Heal NPD

In this episode, Dr. Mark Ettensohn examines what self-esteem actually looks like in pathological narcissism and why common explanations such as “low self-esteem hidden beneath grandiosity” or “grandiosity masking shame” oversimplify a much more complicated psychological process. 
The episode begins by examining self-esteem as a regulatory system rather than a fixed quantity that a person either has or does not have. Healthy self-esteem is generally stable, realistic, and basically positive. Dr. Ettensohn explains how pathological narcissism can involve difficulties in all three areas, producing self-appraisals that are unstable, highly reactive to circumstances, and capable of shifting between unrealistically positive and unrealistically negative views of the self.
The discussion explores the grandiose and vulnerable self-states associated with pathological narcissism. Grandiosity can involve genuine feelings of superiority, exceptionalism, or importance, while vulnerable states may involve shame, humiliation, inadequacy, depression, envy, or anxiety. These states can alternate, overlap, and interact in complicated ways. Neither necessarily represents the person's “real” self hiding underneath the other.
Dr. Ettensohn also discusses the development of self-esteem regulation, including the interaction between temperament, heritable traits, relationships, and developmental experience. Rather than reducing pathological narcissism to a single cause, contemporary models understand personality pathology as emerging through complex interactions between the characteristics people bring into the world and the experiences through which their personalities develop.
The episode then considers behaviors frequently associated with pathological narcissism, including arrogance, entitlement, idealization, devaluation, exploitation, and impaired empathy. These features are often discussed as though they stand apart from problems of self-esteem. Dr. Ettensohn explains how they can instead function within a larger system of self-esteem regulation, particularly when grandiosity is recruited to maintain or restore a threatened sense of self.
At the same time, none of these features by itself establishes pathological narcissism. People can be arrogant, entitled, grandiose, low in empathy, or insecure without having NPD. They can also have unstable or chronically low self-esteem without being narcissistic. Pathological narcissism refers to the larger organization of these features: the vulnerability of the self-esteem system, grandiose and vulnerable self-states, and the characteristic regulatory strategies used to maintain, protect, or restore the person’s sense of self.
Ultimately, the episode challenges attempts to reduce narcissistic psychology to a single hidden truth beneath the surface. Grandiosity can sometimes defend against shame, but that particular dynamic should not be mistaken for an explanation of the disorder as a whole.⸻Additional ResourcesWebsite: https://healnpd.orgNewsletter: https://healnpd.substack.com
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About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this episode, Dr. Mark Ettensohn examines the circular logic that often appears in popular “narcissistic abuse” discourse and how it can create a closed system for interpreting other people’s behavior.
The episode begins with a pattern Dr. Ettensohn has repeatedly encountered online: once someone concludes that another person is a narcissist, virtually any response can become further evidence of narcissism. Disagreement becomes an inability to tolerate criticism. Anger becomes narcissistic rage. Denial becomes DARVO. Withdrawal becomes the silent treatment. An apology becomes manipulation or hoovering. Even evidence that contradicts the original conclusion can be reinterpreted as proof that the narcissist has successfully deceived others.
Dr. Ettensohn argues that this creates an essentially unfalsifiable framework. If both an accusation and its denial can be treated as evidence of guilt, there is no independent standard by which the original interpretation can be tested or revised. Rather than asking what explanation best accounts for another person’s behavior, the process begins with a conclusion and assembles evidence around it.
Drawing on his experience conducting psychological assessments, Dr. Ettensohn discusses how this reasoning can persist even when a person does not meet criteria for Narcissistic Personality Disorder or pathological narcissism. He explores how the extensive vocabulary of popular narcissistic-abuse content can encourage people to infer hidden motives and psychological states from ambiguous behavior while becoming increasingly resistant to alternative explanations.
The episode also challenges the widespread conflation of pathological narcissism with abuse. People with NPD can behave abusively, but abusive behavior does not itself establish the presence of pathological narcissism. Recent research has likewise raised questions about treating pathological narcissism as a general explanation for intimate partner abuse.
Ultimately, the discussion asks a basic epistemological question: If every possible response can be interpreted as evidence that someone is a narcissist, what evidence could ever show that the conclusion was wrong?
References:Day, N. J. S., Kealy, D., Biberdzic, M., Green, A., Denmeade, G., & Grenyer, B. F. S. (2025). Coercive control and intimate partner violence: Relationship with personality disorder severity and pathological narcissism. Personality and Mental Health, 19(4), e70038.
https://onlinelibrary.wiley.com/doi/full/10.1002/pmh.70038
⸻Additional Resources
Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
  About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this follow-up to a previous episode, Dr. Mark Ettensohn examines a central problem in the way narcissism is commonly discussed online: the assumption that abusive behavior is sufficient evidence of narcissism.
The episode argues that this conclusion arises, in part, from a longstanding problem in the DSM diagnostic criteria for Narcissistic Personality Disorder. Many of the interpersonal characteristics traditionally associated with NPD, including entitlement, impaired empathy, exploitation, arrogance, and refusal to take responsibility, are also common features of abusive relationships in general. As a result, virtually any abusive relationship can appear “narcissistic” without establishing that pathological narcissism is actually present.
Dr. Ettensohn explores how this lack of specificity has contributed to the widespread popularity of the concept of “narcissistic abuse,” and why it has become increasingly difficult to distinguish abusive behavior from pathological narcissism itself. He argues that contemporary research has moved toward understanding pathological narcissism as a disorder of identity and self-esteem regulation characterized by fluctuating grandiose and vulnerable states, rather than simply a collection of observable interpersonal behaviors.
The episode also examines how popular discussions of narcissism often continue to rely on the older behavioral framework while separating the term “narcissism” from its underlying clinical construct. Dr. Ettensohn argues that this creates conceptual confusion, contributes to public stigma surrounding NPD, and encourages people to mistake abuse itself for evidence of narcissistic pathology.
Ultimately, the discussion asks a simple question: When does abusive behavior actually indicate pathological narcissism, and when are we simply describing abuse?
To see the video this follows up: https://youtu.be/lcIEM7IVXxk
⸻
Additional Resources
Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
 
