Working with Individuals Diagnosed with Narcissistic Personality Disorder

There was a swan at the edge of a river and a scorpion approached asking the swan if she would kindly give him a ride to the other side of the river on her back. The swan said, “no, you are a scorpion, you will sting me and I will die.” The scorpion assured the swan that he wouldn’t do that, all he wanted was a ride to the other side and he promised she was safe with him. So the swan gave in and allowed the scorpion to climb upon her back. She swam to the other side and just before reaching the shore the scorpion stung her and jumped to safety. As the swan was sinking, slowly dying from the poisons she asked the scorpion why he broke his promise and stung her. The scorpion said, “I’m a scorpion, that is what I do.”  (LaRoche, n.d.) 

I read a longer version of this story from the book, Should I Stay or Should I Go? By Dr. Ramani Durvasula, a well-known psychologist who studies and works with narcissistic personality disorder (NPD). Those who have been in a relationship or have known someone with NPD may find this story to feel familiar. We live in an age where the word narcissism gets thrown around loosely without really understanding the core traits of NPD. According to the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), NPD is defined as “a pervasive pattern of grandiosity, a constant need for admiration, and a lack of empathy.” The lack of empathy is a key criterion as most individuals display traits of narcissism, but what really makes it pathological is the inability to emotionally place themselves in anyone else’s shoes but their own. 

This pathological disability stems from a deep-rooted lack of self-esteem and a poor to non-existent sense of self; therefore, they seek it from others through attention and admiration. Psychoanalyst Otto Fenichel developed the concept, “narcissistic supply” which is essential to a narcissist’s survival. A narcissist will do whatever it takes to maintain their own supply and will seek it through common NPD behaviors of gaslighting, manipulation, projection, and lies. So how does a narcissist seek therapy if they can not reflect inward? Well, not so easily. People with NPD do not seek therapy because they have learned of their own diagnosis. But rather when their supply has been depleted to the degree that they hit “rock bottom.” Meaning, the co-dependent individuals that have been supplying them have made the brave decision to go no-contact or learned to develop boundaries for themselves, leaving the narcissist starved. 

As  therapists, we assist individuals who can acknowledge and reflect on their own deep-rooted emotions and maladaptive behaviors despite how painful and challenging it may seem. With a narcissist, the goal is not necessarily to change who they are, that is a recipe for failure. However, what has helped me when working with these individuals is to focus on building trust and a relationship with the person (with much countertransference) in order to overcome resistance to therapy. It is important to remind them why they are seeking treatment in the first place (re-build their narcissistic supply). Once a relationship is formed, you can work on identifying their maladaptive behaviors and point out how the behaviors are in fact doing the opposite towards building their narcissistic supply. An individual with NPD exhibits grandiosity, therefore, their reality is far different than the average person. It can be quite challenging to change their reality which is why it is important as a therapist to learn about the narcissist’s own reality as a form of rapport building. Then you can work together on new behaviors in order to achieve their goal of seeking supply. When the narcissist learns to respect the therapist, modeling healthy relationship behaviors within the therapeutic relationship can help with behavior change. 

This sounds easy when it’s said and done, but the reality that is faced during treatment, especially when pointing out their maladaptive behaviors, is to see the narcissist act out of rage, throw tantrums, and stop treatment as a whole. My method working with these individuals is from a psychoanalytical lens, as a narcissist is triggered by their own “lack of,” which is projected onto a therapist and others around them. Using transference can be beneficial in order to understand their childhood family dynamics so the therapist can better develop empathy towards the narcissistic behaviors and assist them in confronting their own poor self-esteem.