Therapy For Narcissistic Personality Disorder

Understanding Narcissistic Personality Disorder and the role of therapy

You may have heard the term “narcissist” used to describe someone who is excessively vain or arrogant, but clinical narcissism goes beyond just being self-centered. Narcissistic personality disorder (NPD) is a mental health condition that can have serious impacts, both on those who are living with it and their loved ones. Individuals with narcissistic personality disorder—also called pathological narcissism—may experience intense emotions, struggle with self-regulation, and have fragile self-esteem. While living with narcissistic pathology can be challenging, the condition can be addressed through proper treatment, including psychotherapy. Therapy can help people with NPD manage their emotional reactions, replace unhelpful thought patterns, and engage in overall self-enhancement. In this article, we will explore the key narcissistic personality disorder symptoms, different types of therapy that can be used for treating NPD, and how therapy can serve as a treatment and help those with NPD improve their relationships and develop a healthy sense of self-esteem.

DSM-V definition of narcissistic personality disorder

Symptoms of narcissistic personality disorder

It is important to note that not everyone who exhibits narcissistic tendencies has narcissistic personality disorder. Almost everyone experiences difficult feelings such as jealousy and frustration when things don’t turn out as planned, and many people’s outward expressions of self-centered behaviors may stem from strong self-criticism. That being said, it is important to learn to recognize and treat NPD to improve these people’s quality of life and their relationships with others.

NPD may present as a sense of excessive superiority, often accompanied by problems interacting with others. Those with NPD may see other people more as a means of getting what they want, which can lead to conflict—especially with friends and family members. NPD can also cause emotional dysregulation, which may lead to further tension or instability.

Some of the symptoms of narcissistic personality disorder include the following narcissistic traits:

• An inflated sense of self-importance (also called a grandiose sense of self) is one symptom of narcissistic personality disorder
• Frequent thoughts of being perceived as “better” than others can be a characteristic of narcissistic personality disorder
• A sense of entitlement to favorable treatment or special favors
• Taking advantage of others to increase personal gain
• Envy of others
• Someone with narcissistic personality disorder has a lack of understanding of the needs and feelings of others

Symptoms of narcissistic personality disorder may also arise alongside those of other psychiatric disorders. Depressive disorders, anxiety disorder, obsessive compulsive disorder, and substance use disorders are all common comorbidities. Further, NPD can co-occur with other personality disorders, such as borderline personality disorder and antisocial personality disorder. According to Harvard Medical School, NPD impacts approximately 5% of people in the United States. 

Types of narcissism: Vulnerable vs. grandiose

There are two primary types of narcissism: vulnerable narcissism and grandiose narcissism. Both forms involve an inflated sense of self-importance, entitlement, and hostility in interpersonal interactions. Individuals with both types often have fragile self-esteem, as well. (People with grandiose narcissism may appear to have high self-esteem, but they often are masking feelings of inadequacy or self-doubt.) However, people with narcissistic grandiosity tend to externalize, while those with narcissistic vulnerability tend to internalize. 

Grandiose narcissism is characterized by overt acts of admiration seeking, manipulation, and self-aggrandizement. Vulnerable narcissism, on the other hand, is typically marked by low self-esteem, anxiety, and sensitivity to rejection. Due to feelings of inadequacy, individuals with vulnerable narcissism engage in self-esteem regulation by seeking validation from others. Vulnerable narcissists are also thought to struggle more with emotion regulation. They may suppress their feelings and utilize other avoidance strategies instead of expressing themselves. 

Causes of NPD: Developmental factors and other contributors

While there is no unified theory regarding the causes of narcissistic personality disorder, experts believe there are various biological, environmental, and developmental factors that can influence its development. As with other psychiatric disorders—including most personality disorders—NPD is thought to have a strong genetic basis. Further, an individual’s upbringing may contribute to narcissistic traits. Individuals with caregivers who were neglectful or unsupportive may start to engage in self-esteem regulation by inflating their self-worth. Additionally, when caregivers struggle to control intense emotions, children may learn that emotional dysregulation is an acceptable means of meeting their needs. This can impact their interpersonal functioning, potentially making it hard for them to connect with others in healthy ways.

