Therapy For Narcissistic Personality Disorder
A de’ignis article on the systemic therapy of personality disorders using the example of narcissism, its intrapsychic patterns and being a guest in the world of the sufferer. If you would like more information or have any questions about our services, please feel free to use our contact form. We will get back to you as soon as possible.
The good news: people with a narcissistic personality style on a disorder continuum are people like you and me, just maybe “a bit more” of them. Another piece of good news: criterion-referenced research1 has shown that the number of diagnostic criteria met drops significantly after initial diagnosis. This reduces the stability myth and encourages committed therapy, as in other disorder areas.2 As already depicted in DSM-5, ICD 11 will also move from a categorical classification of differential types based on polythetic lists of criteria to a largely dimensional classification.3 As systemic therapy is increasingly challenged by individual therapy, an interest in intrapsychic processes of the individual is also developing here within the framework of systemic thinking on the background of neurobiological research results, namely the feeling-thinking-behavior patterns (FDV) of the individual. The picture of personality disorders (PS) is characterized by a massively developed ICH-syntonia, so that with the view on intrapsychic processes and individual FDV-patterns systemic therapy now becomes connectable for the individual setting here as well. This is also interesting because systemic therapy, with its recognition as a scientific healing method and socio-legal recognition, is in a phase that virtually demands a renewed examination of disorder-specific concepts under the umbrella of the health care system. For historically, a first phase with successful concepts for clinical pictures such as schizophrenia, eating disorders, psychosomatic illnesses and affective disorders was followed by a second phase that was rather characterized by targeted abandonment and strict rejection of all forms of disorder-specific coding. Overall, the individual, practitioner or treated, benefits from this expanded development of exchange and discourse among the various schools of therapy, rather than the previous competitive demarcation. Thus, this paper also sees itself as a systemic therapeutic addition to the treatment repertoire of personality disorders, using the example of narcissistic personality disorder (NPS). Dariia / AdobeStock
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Narcissistic personality disorder as a relationship disorder
There is now widespread agreement that a personality disorder is not so much a personality disorder as a relationship disorder, and dimensionally, it is not pathological in nature. The person affected should quietly keep her style. Rather, she or he should learn to deal with it in such a way that personal suffering in various relationship contexts is less stressful or even destructive. This would be a therapy goal.4 The systemic therapist externalizes quasi intrapsychic patterns and conceptualizes them as so-called FDV patterns. Pattern recognition, pattern description and stimulation to change patterns in order to modify a personality style are then again basic competencies and interventions of systemic therapy. For therapeutic work in dealing with dysfunctional FDV programs we can then also draw on most of the repertoire of systemic methodological diversity such as circularity, scaling, intentional deterioration, focusing on exceptions, genogram work, homework, reframing and positive connotation, metaphor work, externalizing, resource activation, visualizing methods, etc. However, less functional for the treatment of personality disorders proves to be strict solution orientation, purely interactional understanding, provocative approaches and dogmatic resource orientation due to the relational disorder and intentional focus on FDV patterns. Especially in narcissistic personality disorder represents Recognition and attention represents the central relational motive, which often simultaneously serves a very pronounced susceptibility to massive mortification in the presence of disappointed expectation and excessive demand. A profound pattern of grandiosity of one’s own person is coupled as observable behavior with a need for admiration and coupled with exaggerated expectation of preferential treatment. Disturbances show up in the areas of relational behavior, emotionality and impulse control, perception of reality, and lastly, self-perception and self-presentation. Resulting tensions and conflicts will also show up in the therapeutic relationship. This is experienced by many practitioners as exhausting, challenging, or difficult because of the excessive need for recognition in their dysfunctional patterns, which also causes them to address appropriate invitations and tests to the therapists.
Important therapeutic attitude
The therapist sees himself or herself in the metaphor of an invitee, as a guest whom the client has asked to participate in his or her life for a limited time and to help shape it at some points. This image allows for loving compassion, respect and appreciation towards the host. On this ground, humor or a paradoxical intervention would also be possible.
Building relational credit – recognizing communicative interactional rules of operation via structural coupling.
