1. The programme at a glance
Indication. Narcissistic personality in adults, as outpatients, in a grandiose or vulnerable form, with distress or impairment, and a request that the patient makes — even indirectly.
Reference model. Cognitive therapy for personality disorders (Beck et al., 2015), centred on conditional self-worth, shame and defensive responses to threat (section 4). It borrows from schema therapy (Young et al., 2003) the notion of mode, that is, the emotional state and way of reacting that dominate in a person at a given moment: the self-aggrandising mode, the detached self-soothing mode, and the vulnerable part, which carries the shame, overlap with the overcompensation, withdrawal and shame of the cycle in section 4. It adds work on the capacity to represent others' mental states when tension rises (session 11).
Format. Treatment lasting about a year, some forty sessions; this manual describes sixteen key sessions, organised in five phases; each key session may take two or three. Sessions last 50 minutes and are weekly; three booster sessions, at one, three and six months after the last session, follow the end of the programme (session 16). Early dropout is common in this indication, and calls for vigilance from the very first session (section 31).
Targeted mechanism. Make visible the cycle linking conditional self-worth, threat, shame and defensive responses; recognise and name shame; get through criticism and failure without collapsing or attacking; reduce anger and devaluation; soften excessive demands; restore the capacity to perceive the other person; repair; and build a sense of self-worth that can bear the ordinary.
| Phase |
Session |
Focus |
Session deliverable |
| I. Alliance |
1 |
Meeting without humiliating |
Reason for coming stated, patient's competence acknowledged |
|
2 |
Goals in the patient's own terms |
Goals chosen, written framework |
|
3 |
Assess |
Mood, suicide risk and consequences assessed |
| II. Understand |
4 |
The cycle of fragile worth |
Cycle drawn with a real episode |
|
5 |
What superiority protects and costs |
Balance written |
|
6 |
Shame |
Shame identified beneath two reactions |
| III. Change |
7 |
Criticism and failure |
One criticism got through differently |
|
8 |
Anger and devaluation |
Response delay established |
|
9 |
Demands and perfectionism |
Two demands softened |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Relationships |
11 |
The other person exists |
A situation reviewed from the other person's point of view |
|
12 |
Repairing |
A repair prepared |
|
13 |
Reciprocity |
An exchange rebalanced |
| V. Consolidate |
14 |
What lies beneath |
Beliefs and history linked |
|
15 |
A realistic sense of self-worth |
Values written, the ordinary accepted |
|
16 |
Review, relapse, next steps |
Plan written, measures repeated |
The last column shows what each session should have produced; each item is detailed in the corresponding session (sections 15 to 30).
What distinguishes this programme from the other manuals on this site. Three things: a patient who can idealise and then devalue their therapist in the same month; a shame that is almost never spoken and that organises everything; and a suicide risk hidden behind self-assurance.
2. Before you begin
The four preliminary decisions
1. Which form dominates? Grandiose, vulnerable, or alternating. The form changes how to engage the patient. Sections 3 and 36.
2. Is there depression or suicide risk? Particularly after a failure, a break-up, a disgrace, legal proceedings. Section 9.
3. Is there violence? Towards a partner, children, subordinates, or coercive control, that is, a set of behaviours — surveillance, isolation, control of money, threats — through which a person restricts their partner's freedom. Section 35.
4. What is the patient asking for? Often not "to change my personality". Rather: to stop being depressed, to save their relationship, to resolve a conflict at work. That is the request you accept.
What this programme does not treat
Patients in whom antisocial traits dominate, with exploitation of others, transgression and violence, who fall under the corresponding manual, Antisocial personality: a therapist's manual, and a risk assessment.
Manic or hypomanic episodes, in which grandiosity, confined to the episode, belongs to a mood disorder (section 7).
Situations of active intimate partner violence, which call first for the victim's protection and a specialised programme for the perpetrator.
How to use it
Read sections 3 to 14 first: they ground the choices made in the sessions. Read section 31 before the first session: the alliance is at stake from the outset, and early dropout is common. The sessions described are key sessions; each may take two or three. Section 39 sets out what must not be dropped. The folder given to the patient contains seven worksheets: 1 "What I want to achieve", with "How we work together" (session 2), 2 "My circle" (sessions 4 and 5), 3 "Just before", on shame (session 6), 4 "Criticism and anger" (sessions 7 and 8), 5 "Other people" (sessions 11 to 13), 6 "From demands to values" (sessions 9 and 15), 7 "When I am hurt" (session 16 and section 33); session 14 has no worksheet of its own.
3. The clinical picture
What defines the disorder
The disorder combines a lasting, pervasive pattern of grandiosity — in fantasy or behaviour —, a need for admiration and a lack of empathy, present since early adulthood and across a range of contexts.
The forms it takes
An exaggerated sense of one's own importance: exaggerating achievements, expecting to be recognised as superior.
Fantasies of unlimited success, power, brilliance, beauty or ideal love.
The conviction of being special, of being understandable only by high-status people or institutions.
An excessive need for admiration.
A sense of entitlement: expecting special treatment, expecting others to fall in with one's expectations.
Exploiting others to achieve one's ends.
A lack of empathy: difficulty recognising others' feelings and needs, or unwillingness to do so.
Envy, or the conviction of being envied.
Arrogance, haughty attitudes.