NPD and feelings of insecurity and low self-esteem

Conversely, NPD may also be associated with secret feelings of insecurity or low self-esteem (about both physical appearance and personality traits) as well as trouble with personal relationships. It is not uncommon for people with NPD to have coexisting mental health conditions such as depression, bipolar disorder, or substance use disorders.

According to the American Journal of Psychiatry, These conflicting symptoms can make it hard to get narcissistic personality disorder diagnosed, as other mood and personality disorders can present similar symptoms. It’s usually best to contact a mental health professional for an official diagnosis if you are looking to seek treatment.

The best therapy for narcissistic personality disorder

Like other personality disorders, NPD is a mental health condition that can cause significant distress to both those who have it and the people in their lives. Skills like emotion regulation and self-esteem regulation may be difficult for people with NPD to develop. Further, reaching out for help can be hard for individuals with narcissistic traits due to their self-perception. That being said, it is possible to treat NPD with the help of psychotherapy.

Currently, there are no medications specifically designed to treat NPD, that said, there are a variety of options available for treating NPD, including therapy for narcissistic personality disorder. In cases where NPD is accompanied by another mental health condition, like depression or anxiety, medication may be useful in treating the symptoms of those conditions. However, psychotherapy and counseling (particularly individual therapy) remain the primary treatment to address the symptoms of narcissistic personality disorder. 

For people with NPD, psychotherapy can be a tool for self-enhancement and personal growth, helping them engage in self-regulation, practice emotional empathy, and enhance interpersonal functioning.

Several types of treatment exist that may help those with NPD improve their self-esteem and learn to connect with others in a healthier, more constructive way. This is because, as with other medical conditions, personal mental health challenges differ—and not every person with NPD is going to respond well to the same treatment. It is better to consult a licensed therapist to know the right psychotherapy that is suited for the condition.

Different types of therapy for NPD

Therapy may be given in an individual or group therapy format. The types of therapy for narcissistic personality disorder include:

Schema therapy

The goal of schema therapy is to identify and change “schemas,” or negative feelings around traumatic events and thoughts, that may be causing a person distress. Schema therapy is a modality that has similarities with cognitive behavioral therapy, or CBT. Cognitive behavioral therapy is an approach that helps individuals develop greater self-awareness regarding the connections between their thoughts, feelings, and behaviors.

Transference-focused psychotherapy (TFP) for narcissistic personality disorder

Transference-focused psychotherapy concentrates on the therapeutic relationship between an individual and their therapist, with the goal of improving behavior and communication. During this therapy a person may direct their own feelings and emotional distress towards a therapist. Doing this type of psychotherapy enables a person with NPD to practice emotion regulation and may improve relationship skills. 

Gestalt counseling 

Mentalization-based counseling 

Also known as MBT, this is a form of counseling focused on understanding one’s mental state and how it can influence behavior and perception. It may focus on relaxation techniques and distress tolerance.

Metacognitive interpersonal therapy 

Metacognitive interpersonal therapy focuses on helping an individual better understand how they view their thoughts and ways of thinking and interpersonal effectiveness skills. Metacognitive interpersonal therapy (MIT) works by dismantling narcissistic thought patterns at their base by improving a patient’s access to their “inner states” or the emotional and mental states that lead to these patterns. It generally works toward being able to recognize, pause, and restructure these patterns for a healthier worldview. Undertaking metacognitive interpersonal therapy requires regular supervision by a mental health professional.

Eye movement desensitization and reprocessing therapy

Eye Movement Desensitization and Reprocessing therapy, also called EMDR, is a psychotherapeutic approach primarily designed to alleviate distress associated with traumatic memories. EMDR therapy is commonly used for individuals who have experienced trauma, such as post-traumatic stress disorder (PTSD). While EMDR is not a primary treatment for personality disorders like Narcissistic Personality Disorder (NPD), it may be used by a mental health provider to indirectly impact certain symptoms or issues related to trauma.

