Therapy for Clients with Personality Disorders

1. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
2. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
3. Is often envious of others or believes that others are envious of him or her.
4. Shows arrogant, haughty behaviors or attitudes.  

Individuals with NPD often present with a fragile underlying self-esteem that is masked by their grandiose exterior. They are highly sensitive to criticism, although they may not outwardly display this vulnerability. Their relationships are often strained due to their lack of empathy and exploitative tendencies.

Therapeutic Approach and Modality: Psychodynamic Individual Therapy

I would select individual psychotherapy as the modality and a psychodynamic approach for treating a client with NPD.

Justification for Individual Therapy:

Individual therapy provides a safe and contained space for the client to explore their internal world, including the underlying insecurities and unmet needs that often fuel their narcissistic defenses. The one-on-one setting allows for the development of a deep therapeutic relationship, which is crucial for addressing the client’s relational difficulties and fostering self-reflection. Group therapy, while potentially beneficial later in treatment for interpersonal skill development, may initially be challenging for individuals with NPD due to their need for attention and potential for disruptive behaviors. Family therapy might be indicated if the client’s narcissistic traits significantly impact family dynamics, but individual therapy is often the necessary first step to address the core psychological issues.

Justification for Psychodynamic Approach:

The psychodynamic approach, with its focus on unconscious processes, early life experiences, and interpersonal patterns, is particularly relevant for understanding the development and maintenance of NPD (Ronningstam, 2016). This approach posits that narcissistic traits often stem from early relational experiences that hindered the development of a secure and cohesive sense of self. Grandiosity and the need for admiration can be seen as defensive mechanisms against feelings of inadequacy and vulnerability.

Key therapeutic techniques within a psychodynamic framework that would be employed include:

• Exploration of Early Relationships: Examining early childhood experiences and relationships with primary caregivers can shed light on the origins of the client’s self-esteem issues and relational patterns.
• Analysis of Transference: The therapeutic relationship itself becomes a crucial tool for understanding the client’s interpersonal dynamics. The client may unconsciously reenact patterns of relating, such as demanding admiration or devaluing the therapist, providing valuable insights into their typical interactions.
• Focus on Affect: Helping the client identify and understand their underlying emotions, particularly those related to shame, vulnerability, and anger, which are often masked by their narcissistic defenses.
• Interpretation: Carefully timed interpretations of the client’s defenses, relational patterns, and underlying feelings can help them gain insight into their behavior and its impact on others.

The psychodynamic approach emphasizes a long-term perspective, recognizing that deep-seated personality patterns require time and consistent effort to change. The therapist’s role is to be a consistent and reliable presence, offering empathy while also gently challenging the client’s distorted perceptions and maladaptive behaviors.

Sharing the Diagnosis and the Therapeutic Relationship

A therapeutic relationship in psychiatry is a collaborative and professional alliance between a client and a mental health professional. It is characterized by trust, empathy, respect, and clear boundaries. The therapeutic relationship provides a safe and supportive environment for the client to explore their thoughts, feelings, and behaviors, ultimately working towards therapeutic goals (Gelso & Hayes, 2001).

Sharing a diagnosis of NPD requires careful consideration to avoid damaging this crucial alliance. The timing, language, and context of sharing the diagnosis will differ depending on the therapeutic modality.

Individual Therapy:

In an individual session, I would approach sharing the diagnosis after a significant degree of trust and rapport has been established. I would avoid blunt or judgmental language. Instead, I might begin by summarizing some of the patterns we have observed together, focusing on the client’s experiences and behaviors rather than directly labeling them. For example, I might say, “We’ve talked about how important it is for you to feel successful and recognized, and also how hurt you feel when you perceive others as not acknowledging your achievements. We’ve also explored some of the difficulties you’ve experienced in close relationships, where others may have felt unheard or that their needs weren’t being considered.”

Following this, I might gently introduce the diagnostic framework by saying something like, “These patterns that we’re seeing are consistent with what we understand as Narcissistic Personality Disorder. This is a way of understanding a particular set of traits and difficulties that many people experience. It doesn’t define who you are, but it can help us understand some of the challenges you’ve faced and guide our work together in addressing them.” It is crucial to emphasize that the diagnosis is a descriptive tool, not a judgment, and that therapy aims to help the client understand themselves better and develop healthier ways of relating to others. I would also be prepared for a range of reactions, including denial, anger, or even a superficial acceptance used to gain admiration for being “complex.” Ongoing dialogue and addressing the client’s emotional response to the diagnosis are essential.

Family Therapy:

Sharing the diagnosis in a family session requires even greater sensitivity. The focus should be on how the client’s NPD traits impact family dynamics and how the family can collaboratively work towards healthier interactions. I would likely meet with the individual client first to discuss the potential for involving the family and to gauge their willingness and readiness.

