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Narcissistic Personality Disorder: Re-Imagining Treatment

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Background:

I have been a consumer of mental health services for a litany of diagnoses, including but not limited to NPD (Narcissistic Personality Disorder). With this said, we will explore existing definitions of NPD and offer additional insight into other possible treatment pathways for people seeking support and resources to battle this disorder. 

 

NPD is complex and bound up in the medicalization of personality issues into pathology through the use of the DSM-5 Diagnostic Manual for Mental Disorders. I am suggesting there may be different available options and treatment pathways for targeting the symptoms which consumers need relief from to be successful in their lives. The stage for new conversations around personality disorders, their treatment, and diagnosis is upon us for folks who have been historically limited by their psychiatric label.

DSM-5 Definition and Criteria:

The DSM-5 offers a diatribe cataloging the specific symptoms of NPD. According to the manual, is indicated by five or more of the following symptoms:

• Exaggerates own importance

• Is preoccupied with fantasies of success, power, beauty, intelligence or ideal romance

• Believes he or she is unique and can only be understood by other special people or institutions

• Requires constant attention and admiration from others

• Has unreasonable expectations of favorable treatment

• Takes advantage of others to reach his or her own goals

• Disregards the feelings of others, lacks empathy

• Is often envious of others or believes other people are jealous of him or her

• Shows arrogant behaviors and attitudes

Treatment Approaches in Psychotherapy

Research suggests diagnosing symptoms like “grandiosity and defensiveness” during the onset of treatment is not the right way to drive therapy forward for NPD people. People typically carrying this diagnosis create complications for clinicians providing psychotherapy when such symptoms are targeted first during treatment. I am now suggesting a new approach that realizes these so-called symptoms for NPD and understands them as strengths for therapists to capitalize on rather than fires, which must be extinguished at all costs.

 

Firstly, people don’t come in through the therapy office door, by in large, requesting treatment for their NPD. NPD can contribute to other diagnoses and psychosocial & psychological problems for patients to manage on their own without treatment. For example, typically NPD patients present with depression or related anxiety because of various symptoms and unmet needs which drive these patients into treatment.

 

Based on this assumption, I would hazard to say that psychotherapy’s primary focus should not be on treating the NPD symptom but, instead, on its manifestation into other psychiatric and psychological problems. These may include, e.g., Depression, Anxiety, and other affective state regulators, which become corrupted when the NPD symptom becomes active.

Thus, instead of re-inventing the wheel in psychotherapy, practitioners can focus on treating the real problem with the same sophistication as any other disorder that fits the treatment approach. This can be done in group therapy, which has proven to help clients gain the reflective lens necessary to cultivate personal insight into their interpersonal landscapes.

Except for “lacking empathy,” most if not all of the so-called NPD indicators can be mobilized into strengths for consumers in NPD treatment. I will use the example of grandiosity and requiring excessive admiration from others to illustrate how this “deficit” can be flipped into strength and even an asset to the person carrying this label.

Let’s come back to my concept of Too Big to Fail. In short, this means it is in the interest of people carrying a diagnosis to mobilize all of their resources and support to meet their day-to-day challenges to reduce the likelihood of their opportunities turning up short of their expectations and hopes.

Simply put, there is never a reason not to be fully prepared in the day’s endeavors and be ready for anything. In a world where the unlikely is possible, and there is no definite, I can fully understand why people carrying this diagnosis are labeled as grandiose and self-centered. Instead, being mindful and articulate about one’s own needs as a consumer and being adamant about what it will take for a person to succeed in life ia really about surviving in the world. 

Finally, it is not the therapist’s role to teach empathy unless that is the stuck point in the work, which keeps someone from realizing their missed opportunity for insight. However, empathy can be re-framed and posited as skill or technique for people to learn in psychotherapy to barter for their own goals without walking over the needs of others in his or her life.

Through bartering, people will be less inclined to feel envious because they participate in a system that leaves room for greater exchange of ideas and currency for people carrying this diagnosis. Instead of placing limitations and teaching restraint, people with this diagnosis are taught to reach for the upper limits of their success.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

About the Author

J. Peters

Max Guttman '08, MSW '12, is the owner of Recovery Now, a private mental health practice. Through his work as a Licensed Clinical Social Worker, therapist and disability rights advocate, Max fights for those without a voice in various New York City care systems. He received a 2020 Bearcats of the Last Decade 10 Under 10 award from the Binghamton University Alumni Association.

Guttman treats clients with anxiety and depression, but specializes in issues related to psychosis or schizoaffective spectrum disorders. He frequently writes on his lived experiences with schizophrenia.

"I knew my illness was so complex that I’d need a professional understanding of its treatment to gain any real momentum in recovery," Guttman says. "After undergraduate school and the onset of my illness, I evaluated different graduate programs that could serve as a career and mechanism to guide and direct my self-care. After experiencing the helping hand of my social worker and therapist right after my 'break,' I chose social work education because of its robust skill set and foundation of knowledge I needed to heal and help others."

"In a world of increasing tragedy, we should help people learn from our lived experiences. My experience brings humility, authenticity and candidness to my practice. People genuinely appreciate candidness when it comes to their health and recovery. Humility provides space for mistakes and appraisal of progress. I thank my lived experience for contributing to a more egalitarian therapeutic experience for my clients."

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