When I started working as a clinical psychologist, I quickly found myself at odds with the concept of personality disorders. I found the construct incredibly deficit-oriented. Saying something along the lines of “Mr. X has a deranged personality.” always sounded incredibly harsh to me, demeaning even. As if the affected person was deficient as a human being, somehow especially damaged, totally kaputt. With that image in my head, I had this idea that patients who had been diagnosed with a personality disorder were very “difficult”, the therapy sluggish and progress hard-earned or next to impossible. Until I got to know a different model of what the DSM (Diagnostic and Statistic Manual of Mental Disorders, primarily used in the USA to diagnose mental disorders) and the ICD (International Classification of Diseases, primarily used in the European Union) call “personality disorders”, based on the concept of clarification-centered psychotherapy (a mix of cognitive behavioral therapy and client-centered psychotherapy) by German psychologist Rainer Sachse. His ideas really conciliated me with the concept of personality disorders and rid me of (at least some of) my prejudices and the more irrational aspects of my apprehension. Here’s why:
Now there is a lot of professional literature on the subject and I don’t want to go into that much detail as far as theory is concerned. Here, I’ll only try to explain in rough terms and as simply as possible how I understood the model behind Sachse’s understanding of “personality disorders”. If you’re interested, just write me a private message and I can recommend some books to you.
Sachse doesn’t seem to be a fan of the term “personality disorder”. Instead, he focuses on how people with “personality disorders” build and maintain relationships, how they interact with other human beings. He notices, that the reason these patients are considered “difficult” is because the way they interact with people, and therefore also the therapist, seems to follow different rules than apply to patients who don’t have a “personality disorder”. Some might seem to be more distrustful, or more easily offended, some more “needy”, less flexible in their thoughts and behavior than other patients… which can lead to frustration, annoyance, even anger on the therapist’s side – and that does not bode well for establishing the trusting patient-therapist relationship that is the basis of all psychotherapy. Without a stable, trusting relationship, you can kiss any psychotherapy goodbye. It won’t work. So why does establishing that relationship seem to be more difficult with this “sort” of patients than with others? I’m going to take a big swing here, but please bear with me.
Enter Sachse. He claims that the behavior and experience of all human beings is shaped by what he calls schemata (not unlike those of Young’s schema therapy). These patterns are formed by early learning processes during childhood and influence our behavior to a large extent automatically, without our conscious decision to let them do so. Schemata develop as a means to help us fulfill our needs and act in accordance with our motives, for instance love, relationship, security, recognition, appreciation and so forth. In childhood, the most important source of satisfaction for those needs are our parents (or whoever is the most important caregiver. For simplicity’s sake, I will speak only of parents in this post). We all strive to satisfy those aforementioned needs. As long as they’re not satisfied, they’ll continue to drive our behavior. Just like when you’re hungry. You won’t stop being hungry until you’ve eaten. As long as your basic needs (food, shelter, security) are not satisfied, you are not very likely to occupy yourself with needs higher up in the hierarchy, such as individual fulfillment. Try enjoying a philosophical argument when you haven’t eaten for a while and all you can think about is high calorie deliciousness. So, as long as a need is not satisfied, it will continue to make itself known to you, you will be driven to satisfy that need. Like run to the next Kebab place and order one extra large with double meat and cheese on top.
With the needs higher up the hierarchy, it’s not so different. As long as your need, for instance, to feel important to and loved by a person that’s very close to you is not satisfied, it will stay “active”. I’ll try to make up an example for how according to Sachse, personality disorders or “relationship disorders” as he calls them, are formed. I’m going to simplify the process somewhat, for the sake of quickly getting to the point. In reality of course, things are much more complex.
So when a child, let’s call her Maria, grows up in an environment where one or more of her needs are being repeatedly and/or continuously ignored, those needs will remain unsatisfied and high in the hierarchy. She will do anything in her power to satisfy the need nevertheless. That’s not a conscious act, it’s automatic. If her parents repeatedly and/or continuously give her the impression that she’s a nuisance, disturbing them, getting on their nerves, what will she most likely infer from that about herself as a person? Probably something along the lines of “I’m not important”, “I don’t have anything worthwhile to give to others” or “I’m boring”. And what is she maybe going to learn about how relationships work? Perhaps something like “In a relationship, one is ignored, not taken seriously, not respected”, “In a relationship, you won’t get help when you need it” or “Relationships are not reliable”.
Maria will then of course try to satisfy that need that is lying idle – which is not a conscious act, she just does what she has to do. For example, she could begin to show colorful or funny or otherwise extraverted behavior, dress strikingly, be loud, outgoing – anything to literally gain attention from her parents, to make them care, maybe even give out some praise or positive recognition. This then serves as a confirmation of the displayed behavior. Maria will continue to express it, because it works. However, this is not a conscious decision. And, she will learn that she has to behave that way in order to get what she needs. The underlying schemata, see above, will be implicitly validated. There is no learning process to tell her that she is important and has great things to give to others without exaggeration or grandiosity, but simply by being who she is. She will implicitly assume that in order to be considered important to someone, she will have to put on a show, to make a huge effort for it. Lwaxana Troi, a fictional alien character from the Star Trek franchise, is a good pop-culture example of someone who, were she human, might be diagnosed with a personality disorder if she ever sought psychiatric help. She can serve as a fictional illustration of how Maria might be like. Lwaxana Troi is a glamorous diva, her wardrobe is as outrageous as her transgressive behavior. You cannot ignore this character, she is the center of attention wherever she goes and does not take kindly to being ignored. If anyone ever even manages to do that. Men are either intimated or enchanted by her, or both. She’s a polarizing persona, direct, very confident, charming – but also sometimes insensitive to others’ boundaries and feelings. She is someone who can drive you mad and make you fall in love with her at the same time. People she interacts with in the Star Trek series are often fascinated and angered by her simultaneously.
