Principles of psychodynamic treatment for patients with narcissistic personality disorder

Attention to what patients with narcissistic personality disorder do is usually at least as important as what they say, and this attention invites patients to examine their behaviors with the hope of promoting self-awareness and integration.

“However, attention to what patients with the disorder do is usually at least as important as what they say. This attention invites patients to examine their behaviors with the hope of promoting self-awareness and integration (99, 100).”

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).”

Despite high dropout rates of 63-64%, psychodynamic therapies remain the conventional treatment for PN, with long-term individual psychotherapy as the cornerstone.

“Despite high dropout rates of 63-64% (70) psychodynamic therapies remain the conventional treatment for PN, with long-term individual psychotherapy as the cornerstone (71).”

Narcissistic patients benefit from a balance of expressive interventions offering interpretive insights when receptive and supportive strategies during vulnerability.

“Narcissistic patients benefit from a balance of expressive interventions that offer interpretive insights when they are receptive and supportive strategies during periods of heightened vulnerability or narcissistic injury (71).”

Therapists frequently report hostile, criticized, and helpless countertransference reactions when working with NPD patients, often feeling devalued, disconnected, or ineffective.

“Therapists frequently report experiencing hostile, criticized, and helpless countertransference reactions when working with NPD patients, often feeling devalued, disconnected, or ineffective in treatment (71, 186).”

Narcissistic patients often seek admiration that becomes expectation, idealize the therapist then devalue them when validation goes unmet, and treat the therapist as a passive sounding board, undermining mutuality.

“These dynamics often materialize with narcissistic patients seeking admiration that quickly becomes expectation, idealizing the therapist only to later devalue them when their need for validation goes unmet, and treating the therapist as a passive sounding board, undermining any sense of mutuality (70, 71, 154).”