Objective Evidence suggests that pathological narcissism impacts psychotherapy process and outcome. This study investigates whether traits of pathological narcissism account for distinctiveness (construal) of patients' interpersonal perceptions in treatment settings. Methods Patients enrolled in psychological/psychotherapeutic treatment (N = 150) described a segment of a session in a written format and subsequently assessed both self‐ and clinician's behavior on the dimensions of dominance and hostility (patient‐reported ratings), along with their pathological narcissistic traits. Three independent raters also assessed interpersonal behaviors (observer‐reported ratings) based on the written session descriptions. Indices of construal were defined by the residuals of self‐reported (net of observer‐reported) ratings and were regressed onto pathological narcissistic traits. Results No association emerged between pathological narcissism and construal in patients' perceptions of their clinicians. However, grandiose traits of pathological narcissism were related to distinctively perceiving oneself as more dominant, while vulnerable traits were related to distinctively perceiving oneself as more hostile. The former association (but not the latter) also held after incorporating additional observer ratings to investigate the robustness of the results. Conclusion Findings are discussed in light of treatment‐related self‐enhancement and self‐concealment processes.