Narcissistic personality disorder (NPD), or narcissism, as it’s often called, is one of the cluster B personality disorders, or emotional/impulsive personality disorders.
Narcissism is one of the least studied personality disorders. Different subtypes of narcissism present with varying features, making diagnosis challenging. People with narcissism may also see no need for counseling and consider it pointless or beneath them. If they do begin therapy, they may react angrily when faced with challenges, try to manipulate their therapist, or find it hard to consider things from other perspectives. They often leave therapy early, especially if they don’t see any benefit in it.
Recent research aims to identify new therapy approaches that can help people living with personality disorders achieve lasting change. Schema therapy, one such treatment, is considered helpful for people who don’t respond well to other types of therapy. It’s proven effective in treating borderline personality, another condition long considered difficult to treat.
Research looking at schema therapy for narcissism is still in the early stages, but existing clinical data suggests it has promise.
People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others.
The Roots of Narcissism
Personality disorders are characterized by rigid, long-lasting patterns of behavior that affect life and relationships, causing distress and making it difficult to function. People living with personality disorders may not always recognize that some of their behaviors cause problems or affect others negatively.
Like other personality disorders, narcissism is a serious mental health issue. Many consider it more serious and harmful than most other personality disorders, since people with narcissism generally lack empathy and may not care about the effects of their actions.
The causes of narcissism aren’t fully understood. Some potential factors in development may include:
- Having a parent who is extremely adoring or overly critical, or a parent who switches between these modes
- Having a parent with narcissism
- Inheriting certain traits that increase risk for personality disorders
- Experiencing trauma, abuse, neglect, or indifferent parenting
People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others. Since connecting with people on an intimate level requires a level of vulnerability, people with narcissism may avoid meaningful relationships in order to protect their illusion of grandiosity and keep an unstable self-identity from being revealed.
Researchers have identified four main subtypes of NPD. It’s possible to have features of multiple subtypes or shift between subtypes at different points in life.
- Overt narcissism most often involves entitled, attention-seeking behavior. A primary feature is an exaggerated sense of self-importance. People with this subtype tend to be charming and arrogant and often exploit others. They may do fairly well in the workplace but struggle to get along with others or do tasks they consider demeaning or otherwise beneath them.
- Covert narcissism may include anxiety, significant emotional distress, and extreme sensitivity to criticism or perceived insults. This subtype is often characterized by shyness, even social isolation. People with covert narcissism tend to have an internal sense of superiority and fantasize about their talents being recognized while speaking modestly about themselves, even putting themselves down.
- High-functioning narcissism involves similar traits to overt narcissism, but people with this subtype can generally function well in society and may not appear to have a personality disorder. They are often able to adapt narcissistic traits such as charm and competitiveness in order to achieve success and may have relationships that are shallow but lasting. Criticism, perceived failure, or age-related challenges such as poor health or perceived loss of attractiveness may cause distress or crisis.
- Malignant narcissism, considered the most severe subtype, involves overt narcissism traits along with traits of antisocial personality and paranoia. People with this subtype may lie and manipulate others easily, behave in aggressive ways, enjoy intimidating others, and avoid any work or task unless it benefits them in some way. They often have no desire to change, so treatment may be very difficult.
Narcissism often involves symptoms that are less known than grandiosity and lack of empathy, including:
Most people with narcissism struggle to maintain employment and personal relationships, changing partners readily when they don’t receive the admiration they need. It’s also common for people to fantasize about being recognized for their superiority and humiliating people who have “wronged” them.
When therapy can help address these concerns, particularly vulnerability and self-esteem, narcissistic behaviors may improve.
Schema Therapy: An Effective Treatment for Narcissistic Personality?
Even when people with narcissism do seek therapy, whether for distress related to narcissism or other mental health symptoms, treatment can be complicated. Believing a therapist has insulted them, failed to recognize their specialness, or isn’t skilled or reputable enough to treat them leads many people with narcissism to quit therapy early in treatment. Research suggests therapy progresses more slowly for people with narcissism, leading to slower improvement of symptoms.
Schema therapy, however, may have increased potential to treat NPD. Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life. For narcissism, this is often the persistent, private sense of inferiority and fear of failure.
Schema therapy combines elements of cognitive behavioral therapy, emotion-focused therapy, Gestalt therapy, and psychodynamic therapy, among others. The idea behind this approach is that schemas, or patterns of thought and behavior, develop as a result of unmet emotional needs and other early childhood experiences. These schemas are reinforced throughout life by challenges, abuse, trauma, and other negative or harmful experiences. Unless they’re addressed in positive ways, they contribute to the development of harmful or unhealthy methods of coping. These coping styles can affect behavior throughout life, often in ways that cause distress.
Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life.
The goal of the approach is to help people identify needs that weren’t met in childhood and learn how to get them met in healthy ways that don’t cause harm, either to themselves or to others. To help clients achieve this goal, schema therapists group schemas and coping responses into modes and use a range of strategies to address them, including roleplay, interpersonal techniques, and cognitive behavioral approaches. Therapists may set limits, as a parent would, within the bounds of the therapeutic relationship to help clients confront schemas.
The schema modes commonly associated with narcissism are:
- Detached Protector/Self-Soother: This avoidant mode involves behaviors that are soothing, stimulating, or distracting—anything that helps turn off emotions. These behaviors might include substance abuse, risky sex, gambling, fantasizing, or overwork. It’s also common to shut out or reject people as well as emotions. Typical function isn’t always affected, but it may seem almost mechanical and lack any personal investment.
