Alliance building and narcissistic personality disorder

What This Research Found

Elsa Ronningstam’s “Alliance building and narcissistic personality disorder” addresses one of the most challenging questions in clinical psychology: how can therapists establish working relationships with patients whose core pathology makes them resistant to the very conditions therapy requires? Published in the Journal of Clinical Psychology in 2012, this article synthesises clinical wisdom about treating narcissistic personality disorder while acknowledging the uncomfortable reality that evidence-based treatments for this population remain scarce.

The fundamental paradox of NPD treatment. Ronningstam begins by articulating why therapeutic alliance—the collaborative relationship between therapist and patient that predicts treatment success across modalities—is so difficult to establish with narcissistic patients. Therapy requires vulnerability, but narcissists defend against vulnerability as if it were death. Therapy requires acknowledging imperfection, but the narcissistic grandiose self exists precisely to ward off such acknowledgment. Therapy positions the clinician as expert and the patient as needing help, but narcissists cannot tolerate the “one-down” position without experiencing unbearable shame. The very conditions that make therapy possible threaten the narcissist’s entire psychological architecture. This explains why most narcissists never seek treatment, why those who do often present with other concerns (depression, anxiety, relationship problems) while concealing the underlying narcissistic dynamics, and why dropout rates are extraordinarily high even among those who initially engage.

How narcissistic defenses manifest in the consulting room. Ronningstam details the specific ways narcissistic patients undermine therapeutic alliance. They may arrive with an attitude of superiority, subtly or overtly communicating that they are more intelligent, accomplished, or sophisticated than the therapist. They test boundaries relentlessly—seeking special scheduling accommodations, questioning the therapist’s credentials, attempting to control the agenda. They engage in idealisation followed by devaluation: the therapist who was initially “the first person who really understands me” becomes “just like all the others” when they fail to provide unlimited admiration or dare to offer challenging observations. They may compete with the therapist, dismissing interpretations while offering their own analyses, or they may become excessively compliant in ways that prevent genuine engagement. Throughout, they struggle to allow the therapist to matter, because mattering means vulnerability to disappointment.

The therapist’s experience and countertransference challenges. Ronningstam does not minimise the personal demands placed on therapists working with narcissistic patients. Sustained devaluation is difficult to tolerate without becoming defensive or withdrawing emotionally. The narcissist’s need to control can leave therapists feeling ineffective, manipulated, or constantly off-balance. Empathising with grandiosity risks colluding with defenses, while challenging grandiosity triggers narcissistic injury and potential dropout. The therapist may find themselves working harder than the patient, carrying hope for treatment that the patient does not share. Ronningstam emphasises that therapists must maintain awareness of their own reactions, seek consultation and supervision, and honestly assess whether they have the resilience and support systems to work with this population. Taking narcissistic patients’ attacks personally is human but therapeutically counterproductive; therapists who need to be appreciated, who cannot tolerate seeming ineffective, or who become punitive in response to devaluation should not treat NPD.

Strategies for building alliance despite resistance. Despite these challenges, Ronningstam outlines approaches that can sometimes enable therapeutic engagement. Therapists must seek the wounded person beneath the grandiosity—understanding that the defensive facade protects against unbearable shame and emptiness—while not colluding with that facade. They must address shame sensitivity indirectly, allowing patients to discover their own patterns rather than having them pointed out. Interventions must be paced carefully: premature interpretation of narcissistic defenses triggers injury and dropout. The therapist must tolerate being controlled, devalued, and found wanting while maintaining professional boundaries and genuine engagement. When moments of authentic vulnerability emerge, the therapist must respond with empathy rather than immediately interpreting, creating space for the patient to experience being genuinely seen without annihilation. This work requires exceptional patience—treatment often spans years with frequent setbacks—and realistic expectations about outcomes.

How This Research Is Used in the Book

Ronningstam’s work on therapeutic alliance appears in Narcissus and the Child in the context of understanding why narcissistic individuals rarely change and why treatment efforts so often fail. In Chapter 3: The Borderline Sibling, the book uses Ronningstam’s research to explain the fundamental differences between borderline and narcissistic treatment responsiveness:

“Limited evidence-based treatments for NPD confirm the difficulty. Transference-Focused Psychotherapy, effective for borderline patients, has been adapted for narcissistic presentations but shows almost no success.”

