Impulsive acting out patients are discussed in relation to the vulnerability of the grandiose self and a resulting narcissistic imbalance which underlies their behaviour. These difficulties are often managed in psychotherapy by a limit-setting, reality-testing and confrontational approach. Although helpful and necessary at times, such interventions are rarely sufficient by themselves to promote the requisite structural change which is the ultimate goal of treatment. This paper focuses on additional technical implications for the psychoanalytic psychotherapy of these patients arising from a consideration of the core narcissistic problem.