14 Psychologists Describe What It’s Like To Treat A Narcissistic Patient

1. God, he is an asshole.

“I’m working with one right now. It is extremely frustrating. He is not coming to see me because he needs help with his narcissism, he is there because he is ‘depressed.’ He is not depressed. At all. He has manipulated his way into getting disability payments from the VA for depression and comes to therapy to continue establishment of this pretend issue. It is really hard as I am newer in my career as a therapist and he constantly attempts to manipulate and challenge me. He is desperate to figure me out, always trying to talk to me as if I am his peer and he is a therapist as well (wants me to analyze others in session with him).

Right now we are working through how to manage his frustration with people he finds are beneath him/unhelpful in advancing his facade he has built. It’s gradual, but I doubt I will ever directly work with him on the narcissistic aspect. He believes his therapy is for depression and I have to treat him from that point of view.

But God, he is an asshole.”

2. Everything is the fault of others.

“Most people with NPD don’t recognize it. Everything is the fault of others. Testament focus isn’t on ‘fixing’ them. Personality Disorders are ingrained beliefs—part of personality.

The approach is teaching them how to deal with ‘stupid’ people effectively.”

3. Every patient I have treated for narcissism has no idea.

“Every patient I have treated for narcissism has no idea. It’s part of the disorder most times.”

4. Eventually, they will realize that ‘when everyone you meet is an asshole, you’re probably the asshole’ applies to them.

“Most people with NPD don’t realize they have it and won’t hear of considering that they might have it.

You just don’t bother treating that aspect. If they aren’t ready to deal with that, then you don’t deal with it yet. Same as with any other condition we see in therapy.

What you do do is help them figure out how to interact with all the ‘stupid’ people in their life, use rational emotive behavioral and dialectical behavioral therapy when appropriate, and basically do damage control. Eventually, they will realize that ‘when everyone you meet is an asshole, you’re probably the asshole’ applies to them and start talking about it.

But with NPD, you cannot press a diagnosis onto them and you cannot do so too quickly. It’s a very delicate…well…for lack of a better word, game. Everything must be in balance and planned.

Plus, NPD isn’t something that you give medication for or can solve quickly, so it’s not something that really needs to be diagnosed. It can be helpful to know when making a treatment plan or calculating how to interact with the client, but it’s not something you need to broadcast to the client.”

5. Most narcissists don’t have a problem at all calling themselves a narcissist.

“Most narcissists don’t have a problem at all calling themselves a narcissist. At least the ones on the strong end of the spectrum don’t. However most narcissists don’t go to therapy because of their narcissism but because of another mental disorder (depression is common).”

—joscelline

6. They’re so damn bitter and they often can’t get any further than complaining about everybody else.

“I worked in a psychiatric hospital for decades and narcissism as a defense fails in later stages of life. A lot of 45 to 65 year old males who just want to kill themselves and who talk over me constantly. Some would definitely fulfill the criteria for full-blown NPD but it’s not really necessary, or appropriate, to address it in that setting. Some constantly talk about accomplishments in early life. Others have sad stories of being successful and losing everything, often to drug addiction. They often had estranged family that they would want to engage again for support. They have constant complaints about everybody else.

I don’t know how much it changed therapy, I feel like I often had to be a bit gentler with them, to keep some of those reactionary defenses at bay, so they can stay calm enough to process stuff.

Outside of that more acute setting it seems like narcissistic people are at least minimally aware they are different than others. I think the worse the symptoms are the less they seem aware of it. The worst one I’ve seen have almost constant complaints about everyone else in their lives and even society as a whole. The saddest cases are the ones that are really failing at life. They’re so damn bitter and they often can’t get any further than complaining about everybody else. Just when you think they may have connected with something, to gain some insight, they go into complaint mode.”

7. Unfortunately, our society often allows them to become much more successful than they are qualified to be.

“I’ve known some in undergraduate. They would casually admit to narcissistic tendencies but just in a way to laugh it off. I don’t think they really understood how they came off to the people around them. Unfortunately, our society often allows them to become much more successful than they are qualified to be. We value some traits that are stronger in narcissists. Also many people want to avoid the confrontation so they admit defeat ahead of time.”

8. The common problem with narcissists is that they inherently don’t believe that they should have to change.

“I am in school to be a therapist, so not quite there yet to have a narcissistic client, but my uncle has been diagnosed by two different therapists as having narcissistic personality disorder.

He was in the treatment for depression for a bit, but therapy was largely ineffective mostly because he didn’t think he needed it. Everyone else around him is the problem.

My mom and her other siblings have been paying his rent and other utilities for the past 9 years because they worry he will become homeless or kill himself.

He used to be a successful architect, but lost his job due to inability to work with others in a professional setting (was constantly late and refused to work within budget constraints). He now smokes pot all the time and lives with his girlfriend. They are still together almost exclusively because they could not afford to live anywhere else without my family paying for them.

In response to the original question regarding how you would treat him, the idea would be to get a buy in somehow for how therapy could help him. However, the common problem with narcissists is that they inherently don’t believe that they should have to change, so even in therapy weekly the process is long and arduous.”

9. The way you usually handle it is by playing their game, for lack of a better word. You talk about all those ‘stupid/idiot/asshole’ people who’ve ‘done them wrong.’

“Most NPDs don’t actually know or recognize that they have it. Most refuse to accept it. If you tried to tell them that they have it, they’d react very negatively and often close off and any attempt at ‘treating’ them goes out the window. That’s part of them being narcissistic.

