Radical Humility

How to curb the effects of narcissism: the role of psychotherapy

Psychotherapy and narcissism

Introduction

Some people would assume that individuals who exhibit pronounced levels of narcissism, or even Narcissistic Personality Disorder, may be too conceited to visit a psychotherapist, psychologist, or counsellor.  However, these individuals may seek psychological treatment but seldom to treat narcissism.  Instead, narcissistic people often seek treatment to resolve matters that could threaten their reputation, such as

  • a failure in their relationship,
  • severe problems at work,
  • or a range of other challenges (see Kacel et al., 2017).

Yet, the goals and priorities of therapy depend on the facets of narcissism these individuals exhibit as well as the other challenges or co-morbidities they experience.  To illustrate some potential goals and priorities

  • as Kramer et al. (2018) revealed, when clients present with narcissism and depression, therapy that introduces self-compassion as a means to regulate emotions is especially likely to predict improvements,
  • as Kealy et al. (2017) discovered, when clients present with narcissism, therapists frequently prioritise discussions around how to manage interpersonal conflicts and challenges.

The complication, however, is the characteristics that ignited these problems, such a resistance to feedback or limited introspection, are the same characteristics that might impede treatment.  Many of these characteristics may also disrupt the therapeutic alliance (Ronningstam, 2012).

Common therapeutic practices

Clinicians have applied a range of modalities or therapies to treat narcissistic clients.  Examples include

Several articles and books outline some guidelines and strategies that psychotherapists and counsellors should apply when treating a client who exhibits significant narcissism (e.g., Dimaggio, 2022; Gabbard & Crisp, 2018; Weinberg et al., 2019; Weinberg & Ronningstam, 2020). For example, according to Weinberg and Ronningstam (2020), and partly derived from their experiences, clinicians who treat narcissistic clients should

  • collaboratively negotiate tangible, meaningful, but realistic therapeutic goals,
  • foster a trusting therapeutic alliance—perhaps by introducing concepts such as self-compassion to manage shame,
  • co-design contracts to manage behaviours that could disrupt therapy, such as hostility or limited attendance,
  • when challenging the client, demonstrate empathy and explore alternatives rather than confront belief or behaviours too explicitly,
  • enable clients to choose various options, partly to foster a sense of agency and ownership,
  • set the goal to change behaviour gradually and iteratively over an extended time.

In addition to these strategies, clinicians should refrain from attempts to

  • establish their superiority over the client,
  • encourage their grandiose fantasies or confront these fantasies too harshly,
  • trivialise or disregard behaviours that disrupt therapy, such as hostility or devaluation.  

Case studies about the benefits of psychotherapy in narcissistic clients

To characterise the benefits of psychotherapy to clients diagnosed with narcissistic personality disorder, Ronningstam and Weinberg (2023) examined case reports, prepared by eight therapists about one of their clients.  The therapists had applied a range of modalities, including dialectical behaviour therapy, mentalisation-based therapy, and transference-focused therapy, to treat these individuals.  The therapists had been instructed to write case reports, comprising about 20 pages, on

  • the background of these clients, including the reason these individuals were seeking treatment and their history of problems,
  • the diagnostic assessment as well as the initial reactions towards the client,
  • the changes they observed over specific timeframes in behaviour, personality, relationships, work, and other attributes as well as challenges they experienced, such as resistance and impediments.

In essence, this analysis revealed that all clients demonstrated improvements in their life, such as work, education, and relationships, as well as in their personality.  Their diagnosis of narcissistic personality disorder was in remission (Ronningstam & Weinberg, 2023).  Specifically

  • none of the clients were working or studying officially before the treatment, but all of the clients were working or studying after the treatment,
  • after the treatment, all these individuals were involved in stable relationships or dating,
  • their Global Assessment of Functioning scores had risen from about 40—indicating major impairment in work, relationships, or mood—to about 70—indicating mild symptoms or concerns,
  • six of the clients had initially exhibited marked resistance, such as limited motivation, scepticism towards the diagnosis, or defiance towards recommendations,
  • the first signs of change revolved around greater commitment to work or studies, the capacity to reflect or mentalise, or improvements in friendships,
  • only a minority of clients improved their capacity to tolerate imperfections or vulnerability—but most clients gradually demonstrated fewer signs of narcissism, such as fewer grandiose fantasies or denigration of other people (Ronningstam & Weinberg, 2023).

Seven of the patients were also participating in residential programs, group therapy, family therapy, and other treatments.  Therefore, the precise cause of these improvements cannot be established from this study.

