Building a therapeutic alliance with a patient with pathological narcissism or narcissistic personality disorder is a challenging process. A combined alliance building and diagnostic strategy is outlined that promotes patients’ motivation and active engagement in identifying their own problems. The main focus is on identifying grandiosity, self‐regulatory patterns, and behavioral fluctuations in their social and interpersonal contexts while engaging the patient in meaningful clarifications and collaborative inquiry. A definition of grandiosity as a diagnostic characterological trait is suggested, one that captures self‐criticism, inferiority, and fragility in addition to superiority, assertiveness, perfectionism, high ideals, and self‐enhancing and self‐serving interpersonal behavior. These reformulations serve to expand the spectrum of grandiosity‐promoting strivings and activities, capture their fluctuations, and help clinicians attend to narcissistic individuals’ internal experiences and motivation as well as to their external presentation and interpersonal self‐enhancing, self‐serving, controlling, and aggressive behavior. A case example illustrates this process.