 20% of the total patient population (Weinberg & Ronningstam, 2022). NPD is, therefore, inherently impactful to others in proximity and highly likely to present in a clinician’s office.

Narcissistic Personality Disorder and Clinical Insight

Adults not living with NPD typically exhibit constitutional flexibility; the ability to adjust their personality features in the face of deficient interactions with themselves and/or others (Lester, 2018). People living with personality disorders have disturbances in the adjustable elements of their identity and with interpersonal (empathy and intimacy) personality traits (American Psychiatric Association, 2022). Personality disorders are not mental illnesses consistent with a symptomatic deviation from baseline functioning, but rather a complete and established state of being (Lester, 2018).

Individuals with NPD demonstrate traits of entitlement and low harm avoidance (Mitra et al., 2024), along with dysregulated self-esteem that represents a fragile ego (Ronningstam, 2005). This presents a contradiction between perfectionism and shame. Due to their additional characteristic combination of relational antagonism and fear of vulnerability, their clinical history is likely to reveal tumultuous relationships and increased isolation over time (Mitra et al., 2024).

Personality disorders are defined by the persevering of behaviors despite evidence of negative consequences (Lester, 2018). This is partly why there are few validated treatments for NPD and many studies imply that this disorder is untreatable (Mitra et al., 2024). Overall, NPD is a persistent condition that can gradually and slowly improve with a focus on symptom-specific interventions (Weinberg & Ronningstam, 2022).

NPD often co-occurs with other mental health conditions, such as bipolar disorders, substance use disorders, depression, and anxiety (Stinson et al., 2008). However, while other disorders may be the primary presenting problem in therapeutic settings, many of them may be misdiagnosed side effects of the isolated and emotionally dysregulated nature of NPD (Lester, 2018). Regardless, dissatisfaction in life may encourage patients with NPD to seek therapy.

Identifying the presence of NPD (or any personality disorder) is imperative to successful treatment outcomes (Lester, 2018). Due to the move to a dimensional model for diagnosis, previous personality assessment instruments are now outdated (Blüml & Doering, 2021). Appropriate assessments based on underlying themes and conflicts include the Operationalized Psychodynamic Diagnosis (OPD-2), Structured Interview for Personality Organization-Revised (STIPO-R; Blüml & Doering, 2021) or the Level of Personality Functioning Scale (LPFS; American Psychiatric Association, 2022).

Narcissistic Personality Disorder and Individual Therapy

There is a misconception that pathologically narcissistic people do not go to therapy. Dr. Craig Malkin (2024), a leading expert in NPD counseling, states that people with NPD frequently do, in fact, present in therapy. They often seek help under a grandiose victimhood mentality, primarily expressing distress about their relationships (Malkin, 2024). The presentation of grandiosity is often a defense against internal states of vulnerability (Janusz et al., 2021), which can inhibit an effective therapeutic alliance. A functional therapeutic relationship is marked by the extent to which the patient and therapist are genuine and self-reflecting with each other (Gelso, 2014), so this can be a treatment barrier for individuals with NPD.

NPD is an egosyntonic disorder, meaning a patient’s understanding of themselves is poor, and accepting self-deficit is not congruent with their sense of self (Mitra et al., 2024). In therapy settings, patients with NPD often become resistant to the therapeutic process of exploring and reflecting on their inner state or learning how to better connect with others (Lester, 2018; Malkin, 2024). Many therapists feel it is difficult to work with these patients and may experience disconcerting interactions during treatment that can cause a sense of unease (Janusz et al., 2021). A therapist’s confusion and recognition of a patient’s disingenuousness are tell-tale signs of the presence of a personality disorder and are often contributing factors to the ineffectiveness of traditional psychotherapy (Lester, 2018). Malkin (2024) also notes that a sense of inauthenticity or lack of accountability from a patient is often the first indicator of the presence of NPD.

Studies indicate that people with NPD may be aware that they are somewhat narcissistic (Carlson et al., 2011), however, they lack an observing ego and have extreme difficulty with self-correction (Lester, 2018). Despite the ongoing struggle with sustaining meaningful and healthy relationships due to the nature of their pathology, most people with NPD are not likely to change (Lester, 2018; Mitra et al., 2024).

