Couples Counsellor: Insights on Therapy for Narcissism
Most people with clinical narcissism do not voluntarily pursue therapy. They tend to seek professional help only after experiencing a major collapse in their personal or professional life, or when strongly urged by family members.
To diagnose narcissistic personality disorder (NPD) according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the traits must form a pervasive pattern of
- grandiosity,
- attention seeking,
- entitlement,
- lack of empathy,
- exploitative behaviour.
beginning in early adulthood and present across various contexts. Crucially, these features must be omnipresent and maladaptive in multiple contexts. Furthermore, they must cause significant impairment, including the individual’s own well-being, and clearly go beyond ordinary self-centeredness.
Kernberg’s Continuum
According to Kernberg’s object relations model, narcissism exists on a continuum from pathological through malignant to psychopathy.
At the healthier end, pathological narcissism functions as a defence. The individual protects the self through splitting, where they experience themselves as good and project what feels bad or threatening onto others. When aggression and hatred become more dominant, this shifts into malignant narcissism. This type is marked by exploitation, contempt, and a lack of concern for others. At the furthest end of the continuum is psychopathy. Here, hate and aggression prevail, and other people are mostly experienced as objects to use or harm.
A key clinical implication is that the greater the capacity for care, concern, and connection, the more potential there is for treatment (typically in pathological narcissism). As hatred and aggression increase, the person moves further along the continuum toward states that are far more difficult to treat.
Challenges of Couples Therapy Involving NPD
Clinical narcissism may manifest in relationships or marriage in two distinct forms: grandiose and vulnerable narcissism. They are sometimes referred to as overt and covert, respectively. The two constructs differ in how they are experienced internally and expressed outwardly.
However, narcissism-related relationship struggles are more or less the same in both forms. They involve persistent ongoing hostility, criticism, insults, and overall aggressive (passively or actively) or exploitative behaviour. In more severe cases, couples therapy, whether online or in-person, can be extremely challenging. It may even be contraindicated. Resistance to empathy and patterns of interpersonal malice can make the therapy ineffective and, at times, even harmful. Individuals with narcissism may enter therapy in bad faith, using sessions to reinforce their worldview. They may distort events or weaponise the process against their partner. Feedback given in front of a partner can trigger defensiveness, denial and accusations of bias. Moreover, it often leads to premature termination of couples therapy or marriage counselling.
Couples Treatment for Cases Involving Narcissism
In cases of pathological narcissism, some strategies can make therapy more helpful. First of all, a therapist’s ability to remain non-confrontational helps reduce the client’s defensiveness. Secondly, therapists’ self-awareness is crucial in maintaining boundaries. Finally, noticing even the smallest moments of cooperation can provide valuable insights for both the client with NPD and the counsellor. At its core, individuals with NPD are highly sensitive to rejection or criticism. They may avoid situations that could make them feel inadequate. When confronted, they often react with withdrawal or bursts of anger. These responses work as defences that mask a fragile sense of self-worth and underlying vulnerability, which are central to the disorder.
That said, therapy addressing narcissism is a long-term commitment. For relationship problems involving NPD traits, it’s advisable to have individual counselling or psychotherapy for each partner in parallel to couples treatment.
However, if you are dealing with more severe forms of narcissism (malignant or psychopathy), your focus needs to be on protecting yourself. This includes setting clear boundaries, strengthening support outside the relationship, tending to your own mental health, e.g. through counselling or therapy. Be realistic about their capacity for change. In some cases, safeguarding your well-being may mean considering separation.