Like everyone on Axis 2, the person with Narcissistic Personality Disorder thinks they are fine. Obviously the problem is everybody else. They will just go through their whole life blaming other people. That’s how they ride.
They rarely if ever show up for therapy, and when they do, it is often at the behest of others who are forcing them into therapy because the narcissists is driving these people insane and ruining their lives. Once in therapy, the narcissist plays games, engages in a boatload of manipulation, does no work on themselves because after all there is nothing to be done, and often engages in a lot of ego and narcissistic games with the therapist, including insulting the therapist, thinking he is better than the therapist and telling him so, deciding that the therapist is a lousy therapist, etc.
If you tell them they are narcissists, will generally either reject the diagnosis, ignore it, blow it off with some humorous blustery remark, decide that psychiatry is a pseudoscience, or say, “So what? I like being this way.”
They might take it as an insult, but they usually will not react aggressively. Instead you will see a spark of recognition and alarm in their eyes. The narcissist is not an idiot. Many are highly intelligent and in fact, sadly it goes with the territory. At some level, most if not all narcissists now what is going on. The problems is they don’t care, or they like to be this way.
If you keep reminding the narcissist of what he is, he will stop being flippant about it and start getting aggressive. Expect dirty fighting, devious and crafty manipulation, nasty insults, or walking out of the room. Keep it up, and the narcissist will just end the relationship. The narcissist is not going to sit there and let you call him a narcissist all day. He’s too good for such degrading treatment. If he cannot do that, at some point, he will probably create a nuclear explosion of a fight and try to terrorize you into not bringing up the subject again.
Generally speaking, they are a complete waste of time in the office, therapy with them is often quite unpleasant, and nothing gets done anyway. It’s not uncommon for the therapist to simply fire the narcissist as client, informing him that nothing is getting done. This a relief to the narcissist, as now he has an excuse to quit the degrading therapy. Technically this is client abandonment and an ethics violation, but the decision is always mutual, and nothing was getting done anyway, so why prolong the pointless endeavor?
Theoretically, the narcissist can be cured. Since lions cannot change into tigers, all we can do with personality disorders is turn the bad side of a basic personality type into the good side of that type. The good side of Narcissistic Personality is Confident Personality. These people can be a bit much too, but they are healthy enough that they can function quite well especially in a hyper-competitive capitalist society like ours. The goal of therapy with an NPD is to turn them into a Confident Personality. But good luck with that.
There is so much more to talk about with narcissism and NPD, but let’s leave that for another day.