Narcissists don’t go to counseling because they realize they’re selfish and lack empathy. They rarely have insight into their ways of being. Diagnosing any personality disorder can take time and experience getting to know the client. It can be difficult to diagnose a narcissist. Problems such as depression, anxiety disorders, substance issues, and other mood disorders are common and those symptoms may have to be addressed before the counselor can get a sense of what is underneath them. Instruments such as the Personality Assessment Inventory, the Narcissistic Personality Inventory and others may provide additional helpful information. Getting collateral information from loved ones, including information about the client’s childhood circumstances, can be enlightening, as well.
There are some “red flags” that may alert the therapist to possible narcissism. Whether its symptom relief or something else, therapy is usually about an agenda they have. Everyone should come in with goals in mind, but agendas are different than therapy goals. That’s been my experience. They want a letter written to someone helping them get something they want, whether its to DSS, trying to file for disability, needing counseling for PTI due to having committed a crime, trying to get FMLA from work, needing a psychiatric explanation for why they should receive certain special consideration, or wanting something for an attorney or whatever. Maybe someone has told them it will look better for them if they go to a few counseling sessions. They want their spouse not to leave them so they agree to see me a few times. Sometimes, they want me to tell them what they can do to get what they want, as far as getting another person to see things their way. Other times, they want me to agree with them that they’re right about something.
Many narcissists come across as charming but shallow. Obviously, their comments tend to be self-focussed and they don’t tend to admit to mistakes or be very open to considering another person’s perspective. They can easily become defensive. They often present with a sense of entitlement. They often start trying to get special accommodations. These might be longer sessions, not having to pay their copays, or wanting to talk to the therapist a lot between sessions. They act as if they are the most important client the counselor has.
Narcissists often have histories of job and relationship problems. They got fired because they wouldn’t do things the way they were asked to, were disrespectful to those in authority, or because they became difficult to get along with. Or, they have quit job after job because they felt unappreciated. Many try and go into business for themselves but can’t keep employees. Common professions for narcissists include doctors, lawyers, pastors, and politicians. They like high-status jobs where they can have a lot of influence and where they can receive admiration and appreciation. They may have a lot of financial problems because they’ve tried to find happiness in possessions or “buying” love.
They may be upset because someone in their life is trying to set limits with them. Someone may be fed up with their selfishness and lack of sensitivity. They may be upset that a parent, child, or spouse has called them out on unacceptable behaviors, such as lying, being unfaithful, or exploiting other people in some way. They may want help convincing another person to change or want the counselor to “fix” someone in their life who is causing them some sort of difficulty or inconvenience.
Narcissists are usually not good therapy candidates. They try and discredit or one up the therapist and blame all their problems on other people. If the counselor doesn’t say what the narcissist wants to hear, they usually discontinue counseling. If change doesn’t happen quickly, they usually don’t have patience for the process and decide counseling can’t help them. Many of them come in wanting a “quick fix” for their distress or an easy solution for the problem they have. If the counselor can’t do what they want, they give up and disappear.
There isn’t much solid research on what really works when treating a narcissist. Meds can be helpful with certain symptoms, but don’t change personality and core ways of thinking and relating. Few narcissists can have the insight or patience to truly pursue lasting change. Factors such as willingness to trust the therapist, willingness to be honest and open to their real feelings and life experiences, and a realization of how certain ways of being aren’t “working for them,” make the narcissist more likely to benefit from counseling. Recently, treatments that combine the directive aspects of cognitive-behavioral therapy with interpretive, transference-based psychodynamic techniques have been formally studied and proposed as an additional model in the range of approaches to narcissistic personality disorder.
Regardless of the type of therapy used, therapists should be prepared to set firm boundaries with narcissistic clients. They should be clear about what they can and can’t do in the role of counselor. clients who display strong features of narcissism should be carefully screened for substance abuse issues and suicidal thinking. They very likely will not tell the truth about these issues, but other family members may “narc” on them out of concern for the narcissist’s well-being.
clients believed to be suicidal should be asked to sign a safety contract. Family members should be instructed about how to respond to threats or gestures. I tell them to call 911 rather than going to the person’s home themselves since suicidal gestures made by a narcissist are often engaged in to get what they want, which is more attention from particular people. To stabilize the patient, a brief, goal-oriented hospitalization may be necessary.
Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalization of blame for psychological distress, and impaired impulse control put the children of these patients at risk for neglect or abuse. Domestic violence may be an issue, as well. Some narcissists even come in with a spouse to try and tell the therapist what needs to be “fixed” about that person and to try and control the therapy. They’ll claim their spouse has some sort of major problem that needs to be dealt with or want us to “fix” their kid. They don’t want to be told anything they might do differently to help the situation, though.