In the family session, I would frame the discussion around the observed patterns of interaction rather than directly labeling the individual in front of the family. For example, I might say, “We’ve discussed how [client’s name]’s need for recognition can sometimes lead to others feeling overlooked, or how disagreements can become difficult when there’s a strong need to be right. These patterns can be understood within the framework of Narcissistic Personality Disorder, which involves a heightened sensitivity to how one is perceived and difficulties in recognizing the perspectives of others.” The goal here is to educate the family about the disorder and its impact, fostering empathy and a collaborative approach to managing its effects on the family system. Blaming or alienating the identified client should be avoided. The focus should be on improving communication and setting healthy boundaries within the family.

Group Therapy:

Sharing a diagnosis of NPD in a group setting would generally be approached with extreme caution and only after careful consideration of the group dynamics and the client’s level of insight and stability. It is often more beneficial for the group members to observe and provide feedback on the client’s narcissistic behaviors in real-time, under the therapist’s guidance, rather than for the therapist to directly disclose the diagnosis.

If the diagnosis were to be shared, it would likely occur in a private individual session first, with a subsequent carefully planned discussion in the group if the client is open to it and the therapist deems it therapeutically appropriate for both the individual and the group. The focus in the group would be on understanding how narcissistic traits manifest in interpersonal interactions and how the group can provide a safe space for feedback and the development of more empathetic relating. The therapist would need to carefully manage the potential for the client to dominate the group or react defensively to feedback. Direct labeling by the therapist in front of the group could be shaming and counterproductive. Instead, the group can offer valuable perspectives on the impact of the client’s behaviors, which can indirectly contribute to the client’s self-awareness.

In all modalities, the overarching principle is to share the diagnosis in a way that fosters understanding and hope for change, rather than creating shame, blame, or a sense of being irrevocably flawed. The therapeutic relationship must remain the priority, serving as the foundation for the challenging work of addressing deeply ingrained personality patterns.

Supporting Sources

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Author.

   • Scholarly Nature: The DSM-5-TR is the standard classification of mental disorders used by mental health professionals in the United States and internationally. It is the product of extensive research and expert consensus, making it a foundational scholarly text in the field of psychiatry.
   • Relevance: This source provides the diagnostic criteria for Narcissistic Personality Disorder, which is essential for understanding the disorder being discussed.

2. Ronningstam, E. (2016). Psychodynamic diagnostic manual: PDM-2. Guilford Press.

   • Scholarly Nature: The Psychodynamic Diagnostic Manual (PDM-2) represents a collaborative effort by psychodynamic clinicians and researchers to provide a comprehensive framework for understanding personality functioning and psychopathology from a psychodynamic perspective. It integrates clinical experience with empirical findings.
   • Relevance: This source offers a detailed psychodynamic understanding of Narcissistic Personality Disorder, including its developmental origins and underlying psychological dynamics, supporting the rationale for using a psychodynamic approach in treatment.

3. Gelso, C. J., & Hayes, J. A. (2001). The therapeutic relationship: Theory, research, and practice. John Wiley & Sons.

   • Scholarly Nature: This book is a widely cited and influential work in the field of psychotherapy, providing a comprehensive overview of the theory, research, and practice related to the therapeutic relationship. It draws upon extensive empirical literature.
   • Relevance: This source provides a foundational understanding of what constitutes a therapeutic relationship in psychiatry, which is crucial for discussing the ethical and practical considerations of sharing a diagnosis.

Reflecting on Treating Clients with Personality Disorders: A Focus on Narcissistic Personality Disorder

This week’s Learning Resources provided valuable insights into the complexities of treating clients with personality disorders. A central theme across the materials emphasized the importance of establishing a strong therapeutic relationship characterized by empathy, consistency, and clear boundaries. Given the often ingrained and rigid patterns of thinking and behavior associated with these disorders, a flexible and patient approach is crucial. The resources highlighted the potential for challenges related to transference and countertransference, underscoring the need for the therapist’s self-awareness and ongoing supervision. Furthermore, the ethical considerations surrounding diagnosis and treatment, particularly in avoiding labeling and fostering client autonomy, were consistently stressed.

For this paper, I will focus on Narcissistic Personality Disorder (NPD) and explore the use of individual psychotherapy with a psychodynamic approach for its treatment.

Narcissistic Personality Disorder: A Brief Overview

Narcissistic Personality Disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts. The DSM-5-TR (American Psychiatric Association, 2022) outlines the following diagnostic criteria (at least five of these must be present):  

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.  
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).  
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).