What Therapy Approaches Work Best for Narcissists
Working with narcissistic clients can be incredibly complex. Most of us weren’t trained to expect how resistant, brittle, and subtly manipulative the therapeutic process can become with these patients.
What’s more, they rarely walk into therapy saying, “Help me with my narcissism.” Instead, they come in after a painful breakup, a career setback, or a humiliating public failure. Their grandiosity is cracked, but not gone.
And here’s where it gets tricky: the same defenses that help them survive the world — grandiosity, entitlement, devaluation — are the ones that make treatment hard to sustain. The very structure of narcissism is designed to avoid the kind of deep, vulnerable work therapy requires.
In this piece, I want to share what current clinical thinking and research tell us about working with narcissistic patients.
My goal isn’t to rehash DSM criteria — you already know that. Instead, I’ll focus on practical ideas and newer models that can help us do better work with this population.
How to think about narcissism as a therapy target
Before we dive into therapy models, I think it’s critical that we get more precise about what we’re actually treating when we treat narcissism.
Too often, “narcissist” becomes shorthand for difficult or grandiose clients. But the clinical reality is more subtle — and that’s where some therapeutic leverage lies.
Narcissism isn’t one thing
We now have robust evidence that narcissism isn’t a unitary construct. Pincus and Lukowitsky’s dimensional model (2010) — which many of you are likely familiar with — makes this especially clear: grandiose narcissism and vulnerable narcissism operate quite differently in the therapy room.
- Grandiose narcissism presents with overt entitlement, superiority, and interpersonal exploitation. These patients may be dismissive of the therapist, see themselves as “above therapy,” and engage in power struggles.
- Vulnerable narcissism often looks like chronic shame, hypersensitivity to criticism, and emotional dysregulation. These clients may idealize the therapist early on and then suddenly devalue them in response to perceived slights.
Of course, many patients shift between these poles — especially under relational stress. If we treat them as a monolith, we miss opportunities to fine-tune interventions.
The personality structure is the real target
Here’s the piece I find most helpful to remind myself of when I’m stuck with a narcissistic client: we’re not trying to “reduce narcissism.” We’re trying to help the patient develop a more coherent, integrated, and flexible sense of self and other.
What keeps narcissistic pathology rigid and repetitive is fragmentation at the level of self-representation:
- Self-esteem is externally regulated and fragile.
- The self is split into grandiose and devalued parts.
- Other people are either idealized extensions of the self or treated as threats.
Our real therapeutic target, then, is integration. This is why simply challenging narcissistic behaviors often backfires — it threatens an already precarious psychic equilibrium.
Treat the person, not just the diagnosis
Another key principle: narcissistic traits rarely exist in isolation. In clinical samples, NPD often co-occurs with:
- Borderline traits (especially in vulnerable narcissism)
- Avoidant and obsessive-compulsive features
- Mood and anxiety disorders
- Substance use problems
In practice, this means we need to assess narcissistic dynamics in the context of the patient’s whole personality structure and comorbidities.
I’ve worked with patients who presented as highly grandiose, but once their depression was treated, much of that grandiosity softened. In others, treating complex trauma brought more capacity for empathy online.
The alliance is both the diagnostic test and the treatment
Finally, I’d argue that the quality of the therapeutic alliance itself is one of the best indicators of where a narcissistic patient is functioning — and one of the primary vehicles of change.
Watch for these alliance dynamics:
- Idealization → devaluation cycles: These are common in early treatment and signal fragile self-organization.
- Defensive distance: Patients may intellectualize or use charm to avoid genuine relational contact.
- Rupture-repair patterns: The ability (or inability) to tolerate alliance ruptures without collapse offers rich diagnostic data and shapes treatment direction.
One patient of mine, a CEO with classic grandiose traits, began therapy with a performance — every session a monologue about his achievements. The first time I gently challenged this, he stormed out. But when he returned and we could process the rupture, it marked a major shift: he could begin to experience me not as an audience, but as a real other.
Moments like this — subtle but powerful — are where the real work happens.
Next, I’ll walk through specific therapy approaches that offer strong clinical traction with narcissistic patients — including newer models that go beyond traditional psychodynamic frameworks.
Stay tuned.
