My Thoughts On Personality Disorders

When I first entered the field of mental health I was taught to believe that Personality Disorders were the mental health equivalent of terminal Cancer. The message was that all we could do was manage these clients.  I was told that they would exhaust me and disappoint me and manipulate me and never ever get better.  At that time, there wasn’t much awareness of Personality Disorders in the general population.  It was a mental health insider’s term for “completely crazy”.  I would receive referrals for teenagers where other therapists called them “budding borderlines” (Borderline Personality Disorder).  They were “budding” because it’s not ethical or accurate to diagnose Personality Disorders before age 18.  So adding the “budding” felt like a good way to communicate the same thing while not actually diagnosing.  It made me furious.

The more I got to know these children and adults who were diagnosed with Personality Disorders (or budding Personality Disorders), the more I questioned these diagnoses at all.  I began to see common themes in these clients.  They all had pretty cruddy experiences with their primary attachment figures and/or they were all in the midst of a significant identity crisis.  It felt more like a response to traumatic relationships and an unclear sense of identity than full on “crazy”.  Their responses to their histories and current situations made perfect sense to me.  It seemed to me that if these clients heard that their actions made perfect sense, they might actually get better.  It seemed to me that if we could treat attachment issues, we could treat Personality Disorders.  Turns out, I was right because I have successfully treated folks that others have diagnosed with Personality Disorders and I will happily continue to do so.

Unfortunately, the vast majority of therapists I meet still believe what I was taught all those years ago.  They avoid treating folks who demonstrate behaviors that would fit criteria for a Personality Disorder.  When they do treat them, they take a maintenance approach, assuming the client will never really be well.  They condescend and are cold in order to keep healthy boundaries.  When they treat their partners or family members they tell them to never expect their loved one to get better.  They tell clients that they have a Personality Disorder and that they’ll never truly get better.  And now, with information so incredibly available online, anyone who Google’s Narcissistic Personality Disorder (NPD) or Histrionic Personality (HPD) Disorder or Borderline Personality Disorder (BPD) will be told what I was told all those years ago.  Then they decide to go ahead and informally diagnose someone in their lives and then write them off—the opposite of what is really needed to treat attachment issues.

So here are some things I’d like everyone to know about Personality Disorders—not based on research-- not backed up in any journal or peer reviewed paper—just what I’ve seen and come to believe in my 15 years in this field.

 

1.     Personality Disordered Behavior is Never Benefitted From a Diagnosis of a Personality Disorder.  I have never and will never use a Personality Disorder diagnosis.  Because it has been so associated with folks never getting well, it stops the momentum to get well and stigmatizes clients.  I will sometimes talk to partners or family members about Personality Disorder behaviors in their loved ones, but only if they are clear that it is not appropriate to label their loved one and only if they hear my whole spiel on how these behaviors come to be.

2.    Many Personality Disordered Behaviors Are Linked To Developmental Norms, Gender Stereotypes or Systemic Issues.  You’d be surprised how many incredibly stable and successful people have told me that they were either diagnosed with a Personality Disorder or believed they had one at some point in their life.  Our 20’s are a tumultuous time filled with questions about identity, how to get our needs met, how to set boundaries, how to deal with rejection etc.  It is quite normal for folks to act pretty erratically during this time.  I’ve also seen folks who are struggling with their sexual orientation and trying to maintain a monogamous relationship get diagnosed with a Personality Disorder.  They simply can’t pin down their identity and behave erratically in response to their fear of rejection. This erratic behavior is diagnosed when it may be quite normal.  (Think women being locked in an insane asylum for wanting a divorce in the 50’s with a diagnosis of Histrionic Personality Disorder) 

3.    Personality Disorders Are All About Self-Protection:  In essence, every one of the Personality Disorders can easily be lined up with one of the attachment styles identified through attachment theory.  Our brains learn how to get the most connection and the least rejection as we interact with our primary attachment figures as infants.  Over time, our brains tell us to do the same thing in all relationships to get the most connection and the least rejection.  Unless we have lots of new secure attachment experiences, we will just keep doing the dysfunctional thing to get what we need.  So every behavior, from behaving as if you are too good for everyone else (NPD) to moving between idealization to demonization of loved ones (BPD), is an effort to protect the self from rejection while still obtaining connection.  It isn’t until we have consistent, healthy attachments that we can begin to re-train the brain and do it differently.

4.    Folks Who Demonstrate Personality Disordered Behaviors Benefit From Therapy:  I’ve seen it too frequently to believe otherwise.  A long-term relationship with a therapist can begin to support clients in believing a different story about relationships and self-worth.  Folks who struggle with attachment and identity issues benefit greatly from consistency, clear boundaries, compassion and non-judgment.  Because the behaviors they’ve shown tend to push others away, they often get the same information about people over and over again.  Others are not to be trusted to stick around. Others are not to be trusted to love them as they are.  Others are unpredictable and unkind and selfish.  The belief that they are not worthy of real love is confirmed when people push them away or judge their behavior.  A skilled therapist who does not reject, but also does not rescue can support someone in the process of learning how to do relationships well.  It is also incredibly important for these folks to be educated on the reason behind the behavior so that they can have hope for their ability to do it differently.

5.    Loved Ones Need Therapy Too:  If you are in a relationship with someone who demonstrates these behaviors, you need a therapist too.  To have relationships with folks who struggle with connection and attachment you must have good boundaries.  Not many people do, in my experience.  Having a therapist will help you to set appropriate boundaries to protect yourself while also not adding to the attachment issues that your loved one has.

6.    Empathy Goes A Long Way:  Try to imagine what it must be like to be so uncertain of your own worthiness of love that you push people away as soon as they get close.  Or imagine being so unclear on who you are separate from how you can please others that you can only protect yourself by believing you are better than everyone else.  Try to imagine that every time you get close to someone you are so terrified of losing them that you wind up in a panic.  All of these difficult behaviors are a result of something.  That doesn’t mean you have to rescue or fix or submit your needs to make them feel better—but it does mean you can avoid judging or writing them off.

 

These behaviors are hard to deal with.  They are hard for friends and family, they are hard for the therapists that want to support and they are excruciating for those who are ashamed that these are their behaviors.  But they need not be forever and these clients need not be alone in this world.  So the next time you click on a “10 things to know about Narcissists” post, or a “What every child of a Narcissist experiences” post dig a little deeper.   There’s more than meets the eye.