Now we come to the reckoning. Do you, or someone close to you, have some sort of personality disturbance? If so, what can be done about it? As you might guess, the answer to the first part of this question is unlikely to be negative. What almost everybody finds is that it is much easier finding personality disturbance in others rather than in oneself. This is not surprising, as we tend to protect ourselves from the harshest of criticisms unless we have a personality structure prone to self-flagellation. This is unfortunately true of the borderline syndrome discussed earlier.
So it is worthwhile trying to be as objective as possible in assessing personality and it is useful to break this down into elements that are relatively neutral. The following procedure can be used with anyone you know – let us just label this person X.
If the first answer is ‘yes’ and the second ‘no’, then check again to be absolutely certain they are not telling fibs. If they are not, they can probably be placed in the small group called ‘no personality disturbance’. Some people might call them ‘nice but boring’, but these critics might be a little envious.
Many more people would come into the ‘avoid or create trouble category’, even though most of their relationships are harmonious. For this group we have further questions.
This is the area of personality difficulty, and if the answers to any of these questions is ‘yes’, I suspect you (or X) have a degree of personality difficulty. Why do I come to this conclusion? Can’t we all have likes and dislikes without being labelled as abnormal in some way? Well, we have to keep a sense of proportion. As a football supporter it may be perfectly reasonable to avoid groups of supporters of an opposing club, but this is not always true and hardly a persistent problem. Here I am discussing groups that you might be expected to meet and mix with, either at work or in your spare time, yet cannot abide their company.
The most frequent response to this situation is to blame this group rather than yourself: ‘I don’t mix with them because they don’t like me, and anyway I have nothing in common with them.’ This may be partly true, but you contribute to this as well. In the first chapter of this book I admitted that I had personality difficulty. I avoid groups or people who stimulate my anti-authority feelings, not least as I feel I might be provoked into saying something I shouldn’t if I remained in their company. When I was 14 and queueing up to go into a cinema (you needed to queue up in those days), we saw a man being chased by a policeman. I remember my father saying, ‘I wonder if we should be giving some help,’ to be contradicted promptly by my Irish mother, ‘What do you mean? We should trip the copper up.’ My own feelings at the time chimed with my mother’s, even though I could not possibly support these views if asked in the cold light of day.
So if you avoid situations where you might do things you regret, or if you do enter them and get into trouble, the easy option of blaming others is not good enough, particularly if the problem keeps repeating.
It has taken quite a few chapters to describe all the features of personality dysfunction – and by dysfunction we include everybody who does not fall into the small area of ‘normal personality’. So I am assuming that most of my readers are interested to know where they, and others close to them, are on the personality spectrum, but before we evaluate this, we need to be sure that many of the misconceptions about personality disorder are no longer in our minds. Here they are.
One of the reasons why I analysed my own personality in the first chapter of this book is that I wanted to do, consciously for the first time and over a long timescale, what I am asking the reader to do now. Before we examine the personalities of those about us we should look carefully at our own, even though it may be uncomfortable. It is curious how attractive it is to look at errors in others but not those in ourselves.
As interpersonal functioning is at the core of personality disorder, it is worthwhile looking at all the occasions in the past where you had problems in interacting with other people. There are few people who have not had any obvious difficulties in this respect. Some are genuinely saint-like, always seeing the best in people and defusing every hint of conflict. But most of us get annoyed, behave badly, irritate others, have periods when we avoid or will not speak to some people, or say and do things that we regret afterwards.
If these experiences are true of you it does not mean you have any personality problems, but if they have occurred repeatedly it is quite another matter. And, when they do recur, there is a natural tendency to blame the other person for the problems rather than yourself. The opposite may occur, when you blame yourself unduly and unfairly, but this is much less common. There are also others, particularly those in the borderline category, who oscillate wildly between blaming others and then blaming themselves.
Assuming you have some degree of personality dysfunction, the next stage is to decide its level of severity. Personality difficulty is by far the biggest group here. This level applies to people who have repeated problems in some situations but not others. Here we are talking about normal situations that tend to recur in people’s lives, not ones that are highly unusual. So if you only have real difficulties in relating to people when you are being interviewed for a very important job, this is a specific social anxiety that is not directly related to personality. But if you lose your cool when being interviewed for any task, and if this occurs repeatedly, this could come under the heading of ‘problems with authority figures’, and be personality difficulty.
People with personality difficulty often show no evidence of any problems away from these aggravating settings. It is sometimes quite easy to pick up those who have personality difficulty from ordinary conversations. If you happen to meet a person only in one situation – say, for example, on a train on the way to work – all your experience will be based on this one environment. So if the other person seems to be uneasy and unduly sensitive because they are bothered about other people over-hearing your conversation, you can be left with the idea that they are normally suspicious or difficult people. Later, when you talk to someone else who knows that person well you realize that it is just the situation that has created the problem.