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
 
About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

 
About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

Dr. Mark Ettensohn examines the common claim that personality disorders such as narcissistic personality disorder (NPD) are either caused by trauma or are primarily genetic. He argues that this framing presents a false dichotomy and does not reflect how personality development is understood in contemporary psychology.
The discussion begins by reconsidering what psychologists mean by the word trauma. Rather than treating trauma as a particular kind of event, Dr. Ettensohn explores the idea that trauma is better understood as the psychological injury resulting from life experiences. This distinction helps explain why children raised in the same family can have very different developmental outcomes despite sharing many of the same experiences.
The episode also examines the role of temperament and other heritable factors in personality development. While genetic predispositions influence how individuals experience and respond to their environments, they do not determine personality disorders in isolation. Instead, personality emerges through the ongoing interaction between biology and developmental experience.
Finally, Dr. Ettensohn addresses common arguments based on brain imaging and twin studies, explaining why these findings are often misunderstood in discussions about heritability. The episode considers the importance of construct validity, operationalization, and measurement when interpreting research on personality disorders, arguing that simplistic claims about either trauma or genetics fail to capture the complexity of human psychological development.
Additional Resources
Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON GOOGLE PODCASTS: https://rb.gy/fotpcaLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
 
About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

Dr. Mark Ettensohn examines the concept of “narcissistic abuse” and explains why he no longer considers it a coherent psychological construct.
Using the comment from a viewer as a starting point, the discussion explores a common misconception: that skepticism toward the concept of narcissistic abuse reflects a lack of empathy for victims. Dr. Ettensohn argues that his concern is not with the reality of abuse or the suffering of those who experience it, but with the explanatory framework that has developed around the term.
The episode examines the concept through the lens of construct validity, asking what psychological phenomenon the term actually refers to and whether it identifies a distinct form of abuse beyond categories that are already well established in psychology. The discussion considers the problems of operationalization, the distinction between observation and inference, and why labeling abuse according to the presumed diagnosis of the perpetrator differs from defining abuse by the harm it causes.
Dr. Ettensohn also revisits his own earlier use of the term, explaining how his thinking has evolved over time. He distinguishes between psychoanalytic concepts such as narcissistic injury and the contemporary online usage of “narcissistic abuse,” arguing that these represent fundamentally different theoretical models.
Finally, the episode explores how explanatory frameworks shape memory and interpretation, and why concepts that incorporate assumptions about another person’s motivations or diagnosis may become difficult to evaluate critically. Throughout, the discussion argues for greater conceptual precision in psychology while emphasizing that questioning a psychological construct is not the same as questioning the reality of abuse.
Additional Resources
Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgHLISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON GOOGLE PODCASTS: https://rb.gy/fotpcaLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
 
