What Type of Narcissist Does Well in Therapy?

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Until recently, there was one sentence that I never expected to hear from a prospective client: “I think I'm a narcissist. Do you treat Narcissistic Personality Disorder?”

In the past, most people with narcissistic disorders who entered therapy with me either did not know that they qualified for that diagnosis or were given an ultimatum by their spouse, “Go for therapy or I'm leaving you.”

Now, because of the explosion of interest in Narcissistic Personality Disorder and easy access to information about it on the internet, about half of my clients with Narcissistic Personality Disorder contact me because they recognize that they are narcissists and need a therapist who knows enough about that diagnosis to help them.

I think of these clients as self-aware narcissists. I have identified seven characteristics that self-aware narcissists have in common that make them good candidates for psychotherapy.

Note: In this post, I am using the terms “narcissist,” “narcissistic,” and “narcissistic adaptation" as a shorthand for referring to clients who qualify for a diagnosis of Narcissistic Personality Disorder. I prefer the word “adaptation” to “disorder” because it emphasizes that Narcissistic Personality Disorder usually begins as a child’s attempt to creatively adapt to the limitations of his or her early home environment.

Seven Characteristics of Self-Aware Narcissists

1. Motivated
2. High-Functioning
3. Psychologically Minded
4. Capacity for Self-Reflection
5. Highly Intelligent
6. Strong Ego
7. Desire for Self-Improvement

Motivated: There is something going on in their lives that they do not like and want to change. It could be that their second marriage is failing or that they are not doing as well as they could at work. If nothing is going wrong, they are unlikely to enter therapy or go to the trouble of researching their diagnosis.

High-Functioning: They are able to navigate everyday life without significant difficulty. They are able to initiate projects and finish them. They graduated from school, have a job, and a stable living environment. They are able to make friends.

If they are too low-functioning, all their energy will be spent on simply surviving. They are much less likely to worry about their diagnosis when they are worried about their next meal and their latest eviction notice.

Psychologically Minded: This is the capacity to be genuinely interested in why people act as they do. Many people who do well in therapy and are interested in their diagnosis have an innate interest in people and are curious about how people think and behave. They are more likely to be attracted to reading popular psychology columns and books with psychological themes than people who do not come for therapy. Narcissists who are psychologically minded are likely to stick with their psychotherapy longer because they enjoy the process of self-discovery.

Capacity for Self-Reflection: This relates to both the capacity to look objectively at one’s own motives and behaviors and the willingness to do so. Most people with narcissistic adaptations are too busy trying to convince themselves and everyone else that they are perfect to ever look within for the source of their problems. Instead, they spend their mental energy on finding ingenious ways to blame other people and try to convince them to change. Only a few narcissists out of thousands are willing to voluntarily self-reflect and are desperate enough to do so.

Highly Intelligent: All other things being equal, highly intelligent people are more likely to see the big picture and be capable of understanding the difference between their perceptions and reality. As one of my self-aware narcissistic clients said: “Just because it feels real to me, does not mean it is real.”

Strong Ego: This can be thought of as the ability to remain relatively emotionally stable and in touch with reality when you are under internal or external stress. Being in therapy is a bit like living in your house while it is being renovated. There will be a certain amount of chaos, mess, and uncertainty during the construction. In therapy, as in renovation, one needs to have a lot of strong internal supports so that when the therapist challenges a narcissistic defense, the whole structure does not collapse.

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Many narcissists cannot sustain their functioning when their narcissistic defenses are removed, and they get in touch with their underlying shame. The dismantling of their whole narcissistic worldview has to be done very slowly and carefully. This is one of the reasons that the psychotherapy of narcissistic disorders takes so long. It is also the reason why so many narcissists quit therapy before they reach their goals.

The therapist has to make sure that the client is learning and starting to utilize new healthier coping mechanisms before asking the client to give up all of the narcissistic ones. If that is not possible, then the number of therapy sessions per week needs to be increased. This allows the therapist to “loan the client the therapist's ego strength” while the client goes through this difficult and delicate process.

Desire for Self-Improvement: There is a subset of people with narcissistic adaptations who want to evolve and are willing to do the hard work necessary. These are often the same type of people who decide to learn a new language or sign up for classes on topics that they wished that they had studied in college.

These clients can envision themselves changing and growing. They believe that change is possible. As one client said to me: “Once I see that I could do something better, I want to learn how.”

Punchline: Some people with narcissistic adaptations are better candidates for psychotherapy than others. In general, people with Narcissistic Personality Disorder who are very motivated, high functioning, intelligent, psychologically minded, have the capacity for self-reflection, good ego strength, and an interest in pursuing self-improvement are more likely to enjoy their therapy and stick with it long enough to make significant improvements.

Adapted and expanded from a post on Quora (Nov. 15, 2018).

To find a therapist, please visit the Psychology Today Therapy Directory.