Psychotherapy

Individual psychotherapy is the treatment of choice for narcissistic patients. Various approaches can be used.

In Kohut's self-psychology approach transference is used as both a diagnostic and a therapeutic tool. Idealizing transference is supported and left uninterpreted until optimal disillusionment gradually develops through the therapist's unintended but inevitable empathic failures. At this point the patient may integrate his or her own and the therapist's realistic limitations.

Modell's approach(94) focuses on a therapeutic relationship within an ego-psychology object relations model. At first, the narcissistic idealization and the patient's incapacity to absorb interpretations are respected in a 'holding' function. Later, the grandiose self is gradually interpreted, and the treatment largely corresponds to that of Kernberg.

Kernberg(4 ,62) suggests that the approach should vary according to the degree of disturbance. Psychoanalysis is suggested for some well-functioning narcissistic patients, and expressive psychotherapy is indicated for narcissistic pathology with overt borderline features. A systematic analysis is made of both the grandiose self, which presents itself pervasively in the transference, and the patient's use of primitive defences, especially devaluation and idealization. Supportive therapy is indicated for malignant narcissism. Sometimes it may be needed as a preparatory period for expressive psychotherapy. Group therapy may be combined with individual therapy, during which peer confrontation of grandiosity and a shared 'special relationship' with the therapist might be useful. Hospital admission is required only in severe depressive decompensations.

The treatment of narcissistic individuals inevitably arouses serious countertransference problems, because of the emotional detachment, demanding behaviour, and devaluative actions of narcissistic patients. The therapist should have worked through his or her own narcissism and retain an empathic and non-judgemental attitude.

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