Steele's Notes on NPD
NPD vs BPD
Generally have less capacity than BPD to mentalize, lack more insight, have more difficulty recalling early abuse/neglect, have less empathy toward others
Severely avoidant of genuine connection;
May need to keep a power differential in the relationship
Don’t respond well to being reassured that they are “human” and “normal,” unlike most borderline clients.
Classic NPD symptoms & behaviours
Arrogant, entitled, critical, controlling, lacks empathy
Inflated “self” is a defense against shame and devalued “self”
Experiences related to devalued self are completely avoided or denied
Generally are unable to acknowledge devalued self
Therapist should not explicitly confront the defense
Acknowledge that it might be lonely and challenging to feel that no one else is good enough
Explore any perceived disadvantages to the defense
Fragile NPD
Alternate between grandiosity and inadequacy
Unhappy, critical of others, anxious, envious, competitive, and have extreme reactions to perceived slights or criticism
Tend to obsessively compare themselves with others
Strong perfectionism
Have narcissistic defenses that work well until they are criticized or rejected
Can access their devalued self: therapist can focus on root causes of devalued self
Reversed NPD
Strong belief and need to be the worst, the sickest, the most traumatized patient
Underlying need to be special, but due to dysfunction, not adequacy
Strong need for validation and compassion
Therapist focuses on emotional validation and less on content of distress
Encourage client to communicate through more positive experiences and affect (compassionately shift focus from negative to positive experiences
Treatment approaches for NPD
Trauma-based in many clients
Certainly affected by quality of early relationships (neglect)
Work with conflicting idealized and devalued selves
Work with inner critic and perfectionism
Mentalization based treatment
Transference based psychotherapy
Dialectical behavior therapy
EMDR and other approaches to resolve early traumatic memories (often not explicitly accessible in the narcissistic patient)
Treatment approaches in Fragile NPD
Identify the conflicting idealized and devalued selves
Help client notice swings between the two
Help client recognize the distortions in both
“I suffer more than anyone; my abuse was the worst; I am completely damaged”
Versus
“I could have been and should be the best”
Help client deal with relentless inner critic
From Kathy Steele’s presentation 'Integrating Personality Disorders in our Work with Complex Trauma and Dissociation' (PDF), 18 August 2021, Delphi Centre.
[Transcribed from a PowerPoint presentation without notes; therefore this post is without context]
