http://www.americanpsychotherapy.com/online_magazine_article_3004.php

Article #3004

ANNALS JULY/AUGUST 2002



Psychotherapeutic Assessment and Treatment of Narcissistic
Personality Disorder




By Robert C. Schwartz, Ph.D., DAPA


Shannon D. Smith, Ph.D., DAPA



Abstract


Narcissistic personality disorder is a common and often disabling
syndrome. Although persons with narcissistic personality disorder
are often difficult to treat, certain psychotherapeutic strategies
have been identified which can lead to effective interventions with
these clients. This article presents strategies for assessing and
treating narcissistic personality disorder during psychotherapy.
Both theoretical and research literature is summarized in order to
highlight useful approaches to working with clients manifesting
narcissistic characteristics.



Key words


Assessment, diagnosis, treatment, narcissistic personality disorder


Narcissistic Personality Disorder (NPD) is essentially characterized
as a long-term, pervasive character disorder that is defined by a
consistent pattern of grandiosity, a strong need for admiration, and
a distinct lack of empathy, which begins in late adolescence or
early adulthood. Individuals diagnosed with NPD routinely
overestimate their personal abilities, often appearing arrogant and
boastful. They also tend to naturally believe that others ascribe
the same importance to their abilities as they do. However, when
praise or assumed value is not forthcoming, they usually react
swiftly and intensely. Such reactions may range from surprise and
shock, to emotional deflation and depression, to extreme anger and
hostility. These responses are generally thought to occur after the
individual's sense of self-worth falters. More specifically, persons
with NPD invariably have a very fragile sense of self-esteem that is
dependent upon external validation (American Psychiatric Association
[APA], 2000).



The underlying perception of helplessness, worthlessness, and fear
of failure in clients with NPD often leads to the formation of
psychological armor as an unconscious attempt to defend against
intense personal shame. Outwardly, this armor is characterized by
associating with others perceived as having "higher status" or
social power. Inwardly, it takes the form of ruminating about
overdue admiration from others, displays of privilege, idealization
of a special few (e.g., "the best doctor in town") while the client
outwardly devalues most others. Further, it can appear as a sense of
entitlement in social situations, lack of sensitivity toward and
exploitation of others, begrudging others' successes and
possessions, and a total concern for one's own welfare.



In terms of categorical data, the Diagnostic and Statistical Manual
of Mental Disorders (APA, 2000) has grouped NPD together
under "Cluster B" personality disorders with its sister disorders
(including Borderline, Histrionic, and Antisocial Personality
Disorders). Beginning in early adulthood, an individual must
demonstrate at least five of the following DSM-IV diagnostic
criteria in any combination to qualify for NPD: a grandiose sense of
self-importance; a preoccupation with fantasies of success, power,
beauty, or brilliance; a belief that he/she is special and unique; a
need for excessive admiration; a sense of entitlement;
interpersonally exploitative behaviors; a lack of empathy for the
needs of others; envy toward others and a belief that others are
envious of him/her; and finally, arrogant, haughty behaviors. When
conducting a clinical assessment, it is imperative for the
psychotherapist to conduct a thorough review of each of the
established criterion in an effort to ensure an accurate diagnosis.
The therapist is also encouraged to employ an assessment instrument
such as the Narcissistic Personality Inventory (NPI) (Raskin & Hall,
1979; Raskin & Hall, 1981; Raskin & Terry, 1988) to assist in the
accuracy of the diagnosis.



The lifetime prevalence rate of NPD is approximately 0.5-1 percent;
however, the estimated prevalence in clinical settings is
approximately 2-16 percent. Almost 75 percent of individuals
diagnosed with NPD are male (APA, 2000). Research has demonstrated
that it is a common occurrence to find similar features of all the
above characteristics in the same individual (Lilienfeld, Van
Valkenburg, Larntz, & Akisal, 1986; Reise & Oliver, 1994; Cramer,
1999). Males tend to display more exploitative characteristics than
females, as well as maintain a deeper sense of entitlement than
females who have NPD. The co-occurrence of substance abuse is
another common factor associated with this disorder, which also
appears to be more common among men versus women with NPD (Tschanz,
Morf & Turner, 1998).



NPD has been regarded as one of the most difficult pathologies to
successfully treat (Lawrence, 1987). Beck and Freeman (1990) point
out that when individuals with NPD actually engage in psychotherapy,
it is primarily due to the symptoms of another disorder, most
commonly depression. The lack of actively pursuing treatment for
this condition is symptomatic of the disorder itself; individuals
esteem themselves too highly to consciously consider the need for
treatment. Some clients will project their grandiosity onto the
therapist and develop a love-hate relationship. They are likely to
approach therapy with a sense of entitlement and may seduce the
therapist into supporting their sense of grandiosity.



One of the primary goals of psychotherapeutic treatment with clients
having NPD is helping them build internally generated self-
acceptance, without needing to either inflate the self or disparage
others (McWilliams, 1994). A significant challenge is to help
clients gain awareness and honesty toward the nature of their needs
without stimulating their vulnerability to such an extent that
internal shame hinders the therapeutic process.