Dialectical behavior therapy for narcissism

Dialectical-behavioral therapy, also known as DBT, this modality concentrates on helping individuals manage their emotions and improve their behaviors while learning to accept challenging situations with realistic expectations for their outcomes. Dialectical behavior therapy is based on cognitive behavioral therapy, CBT, and it’s also a common option for borderline personality disorder. Sessions for dialectical behavior therapy (DBT) may focus on changing certain traits (e.g., persistent feelings of envy) and maladaptive patterns (e.g., self-esteem dysregulation) using healthy coping mechanisms to build better interpersonal relationships and increase healthy thought patterns. 

Like other personality and mental conditions, the best NPD treatment will vary from person to person. If you are seeking treatment to help with NPD, your mental health professional may recommend a range of approaches depending on your individual needs, background, and situation. For example, you may find that group therapy helps you develop greater emotional empathy, as it allows you to directly work with other participants while examining your symptoms from a clinical perspective.  

Addressing comorbid conditions

Narcissistic personality disorder can arise alongside several other psychiatric disorders. Potential comorbid conditions include anxiety disorders, depressive disorders, trauma-related disorders, obsessive-compulsive disorder, and substance use disorders. Further, other personality disorders, such as antisocial personality disorder or borderline personality disorder, may be co-occurring conditions. These comorbidities can worsen challenges like emotional dysregulation and interpersonal conflict. Psychotherapy is an effective modality for those seeking to address comorbid conditions. A therapist can help you manage symptoms of multiple conditions and develop important skills, such as self-regulation. 

Building emotional awareness and healthier relationships

Challenges related to emotional empathy and certain behavioral patterns can significantly impact interpersonal functioning in individuals with narcissistic patterns. For people with NPD, learning to engage in self-regulation—the ability to understand and manage one’s own emotions—can help them not only foster personal growth but also healthier connections. For example, greater emotional awareness can help an individual understand why their behaviors elicit certain emotional reactions from loved ones. If you’re living with NPD, a therapist can help you practice self-regulation and build strong, healthy bonds. 

The role of group therapy and support systems

Social support can play a crucial role in our ability to foster wellness. Group therapy allows individuals with NPD to work through mental health concerns and cultivate personal growth while benefitting from the emotional support of other participants. This format also provides individuals with the opportunity to improve interpersonal functioning by engaging with people experiencing similar challenges. Working together, participants can develop greater social awareness, practice self-regulation, and build emotional empathy. 

How therapy for narcissistic personality disorder can help loved ones 

Narcissistic personality disorder doesn’t just affect those who experience it; it can also immensely impact that person’s friends and family. Loved ones may feel isolated or taken advantage of by those with NPD. They may experience narcissistic abuse, frustration, anger, and distress at the person’s perceived lack of empathy or compassion. In fact, a 2021 study found a 69% rate of depression and an 82% rate of anxiety among those who were living with someone with NPD.

Counseling may also be beneficial in helping the loved ones of individuals who develop NPD to cope with these and other mental health and emotional impacts. For situations in which a loved one’s NPD has led to symptoms of anxiety and depression, which can make leaving the house difficult, it may be beneficial to seek treatment online. In general, the cost of traditional in-person talk therapy can range anywhere from $100 to $200 per session without insurance, whereas online therapy may cost about $20 to $90, depending on the platform that you pick. Through a platform like BetterHelp, individuals who seek therapy can attend sessions from the comfort of their own homes. Online therapy prices with BetterHelp can range from $70 to $100 per week and $260-$400 for monthly billing.

Efficacy of online counseling

Online counseling has been found to be an effective alternative to in-person counseling when it comes to treating symptoms of depression, anxiety, and various other mental health conditions. A study from 2013 found that an internet-based intervention for depression was “equally beneficial to regular face-to-face therapy.”

Whether you seek help in person or online, counseling can be an invaluable tool for helping the friends and family of those with NPD navigate their loved one’s condition, gaining support, and developing constructive coping skills.