Is Narcissism Treatable?

This psychologist has built her career on it.

Posted Oct 18, 2019

qthomasbower/Creative Commons.
Source: qthomasbower/Creative Commons.

Elinor Greenberg isn't your average Manhattan psychologist. She works with clients who have one of the most combative, challenging conditions on the human mental map—narcissistic personality disorder (NPD). Entrenched and notoriously difficult to treat, NPD is characterized by arrogant grandiosity, a lack of empathy, and an often savage defensiveness driven by underlying shame and emotional instability. 

A faculty member at the New York Institute for Gestalt Therapy and the Gestalt Center for Psychotherapy and Training with over 40 years of clinical experience, Greenberg attributes her early interest in personality disorders to her fondness for certain friends and family members with such conditions. "As a result of my positive experiences with people with personality disorders, I didn’t share the usual prejudices against them and was comfortable with them as long as they were moderately functional," she explains. "I found that I enjoyed many of these clients and was good at adapting my interventions to suit them." Professional missteps also motivated her: "I had some spectacular failures early in my career where clients left cursing me, and I wanted to understand what was going on and how to do better therapy with them."

Understanding NPD as a Survival Adaption

Preferring the term personality "adaptation" to "disorder," Greenberg sees NPD as a response to formative childhood invalidation by primary caregivers. Whether feeling eclipsed or rejected by a domineering and/or devaluing narcissistic parent, or by parents whose acceptance is conditional, children who develop NPD are unable to form a stable sense of identity and self-worth and adopt a persona in place of personal authenticity. "They weren't born empty," Greenberg says. "All narcissists have had to suppress things about themselves in their family. If there is a real gap between the child's self and the family values, it can be the most traumatic circumstance." 

Diagnosing NPD

Although there are many diagnostic indicators for narcissistic personality disorder, Greenberg identifies the most salient ones as "the three S's"—being intensely status conscious, sensitive to slights, and vulnerable to shame. She describes several examples of clients who exhibited these qualities. One told her that she thought Greenberg was an excellent doctor but found her New York accent distasteful and was unwilling to be associated with her because of it. Another was angry about having to wait for a few minutes in the hallway outside her door before his appointment and spent his session raging. Still another, when asked about her goals for therapy, said in earnest, "I want everything you have: your diplomas, your husband, your house, your practice, and your long red hair." Greenberg admits, "It was kind of creepy." 

As for giving her NPD clients a diagnosis, she rarely talks openly about narcissism in therapy but may discuss it if a client asks and it seems productive to treatment.

Treating NPD

Greenberg's time-tested techniques for treating NPD involve a long-term professional investment of patience, mirroring, and empathy—all things the narcissistic personality desperately seeks (read: furiously demands) from others but lacks the ability to give in return. She explains that the process involves a lengthy and exhaustive partnership that most clients don't stick around for. About a third quit after a few sessions, another third make progress but stop prematurely, and, Greenberg says, the final third do extremely well, staying in treatment for an average of about seven years.

Elinor Greenberg
Elinor Greenberg
Source: Elinor Greenberg

"Some clients are able to tolerate meaningful self-reflection fairly quickly, while others are so resistant that I might do only empathy-based interventions for up to a year," she explains. In time she works to help clients recognize that their extreme reactions are counterproductive, and she uses reframing to help them build more stable and realistic self-esteem. "By noticing something real and specific, especially things they haven’t noticed about themselves, I get them out of their depression," she says. "Eventually when they start to get down on themselves they are able to hear my voice instead of their usual internal harsh attacking voice." 

For narcissistic clients seeking better relationships, Greenberg guides them away from "one-mindedness" where they only see their own point of view and attack others below the belt. She encourages them to think and speak in "we" language instead of blaming others: "It's like algebra, with two sides of the equation. They recognize that each have rights in the relationship, and for it to be successful they both have to be successful. It's fascinating when you see the shift. They develop object constancy with regard to the relationship."

Greenberg says that some of her narcissistic clients enter therapy with little to no understanding of intimacy. One client in his 60s had never had a romantic relationship, believing that he hadn't met the right person. Through his long therapeutic process, he did not develop empathy for others or form close relationships, but he did learn to change some of his destructive patterns and behaviors. "He realized that yelling at people and pretending to be superior just made him insecure and depressed later because he worried he would be revealed as a fraud. He was able to stabilize his inflated highs and deflated lows," Greenberg says.

Another client was sent to therapy by his wife, who was threatening divorce. Greenberg helped him see that he was projecting his own unrealistic expectations of perfection onto his family and experiencing rage when they failed to live up to his standards. She guided him to think of their points of view as a way for him to see that they were not intentionally hurting or disrespecting him. "Things improved, they survived as a family, and he started to develop, very slowly, some empathy," she says.

The Pitfalls and Rewards of Working with NPD Clients

About the ups and downs of working with narcissistic clients, Greenberg says, "Some are harder to work with, and some are very pleasant to be with and become some of my favorites." She acknowledges that sometimes her clients trigger difficult personal reactions such as being angered when a client cancels an appointment to have a last-minute manicure, envying a client's grandiose depiction of their "perfect" life, and feeling disturbed by clients' abusiveness toward others.

But Greenberg remains upbeat and passionate about her work and her conviction that positive change is possible. She enjoys injecting humor into her practice and considers herself a perfection buster. "This whole business of perfection is a lie," she says. "John Wayne's real name was Marion Morrison. Cary Grant was Archibald Leach. I like surprising and delighting instead of shaming and deflating. Everybody can evolve."