Treatment of Narcissism

Difficulties in therapy and egosyntonia

Treatment of NPD is notoriously difficult due to the "egosyntonic" nature of the disorder: patients do not perceive their personality traits (arrogance, demandingness, lack of empathy) as problematic or alien to them; on the contrary, they often see them as virtues or logical responses to their superiority. They rarely go to therapy to "become less narcissistic".

Generally, they come to consultation due to external crises; a divorce, work problems or depression; or pressured by others. This lack of illness awareness creates enormous initial resistance.

The patient may deva lue the therapist if he or she does not feel sufficiently admired or, paradoxically, idealize the therapist to feel associated with a "superior expert," only to discard him or her at the first frustration.

The therapist must carefully navigate between validating the patient's suffering and gently confronting his maladaptive patterns, avoiding activating his shame or anger defense.

Cognitive techniques and countertransference management

The therapeutic approach requires specific strategies. Cognitive-behavioral therapy works on the identification and modification of cognitive distortions, especially those related to grandiose self-image and unrealistic expectations about others.

Techniques such as "restructuring with images" help to visualize ways of being valuable without the need to be superior.

Systematic desensitization is also used to reduce hypersensitivity to criticism.

A crucial aspect is the management of countertransference: the therapist's emotional reactions to the patient. It is common to feel irritated, bored or intimidated by the arrogance of the narcissist.

The practitioner should not engage in power struggles. Instead, approaches such as "cognitive appraisal therapy" suggest that the therapist maintain a benevolent but firm position of authority, earning the patient's respect so that he or she can then influence the patient.

It seeks to foster empathy through role reversal and to help the patient take responsibility for his or her behavior by transforming grandiose fantasies into realistic and tangible goals.

Summary

Treatment is difficult because the disorder is "egosyntonic": the patient does not see his or her traits as problematic. They often come to therapy pressured by external crises, showing great resistance to change.

The therapist must carefully manage countertransference so as not to fall into power struggles or intimidation. A benevolent authoritative stance is required that validates suffering without feeding grandiosity.

Cognitive techniques seek to modify distorted self-image and unrealistic expectations. The goal is to foster empathy, take responsibility for behavior, and transform unattainable fantasies into realistic and tangible goals.