- Between 63 and 64 percent of narcissism patients quit therapy before it can work.
- Schema therapy cuts dropout rates to 23% by carefully building emotional safety.
- Younger patients improve more readily because life crises give therapy greater leverage.
Elsa Ronningstam has the measured patience of someone who's spent decades watching theories collapse slowly. At McLean Hospital, she tracked narcissistic personality disorder treatment outcomes with a clinician's eye for patterns others missed.
The pattern puzzled her. Patients improved when they stayed in therapy. The problem was keeping them there.
Between 63 and 64 percent quit.
The internet insists narcissists can't change. Mental health forums repeat it. Family members believe it. Even some therapists, after watching patient after patient disappear, started believing it themselves. They were mistaking the dropout problem for a treatment problem–abandoning an approach that worked because patients abandoned them first.
But longitudinal studies tracking patients over years tell a different story. People with narcissistic personality disorder can improve. The catch is that self-reflection hurts enough that most bail before they see results.
Key figure
63%
of narcissism patients quit therapy before treatment can work
The Dropout Problem Reveals the Treatment Challenge
The disorder affects roughly 1 to 2 percent of the general population. It shows up about 50 to 75 percent more often in men. And it makes relationships miserable for everyone involved.
Clinical psychologist Elinor Greenberg, who describes narcissistic dynamics with the dry precision of someone who's heard every deflection, put it plainly: many narcissists enter therapy for the wrong reasons. A spouse threatens to leave. A boss demands it. They show up expecting the therapist to confirm they're fine and everyone else is the problem.
When therapy starts prodding at self-esteem regulation and empathy deficits, patients often disappear. Some find new therapists who'll validate them. Others decide therapy is useless.
When Ronningstam's team compared notes across institutions, the pattern emerged clearly. Three different research groups, working independently, kept finding the same predictors: dismissive attachment, shame intolerance, perfectionism. The very traits therapists needed to address were the ones driving patients out the door.
What Actually Works Takes Time
Ronningstam's team reviewed treatment approaches that managed to keep patients engaged. They found commonalities: clear goals, attention to the therapeutic relationship, work on self-esteem and interpersonal patterns, careful alliance building, and constant monitoring of the therapist's own emotional reactions.
Schema therapy showed particularly interesting results. Developed by psychologist Jeffrey Young for patients who don't respond to standard approaches, it combines cognitive techniques with what therapists call "limited reparenting"–a carefully bounded form of emotional support.
What is schema therapy?
Schema therapy is a form of psychotherapy developed for people who don't respond well to standard treatments. It works by identifying deep emotional patterns – called schemas – formed in childhood, and uses techniques including role-play and guided imagery to help patients process and change them. For narcissistic patients, it aims to gently reach the hidden vulnerability beneath the defensive surface.
A meta-analysis of schema therapy studies found a 23.3 percent dropout rate across personality disorders. Still high, but markedly better than the 63 percent seen in traditional psychotherapy for narcissistic personality disorder.
The treatment focuses on schema modes–different emotional states narcissistic patients cycle through. There's the self-aggrandizer mode, where superiority masks vulnerability. The detached protector mode, where emotional shutdown prevents pain. And underneath, what schema therapists call the vulnerable child mode, carrying shame and inadequacy.
Getting patients to access that vulnerable state without fleeing therapy is delicate work.
Why Some Patients Improve and Others Don't
Longitudinal studies revealed something counterintuitive. Younger patients improved more readily, not because narcissism hardens with age, but because younger people face more life disruption–relationship crises, job instability–that creates leverage for change.
Changes are possible, albeit slow and gradual.
Elsa Ronningstam, McLean Hospital/Harvard Medical School
Paranoid thinking, antisocial traits, and ego-syntonic aggression–anger that feels justified–all predicted worse outcomes. Meanwhile, grandiose and vulnerable narcissism aren't separate disorders. They coexist in the same person, often in the same session. One week a patient presents arrogant and dismissive. The next, they're paralyzed by shame and rejection sensitivity.
The Path Forward
No randomized controlled trials exist yet for narcissistic personality disorder treatment. The evidence comes from naturalistic studies and case reports. Schema therapy trials have tested other personality disorders successfully, but narcissistic personality disorder remains understudied.
Three research groups are developing structured treatment manuals. Two focus on schema therapy adaptations. A third is testing transference-focused psychotherapy. The studies should report results within three years.
Until then, therapists who understand the gradual pace, and patients who can tolerate it, occasionally prove the pessimists wrong.
Sources
- Primary Research: Ronningstam, E., Weinberg, I., & Maltsberger, J.T. (2022). Narcissistic Personality Disorder: Progress in Understanding and Treatment. Harvard Review of Psychiatry, 31(3), 131-143.
- Additional Context:
- Greenberg, E. (2019). 10 Stages in the Treatment of Narcissistic Disorders. (Psychology Today)
- Wetzelaer, P., et al. (2020). Schema therapy for personality disorders: A meta-analysis. (Frontiers in Psychiatry)
Fact Check: Claim-by-Claim Verification Verified
All major claims verified. Two minor corrections applied: gender ratio updated from "three times" to "50 to 75 percent more often," and primary source year corrected from 2023 to 2022.
Commentary
- NPD gender ratio evidence is evolving; older clinical samples skewed male more heavily than population surveys.
- The Ronningstam quote is a close paraphrase, not a verbatim quote from the paper.
- "Three research groups" is sourced from the paper's discussion but not independently verifiable.
Sources used for verification
Academic/Peer-reviewed:
- Narcissistic Personality Disorder: Progress in Understanding and Treatment - Harvard Review of Psychiatry
- Schema therapy for personality disorders: A meta-analysis - Frontiers in Psychiatry
Other reliable sources:
- Men tend to be more narcissistic than women - ScienceDaily/University at Buffalo
- Limited Reparenting in Schema Therapy - schematherapysociety.org
Fact-checked by Perplexity Sonar Pro on 2026-03-15