This observation reflects Ronningstam’s acknowledgment that even approaches with demonstrated efficacy for other personality disorders struggle with NPD. The book also draws on her work to describe what successful treatment requires from clinicians:

“Successful therapists often show exceptional patience and capacity to tolerate being devalued while seeking the wounded person beneath grandiosity.”

This captures Ronningstam’s central insight: that therapeutic alliance with narcissistic patients requires therapists to maintain empathy and engagement through sustained attacks on their competence and worth. The book uses this research to help readers understand why expecting the narcissist in their life to seek and benefit from therapy is often unrealistic—not because treatment is categorically impossible, but because the disorder itself creates formidable barriers to the very help that might enable change.

Why This Matters for Survivors

For those who have been harmed by narcissistic individuals—whether parents, partners, or others—Ronningstam’s research addresses one of the most painful questions survivors face: why won’t they get help?

Their treatment resistance is a feature of the disorder, not a choice they can simply overcome. You may have hoped, pleaded, or even delivered ultimatums about therapy. You may have researched treatment options, found qualified therapists, and made appointments they never kept or attended once and never returned. Ronningstam’s work explains that this pattern reflects the disorder’s fundamental structure, not insufficient motivation or your failure to communicate its importance. The narcissist cannot engage in genuine therapy for the same reasons they could not genuinely engage with you: vulnerability feels like annihilation, needing another person feels like weakness, and acknowledging imperfection triggers unbearable shame. The defenses that made relationship impossible make treatment equally impossible.

Understanding this can help you release the rescue fantasy. Many survivors maintain hope that the right therapist, the right intervention, or enough love and support could unlock change. Ronningstam’s research suggests this hope, while compassionate, underestimates the structural barriers. Narcissists do not merely resist treatment; they experience the conditions treatment requires—vulnerability, honesty, acknowledgment of fault—as existential threats. The very capacity that would allow them to engage in therapy is the capacity their disorder has damaged. This does not mean change is categorically impossible, but it means change cannot come from your efforts, your waiting, or your suffering. If change comes at all, it comes from within the narcissist through a painful process they must choose and sustain despite every defensive impulse to flee.

Their devaluation of you followed the same pattern they would show any therapist. Ronningstam describes how narcissistic patients idealise therapists initially, then devalue them when the therapist inevitably fails to provide unlimited admiration or challenges the narcissistic worldview. You likely experienced this cycle: being wonderful, then suddenly worthless, with no change on your part explaining the shift. Understanding that this pattern would repeat with any therapist—that the most skilled, empathic clinician in the world would eventually be devalued just as you were—can help you recognise that the devaluation was about their pathology, not your inadequacy.

Their attacks on your competence and worth reflect their internal world, not reality. Just as narcissistic patients attack therapists’ credentials, intelligence, and effectiveness, they attacked your worth, your motives, your perceptions. Ronningstam explains this as defensive displacement: by finding fault with others, the narcissist maintains the grandiose self-image that protects against unbearable shame. Their criticisms of you served the same function as their criticisms of anyone who threatens their defensive structure. The content of their attacks reveals their own fears and inadequacies projected outward, not accurate assessments of who you are.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed clinicians, Ronningstam’s work on therapeutic alliance provides essential guidance for both assessing narcissistic pathology and treating its victims.

Realistic assessment of treatment likelihood. When a narcissistic individual is referred for treatment—often at a partner’s insistence, by court order, or following a crisis—clinicians should assess motivation honestly. Is the patient acknowledging any contribution to their difficulties, or exclusively blaming others? Do they show any genuine curiosity about their own patterns, or only seek validation for their existing views? Have they engaged in previous therapy, and if so, why did it end? Ronningstam’s work suggests that patients who present under external pressure, who see nothing wrong with themselves, and who quickly devalue the therapeutic relationship are unlikely to remain in treatment long enough for meaningful work. Clinicians must decide whether to invest limited resources in low-probability cases or to redirect efforts toward more treatable populations.

Preparation for the countertransference storm. Therapists who do take on narcissistic patients must prepare for sustained challenges to their sense of competence. Ronningstam emphasises that devaluation should be expected, not experienced as treatment failure or personal attack. Supervision and consultation are essential—not optional supports but necessities for maintaining perspective. Therapists should honestly assess their own vulnerabilities: those who need to feel helpful, who take criticism personally, or who become punitive when attacked will struggle with this population. The work requires unusual resilience and robust personal support systems.

