Strategic Issues in the Psychotherapy of Patients with Narcissistic Pathology

Narcissistic personality disorder is a relatively uncommon diagnosis in clinical settings; however, these patients are frequently in need of and referred for long-term psychotherapy. Such patients may not seek therapy willingly but do so at a time when they experience sufficient vulnerability to accept therapy. Given these and other characteristics, the narcissistic patient can be challenging for therapists. This paper suggests some strategic approaches that may be employed with patients with narcissistic pathology. Partly, these approaches incorporate more contemporary understandings of narcissistic pathology such as appreciating that these patients can present both the grandiose and vulnerable elements of narcissistic pathology and that a gender focus using theories of masculinity may enlighten our approach to these patients. Specifically the strategies reviewed are: starting therapy by assessing for the patient’s vulnerable characteristics and offering some gratification for their need for acknowledgement; monitoring and managing the risk of suicide and comorbid disorder in patients with narcissistic pathology and in the working through phase of therapy, recognizing the need for patients to developed increased self-cohesion and the importance of supervision/consultation in the working through process of therapy.