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Pathological narcissism is organized by a pathological grandiose self, a compensatory, defensive structure in which the individual’s experience of self and others is overshadowed by an idealized version of the self (perceived as superior) that replaces a more realistic self-representation that integrates both strengths and vulnerabilities. Narcissistic personality disorder (NPD) is a complex psychological condition that involves a consistent pattern of behaviors lasting over time and occurring in various social contexts, which can lead to significant impairments in social relationships and occupational functioning. A contemporary object relations model approach provides a theoretical framework for understanding the distorted and often contradictory representations of self and others that underlie the fluctuating mental states of those with pathological narcissism. In transference-focused psychotherapy (TFP) for narcissistic pathology, or TFP-N, the strategies, tactics, and techniques of TFP are adapted and extended with specific modifications to address the special clinical challenges posed by patients with this condition. TFP training serves as a useful, integrative, and dimensional model, which is well-suited for residency programs, allowing residents to gain experience in intensive psychodynamic treatment for personality disorders (PDs). This paper presents a case study of a patient with severe NPD treated in a psychiatry residency program using TFP.