The author presents his understanding and experience of working with clients who exhibit pathological narcissism. Some of the challenges that arise in the treatment process are considered from a psychodynamic perspective, particularly how destructive elements manifest themselves and impact the therapeutic relationship. After a brief overview of various theories, the etiology of narcissism, transference issues, and narcissistic vulnerabilities, the author focuses on pathological processes, particularly destructive elements. The challenge of working with these issues is described, including the way the defenses of the narcissistically organized client are threatened by the separateness of the client and the therapist. The article concludes with an examination of those aspects of treatment that must be considered when undertaking psychotherapy with narcissistic individuals, particularly from a relational orientation.
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