Therapy for Narcissism: 7 Types & What to Expect

Can a Narcissist Change?

Although it is difficult and rare for a narcissist to change, it is possible. For narcissists to change, they must be willing and ready to admit that they may be experiencing a personality disorder, take responsibility for their actions, and put in the continuous effort needed to alter their behaviors. It’s also important for a narcissist to work through any trauma that may have impacted their development, acknowledge any narcissistic genetic history, and recognize, but not blame, any problematic parenting they might have grown up with.

Narcissistic personality disorder (NPD) is considered a chronic mental health disorder that presents itself through highly selfish behaviors, such as an inflated ego, a preoccupation with power and prestige, engaging in manipulation and exploitation for their own gain, lacking empathy, demanding excessive attention and reassurance, and acting generally arrogant in most relationships within their lives.¹ Having a chronic mental health personality disorder generally means that these symptoms will be present for the entirety of a person’s life and will remain constant, despite the environment and relationship it is impacting.

Why Do Narcissists Go to Therapy?

If a person with NPD seeks mental health treatment, it is more often for secondary stressors – such as work stress or strained relationships. Because NPD is such a pervasive issue, they will usually avoid or struggle to address the underlying cause of their secondary stressors because the nature of this disorder convinces them there cannot be major flaws within themselves.

A person with NPD may seek therapy because of:

• Substance misuse or abuse
• Depression
• Anxiety
• Problems at work
• Relationship problems
• Trauma symptoms
• Feeling a lack of connection (as a way to fill their narcissistic supply)²

7 Therapy Options for Narcissism

There are many options and different ways to approach healing for NPD. Narcissism creates secondary issues that can also be beneficial to address in therapy. However, treating the underlying issue of narcissism will aim to heal any underlying trauma and address the coping mechanisms that the narcissist used to adapt to trauma and dysfunction. People with NPD typically have a long haul with their treatment and can expect therapy to take years – or longer – to heal and disrupt maladaptive patterns.

Goals of therapy for narcissism may include:

• Identifying behaviors and traits that negatively impact a person’s life
• Exploring traumas that may have influenced one’s behaviors
• Establish emotional and interpersonal safety
• Focus on interpersonal skill development
• Identify and manage coping mechanisms
• Manage self-talk
• Learning empathy skills
• Work to show up authentically

Seven therapy options for narcissism include:

1. Cognitive Behavioral Therapy (CBT)

Therapy that focuses primarily on changing thoughts and behaviors in order to improve their overall functioning is typically some form of CBT. This method specifically works to help people identify how their thoughts and feelings impact their behaviors and to give them control over choosing a new external behavior when difficult thoughts and emotions come up.³

For narcissistic personality disorder, CBT can be helpful to disrupt behaviors that cause strain within their relationships. CBT can also help narcissists challenge distorted and inner beliefs about themselves that can trigger emotional outbursts and narcissistic rage.

CBT techniques include:

• Cognitive restructuring: Cognitive restructuring includes examining and challenging thought patterns and replacing them with healthier and more helpful thought patterns.
• Journaling: Journaling helps patients notice and keep track of thought patterns and viewpoints/beliefs, as well as an exercise to reinforce new beneficial thought patterns.
• Situational exposure: Situational exposure can help a person face their fears and to reduce the avoidance that worsens fears over time.
• Relaxation/stress management exercises: Stress management techniques are used in tandem with exposure and journaling in order to help a person feel in control of managing their emotional state during distressing feelings and thoughts.

2. Gestalt Therapy

Gestalt therapy focuses on changing how a person relates to things and other people by using the therapeutic relationship, non-judgemental perspective sharing, collecting and understanding the context for one’s beliefs, and experimenting with new ways of being.

Since NPD is often partially developed to compensate for unsafe and unhealthy relationships in early life, directly challenging the belief that all relationships are and always will be like this can be majorly disruptive for narcissists in a healthy way. This can also help a narcissist connect to their current autonomy to keep themselves safe in relationships and emotions as adults since narcissistic maladaptive patterns are often developed in childhood when there is little autonomy and control.

