Cognitive Behavioral Strategies for Narcissistic Personality Disorder

This video describes how cognitive behavioral therapy may be applied to treating narcissistic personality disorder (NPD). NPD is a Cluster B personality disorder found in the Diagnostic and Statistical Manual. Cluster B contains personality disorders that are considered dramatic, emotional, or erratic including narcissistic, antisocial, borderline and histrionic personality disorders.
The potential symptoms with NPD are grandiosity, a tendency to have fantasies that involve a lot of power or wealth, feeling special, needing excessive admiration, feeling entitled, tending to exploit people, having difficulty empathizing with other individuals, having envy for other people and believing that other people would envy them, and an attitude of arrogance or pretentiousness. In the mental health treatment community, narcissistic personality disorder tends to have elicit strong reaction. I think there are a variety of reasons for this. One is that oftentimes an individual with NPD who begins therapy will challenge or insult a clinician and there's this tendency to be defensive, which really only makes things worse. This is one of these points where experience and maturity on the clinician side can really help. The highest probability of changing NPD, or any other personality disorder, would be with a long duration of treatment. Even with a long duration of treatment, symptoms may not change, but certainly I'm not aware of any brief therapy that can claim any meaningful level of effectiveness with narcissistic personality disorder. Another factor to remember when treating NPD is a lot of times when individuals with NPD come into treatment, it's because of a crisis or another set of symptoms. We commonly see major depressive disorder, persistent depressive disorder, substance use disorders, and anxiety disorders. Also, there are comorbid personality disorders to consider including the other cluster B personality disorders and paranoid personality disorder. We know that with NPD insight is often a problem, so it's unusual to hear somebody with NPD refer to the world as being problematic. NPD might have a protective element to it. The behaviors might protect a fragile sense of self, so if a clinician tries to take away that protective mechanism especially right away, that might not be a good idea. Cognitive behavioral therapy (CBT) centers on cognition, affect, and behavior. The approach targets each one of these separately and brings them together at different levels. When we consider a potential strategy for treating NPD and we recognize the low level of insight, it makes sense not to challenge the client's worldview directly, but rather point out that behavioral changes may have a plus side. What's interesting about going after the behavioral side first is that it doesn't require the client to acknowledge that there's a lack of awareness or insight. It doesn't require them to acknowledge that they might be missing something. It doesn't require them to realize that other people may not be the problem in situation, but rather just to change the behavior.