Can People With Narcissistic Personality Disorder Really Change?
For a long time, Narcissistic Personality Disorder, often called NPD, was seen as one of the hardest personality disorders to treat. Many clinicians believed that these patients were too defensive, too ashamed, too sensitive to criticism, or too likely to leave therapy before real work could begin. A 2024 study in The Journal of Nervous and Mental Disease offers a more hopeful picture. It followed eight patients with NPD who improved during long-term psychotherapy. By the end of treatment, all eight no longer met the diagnostic criteria for NPD, and all showed major improvements in work, study, independence, and close relationships. This does not mean change is easy or quick. It took between two and a half and five years, and most patients needed more than one type of support. But the study matters because it challenges the old idea that people with NPD cannot change. It suggests that, with the right treatment, real improvement is possible.
Why this question matters so much
Many people know the word “narcissist,” but far fewer understand Narcissistic Personality Disorder properly. NPD is not simply being vain, arrogant, or self-absorbed. It is a serious mental health condition involving unstable self-esteem, a strong need for admiration, difficulty with empathy, and major problems in relationships. Some people with NPD look grand and superior, while others look insecure, ashamed, angry, or deeply sensitive to rejection.
The condition often causes harm in both directions. The person with NPD may hurt others through control, coldness, criticism, entitlement, or emotional volatility. But they also often suffer themselves. Research has linked NPD with depression, anxiety, substance misuse, suicidal risk, work failure, and serious relationship problems. That is why treatment matters. If change is possible, then clinicians, families, and patients need to know that. If change is not possible, then expectations need to be realistic.
This study was set up to ask a very practical question: can psychotherapy actually help people with NPD improve, not just in symptoms, but also in real life? That means not only whether they feel better in a therapy room, but whether they can work, study, form stable relationships, and become more independent.
This study matters because it challenges the old belief that NPD is basically untreatable. It shows that at least some patients can make real and meaningful change.
The researchers looked at eight patients who improved
The study focused on eight patients treated through personality disorder services connected to McLean Hospital. These were not mild or simple cases. The patients had clear Narcissistic Personality Disorder at the start of therapy. They also had a lot of other difficulties. Many had mood disorders, substance use problems, eating disorders, obsessive-compulsive disorder, borderline personality features, or antisocial traits.
At the start of treatment, none of the eight were employed or in school. Only one was in a relationship, and most were financially dependent on their parents. In other words, these were people whose lives were not working well. They were struggling not just internally, but also in the real world.
The therapies lasted between 2.5 and 5 years. That is important. This was not brief treatment. It was long-term work. Most patients received more than one kind of support, such as individual therapy combined with group work, medication, family therapy, or in some cases residential treatment. The study calls this multimodal treatment, meaning several forms of help were used together.
The therapists were experienced professionals, including psychiatrists, psychologists, and a social worker. Many had advanced training in therapies used for severe personality disorders, such as dialectical behaviour therapy, mentalization-based therapy, transference-focused psychotherapy, and good psychiatric management.
What kinds of therapy did they receive?
One interesting part of the study is that there was no single miracle therapy. The patients received different kinds of psychotherapy. Some had psychodynamic or psychoanalytic therapy. Others had transference-focused psychotherapy, mentalization-based therapy, dialectical behaviour therapy, or more flexible and eclectic treatment.
This suggests something important. Change in NPD may not depend on one special method alone. It may depend more on a combination of factors: a skilled therapist, enough time, a strong treatment relationship, willingness to stay in the work, and treatment that adapts to the person’s needs.
That does not mean any therapy will do. The study makes clear that treatment for NPD is difficult. These patients often provoke strong feelings in therapists. They may become dismissive, devaluing, controlling, ashamed, perfectionistic, or easily offended. They may hide important feelings, avoid vulnerability, or leave treatment too early. So therapy needs to be thoughtful, structured, and strong enough to survive these challenges.
Still, the study suggests that improvement is possible across more than one therapy model. That is encouraging, because it means clinicians do not need to wait for one perfect treatment to exist before trying to help.
The study did not find one magic therapy. Instead, it suggests that different psychotherapies can help, especially when treatment is long-term, flexible, and supported by other forms of care.
How the researchers measured change
To make the study more reliable, the researchers did not just rely on vague impressions such as “the patient seemed better.” They used structured ways of rating narcissistic pathology both before and after treatment. They used two separate systems.
