Personality disorder

description of personality disorder from therapist’s perspective

Cannon Beach Nov 2013 - Crescent BeachThis idea of the ‘personality disorder’ gets a lot of traffic in the game of accusations, criticism, judgement, blaming and shaming that goes on in the toxic breakdown of relationships. It’s easy to blame the other of a ‘personality disorder’ based on a superficial understanding, gleaned from online information, or perhaps a psychotherapist. “It’s always about you, you have no concept of what others are feeling so you must have narcissistic personality disorder”, or “first you love me, then you hate me…I’m always walking on eggshells around you so you must have borderline personality disorder”, or “you have no conscience, you lie, and deceive…you don’t care about people, so you must be a ‘sociopath’ (a common term for ‘antisocial personality disorder’).”

There may be a grain of truth to some of these quick and easy street diagnoses, but I think it is important to know what we are talking about when we talk about personality disorder.

Having a ‘personality’ or having character traits that distinguish us from others, implies that we are separate from others, of course, and that we developed those traits when we separated from the maternal field, in the first 18 months, through the 3rd year of life. In that process we developed a sense of ‘other’ that allowed us to be empathically attuned to others, how they see things the same or differently, based on their experiences.

This seems like common sense to an adult, but an infant is primarily narcissistic and can only develop this sense of other, and empathy for the other, by going through a trusting and secure attachment to the primary caregiver. This is the mother in most cases – they break, get disappointed that they can’t remain narcissistic, then there is loving repair, with a sense that I can trust other people, starting with my Mother, or other caregivers.

If the infant and developing toddler had what we call an ‘adverse childhood experience (ACE)’ such as a feeling of neglect, terror, ambiguity and confusion about caregivers, the developing child will most likely internalize the terror and ambiguity of the external environment and, throughout life, project out the expectation that this will happen again and again with anyone they are relating to, which results in a feeling that they can’t trust anyone from moment to moment. Fear and/or anxiety that ‘something bad is going to happen’ can be released at the slightest provocation, causing an eruption of affect or emotion from the lower part of the brain, the part that promotes fight, flight or freeze. Emotions become dysregulated (out of control). If the person being related to is in a position of authority, such as a supervisor in a work environment, the problem can be exacerbated. Intimate relationships are also difficult because they work on trust, and on the unconscious assumption that the primary secure attachment is being re-established, though with an adult sense of separation and boundaries.

An individual whom has had this Adverse Childhood Experience (ACE), leading down the path described above, is said to have ‘insecure attachment issues’, or in a sense we could say ‘unresolved attachment issues’, which results in fear of the other, or excessively clinging to the other or a moving back and forth between the two, with no real sense of the boundary. They would not have that sense of separation, and empathic attunement with the other that someone would have that experienced secure attachment with the primary caregiver.

They give the impression, without boundary, and projecting both negative (and sometimes excessively positive) characteristics onto the other, that they have ‘no core sense of their own selves’. We say that they seem to have no specific character or personality. Hence the terms ‘personality disorder’ or sometimes ‘characteriological disorder’. They seem to have the narcissism of the infant, and they also seem to have an altered sense of reality, because they are projecting and lack that attunement with the other. The term ‘borderline’ was an indication that the individual is ‘on the border between reality and psychosis’, but this is increasingly being seen as an inadequate way to perceive this behavioral phenomenon. The person with personality disorder does project their sense of reality onto the other, but, unlike the schizophrenic, they do understand reality, and often what they have done, in the aftermath, and this can lead to a painful sense of shame, and despair as they are cut off from loving attachments and relationships. In the worse case scenarios, they can become so cut off from the ability to form relationship or to take supervision at work, that they find it difficult to survive, to take on social responsibilities required in the process of making a living as an adult. This can lead to despair, and not uncommonly, suicidal despair.

The therapist helps to heal this issue, by staying with the client, holding all of the swings from positive to negative projection, understanding what is going on, not taking it personally, and often tolerant of the constant breaking and repair in the therapeutic relationship that is painfully necessary and difficult over time. As the person with personality disorder starts to heal, and their old projective defenses start to fall away, they get anxious and depressed. “Can they really replace that old defense with trusting, loving attachment with boundaries?” This is where the therapist stays with the client, often building up that first relationship.

The approach I am describing is largely psychodynamic, emphasizing the healing power in the ‘relationship between the therapist and client – the attachment dynamics’, but other techniques such as Dialectical Behavior Therapy (DBT) are also useful for developing skills in distress tolerance, coping, emotional regulation, and group and interpersonal interaction. The client does really need to develop social skills, and it often takes a group and other processes besides individual psychotherapy to accomplish this.

The good news is that neuroscientists are telling us that the neural and memory circuits in the brain change as we adapt to new ways of relating in the therapeutic setting, and this really can promote healing!