Withdrawal from therapy

Individuals who exhibit narcissism may withdraw from therapy prematurely (Campbell, Waller, et al., 2009; Hilsenroth et al., 1998).  To illustrate, Hilsenroth et al. (1998) examined whether Cluster B personality disorders—such as narcissistic, antisocial, histrionic, and borderline—were associated with therapy attendance.  In a sample of 217 clinical patients, the individuals who exhibited five particular signs or symptoms of personality disorders tended to attend fewer sessions, suggesting they withdrew prematurely.  One of these signs or symptoms, the need to attract excessive admiration, exemplifies narcissism.

Similarly, Campbell, Waller, et al. (2009) showed that narcissistic individuals are more likely to withdraw prematurely from cognitive behavioural therapy in particular.  This study analysed the attendance of 41 clients, who had planned to attend 10 sessions of cognitive behavioural therapy to treat eating disorders.  To measure narcissism, these individuals completed the O’Brien Multiphasic Narcissism Inventory (O’Brien, 1987, 1988).   This inventory gauges three facets of narcissism:

  • narcissistic personality, encompassing entitlement, grandiosity, and exhibitionism,
  • poisonous pedagogy, referring to the degree to which individuals feel they should control other people,
  • narcissistically abused personality, referring to the degree to which individuals perceive themselves as victims and are sensitive to criticism, comparable to vulnerable narcissism.

As the findings revealed, after controlling body mass index, age, and eating pathology (cf., Fairburn & Beglin, 1994), narcissistically abused personality was negatively associated with the number of sessions they attended.  That is, people who exhibit traits that epitomise vulnerable narcissism were more likely to withdraw prematurely.  Arguably, if individuals experience vulnerable narcissism and perceive themselves as special victims, they may feel the therapist does not appreciate or understand their unique needs and challenges.  They might thus withdraw from therapy prematurely.

Impediments to therapeutic alliance

In general, psychotherapy is more likely to be successful when clients and therapists establish a strong therapeutic alliance—defined as the capacity to agree on therapeutic goals and tasks as well as establish an emotional bond.  Unfortunately, because of several reasons, narcissism may disrupt this therapeutic alliance.  For example

  • to demonstrate their superiority, narcissistic clients often disagree with therapists or disrupt the conversation (Gabbard & Crisp, 2018),
  • to minimise fear and establish a sense of control, narcissistic clients may respond aggressively or dismissively in response to a therapist who refers to their imperfections or failures (for a discussion of the neurological underpinnings, see Ronningstam & Baskin-Sommers 2013),
  • narcissistic individuals often refuse to follow instructions, such as complete assignment or apply behavioural modifications outside the session (Dimaggio, 2022), often evoking frustration in therapists,
  • narcissistic individuals also do not like to disclose their concerns, problems, or obstacles candidly (Ronningstam, 2017)—but instead like to distance themselves from these challenges.

Countertransference

The behaviour of narcissistic clients might elicit unhelpful thoughts, feelings, or behaviours in therapists, collectively called countertransference.  That is, narcissistic clients might occasionally idealise and idolise therapists.  But then, if challenged, these narcissistic clients might demonstrate the features of narcissistic rivalry, such as denigrate the therapist to dismiss the feedback. Therefore, while interacting with narcissistic clients, therapists may frequently experience feelings of inadequacy, disengagement, anger, or frustration.

To illustrate, Tanzilli et al. (2017) conducted a study that was designed to characterise this countertransference in a sample of 67 psychodynamic and cognitive-behavioural therapists.  These therapists completed a questionnaire about themselves and one of their patients.  The questionnaire included

The data revealed that narcissism in clients does induce countertransference in clinicians.  In particular, even after controlling social and occupational functioning, narcissistic personality disorder in clients was positively associated with the degree to which therapists felt hostile, devalued, inadequate, and disengaged rather than satisfied or positive (for analogous results, see Colli et al., 2014; Lingiardi et al., 2015; Røssberg et al., 2008).  If co-morbid with other personality disorders, this countertransference was especially pronounced and diverse.   Finally, therapists who were more experienced were not as likely to experience this countertransference—but whether these clinicians adopted a psychodynamic or cognitive-behavioural approach did not affect these reactions significantly (Tanzilli et al., 2017).  

Therapists who assist narcissistic clients must, therefore, manage this countertransference.  They should reflect upon these emotions, thoughts, and behaviours like an impartial observer and perhaps discuss this countertransference with a supervisor or peer.  And, when interacting with clients, they should demonstrate empathy but also gradually expose clients to feedback.