Why do I not use the word ‘treating’ here, and why is it not mentioned in the title of this book? The reason is that I am trying to be accurate about the degree to which we can effect change in people with personality disorder, and, as we have found, for most people with personality dysfunction treatment is the last thing that is wanted. About 85 per cent of people with personality disorder do not want to be treated.1 They regard their personalities as an integral part of their nature and do not want to have them altered. This does not mean that their problems have gone unnoticed – they are often all too prominent – but it is very common for others to be regarded as the source of any problems that may arise. So when it comes to dealing with this large number of people (probably around 20 million in the UK) there is no question of providing treatment. The answer is to minimize the impact of the personality problems so ideally they create no disturbance. If this sounds a little odd it is not meant to be. What we must always realize about personality disorder is that it involves other people, and if those people can make adjustments in the appropriate way the elements of disorder lessen or simply disappear.
What about the 15 per cent of people who have personality disorder and want, sometimes desperately, to be treated? Most of these have ‘borderline personality disorder’, which, as we noted in the previous chapter, is being allowed into the new classification even though it does not properly belong there.
But we cannot remove borderline from the personality spectrum even though it is so unusual. Hagop Akiskal, an expert on mood disorders, mocks the diagnosis of borderline as ‘an adjective in search of a noun’.2 I sometimes think it should be a verb. ‘To borderline’ would describe behaviour that is disruptive, confrontational and impulsive. ‘There you go again, stop borderlining’ might be a better form of defusion than the more common direct reactions.
In the new classification there is an option for the diagnosis of borderline personality disorder, but this is only exercised when the severity level – mild, moderate or severe personality disorder – has been decided. Most of those with the more severe form of the disorder would probably have ‘domain traits’ in the negative affective, dissocial and/or disinhibited groups. By removing the diagnosis of ‘borderline’ from the description ‘personality disorder’ we are not denying the existence of the many people who suffer enormously because of the unpredictability of their emotional states and all the troubles that these bring in tandem. We also hope that the new classification will enable the treatments that currently exist, and that are described in more detail below, to be better focused. About one in six more people with personality disorder currently seem to be in the borderline group, and this accounts for nearly 1 in 100 of the population. Nobody is suggesting that all of these should require intensive treatment; the new classification should help enormously in making the choice.
You will notice that the word ‘treatment’ is now beginning to creep into the text. This is because, despite its position on the fringes of personality disorder, borderline has attracted the most interest in terms of interventions. This is hardly surprising as this is the condition par excellence in which people are desperately seeking relief from highly unpleasant symptoms and behaviour. Because there is such a demand for treatment, and a supply of therapists who are all desperately keen to improve the lot of people who are clearly suffering so badly, any positive results have a tendency to be greatly overstated.
How many people have personality difficulty?
The new classification has not yet been used widely, so the figures can only be estimates, but here they are:
These figures may come as a shock, but are extrapolated, together with other data, from a recent study of the UK population.3 How can it be that most of the population have some degree of personality disturbance? Is this not another example of the medicalization of minor degrees of mental suffering that do not deserve any label? These are fair questions, but I will answer them with an example.
At the time of writing, I have just come back from visiting a hospital. It has not been used as such for many years, but the maternity ward still looks clean and clinical, with a stone floor, shining walls and impeccable hygiene. The nurses there were well trained and committed to their work and many mothers delivered their babies successfully there, with all the staff showing great competence and professionalism. The only thing that differentiated this hospital from other similar units was that, after the birth of each baby, despite the efforts to ensure a safe and healthy birth, both the mother and infant were murdered by injections of phenol. Yes, you can read that sentence again; it is quite shocking.
This maternity unit was in Birkenau, part of the Auschwitz-Birkenau extermination camp run by the German Nazi SS in Poland between 1940 and 1945. Most of the nurses there came from middle-class families. At the time of recruitment, a post in the civilian part of the SS was considered to be a step up in society – the pay was good and there were reliable prospects of promotion. Yet these nurses, all of them, carried out these murders daily in the belief that, by removing Jews, Poles and gypsies from the world, they were performing a service to humanity.
Personality difficulty is characterized by being demonstrated in only certain settings. Auschwitz-Birkenau was a very unusual setting, but the fact that many health professionals there had good relationships and apparently normal and satisfying lives away from their workplace shows that most of them could not be described as evil, sadistic or in any way grossly abnormal in their behaviour. But inside the maternity unit (and elsewhere in the camp), everything changed. The rules of normal behaviour were suspended. Sadism ruled.
