I am Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

In 1978, a medical doctor by the name of J. E. Groves published in the prestigious New England Journal of Medicine an article titled, Taking Care of the Hateful Patient.

In the article, Groves admitted that patients with personality disorders often evoke in their physicians dislike or even outright hatred. Groves described four types of such undesirable patients, dependent clingers, today called codependents, entitled demanders, today we call them narcissists and borderlines, manipulative help rejectors, typically psychopaths and paranoids, borderlines and negativistic passive aggressives, and what he called self-destructive deniers. He was probably referring to schizoids and schizotypals, for instance, or histrionics and borderlines.

Therapists, psychologists, social workers and psychiatrists report similar negative feelings towards such patients. Many of them try to ignore, deny and repress these feelings.

The more mature health professionals realize that denial only exacerbates the undercurrents of tension and resentment, prevents effective patient management and undermines any therapeutic alliance between healer and the ill. It is not easy to cater to the needs of patients with personality disorders, narcissists especially.

By far the worst is the narcissistic patient, patient with a narcissistic personality disorder.

In my book Malignant Self-Love: Narcissism Revisited, I have described the situation.

One of the most important presenting symptoms of a narcissist in therapy is his or her insistence that he or she is equal to the psychotherapist in knowledge, in experience or in social status.

The narcissist in the therapeutic session spices his speech with psychiatric lingo and professional terms, of which by the way he understands little. The narcissist distances himself from his painful emotions by generalizing and analyzing them, by slicing his life and hurt and neatly packaging the results into what he thinks are professional insights.

His message to the psychotherapist is, there is nothing much that you can teach me. I am as intelligent and knowledgeable as you are. You are not superior to me. Actually we are partners. We should both collaborate as equals in this unfortunate state of things in which we inadvertently find ourselves involved.

In their seminal tome, Personality Disorders in Modern Life, Theodore Millon and Roger Davis wrote, page 308. Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid. Interpretation and even general assessment are often difficult to accomplish.

In the third edition of the Oxford Textbook of Psychiatry, page 128, the author cautions, people cannot change their nature but can only change their situations.

There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character. Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve these modest aims.

And finally, the fourth edition of the authoritative Review of General Psychiatry, page 309, says, people with personality disorders cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them. Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with narcissists, although their use has been controversial.

The narcissist is a hateful and difficult patient.