Therapy approaches that actually help with narcissism
Over the years, we’ve moved beyond the old pessimism that “narcissists can’t be treated.” We now have several therapy models — both well-established and emerging — that offer real traction. But let’s be clear: no single approach works for every narcissistic patient. The art is in choosing the right model for the specific pattern of narcissism in front of us and adapting it flexibly as the patient evolves.
Here are some of the therapy approaches I’ve found most useful — with clinical reflections on where they tend to shine and where they can struggle.
Transference-Focused Psychotherapy (TFP)
TFP, developed by Otto Kernberg and colleagues, is probably the most sophisticated model we have for working with patients with severe narcissistic pathology. At its heart, TFP aims to integrate split-off aspects of the self and others through analysis of the transference.
If you’ve worked with highly grandiose patients, you’ll know how central this splitting is. The therapist becomes alternately idealized or devalued — rarely a whole, ordinary person. In TFP, we actively interpret these shifts as they occur in the here-and-now therapeutic relationship.
In my own practice, I’ve found TFP invaluable with patients who have malignant narcissistic traits — the ones whose relational patterns oscillate between seduction and aggression. For example, one patient would oscillate between praising me as a “genius therapist” and accusing me of being incompetent and out to harm him. Through carefully titrated interpretation, he gradually became able to see these distortions as defenses against unbearable shame.
Strengths:
- Gives a structured, deep model for working with personality-level defenses.
- Offers clear guidelines for managing the alliance when it’s under attack.
Challenges:
- Requires high therapist skill and tolerance for intense transference.
- Patients with fragile ego structure may destabilize if the technique is applied too aggressively.
Schema Therapy
Schema Therapy, developed by Jeffrey Young, is a rich integrative model that brings together cognitive-behavioral, attachment, and psychodynamic principles. It’s particularly helpful with vulnerable narcissism and patients with significant early relational trauma.
The focus is on identifying and transforming maladaptive schemas (e.g., defectiveness/shame, entitlement/grandiosity) and working with modes — states of mind that shift dynamically. In practice, this helps patients develop a more stable, compassionate internal world.
One of my most moving cases involved a patient with a severe vulnerable narcissistic pattern. He would often retreat into an angry, dismissive mode when feeling slighted. Through imagery rescripting and mode dialogues, we uncovered a deep core schema of defectiveness rooted in childhood emotional neglect. Over time, his entitlement and rage softened as he built a more compassionate adult mode.
Strengths:
- Offers powerful experiential tools to access core vulnerability.
- Particularly effective with narcissism rooted in early relational trauma.
Challenges:
- Patients with rigid grandiose defenses may initially resist schema work.
- Requires patience and skill to titrate experiential interventions.
Mentalization-Based Therapy (MBT)
MBT, from Peter Fonagy and Anthony Bateman, targets one of the most crucial deficits in narcissistic patients: impaired mentalization — the capacity to understand one’s own and others’ minds as complex and opaque.
Narcissistic defenses often short-circuit mentalization. When triggered, patients shift into psychic equivalence (“if I feel devalued, you must hate me”) or pretend mode (detached intellectualization). MBT focuses on restoring reflective function in these moments.
In my experience, MBT is incredibly helpful with patients who struggle with interpersonal paranoia and misattunement. One client, a tech entrepreneur with overt grandiosity but covert paranoia, would frequently misread benign comments as attacks. Using MBT techniques — staying curious about his interpretations, modeling reflective stance — we gradually built his capacity to mentalize in moments of interpersonal stress.
Strengths:
- Directly targets empathy and reflective function deficits.
- Strong evidence base for personality disorder treatment.
Challenges:
- Requires therapist discipline to avoid being drawn into non-mentalizing interactions.
- Progress can be slow; requires patience.
Psychodynamic Therapy (general)
Many narcissistic patients benefit from good, solid general psychodynamic therapy — provided the therapist has a sophisticated understanding of narcissistic defenses.
Key here is timing and tone of interpretation. Confronting grandiosity too early or too bluntly will likely result in dropout or retaliatory devaluation. I’ve found that building a strong alliance first, and interpreting narcissistic defenses as protective rather than malicious, opens the door to deeper work.
One vignette: I worked with a high-powered lawyer who would often brag about his courtroom triumphs. Rather than confronting this head-on, I reflected on the anxiety and shame that might underlie the need for constant validation. This allowed us to explore early experiences of humiliating failure that drove his compulsive need to dominate.
