Narcissists In Therapy

I don’t like the word narcissist. It’s a blunt and primitive description of a complex cluster of behaviors and feelings. However, rather than complicating this post with a mouthful of more descriptive terminology (such as “people with narcissistic personality traits”) I will rather settle for one word, and stick to it. So here comes a brief note on how and why narcissists present in treatment, what do they expect from psychotherapy, and how likely they are to get benefits from it.

First of all, I should say, that narcissism is a spectrum. To a certain degree, most, if not all, of people will fall on somewhere on the spectrum, and could be seen as slightly narcissistic, but the category I am talking about in this post are mainly those who a highly narcissistic, or suffer from what we call Narcissitic Personality Disorder (NPD).

I heard many times that NPD people rarely seek psychological treatment, and even if they do end up in a therapy room, they flee quickly and often gain little to no benefit from their sessions. Why is that? What do they really seek? How and what a therapist needs to do to achieve successful treatment outcomes with a narcissistic client? And finally, what a “successful” treatment outcome would look like for a narcissist?

I will try and answer those questions by looking at a scope of narcissistic clients that have presented in my practice over several years.  As I work with complex traumatic client’s histories, where childhood traumas are so profound, it is not surprising that narcissists tend to constitute a large proportion of my clients. And I welcome them!

Typically a therapist can “detect” a narcissistic client as soon as their first appointment begins.

Narcissistic clients often present as well spoken, charming, smart and talkative. They want to demonstrate to the therapist and overtly (or covertly) convey that they are “a good person”. Whatever they report, it is mostly about how good they are and how badly they are treated by others. Their life miseries is everyone else’s fault: not appreciative boss at work, ungrateful friends, inattentive spouses, to name a few.

Why Does A Narcissist Begin Psychotherapy?

They often come along with initial complaints of depression, anxiety and panic attacks. However, after telling their stories, they quickly slip into the loophole of blaming everyone else for their symptoms. Afterwards, it is hard for a narcissist to get out or the cycle of blaming others and access the real issue – themselves and what role they play in their own lives. The real issue is always themselves, of course, and their narcissism, but being unable to see that, they fruitlessly continue to focus on “that awful boss, and all unfair life”. It is a challenge for a therapist to try and pull the client out of this loop, no matter how frequently and gently she may be suggesting that it is unhelpful and unproductive to keep talking about everyone else in therapy room, except the client.

What Do Narcissists Seek From Therapy?

Of course, a typical narcissist will be telling to their therapists how stressful their lives are and how they need a little help with managing their symptoms. They do not want a therapist to dig deeper. The fear of seeing themselves and not liking what they see is very terrifying. Ultimately the world is telling them, in the words of others around them, that they are not so pleasant people to be around. But a narcissist needs appraisal and recognition, they desperately want to feel special, and they are even ready to pay for it. So, to a certain degree, sometimes narcissistic clients pay for their weekly sessions, where they can come and get approval, secure an echo chamber, a piece of sympathy and a touch of recognition.

Can Psychotherapy Help A Narcissist?

Sooner or later the bubble of a “special self” will be poked. The therapist will eventually attempt to do their job and try interventions, approaches to let the client achieve some degree of self-awareness. That’s where the forceful resistance is often encountered and many narcissists are quick to drop out of therapy at that point. After many years of experience working with narcissistic clients I would advocate to challenge them later than sooner. Narcissists have the most fragile ego, as their false selves are build entirely on shame.

Narcissists need to hear that they are special and good, and any alternatives to that narrative are shameful to death. So the therapist must thread lightly.

In Session With a Narcissist… What Is It like?

Most of psychotherapy sessions will be just listening to the narcissist talk. A narcissist in the beginning might not even want to hear any feedback or reflections, particularly if a therapist thinks differently than them. Therapists would feel frustrated and compelled to ask “Why are you here?”. Often a narcissist will demand the therapist to agree and “be supportive” of the “fact” that they are mistreated by everyone else and feel [sorry] for them. After all, at the initial stage of therapy, this is truly what they come for. So give it to them! Be as understanding and as attentive as you can, in order to establish trust. You will need it later, when after months and months of getting to know you, the client will finally start trusting a bit and then may be able to handle a little challenge. Try to challenge, but be prepared for anger or  withdrawal. Be sensitive to discuss the impasse in session straight away or shortly after.  They will want you to collude with them and support their view on who is right and who is wrong. When listening to the narcissists’ grievances, connect and sympathize with their feelings rather than focusing on who to blame.

Can Psychotherapy With Narcissists Be Successful?

First of all, what is a successful outcome of therapy? In the case of a narcissist I would say, that such outcomes as being able to step outside the loophole of feeling unhappy and stressed and blaming everyone else is a good start. Then, perhaps, finding the real self. Not the one who is awesome, the best and the smartest, but ordinary self, with imperfections and drawbacks. That real self feels shameful and ugly, so most narcissists will hide it from their closest family and friends, thus never being able to be intimate with others. Once the real self is seen, accepted, nurtured and loved, therapy will be in good progress.

In the course of therapy,  gradually a more satisfying life can begin, where a person (no longer highly narcissistic!) would no longer need to be the best, but can be an ordinary human, that is able to connect with others and tolerate imperfections of others as well. Where they can forgive and move on, and where they will be able to reflect and understand more about themselves and  regard the feelings of others. It is a great outcome and a satisfying life, worth living. Therefore I would strongly recommend therapy for narcissists, and I also believe such outcomes for them are realistic.

When Therapy Is Not Successful 

Sometimes people come to treatment for the wrong reason. I believe that symptoms of psychological distress are real of course. They may be truly experiencing depression or anxiety. Nevertheless their goal in actual therapy session is solely serving the purpose of getting a dose of approval, a pat on the head, a space to rant, and nothing more. If this is the case it is regardless of whether you listen to them for one year or one month, in the end, even to their assessment, you will still remain a useless shrink, who did nothing. Or, in a better scenario, a kind and a nice therapist, but who was also not helpful after all. In that case, there is little you can do, as the responsibility for change and make use of therapy always lies in client’s hands. So if you tried challenging, gentle probing and thoughtful reflections at different points in therapy, and found little success, it is okay to let it go. Clients are ready for change at different times of their lives and for some it takes years to develop ability to change and self-reflect. They might come back to therapy some years later and make another attempt to be honest with themselves.


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