Group Therapies

Narcissists are notoriously unsuitable for collaborative efforts of any kind, let alone group therapy. They immediately size up others as potential Sources of Narcissistic Supply - or as potential competitors. They idealise the first (suppliers) and devalue the latter (competitors). This, obviously, is not very conducive to group therapy.

Moreover, the dynamic of the group is bound to reflect the interactions of its members. Narcissists are individualists. They regard coalitions with disdain and contempt. The need to resort to team work, to adhere to group rules, to succumb to a moderator, and to honour and respect the other members as equals is perceived by them to be humiliating and degrading (a contemptible weakness). Thus, a group containing one or more narcissists is likely to fluctuate between short-term, very small size, coalitions (based on "superiority" and contempt) and narcissistic outbreaks (acting outs) of rage and coercion.

Can Narcissism be Cured?

Adult narcissists can rarely be "cured", though some scholars think otherwise. Still, the earlier the therapeutic intervention, the better the prognosis. A correct diagnosis and a proper mix of treatment modalities in early adolescence guarantees success without relapse in anywhere between one third and one half the cases. Additionally, ageing moderates or even vanquishes some antisocial behaviours.

In their seminal tome, "Personality Disorders in Modern Life" (New York, John Wiley & Sons, 2000), Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid ... Interpretation and even general assessment are often difficult to accomplish..."

The third edition of the "Oxford Textbook of Psychiatry" (Oxford, Oxford University Press, reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only change their situations. There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character ... Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve them."

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.