I do not believe in a manualized method when it comes to therapeutic approaches to narcissism—or to any other symptom or disorder. Every story is unique and brings specific challenges; nonetheless, certain therapeutic considerations arise from a deeper understanding of the core struggles involved.
In working with narcissistic patients, the therapeutic relationship is central, as it is in most cases. The therapist’s task is not simply to uphold boundaries, but to carefully attend to requests that would alter the therapeutic frame—such as demands for exceptions, special treatment, or discounts. It is also essential to listen closely to the potential for idealization and devaluation, remaining attentive without being caught up in these dynamics. At times, firmness is necessary, but above all, the therapist must sustain a third position—listening without being drawn into specular or reactive roles, and maintaining a thoughtful stance throughout the process.
Narcissists rarely present for therapy explicitly for narcissism. Instead, they often seek help for secondary symptoms like depression, uncontrolled anger, frustration manifesting as compulsive behaviors, or panic attacks triggered by perceived failures in their relentless competition with others. Their depression is often tied to a mourning of their idealized self-image, the loss of the fantasy of invincibility and perfection, or a narcissistic injury that has cracked their carefully constructed facade.
Given these complexities, therapeutic approaches to narcissism must address the underlying dynamics with patience and sensitivity, while also navigating potential challenges such as the client’s tendency to manipulate or control the therapeutic process, or their resistance to self-reflection.
Therapeutic Approaches to Narcissism: Bridging the Gap Between the Imaginary and the Symbolic
Narcissists are often trapped in their imaginary—a world of self-aggrandizement and fantasies of omnipotence. (The imaginary, in psychoanalytic terms, is our internal world of images, desires, and fantasies. It is a necessary and vital dimension of our inner life, fueling creativity, aspiration, and the ability to imagine new possibilities. However, when one relies exclusively on the imaginary, it can become a defensive fortress, cut off from interaction with others and the risks that come with it—for example, not knowing how one is seen or what the other person thinks, and being exposed to unpredictability, embarrassment, or shame.)
The symbolic is the set of linguistic, social, and cultural structures (such as words, names, family and social roles, laws, rules, prohibitions) that go beyond the individual. By limiting the subject’s experience, the symbolic gives it form and makes relationship with the other possible.
For example, when a person accepts that they cannot be or do everything they want, that they cannot possess or control everything, and starts to confront rules, roles, and limits, they are entering the symbolic. By accepting the rules of the game, they can truly begin to play the game of life.
On the other hand, those who remain in the illusion of omnipotence stay stuck in the imaginary and easily end up isolated in their own world.
Neither dimension is sufficient on its own: a healthy psyche depends on the interplay between the rich, creative world of the imaginary and the relational, structured world of the symbolic.
Narcissists often defend against any real encounter with otherness, limits, the law, and the possibility of being seen and judged. They fear intrusion and loss of control, which may manifest in dreams of being robbed or exposed. This fear reflects a deep shame and the terror that others will see through their carefully constructed facade and discover their perceived flaws. Therapeutic work is gradual and delicate, as these defenses were built up to protect against very early and painful wounds. Therapy aims to gently guide them into the symbolic, encouraging engagement with language and exploration of the meaning behind their defenses. This also involves helping them discover that meaning is often given to us by the other, is not fully under our control, and is not necessarily universal or shared. For the narcissist, everything is obvious and self-evident; they assume that others think and see the world as they do, and are unaware that meaning is subjective and can be radically different for each person.
Clinical Vignette: Between Reality and Desire
A patient describes a colleague who often shares fascinating stories about supposed romantic encounters with people who live far away or have mysterious jobs. On one occasion, the patient notices that the story closely resembles the plot of a television series she watched recently. Her immediate reaction is to expose her colleague, convinced that she is lying or deceiving others. She does not pause to consider why these stories might be important to her colleague, nor does she wonder what they might represent for her. For her, it is simply a matter of true or false, with no room for interpretation.
Clinical reflection:
This example illustrates how a rigid adherence to binary logic—the need for every statement to be either true or false—prevents any attempt to grasp another possible understanding of someone else’s fantasies. An important step in therapy is to help the patient move from the question “Is it true or false?” to “What might this story mean for the person telling it?”