Survey of psychotherapeutic approaches to narcissistic personality disorder.

The spectrum of Narcissistic Personality Disorder extends from severe impairment to high levels of success, fame, power, and wealth. Several treatment frameworks are available. The therapist must be flexible to choose and shift between libidinal and narcissistic issues to those of ambivalence or ego syntonic character defenses or to focus on ego defense mechanisms or object relationships (Esmiol, 1974). A curative process requires enduring corrective structural changes within distorted intrapsychic configurations manifesting themselves as psychopathology (Horowitz, 1976). These structural changes come about by completion of the working through process. Recurrences will occur, even with insight, but self-mastery enables the patient to take on new functions formerly avoided. In Kohut's view, more cohesive reorganized personality is characterized by (Goldberg, 1973): increased empathy within interpersonal relationships and toward the self; previous rebuffs, failures, and separations of fragmenting consequences and turmoil are experienced with minimal reversible regression; object relations improvement without evidence of extreme narcissistic sensitivity; improved sense of humor indicating a capacity for flexible detachment and distance from the self; emergence and proliferation of satisfying creative talents; increased capacity to work alone and achieve personal gratification; capacity to give without contingencies of anticipated personal gain; and capacity to genuinely recognize and mourn the loss of an important real other.