Narcissistic personality disorder is a chronic condition known for its lack of empathy, need for admiration, and pervasive pattern of grandiosity. This condition affects approximately 1% to 2% of the general population, with higher rates found among those engaging in mental health treatment. Those who seek treatment often reach out for help because of a comorbid condition such as mood, anxiety, or substance use disorders. Other presenting concerns can include legal, relational, and vocational problems. Keep reading to learn how to create a narcissistic personality disorder treatment plan, with the parts that I include + a real-world example.
Narcissistic personality disorder treatment can be challenging to navigate, as the dropout rate for psychotherapy for adults with this condition is about 64%. Those who experience perfectionism, shame, devaluation, and poor attachment have a higher risk of dropping out of treatment prematurely.
These factors highlight the importance of creating a comprehensive and personalized narcissistic personality disorder treatment plan. You can do this by establishing a healthy alliance with clear boundaries, setting realistic goals, addressing underlying self-esteem concerns that contribute to their symptoms, and monitoring countertransference. External motivation is common and can come from a spouse, partner, work, or other family member. Understanding your client’s underlying motivation for treatment can help you personalize your treatment plan for narcissistic personality disorder.
Setting Goals and Objectives With Clients
Creating an effective treatment plan is the first step you can take to reduce the risk of treatment dropout. You may find that your clients enter treatment with hesitation or ambivalence. Some may experience skepticism, which requires thoughtful engagement. Treatment plan goals can provide structure for your sessions, set expectations, and help your clients see the benefits of engaging in psychotherapy.
Your therapeutic alliance should be a strong focus at the beginning of treatment because it can provide a solid foundation to build on. You can do this with simple behaviors, such as being consistent, respectful, and non-judgmental, while maintaining your boundaries. You may see clients demonstrate higher levels of participation if you take a collaborative approach to treatment that allows them to feel heard and understood.
Once you have assessed your client’s source of motivation, you can then begin establishing meaningful treatment goals. This can include addressing external factors. Goals that feel personal and have clear benefits will provoke more engagement than cookie-cutter goals.
Another way to promote session engagement is to use therapeutic worksheets. I have found the clinical worksheets available with TherapyByPro to be valuable resources, especially since they are customizable. This allows me to tailor them to my clients’ symptoms, motivations, and goals. In addition to their treatment plan and session note template, there are several worksheets that I would consider using with a client who has been diagnosed with narcissistic personality disorder, including:
What to Include in a Treatment Plan for Narcissistic Personality Disorder + Example
The remainder of our page will focus on creating a narcissistic personality disorder treatment plan, using the customizable treatment plan offered at TherapyByPro. I gravitate towards this template because it can be adjusted for clients with varying demographics, symptoms, and mental health disorders. Continue reading for an introduction to the hypothetical case for John Smith.
John’s Story:
John is a 40-year-old male who was admitted to an inpatient substance abuse treatment program after completing detox for alcohol. John agreed to detox after being arrested for his second DWI. He was referred to treatment by his attorney, which was supported by his wife, who has been concerned about his drinking since his previous DWI about one year ago.
John reported a long history of drinking beginning as a teenager. He currently drinks most days of the week, consuming 6 to 12 beers per day. During his assessment, he endorsed drinking more than intended, noting that he has intense cravings. His intake paperwork indicated impulsiveness, irritability, and a pattern of risk-taking behaviors like driving impaired.
John showed difficulty understanding how his wife is affected by his drinking and voiced concern about having social repercussions from not being able to drive in his social circle. He blames law enforcement for his DWI, noting that the officer should have let him go because he was close to home and driving safely. John reported being open to inpatient treatment because his attorney said it could help his legal case. While in detox, he began taking Naltrexone to decrease his cravings, which he has found to be helpful.
Agencies Involved and Plans for Care Coordination
For this case, I would consider coordinating care with his primary care physician, especially if he begins taking medications to help manage the frequency and intensity of his cravings. At an inpatient facility, psychiatric care would be available within the unit, which would not typically require additional consents for release.
