The fourth edition of the authoritative "Review of General Psychiatry" (London, Prentice-Hall International, 1995), says (p. 309):

"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."

The reason narcissism is under-reported and healing over-stated is that therapists are being fooled by smart narcissists. Most narcissists are expert manipulators and consummate actors and they learn how to deceive their therapists.

Here are some hard facts:

There are gradations and shades of narcissism. The differences between two narcissists can be great. The existence of grandiosity and empathy or lack thereof are not minor variations. They are serious predictors of future psychodynamics. The prognosis is much better if they do exist. There are cases of spontaneous healing, Acquired Situational Narcissism, and of "short-term NPD" [see Gunderson's and Ronningstam work, 1996]. The prognosis for a classical narcissist (grandiosity, lack of empathy and all) is decidedly not good as far as long-term, lasting, and complete healing. Moreover, narcissists are intensely disliked by therapists. BUT…

Side effects, co-morbid disorders (such as Obsessive-Compulsive behaviors) and some aspects of NPD (the dysphorias, the persecutory delusions, the sense of entitlement, the pathological lying) can be modified (using talk therapy and, depending on the problem, medication). These are not long-term or complete solutions – but some of them do have long-term effects. The DSM is a billing and administration oriented diagnostic tool. It is intended to "tidy" up the psychiatrist's desk. The Axis II Personality Disorders are ill demarcated. The differential diagnoses are vaguely defined. There are some cultural biases and judgements [see the diagnostic criteria of the Schizotypal and Antisocial PDs]. The result is sizeable confusion and multiple diagnoses ("co-morbidity"). NPD was introduced to the DSM in 1980 [DSM-III]. There isn't enough research to substantiate any view or hypothesis about NPD. Future DSM editions may abolish it altogether within the framework of a cluster or a single "personality disorder" category. When we ask: "Can NPD be healed?" we need to realise that we don't know for sure what is NPD and what constitutes long-term healing in the case of an NPD. There are those who seriously claim that NPD is a cultural disease (culture-bound) with a societal determinant. Narcissists in Therapy

In therapy, the general idea is to create the conditions for the True Self to resume its growth: safety, predictability, justice, love and acceptance - a mirroring, re-aprenting, and holding environment. Therapy is supposed to provide these conditions of nurturance and guidance (through transference, cognitive re-labelling or other methods). The narcissist must learn that his past experiences are not laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive.

Most therapists try to co-opt the narcissist's inflated ego (False Self) and defences. They compliment the narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.

By stroking the narcissist's grandiosity, they hope to modify or counter cognitive deficits, thinking errors, and the narcissist's victim-stance. They contract with the narcissist to alter his conduct. Some even go to the extent of medicalizing the disorder, attributing it to a hereditary or biochemical origin and thus "absolving" the narcissist from his responsibility and freeing his mental resources to concentrate on the therapy.

Confronting the narcissist head on and engaging in power politics ("I am cleverer", "My will should prevail", and so on) is decidedly unhelpful and could lead to rage attacks and a deepening of the narcissist's persecutory delusions, bred by his humiliation in the therapeutic setting.

Successes have been reported by applying 12-step techniques (as modified for patients suffering from the Antisocial Personality Disorder), and with treatment modalities as diverse as NLP (Neurolinguistic Programming), Schema Therapy, and EMDR (Eye Movement Desensitization).

But, whatever the type of talk therapy, the narcissist devalues the therapist. His internal dialogue is: "I know best, I know it all, the therapist is less intelligent than I, I can't afford the top level therapists who are the only ones qualified to treat me (as my equals, needless to say), I am actually a therapist myself…"

A litany of self-delusion and fantastic grandiosity (really, defences and resistances) ensues: "He (my therapist) should be my colleague, in certain respects it is he who should accept my professional authority, why won't he be my friend, after all I can use the lingo (psycho-babble) even better than he does? It's us (him and me) against a hostile and ignorant world (shared psychosis, follies-a-deux)…"

Then there is this internal dialog: "Just who does he think he is, asking me all these questions? What are his professional credentials? I am a success and he is a nobody therapist in a dingy office, he is trying to negate my uniqueness, he is an authority figure, I hate him, I will show him, I will humiliate him, prove him ignorant, have his licence revoked (transference). Actually, he is pitiable, a zero, a failure…"

And this is only in the first three sessions of the therapy. This abusive internal exchange becomes more vituperative and pejorative as therapy progresses.

Narcissists generally are averse to being medicated. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks and hate to be "under the influence" of "mind altering" drugs prescribed to them by others.

Additionally, many of them believe that medication is the "great equaliser" – it will make them lose their uniqueness, superiority and so on. That is unless they can convincingly present the act of taking their medicines as "heroism", a daring enterprise of self-exploration, part of a breakthrough clinical trial, and so on.

They often claim that the medicine affects them differently than it does other people, or that they have discovered a new, exciting way of using it, or that they are part of someone's (usually themselves) learning curve ("part of a new approach to dosage", "part of a new cocktail which holds great promise"). Narcissists must dramatise their lives to feel worthy and special. Aut nihil aut unique – either be special or don't be at all. Narcissists are drama queens.

Very much like in the physical world, change is brought about only through incredible powers of torsion and breakage. Only when the narcissist's elasticity gives way, only when he is wounded by his own intransigence – only then is there hope.

It takes nothing less than a real crisis. Ennui is not enough.

Visit Sam's Web site at http://samvak.tripod.com