Strengths:
- Flexible and adaptable across the narcissistic spectrum.
- Allows deep exploration of unconscious dynamics.
Challenges:
- Requires advanced skill in managing transference-countertransference.
- Progress can be uneven and nonlinear.
Cognitive-Behavioral Therapy (CBT)
CBT isn’t typically the first-line treatment for core narcissistic pathology — but it can be very useful for targeting specific dysfunctional beliefs and behaviors.
For example, with patients who struggle with perfectionism and entitlement, cognitive restructuring can help dismantle rigid “should” statements and catastrophic thinking. Behavioral experiments can be used to test grandiose assumptions in real life.
In one case, a patient who believed, “If I’m not the best, I’m worthless,” was guided through experiments where she deliberately took non-leadership roles in group settings. This helped her build a more nuanced self-concept.
Strengths:
- Practical tools for symptom reduction and behavior change.
- Can complement deeper psychodynamic work.
Challenges:
- Doesn’t address core personality structure on its own.
- Risk of reinforcing intellectualization if not integrated carefully.
Clinical strategies that make therapy work
Beyond choosing a model, success with narcissistic patients hinges on how we conduct the therapy — often more so than what model we use. Here are some key principles I’ve found invaluable across approaches.
Establish a clear, sturdy frame
Narcissistic patients often test boundaries — not maliciously, but as a way of managing anxiety about dependency and control. A consistent, transparent frame provides the safety they need to engage meaningfully.
I make it explicit from the outset: session times, limits of confidentiality, expectations about communication between sessions. And when boundary testing occurs — which it will — I reflect on it collaboratively, not punitively.
Anticipate and manage alliance ruptures
Alliance ruptures are inevitable with narcissistic patients. The work lies in using these moments productively.
When a patient devalues me or threatens to quit, I try to stay curious: “What’s happening between us right now that feels so frustrating?” This models a reflective stance and helps shift from reactivity to exploration.
One patient told me after a rupture repair, “That was the first time someone didn’t give up on me when I pushed them away.” Moments like this build the relational trust that makes deeper work possible.
Work with defenses, not against them
Trying to dismantle narcissistic defenses head-on usually triggers massive resistance. Instead, I aim to respect defenses as adaptive, while gently exploring their costs.
For example, if a patient boasts about professional success to ward off shame, I might say: “It sounds like achieving at that level helps you feel safe — and I wonder what it’s like when you can’t always be the best.” This keeps us in a collaborative stance, rather than an adversarial one.
Balance empathy with firmness
Narcissistic patients need both empathic attunement and firm limits. Lean too empathic and you collude with grandiosity; lean too confrontational and you trigger collapse.
A stance I often try to embody: warm, curious, transparent, and gently challenging. For instance, when a patient insisted I praise his latest project, I responded: “I can see this is hugely important to you — and I’m also wondering how you’d feel if you didn’t get that kind of response from others.”
Monitor your own countertransference
Few patient groups evoke stronger countertransference than narcissists. You may feel idealized, devalued, bored, enraged, or manipulated — often all within a single session.
Regular supervision and self-reflection are non-negotiable here. I’ve learned that when I feel an urgent need to “prove” something to a narcissistic patient, I’m likely caught in their dynamic. Awareness of these pulls allows us to stay grounded and therapeutic.
Pace interventions carefully
Finally, timing is everything. Pushing too fast into core shame or trauma can overwhelm a fragile narcissistic structure.
I try to follow the patient’s readiness, watching for moments of openness and retreat. One powerful guideline: if the patient is defending more vigorously than usual, I’ve probably gone too far too soon.
Final Thoughts
Treating narcissistic patients isn’t easy — but it’s some of the most rewarding work we can do. When we understand narcissism not as a fixed character flaw but as a dynamic, defensive structure born of profound vulnerability, we can approach these patients with more compassion and clinical creativity.
No single model holds all the answers. The best work integrates insights from TFP, Schema Therapy, MBT, psychodynamic thinking, and even CBT — all held within a strong, reflective therapeutic relationship.
Above all, we must remember: progress will be slow, nonlinear, and hard-won — but it is possible. I’ve seen deeply entrenched narcissistic patterns shift over time, allowing patients to build more flexible, authentic, and connected lives.
And in those moments, the work is worth every ounce of effort.
