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Treatment for narcissistic personality disorder typically entails several years of weekly psychotherapy sessions. Different theoretical approaches may govern how a therapist would conduct such sessions. Some clinicians favor theories established by Heinz Kohut and others lean toward approaches suggested by Otto Kernberg and James Masterson. These experts all employed Object Relations theories in different ways to address narcissism.
The matter is much more complex because narcissists usually don’t recognize their behavior as a disorder and if they enter therapy, it’s generally not to seek treatment for narcissistic personality disorder. Instead, people with this condition usually see a therapist because they’re experiencing problems or disappointments they view as having occurred through no fault of their own. Since the narcissist considers himself perfect, any problem exists outside of him, and therapy is viewed as an external solution that should correct the problem and doesn’t have anything to do with attending to personal issues or committing to transformative change. Helping the client transition to a view where personal behavior and mental status are acknowledged as contributing to disappointments or problems is very challenging.
As mentioned, a clinician could approach this in several ways. A Kohutian giving treatment for narcissistic personality disorder would likely work on developing a strong transferential relationship with the narcissist through use of mirroring techniques from a deeply empathic perspective. Mirroring affirms and makes clients feel valued and appreciated and they may, in turn, develop strong feelings for the therapist and feel safer examining the self.
Mirroring also models a way for the client to gradually turn empathy toward the self. Over time, the client develops compensatory structures that help to reduce the negative behaviors narcissism causes. Toward the end of his career, Kohut concluded that a full analysis such as that undertaken by a true Freudian wasn’t always necessary. Instead, once compensatory structures were established, many patients did well without additional therapy.
Other approaches in the treatment for narcissistic personality disorder are more confrontational. Therapists could directly point out inconsistencies or behavior patterns to the client that suggest problems and they may try to avoid mirroring because they don’t want clients to depend on therapists to fuel their narcissism. The danger of confrontation remains that a person with very strong defenses may merely decide to leave therapy. As long as the problems in life are viewed as external, anyone who appears not to be helping isn’t necessary. Early confrontation may only be appropriate to people who are higher functioning narcissists with some degree of tolerance for critique, and this doesn’t describe all people with the disorder.
No matter what theories of treatment for narcissistic personality disorder are used, therapists can shift their approach or include additional psychological theories that best serve each individual. In the end, therapy aims to help people with this condition recognize it, understand its underlying features, and work on changing behaviors.