Gestalt techniques that may be used include:

• Role-playing: Often taking the form of the “empty chair” exercise, role-playing by talking to a different version of yourself or another person can help a person to practice new ways to relate to others, to validate their own experience, and to draw attention to one’s own feelings and beliefs.
• Identifying verbal and body language: Taking note of changes and usage of different phrases and body language is a focal point of Gestalt therapy in which a person begins to take responsibility for themselves rather than focusing and blaming others.
• Exaggeration: Exaggeration gives a “voice” to any emotion or body language that a person is struggling to feel or to engage with in order to externalize what the person is feeling so it can feel easier to manage.
• Creative art creation: Creating drawings, sculptures, and paintings is often done in Gestalt therapy in order to help identify and externally process emotions in the current moment that may have previously been unconscious.

3. Schema Therapy

Schema therapy combines aspects from cognitive-behavioral therapy approaches, Gestalt, and object and attachment relations theories. The schema therapy approach believes that people develop “schemas” that help them make sense of their lives and experiences, and people use these categories to determine the most likely outcomes in any given situation to save time and energy.

Since narcissism is generally considered an adaptive mental health disorder in response to genetics and childhood trauma, it can be helpful to re-examine the schemas a narcissist may develop to cope with abnormal situations in their childhood. Replacing unhelpful schemas can be a huge first step in changing how narcissists approach others and the world.

Schema therapy techniques that may be used include:

• Limited reparenting: Examining the parenting received in childhood and filling any unmet gaps in adulthood can help a person to make sense of and move forward from dysfunctional and toxic parenting that influenced their NPD.
• Empathetic confrontation: The therapist nonjudgmentally confronts maladaptive thoughts and behavioral patterns to address and reduce reactivity to narcissistic injury.
• Guided imagery: Imagining various scenarios and triggers as well as a person’s response to them can help a person to feel empowered to approach situations differently in the future.
• Narrative development: By creating a “narrative” of one’s life, one can better see how they developed certain schemas as adaptive behaviors and reduce shame and resistance to behavioral change moving forward.^{4, 5}

4. Dialectical Behavioral Therapy (DBT)

Dialectical behavior therapy is focused on helping people to better tolerate emotional distress by developing new skills and strategies for their maladaptive patterns. Skills that a person might learn in DBT could include better interpersonal relating, mindfulness, emotional regulation, and distress tolerance, as well as identifying and replacing current unhelpful patterns.

Much of narcissists’ struggles in their relationships stem from an inability to handle distress without high levels of reactivity from narcissistic injury, as well as manipulative and exploitative behavior patterns to meet their needs. DBT can help people with NPD to recognize these patterns, better handle the internal distress and shame they may experience, and respond to others in less destructive ways.⁶

DBT therapy techniques that may be used include:

• Acceptance Skills: Mindfulness and distress tolerance can help clients to sit in uncomfortable feelings and to not react to them in impulsive and destructive ways, which can help improve a person’s confidence and relationships.
• Interpersonal effectiveness skills: Interpersonal effectiveness skills are directed at positively impacting a person’s ways of relating to others, which can help them feel safer and influence how they can relate to others.
• Self-soothing: Self-soothing increases a person’s distress tolerance, often by using grounding techniques, to allow a person to continue to function and cope without having a disruptive emotional outburst.
• Chain Analysis: This is an in-depth analysis of the sensations, feelings, thoughts, and actions that ultimately lead to problematic behavior. Through chain analysis, a person can better understand their behavior and identify ways to change.⁷

5. Eye Movement Desensitization & Reprocessing Therapy (EMDR)

EMDR is a therapeutic approach that treats the underlying trauma a person may have experienced by using bilateral stimulation. EMDR generally does not require the same time required by prolonged exposure therapies or the extensive development of skills required by other trauma-focused therapy treatments.

People with NPD have often experienced trauma, particularly during their childhood, so it can be difficult to untangle the development of NPD from the experience of trauma.⁸ Working through childhood trauma can help a person to heal one possible contributing factor in order to move forward with unlearning the narcissistic tendencies they may have developed to emotionally protect themselves.

