Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder
Abstract
This article identifies guiding principles in effective psychotherapies of patients with narcissistic personality disorder (NPD) and cautions against some common pitfalls. Individual psychotherapies of NPD patients were examined by both authors, who tested whether or not some principles, recommended in the literature, effectively promote these therapies and help these patients in moving forward with their lives and with effective therapy use. The authors identify a number of principles that were associated with more positive therapy development: helping patients identify goals and direction of their therapies, promoting a sense of agency, promoting a shift of focus to sense of vulnerability, and anticipating difficulty in developing and maintaining the treatment alliance. Common mistakes in these treatments are engaging in a power struggle with the patient, overindulging the grandiosity of the patient, directly challenging the grandiosity of the patient, and ignoring treatment-interfering behaviors. Identification of principles of effective therapies with NPD patients can help with the development of more effective treatment approaches for NPD.
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Gaining awareness of dynamics and understanding factors that affect the patient helps patients with narcissistic personality disorder develop a more coherent narrative about themselves.
“One aspect of treatment is gaining awareness of these dynamics and understanding the factors that affect the patient (e.g., feeling humiliated when evaluated). This awareness helps patients to develop a more coherent narrative about themselves (2).”
From Narcissistic Personality Disorder: Progress in Understanding and Treatment (2022) · cites this paper as [2]
Attention to the therapeutic relationship invites work on the ability to negotiate conflicting perceptions, staying connected through affective storms, and staying open-minded through cycles of alliance, rupture, and repair.
“Attention to the therapeutic relationship invites work on the ability to negotiate conflicting perceptions, staying connected through affective storms, and staying open-minded through cycles of alliance, rupture, and repair (2, 99–101).”
From Narcissistic Personality Disorder: Progress in Understanding and Treatment (2022) · cites this paper as [2]
Building a collaborative treatment alliance with patients with narcissistic personality disorder is both a strategy to increase the effectiveness of treatment and a treatment goal.
“Building a collaborative treatment alliance with patients is both a strategy to increase the effectiveness of treatment as well as a treatment goal (2).”
From Narcissistic Personality Disorder: Progress in Understanding and Treatment (2022) · cites this paper as [2]
For patients with PN, forming and maintaining a strong alliance is hindered by dismissive attachment styles, distrust toward therapist, and excessive self-reliance.
“For patients with PN, forming and maintaining a strong alliance is often hindered by dismissive attachment styles, distrust toward the therapist, and excessive self-reliance (59, 129).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [59]
Interpersonal defensiveness can cause narcissistic patients to resist improvement, with grandiosity and pseudo-self-sufficiency making it difficult to internalize help, while fear of dependence causes them to devalue it as a way to stabilize their self-concept.
“Interpersonal defensiveness can cause narcissistic patients to resist improvement, with grandiosity and pseudo-self-sufficiency making it difficult to internalize help, while fear of dependence causes them to devalue it as a way to stabilize their self-concept (59).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [59]
PN patients often struggle to access and verbalize emotions.
“Given that PN patients often struggle to access and verbalize emotions, therapists must remain patient, validating, and persistent in helping them develop a greater awareness of their internal states (59, 60).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [59]
Patients with PN may deny therapeutic change even as it occurs or attribute progress solely to the drug rather than the therapeutic relationship.
“Resistant to acknowledging others’ contributions, patients with PN may deny therapeutic change even as it occurs or attribute progress solely to the drug rather than the therapeutic relationship (59).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [59]
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References 72 · Cited by 51
- Authors
- Weinberg, I., & Ronningstam, E.
- Affiliations
- McLean Hospital (US)
- Venue
- Journal of Personality Disorders
- Publisher
- Guilford Publications
- Published
- 2020-03
- Volume
- 34
- Issue
- Supplement
- Pages
- 122-142
- ISSN
- 0885-579X (ISSN-L)
- OpenAlex
- W3010994699
- Cited by
- 51
- References
- 72
- Citations by year
- 2026: 8 · 2025: 12 · 2024: 7 · 2023: 10 · 2022: 10 · 2021: 4
- FWCI
- 2.41
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Personality Disorders (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- narcissistic personality disorder, psychotherapy, treatment alliance, grandiosity, power struggles, treatment goals, sense of agency, vulnerability
- MeSH terms
- Delusions, Humans, Personality Disorders, Psychotherapy, Mood Disorders
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