The problem is even if they admit to having a mental health condition some of them refuse to take any responsibility for their actions, like they’ll say ‘That was a manic/depressive episode’ as it’s a get out of all responsibilities card.
I have somewhat mixed feelings on this. On the one hand you're absolutely right; people who act out abusively, even while in the midst of a manic or depressive episode, need to acknowledge that what they did was unacceptable and take steps towards changing their behavior for the sake of other people in their lives, otherwise what they did constitutes as abuse regardless of how they personally viewed it.
On the other hand, manic and depressive episodes are fucked because they can absolutely warp your perception of events and sense of identity, especially if you've experienced them throughout your entire life; it also doesn't help that as much as people suffering from mental health issues can be toxic, there are also people around them that can feed into that shit deliberately because enabling them allows them to be easily manipulated if an abuser can figure out what sets them off.
As a somewhat grim example, I knew a guy who dated a bipolar chick on and off, and he would deliberately gaslight and belittle her in small ways in order to set her off over the span of two weeks; then they'd have a huge argument during which he'd storm out and she'd buy weed, smoke it, pass out, and then he'd go back the next day in order to get make-up sex and any leftover pot she didn't use for free. He had it rigged like clockwork because he was able to predict her emotional cycles and responses and used her mental illness to fuck with her in a way that benefited him. He bragged about this openly to me and when I didn't share his point of view he tried to shrug it off as "you know how passionate some relationships can be", as if constant arguing and a deliberate manipulation was in some way beneficial to both of them.
When she started going into therapy and got medicated, she actually had the hindsight to realize what he did to her and how staying with him had cost her friends and family in the long run; but that was also a double-edged sword, because oftentimes hindsight like that makes someone take the responsibility and awareness of everything they did or didn't do prior onto themselves all at once in a way that can drive them back into harmful behaviors, because they may believe that they did, in fact, deserve to be treated like shit. Guilt over things you do while you aren't entirely in control of your mental state can really fuck someone up in the long run unless acknowledged in a gradual fashion, which is where you get a lot of denial and relapsing behavior.
This example wasn't remote, either; I grew up with a lot of Cluster Bs and I saw many variants on this behavior, including parental/child relationships being similarly "rigged" in order to feed unhealthy cycles to get specific responses.
This is why demanding someone hold themselves accountable the second they start taking meds is a bad idea, from a mental health perspective; it's not that the person in question is necessarily in denial about what they did (although some might be), but rather that it reinforces a lot of personal suspicions that they might not deserve the opportunity to become a better person, so why bother. This is why medication and therapy are both critical and needed to work in tandem; pills on their own barely do anything and a lot of the time it's more about the commitment. The action of taking medication, like the action of going to therapy, is something that can become an ingrained behavior and framework to start from on it's own, even if medicated reliance is not an ideal outcome for most other people on the planet.
Malignant narc survivor (just barely) here.
(M) NPD and BPD people are the closest thing to classical theological perceptions of evil on earth. They need to be bound from doing harm. Whether this means disappearing them if you can get away with it, having them comitted (very difficult)or provoking them into doing something extravagant to have them jailed longterm (dangerous) , they need to be destroyed. There is no curing these people.
Similar situation here, except the BPD/NPD who nearly killed me got pressured into regular therapy/medication and, after ten years of both, has not shown any sign of malignant behavior since due to having a social structure reinforced to make sure that treatment continues. I would never, ever recommend that anybody wait for a similar situation, either; I just got unbelievably lucky that someone recognized what was going on and was actually in a position to help.
There is absolutely no permanent, one-time "cure" for Cluster B disorders, but for those who are receptive enough there can at least be mitigation. I'm well aware that if the person in my life stopped taking their meds or going to therapy, we'd be back at square one, and they are aware that I am not going to stay a second time if that happens.
All this is to say that if you have any opportunity to escape a malignant narc, take it at the first opportunity. Don't expect them to change because, even if they do, odds are it will not be contingent on your presence. I got extremely fucking lucky. Most people don't.