Example for John:
Care Coordination: Primary Care Physician, Dr. Smith (123)456-7890
Clinical Diagnoses
Based on the information provided, John meets the criteria for Narcissistic Personality Disorder (NPD) and Alcohol Use Disorder (AUD), Severe. As an inpatient rehabilitation program, the focus of his intake would be on understanding his addiction. The severity rating for his addiction was based on the hazardous use, continued use despite previous DWI, impaired judgment, risk-taking behaviors, and an increase in the amount and frequency of his use.
Example for John:
Clinical Diagnosis: Alcohol Use Disorder, Severe (303.90), and Narcissistic Personality Disorder (301.81)
Current Medications and Responses
While in detox, John began taking Naltrexone to manage cravings. Since he found this medication to be helpful, it would be continued. This medication can be used long-term in some cases. Medical providers often require liver function tests for continued use. If his medication regimen changes, the treatment plan can be modified accordingly.
Example for John:
Current Medications: Naltrexone, 50mg once daily
Presenting Problem and Related Symptoms
The case conceptualization included in this section of your treatment plan should clearly support your included diagnosis with evidence of your client’s symptoms. The content should also support the goals and objectives that will be included in the following section of your narcissistic personality disorder treatment plan.
Example for John:
John is a 40-year-old male who was admitted to an inpatient substance use treatment program following successful completion of alcohol detoxification. This admission occurred after his second arrest for driving while intoxicated (DWI), with referral initiated by his attorney and supported by his wife. She reports longstanding concern about his alcohol use following a previous DWI approximately one year earlier, showcasing a persistent and escalating pattern of alcohol use.
John reports alcohol use beginning in adolescence, which progressed to near-daily drinking in adulthood. He reported consuming approximately 6 to 12 beers per day, 5 to 6 days each week. He acknowledged drinking in larger amounts than intended and experiencing intense cravings, consistent with loss of control over use. Further discussion indicated impulsivity, irritability, and recurrent engagement in high-risk behaviors, including driving while impaired, despite awareness of legal and safety consequences.
Additionally, John exhibits personality features consistent with Narcissistic Personality Disorder. During assessment, he demonstrated limited empathy for the impact of his drinking on his wife, with a larger concern being on the consequences his social life and reputation could have. He externalized blame for his most recent DWI, asserting that law enforcement acted unfairly and should have exercised discretion due to his proximity to home. DWI paperwork indicated that he was speeding and showing signs of impaired driving.
John’s motivation for treatment is external, mainly, as his attorney advised that it could positively influence his legal outcome. While in detox, John began taking naltrexone to decrease his alcohol cravings and found it to be helpful. He is receptive to completing rehab, though he struggles to see the benefits of sobriety outside of helping his pending DWI case.
Goals and Objectives
When possible, I try to have a collaborative approach to developing treatment plan goals and objectives. I have found that this can support the therapeutic relationship and ensure that my clients are motivated for the goals we are working towards. This section of my treatment plans is updated during routine treatment plan reviews to reflect their progress or circle back to more prevalent concerns.
Example for John:
Goal 1: Maintain Sobriety
- Objective 1: Continue taking Naltrexone as prescribed
- Objective 2: Identify the benefits and downsides of continued alcohol use
- Objective 3: Utilize relapse prevention skills with cravings, triggers, and other high-risk experiences
- Objective 4: Establish a daily routine that supports recovery to avoid downtime and boredom
Goal 2: Increase Accountability
- Objective 1: Explore and identify alcohol-related behaviors that he is responsible for
- Objective 2: Learn and implement impulse-control strategies to reduce impulsivity
- Objective 3: Identify transportation alternatives to stop driving while impaired
- Objective 4: Develop a relapse prevention plan that can be used post-discharge
Goal 3: Improve Insight and Interpersonal Challenges Related to NPD Symptoms
- Objective 1: Increase awareness of the interpersonal impact of symptoms like entitlement, lack of empathy, and defensiveness
- Objective 2: Increase emotional awareness and ability to tolerate vulnerability
- Objective 3: Reduce blaming behaviors
Specific Interventions to Be Used
I find this section of my treatment plans to be helpful before individual or group sessions. The interventions section of my treatment plans outlines specific, evidence-based interventions that support the current goals and objectives. This can be a good reminder of what we have worked on and what we’re working towards in session.
