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Freud drew attention to three major obstacles in working with narcississtic patients: indifference, hostility, and the absence of a coherent ego.
About indifference Freud (1917) says: “They manifest no transference and for that reason are inaccessible to our efforts.”
Freud (1912) writes of hostility: “Where the capacity for transference has become essentially limited to a negative order, as is the case with paranoics, there ceases to be any possibility of influence or cure.”
The absence of a coherent ego is an obstacle because analysis requires a strong ego. Freud (1940) says of the ego needed for analysis: “It must, however hard it may be pressed by the hostile powers, have retained a certain amount of coherence and some fragment of understanding for the demands of reality.”
In his final work, The Outline of Psychoanalysis, Freud (1940) regretfully concedes that psychoanalysis does not yet possess the techniques for working with narcissistic patients.
We must renounce the idea of trying our plan of cure upon psychotics—renounce it perhaps forever or perhaps only for the time being, till we have found some other plan better adapted for them. (p. 173)
Plans better adapted to them have dominated the psychoanalytic literature for several decades.
In the 1930s and 1940s Melanie Klein and Hyman Spotnitz were focussing on the aggressive side of Freud's dual drive theory.