EMDR therapy techniques that may be used include:

• History Taking: By outlining the whole history of past experiences and current stressors, the therapist and patient can identify specific memories to target during reprocessing.
• Bilateral Stimulation: The therapist will use a variety of exercises to engage both sides of the body/brain while exposing the patient to stressful memories, breaking associations between memories and negative symptoms.
• Installation: Through installation, the therapist reinforces the new belief now that the distress related to the targeted memory has been relieved.
• Closure and Homework: At the end of the session, the therapist reviews progress made and may assign homework (such as visualizations, journaling, and relaxation techniques) in order to keep making progress until the next session.

6. Transference-Focused Psychotherapy (TFP)

Transference-focused psychotherapy works to heal relational dynamics by directly using the relationship between the client and their therapist. This therapy specifically focuses on the client’s feelings toward the therapist (particularly their anger, aggression, envy, grandiosity, and defensiveness) and the learnings from other interactions in their life that could inform them of how to show up within this relationship.⁹

Narcissism can be difficult to treat because a core piece of NPD is a denial of accountability for their own actions, so therapy that uses the relationship between the therapist and client gives the client a direct relational dynamic to acknowledge and work within an emotionally safe way. The therapist is able to use their own reactions and feelings to reflect how a narcissist’s behaviors impact others negatively and inhibit relationships.

Transference-focused psychotherapy techniques include:

• Treatment contract: This is the framework that a therapist and client establish for treatment that includes goals and required activities to build trust with the therapist and as a tool for accountability.
• Boundary work: TFP works on directly challenging a person’s most uncomfortable and destructive behaviors, so it is common for a therapist to discuss boundaries early and often throughout therapy.
• Reality testing: This is the direct confrontation and challenge of a person’s ideas and beliefs with the reality of the situation.
• Behavioral activation: Encouraging and planning for behaviors that bring a sense of accomplishment and reward in order to replace maladaptive coping behaviors.¹⁰

7. Mentalization-Based Therapy (MBT)

Mentalization-based therapy is based on a person’s ability to mentalize, which includes inferring another person’s mental state based on social cues, such as facial expression and tone. Being able to better mentalize the self and others is a reassurance and soothing factor within interpersonal relationships.

It is believed that mentalization is developed through experiencing secure attachment with a caregiver. Since many people who develop narcissism also experienced insecure attachment with caregivers, working to develop mentalization in therapy can help someone with NPD reparent themselves and experience safe emotional relating to their therapist in a corrective way.¹¹

Mentalization-based therapy techniques include:

• Inner state questioning: A therapist will often ask for the internal thought processes of clients in order to understand and reframe their beliefs with relating.
• Using transference: Therapists will often encourage clients to share how they feel toward the therapist at different times in order to help the client understand and challenge how they react to their beliefs and feelings.
• Doing a “dream journey”: This is the mental creation of a “safe place” after working through physical and emotional relaxation techniques in order to give the client an anchor while exploring difficult feelings and thoughts.
• Practicing alternative perspectives: Therapists will often have the client reimagine a relational interaction from their perspective and then practice trying out what the other person may have been feeling with the therapist’s guidance.¹²

Is Therapy for Narcissism Effective?

While therapy for narcissism can be effective, it generally takes a long time with a high level of engagement from the person with NPD. The factors that impact therapy’s success the greatest include the relationship with the therapist, as well as the client’s attitude related to treatment. Important attitudes related to therapy that will increase the odds of having success include determination, willingness to work on being open, patience, and persistence.

Does Medication Help With NPD?

While there are no medications specifically for treating NPD, a person may be prescribed medication if they show symptoms of other mental health conditions. For example, someone experiencing depression or anxiety may be prescribed an SSRI or an SNRI, depending on what works best for them. Managing other mental health concerns gives a person the ability to focus on the NPD that may be severely impacting the anxiety, depression or other mental health concern.

How to Find a Therapist

NPD is a complex struggle that will benefit from working with a mental health professional. Working with the right therapist is the fundamental piece to the treatment’s success, so be sure to look for someone who has experience with narcissism and pulls from one of the modalities listed in this article. If you’re ready to start, an online therapist directory can help you narrow your choices and identify the best fit for your needs.

Final Thoughts

While experiencing and realizing you may be dealing with Narcissistic Personality Disorder can be stressful, it is important to remember that there are options to help you take accountability and change your behaviors in the future. Come into your therapy sessions with an open mind and give yourself grace, your future self will thank you. There is relief within and after all the hard work.