A formal diagnosis of NPD is associated with a 63% to 64% dropout rate from psychotherapy (Weinberg & Ronningstam, 2022). Because NPD involves increased insecurity and hypersensitivity, a more effective intervention strategy may be to emphasize the interpersonal cost of being seen as “potentially” narcissistic (Carlson et al., 2011). Regardless of whether a diagnosis of NPD is made, mental health professionals should be alert to the presence of pathological narcissism in their patients, as it will impact overall treatment progression and outcomes (Yakeley, 2018). Therapists may need to operate with an understanding of the diagnosis without the ability to collaborate with the patient, which is counterintuitive in traditional psychotherapeutic practice (Lester, 2018). Maintaining professional clarity and clear treatment goals are essential, and the focus should be on stabilizing functioning and reducing interpersonal conflict (Lester, 2018; Mitra et al., 2024).

NPD treatment objectives should include addressing destructive behavior patterns and increasing overall stability in identity and interpersonal dysregulation to reduce problematic interactions (Blüml & Doering, 2021; Janusz et al., 2021). Treatment modalities that are more effective for targeting personality functioning include Dialectical Behavior Therapy, Schema-Focused Therapy, Transference-Focused Psychotherapy, and Mentalization-Based Therapy (Blüml & Doering, 2021; Yakeley, 2018).      

Paramount to any treatment is the need for therapists to understand the interpersonal practices of patients with NPD. Highly narcissistic patients are prone to power struggles while in therapy in an attempt to provoke and control the therapist (Janusz et al., 2021). If the therapist is not skilled or trained to work with folks with NPD, they may become lost in their countertransference or even become orchestrated by the patient (Mitra et al., 2024). Working with NPD commonly invokes feelings of shame and resentment in therapists, which may make it difficult to seek and effectively use supervision or consultation (Yakeley, 2018). Utilizing supervision and consultation while working with patients living with personality disorders is crucial for helping to regulate the therapist’s emotional responses and to prevent burnout (Lester, 2018). Additionally, obtaining specialized training or referring to more qualified and skilled providers is always appropriate.

Narcissistic Personality Disorder and Couples Therapy

Many studies find that narcissistic partners are highly problematic for their significant other who frequently report basic communication problems, hostility, frequent criticisms, insults, and overall aggressive and exploitative behaviors (Janusz et al., 2021). In some cases for people with NPD, identity preservation, empathy resistance, and interpersonal malice make couples therapy contraindicated for partners. Because NPD is a pattern of malevolently influencing interactional practices, couples therapy can often be counterproductive and even harmful (Janusz et al., 2021). Those fitting criteria for NPD mayuse therapy in bad faith and as a form of confirmation bias; potentially misrepresenting or weaponizing therapy in an attempt to manipulate others. The patient with NPD may have difficulty containing their need for power and control over both their partner and the therapist (Janusz et al., 2021).

One common presenting quality of folks with NPD in therapy is their insistence on knowledge equality with the therapist, echoing their speech and professional lingo (Vaknin, 2008). Further, narcissists methodically distance themselves from difficult emotions, package ordinary concerns under grandiose victimhood, and seek the therapist’s validation for their intellectualized problem-solving (Vaknin, 2008). The difficulty of engaging in good-faith collaboration with an NPD patient is amplified by their fragile ego. Researchers have noted heightened defensiveness in individuals when a narcissistic partner is witnessing a therapist’s feedback. Rejection of a diagnosis, reports of unfair treatment, or premature termination from therapy are high risks when working with these couples (Janusz et al., 2021). Couples therapy can, however, provide a naturalistic setting for the interpersonal spectacle of circular, destructive communication patterns with an NPD patient. It is advised that therapists exhibit caution and organize initial sessions in an extremely gentle, unobtrusive manner to prevent defensiveness and to promote cooperation (Janusz et al., 2021).

Narcissistic Personality Disorder and Group Therapy

Patients with NPD often make flattering first impressions that deteriorate over time as people get to know them. Their reputation becomes more negative as people see them as disagreeable and low on conscientiousness, emotional stability, openness, and adjustability (Carlson et al., 2011). This phenomenon may be emphasized within the dynamics of group and family therapy.

