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SHOULD WE CALL THEM HUMAN?
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Treatment Options
Aims of Treatment should focus on aiding the narcissist
to increase his empathy for others, helping him learn to
accept slights and rejections from others without
feeling threatened, and developing a more realistic view
of his abilities.
Personality disorders are a challenge to treat. This is
because an individual is defined by his personality and
personality is an essential part of a person's
self-perception. A narcissist does not willingly seek
treatment because he does not wish anyone to think that
he has any weaknesses. He experiences needing help as
demeaning. When a narcissistic individual does present
for treatment it is usually at the insistence of a
family member, upon the occurrence of a major life
crisis, or issues other than personality problems.
Since a narcissist does not tolerate discomfort well, he
has difficulty coping with depression or anxiety (two of
the issues which might precipitate his presenting for
therapy of his own accord). If you want the narcissist
to seek treatment then make sure he is lacking in
narcissistic supply. He could go into a depression and
then perhaps seek treatment.
Narcissists will present with a wide range of pathology.
No matter the pathology the narcissist possesses,
however, he does not see his difficulty interacting with
others as part of his problem. He projects his
relational problems onto others and describes others as
having trouble interacting with him.
Treating the narcissist is difficult because the
narcissist attempts to sustain an image of perfection
and indestructibility. Underneath this facade is an
insecure person with low self-esteem. By presenting with
this seemly secure self-image, the narcissist is
protecting himself from his worse fear--that people will
find out that he has imperfections and weaknesses just
like everyone else. Coping skills to improve
interpersonal relationships and to aid the narcissist to
focus on his actual abilities (not those that he
fantasizes he has) are usually dealt with in
psychotherapy.
Pharmacological Intervention
No specific pharmacological intervention for NPD has
been found. Underlying symptoms of Axis I diagnoses are
usually treated with antidepressants or other drugs.
Individual Therapy
Long-term psychodynamic therapy has been found to be the
most effective in working with this disorder. The
therapist must create an accepting environment, thus
allowing the patient to develop an idealizing
transference toward the therapist. An active
confrontation of the patient's anger, envy of others,
specific need to be self-sufficient, and exploitation of
other difficulties can inflict a narcissistic injury. If
this occurs then the patient will in all likelihood
terminate therapy.
Usually most therapists treat the co-existing mental
disorders and not NPD itself except in cases of crisis.
A therapist should be aware that he/she must help
sustain the narcissist's self-image and help the patient
use their narcissistic characteristics to develop a
self-image which is not based on fear.
In order for therapy to be successful, a strong alliance
must exist between the therapist and the patient. This
can only be accomplished in long-term therapy. A general
non-defensive and non-competitive atmosphere must be
created in the therapy room. When working with NPD a
therapist will have to deal with the unreasonable
demands of the patient, their expectations, and their
criticisms. NPD patients do not accept their own defects
and aiding the patient in learning how to acknowledge
these defects is an important part of the therapeutic
intervention. However, the NPD patient will run from any
situation where his self-esteem is diminished.
Therefore, any confrontation by the therapist must be
clear, direct, repetitive, and firm to break through the
defense mechanisms used by the NPD patient.
During therapy the patient will scrutinize not only the
verbalizations, but also the non-verbal behaviors of the
therapist searching for ways that the therapist is
responding negatively to his self-aggrandizement or
arrogance. He will take any such signals as rejection.
Even during extended therapy only small changes should
be expected in the patient's personality. The therapist
should also be aware that it is impossible as therapy
progresses not to disappoint these patients.
Group Therapy
Group therapy is rarely the primary tool for NPD. In
group therapy narcissists tend to dominate the group or
tire the other members. It can be valuable as an
addition to individual therapy. Patients are encouraged
to explore their behavior toward others and to
experience empathy with other group members.
Narcissists, however, tend to see groups as competitive
and feel that they are not receiving enough of the group
leader's attention. This makes them think that their own
need for empathy is not being met. Narcissists also do
not tend to respond well to critical feedback which
might come from other group members. They tend to drop
out of group of the first sign of criticism.
Hospitalization
Patients with severe NPD are frequently hospitalized.
Some are very impulsive and self-destructive and have
poor reality testing. This comes about because of co
morbid diagnosis on Axis I. Hospitalization should be
brief and specific to the treatment of the presenting
symptoms.
Prognosis
Treatment of the narcissist does not usually have
positive results except for reducing the side effects of
depression and anxiety which are treated with
medication. The narcissist does not usually stay in
treatment long enough for therapy to be beneficial.
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