The National Education Alliance for Borderline Personality Disorder’s (NEA-BPD’s) call-in series featured a lecture by Frank Yeomans, MD, PhD, regarding Narcissistic Personality Disorder (NPD). In an earlier article, we re-capped what Yeomans laid out as the defining characteristics of Narcissistic Personality Disorder (NPD). In this article, we will look at the two types of narcissists Yeomans spoke about and the obstacles that might be in the way of effective NPD treatment.
Narcissists have unrealistic images of themselves as being flawless people who are superior to others. The image of perfection that narcissists project is there to cover up the fact that on the inside they are remarkably insecure and have very low self-esteem. Yeomans suggested that there are two types of narcissists – thick-skinned and thin-skinned – and that thin-skinned narcissists may be more likely to seek NPD treatment.
As Yeomans explained it, a thick-skinned narcissist has a very effective defensive armor that they use to fend off any observations or criticisms that might reveal their negative traits. They don’t acknowledge or absorb criticism at all, so they remain in a bubble where nothing they do is wrong and everyone else is inferior to them and to blame.
Thick-skinned narcissists have an extra layer of unreality protecting them from meaningful self-realizations that might threaten their sense of themselves as superior human beings.
On the other hand, Yeomans described thin-skinned narcissists as being much more fragile when it comes to perceived criticism. A thin-skinned narcissist’s sense of grandiosity may crumble simply as a result of looking at them the wrong way.
Thin-skinned narcissists may be more likely to seek professional NPD treatment for their problems, as it is not uncommon for them to develop depression or powerful feelings of hopelessness. Once NPD treatment has begun, it may take awhile before a therapist determines that the underlying issue of narcissism is what is really behind the patient’s depression.
Challenges of NPD Treatment
Due to the fact that narcissists cannot emotionally tolerate perceived flaws or imperfections in themselves, Narcissistic Personality Disorder treatment presents some real challenges. Therapists must seek to guide their narcissistic clients toward important self-realizations without alienating them from the therapeutic process altogether.
The goal of treating Narcissistic Personality Disorder is to help the client develop a healthy, balanced sense of themselves with both strengths and weaknesses. However, therapists with narcissistic clients often must tread very carefully in order to avoid challenging their clients’ defensive systems and causing them to flee NPD treatment altogether.
Yeomans described some of the challenges to effective treatment of Narcissistic Personality Disorder. He explained that clients can be so remarkably over-sensitive to criticism that they devalue the therapist completely by taking a position of arrogant superiority over them. If the patient has no respect for the therapist, it can make progress difficult.
In one instance when his client continually pointed out how inferior she believed her therapist to be, Yeomans replied with compassion that “it must be difficult to have a therapist with so many limitations.” In saying this, he accepted the flaw she was projecting on to him and demonstrated that accepting a flaw about himself did not make him less whole or less capable of doing his job effectively.
Over time, by taking their patient’s criticisms in stride, the therapist becomes an example of a person who has both positive and negative characteristics and a realistic self-image. When a patient sees this quality in their therapist, they may be able to see it in themselves as well and eventually work toward a more balanced and healthy self-image.