What is the role of psychotherapy in the treatment of narcissistic personality disorder (NPD)?

Updated: May 16, 2018
  • Author: Sheenie Ambardar, MD; Chief Editor: David Bienenfeld, MD  more...
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Whereas individual psychoanalytic psychotherapy is the method of choice for the treatment of NPD, there has been much debate as to exactly what constitutes optimal treatment. The 2 main schools of thought in this regard are Otto Kernberg’s object-relations approach and Heinz Kohut’s self-psychology approach, which offer different and seemingly contradictory ways of approaching the narcissistic patient. [14]

In Kernberg’s approach, the job of the therapist is to actively interpret the patient’s narcissistic defenses while at the same time illuminating the patient’s negative transferences. Kernberg believed that the end goal of therapy was to eradicate or diminish the patient’s pathologic grandiose self through direct confrontation. [14]

By contrast, Kohut advocated a more empathic approach, with the therapist actually encouraging the patient’s grandiosity and promoting the development of idealization in the transference. Kohut’s end goal was to bolster the patient’s inherently deficient self-structure. [14]

No definitive studies have strongly favored one therapeutic stance over another. Currently, most clinicians embrace a style that fuses elements of both. The general preference is for a flexible and moderate approach that combines an empathic understanding of the patient’s need for narcissistic defenses with a thorough exploration of those defenses.

In line with such an approach, the therapist should recognize the self-preserving role that narcissism plays in the patient’s daily life and should be cautious about tearing down narcissistic defenses too quickly. At the same time, the therapist should strive to help the patient gain a realistic understanding of his or her own behavioral deficiencies. [14]

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