Although individual psychodynamically informed treatment is generally recommended to achieve lasting character change, other therapeutic modalities have a role in special circumstances. Conjoint marital and individual therapy have been found useful in the treatment of narcissistic decompensations of what Bird et al. dubbed “the ‘collapsible’ man of prominence.” These authors described prominent, successful, narcissistic men who presented in childlike crises characterized by feelings of helplessness, inadequacy, desperation, and confusion. Although they tended at first to blame work-related stress, closer evaluation revealed that a threat to the stability of their marriages was the true precipitant. They needed to be viewed as faultless, perfect, and strong, and without the admiration of their wives, their sense of well-being collapsed and their self-cohesion fragmented. Their wives functioned as primitive selfobjects. The wives themselves had strong needs for self-effacement and service to others, yet even they had come to the ends of their ropes with their insatiably demanding husbands. The treatment involved intensive long-term individual psychotherapy for both spouses, as well as conjoint marital therapy for those couples who, through their individual therapies, had come to the point of being able to modify their marital interaction. The husbands were then able to tolerate conflict within the marriage without collapse. The wives no longer needed their husbands to depend on them for admiration and were able to abandon the position of the fed-up, angry wife.

In addition to such matching of narcissistic and masochistic partners, we have frequently encountered marital pairing of narcissistic with borderline personalities. In such couples, the ever-demanding borderline partner serves as an externalization of the narcissistic individual’s own superego. In this way, the narcissist’s inner psychic struggle is externalized, and his or her own relentless superego demands are simultaneously defended against (the “irrationality” of his wife’s demands) and satisfied (he continues to “try,” hopelessly, to be the “perfect husband”). His emotional detachment and guardedness against intimacy are also easily rationalized in the face of such a threatening partner. At the same time, he can vicariously enjoy the acting-out of aggression while disavowing it. The elucidation of such dynamics in conjoint individual and marital therapy can contribute to a loosening of destructive marital patterns. According to one student of marital therapy for narcissistic individuals, successful therapy can serve as a “reparative interpersonal experience”.

Group Therapy
Narcissistic patients generally have been considered problematic candidates for treatment with group therapy. Their lack of empathy, sense of entitlement, and hunger for admiration can lead to their being scapegoated and extruded from the group. Moreover, their devaluation of the group and of the therapist can be destructive of group cohesion and the therapeutic experience of other group members.

Paradoxically, some of the very same interpersonal problems that make narcissistic patients difficult group members are indications for group treatment. If the patient has some redeeming feature (such as a sense of humor) that allows him or her to become integrated into the group, and if the group itself is coherent and mutually supportive, then the group can function as a safe “holding environment.” Within this environment, the narcissistic individual’s pathological behavior can be confronted firmly yet supportively and underlying, formerly disavowed needs and affects acknowledged. Maladaptive interpersonal patterns can be modified under the effect of modeling and group pressures to become involved in the problems of others and to take emotional risks. The group experience can mobilize and alter deeply entrenched patterns that may otherwise stalemate individual treatments.

However, group therapy alone, without concomitant individual psychotherapy, is rarely if ever sufficient treatment.

Conclusions
The treatment of narcissistic personality disorder is always challenging and frequently taxing for the therapist. Whatever the particular goals and modalities of a treatment, an understanding and empathic appreciation of the psychodynamics of narcissistic personality disorder, as well as of narcissistic transferences and countertransferences, are essential for therapeutic work. Many therapists find that a patient roster that includes more than a handful of patients with narcissistic personality disorder in psychotherapy at any one time can seriously strain their capacity for sustained empathic and interpretive work. Timely consultation with a colleague is recommended for a therapist who is experiencing countertransference responses to a patient with narcissistic personality disorder that are interfering with the treatment of the patient or even with the therapist’s overall professional functioning. Such responses are not uncommon.

We have emphasized the difficulties inherent in the treatment of narcissistic personality disorder. The potential rewards are in proportion to certain difficulties. Whether in a brief therapy or in psychoanalysis, in marital treatment or in a group, the coming alive affectively, sometimes for the first time, of a patient with narcissistic personality disorder can be a profoundly gratifying experience for both the patient and the therapist.