Learning Objectives

After reading this article, you should be able to:

1. Differentiate and categorize examples of "healthy" narcissism and "pathological" narcissism in clinical contexts.
2. Identify and describe the specific challenges in treating Narcissistic Personality Disorder (NPD), integrating this knowledge into clinical practice.
3. Examine and summarize the key elements and stages of transference-focused psychotherapy for NPD, aiming to apply these concepts in clinical settings.

CPTR: Can you tell us how you conceive of narcissistic personality disorder and how it differs from what psychodynamic theorists describe as healthy narcissism? Where and how do we draw this line?

Dr. Yeomans: Healthy narcissism has to do with the capacity to love and appreciate oneself in a realistic way; to have good feelings about oneself; to judge oneself, to evaluate oneself in accordance with true things: the real potential one has a person and the circumstances in which a person lives and functions. So, healthy narcissism is feeling good about oneself because one has achieved a satisfactory kind of position in the world that’s in sync with one’s capacities and the realities of the society and the social circumstances you are in in the present.

CPTR: And pathological narcissism?

Pathological narcissism is mostly a defense (Kampe L et al, Front Psychiatry 2021;12:661948). The traditional DSM definition is about arrogance, grandiosity, excessive pride, and exploitation of others. Now I don’t disagree with those as characterizing many people who have narcissistic pathology, but what seems to be the case is that all of the arrogance and pride and boastfulness is a defense against a horrible sense of inferiority that’s at the core of the person’s sense of self; they just don’t feel like they’re worth anything. It’s even worse in my clinical experience than feeling inferior; you just feel like you’re nothing; you feel like you barely exist so you have to compensate for that by this show of importance and arrogance and superiority.

CPTR: Is it fair to say that your view is that pathological narcissism does not exist on the same spectrum, if you will, as what we might describe as healthy narcissism; that we are really dealing with a discrete entity that is categorically different from healthy narcissism?

Dr. Yeomans: It’s an important debate you’re putting your finger on. When we were writing our recent book, we spent quite a good deal of time deciding on whether the title would be Treating Narcissistic Personality Disorder – that was the first choice, but we went with the second choice which is Treating Narcissistic Pathology. Narcissistic personality disorder is an entity that as we see has kind of a clearer definition, whereas narcissistic pathology has a spectrum with all different levels of severity and problems. So if we are talking about narcissistic personality disorder, I see that as a reasonably well-defined entity, but the trend in all personality disorders these days is to see them dimensionally as across a spectrum rather than categorically (Monaghan C and Bizumic B, Front Psychiatry 2023;14:1098452).

CPTR: A common belief amongst the general public and I think even some psychotherapists is that narcissistic personality disorder is a largely untreatable condition. What is your take on this and what does the research tell us in this regard?

Dr. Yeomans: Well, first of all, unfortunately, there is to my knowledge no good research on the treatment of narcissistic personality disorder. There’s a lot of research on the treatment of borderline personality disorder. I don’t know of any randomized controlled trials of narcissistic personality disorder. But the notion that people with, let’s call it NPD for time’s sake, are not treatable is a pretty strongly held opinion. When I was a resident in psychiatry some of my highly esteemed and very skilled professors communicated that. So we are fighting an uphill battle. Our experience as a group is that people with NPD can respond successfully to treatment, but it’s a real long haul and a difficult treatment to engage in.

The first problem, of course, is the patient needs to be motivated for treatment and there are two problems there. One is that the nature of the narcissistic defensive system often leaves people seeing the problem outside. They always are projecting onto others and it’s this one that’s frustrating my career; it’s not the way I behave and so on and so forth. So a lot of people with NPD don’t acknowledge a problem within themselves. The second and related issue is how painful it is if they do begin to see a problem in themselves. It can be devastating. And that’s part of the work to help the person go through the extremely difficult experience of getting in touch with what they are defending against – that awful negative sense of self.

CPTR: Can you describe the different stages of psychotherapy with the patient with NPD and how you  typically proceed over the course of treatment?

Dr. Yeomans: We start with a very careful assessment because one of the very important things for clinicians to know is that NPD can exist underneath other clinical presentations. In particular, I’ve seen many cases of treatment-refractory or treatment-resistant depression (Kealy D, Laverdiere O, and Pinkus A, J Nerv Ment Dis 2020;10.1097) People are depressed, all of the classical treatments for depression fail, and you have to wonder is there a narcissistic personality structure underlying that. So you do a very careful assessment.

CPTR: And after the assessment?

Dr. Yeomans: If you have found that the most likely diagnosis is NPD, you have to, in our mind, have a laymen’s kind of discussion of your diagnostic impression. You don’t say, “You know I think you’re a narcissist.” That could be a little harsh and could be a narcissistic injury. But we try to explain that even though you’ve been treated for depression or whatever for a long time, we think the problem is more along the lines of what we call a personality disorder, which is a term that many people bristle against, but it’s really nothing to be ashamed of. It really has to do with your core kind of automatic instinctive sense of you, who you are, and who you are in the world and how others are in relation to you, and we want to examine all that in the course of therapy. 

CPTR: And then? 

