The Little Shaman is a spiritual coach & specialist in cluster B personality disorders, with a popular YouTube show and clients worldwide.
The question of therapy regarding narcissistic people is a complicated one for a few reasons. Firstly, if someone is higher-functioning, it may be very hard to spot the amount of difficulty they are having in just every day life. Remember, pathological narcissism doesn't exist in someone because they chose to lack basic, fundamental skills and abilities. It manifests into a primitive compensation for the fact that they are lacking these things in the first place. Creating the appearance/impression that they are able to do things they can't really do is part of their adaptation. It's how they survive, and many of them are very good at it.
Mimicry and mirroring are compensations for lacking empathy and a stable identity. Avoidance, projection and denial are compensations for the inability to process. Enmeshment is a compensation for being unable to create intimacy. Receiving supply is a compensation for lacking the ability to create self-worth. Unless someone really has a chance to observe this person over a long period of time and really understands what they are looking at, they may not realize that what they are being shown is not what it appears to be. It can be extremely difficult to recognize the level of difficulty the person is having in the first place; they don't appear to be significantly disordered, so the subject of therapy may never even come up.
Secondly, even if therapy does become part of the discussion, the narcissistic person is often very reluctant to participate. Their entire dysfunction has evolved to protect them from ever believing there is anything wrong, that they are ever at fault, or that they could ever be less than perfect. This, again, is a primitive overcompensation for feelings of self-loathing and toxic shame. If you need therapy, something is wrong with you. If something is wrong with you, you are not perfect. If you're not perfect, you have no value. So the discussion of "Hey, there might be a problem, let's go to therapy" is doomed from the start in this situation. The very suggestion that something is wrong with a narcissist or could be wrong is usually received very badly. Generally, they will either flat out refuse to go or they will agree to go only because they believe the problem is you.
If they do agree to go, or are somehow forced to go either through the court system or because they face the threat of losing an important relationship, the problems are not over. Many people believe that the big hurdle to treatment and recovery for narcissistic people is that they won't go to therapy at all, which implies that if you could get them there, the problem is solvable. This is not the case. While of course narcissism is a spectrum and some lower-spectrum narcissistic people may be helped by therapy, what we generally find is that narcissists do not respond well to therapy. They may play along or even seem to be improving, but what we usually find with cases of severe narcissistic pathology is that they are manipulating the therapist and/or simply lying about how life outside of therapy is going.
Narcissists only have one way of relating to people, and therapists are not an exception to this in any way. Some narcissists actually enjoy therapy because it is a situation they are in complete control of, where no one can call them out or even really question them about anything they are saying.
It is the same with couples therapy or family counseling. As with any other situation where someone who could be swayed is involved, the narcissistic person simply attempts to sell themselves and their narrative to that person over and over. This is the goal. There is no real desire to resolve issues or work on things. They are simply trying to "win" the other person on to their side, which means they've won therapy. This is why they so often accuse others of trying to turn the therapist against them or otherwise trying to get the therapist on their side; this is actually what they are trying to do. This is the goal of the interaction. It is a contest where the winner is not the person who is right or fair, but the person who can convince the trophy to side with them. There is no understanding that this is not a contest and that the goal is to work together. This is about protecting and projecting their image at all costs so that the third party's emotional reactions - their untainted supply, in other words - belong to the narcissist.
Narcissists can only experience themselves through the reflections of themselves they receive via the reactions and feelings of other people, and therapists are no different. A narcissist interacts with everyone the same way: they constantly attempt to sell themselves and their narrative about the situation or relationship in order to create the image of themselves they want the other person to have. This image could be anything; the hero, the victim, the martyr, the monster, the tough guy, the vixen... whatever they would like to see themselves as in this situation or in general. But whatever it is, every sentence, every action, every reaction, every everything has that goal at the bottom of it. Therapy is useless in this situation. Whatever is not blatant, conscious manipulation is still misperceived, distorted reality. Consequently, the real issues are never explored and may never even be acknowledged. In situations where they are challenged, narcissists in voluntary therapy will often stop going and in situations where they are being forced to go, they may become so combative and unpleasant that the therapist refuses to work with them anymore.
But what about in cases where narcissists are forced to confront the fact that they've been diagnosed with a personality disorder - or misdiagnosed with some other mental health challenge, as is often the case? Surely this will force them to at least acknowledge the fact that it's a possibility they have a real problem, right? Not really. Many narcissists remain in denial even after diagnosis, regardless of the type of diagnosis they receive. They may claim it was a mistake or that there was some other error or bias that caused them to be labeled when there is nothing wrong with them. Those who will acknowledge the reality of the diagnosis often either ignore the gravity of it completely by refusing to acknowledge they display any of the symptoms or behaviors associated with the disorder, or use it to their advantage. It can turn into a situation where the narcissist weaponizes being formally diagnosed with a mental disorder or illness, using it as a way to say that those calling them on their behavior are abusing and mistreating them when then they can't help how they act or expect them to be normal when they aren't. Some may even do both, using the diagnosis as a weapon at times and denying it completely at other times. It is, like everything, something to be used at their convenience and discarded or ignored when it is inconvenient.
It is unfortunate, but it's not uncommon at all. No matter what the situation is, the narcissist still has no responsibility to do anything at all; they believe that it is your responsibility to do something about it. So even when they do acknowledge that there is some kind of issue, they still often acknowledge nothing regarding their own actual behavior, and regarding responsibility, the song remains the same: "Yes, I have a mental illness, or a disorder. That means YOU need to fix things for me, YOU need to make things OK for me, YOU change how YOU treat me!"
The truth is, while it may be understandable to remain hopeful about therapy in this situation, it really isn't the solution. Even when someone can find a therapist who understands pathological narcissism, that does nothing to change the way narcissistic people think, how they approach situations or help create the abilities and skills they are lacking. We don't know yet how to install the internal framework these personalities are lacking when they don't even have the basic framework to build upon. Even worse, there is a complicated, unadaptable framework in its place that needs to be dismantled first. Imagine a house that's already built and finished, where you are trying to remove the frame of the entire house and replace it without destroying the house. It can't be done.
We can teach narcissists about differing perspectives, though they may not understand that or be able to apply it. We can teach them to modify or control their behavior, but if they don't want to do that or don't think they need to, there is not much that can be done to change that. It's a shame that the defense mechanisms that have evolved to protect them end up literally preventing them from seeing exactly what it is they need to see in order to change their own lives. But that's the way it is.