Dialectical behaviour therapy

Introduction

Some therapists utilise dialectical behaviour therapy, or DBT, to treat narcissistic clients. This approach, however, was initially developed to treat borderline personality disorder (Linehan, 1993; Linehan & Dimeff, 2001; Linehan & Wilks, 2015).  Indeed, many studies, including randomised control trials, have revealed that DBT does diminish the incidence of self-injury, suicide attempts, hospitalisation, and other problems that frequently emanate from borderline personality disorder (e.g., Koons et al., 2001; Lineham, Comtois, et al., 2006; Verheul et al, 2003).

Dialectics refers to the attempts of individuals to reconcile two opposing forces.  This therapeutic approach is called dialectical behaviour therapy because the therapist and client must reconcile two conflicting goals:

  • the need for clients to accept themselves, including unpleasant emotions or flaws,
  • the need for clients to change and respond more effectively to challenges.

Typically, a range of opportunities, such as skills training in groups, coaching calls, and contact with ancillary treatment providers, complement the individual therapy sessions.   In groups, for example, individuals learn four main sets of skills:

  • mindfulness skills, in which participants learn to observe, recognise, and accept unpleasant thoughts and emotions,
  • distress tolerance, in which individuals learn how to cope and withstand intense, unpleasant emotions—such as telephone a friend, immerse themselves in warm water, breathe slowly, walk briskly, and so forth—to prevent outbursts or other reactions that could ruin friendships,
  • emotional regulation to utilise and to regulate emotions effectively, such as checking the emotions are justified, implementing the opposite response to the action they would like to initiate, and developing positive routines,
  • interpersonal effectiveness skills, in which individuals learn how to maintain effective relationships, such as learn how to validate other people but also be assertive—using an acronym called DEAR MAN: describe, express, assert, reinforce, mindful, appear confident, and negotiate.

During individual sessions, therapists first attempt to address behaviours that could be damaging, such as self-injury or suicidal ideation.  Next, therapists attempt to address behaviours that could impede therapy, such as disregarding homework.  Then, therapists address behaviours that could impede quality of life, such as compulsive spending or other impulsive behaviours.  Each of these discussions alternate between acceptance or validation and change.

Relevance to narcissistic personality disorder

According to Reed-Knight and Fischer (2011), for several reasons, dialectical behaviour therapy may also be applicable to clients who exhibit narcissism.  To illustrate these reasons:

  • narcissistic personality disorder often coincides with borderline personality disorder (Becker, Edell, et al., 2000),
  • the signs and symptoms of narcissism, especially vulnerable or covert narcissism, overlap considerably with the signs and symptoms of borderline personality disorder (Miller, Dir, et al., 2010)—such as emotional dysregulation.

A case study with a client who was diagnosed with narcissistic and borderline personality disorder

To illustrate how dialectical behaviour therapy could be applied to assist narcissistic clients, Reed-Knight and Fischer (2011) outlined a case study, revolving around a client who had been diagnosed with narcissistic and borderline personality disorder.  The client wanted to overcome profound feelings of discontent.  Several sessions uncovered multiple causes of this discontent that exemplify narcissism: envy, entitlement, and extramarital affairs, for example.  To address the envy

  • the therapist and client labelled these thoughts as “grass is greener thoughts”,
  • the client was encouraged to record these thoughts, such as “Other women have more loving husbands than I do because they drive better cars”,
  • functional analysis—to ascertain the antecedent and consequence of some behaviour or thought—revealed that such thoughts evoked feelings of envy, and this envy incited unhelpful behaviours, such as extra-marital affairs or scratching a car,
  • several behaviours, such as driving in expensive neighbourhoods, would often reinforce these thoughts,
  • after a few months, to address these grass is greener thoughts, the therapist introduced mindfulness techniques to observe and to accept these cognitions rather than reframe these thoughts,
  • once the client could mindfully observe these cognitions, the therapist introduced distress tolerance and emotional regulation to respond appropriate to these thoughts—such as adaptive responses that could supplant extramarital affairs or other unhelpful behaviours,
  • the therapist demonstrated how the client could identify and label unpleasant emotions, such as envy,
  • in addition, the therapist encouraged the client to initiate the opposite action to an unhelpful urge, such as counting her blessings or listing the positive features of her life,
  • the therapist also introduced strategies to diminish the frequency with which the client checks her bank account—another source of envy,
  • finally, the therapist recognised inconsistencies between her values and behaviours—and commenced a discussion on how to resolve this inconsistency.

Mentalisation-based therapy

Introduction

Like dialectical behavioural therapy, mentalisation-based therapy was originally designed to treat borderline personality (Fonagy & Bateman, 2009; Fonagy & Luyten, 2009) but has been adapted to manage antisocial personality disorder (Fonagy et al., 2025) and pathological narcissism (Choi-Kain et al., 2022) as well.  In essence, mentalisation-based therapy helps individuals mentalise—that is, decipher, access, and contemplate feelings, motives, and other mental states. 