The first was the standard DSM-5 criteria for Narcissistic Personality Disorder. A person needs to meet at least five of the nine criteria to qualify for the diagnosis. The second was the Diagnostic Interview for Narcissism, often called the DIN, which is a more detailed interview looking at grandiosity, relationships, emotional reactivity, mood states, and social or moral adaptation.
They also looked at real-life functioning. Were the patients working? Were they in school? Were they financially independent? Were they able to form and maintain close relationships? These questions matter because someone can seem better in theory but still remain unable to function in daily life.
Another strength of the study was that both therapists and researchers rated the cases, and their level of agreement was good. That is helpful because one common problem in therapy studies is that therapists may overestimate progress. Here, the agreement between clinician and researcher ratings was strong, which adds credibility to the findings.
The results were striking
The central finding was simple but powerful: all eight patients improved enough that they no longer met diagnostic criteria for NPD by the end of therapy. At the start, they clearly qualified for the disorder. At the end, none of them did.
Their narcissistic symptoms dropped sharply. On average, the number of DSM-5 narcissism criteria they met fell from 7.75 at the beginning to 2.31 after treatment. Their scores on the DIN also fell dramatically, from an average of 11.0 to 0.75. These were large changes, not tiny statistical shifts.
Just as importantly, their lives improved. At the beginning, none were employed or in school. By the end, five were employed and three were in school. All became financially independent. Relationship functioning improved too. At the start, seven were not in close relationships. By the end, six were in stable long-term relationships, one was dating, and only one remained single by choice.
This is what makes the study so important. It did not only show symptom change on paper. It showed better functioning in the real world. People were not just less narcissistic by rating scale. They were working, studying, partnering, and living with more independence.
By the end of treatment, all eight patients no longer met criteria for NPD, and all had made major gains in work, education, relationships, and independence.
What might improvement actually look like in daily life?
Numbers are helpful, but they can feel abstract. So what might this kind of improvement look like in ordinary life? The case descriptions in the study give us clues.
In one example, a therapist challenged a patient’s passive expectation that life would somehow sort itself out. That conversation helped the patient move towards getting a job. In another case, the therapist kept encouraging a patient to be less certain about other people’s bad intentions and more curious about her own role in interactions. Over time, she became more reflective and less reactive.
Another patient processed anger, shame, and envy in therapy and later became more active professionally. One man worked on being more honest and open, and his communication with his wife improved. Another used exposure-based work to face fears of being judged and gradually returned to dating and social contact.
These examples matter because they show that change in NPD may not begin with a dramatic personality transformation. It may begin with smaller steps: being more honest, tolerating feedback, controlling anger, reflecting instead of reacting, applying for work, accepting help, facing shame, or staying in relationships without pulling away or attacking.
Over time, those smaller steps may add up to real personality change.
Why treatment for NPD is so hard in the first place
To appreciate the findings, it helps to understand how difficult NPD is to treat. The study explains that about two thirds of patients with NPD tend to leave treatment early. That alone makes progress hard to study. If people do not stay, there is little chance for change.
Patients with NPD may also trigger strong reactions in therapists. Therapists may feel criticised, helpless, angry, bored, worried, devalued, or pulled into power struggles. These are not small issues. If not managed properly, they can damage the treatment relationship and lead to stalemates or dropout.
Several features of NPD can interfere with therapy. Dismissive attachment may make it hard for patients to trust and open up. Perfectionism can make mistakes or ordinary human limitations feel unbearable. Shame can slow progress because the patient may avoid anything that feels exposing. Devaluation of others can lead the patient to dismiss the therapist, the treatment, or the whole process as useless.
This is why the study’s hopeful message should not be misunderstood. It is not saying NPD is easy to treat. It is saying that even though treatment is very challenging, some patients do make deep change when therapy survives long enough and works well enough.
NPD is not easy to treat. Patients may be ashamed, defensive, perfectionistic, or quick to leave. That is exactly why evidence of change is so important.
Could these patients have improved without therapy?
The researchers were careful about this question. Because the study only looked at patients who improved, and because it was not a randomized controlled trial, it cannot prove with certainty that therapy caused all the change. The authors openly discuss this limitation.
For example, people sometimes improve over time simply because they mature. Life events can also help. A new job, a loss, a relationship, or a crisis may push someone to reflect and grow. The researchers acknowledge that these things may have contributed.
However, when they looked closely at the case reports, they found many signs that therapy played an important part. Specific changes were linked to specific therapeutic conversations, interventions, or ongoing work. In some cases, therapy helped patients process life events in ways that made growth possible. In others, therapy appeared to directly support concrete change, such as returning to work, becoming more reflective, managing anger, or becoming more honest in relationships.
