A Guide To Cognitive Behavioral Therapy (CBT) For Narcissistic Personality Disorder

If you or someone you know has narcissistic personality disorder (NPD), then you may be familiar with some of the challenges that can accompany this condition. An individual with narcissistic personality disorder often has an inflated sense of their own importance, seeing themselves as superior to others. Someone with NPD may also have difficulty recognizing and empathizing with other people’s feelings. Given these dynamics, NPD can make it difficult to form and maintain healthy relationships with others. Still, treatment can help. NPD can be treated through psychotherapy such as cognitive behavioral therapy (CBT), for instance. 

An overview of cognitive behavioral therapy

Cognitive behavioral therapy, or CBT, is a common type of talk therapy that can help people identify unhelpful thought patterns and behaviors and replace them with healthier alternatives. Cognitive behavioral therapy (CBT) has been extensively researched and found to be an effective treatment for several mental health concerns and conditions, such as depression, anxiety, eating disorders, and relationship conflict, for example.  

As noted by the American Psychological Association, CBT has been shown to be just as or more effective than other types of therapy or psychiatric medication. It is based on core principles that include:

• Psychological problems are at least partly based on unhelpful ways of thinking and unhelpful patterns of behavior. 
• People experiencing psychological problems can learn coping strategies that reduce their symptoms and improve their day-to-day functioning.

Cognitive behavioral therapy (CBT) is designed to help people reverse cognitive distortions, which are those unhelpful thoughts and behaviors that lead to unhealthy behaviors. A few common cognitive distortions are:

• Catastrophic thinking
• Discounting the positive
• Jumping to conclusions
• Mental filtering
• Black-and-white thinking
• Overgeneralizing

Cognitive behavioral therapy (CBT) is typically a short-term treatment, often comprised of around five to 20 sessions. Still, you can work with your therapist to determine how many therapy sessions you need. The duration of therapy may depend on the severity of your symptoms, how long you’ve been experiencing your condition, your current stress levels, and how receptive you are to change, for instance. 

An overview of narcissistic personality disorder

An individual with narcissistic personality disorder (NPD) may have an inflated sense of their own importance and little regard for others. Someone with NPD may seem to need excessive attention, praise, and compliments, and deep down, they may feel insecure and have low self-worth.  It is estimated that the condition affects around 1 to 6% of the population. 

To be diagnosed with NPD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a person must exhibit at least five of the following symptoms:

• Possesses a grandiose sense of self-importance
• Preoccupation with success, power, brilliance, beauty, or perfect love
• Belief that they are special and should only associate with other special people
• Entitled, with unreasonable expectations of favorable treatment
• Exploits others to get what they want
• Displays arrogance and haughty behaviors
• Envious of others, or believes people are envious of them
• Needs excessive admiration
• Has no empathy and demonstrates no concern for the needs of others

To diagnose narcissistic personality disorder, a clinician must examine long-term patterns of functioning. People with NPD may also experience other mood and personality disorders, like borderline personality disorder. 

How is CBT used to treat narcissistic personality disorder?

Themost common treatment for NPD is psychotherapy. There are currently no medications available to treat the condition. However, since NPD is often accompanied by other mental health conditions such as anxiety or depression, medication may be used to treat these other disorders.

Some common symptoms of NPD—such as difficulty listening to feedback, feelings of entitlement, and a reluctance to admit shortcomings—may make it difficult for someone with NPD to actively participate in therapy. Still, when someone with NPD seeks behavioral therapy such as CBT, treatment may help reduce their symptoms. 

During CBT for narcissistic personality disorder, therapists may use several techniques to help patients adopt a healthier way of thinking.

Restructuring 

This technique involves identifying negative thought patterns and then reframing them to be more positive and productive. There is a five-step framework that can guide this approach:

1. Identify the upsetting situation.
2. Identify the most upsetting or irrational feeling from that situation.
3. Identify thoughts about the situation that underlie the feelings.
4. Evaluate the accuracy of the upsetting thought.
5. Decide whether the upsetting thought is accurate, and then take action accordingly. 

Cognitive restructuring can be used to reshape cognitive distortions commonly associated with NPD such as black-and-white thinking and magnification, for example.

Exposure

Exposure therapy can help people confront specific fears. For someone with NPD, this may require them to put themselves in situations that challenge their self-importance or to display empathy and care for other people. 

Journaling

Through journaling, someone with NPD may be able to observe their thoughts from a more objective point of view by revisiting them after they’ve occurred. Individuals may be asked to record negative thoughts or perceptions regarding interactions with various people. This allows them to identify potentially troubling thought patterns and work with the therapist to change them.

Role playing

During role-playing, the therapist and patient can work through behaviors that the patient may present in various situations. For example, the therapist could pretend to be someone the patient meets at an event, and the individual with NPD can practice asking questions about the other person, rather than only talking about themselves. 

Behavior experiments

Behavioral experiments can help a person test and modify inaccurate beliefs. For example, a person with NPD may participate in a discovery experiment where they learn more about a situation outside of their own beliefs. 

Skills training

Skills training may include behavior rehearsal, relaxation training, or social skills training, for example. Through this strategy, the patient may learn to act more appropriately in a variety of social settings.

Guided discovery

During guided discovery, a therapist may try to learn more about the patient’s beliefs, then ask open-ended questions designed to challenge those beliefs. Often, the goal here is to ask questions that allow information to be brought to the patient’s awareness. From there, the individual can begin to consider the problems they are facing as well as potential solutions.  

Psychoeducation

Like with other personality disorders, like borderline personality disorder, someone with NPD may not be fully aware of their symptoms or how they impact others. Through psychoeducation, the patient can learn more about narcissistic personality disorder and how it impacts their thoughts and behaviors. 

How online therapy can help

Some individuals with NPD may experience symptoms that might make engaging in therapy feel difficult. For instance, they may be worried about how others might perceive them if they are observed seeking help. In such cases, online therapy may offer a convenient alternative. Online therapy can be conducted anywhere that an individual has internet such as their home, for instance, eliminating the need to travel to a counseling office and interact with others there. 

Online therapy has been shown to be an effective treatment option for a range of mental health concerns, and there is strong evidence supporting the effectiveness of online CBT in particular. For instance, one study conducted an overview of the effectiveness of internet-based CBT (ICBT) in the treatment of psychiatric disorders, and it concluded that “ICBT is useful in treating mental health and medical illnesses with psychiatric comorbidities”.