Relevance to narcissism

Drozek and Unruh (2020) offers some insights into why mentalisation-based therapy might be pertinent to narcissism.  Specifically, some parents treat their children as special and entitled, called overvaluation.  These parents, for example, may express statements that inflate the achievements and capabilities of their children, such as “You are so clever” or “You are so confident”.  Consequently, these children perceive themselves as special and entitled, often evolving into narcissism.  As they age, they strive vigorously to maintain their image of themselves as special, successful, and capable—an image they have internalised from their parents.   These experiences compromise their capacity to mentalise.  Specifically

  • because they are depicted as clever and confident, but do not necessarily experience feelings that match these attributes, they learn to dissociate themselves from their emotions; awareness of their mental states dissipates,
  • because they strive to be perceived as special successful, and capable, they are not as inclined to cooperate or help other people, often diminishing empathy; their awareness of the mental states of other individuals dissipates as well.

Indeed, many studies have confirmed that narcissism impedes mentalisation.  For example, despite some nuances, narcissism tends to impair

Application of mentalisation-based therapy to narcissism

Drozek and Unruh (2020) also outline how therapists can apply mentalisation-based therapy to treat and to assist narcissistic clients (for more details, see Drozek et al., 2023).  First, therapists should adopt an active rather than passive stance to encourage mentalising.  That is, therapists should

  • when discussing relevant events, pose questions to the client about their mental states and feelings as well as the mental states or feelings of other individuals,
  • disclose their own mental states, when relevant, such as “I am feeling a sense of relief after you said…”,
  • recognise the mental states of clients during the session and tailor interventions or suggestions that are compatible with these mental states, such as “Because you are feeling exhausted now, perhaps we can instead discuss….”.

Second, therapists should adopt a humble stance as well.  To illustrate, therapists should

  • acknowledge they can never truly appreciate the mental states of the client,
  • behave authentically, devoid of pretence or feigned confidence,
  • embrace and enjoy different perspectives between the client and themselves,
  • genuinely acknowledge their mistakes, misinterpretations, or behaviours that might have impeded the conversation.

Therapists who adopt this stance then tend to initiate a series of phases or activities to improve mentalisation.  Specifically, therapists first help clients recognise their mental states, such as their emotions, as well as the mental states of other people.  To illustrate, after discussing some event, like a conflict, the therapists might

  • ask “What were you feeling?”,
  • ask “What do you think this person wanted?”
  • validate the feelings of this client, expressing phrases like “So you sound like you were feeling ashamed”.

Next, therapists might encourage clients to consider why they or other people were experiencing these feelings, motives, or states.  For instance, therapists might ask

  • “You felt both embarrassed and angry; do you feel these emotions are connected?” or
  • “Why would this person feel offended?”

Then, if the cognitions of these clients seem too rigid, certain, and simplistic, therapists might address this rigidity.  For example, the therapist may

  • pose questions about why the client has formed some opinion—and explore the evidence that supports or opposes this opinion,
  • discuss with the client the potential impact of rigid, certain, and simplistic beliefs—and explore or share nuanced alternatives.

Finally, the therapist could attempt to address the limitations in mentalisation.  For instance, the therapist may

  • share their belief that perhaps the client is not always cognisant of his or her emotions or does not always empathise with the feelings of other people,
  • discuss the consequences of these tendencies to motivate change,
  • offer advice on how to recognise and contemplate these mental states.

Evidence that corroborates mentalisation-based therapy in general

Studies have confirmed that mentalisation-based therapy can be effective in clients who have been diagnosed with borderline personality disorder, some of whom exhibited narcissism as well For example, in some research that Bateman and Fonagy (2013) published

  • after 18 months of therapy, about 75% of outpatients fully recovered if they had received mentalisation-based therapy whereas only 25% of outpatients fully recovered if they had received structured clinical management,
  • mentalisation-based therapy, compared to structured clinical management, was significantly more likely to diminish self-harm, depression, and interpersonal problems.

Other studies have also substantiated the benefits of mentalisation-based therapy.  Some of these studies were randomised control trials, often designed to explore the impact of this approach in children and adolescents (Beck, Bo, et al., 2020; Halfon et al., 2024; Rossouw & Fonagy, 2012).