Survivors of narcissistic abuse need specialised understanding. Patients who were raised by or partnered with narcissists present with distinct clinical features that Ronningstam’s framework illuminates. They have experienced sustained devaluation from someone they depended upon. They have been trained to doubt their own perceptions by someone who reframed reality to serve narcissistic needs. They may have developed trauma bonds that persist despite conscious understanding of harm. Treatment must prioritise validating their experiences, rebuilding trust in their own perceptions, and helping them understand that the narcissist’s treatment of them reflected pathology, not their actual worth. Ronningstam’s description of how narcissistic patients treat therapists helps survivors recognise familiar patterns: the idealisation-devaluation cycle, the attacks on competence, the projection of fault.

Psychoeducation about treatment limitations can protect survivors. Survivors often harbour hopes that the narcissist will eventually seek help and change. Clinicians can use Ronningstam’s research to provide realistic expectations without extinguishing all hope. The likelihood of sustained treatment engagement is low. The likelihood of meaningful change, even with engagement, remains uncertain. The structural barriers—intolerance of vulnerability, shame sensitivity, need for grandiose defenses—are features of the disorder, not choices the narcissist can simply override. This information can help survivors make decisions about their own lives without waiting indefinitely for change that may never come.

Broader Implications

Ronningstam’s analysis of therapeutic alliance in NPD extends beyond individual treatment to illuminate patterns across social systems where narcissistic individuals operate.

The Mental Health System’s Limitations

Mental health systems are designed around assumptions that do not hold for narcissistic patients: that distress motivates treatment-seeking, that patients want to change, that therapist expertise is welcomed. Ronningstam’s work reveals how these assumptions break down with NPD. Narcissists may present for treatment but resist its fundamental requirements. They may use therapy to obtain validation rather than insight, to blame others rather than examine themselves, to acquire psychological language for manipulation rather than genuine self-understanding. Mental health systems might consider developing specialised assessment protocols that distinguish genuine treatment motivation from coerced attendance or supply-seeking, ensuring that limited resources are directed toward patients likely to benefit.

Forensic and Legal Implications

Courts frequently mandate therapy for narcissistic individuals—in custody disputes, domestic violence cases, workplace harassment situations. Ronningstam’s research raises questions about whether mandated treatment serves its intended purpose. A narcissistic individual attending therapy under court order may appear compliant while internally dismissing the process, may provide the “correct” responses without genuine engagement, or may use therapeutic language to further manipulate victims. Forensic evaluators familiar with Ronningstam’s work can better assess whether apparent treatment compliance reflects genuine change or sophisticated impression management. Courts might also consider that mandating therapy for NPD is categorically different from mandating it for conditions where treatment motivation is less structurally impaired.

Workplace Training and Human Resources

Organisations increasingly recognise narcissistic leadership as a source of toxic workplace culture. Ronningstam’s framework suggests that standard interventions—coaching, feedback, leadership development programs—may be ineffective because they require the same vulnerability that narcissists cannot tolerate. A narcissistic executive receiving feedback will likely externalise blame, devalue the feedback source, or appear to accept criticism while internally dismissing it. Organisations might consider that addressing narcissistic leadership requires structural changes (limiting power, increasing accountability, protecting subordinates) rather than expecting the individual to change through coaching or development programs that their pathology prevents them from genuinely engaging with.

The Therapy Industry and Consumer Protection

The growing therapy industry sometimes oversells treatment possibilities for personality disorders. Ronningstam’s honest assessment—that evidence-based treatments for NPD remain limited and that even specialised approaches show modest success—provides a corrective. Family members researching treatment options for narcissistic relatives should understand realistic expectations. Therapists marketing personality disorder treatment should represent success rates honestly. The field might consider whether ethical obligations require clearer communication about the limitations of current treatment knowledge, particularly for conditions where treatment resistance is a core feature.

Training and Professional Development

Ronningstam’s description of the personal demands placed on therapists treating NPD has implications for clinical training. Most graduate programs provide minimal education about personality disorders and even less about the specific countertransference challenges they present. Therapists may take on narcissistic patients without adequate preparation, leading to burnout, therapeutic ruptures, or even harm to the clinician. Training programs might consider whether personality disorder treatment warrants specialised preparation, including not just intellectual understanding but experiential training in managing the emotional demands of this work.

Implications for Survivors Seeking Validation

For decades, survivors of narcissistic abuse have been told that their abusers could change if only they had the right treatment, enough love, or sufficient motivation. Ronningstam’s research, by honestly detailing treatment limitations, provides validation for survivors who have been blamed for not trying hard enough to help the narcissist change. Understanding that treatment resistance is structural—not a matter of insufficient motivation that more love could overcome—can help survivors release guilt about “giving up” on someone whose disorder prevented genuine engagement with help.