A core presentation of most patients with personality disorders is their tendency to be surrounded by ongoing “drama,” likely attributable to their resistance to problem-solve (Lester, 2018). Group therapy presents a controlled setting for identifying and potentially correcting this trend. Further, characteristic attempts by patients with NPD to maintain control in relational communication patterns may be more difficult to perpetuate in groups that are specifically monitored for their interactional quality (Janusz et al., 2021). Group facilitators and other group members have an opportunity to model real-time functional relationships and can model healthy communication behaviors to patients with NPD. Therapists can name harmful patterns in aversive behaviors that range from mundane rudeness or defensiveness to serious violations that go beyond insensitivity to cruelty and destruction (Follingstad, 2007).

Studies note that empathy impairment associated with NPD may not be inherent but rather a conscious choice based on feelings of intolerance, self-regulatory impulses, processing difficulties, and conflicting interests (Weinberg & Ronningstam, 2022). Group facilitators can prioritize a focused approach to identifying how various exchanges are experienced and perceived by other group members. This information can educate people on the interpersonal context and impact of psychological aggression (Follingstad, 2007). Therefore, all group members can become empowered by an increased ability to discern normative interactions from harmful ones.

Narcissistic Personality Disorder Outside of Therapy

Some experts have proposed it would be appropriate to create an obverse condition, named narcissistic victim syndrome, to help treat insidious psychological damage inflicted by people with NPD (Fletcher, 2023). Indeed, partners and family members of people with NPD often feel victimized by the person’s destructive relational behaviors. Interpersonal dysfunction, antagonism, and hostility are well-documented aspects of people with NPD that exact a significant toll on individuals in relations with them (Day et al., 2020).

For people who may interact with someone with NPD, whether professionally or personally, it is advised to learn about psychologically abusive patterns and formulaic moves. Maladaptive manipulation tactics include scapegoating, passive aggression, triangulation, silent treatment, bullying, gaslighting, intermittent reinforcement, defamation, mockery, criticism, disregard, and ridicule (Fletcher, 2023; Petric, 2022; Sackett & Saunders, 1999). People with both vulnerable and grandiose NPD have even been shown to use strategic jealousy induction, or intentionally and subtly invoking feelings of jealousy in their partners to maintain power and control (Tortoriello et al., 2017).

Destructive NPD relational patterns may be elusive to discern in the moment when attempting to engage in conflict resolution and boundary setting. Over time, navigating someone’s NPD may leave people feeling disoriented and can result in psychological harm. It has been shown that ongoing verbal criticisms and sadistic patterns of interpersonal control are experienced as more disturbing and injurious than physical violence (Follingstad, 2007; Sackett & Saunders, 1999). The worst-case scenario would be a “systematically devious psychological process engendered by one person such that the partner comes to be mentally confused without the wherewithal to identify the process” (Follingstad, 2007, p. 447).

Victims of psychological violence may suffer from distinctively complex mental health consequences. Complex post-traumatic stress disorder, also referred to as C-PTSD, contains common symptoms of this particular type of interpersonal trauma, such as, disruption of a sense of self, dissociation, depression, anxiety, suicidality, sleep disturbance, and substance abuse (Dokkedahl et al., 2019). Further, a history of interpersonal trauma is the most consistent predictor of subsequent trauma exposure (Jaffe et al., 2019). Alarmingly, research repeatedly notes that anger outbursts are intrinsic to the narcissistic personality (Green & Charles, 2019). Unfortunately, outbursts and rage are not evaluated as part of current diagnostic criteria for NPD. These tantrums, even in those who do not meet full criteria for NPD, more often than not lead to physical violence (Green & Charles, 2019).

Awareness of the characteristics of NPD is worthwhile to prevent and heal from potential entanglements and victimization. Specific interventions for narcissistic abuse should provide nervous system regulation, targeted deprogramming, psychoeducation, and development of protective factors that promote self-worth, autonomous identity, and post-traumatic growth to heal and prevent future harm.

NPD is an unfortunate conditional state, however, compassion must be held with discernment. Kindness at the expense of one’s boundaries and sense of self could become kindness exploited and weaponized. Therapists should be attuned to the prevalence rates, clinical presentation, treatment implications, and potential destructive effects of NPD. Whether in person or in close proximity, distress related to this disorder will likely walk through the office door.