Transference-focused psychotherapy

Introduction

Clinicians have also applied transference-focused psychotherapy to manage borderline and narcissistic personality disorders as well as other mental health concerns.  Transference-focused psychotherapy emanated from object-relations theory—a theory that can be significantly traced to the work of Melanie Klein (1933, 1952), Donald Winnicott (1986), Harry Guntrip (1968), and later Otto Kernberg (1986, 1988, 1995).  Scholars have proposed many variants of this theory.  However, in essence, object-relations theory assumes that

  • during their first few years of life, children develop templates, schemas, or models about themselves, derived from their experiences with caregivers and other significant people,
  • for example, if praised and respected, they might develop the belief they are worthy in many settings; otherwise, they might develop the belief they are unworthy,
  • likewise, from these experiences, children develop templates, schemas, or models about other people—especially about whether other people tend to be caring or dismissive,
  • as children mature, these templates or schemas evolve; for instance, these individuals may learn to perceive some demographics as caring and supportive but other demographics as uncaring or unsupportive,
  • if caregivers tend to respond harshly to flaws or mistakes, these children may develop a tendency to split, in which they perceive other individuals or even themselves as either entirely good or entirely bad,
  • they might, for example, glorify someone one day and then, in response to a trivial event, vilify this person in the future, often compromising their capacity to maintain secure relationships.

Transference-focused psychotherapy was primarily designed to overcome this splitting (Kernberg, Yeomans, et al., 2008; Kernberg, 2016). In essence, when therapists apply this approach, they observe how clients respond to feedback and to advice—and utilise this information to understand, demonstrate, and modify their templates or schemas.  Specifically,

  • they consider the transference of clients—or tendency of clients to relate to the therapist as if they were someone from their past,
  • to illustrate, they might perceive the therapist as critical partly because their parents were disapproving and they now, consequently, tend to perceive authority figures as disparaging.

To apply this approach, therapists follow a manual in which they complete a sequence of activities in order.  For example

  • rather than attempt to shun emotional reactions, the therapist will initiate discussions about matters that could be sensitive or emotive,
  • the therapist will then help the clients recognise  and express their reactions to the therapist, such as “You seem to feel my words are critical, and you feel misunderstood”,
  • the therapist then outlines the schemas of themselves and other people that correspond to these reactions, such as a self-schema that feels judged and inferior as well as an other-schema that is critical and disapproving,
  • the therapist may then highlight contradictory tendencies, such as “You are very confident at work” or “You did describe as supportive as well, so perhaps you experience me in different ways”,
  • finally, the therapist attempts to integrate this information to cultivate more nuanced schemas, such as “people can be supportive but insensitive at times” or “you can be competent and flawed”.   

Application of transference-focused psychotherapy to narcissism: A case study

Scholars have adapted transference-focused psychotherapy to treat narcissistic personality disorder (Diamond & Hersh, 2020; Diamond, Yeomans, & Keefe, 2021; Diamond, Yeomans, Stern, et al., 2021).  Cerda Ramos and Medina Vidales (2025) outlined a case study in which a therapist applied transference-focused psychotherapy to treat a client with narcissism.  Both the therapist and client were male.  The client was 18, single, and had recently been expelled from high school after acts of aggression towards classmates.  He had lived with a neglectful biological family, then an orphanage, and finally was adopted by a supportive family.  While living with his adopted family, his behaviour initially improved but gradually deteriorated, manifesting as lying, interpersonal conflicts, feelings of isolation, pulling his own hair, and even attempted suicide. 

After limited progress from antidepressants, cognitive-behavioural therapy, and other treatments, he was admitted into a psychiatric inpatient unit and underwent comprehensive assessments that included

  • the Structured Interview of Personality Organization-Revised (Clarkin et al., 2016),
  • the Inventory of Personality Organization, and
  • the Initial Diagnostic Self-Application Filter for the Level of Personality Organization and Functioning.

These assessments uncovered a raft of concerns. His perception of himself and other people was unstable and thus fragmented rather than integrated. He directed aggression towards himself and other people, often incited by envy.  He also exhibited the hallmarks of narcissistic personality disorder, such as a pronounced need to be admired, exploitative behaviour, limited empathy, and significant fluctuations between grandiose fantasies to shame. Evidence of splitting was pronounced as well.   

Initially, he received psychoeducation, in which he was informed about his unstable sense of self and need to eradicate the negative features of himself.  This explanation resonated with him.  Consequently, the therapist formulated a treatment plan, revolving around transference-focused psychotherapy.  This plan revolved around the stated goals of the client: to avoid trouble, to complete his studies, and to relate to other people better.  Complementing the three sessions each week, the client also attended occupational therapy activities, psychoeducational workshops, family sessions, and group meetings on responsibility and emotional regulation.