In essence, it is a matter of setting up an intervention that is external to the system in such a way that it infiltrates the system’s internal operational network and brings about changes within its mode of operation, even though the system would resist a change coming from the outside.5 Structural coupling describes the reciprocal influence by which two living systems that encounter each other repeatedly stimulate each other to make structural changes. The challenge is to first enter into the logic of the client system before scattering initial doubts or expressing small irritations in order to build up a certain relationship credit. It is essential to recognize the respective rules of operation, which in the narcissistic pattern are called, for example, recognition and attention. It turns out to be useful to generate very many doctrines within the operational logic, to work with very many compliments and to create trust through increased mirroring. For example: “What they are telling me is really a very special story and it is very important for me to understand how they meant it. Please correct me immediately if you feel I am on the wrong track!”. This requires one thing above all: patience. At the beginning of therapy, all possibilities should be used to satisfy the client’s respective central need; in the case of narcissistic personality disorder, this can often mean a lot of attention.
Humor and gentle irony to manage ambivalence
The second phase is about exploring dysfunctional patterns and acting in the tension between “fulfilling desires and revealing deficits.” A well-dosed portion of humor makes delicate messages easier to digest, a benevolent wink can also be supportive, and a certain intentionally naïve attitude can prove helpful, insofar as relationship credit has been built up: “That’s remarkable! How exactly do you actually manage, Ms. X, to convince your counterpart again and again that they are invisible? It’s almost a talent in its own right!”
“A good dose of humor makes delicate messages easier to digest.”
Recognizing and utilizing invitations from specific interactional patterns.
The client’s intrapsychic process, conceptualized as a specific FDV pattern, becomes the focus of therapy. However, these patterns are not overtly offered, but the suffering associated with them is described. Offered instead are symptoms of a depressive, anxious, or somatizing disorder. The interactional patterns or schemas that generate or maintain problems are so much a part of one’s identity that a problem or disorder value is not recognizable by the sufferer himself (ego syntony). In narcissistic personality disorders, comorbid disorders often include depressive episodes, burn-out, somatoform and sleep disorders, and often suicidal tendencies. Initially, therefore, the therapist-client interaction is determined by the client’s specific FDV programs, and the therapist is challenged to identify the rules as quickly as possible in order to couple optimally. Initially, rules and controlling FDV programs should not be questioned, but at the same time they should be checked for their usefulness with regard to the intended problem solution. Questioning content at this stage is also unfavorable for building relational credit and achieving the desired structural coupling, as content is only in service of FDV patterns and interaction rules. Dysfunctional FDV patterns should be carefully developed in the course of therapy until they are more functional as a solution to the original problem. For this purpose, it is necessary to find suitable interventions that interrupt the existing rules and stimulate further development, systemically speaking: A pattern disruption. Inner questionnaire: Which “invitations” give indication of the respective logic of the narcissistic personality disorder? How does it succeed to couple in the respective logic? What kind of (dis)disorders are helpful?
Examples of invitations typical of the narcissistic personality disorder
Invitation to offend Excessive entitlement behavior very quickly provokes massive mortification. Minimal triggers, such as a postponement of an appointment by one hour, can already trigger offending. Structural coupling: “I’m sorry, I must have seriously annoyed or even offended you with my request for a postponement. That was not my intention! What can I do to help you and me get back to work?” Invitation to the “extra sausage” The desire to be seen enough is often expressed through aggressive demands, which often invites denial or counteraggression. Structural coupling: “You’re probably right. The therapy framework is certainly too narrow for special needs like yours. Do you have any ideas on how our services could still be best utilized by you?” Invitation to the “good note” Attention is often earned through considerable effort, including, for example, completing therapeutic homework. Structural coupling: “Now I’m impressed! Not only did you do the homework very conscientiously, but you modified it in a way I wouldn’t have thought of, awesome!” Invitation to Permanent Crisis Intervention Extreme reactions to not receiving enough attention subjectively for the client, often show up in a massive mood collapse and even suicidal thoughts. Structural coupling: “Mr./Mrs. X, I need your support on this, because I take this very seriously and have also observed that some sessions seem not to be helpful at all. What exactly is the reason for that? Do you have any ideas? What would have to happen to make this better?” Invitation to a joint “flight of fancy” Glorification and elevation of the therapist often serve to secure relationships, which can equally often lead to quick crashes. The key here is to remain humble and grounded. Structural Coupling: “I’m glad you feel that way, of course. At the same time, it arouses concern that your expectations of me and the therapy are so high, because you could be disappointed all the more easily, which can never be ruled out. Suppose such a disappointment did occur – how would you and I deal with it?” Dariia / AdobeStock
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The patterns complementary disturb
General appreciation of the patient’s person and his narratives, require vigilance on the part of the therapist, pose a challenge to all practitioners and at the same time prove to be key. An access to the inner world of the client and his individual FDV patterns is created, which through appreciation simultaneously reduces the intensity and frequency of the manifold invitations described above. If then the basic need for recognition and attention is sufficiently satisfied, three possibilities of intervention are available, which can possibly even be used in one step:  positive connotation: “Sometimes you have no choice but to go for the jugular.”,  sample prescription: “… if you feel left out again, then just let the colleague feel that clearly again, seems to be no other way”,  Alternatives: “If you imagine this going on for the next three months, wouldn’t it perhaps make sense to try a different strategy as well, what might that be?”
