"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."

The reason narcissism is under-reported and healing over-stated is that therapists are being fooled by smart narcissists. Most narcissists are expert manipulators and consummate actors and they learn how to deceive their therapists.

Here are some hard facts:

There are gradations and shades of narcissism. The differences between two narcissists can be great. The existence of grandiosity and empathy or lack thereof are not minor variations. They are serious predictors of future psychodynamics. The prognosis is much better if they do exist. There are cases of spontaneous healing, Acquired Situational Narcissism, and of "short-term NPD" [see Gunderson's and Ronningstam work, 1996]. The prognosis for a classical narcissist (grandiosity, lack of empathy and all) is decidedly not good as far as long-term, lasting, and complete healing. Moreover, narcissists are intensely disliked by therapists. BUT…

Side effects, co-morbid disorders (such as Obsessive-Compulsive behaviors) and some aspects of NPD (the dysphorias, persecutory delusions, sense of entitlement, pathological lying) can be modified (using talk therapy and, depending on problem, medication). These are not long-term or complete solutions – but some of them do have long-term effects. The DSM is a billing and administration oriented diagnostic tool. It is intended to "tidy" up psychiatrist's desk. The Axis II Personality Disorders are ill demarcated. The differential diagnoses are vaguely defined. There are some cultural biases and judgements [see diagnostic criteria of Schizotypal and Antisocial PDs]. The result is sizeable confusion and multiple diagnoses ("co-morbidity"). NPD was introduced to DSM in 1980 [DSM-III]. There isn't enough research to substantiate any view or hypothesis about NPD. Future DSM editions may abolish it altogether within framework of a cluster or a single "personality disorder" category. When we ask: "Can NPD be healed?" we need to realise that we don't know for sure what is NPD and what constitutes long-term healing in case of an NPD. There are those who seriously claim that NPD is a cultural disease (culture-bound) with a societal determinant. Narcissists in Therapy

In therapy, general idea is to create conditions for True Self to resume its growth: safety, predictability, justice, love and acceptance - a mirroring, re-aprenting, and holding environment. Therapy is supposed to provide these conditions of nurturance and guidance (through transference, cognitive re-labelling or other methods). The narcissist must learn that his past experiences are not laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive.

Most therapists try to co-opt narcissist's inflated ego (False Self) and defences. They compliment narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.

The same applies to alleged heredity of mental illness. Single genes or gene complexes are frequently "associated" with mental health diagnoses, personality traits, or behaviour patterns. But too little is known to establish irrefutable sequences of causes-and-effects. Even less is proven about interaction of nature and nurture, genotype and phenotype, plasticity of brain and psychological impact of trauma, abuse, upbringing, role models, peers, and other environmental elements.

Nor is distinction between psychotropic substances and talk therapy that clear-cut. Words and interaction with therapist also affect brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines – as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) – treat symptoms, not underlying processes that yield them.

IV. The Variance of Mental Disease

If mental illnesses are bodily and empirical, they should be invariant both temporally and spatially, across cultures and societies. This, to some degree, is, indeed, case. Psychological diseases are not context dependent – but pathologizing of certain behaviours is. Suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, even psychosis are considered sick by some cultures – and utterly normative or advantageous in others.

This was to be expected. The human mind and its dysfunctions are alike around world. But values differ from time to time and from one place to another. Hence, disagreements about propriety and desirability of human actions and inaction are bound to arise in a symptom-based diagnostic system.

As long as pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms – i.e., mostly on observed or reported behaviours – they remain vulnerable to such discord and devoid of much-sought universality and rigor.

V. Mental Disorders and Social Order

The mentally sick receive same treatment as carriers of AIDS or SARS or Ebola virus or smallpox. They are sometimes quarantined against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy. This is done in name of greater good, largely as a preventive policy.

Conspiracy theories notwithstanding, it is impossible to ignore enormous interests vested in psychiatry and psychopharmacology. The multibillion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departments, and law enforcement agencies rely, for their continued and exponential growth, on propagation of concept of "mental illness" and its corollaries: treatment and research.

VI. Mental Ailment as a Useful Metaphor

Abstract concepts form core of all branches of human knowledge. No one has ever seen a quark, or untangled a chemical bond, or surfed an electromagnetic wave, or visited unconscious. These are useful metaphors, theoretical entities with explanatory or descriptive power.

"Mental health disorders" are no different. They are shorthand for capturing unsettling quiddity of "the Other". Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed. Relegating both dangerous and idiosyncratic to collective fringes is a vital technique of social engineering.

The aim is progress through social cohesion and regulation of innovation and creative destruction. Psychiatry, therefore, is reifies society's preference of evolution to revolution, or, worse still, to mayhem. As is often case with human endeavour, it is a noble cause, unscrupulously and dogmatically pursued.

VII. The Insanity Defense

"It is an ill thing to knock against a deaf-mute, an imbecile, or a minor. He that wounds them is culpable, but if they wound him they are not culpable." (Mishna, Babylonian Talmud)

If mental illness is culture-dependent and mostly serves as an organizing social principle - what should we make of insanity defense (NGRI- Not Guilty by Reason of Insanity)?