The way you usually handle it is by playing their game, for lack of a better word. You talk about all those ‘stupid/idiot/asshole’ people who’ve ‘done them wrong.’ Over a VERY long time you try to lead them like a horse to water to the recognition that if everyone in their life is like that, then maybe, just maybe, it’s him and not them.

The fact is that, especially in my opinion, NPD isn’t treatable. There are no medications for it or something and there’s no real way to get rid of it. What you can do is manage the symptoms, once you are able to get the person to the understanding that there actually is something wrong with them. But that takes a very, very long time.

Actually, someone in my immediate family has NPD. As expected, he has no idea he has it, refuses to hear that there could be anything wrong with him, and would never dream about getting therapy. Most patients with NPD aren’t there voluntarily or, if they are, they aren’t there for their NPD, at least not directly.”

10. THEY don’t have any problems; it’s everyone else who has a problem.

“In my experience people with NPD generally don’t come in on their own because THEY don’t have any problems, it’s everyone else who has a problem. I usually see people with NPD when they come in with their partner. It can be really difficult to fix a couple when one party can’t admit their faults. I had one guy who named his own faults purely because he thought it made him look good, not because he wanted to make any effort to change. In the end you really have to help the couple find behaviors that work for both of them, even if the person with NPD doesn’t change their opinion of themselves. You can say well, I know this sounds dumb to you but look how much better it makes the family run, etc. The tragic thing about personality disorders is that they don’t go away, you can’t ‘cure’ Borderline of Narcissism. The best you can do is help the person find behaviors that work well for them.”

11. Others are just supporting actors in the show that is ‘their life.’

“Personality disorders, in general, are next to impossible to treat. Rather than focus on personality, the focus of therapy should be on problem behaviors, as identified by the client, and the underlying thoughts or beliefs or emotions. The hard part with NPD is helping clients to develop empathy, as typically a narcissistic person is not only focused primarily on themselves but also sees others as less important, as if others are just supporting actors in the show that is ‘their life.’”

12. Telling someone ‘you have Narcissistic Personality Disorder’ and subsequently explaining it can go wrong in a lot of ways.

“The thing is, many people with personality disorders don’t realize they have them in the first place. Personality disorders affect your entire world view and skew your ideas of what would be considered ‘healthy,’ ‘normal,’ ‘appropriate,’ etc.

A person with NPD in my office probably isn’t there to get treated for NPD. They’re probably there for something like anger management (e.g., lashing out when they get called out), depression (feeling isolated and lonely because nobody ‘gets them’), and so on. The topic of NPD may likely never come up, and even then discussing it would have to be a highly calculated risk. Telling someone ‘you have Narcissistic Personality Disorder’ and subsequently explaining it can go wrong in a lot of ways. You have to weigh the benefit of discussing the diagnosis versus focusing on addressing the behaviors that led to treatment in the first place.

A diagnosis exists to give names to clusters of symptoms so practitioners have a common language. In my clinical training, I was taught not give too much weight to a diagnosis in my interactions with clients. If the client does, we can have a conversation about what the diagnosis means to them and how we can work together on it. Personally, I’ve never really had clients who were terribly worried about their diagnoses.”

13. You only need one question to assess a narcissist. ‘Are you a narcissist?’ If they answer yes, chances are they almost certainly are.

“I have never treated one myself, but interestingly enough I remember this articlewhich says that it’s possible you only need one question to assess a narcissist. ‘Are you a narcissist?’ If they answer yes, chances are they almost certainly are because narcissists are notorious for being unashamedly egotistical and don’t see that as a bad thing.”

14. Issue at hand: Patient has delusions of persecution, frequently believes people hate them and treat them unfairly as a result.

“Dialectical Behavioral Therapy [DBT] has a lot of merit in treating narcissists in my experience. They often don’t take possibilities that don’t fit within their very rigid view of themselves seriously, but don’t always have trouble imagining those possibilities on their own if asked to do so ‘purely hypothetically’ or when talking about an imaginary person who is ‘totally not them.’ By having them take what they believe to be true and then imagine the exact opposite of that belief, for example, and then asking them to try to imagine a scenario in which something in the middle could be true, they can often be led to have a more nuanced view then they will normally allow themselves, which can then be taken out of the hypothetical situation and directed at allowing them to have insight into their own behavior.

It can be a pretty nuanced conversation structure that doesn’t necessarily demonstrate itself over the course of just one exchange, but if I had to make a mock-up of it at its most essential it might look something like this.

Issue at hand: Patient has delusions of persecution, frequently believes people hate them and treat them unfairly as a result.

Me: What do you think its like to be someone who everyone loves? How do people show love and how might you imagine someone knows when they are loved?

Patient: [Answer]

Me: Now how do you think that works in more complicated situations where someone isn’t hated, but they’re not loved either or situations where people have mixed feelings about each other? Have you ever had mixed feelings about someone that weren’t purely good or bad?

Patient: [Insight X]

Me: Oh? Insight X? You know that reminds me a bit of what’s going on with your boss, you mentioned you’d been having some problems with her…

DBT is a huge, huge, huge game-changer in the mental health world. BPD and other personality disorders such as NPD were seen as ‘unfixable’ and ‘untreatable.’ But these skills are amazing at putting people in their best frame of mind for dealing with whatever life hands you. I highly recommend DBT to everyone.”