Limitations and Considerations

Ronningstam’s influential article has limitations that warrant acknowledgment in interpreting its findings.

Clinical observation rather than controlled research. The article synthesises clinical experience and existing literature rather than presenting new empirical findings. While Ronningstam’s decades of experience provide valuable insights, the recommendations for alliance-building have not been subjected to randomised controlled testing. What works for one clinician’s narcissistic patients may not generalise. The field lacks the controlled trials that would validate specific therapeutic techniques for this population.

Sample bias toward clinical presentations. Ronningstam’s observations derive from narcissistic individuals who presented for treatment—a subset that may differ systematically from the larger NPD population. Those who reach clinical attention may be experiencing crisis, may have exhausted other coping mechanisms, or may have vulnerable rather than grandiose presentations that generate more subjective distress. The most functionally successful narcissists—those whose grandiosity is rewarded by professional achievement—may never encounter mental health services, limiting the generalisability of clinical observations.

Cultural and contextual factors. The article focuses on individual psychotherapy in Western clinical settings. How narcissism manifests across cultures, how alliance challenges vary with cultural expectations about help-seeking and authority, and whether the same therapeutic strategies apply across contexts remain underexplored. What constitutes appropriate therapeutic stance in one cultural context may be ineffective or inappropriate in another.

Evolution of treatment approaches. Since 2012, additional work on NPD treatment has emerged, including modifications of schema therapy, mentalization-based approaches, and transference-focused psychotherapy for narcissistic populations. While Ronningstam’s fundamental insights about alliance challenges remain valid, the treatment landscape continues to evolve. Clinicians should supplement this article with more recent literature on specific treatment modalities.

Historical Context

Alliance building and narcissistic personality disorder appeared in 2012 during a period of growing interest in personality disorder treatment alongside ongoing uncertainty about NPD specifically. The preceding decades had seen significant advances in treating borderline personality disorder, with Dialectical Behaviour Therapy, Mentalization-Based Treatment, and Transference-Focused Psychotherapy all demonstrating efficacy in randomised trials. This progress had not extended to NPD. While the same treatment modalities were being explored for narcissistic presentations, evidence remained limited and outcomes less encouraging.

The article also appeared as public awareness of narcissism was increasing. The term had entered popular discourse, with “narcissist” becoming a common descriptor for difficult people. Yet this popularisation often obscured the clinical complexity Ronningstam addressed. Her article provided a corrective: narcissistic personality disorder is not simply selfishness or arrogance, but a deeply entrenched pattern of defensive organisation that resists the very conditions treatment requires.

Ronningstam wrote from a position of unique authority. Her work at McLean Hospital, her role in DSM-5 development, and her decades of clinical and research focus on NPD made her one of the field’s foremost experts. Her willingness to acknowledge treatment limitations—rather than overselling possibilities—reflected scientific honesty that served both clinicians and the patients and families who needed realistic expectations.

The article has been cited extensively in subsequent literature on personality disorder treatment and has informed how clinicians understand and approach therapeutic work with narcissistic patients. Its core insights—that alliance is the central challenge, that the disorder itself creates treatment resistance, that exceptional demands are placed on therapists—remain as relevant today as when first published.

Further Reading

• Ronningstam, E. (2005). Identifying and Understanding the Narcissistic Personality. Oxford University Press.
• Ronningstam, E. (2017). Intersect between self-esteem and emotion regulation in narcissistic personality disorder: Implications for alliance building and treatment. Borderline Personality Disorder and Emotion Dysregulation, 4, 3.
• Ronningstam, E. & Weinberg, I. (2013). Narcissistic personality disorder: Progress in recognition and treatment. FOCUS, 11(2), 167-177.
• Kernberg, O.F. (1975). Borderline Conditions and Pathological Narcissism. Jason Aronson.
• Kohut, H. (1971). The Analysis of the Self. International Universities Press.
• Clarkin, J.F., Yeomans, F.E., & Kernberg, O.F. (2006). Psychotherapy for Borderline Personality: Focusing on Object Relations. American Psychiatric Publishing.
• Diamond, D., Yeomans, F.E., Stern, B.L., & Levy, K.N. (2021). Treating Pathological Narcissism with Transference-Focused Psychotherapy. Guilford Press.
• Pincus, A.L. & Lukowitsky, M.R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421-446.