How to Spot a Narcissist in the Counselling Room

Today, I wish to discuss a contentious issue within the realm of therapy: narcissistic personality disorder and its impact on relationships. Additionally, I aim to explore how individuals and couples affected by this personality disorder may present themselves in a counselling setting and identify key aspects therapists should be aware of.

Let's begin by defining NPD. According to the fifth edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders), Narcissistic Personality Disorder (NPD) is categorised among the ten recognised personality disorders. The following criteria are used for an official diagnosis of NPD:

• A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognised as superior without commensurate achievements)

• A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions

• A need for excessive admiration

• A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)

• Interpersonally exploitive behaviour (ie, the individual takes advantage of others to achieve his or her own ends)

• A lack of empathy (unwillingness to recognise or identify with the feelings and needs of others)

• Envy of others or a belief that others are envious of him or her

• An exhibition of arrogant and condescending behaviours or attitudes

While this list is helpful, some may argue that it describes only a few different presentations of NPD, and that there is a lot more variety and nuance in terms of how different narcissists with different traits can present themselves, especially in the area of intimate relationships.

As a therapist specialising in relationship counselling, I can assert from professional experience that identifying a narcissist can be quite challenging. This difficulty is compounded by the fact that only a limited number of therapists worldwide are trained to recognise and address this personality disorder.

Additionally, in many Western countries, therapists are prohibited from diagnosing or even suggesting that a client might have a personality disorder, especially in the absence of the client. Consequently, when working with an individual who describes being in a relationship with a "very challenging partner" displaying difficult behaviour, therapists are often discouraged from addressing it directly.

Furthermore, a major challenge in treating individuals with Narcissistic Personality Disorder (NPD) is their inherent psychological rigidity and unwillingness to accept responsibility for their actions, which are fundamental aspects of the disorder. Consequently, even if a therapist addresses these issues, it may result in a negative outcome. Nonetheless, this represents only one perspective on narcissism.

Given these challenges, how can a therapist identify these traits and work effectively with such clients? This topic is widely debated within the professional community, with significant differences in opinion among various schools of thought. Some practitioners contend that addressing Narcissistic Personality Disorder (NPD) in therapy is feasible by concentrating on the individual's core trauma and helping them take responsibility for their problematic behaviour.

As previously stated, some argue that individuals with Narcissistic Personality Disorder (NPD) inherently lack the ability for self-reflection. Their narcissism serves as an impenetrable defence mechanism, shielding them from the underlying shame that contributes to their abusive behaviour and entitled mindset. According to this perspective, therapy could potentially exacerbate the situation by exposing deep-seated toxic shame, which may increase the risk of more severe behaviour. The narcissist's inability to cope with this exposure could place their partner at even greater risk.

Some individuals challenge the idea that those with Narcissistic Personality Disorder (NPD) experience profound underlying shame and grapple with self-esteem issues. They argue that individuals with narcissistic traits deliberately choose manipulative and exploitative behaviours, suggesting that trauma is not the primary cause of their disorder. Instead, they propose that NPD is a pathology with a significant genetic component. Additionally, they point out that many individuals who have endured extensive trauma do not resort to manipulation and exploitation for personal gain as someone with NPD does.

Ultimately, this remains a field requiring further evidence-based research, with a need for broader acknowledgment of the significance and prevalence of disordered individuals by both society and the therapeutic community. The topic is contentious for a reason, as many find it challenging to accept the possibility that some individuals may inherently lack empathy, kindness, and integrity, and may have malicious intentions.