Can a Person with Narcissistic Personality Disorder Benefit from Therapy?

Rev. Sheri Heller, LCSW

I used to ascribe to the fundamental notion, based on psychologist and author Alice Miller’s observations in The Drama of the Gifted Child, that irrespective of one’s genetic imprint or constitution, character pathology was a result of the absence of love and trust in a child’s formative years.

Miller wrote,

“All the childhood histories of serial killers and dictators (Hitler, Stalin, Mao) I have examined showed them without exception to have been the victims of extreme cruelty, although they themselves steadfastly denied this.”

Hence, irrespective of inconceivable signs of relentless savagery, Miller believed we are all born innocent. She proclaimed that positive human inclinations are inherent and that we enter the world with a foundation for morality, such as altruism and empathy. Miller’s contentions imply that a malignant narcissist can retrieve the virtuous traits which have been compartmentalized in the service of survival. Ostensibly, with the involvement of corrective relational experiences and humanistic trauma focused therapy the narcissist can reclaim their true loving self.

In hindsight, I view this as a huge blind spot. Needless to say, I no longer think this way.

Indeed, the conundrum of nature versus nurture is most potent when examining human evil. The reality is, evidence suggests that malignant narcissism and psychopathy is an interaction between genetics and the environment. Furthermore, our genetic make-up influences brain structure. This is particularly relevant because the pinnacle of malignant narcissists, commonly referred to as psychopaths, apparently have different brains than the rest of us.

Researchers at the University of Wisconsin-Madison discovered through the application of brain imaging that psychopaths have reduced connections between the part of the brain responsible for sentiments such as empathy and guilt, and the amygdala which mediates fear and anxiety.

Likewise, Neuroscientist and psychologist Dr. Kent Kiehl conducted a study at a correctional facility in New Mexico, in which the three thousand images procured from an MRI scanner led him to conclude that brain abnormality is associated with criminal psychopathy. Specifically, Dr. Kiehl discovered that the limbic system of a psychopath’s brain has reduced grey matter density and reduced prefrontal connectivity. Essentially, the brain circuitry that is disrupted in psychopaths is responsible for emotional processing and moral decision making.

Further confirmation of an inherent predisposition towards malignant narcissism is evidenced in the remarkable story of neuroscientist James Fallon, who identifies as a “pro-social psychopath".

Fallon was involved in a research study designed to detect correlative brain patterns with psychopathic behaviors. While sifting through PET scans, Fallon came upon an image revealing pathological indicators of psychopathy. Curious, he investigated who the subject was and discovered that the psychopathic brain he came upon was his own. Genetic testing also revealed the presence of high-risk alleles or variant genes for violence, aggression and low empathy.

While Fallon presents as a happily married pillar of society, in an interview with Smithsonian Magazine he professed that he was always vehemently aggressive and power hungry. Although throughout the years, folks referred to Fallon as ‘psychopathic’ he attributes his being born into a remarkably loving and protective family as the basis for his not going off the deep end with expressing his violent inclinations, albeit he did deliberately expose his brother to the lethal Marburg virus during a perilous camping trip in Kenya.

Fallon explains, “As I was growing up, people all throughout my life said I could be some kind of gang leader or Mafioso don because of certain behavior. Some parents forbade their children from hanging out with me. They’d wonder how I turned out so well — a family guy, successful, professional, never been to jail and all that.” (The Atlantic, Jan. 2014)

Although Fallon admittedly never truly cared about other’s feelings, his social image relied on presenting as one who does. This suggests a narcissist can adjust behavior to operate in humane ways if it benefits them. Fallon can choose to ‘do the right thing’ and yet he admits it is motivated solely by wanting to show others he is a psychopath who can pull off ‘being nice’. These motivations are prominent in communal narcissists such as social justice warriors, politicians, notable religious figures and cause celebs who can expertly hide behind a veneer of virtue and philanthropy.

Narcissistic Personality Disorder, the form of narcissism that is deep-rooted and intractable, is determined by persistent and chronic symptoms. Many adults with NPD evidenced signs of oppositional behavior as children, foreshadowing a sociopathic disposition.

So, returning to the question at hand; can a personality disordered malignant narcissist (as opposed to the individual presenting with narcissistic traits) benefit from humanistic psychotherapy?

Despite there not being randomized controlled trials of psychological interventions for psychopathy published in clinical literature, based on the malignant narcissist’s biological inheritance and their inability to form a genuine, meaningful attachment I am prone to believe that a malignant narcissist cannot benefit from the sort of therapy predicated on the cultivation of a strong therapeutic alliance.

The relationship between a client and therapist is a collaborative effort intent on accessing the clients’ innate wisdom and healing. In fact, the most consistent finding of psychotherapy research is that, “the quality of the therapeutic alliance is the most robust predictor of outcome.” (Safran & Muran). The strength of the therapeutic alliance operates from the core belief that the client-therapist bond assists with actualizing potentials related to one’s inherent goodness and the application of free will.