Demonstrating patience during therapy is certainly required of
therapists. One major complication often encountered during this
process is that of countertransference. Such reactions evoked within
these clients can include boredom and/or demoralization. Thus, it is
important to remain inside the client's lived experience, so that
true empathy can guide the clinical process. A consistent empathic
stance will allow the psychotherapist to gain awareness of the
client's moment-to-moment psychological responses and emotional
needs. In addition, it provides clinical information that can be
utilized in future sessions by the psychotherapist. For example,
when countertransference reactions are induced within the
psychotherapist, he or she can recognize that such experiences are
indeed what the client may actually be feeling at a core level
(McWilliams, 1994).



Another therapeutic guideline to be utilized when working with NPD
clients is the modeling of acceptance and tolerance of human
imperfection(s). Imperfections found not only within oneself, but
also those blemishes within others, should be accepted non-
judgmentally. These matter-of-fact assumptions, that all humans have
flaws and that mistakes can be motivational and invigorating, may
initially be foreign to these clients. However, when gently mirrored
by employing an objective, supportive, nonjudgmental stance, the
client is afforded the opportunity to slowly internalize a more
positive and accepting attitude toward his or her inherent frailty.
Conflicts that arise during the treatment of NPD can produce chronic
feelings of emptiness, longing, fragmentation and confusion (Waska,
1996). Therefore, another important aspect of psychotherapy is the
therapist's own acknowledgment of any therapeutic errors during
therapy sessions. Particularly salient is making note of any lapses
in empathy which may potentially impact the client in a negative
manner. This should be done in a way that does not display a self-
critical attitude on the part of the therapist, as to avoid
demonstrating that mistakes are necessarily "wrong" and requiring
self-censure. Instead, this is accomplished through gentle
questioning, combined with empathic mirroring of the client's needs.
The psychotherapist is advised to slowly guide the psychotherapeutic
process toward aiding the client to objectively understand his or
her needs, and more importantly, how to meet such needs. For
example, a psychotherapist might ask, "At the time when you felt
angry due to your wife's `insensitivity,' did you make your needs
explicit?" (McWilliams, 1994).



The following case example illustrates the above treatment
approaches when working with a client diagnosed with NPD. Charles, a
43-year-old man who never married, has been struggling with what he
describes as his life-long history of relationship failure. He
attributes this failure to his arrogance and selfishness, and simply
demanding absolute perfection. He also described one separate
occasion of becoming verbally explosive and mildly physically
aggressive while under the influence of alcohol. Although he
recognizes his pathology, he states, "I simply cannot change who I
am. I guess I will never be able to have a relationship with anyone
but myself!" This type of self-disparaging remark should be
confronted with Charles. The therapist may assist Charles in
recognizing his limitations by suggesting that mistakes often
provide an opportunity for growth. Also, fostering a self-accepting
attitude, the therapist would state the following, "Charles, we both
agree that this incident was not an acceptable form of behavior.
However, it appears as if you base your self-perception on this
incident. You may recall that over the past year you have
established several positive relationships, including your
relationship with your new partner Jane and your recent
reconciliation with your father." As the therapist holds Charles
responsible for his unacceptable behavior, he also encourages
Charles to focus on his positive relationship achievements.



The rationale for the above approach is to assist clients with NPD
toward recognizing alternative methods, and ultimately more
effective ways of responding behaviorally and emotionally. Thus, the
client will succeed when attempting to fulfill his or her spoken
and/or unspoken needs. More importantly, the client will attain such
fulfillment without directly eliciting either shame (due to weakness
about asking for something) or anger (due to other people not
consistently fulfilling one's unspoken desires). By using constant
mindfulness of the client's underlying internal self-state, the
therapist can discern the appropriate psychotherapeutic pace while
moving the client forward. Once again, this is accomplished in a
safe, supportive psychotherapeutic environment as the client
journeys through an often difficult and frightening path of change.
Therefore, it is imperative that the therapist him or herself be
certain to model a calm, caring, empathic, yet objective
psychotherapeutic relationship with the client suffering with
Narcissistic Personality Disorder.



About the Authors


Shannon D. Smith, Ph.D., PCC, NCC, DAPA, completed his M.A. in
Pastoral Counseling at the University of Ashland, Seminary Division,
Ashland, Ohio, and his Ph.D. in Counseling from Oregon State
University, Corvallis, Ore. He has worked as a Child and Family
therapist in community mental health and as a school counselor in
the public school system (K-12). Currently, he is an assistant
professor in the Department of Counseling at the University of
Akron, Akron, Ohio. His research interests include the diagnosis and
treatment of major mental disorders, child and family therapy,
school counseling, play therapy, counselor education and the use of
technology in counseling. Of particular interest to Dr. Smith is the
diagnosis and treatment of Attention Deficit Hyperactivity Disorder
(ADHD) in children and adults.


Robert C. Schwartz, Ph.D., DAPA, graduated from the University of
Florida with a doctorate in Mental Health Counseling. He is
currently an Assistant Professor in the Department of Counseling and
Director of the Clinic for Child Study and Family Therapy at the
University of Akron in Ohio. He is a National Certified Counseling,
a Certified Clinical Mental Health Counseling and a Licensed
Professional Clinical Counselor in the State of Ohio. His research
interests include depressive and personality disorders,
schizophrenia and spirituality.



References


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5. Lilienfeld, S.O., Van Valkenburg, C., Larntz, K., & Akiskal, H.S.
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Copyright 2002, American Psychotherapy Association