So the study does not claim that therapy alone explained everything. Instead, it suggests that treatment was likely part of the change process, even if life events and maturity also mattered.
What factors may help people with NPD change?
The authors highlight several possible factors that may support improvement. These are not proven rules, but they are thoughtful observations from the cases.
One factor was openness and motivation for change. Patients did not need to be perfect or easy, but they seemed to need at least some part of themselves that wanted things to be different. Another factor was the capacity for work or study. This may sound odd, but it points to the importance of being able to invest in real-world goals, not just in fantasy.
The ability to stay in close and committed relationships also seemed relevant. This makes sense because treatment itself is a relationship, and change often depends on being able to stay engaged through disappointment, conflict, and vulnerability.
The multimodal nature of treatment also probably helped. Many of the patients did not just have weekly therapy and nothing else. They had several forms of support working together. In addition, co-occurring problems such as borderline traits or addiction may have increased motivation for change because the consequences of staying the same had become too painful.
The study also suggests that life events and treatment often worked together. A work challenge, loss, or relationship problem might create pressure. Therapy then helped the patient think about it, feel it, and respond differently. In this way, change did not happen inside treatment alone or outside it alone, but through an interaction between life and therapy.
Change seemed more likely when patients had some motivation, some ability to stay engaged, and treatment strong enough to support them through real-life challenges.
What this means for families and loved ones
For partners, parents, siblings, and friends, this study offers cautious hope. If you have lived with someone with strong narcissistic pathology, you may have felt that nothing ever changes. Promises are made, crises happen, blame moves around, and then the same patterns return. This study suggests that change is possible, but it is usually slow, hard, and tied to serious long-term treatment.
That matters because it protects against two extremes. One extreme is hopelessness: “They will never change, so there is no point.” The other extreme is fantasy: “One apology or one insight means they are now completely different.” The study supports a middle position. Change can happen, but it usually takes years, not weeks. It often involves setbacks, multiple forms of support, and a great deal of emotional work.
It also reminds families that functioning matters. Real improvement is not only the person sounding more insightful. It is whether they can work, carry responsibility, form healthier relationships, manage anger, tolerate shame, and become more independent. That is the kind of change that truly alters lives.
For carers, this can also guide boundaries. Hope does not mean tolerating abuse or waiting forever without evidence. It means recognising that deep change is possible while still judging progress by real behaviour over time.
The study has limits, but it still matters
The authors are honest about the weaknesses of the research. The study used only eight patients, and those eight were selected because they had improved. That means the findings cannot tell us how often this kind of change happens in the wider population of people with NPD. There was also no control group, no random assignment, and no fully independent diagnostic interviews with the patients themselves at follow-up.
So this is not the final answer. It is an early but important piece of evidence. It shows that improvement can happen. It does not prove that everyone with NPD will improve, or that all therapies work equally well, or that therapy alone caused every change.
Still, this kind of study is valuable. In a field where people have often assumed that NPD patients do not change, simply documenting convincing examples of change is important. It gives researchers something to build on. It also helps shift the conversation from “Can they ever improve?” to “What helps improvement happen, for whom, and under what conditions?”
This was a small and selected sample, so it does not prove that all people with NPD will improve. But it does show that meaningful change is possible and worth studying seriously.
Conclusion
This 2024 case series offers one of the clearest hopeful messages yet in the treatment of Narcissistic Personality Disorder. Eight patients with NPD who stayed in long-term psychotherapy showed major change over 2.5 to 5 years. By the end, none still met criteria for NPD, and all had improved in important areas of real life such as work, study, financial independence, and relationships.
The study does not claim that change is fast, easy, or guaranteed. NPD remains a difficult condition to treat. Many patients drop out. Many therapies fail. Shame, perfectionism, defensiveness, devaluation, and fear of dependence can all get in the way. But difficulty is not the same as impossibility.
That may be the most important message of all. People with NPD are not automatically beyond help. Some do change. And if future research can identify more clearly what supports that change, treatment may become stronger, more targeted, and more hopeful for patients and families alike.
Source note
This article is based on the study Can Patients With Narcissistic Personality Disorder Change? A Case Series by Igor Weinberg, Elsa Ronningstam, Caitlin Ravichandran, and John G. Gunderson, published in The Journal of Nervous and Mental Disease in July 2024.
Read the original article here: https://journals.lww.com/jonmd/fulltext/2024/07000/can_patients_with_narcissistic_personality.6.aspx