Accordingly, to form and benefit from a healing humanistic therapeutic alliance, a modicum of empathy and humility must be available to both the client and the therapist. However, for the malignant narcissist the proclivity for domination overshadows the capacity for love. When narcissism falls within the malignant range, there is an absence of empathy and an intense need for aggrandizing, attention, and admiration. Hence, they are simply not able to form an alliance characterized by the deep respect and genuine acceptance that could foster intrinsic healing and self-determination.

The personality disordered narcissist harbors extreme expectations, reinforced by a deluded sense of entitlement and ‘specialness’. They evidence a persistent lack of compassion and insight, yet have the ability to impersonate feelings so as to manipulate others and achieve desired outcomes. Their need to be admired and in control infiltrates their relational maneuvering. In the most extreme form malignant narcissists are psychopaths, driven towards criminality and the urge to sadistically destroy others.

Yet, even though NPD is not curable, as one can’t magically conjure up empathy and morality, narcissists are nevertheless treatable with behavioral methods. Early detection might even result in a positive outcome with Dialectical Behavioral Therapy and what is known as The Decompression Model, which consists of positive reinforcement and aggression replacement cognitive-behavioral therapy.

At the Mendota Juvenile Treatment Center in Wisconsin, where high risk troubled youth present in the severe range on the Youth Psychopathy Checklist, the Decompression Model of treatment is the chosen approach to criminal rehabilitation.

Primary narcissism is an essential part of normal development. Psychiatrist and psychoanalyst Otto Kernberg described healthy narcissism as a cohesive integrated self. Indeed, a child’s normal narcissistic entitlement is the foundation for a healthy emerging authentic mature character that has a compassionate awareness of self and others.

How benign or destructive a narcissist is depends on where they land on the spectrum. When we move into the unhealthy, destructive realm we begin to see rigid personality traits and exploitive entitled ways of operating indicative of Narcissistic Personality Disorder. It is here, as a clinician specializing in the treatment of complex trauma, that I draw a line.

It follows that by the time I met with Emily and Jake for a consultation I was firm in my conviction that while I would consider rendering treatment services to those presenting with narcissistic traits (with the full understanding that the process will be challenging, prolonged and inclusive of decompensation), I would unequivocally not attempt to treat someone presenting with NPD. This stance was tested when couple’s sessions with Emily and Jake ensued.

The seemingly sensitive, poised and levelheaded Jake turned out to be a covert Jekyll and Hyde narcissist. His Jekyll persona seemed caring and contrite, but behind closed doors his malevolence surfaced. It didn’t take long to discover that Emily’s blatant distress was a direct result of years of concealed marital abuse.

During sessions, Jake attempted to manipulate the process by pathologizing Emily and deflecting responsibility. He repeatedly conveyed his hardship with graciously tolerating his ostensibly ‘mentally ill’ unsupportive wife. When he failed to convince me of his victimization, and evidenced an obvious disinterest in doing any genuine therapeutic work, it became pointless to proceed. Above all, his trivializing of episodic physical violence, arbitrary disappearances and sadistic exploitation of Emily’s dependency needs revealed who he was behind the mask.

I am grateful that I was at a place in my understanding of NPD, that the couple's work did not culminate in a perverse collaboration between myself and Jake. As a result, Jake was not enabled to fulfill a stealth agenda while further subverting Emily’s reality. Tragically, however, this is more the exception than the rule.

Like many colleagues who maintain that all wounds and disorders are reparable given the right conditions and a corrective therapeutic bond, in the past I would have erroneously structured treatment to address co-created problems contributing to the marital discord. I might have colluded in the faulty premise that the narcissist was simply triggered by their partner’s behavior, thus implying that the modification of the victim’s behavior was integral to achieving harmony.

I now know that framing abuse perpetrated by a malignant narcissist as a mutual exchange between equal parties consequentially sends the message that any sort of behavior, including physical violence, is allowable and treatable through the couples modality. It fails to recognize the inherent power differential in an abusive relationship with a disordered narcissist and the fundamental incompatibility of love and domination. Additionally, it mitigates the responsibility of the narcissist and hence stigmatizes the victim.

The testimonies of many of the folks I treat for complex trauma rooted in narcissistic abuse, affirms that prior therapy experiences mitigated their reality by suggesting that their suffering, brought about by gaslighting, lies, infidelities, violence, and myriad forms of deception was somehow faulty and exaggerated.

Thus, therapists who maintain that human nature belies evil are complicit in a delusional set-up which has severe repercussions for victims of narcissistic abuse. This posturing prohibits the acknowledgement of the dark side of humanity and consequently impedes consciousness and ultimately healing. It offers illusory hope of repairing that which can’t be fixed. Worst of all, it places the burden on victims of human evil to legitimize their reality and their suffering.

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As a survivor (and thriver) of complex trauma and a seasoned therapist specializing in treating complex trauma, narcissistic abuse syndrome and addictions, I am intent on creating content that affords informative insight, hope and healing from psychological disorders. I aim for my creative content to assist readers with tapping into the resiliency of the human condition while recognizing the countless challenges of being human.

New York City, NY

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