Example for John:
Intervention 1: MI-based exploration of his ambivalence toward sobriety
Motivational Interviewing techniques will be used to explore John’s mixed feelings about sobriety, strengthen intrinsic motivation for change, and increase alignment between his values, goals, and substance use behaviors.
Responsible Person: Counselor
Intervention 2: Identify triggers, internal and external, that contribute to continued alcohol use
John will identify emotional states, thought patterns, social situations, and environmental cues that increase cravings or lead to alcohol use, increasing awareness of relapse risk factors.
Responsible Person: John
Intervention 3: Behavioral chain analysis regarding his recent DWI arrest
A behavioral chain analysis will be completed to examine events, thoughts, emotions, and behaviors leading up to the DWI, as well as consequences, to identify intervention points and alternative coping responses.
Responsible Person: Counselor and John
Intervention 4: Psychoeducation regarding alcohol’s effect on judgment, coordination, and the cycle of addiction and relapse
Psychoeducation will be provided to increase insight into how alcohol impacts decision-making, impulse control, and physical coordination, as well as reinforce understanding of the addiction and relapse cycle.
Responsible Person: Counselor
Intervention 5: Develop a safety plan that includes alternative transportation plans and identifies social supports
Responsible Person: John
Intervention 6: Identify maladaptive schemas, such as entitlement and grandiosity
Responsible Person: John and Counselor
Family Involvement
For this case, it may be helpful to begin couples counseling for John and his wife. This can help improve communication, establish boundaries, and rebuild trust. This can also be a valuable time to provide his wife with education regarding alcoholism, recovery, and narcissistic personality disorder. Family programming is common in inpatient rehabs and can often be continued in outpatient settings.
Example for John:
Family Involvement: Couples Counseling with his Wife
Additional Services and Interventions
A standard recommendation for those in rehab programs is peer-led 2-step programs. A popular example is Alcoholics Anonymous. This program can provide continued support at home, hold people accountable, and help establish a recovery-oriented routine. Rehabs often include meetings as part of comprehensive care so clients can acclimate to themselves and to groups.
Example for John:
Additional Services: Attend AA meetings 3 x week
Estimation for Completion
Based on his symptoms, it is likely that his rehab stay would last eight weeks. This, of course, is impacted by his progress and other factors, such as insurance coverage. Insurance may require prior authorization demonstrating the medical necessity for care before his admission.
Example for John:
Estimated Time for Completion: 8 weeks of inpatient rehab
Aftercare Plans
As noted earlier, dropout rates for those with an NPD diagnosis are high. I use the aftercare section of my treatment plan as a guide for referrals, in the event of early termination or discharge. In this case, since John is receiving inpatient treatment, I would recommend that he see his primary care physician for a referral to continue his treatment. If he completes rehab, outpatient care is typically recommended. Depending on the severity of his symptoms, this may include partial hospitalization, intensive outpatient, or traditional outpatient care.
Example for Jane:
Aftercare Plans: Refer to Primary Care Physician for medication management services and referral for continued substance abuse and mental health treatment.
Final Thoughts On Creating a Narcissistic Personality Disorder Treatment Plan
When you begin developing your narcissistic personality disorder treatment plan, focusing on tailoring it to your client’s needs can help minimize the chances of an early dropout. It is common for adults with NPD to be hesitant or ambivalent regarding treatment and to have external motivations driving their treatment participation.
Developing a treatment plan collaboratively with your client can help promote participation and the continuation of treatment. To learn more about evidence-based approaches for narcissistic personality or substance use disorders, consider training and continuing education opportunities in your respective field.
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Resources:
- Weinberg I, Ronningstam E. Narcissistic Personality Disorder: Progress in Understanding and Treatment. Focus (Am Psychiatr Publ). 2022 Oct;20(4):368-377. doi: 10.1176/appi.focus.20220052. Epub 2022 Oct 25. PMID: 37200887; PMCID: PMC10187400.
