Based on research and clinical literature (notably from Gabbard, Kernberg, Ronningstam, Dimaggio, Levy, and others), individuals with Narcissistic Personality Disorder (NPD) or prominent narcissistic traits often face distinct and predictable treatment obstacles. These challenges don’t make recovery impossible—but they do require specialized, trauma-informed, and often long-term therapeutic approaches.

1. Deep Shame and Defensiveness

Core Issue:
Beneath narcissistic defenses is usually intense, unprocessed shame. Therapy threatens to expose this, so the individual may lash out, withdraw, or intellectualize instead of feeling.

How it shows up in therapy:
• Overreacting to constructive feedback
• Avoiding vulnerability at all costs
• Needing to appear “together” or superior even in pain
• Denial of emotional needs or struggles

Clinical Insight:
Defenses are not lies—they’re survival strategies. The shame is often preverbal and linked to attachment wounds, not just ego.

2. Idealization and Devaluation of the Therapist

Core Issue:
Narcissistic individuals often operate in extremes. They may initially idealize the therapist as all-knowing, then suddenly devalue them for not meeting impossible emotional expectations.

How it shows up in therapy:
• Rapid shifts from admiration to contempt
• Viewing the therapist as either “perfect” or “useless”
• Testing the therapist’s loyalty, power, or patience

Clinical Insight:
These dynamics reenact early attachment traumas. Working through them in-session (instead of avoiding or pathologizing them) is often where real healing begins.

3. Difficulty Trusting the Therapeutic Relationship

Core Issue:
Many narcissistic clients have histories of conditional love, betrayal, or emotional neglect. Trusting that someone will see their worst traits and still stay is terrifying.

How it shows up in therapy:
• Keeping things superficial
• Withholding emotional truth
• Testing boundaries to provoke rejection
• Sabotaging progress when intimacy increases

Clinical Insight:
“Resistance” is often a trauma response, not arrogance. Building safety is a slow process—and consistency is key.

4. Fear of Dependency or Vulnerability

Core Issue:
Needing others can feel humiliating or unsafe. Admitting reliance on a therapist may be experienced as weakness or a threat to self-sufficiency.

How it shows up in therapy:
• Over-intellectualizing instead of feeling
• Avoiding emotions tied to childhood, grief, or trauma
• Reacting with rage or withdrawal when feeling exposed
• Ending therapy prematurely just as deeper work begins

Clinical Insight:
The goal isn’t to eliminate defenses, but to slowly replace them with more adaptive emotional regulation.

5. Lack of Internalized Empathy or Mentalization (Early On)

Core Issue:
Some narcissistic individuals struggle to consistently imagine how others feel—especially in moments of emotional intensity.

How it shows up in therapy:
• Minimizing the impact of their actions
• Struggling to process others’ emotions unless they are personally affected
• Mistaking empathy for weakness, manipulation, or obligation

Clinical Insight:
Empathy is learnable. It’s often blocked by shame, not absent entirely.

6. Grandiosity and Overidentification with Intelligence or Achievement

Core Issue:
Many individuals with narcissistic traits equate their worth with being “exceptional.” Therapy may feel insulting if it challenges that identity.

How it shows up in therapy:
• Arguing with the therapist to “win”
• Using insight to appear evolved while avoiding emotional change
• Dismissing therapeutic goals as too basic, slow, or irrelevant
• Needing to feel like the smartest person in the room

Clinical Insight:
Appealing to strength (e.g., “This takes real courage”) works better than pathologizing defenses. Narcissistic clients often respond to respectful challenge, not confrontation.

7. Unrealistic Expectations About Speed of Change

Core Issue:
Because narcissism often includes perfectionism and impatience, therapy may be abandoned if results aren’t immediate.

How it shows up in therapy:
• Asking for “hacks” or “shortcuts”
• Becoming frustrated when pain persists despite insight
• Feeling entitled to recovery without uncomfortable emotions
• Claiming therapy “isn’t working” after a single triggering session

Clinical Insight:
Setting clear expectations from the start is essential. Progress often begins with relational safety, not symptom relief.

8. Externalization of Blame

Core Issue:
Because narcissism often includes fragile self-esteem, accepting fault can feel annihilating. Blame is projected outward to preserve self-worth.

How it shows up in therapy:
• Blaming others for every relational rupture
• Minimizing or justifying hurtful behavior
• Rewriting past experiences to avoid accountability

Clinical Insight:
Blame reduction happens after shame is regulated. Demanding accountability too early can reinforce defenses.




These are not signs of failure. They are part of the process—and can be worked through with skillful support. It can be uncomfortable to discuss these obstacles with treatment providers, but doing so is a great way to practice healthy confrontation in a safe environment and start learning effective communication, realistic expectations, and often will reveal unhealed dynamics and patterns that the disorder may be hiding from when oneself.