7 Minutes
Maybe you know someone who always shifts the blame onto others, smirks when caught in a lie, or twists a conversation until you find yourself apologizing for their mistakes. Over time, you might wonder: can a person who behaves like that ever truly change? This article looks at what psychology and clinical research say about narcissism, the types of treatment available, why therapy can be difficult, and which new approaches are being explored.
Understanding narcissism: traits, types, and when it becomes pathological
Narcissism exists on a spectrum. At one end are personality traits like self-focus, entitlement, and charm. At the far end sits narcissistic personality disorder (NPD), a diagnosable and persistent pattern of thinking, feeling, and behaving that causes significant distress or impairment.
Clinicians commonly distinguish between two broad presentations: grandiose and vulnerable narcissism. Grandiose individuals typically present as confident, entitled, and superior, often seeking admiration. Vulnerable narcissists are hypersensitive to criticism and may appear defensive, anxious, or resentful. Both forms can include manipulative behaviors, passive-aggression, and social exclusion — tactics used to protect a fragile self-image.
When narcissistic traits grow severe enough to be called pathological, they can damage relationships, careers, and sometimes personal safety. Research has also linked higher narcissism with increased interpersonal conflict and, in some cases, a higher risk of aggression or violence when individuals feel threatened.
Therapy options: what works and why it's complicated
There is no simple cure for a lifelong personality pattern. However, clinical evidence and therapist experience indicate that structured psychological treatment can reduce symptoms and improve functioning. The most widely used starting point is talking therapies — approaches that focus on self-awareness, cognitive patterns, and interpersonal behavior.
Cognitive behavioral therapy (CBT) is often applied to help clients identify and challenge distorted thoughts, then practice alternative behaviors. For narcissistic patients, CBT can target entitlement, black-and-white thinking, and automatic defenses. But many clinicians prefer therapies that emphasize relational understanding and long-term personality change, sometimes called introspective or psychodynamic relational techniques.
Why forming trust is the real therapy challenge
One recurrent obstacle is that narcissistic patients often fear vulnerability. They may come to therapy to make a favorable impression, maintain a confident façade, or avoid admitting weakness. That makes building therapeutic rapport difficult: a clinician must be consistently nonjudgmental, reflective, and skilled at navigating requests for praise or hostility while gently encouraging self-examination.
Because of these dynamics, dropout rates among people with high narcissism are markedly higher than average. General therapy dropout ranges from roughly 10–50 percent, yet studies report dropout rates around 63–64 percent for narcissistic clients. Adding to the challenge, most people with NPD do not seek therapy specifically for narcissism — they typically arrive for external problems such as divorce or job loss, or secondary emotional issues like depression after perceived rejection.
Borrowed lessons: adapting therapies from other personality disorders
Innovations in treating personality disorders often come from work with borderline personality disorder (BPD), where long-term modalities have more evidence. Several BPD treatments have been adapted for narcissistic presentations, including:
- Dialectical behavior therapy (DBT) — teaches emotion regulation and distress tolerance while encouraging acceptance.
- Mentalization-based therapy (MBT) — helps people understand their own and others’ mental states and how these link to behavior.
- Schema therapy — targets entrenched cognitive/emotional blueprints, for example, a core belief that needs will never be met.
These approaches can be promising, but evidence specifically for NPD remains limited. They share the same hurdles: long treatment duration, the need for a trusting alliance, and the therapist’s skill in holding boundaries while offering empathic exploration.
Experimental directions: MDMA-assisted therapy and the ethical landscape
In recent years, some researchers have proposed more radical adjuncts to psychotherapy to overcome barriers of defensiveness and emotional closure. In April 2025, psychiatric researchers Alexa Albert and Anthony Back suggested that psychedelic-assisted therapies, particularly MDMA-assisted therapy, could open a 'window' where narcissistic clients are more receptive to relational work. MDMA is known to temporarily enhance feelings of closeness, empathy, and trust in some people — qualities that could, in theory, lower defenses and allow deeper processing.
But this idea is theoretical for NPD. While MDMA-assisted therapy has shown promise in treating post-traumatic stress disorder, it carries risks: possible worsening of mental health in some cases, unpredictable psychological reactions, and a critical requirement for an established therapeutic alliance. Legal hurdles are also substantial — for example, in the UK MDMA is classified under Schedule 1 of the Misuse of Drugs regulations, restricting clinical research and prescription. Calls to reclassify the drug for trials have not yet produced change.
Given the legal and safety barriers, most clinicians currently rely on traditional therapeutic skills rather than pharmacological shortcuts. Any future introduction of psychedelic-assisted therapy would demand rigorous trials, strong ethical oversight, and careful screening to avoid harm.
Practical implications for patients and partners
So what does this mean for people affected by narcissistic behavior? First, change is possible but usually slow. Effective treatment requires consistent, long-term work and a clinician experienced in personality disorders. For loved ones, clear boundaries, safety planning, and access to support are crucial: partners and family often carry relational fallout and may benefit from their own therapy to process trauma or chronic emotional harm.
Clinicians emphasize that many patients with narcissistic traits enter therapy during low, vulnerable states rather than while projecting grandiosity. That vulnerability can be an opportunity for change — but only if the therapist recognizes shifting presentations, adjusts the treatment plan, and maintains containment when grandiose defenses re-emerge.
Expert Insight
Dr. Elena Morris, clinical psychologist and lecturer in personality psychiatry, reflects on clinical realities: 'Therapy with narcissistic patients is rarely linear. You may see progress in one domain — better emotion regulation, improved perspective-taking — while other defenses remain. The key is persistence and an alliance that tolerates both strengths and shame. Therapists must be prepared for setbacks and sudden ruptures, and partners need realistic expectations about pace and limits of change.'
That balanced view captures the pragmatic optimism emerging in the field: change is not guaranteed, but it is attainable with careful, skilled intervention.
For now, clinicians continue to rely on evidence-based talking therapies, adapted modalities from other personality disorder treatments, and careful clinical judgment. Experimental ideas like MDMA-assisted therapy are intriguing but remain speculative for narcissism until more trials and legal reforms take place. If you’re affected by a narcissistic relationship — either as the person seeking help or as someone close to them — seek a clinician experienced with personality disorders, prioritize safety and boundaries, and remember that transformation, when it occurs, is usually gradual and painstaking.
Source: sciencealert
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