During the three sessions each week, the client was encouraged to raise emotional material such as concerns about his image, interpersonal challenges, impulses around self-harm, and so forth.  Initially, the client questioned whether the therapist was interested in him, with statements like “Why should I tell you how I feel? You see me because that’s your job…to you, I’m just another patient”.   In response

  • the therapist highlighted this internalised schema, indicating the client perceives the therapist as indifferent and unable to care,
  • the client then replied “You think that everything is about you, but it’s not. I don’t want to offend you. . . or maybe I do; I really don’t care about you at all”,
  • the therapist indicated that such a response may be indicative of a reversal in roles, in which the client is exhibiting the indifference he projected onto the therapist,
  • although this pattern was sustained over multiple sessions, the client became aware of these reactions and progressed on his goals.

The therapeutic plan was then revised, prioritising the likely transition to outpatient management (cf., Rufat & Grilló, 2024).  For example, the client agreed to

  • attend two sessions a week
  • refrain from stealing, self-harm, and aggression,
  • contact emergency in response to self-harming behaviours or suicidal plans,
  • commit to specific academic, occupational, and volunteering activities

As part of this agreement, the therapist committed to attend the individual sessions and help the client understand his experiences collaboratively (Delaney & Yeomans, 2021).  He initially fulfilled these plans but soon became irritable when discussing his volunteering activities and was later caught stealing.  When the matter was raised, the client replied “I’ve already told them that I didn’t do it, and they can believe whatever they want… I guess that’s normal given my history… if you want to believe whatever you want, go ahead. I don’t care”.  However, the evidence was incontrovertible.  So, the therapist encouraged him to

  • apologise and return the belongings,
  • seek understanding to maintain this volunteering position or seek an alternative, and
  • commit to refraining from such actions in the future.

He later conceded that, after discovering the theft, the therapist might end the sessions.  This behaviour, therefore, might have emanated from anxieties around depending on someone excessively.  Indeed, in some subsequent sessions, he derided the therapist.  In response, the therapist experienced countertransference, such as feelings of insignificance and futility.  The therapist then identified and discussed this transference and countertransference to foster awareness of these relationship dynamics.  Soon after, the client disclosed vulnerability and sadness when discussing the death of a pet and thanked the therapist.  By the time the case study was written, the client was still experiencing some splitting but was more aware of these tendencies and responded more adaptively.

Metacognitive interpersonal therapy

Overview

In collaboration with colleagues, Giancarlo Dimaggio, an Italian psychotherapist, developed a useful therapeutic approach called metacognitive interpersonal therapy.  Metacognitive interpersonal therapy was initially designed to treat personality disorders—including narcissistic personality disorder (Dimaggio, 2022; Dimaggio & Attinà, 2012; Dimaggio & Valentino, 2024), obsessive-compulsive personality disorder (Dimaggio, Carcione, et al., 2011), and avoidant personality disorder (Dimaggio, D’Urzo, et al., 2015).  However, this therapy can be extended to other mental health disorders, such as schizophrenia (Salvatore et al., 2018). 

In essence, metacognitive interpersonal therapists help people understand their thoughts and feelings as well as the thoughts and feelings of other people, called meta-cognition, to improve their relationships.  This approach is predicated on the assumption that two problems underpin many psychological problems:

  • meta-cognitive deficits: a limitation in the capacity of individuals to recognise, differentiate, and contemplate either their emotions and thoughts or the emotions and thoughts of other people,
  • maladaptive interpersonal schemas: unhelpful beliefs and assumptions about relationships, such as “I will be rejected if I show vulnerability”, derived from earlier experiences,
  • these meta-cognitive deficits compromise the capacity of individuals to overcome maladaptive interpersonal schemas.

To illustrate these meta-cognitive deficits, some people, especially people who exhibit personality disorders,

  • cannot readily monitor, recognise, and identify their mental states—including their emotions and thoughts; for example, they may not realise they feel ashamed,
  • cannot readily differentiate these mental states—and may, for example, confuse their thoughts with facts,
  • cannot readily integrate divergent thoughts and feelings to generate a coherent and nuanced understanding of themselves and other people,
  • cannot readily decentre—or recognise that other people might not share the same perspective as themselves.

During the session, the therapist can utilise a range of strategies to enhance the metacognition of clients as well as revise maladaptive interpersonal schemas—such as narrative exploration, metacognitive scaffolding, experiential activities, role play, and schema revision.  For example, during the session, therapists may

  • invite clients to recount a specific interpersonal episodes, such as a conflict, in detail,
  • pose questions that encourage clients to identify their feelings during this event as precisely as possible and to consider the causes of these feelings
  • pose questions that encourage clients to identify their thoughts during this event—and then to explore alternative interpretations or perspectives
  • after collating enough of these examples, pose questions that enable clients to recognise patterns in how they think about events or interpersonal beliefs,
  • encourage clients to test the accuracy of these interpersonal beliefs and gradually establish more nuanced perspectives,
  • introduce role-play to rehearse alternative interpersonal responses.