This basic framework from systemic understanding of therapy results in another valuable contribution for the challenging, but also exciting and creative accompaniment of people with narcissistic personality disorder. According to a study by A. Vater, the remission rate of narcissistic personality disorder is about 50 percent in two years. Reason for legitimate hope to accompany people more toward healthy self-worth and self-confidence, as a guest, as an invitee.
“Without sympathy, there is no cure.” Sandor Ferenczi Enfant terrible of psychoanalysis, 1873-1933
1 Collaborative Longitudinal Personality Study, Grunderson et. al, 2012. 2 P. Fiedler, University of Heidelberg, 2019 3 Herpertz, S. C. (2018). New ways of classifying personality disorders in ICD-11. advances in neurology/psychiatry, 86, 150-155. Stuttgart: Georg Thieme Verlag KG. 4 Sachse, R. (2010). Understanding personality disorders. Cologne: Psychiatrieverlag. 5 Wilke, H. (1999): Systems theory II: Intervention theory. Introduction to the theory of intervention in complex social systems. Stuttgart: Fischer/UTB, p. 122.
- Fiedler, P. (2012). Personality disorders. Weinheim Basel: Beltz Verlag.
- Herpertz, S. C. (2018). New ways of classifying personality disorders in ICD-11. advances in neurology/psychiatry, 86, 150-155. Stuttgart: Georg Thieme Verlag KG.
- Lammers, C.-H., Vater, A., Roepke, S. (2013). Narcissistic personality disorder. Der Nervenarzt, 84, 879- 888. Berlin Heidelberg: Springer Verlag.
- Sachse, R. (2014). Clarification-oriented behavioral therapy of narcissism. Psychotherapy, vol 19-1, 43-50. CIP Media: Munich.
- Sachse, R. (2006). Narcissistic personality disorders. Psychotherapy, vol 11, issue 2, 241-246. CIP Media: Munich.
- Sachse, R. (2010). Understanding personality disorders. Cologne: Psychiatrieverlag.
- Sonnenmoser, M. (2014). Narcissistic personality disorder. Disorder with many facets. Deutsches Ärzteblatt, issue 12, 567-568.
- Vater, A., Ritter, K., Strunz, S. et al (2013): Stability of narcissistic personality disorder: tracking categorical and dismensional rating systems across 2 years. Personality Disorders: Theory, Research, and Treatment. Berlin Heidelberg: Springer Verlag.
- Wagner, E., Henz, K., Kilian, H. (2016): Personality disorders. Treating disorders systemically. Vol. 6, Heidelberg: Carl-Auer Verlag.
- Wagner, E., Russinger, U. (2019): Emotion-based systemic therapy. Understanding and treating intrapsychic processes. Stuttgart: Klett-Cotta Verlag.
- Wilke, H. (1999): Systems theory II: Intervention theory. Introduction to the theory of intervention in complex social systems. Stuttgart: Fischer/UTB.