The two forms
The grandiose form: self-assurance, dominance, active pursuit of admiration, charm, exploitation, anger when contradicted. It is visible, and seldom seeks help.
The vulnerable form: touchiness, anxiety, shame, withdrawal, a sense of being misunderstood or unrecognised, resentment, secretly held fantasies of greatness, depression. It seeks help more often, and is often mistaken for avoidant personality or depression.
The two forms often alternate in the same person: grandiose when all is well, vulnerable after a failure. The classifications mainly describe the first; clinical practice often meets the second.
What patients describe
Rarely narcissism. They describe a world that does not recognise their worth, mediocre or jealous colleagues, a partner who does not understand them, unjust failures. They also describe, when the alliance allows, an exhaustion at having to shine, a fear of being exposed as ordinary, an emptiness, a loneliness in the midst of admiration, and a shame that can become unbearable.
What you see in the consultation
Depending on the form: a self-assurance that seeks to impress, questions about the therapist's qualifications, a way of correcting or dominating the exchange; or a wounded reserve, touchiness at the slightest remark, a complaint of being misunderstood. In both cases, great sensitivity to anything resembling a judgement, and rapid swings between idealisation and devaluation of the therapist.
Epidemiology
General population estimates vary widely depending on methods. The categorical diagnosis, that of the DSM (section 6), is more often made in men. The vulnerable form is probably underdiagnosed. The disorder is associated with relationship difficulties, depression, substance use, and suicide risk after setbacks.
4. The cycle of fragile worth
The model guiding this programme is cognitive and interpersonal. It is presented to the patient without jargon, and without the word "narcissism" if they do not use it.
The central piece
Conditional self-worth: I'm only worth something if I'm exceptional; being ordinary means being worthless; if I'm not the best, I'm nothing. It comes with an excessive ideal self and a shame lurking behind every gap between oneself and that ideal.
It forms in a variety of histories — worth granted only for achievements, boundless admiration that never learned to bear the ordinary, neglect or humiliation that made superiority necessary —, and you do not impose it.
The links
1. A situation of comparison or evaluation. Criticism, a failure, a colleague promoted, a partner less attentive, a look, an expectation.
2. Perceived threat. The gap from the ideal becomes visible: they're going to see I'm not so exceptional.
3. Shame, often brief, rarely conscious, almost never voiced.
4. The defensive response, in one of three forms:
attack — anger, devaluing the other person, contempt, retaliation;
overcompensation — self-aggrandisement, reminding others of one's achievements, dominating;
withdrawal — isolating oneself, self-soothing by solitary means, substance use, losing interest.
5. The immediate effect. Shame is kept at bay, self-worth restored for a while. The response is reinforced: because it brings relief, it is more likely to return at the next threat.
6. Others' reactions. Conflicts, distancing, lost relationships, professional sanctions, isolation.
7. The confirmation, in two forms: other people are mediocre and jealous — which maintains grandiosity — or I'm worthless — which opens onto collapse.
Collapse
When defences are no longer enough — a massive failure, a break-up, public disgrace, illness, ageing —, shame overflows. This is the moment of depression, substance use, and suicide risk. Section 33.
Empathy under threat
Many narcissistic patients can represent what others feel; they often do so very well when they are not threatened. It is under threat that the other person disappears, reduced to an obstacle or a mirror, who now counts only for the image they reflect back. So the work bears less on learning empathy than on its availability when shame is present.
What the treatment does
It makes the cycle visible, teaches recognition and naming of shame, replaces defensive responses with other ways of getting through threat, softens demands and conditional self-worth, gives the other person back their place, and builds a sense of self-worth that can bear the ordinary.
What the model explains to the patient
That they have set the bar very high, and are paying the price. That their reactions of anger or withdrawal protect them from real pain. That this protection is costing them their relationships and sometimes their career. And that it is possible to learn to bear not being exceptional at every moment, without ceasing to be someone.
5. Ordinary narcissism, the popular figure and the disorder
Why this section exists
Because the word "narcissistic" is everywhere: in the media, self-help books, social media, separations. It sometimes denotes ordinary self-confidence, sometimes a difficult partner, sometimes a predator. This confusion harms patients who really have the disorder, and people who suffer from it around them.
What needs to be distinguished
Healthy self-esteem, stable, able to bear criticism and failure.
Ordinary narcissism, a personality trait present in everyone to varying degrees, sometimes useful — ambition, self-assurance, leadership.
Marked narcissistic traits, without major distress or impairment.
Narcissistic personality disorder, with rigid functioning and impairment.
The "narcissistic pervert"
This term, very widespread in the French-speaking world, is not a diagnosis: it appears in neither the DSM-5-TR nor the ICD-11. It came from psychoanalytic thinking, and has become a popular figure denoting a manipulative, cold, destructive person in relationships. What the term describes may, depending on the case, fall under narcissistic personality, antisocial personality, psychopathy, or behaviours of violence and coercive control that correspond to no personality disorder.
What you do: you do not use it as a diagnosis. You hear the suffering of people who use it to describe what they have been through, and refer them to appropriate help, especially in cases of violence or coercive control. You do not use it for a patient.
The weight of the label
The diagnosis of narcissistic personality is today a common insult. Announcing it bluntly to a patient with fragile self-worth can provoke a rupture or a collapse. You describe the difficulties, talk about fragile self-worth and sensitivity to criticism, and answer honestly if the patient asks.