To facilitate these conversations, therapists often utilise the following pattern in which they

  • identify which events elicit unpleasant emotions in their client, such as criticism,
  • explore how clients interpret these events; for example, the client may feel rejected by this other person,
  • identify the interpersonal beliefs of clients that explain these interpretations, such as “if I am rejected by one person, nobody will like me”,
  • clarify how the clients cope with these emotions and thoughts, such as withdraw.  

Therapists tend to adopt a collaborative therapeutic stance, in which they actively and mutually engage in the discussion to identify the mental states of their client and other people.

Application to narcissistic personality disorder

Dimaggio and Attinà (2012) outlined how metacognitive interpersonal therapy could be applied to treat clients who have been diagnosed with narcissistic personality disorder.  Initially, and over the course of this therapy, therapists strive to establish a trusting, respectful alliance.  They should attempt to develop a collaborative stance, minimising the tendency to dominate and recognise their possible role in ruptures or misunderstandings.

The first set of activities, called stage setting, are designed to foster a shared understanding of the problem the clients want to solve and to enable these clients to gradually become aware of their feelings, thoughts, and other mental states.  During this stage,

  • therapists should discuss a specific interpersonal episode in detail several times, including the dialogue, striving to unearth overlooked facets each time—rather than accept broader, generalised descriptions,
  • while recounting these events, clients should be encouraged to label their feelings as precisely as possible as well as to consider the triggers or events that incited these emotions,
  • once a reasonable number of these memories have been explored, therapists should utilise these discussions to pose hypotheses about the rigid and unhelpful interpersonal schemas or beliefs of the client; narcissistic clients, for example, may recognise they tend to perceive interactions as opportunities to outperform or undermine the other person, to attract respect and admiration, and to defend themselves against hostile people,
  • therapists can then explore how these motives, such as attempts to attract respect and admiration, compel individuals to pursue actions that are incompatible with their core needs, goals, and values, such as the need to establish relationship and maintain autonomy, impairing satisfaction in life.

The second set of activities, called change promoting, is intended to effect change in clients.   During this stage,

  • therapists demonstrate how the beliefs and thoughts of clients may not entirely overlap with reality—and other perspectives of possible,
  • therapists normalise the need to seek admiration and status, and even concede they experience this need; however, therapists suggest the clients should set this goal aside transiently to develop healthier thoughts, feelings, and behaviours, enabling this status to develop naturally and gradually over time,
  • the clients and therapist collectively uncover courses of action and behaviour that may be more compatible with core values, such as healthy relationships,
  • therapists encourage clients to recognise their unhelpful schemas from afar, as if an impartial observer, and to uncover more nuanced and helpful perspectives.

A case study

To illustrate meta-cognitive interpersonal therapy, Dimaggio and Attinà (2012) presented a detailed case study about a young man, called Lucian, who sought therapy after leaving university because of challenges with his studies and his peers.  He epitomised narcissistic personality disorder, depicting himself as uniquely talented: a person who could have led an army during Roman times, like Alexander the Great. He exhibited rage and shame in response to criticism.  Because he did not want to be derided or rejected, he pursued perfectionistic standards.  He could not articulate his mental states, besides references to strong emotions like anger and anxiety.  Instead, his narrative style was abstract, devoid of specific autobiographical memories.

He could not appreciate the emotions and perspective of other people effectively. He was contemptuous even of his few longstanding friends—and yet coveted a bond with the community. His father was strict and controlling, a man he despised.  His mother, his main confidante, was anxious.

Besides narcissistic personality disorder, Lucian exhibited avoidant personality disorder, obsessive-compulsive personality disorder, and symptoms of social phobia and depression.  He did concede feelings of inadequacy and vulnerability but the therapist decided not to pursue or activate these vulnerable facets of narcissism in the preliminary phases.   

To establish and to maintain a strong therapeutic alliance,

  • the therapist did not challenge the contemptuous attitudes that Lucian had expressed about other people,
  • instead, she appeared curious and interested in all his comments rather than judgmental
  • his grandiose fantasies were validated emotionally, such as “as “I realise you are pursuing great ambitions that are not currently met”.   
  • when Lucian conceded he felt inept sometimes, the therapist disclosed moments in which she felt incapable, encouraging further disclosures.