Narcissistic Personality Disorder
© XtravaganT / fotolia.com In this section you will find a clear summary of all important information about narcissistic personality disorder. A classification of narcissistic personality disorder in the overall concept of narcissism as well as further information on characteristics, causes, manifestations, severity and treatment options of narcissism as well as the origin of the term can be found in the article Narcissism. Colloquially, a “narcissist” is a person who displays pronounced egoism, arrogance and selfishness and behaves ruthlessly towards others. Narcissistic personality disorder, on the other hand, is a profound personality disorder in which there is a lack of self-esteem and a strong sensitivity to criticism. These characteristics alternate with a conspicuous self-admiration and exaggerated vanity and an exaggerated outward self-confidence. The latter serves the affected persons to compensate for their low self-esteem. In addition, they have difficulty empathizing with other people. Sufferers tend to present themselves as great to the outside world. For example, they emphasize their professional achievements, appear very status-conscious or have a tendency to engage in exclusive activities. They often overestimate their own abilities or present them as better than they really are. In addition, they tend to lie – with the aim of gaining attention and recognition or of getting their own way. Because of their low empathy, they often behave towards others in a way they would not like to be treated: They exploit others or destroy their achievements out of envy. © Dmitry Ersler / fotolia.com Michael was convinced that he was a special person: he considered himself intelligent and good-looking, and someone who excelled professionally, had a large circle of friends and acquaintances, and always had an intense relationship with an attractive woman. Even as a child and teenager, he had believed that he was actually entitled to more than he got. He applied for a job offer as editor of a newspaper with the words: “I am extraordinarily talented. I am sure that I will do great things in this position and will soon create a new standard in this region.” In his new job, he did perform well – but not as outstandingly as he himself believed. Moreover, after a short time, he was extremely unpopular with his colleagues and employees. They thought he was arrogant, conceited and self-centered. He often bragged about grandiose plans, manipulated others, had choleric emotional outbursts and refused to take responsibility when something went wrong. If someone criticized him only slightly, he became angry and was convinced that the others were only envious of him. At first glance, Michael was charming and socially successful. However, he only used his charm to take advantage of other people. His relationships were also superficial: he often had enough of his partners after a short time, then treated them dismissively and broke up with them rather callously. He himself was not sad about the breakups – and other people meant nothing to him either, except when they were useful for his goals. (adapted from Comer, 2008)
Symptoms and prevalence of narcissistic personality disorder.
Sufferers have According to the DSM Have an exaggerated idea of how important they themselves are. They demand and expect to be constantly admired and praised by others. At the same time, they have limited ability to take other people’s perspectives. The disorder begins in adolescence or early adulthood. At least five of the following criteria must be met:
- Affected individuals have a grandiose understanding of their own importance. For example, they exaggerate their accomplishments and talents or expect to be recognized as superior by others without corresponding accomplishments.
- They are strongly taken in by fantasies of boundless success, power, brilliance, beauty or ideal love.
- They believe themselves to be “special” and unique. Therefore, they are convinced that they only need to be understood by or have contact with other “special” or highly placed people.
- They need excessive admiration.
- They display a high sense of entitlement. This means that they have an exaggerated expectation that expectations will automatically be met or that they will be treated particularly favorably.
- They behave exploitatively in interpersonal relationships, meaning they take advantage of others to achieve their own goals.
- They show a lack of empathy, meaning they are unwilling to recognize, accept, or empathize with the feelings or needs of others.
- They are often envious of others or believe others are envious of them.
- They exhibit arrogant, haughty behaviors or views.
In contrast to the DSM, narcissistic personality disorder is in the ICD-10 only listed under “other specific personality disorders,” but is not described in detail there. Read more about the three types of narcissism here.
How common is narcissistic personality disorder? What other disorders often occur at the same time?
Probably less than one percent of the population is affected by the disorder. Of these, 75 percent are men and 25 percent are women. The disorder is often seen together with borderline personality disorder. You can find more information about concomitant disorders here.