About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn and associate Deanna Young, Psy.D.
In this session, the group discusses the article “A Mentalizing Approach for Narcissistic Personality Disorder: Moving From ‘Me-Mode’ to ‘We-Mode’” (Choi-Kain, Simonsen, & Euler, 2022), which explores how Mentalization-Based Treatment (MBT) can be applied to the treatment of narcissistic personality disorder.
The paper argues that many of the challenges clinicians encounter when working with narcissistic patients can be understood through the lens of attachment, mentalization, and epistemic trust. Rather than viewing narcissistic pathology primarily as a problem of entitlement, grandiosity, or lack of empathy, the authors conceptualize it as a disturbance in the capacity to understand oneself and others in psychological terms and to learn from emotionally meaningful relationships.
The discussion explores the article’s central proposal that treatment involves helping patients move from a self-focused “me-mode” toward a more collaborative “we-mode,” in which multiple perspectives can be held in mind simultaneously. Particular attention is given to the ways in which narcissistic adaptations interfere with trust, intimacy, and therapeutic engagement.
Along the way, the conversation examines several key MBT concepts, including:
* Epistemic trust and distrust* Nonmentalizing modes, including pretend mode, psychic equivalence, and teleological thinking* Marked contingent mirroring* The therapeutic alliance as a vehicle for psychological change* Why confrontation and pressure for change can sometimes reinforce narcissistic defenses rather than weaken them
The discussion also considers the broader cultural discourse surrounding narcissism and contrasts popular approaches that emphasize accountability, confrontation, and labeling with psychodynamic and attachment-based approaches that emphasize understanding, curiosity, and the gradual development of trust.
Finally, the group reflects on the practical realities of psychotherapy with narcissistic patients, including the pressures created by partners and family members seeking rapid change, the tendency for therapists to become caught in power struggles, and the challenge of maintaining a mentalizing stance in the face of difficult interpersonal dynamics.
Key themes include:
* Mentalization-Based Treatment (MBT) and narcissistic personality disorder* Attachment theory and personality pathology* Epistemic trust as a foundation for psychological growth* The relationship between vulnerability and grandiosity* Nonmentalizing modes of experience* The role of empathy, curiosity, and validation in treatment* Clinical challenges in working with narcissistic patients
This series is intended for clinicians, trainees, and viewers seeking a nuanced, clinically grounded understanding of narcissism beyond popular discourse.
To learn more about our work, visit:www.HealNPD.org
Additional Resources:Newsletter: https://healnpd.substack.comAssessment and therapy inquiries: https://healnpd.org/contact
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Citation:
Choi-Kain, L. W., Simonsen, S., & Euler, S. (2022). A Mentalizing Approach for Narcissistic Personality Disorder: Moving From “Me-Mode” to “We-Mode.” American Journal of Psychotherapy, 75(1), 38–43.
Full text link: https://www.psychiatryonline.org/doi/epdf/10.1176/appi.psychotherapy.20210017

This is the third part of a three-part exploration of narcissistic personality style at the neurotic level of personality organization.
In this episode, Dr. Ettensohn examines the defensive architecture of neurotic-level narcissism, including the characteristic defenses that allow individuals to manage conflict, preserve relationships, and maintain self-esteem without resorting to the identity fragmentation or reality distortion seen at more severe levels of personality organization.
Drawing on the Defense Mechanisms Rating Scale (DMRS), this episode explores obsessional defenses such as isolation of affect, intellectualization, and undoing, as well as neurotic defenses including repression, reaction formation, and displacement. Through clinical examples, personal reflections, and portrayals from film and literature, Dr. Ettensohn illustrates how these defenses shape emotional experience, interpersonal relationships, and the therapeutic process.
The episode also examines how narcissistic concerns manifest at the neurotic level, including struggles with self-worth, dependency, vulnerability, perfectionism, and grief. Particular attention is given to transference, countertransference, and the unique opportunities and challenges that emerge in psychotherapy with neurotic-level narcissistic personalities.
While neurotic-level functioning represents a profound developmental achievement, it also introduces new emotional realities. As the capacity for integration grows, so too does the capacity to experience loss, guilt, limitation, and sorrow. The movement toward greater psychological health is not the elimination of suffering, but the ability to bear it without abandoning oneself or others.
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About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

