A mentalizing framework for understanding narcissism is outlined, and the resulting modifications of basic mentalization-based treatment (MBT) for narcissistic personality disorder are discussed. Treatment of patients with pathological narcissism requires an emphasis on empathic validation and support of the vulnerable “I-mode.” The dangers of not recognizing low mentalizing in narcissistic functioning are also discussed, as both patient and clinician can fail to recognize pretend mode, which may masquerade as “we-mode.” Together the patient and the therapist may then set up a pretend therapy that can be interminable and that functions only to fuel the mental narcissistic structure. A clinical example of a patient in treatment is used to illustrate the process of treatment.

Although Dawood, Wu, Bliton, and Pincus (this volume) generally describe narcissistic personality pathology, and NPD in particular, in a reasonable and thoughtful way that aligns with our own perspective, the authors’ treatment of narcissism as a largely monolithic and unified construct contributes towards obscuring three important and longstanding methodological issues in the literature. First, variability in the measurement of NPD makes conclusions about the functioning of NPD, broadly defined, vulnerable to error. Second, variability in vulnerable content contained in measures of NPD is likely to be exerting a biasing effect on the strength of internalizing correlates of NPD (e.g., suicidality). Third, the prevalence of small samples containing high levels of vulnerable features may bias researchers toward stronger relations between NPD and internalizing correlates. Overall, the authors urge researchers to empirically resolve disagreements about the structure and process of narcissistic personality pathology in order to move the field towards more precise definition and measurement, and greater scientific confidence in conclusions related to narcissism’s nomological network.