To elicit vivid autobiographical episodes and to access mental states

  • to justify her attempts to elicit autobiographical episodes, the therapist indicated that raw memories may enable her to understand the nuances of his mind better,
  • when Lucian repeated his ambition to be like Alexander the Great, the therapist asked him to imagine this role, to describe how he would have felt, and to identify moments in his life when he had experienced these emotions,
  • these memories revolved around times in which he felt a mismatch between his belief that he is special and the spite of other people.

He later depicted a time in which, before paying a bill at the Post Office, he was concerned he would not perform this task perfectly and would experience humiliation.  He immediately perceived the clerk as distracted and supercilious. “Who does he think he is treating me like this?”, he pondered.  This haughty attitude swiftly evolved into feelings of inferiority.  “He thinks I am an idiot”.  Together, the therapist and Lucian recognised that his motivation to establish social rank and his need to be accepted governed his interactions.  He assumed that, if he was not exceptional, he would be rejected and deemed as worthless.

To explore the associations between his interpersonal beliefs and emotions, Lucian recounted other episodes, such as concerns about a secretarial job he was offered by his brother-in-law.  This episode elicited the following conversation

  • Therapist: “…In the last session, you told me it was better than staying at home doing nothing”,
  • Lucian: “…Yes, but it’s not what I want in my life”,
  • Therapist: “…What’s changed since last week?”
  • Lucian: “…I didn’t like my brother-in-law’s behaviour when we were in an office”.
  • Therapist: “…What didn’t you like?”
  • Lucian: “…We walked down these corridors full of people who didn’t even look at you. They all knew each other”, indicating that Lucian felt rejected rather than accepted. 
  • Therapist: “…I can imagine the tremendous confusion”,
  • Lucian: “…Yes, it was frightful”.
  • Therapist: “While you were with your brother-in-law, what did you think about what you were experiencing…(such as the) things you had to learn to do?”
  • Lucian: “…That I’d have failed and that my brother-in-law and parents would think I couldn’t do even piss easy things”.

The therapist then explored with Lucian other associations between events and his mental states, such as his thoughts and feelings.  The therapist also helped Lucian distinguish expectations and reality—a distinction that is usually attempted later in therapy—primarily to validate his feelings.  The therapist, for example, said “But why do you call them “piss easy”? They aren’t at all. You were right in finding the office chaotic. … You need time and patience. You might ask your brother-in-law how long (he needed to learn the tasks)”.  After further discussion, Lucian recognised that his emotions could more be ascribed to the need to protect himself from criticism.  Together with the therapist, Lucian recognised the following chain of events:

  • I am worried I might be judged negatively. 
  • If I cannot complete tasks perfectly, I will be judged negatively.
  • But I was confused, so I will be judged negatively and perceived as incapable.
  • I will then perceive myself as incapable and experience shame.
  • Because of this shame, I will isolate myself”. 

The therapist next attempted to elicit other comparable memories to uncover consistent interpersonal beliefs, asking questions like “Have you felt something similar in other situations?” These questions prompted the therapist to reframe the causal chain.

  • You strive to achieve success—but believe you will fail and other people will ridicule you.
  • To reinforce this beliefs, you ascribe your success to the suggestion the task must have been easy.
  • If someone wants to develop a friendship with you, you assume they are stupid or damaged.

Lucian agreed with this reformulation and recognised that many episodes are consistent with this model—a model that typified perfectionism.  The therapist, confident that stage setting had largely been achieved, shifted the emphasis to the final phase: change promoting.  Specifically, the therapist first differentiated fantasy and reality. To illustrate

  • the therapist encouraged Lucian to consider his perceptions of himself and other people as hypotheses rather than absolute truths,
  • when Lucian raised his concerns that two people had dismissed him at a party, the therapist indicated that his appraisals are consistent with his schema that he feels inferior and that other people are harsh judges,
  • when Lucian agreed, the therapist underscored how his attention to these individuals was selective: he had, for example, overlooked other cues in which a girl was interested in him,
  • the therapist also revealed a paradox—the belief he should be treated as special even by people who do not know him well—a belief he agreed was unfeasible,
  • the therapist and Lucian then explored other possible reasons the two people had been dismissive, such as the possibility they were uncomfortable with unfamiliar individuals.

Finally, to promote a sense of agency and autonomy, the therapist explored other courses of action that resonate with the innermost wishes of Lucian.  For example,

  • the therapist explored the motivations that underpin his grandiose fantasies, to become an army leader, to clarify his underling wishes,
  • to pursue this role, he became fascinated with ancient history, and wrote an enthralling story about an ancient Roman official; the therapist read and praised the story in the sessions,
  • Lucian then gradually translated his grandiose fantasies into a feasible project, such as studying archaeology.