- Self-Aggrandizer: A mode in the overcompensation category, this involves many behaviors typically associated with narcissism—superiority, entitlement, and manipulative tactics. People in this mode tend to show little interest in anyone but themselves, boast of real or inflated achievements, and openly seek admiration to avoid revealing hidden vulnerabilities and insecurities.
By confronting these modes and working through them with the help of the schema therapist, people in therapy can begin to access the Healthy Adult mode, which helps heal the vulnerabilities of early childhood and fosters healthier modes of coping. After reaching this mode, people may be able to begin functioning at a more typical level and be more able to take responsibility for their actions and see how they affect others.
Schema therapy has been successful in the treatment of other personality disorders, including borderline personality. Clinical trials on its use with narcissism are still forthcoming, but research and clinical observations suggest schema therapy could help people with narcissism have more success in treatment.
Why Do Narcissists Seek Therapy?
People living with NPD often believe themselves superior and struggle to consider the feelings and needs of others. This can make their actions particularly hurtful. Narcissism also often involves intentional manipulation or emotional abuse—behaviors that cause significant pain to partners of people with narcissism. In fact, many therapists specialize in helping the partners of people with narcissism heal.
The typical traits linked to narcissism, along with the tendency of many with NPD to see nothing wrong with their behavior, have contributed to the belief that therapy can’t treat narcissism. But therapy can help people with narcissism improve—if they want to change.
Andrea Schneider, LCSW, a therapist in San Dimas, California, explains what might prompt a person with NPD to seek counseling. “Typically,” she says, “Someone … with narcissistic personality may have some flexibility with some behavioral change when they are confronted with significant stressors (like a relationship ending or other crisis).”
People with NPD may not ever seek therapy for symptoms associated with narcissism. Instead, they might decide to get help for other symptoms or issues. These could be co-occurring conditions or long-term mental health effects associated with narcissism. In many cases, it’s these challenges that contribute to the desire for change.
People with narcissism may seek help for:
- Substance abuse or addiction
- Somatic symptoms
- Health issues
- Anorexia nervosa
- Depression or anxiety (may relate to the failure of others to see them as important or superior)
- Workplace or school challenges
- Relationship or parenting challenges (often seeking therapy at the urging of a partner)
Narcissistic personality and associated conditions can significantly impact quality of life and emotional well-being. Addiction and stress can cause health concerns, for example, while the inability to sustain a relationship could lead to complete isolation.
To date, few studies have looked at treatment for narcissism because people with NPD don’t seek therapy often. If they do, they may only do so because someone else has urged them into it. Therapy can still have benefit, but the person with narcissism must recognize the problems with their behavior and make efforts toward change.
Finding a Schema Therapist
People who don’t see a need to address their behavior are unlikely to be able to make lasting change. But research on schema therapy suggests the approach could benefit people living with narcissism when other types of therapy don’t help. Experts do agree that narcissism often poses treatment challenges for therapists and can make progress in therapy difficult.
Schema therapy involves validation and empathy for a person’s difficulties and distress. When people with narcissism approach therapy with a willingness to change, or at least to make an effort to address harmful behaviors, the mode work involved in schema therapy may help them learn to confront the vulnerabilities they fear in a healthier way.
It can be difficult to find a schema therapist, especially if you live in a smaller city. But many therapists may be trained to incorporate elements of schema therapy into treatment. If you or a loved one has symptoms of narcissistic personality disorder, consider reaching out to a therapist who offers schema therapy or practices mode work. Don’t be discouraged by the myths about narcissism—change is possible for anyone. Begin your search for a trained, compassionate counselor today.
Author’s Note: If you’re involved in a relationship where there is intimate partner abuse of any kind—physical, emotional, or sexual—relationship therapy is usually not recommended. We encourage you to review our crisis page and reach out for support.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
- Behary, W. T., & Dieckmann, E. (2011, July 20). Schema therapy for narcissism: The art of empathic confrontation, limit-setting, and leverage. In W. K. Campbell and J. D. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments. Hoboken, NJ: John Wiley & Sons.
- Behary, W. T., & Dieckmann, E. (2013). Schema therapy for pathological narcissism: The art of adaptive reparenting. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 285-300). Washington, DC, US: American Psychological Association.
- Caligor, E., Levy, K. N., & Yeomans, F. E. (2015, April 30). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5). Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
- Dieckmann, E., & Behary, W. (2015). Schema therapy: An approach for treating narcissistic personality disorder. Fortschritte der Neurologie-Psychiatrie, 83(8), 463-477. doi: 10.1055/s-0035-1553484
- Ekselius, L. (2018). Personality disorder: A disease in disguise. Upsala Journal of Medical Sciences, 123(4), 194-204. doi: 10.1080/03009734.2018.1526235
- Mayo Clinic Staff. (2017, November 18). Narcissistic personality disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662
- Ritzl, A., Csukly, G., Balázs, K., & Égerházi, A. (2018, September 13). Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders. Psychiatry Research, 270, 154-159. doi: 10.1016/j.psychres.2018.09.017
- Young, J., & First, M. (2003). Schema mode listing. Retrieved from http://www.schematherapy.com/id72.htm
- Young, J., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York City, NY: Guildford Press. Retrieved from https://www.guilford.com/excerpts/young.pdf?t
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