Dr. Yeomans: Then we set up the frame of the treatment. We have to have clear parameters with treatment because it becomes a very vague and sometimes unfocused and unending process just to say, “Oh, we’ll sit together and understand things about you and that will lead to change.” No, we have to have clear parameters; we have to have clear goals: better functioning at work, better functioning in relationships. And then once the frame is in place, it is a psychoanalytically-based treatment so it’s up to the patient to begin the free association process, with which there is inevitably difficulty because if you’re a narcissistic person you’re afraid to allow things to spontaneously comes to mind because something might slip out that doesn’t fit with the image you want to give, so there’s a guardedness to begin with.

CPTR: What about countertransference in working with these patients? 

Dr. Yeomans: Almost universally, there’s a devaluing of the therapist: “I thought you were supposed to be good. I’ve been meeting with you for three weeks now and you don’t have anything to offer that I haven’t had before, and that was all worthless.” The two most typical counter-transferences are either to retaliate and kind of argue or fight back when you are devalued or to disengaged and to be in session bodily, but kind of to check out mentally, which is a terrible abandonment of the patient because the patient senses if you have sort of stopped being present with them (Tanzilli A et al, Psychotherapy (Chic) 2017;54(2):184-194).

So the first thing we teach our therapists is to tolerate being devalued. You’re going to go through weeks and probably months of being told, “You’re no good” and “What’s the point of all this?” and “Can’t you do anything useful?” And you have to absorb that. You have to contain that and you have to do what we call hold the projection because the patient is essentially seeing in you the part of themselves that it is too unpleasant, scary or uncomfortable to be in touch with.

In these instances, the therapist might say something like, “It must be frustrating to come here with very high expectations and find a therapist with clear limitations.” That’s what we call “therapist-centered work” or “working in the projection”—the therapist holds the projection of the defective object that the patient cannot yet tolerate experiencing in himself. 

CPTR: How does the patient’s understanding of the therapy relationship ultimately lead to personality change?

Dr. Yeomans: We hope to get the patient to begin to understand what we call the devalued object: the person (in this case, the therapist) who is defective, flawed, imperfect, and yet who can continue to function and do the best they can.  Because in the mind of the narcissistic person either you’re perfect or you’re entirely worthless. But we counteract this by letting ourselves be devalued, by maintaining a steady demeanor in the face of their criticism.  And gradually, the patient begins to recognize our genuine concern and commitment to help them. 

So, when the patient tells us we are no good or useless, we do not respond defensively or become visibly upset but rather just respond in a very neutral and calm way. We might say, “Clearly, you don’t think I am very good at what I do. It must be hard for you to come in here and talk to someone who is so poorly skilled.” 

This non-confrontational response challenges their pre-existing notion of interpersonal dynamics. This is a new experience because their template of a relationship with another person is that one’s got to be superior and one’s got to be inferior; one’s on top and one’s on the bottom. Our neutral stance, which doesn't fit this mold, becomes a point of interest for them, urging them to reconsider their views.

CPTR: How does this relate to the concept of the “negative transference”?

Dr. Yeomans: The negative transference is the view of the therapist as either incompetent or stupid, or even worse, malicious and harmful in some way. And once you help your patient recognize the negative transference, they begin to understand that this negative view of you is part of their pathology. Patients with NPD often feel isolated because they have built grandiose images of themselves that keep them distanced from others. They struggle with genuine connections. Recognizing and understanding their projections can be the first step towards learning how to connect authentically with others. 

So, at this stage, the therapist might interpret the devaluation by saying, “You seem, at times, to really find me to be incompetent, or worse. Perhaps this, in fact, has something to do with the way you have come to see yourself in the world, but it is too difficult for you to acknowledge it.” Essentially what you are trying to do here is to point out that deep down, many people with NPD struggle with feelings of worthlessness and inferiority, which they mask with a façade of superiority. 

CPTR: Generally speaking, in your clinical experience, how long does this work take? 

Dr. Yeomans: I hate to say it because there are so many critics of psychodynamic work, who say it just takes forever, but I couldn’t imagine success in less than three years and sometimes it’s more, it’s four, five or six. 

CPTR: How often do you see the patient in transference-focused psychotherapy for NPD? 

Dr. Yeomans: Ideally twice a week. Now in this day and age most patients somehow think therapy is a once-a-week endeavor. I’m not sure why that seems so widespread. It’s not just by a whim that we think that twice a week is better. When you establish this kind of a therapy, it’s a pretty intense emotional experience. So two contacts a week help the attachment develop much more effectively than once a week. 

CPTR: Thank you very much for your time, Dr. Yeomans.

References in order of appearance in this article:

Kampe L, Bohn J, Remmers C, Hörz-Sagstetter S. It's Not That Great Anymore: The Central Role of Defense Mechanisms in Grandiose and Vulnerable Narcissism. Front Psychiatry. 2021;12:661948. Published 2021 Jun 11. doi:10.3389/fpsyt.2021.661948

Monaghan C, Bizumic B. Dimensional models of personality disorders: Challenges and opportunities. Front Psychiatry. 2023;14:1098452. Published 2023 Mar 7. doi:10.3389/fpsyt.2023.1098452

Kealy D, Laverdière O, Pincus AL. Pathological Narcissism and Symptoms of Major Depressive Disorder Among Psychiatric Outpatients: The Mediating Role of Impaired Emotional Processing. J Nerv Ment Dis. 2020;208(2):161-164. doi:10.1097/NMD.0000000000001114

Tanzilli A, Muzi L, Ronningstam E, Lingiardi V. Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy (Chic). 2017;54(2):184-194. doi:10.1037/pst0000111