Mental health.

Why Some Therapists Won’t Work With Narcissists.

Countertransference and narcissistic personality disorder.

Photo by Dane Deaner on Unsplash

Talk therapists support a person with narcissistic personality disorder (NPD) using psychodynamic or cognitive behavioural therapy along with other forms developed from the therapist's clinical experiences.

“No standardized pharmacological or psychological treatment has been established for persons with narcissistic personality disorder.” — Paroma Mitra and Dimy Fluyau.

Long-term therapy that includes medication for prevailing symptoms of depression, anxiety, paranoia, and psychosis is recommended for managing NPD.

If narcissists make it to therapy, which normally only happens when they’ve reached a crisis point far beyond where we would take things, they often sabotage or terminate therapy, assuming the therapist hasn’t already terminated due to countertransference.

Countertransference and early termination are two reasons therapy rarely work for people with NPD. A list of challenges in treating patients with NPD follows. See the full table with references here.

TABLE 1. Challenges in Treatment of NPD Patients

A. Cognitive

1. Poor recognition of internal states or psychological causes.

2. Intolerance of differences of perspectives.

3. “Reversible perspective” — denial of awareness accomplished in therapy.

4. Refusal to accept logical explanations.

B. Emotional

1. Difficulty accessing, labelling and expressing emotions.

2. Fear and avoidance.

3. Boredom and stimulus hunger.

C. Interpersonal

1. Impoverished relationships.

2. Extreme competitiveness and envy of therapist.

3. Dismissive or “cannot classify” attachment.