Dr. Mark Ettensohn examines the experience of emptiness in narcissistic personality disorder and other forms of personality pathology.
Rather than approaching personality disorders as collections of traits or behaviors, the episode frames them as disturbances in identity. Dr. Ettensohn outlines how the sense of self is constructed through early relational experience and how disruptions in that process can lead to unstable, fragmented, or underdeveloped self-experience.
The discussion focuses on the role of dissociation and splitting in shaping identity, and how different self-states may become organized around incompatible relational experiences. In this context, emptiness is not simply a feeling, but reflects aspects of the self that were never fully recognized, mirrored, or integrated in development.
Dr. Ettensohn also addresses a common misunderstanding in public discourse, where narcissism is equated with observable traits such as arrogance or entitlement. He explains why these descriptions capture only one part of a broader system involving both grandiose and vulnerable states, and how focusing solely on behavior obscures the underlying psychological structure.
The episode concludes with a discussion of clinical implications, emphasizing why treatments that focus only on behavior often fall short, and why effective work with narcissistic pathology requires attention to identity, relational process, and the integration of dissociated aspects of self-experience.
Additional ResourcesWebsite: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON GOOGLE PODCASTS: https://rb.gy/fotpcaLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
 
About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn, joined by his associates Deanna Young, Psy.D., and Danté Spencer, Ph.D.
In this session, the group discusses the paper “Living with Pathological Narcissism: A Qualitative Study” (Day et al., 2020), which examines narcissistic personality pathology from the perspective of partners and family members.
Unlike most research on narcissism, this study does not rely on self-report or clinician ratings. Instead, it draws on qualitative descriptions from over 400 individuals in close relationships with someone exhibiting high levels of pathological narcissistic traits. These accounts provide a window into how narcissism is experienced interpersonally, particularly in intimate and long-term relationships.
The discussion focuses on the study’s central finding: that pathological narcissism is best understood as a system characterized by the co-occurrence of grandiosity and vulnerability. Loved ones described patterns of entitlement, arrogance, and need for admiration alongside insecurity, hypersensitivity, emotional instability, and chronic feelings of emptiness. In the majority of cases, these features were not separate “types,” but fluctuating states within the same individual.
The group explores how these findings challenge common assumptions about narcissism, including the tendency to equate it with overt grandiosity or interpersonal abusiveness. Particular attention is given to the limitations of DSM-based models, which emphasize observable traits while underrepresenting the internal dysregulation and vulnerability that define the disorder.
The conversation also examines broader relational and developmental themes, including:
The oscillation between grandiose and vulnerable self-states
The role of dissociation and splitting in personality organization
The impact of early attachment trauma and “empathic failures”
How narcissistic dynamics are expressed and amplified within close relationships
The tendency for polarized, dehumanizing narratives to emerge in response to relational injury
Finally, the group discusses the concept of “narcissistic abuse,” noting that while experiences of harm in these relationships are real and often significant, the term itself is not a well-defined clinical construct. The discussion emphasizes the importance of distinguishing between lived experience and explanatory frameworks, and of maintaining a nuanced, non-reductive understanding of personality pathology.
Key themes include:
Pathological narcissism as a dysregulated self-state system
The interdependence of grandiosity and vulnerability
Limitations of categorical and trait-based models of narcissism
The relational expression of personality pathology
The role of trauma, attachment, and development in narcissistic adaptation
Clinical implications for assessment, formulation, and treatment
This series is intended for clinicians, trainees, and viewers seeking a nuanced, clinically grounded understanding of narcissism beyond popular discourse.
To learn more about our work, visit:www.HealNPD.org
Additional Resources:Newsletter: https://healnpd.substack.comAssessment and therapy inquiries: https://healnpd.org/contact
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life:https://amzn.to/3nG9FgH
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON GOOGLE PODCASTS: https://rb.gy/fotpcaLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
Citation:Day, N. J. S., Townsend, M. L., & Grenyer, B. F. S. (2020). Living with pathological narcissism: A qualitative study. Borderline Personality Disorder and Emotion Dysregulation, 7(19). 
Full Text Link: https://pmc.ncbi.nlm.nih.gov/articles...
About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org