Navigating the 10 stage treatment journey for Narcissistic Personality Disorder
Tuesday, July 23, 2024.
Contrary to common misconceptions, some folks with Narcissistic Personality Disorder (NPD) can experience meaningful change through dedicated therapy, according to Dr. Elinor Greenberg.
Elinor says that while it’s a challenging process requiring an extensive, long-term commitment, effective treatments do exist.
Here’s a closer look at the 10 stages involved in treating narcissistic disorders, highlighting the potential for growth and transformation in her model.
Understanding Narcissism: Overcoming Misconceptions
Many sources incorrectly assert that NPD is untreatable and that narcissists can manipulate therapists without making genuine progress.
However, this is far from the truth. With the right approach, some of those diagnosed with NPD can achieve significant personal growth.
Greenberg prefers to view NPD as a personality "adaptation" rather than a "disorder," attributing its development to childhood experiences of invalidation by primary caregivers.
Children who feel overshadowed or rejected by narcissistic parents or whose acceptance is conditional often struggle to form a stable sense of self.
They adopt a persona to mask their lack of authentic self-worth. “Narcissists weren't born empty,” Greenberg explains. “They have suppressed parts of themselves to fit family values, leading to significant inner conflict.”
Key Indicators of NPD
Diagnosing NPD involves recognizing key traits, which Greenberg summarizes as "the three S's":
status consciousness, sensitivity to slights, and susceptibility to shame.
She recalls clients who exemplified these characteristics, such as one who criticized her accent despite praising her expertise, another who raged over a brief wait.
Greenberg rarely labels her clients as narcissistic directly unless it aids in their treatment.
Therapeutic Approaches to Treating NPD
Greenberg’s approach to treating NPD requires long-term commitment, empathy, and mirroring—the very things narcissistic folks crave but struggle to reciprocate.
Her method involves helping clients realize their counterproductive behaviors and gradually build realistic self-esteem. This process often spans several years, with only a third of clients seeing significant progress.
Overcoming Narcissistic Behaviors
Greenberg helps clients shift from a self-centered viewpoint to considering others' perspectives, promoting "we" language in relationships to foster mutual respect.
She guides them to recognize the damaging effects of their behaviors and encourages more constructive interactions. One client, for example, learned to manage his destructive patterns despite not developing full empathy, stabilizing his emotional highs and lows.
Challenges and Rewards in Working with NPD Clients
While some clients are more difficult to work with, Greenberg finds some to be engaging and rewarding.
She acknowledges the personal challenges, such as dealing with clients’ cancellations for trivial reasons or their abusive tendencies. Despite these hurdles, Greenberg remains passionate about her work, injecting humor and aiming to debunk the myth of perfection. “Perfection is a lie,” she asserts, highlighting the transformative potential in everyone.
The Challenges of Treating Narcissistic Personality Disorder
Limited Specialist Training
One primary reason for skepticism about NPD treatment is the scarcity of psychotherapists trained specifically to handle this disorder. Most therapists are generalists, and specialized training for NPD is both costly and time-consuming, often requiring several years of advanced study.
Avoidance and Premature Termination
The most prevalent way narcissists present is that they tend to avoid therapy or quit when they feel uncomfortable. This avoidance stems from the inherent difficulty of self-reflection and confronting deep-seated issues like shame and low self-esteem.
The Therapeutic Process: A Staged Approach
Effective therapy for NPD is a long-term commitment, typically spanning 5-10 years. It unfolds in stages, with each phase building upon the previous one. Here is an overview of these stages:
Stage 1: Symptom Relief and Initial Engagement
Most narcissists enter therapy seeking relief from immediate distress or to appease a significant other. Initial sessions focus on addressing these surface-level concerns to establish trust and engagement.
Stage 2: Preventing Future Pain
As therapy progresses, clients begin to understand their triggers and develop strategies to avoid future distress. At this stage, the focus remains self-centered, emphasizing personal pain over the impact on others.
Stage 3: Identifying Defense Mechanisms
Therapists help clients recognize their primary coping strategies, often rooted in childhood experiences. This stage involves exploring these mechanisms without judgment, fostering a deeper understanding of their origins.
Stage 4: Developing New Coping Strategies
Armed with insight into their defenses, clients learn new, constructive ways to meet their needs. This phase involves experimenting with alternative strategies to replace maladaptive behaviors.
Stage 5: Forming New Habits
Replacing ingrained narcissistic habits with healthier ones requires repetitive practice. Through consistent effort, new behaviors become encoded in the brain, gradually replacing old patterns.
Stage 6: Recognizing Impact on Others
Once clients develop effective coping mechanisms, they can begin to consider how their actions affect others. This stage reduces the tendency toward grandiosity and increases the ability to empathize with others’ perspectives.
Stage 7: Addressing Childhood Trauma
With defenses lowered, clients can confront painful childhood experiences. This healing process fosters self-empathy and helps integrate their self-image, leading to a more balanced view of themselves and others.
Stage 8: Updating the Inner Voice
Therapists guide clients in examining and transforming their internal dialogue. By challenging harsh self-criticism and fostering a kinder inner voice, clients develop healthier self-perceptions.
Stage 9: Developing Empathy for Others
Clients begin to extend empathy toward others, particularly those who remind them of their own struggles. This newfound empathy marks a significant shift from self-centeredness to genuine emotional understanding.
Stage 10: Embracing Authenticity
As therapy nears its later stages, clients become more authentic in their interactions. The therapeutic relationship itself serves as a model, showing clients that they can be their true selves without fear of rejection.
The Path to change: a long but rewarding journey
Therapy for NPD is a complex, long-term process that requires patience and perseverance. Few therapists have either the training, or orientation to work with NPD. It’s also very much a “your mileage may vary” experience.
Elinor emphasizes that while not all clients complete every stage, those who persist can achieve substantial improvements in their lives. Each step forward, no matter how small, contributes to their overall growth and well-being.
Through dedicated therapy, folks with Narcissistic Personality Disorder can evolve beyond their initial limitations, leading more fulfilling and authentic lives. The journey is challenging, and not for the squishy.
And from a long-suffering spouse’s point of view, it’s an open question if the juice is worth the squeeze.
Dr. Greenberg tells us that change is indeed possible for some with the right support (which is, unfortunately, in exceedingly short supply).
Be Well, Stay Kind, and Godspeed.
REFERENCES:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Edelman, G. M. (1987). Neural Darwinism: The theory of neuronal group selection. Basic Books.
Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Jason Aronson.
Masterson, J. F. (1981). The narcissistic and borderline disorders: An integrated developmental approach. Brunner/Mazel.
Pincus, A. L., & Lukowitsky, M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421-446.
Ronningstam, E. (2016). Identifying and understanding the narcissistic personality. Oxford University Press.
Stone, M. H. (1993). Abnormalities of personality: Within and beyond the realm of treatment. W.W. Norton & Company.