I do not intend to ridicule or diminish the level of suffering experienced by some people with personality disorders by comparing them to a fictional alien character that in the Star Trek series is often used for adding some comicality – I just think she is really a good illustration in a simplistic manner. Also, I adore the character, beautifully displayed by the wonderful Majel Barrett-Roddenberry and don’t want to insinuate that the character (or even the actress) actually is psychologically “ill” in any way. They both most likely actually aren’t. So, nothing would be farther from my intentions. But her truly opulent and histrionic behavior, were it displayed by a real human, would definitely give me pause as a therapist if she showed up in my practice ;).
So with this illustration in mind, back to Maria. Of course, Maria grows up and takes these schemata, which have become reinforced quite a number of times by now, with her. By the time she is an adult they have become deeply engrained. But since she is an adult now and interaction with other people besides the parents is increased, the pattern of behavior that formed because it worked with the parents might not work as well with others. Maybe she will notice some friction in the relationships she is forming. The old schema that has served her so well during childhood doesn’t work as well in preparing her for the new challenges of forming relationships and for shaping social interactions in adult social life, with subordinates or superiors in the workplace or in romantic relationships. Some people might still react positively to her schemata, with fascination or reverence for her iridescent persona. But maybe she also makes repeated experiences of some people reacting with annoyance to her. They might interpret her behavior as completely over-the-top, extravagant, egocentric. Maybe some people feel put off by what they perceive as extensive posturing, considering her a shallow “drama queen”.
Building lasting relationships maybe starts to become difficult for Maria as she encounters the same difficulties over and over again. The schema, once useul, is starting to generate high costs. Depending on how high those costs are, this is usually the point where people might start seeking therapeutical help. Sometimes not because they see anything wrong with themselves, but because they realize others have a problem with how they behave. Maria realizes she alienates some people she actually wants to be close to. Her need for affection and positive relationships is not satisfied anymore. Unlike someone without a personality disorder who might “only” suffer from depression, Maria doesn’t necessarily get the feeling of “something is wrong with me”. She might just notice that her life isn’t going the way she wants, how she is repeatedly disappointed in relationships but has no clue as to why the same bad things happen to her over and over again. This is what creates psychological stress and what maybe motivates her to seek out therapy.
I find this conceptualization appealing because:
- it focuses not only on the personality of the person suffering from it, but puts more emphasis on the interactional patterns that result from certain deeply held beliefs about how relationships work. It shifts the focus from a rather stable trait to displayed behavior and therefore opens up a whole different therapeutical approach.
- it pays tribute to how those patterns were formed and acknowledges that they are actually a rather clever solution. Without those patterns, the child would probably have suffered a lot more. Those interactional patterns were useful in the past, they’re the result of successful adaptation to difficult circumstances. What when framed as “personality disorder” seems to a large extent only deficient (at least to me), seems a lot more like a sign of resilience and ability to “survive” under adverse conditions. In my experience, it becomes a lot easier for patients to deal with such a stigmatized diagnosis when they can also see the positive sides of it, recognize how the behavior that generates the costs mentioned above used to be a very helpful and necessary strategy they had to adopt as a child in order to provide for their needs. A strategy that now, as an adult, fails in that goal.
As a psychologist, I feel a lot more comfortable with the notion that what the ICD and the DSM-V call “personality disorders” are actually disorders of relationship building. Because the first term, to me, has the connotation of “something is wrong with you as a person, as a human being”. And the second construct focuses more on “the way you build and interact within relationships impedes your ability to care for your needs”. The first one seems to focus on you as a person, the second one on your behavior. Also, it makes the sometimes bizarre behavior of those affected much more understandable to me. When I start to understand the implicit assumptions that formed during someone’s childhood as a means to adapt and that inform her behavior today, it suddenly seems a lot less “difficult” or “annoying”. I can see it for a once useful, maybe even life-saving strategy that has just outlived itself. And that makes it a lot easier for me to emphasize. I don’t have to be annoyed by Maria’s clownish, exaggerated “theatre performances”. I can see how truly entertaining she is, how funny and colorful. How this is a tribute to how she has the ability to take care of herself, otherwise she wouldn’t have developed this strategy. And coming from a place of understanding and appreciation for the positive aspects of her “disorder”, I can more sensitively give her feedback on the problematic aspects of it and start a therapeutic process of change. And she can perhaps more easily take a step back and re-gain insight into what needs she has and how to provide for them in a less cost-intensive manner. That’s my experience at least.
What I find illustrates the long process of therapy of personality disorders quite fittingly is the poem “Autobiography in Five Short Chapters” by Portia Nelson. I like giving it out to some of my patients and until now, every single one of them recognized themselves in it in some way or another. It illustrates the feeling many people with personality disorders get of having the same bad things happen to them over and over, seemingly without any fault of their own. When they start to become fully aware of their schemata and how they make things difficult for them today, they can finally start to change their behavior. They can realize that they were useful in the past, but that they don’t need the old schemata anymore today, in the present. So here it is:
I walk down the street.
There is a deep hole in the sidewalk
I fall in.
I am lost … I am helpless.
It isn’t my fault.
It takes me forever to find a way out.
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I am in the same place
but, it isn’t my fault.
It still takes a long time to get out.
I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall in … it’s a habit.
my eyes are open
I know where I am.
It is my fault.
I get out immediately.
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.
I walk down another street.