Causes of narcissistic personality disorder
© photoschmidt / fotolia.com This disorder is also thought to be caused by an interaction of biological, psychological, and environmental factors. Genetic factors are thought to play a role in its development. In addition, the disorder can be promoted by the fact that the parents show their child little recognition, are not very empathetic and possibly also overtax the child. In order to nevertheless receive recognition, those affected then develop behavior in which they constantly emphasize their own abilities and present themselves as particularly good to the outside world. Psychoanalytical theory assumes that people with narcissistic personality disorder received too little love and recognition from their parents in childhood. However, it could also be that the parents focused on their child and his or her desires and admired him or her excessively for his or her talents. Sufferers constantly vacillate between an overly positive self-image and a fear of not meeting the standards of others. They are convinced that they will only be loved if they do a lot for it and constantly show their talents and specialties, and they need constant confirmation from others. The constant feelings of envy and the lack of empathy can be explained, from the point of view of psychoanalysis, by the fact that the sufferers have an unconscious anger towards others. Their tendency to exploit and manipulate others also results in their inability to develop satisfying interpersonal relationships. Cognitive behavioral therapy assumes that sufferers were treated too positively in their early years – for example, they were idolized, admired, or idealized by their parents. As a result, they develop the self-image of being special and overestimate their own abilities. Narcissism Test
Treatment of narcissistic personality disorder
Narcissistic personality disorder is primarily treated with psychotherapy. However, sufferers rarely come to therapy on their own. Reasons for therapy are usually other mental disorders, especially depression.
Possible problems in psychotherapy and possible solutions
© mpix-foto / fotolia.com Because sufferers see themselves as something special and are reluctant to question this image, the disorder is considered relatively difficult to treat. In therapy, it is therefore helpful to understand this view as a kind of self-protection, which gives patients at least superficial self-esteem and protects them from psychological crises. Another problem in therapy is often that those affected believe they are entitled to very special treatment. In addition, they tend to admire and idealize the therapist on the one hand, but then react again with feelings of envy or devaluation. It is also characteristic that they try to manipulate the therapist into behaving in a certain way. It is therefore important to recognize the central personal needs of the patient and to respond to them – but also to establish clear rules and set limits.
Psychoanalytic and depth psychology-based therapy
Within psychoanalytic therapy, different approaches have been developed to treat narcissistic personality disorder. Transfer-focused psychotherapy according to Otto Kernberg and John Clarkin assumes that therapy should work with interpretations and that patients should be confronted with the fact that their overestimation of themselves is a defense mechanism against anger, aggression, and feelings of envy. In practice, however, it has been shown that this approach often leads to premature termination of therapy. Other psychoanalysts, such as Heinz Kohut, also consider a confrontational approach to be of little use because it only leads to defensive reactions on the part of the patient. Instead, Kohut and his followers see a supportive, empathetic, and caring approach as clearly more appropriate. They emphasize that the therapist should treat the sufferer respectfully and empathetically even when they are either extremely idealizing or devaluing him. In this way, the patient can experience being accepted and valued as a person and gradually develop a more positive self-image in which he or she is not constantly dependent on the admiration of others.
Cognitive behavioral therapy
Here, too, the establishment of a sustainable, appreciative therapeutic relationship is an essential element of therapy. The patient’s idiosyncrasies are not to be evaluated morally. Instead, very concrete experiences and problems are addressed. Characteristic difficulties of the patient in relationships can be worked out from them and gradually changed. In addition, an attempt is made to change unfavorable thought patterns – for example, the idea of having to be good all the time in order to be accepted and valued by others. Patients can learn to stop basing their self-esteem so much on other people’s opinions and to deal better with criticism. Patients’ black-and-white thinking (i.e., the tendency to view themselves or others as grandiose at times, but then again as worthless) is questioned and gradually replaced by a more graded view. In order for those affected to develop more empathy, role-playing with video feedback can be used. Here they can experience how their own behavior affects others and then change it accordingly. Read more about the treatment of narcissism here.
Therapy with psychotropic drugs
As a rule, psychotropic drugs are not considered helpful in narcissistic personality disorder. They are mainly used when other mental disorders are present at the same time, for example, depression.
The narcissistic personality style according to Kuhl & Kazén
People with a narcissistic personality style – which is similar to a narcissistic personality disorder, but less pronounced – attach importance to the special. For example, they are particularly achievement-oriented, prefer fancy clothes, and display a status-conscious demeanor. They are often ambitious and have a high attitude of entitlement. However, this can also lead to them being quickly offended or envious of others. Read more about the manifestations of narcissistic personality traits here. Therapy For Narcissistic Personality Disorder.
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