This extreme example shows the tremendous impact that the environment can have on our behaviour. When I suggest that personality difficulty is extremely common as well as creating problems in life (and there is evidence that it does), I am particularly referring to often brief, but recurring, episodes when people are placed in environments in which they feel uncomfortable or profoundly detest, and react accordingly – badly. Several examples have been mentioned already but there are dozens more. Places in which assessments and interviews are made, public meetings, working with others in restricted space, formal ceremonies, summer camps, crowd occasions, musical evenings, bingo halls, communal dinners, lecture halls, leisure clubs – at least one of these is likely to make you cringe and avoid whenever you can. All of them involve interaction with other people. Personality disorder, unlike any other mental condition, cannot occur in isolation. You cannot have a personality disorder if you are alone on a desert island.
Many more problems arise in people with personality difficulty if there seems to be no way of avoiding the situations that provoke the difficult behaviour. If you are forced to work in a setting that is anathema to you but cannot see an easy way of changing it, then explosions are just round the corner. Sometimes people do not realize they and the situation are reacting together so badly and only blame themselves or others for creating the trouble. This is when some assistance, such as nidotherapy (discussed in the next chapter), may be indicated. When stuck in a rut it is difficult to see out.
But we also need to remember that personality difficulty is not a formal diagnosis in the new classification of personality disorder. It is part of the spectrum that, somewhat artificially, crosses the line into personality disorder at the next stage. I like to think that having a personality difficulty makes you a more interesting person – but I may be biased.
For people with mild personality disorder, whose personality problems are not situational, there are several options. One of these may include seeking medical advice, preferably from a doctor or other health professional who knows you well, sadly becoming rarer than it used to be, and much of the advice given is likely to be along the lines of nidotherapy or other environmental change. One of the main stumbling blocks for people with mild personality disorder is the refusal to admit there is anything wrong, so that everything is blamed on others. This is where improved mutual understanding comes in. If you are able to appreciate, even at a relatively low level of detection, that the negative way other people react to you could at least be partly explained by how you appear to them, you are making progress. So people who chatter incessantly and complain about everything under the sun, yet cannot understand why their company is avoided or those who are persistently irritable and angry and find fault with others, may have to be gently reminded, or better still remind themselves, that they could be a cause, not a consequence, of others’ difficulties.
So what about treatment? Is personality disorder, taken in general, treatable? The simple answer is no. But that does not mean it cannot be helped or reduced to a level that is of little concern. It is a condition that is like the blood disorder haemophilia, in which the normal ability of the blood to clot is absent. This disease cannot be reversed, but by regular injections of a clotting agent it can be managed very successfully.
There are some important differences between personality disturbance and haemophilia. Nobody, unless for extreme religious reasons, refuses treatment for haemophilia, but most people with personality disorder would refuse to have treatment even if it was offered. This may seem hard to believe, but personality is the essential part of ‘I am’, and does not want to be changed into ‘I was’. So even though personality disorder can bring a host of troubles in its wake, the thought of having your very nature altered is just a no-go. Second, we have no predictable, instant treatments, even temporary ones, for personality disorder in the same way that we have for haemophilia. If we had, we could use them for a short time to become the people others would like us to be, before returning to the familiar ungracious and crotchety creatures that are comfortable in their own skins, even if they are detested by others.
Some people maintain that is far too gloomy a view and insist that we now have a large number of highly effective treatments for personality disorder that are revolutionizing attitudes to the subject. This opinion is held by some who work very hard, and with great skill, particularly in treating borderline personality disorder, many of whom devote their professional lives to the different treatments described in the previous chapter. But if we cast a cold eye on all these treatments, we cannot conclude that any of them have any permanent value in reversing the fundamental disorder. They alleviate the symptoms and behaviour, teach strategies that help people to understand others and accommodate them better, and reduce serious behaviours such as self-harm, but underneath very little has changed. This does not mean that the personality will stay exactly the same, as there are changes with age and circumstances, but our valiant attempts to change it by our special treatments only chip away at the edges.
Once we accept this, we have a refreshing set of approaches that will lessen the impact and importance of personality disorder while being aware it may still be lurking in the background. One of these is nidotherapy, discussed in the next chapter. Another is to use our personality problems positively. We have just carried out a very large study4 of a psychological treatment for people who worry excessively about their health, commonly called health anxiety. The treatment was very effective, and five years after treatment finished those who had the treatment were much better than those who did not have it. We assessed personality status at the beginning of the study and were surprised to find that those who had mild personality disorder (mainly in the negative affective domain) showed the greatest benefit of all, and had a much better outcome than those with no personality disturbance). When we looked into this more closely we found that this personality group had been much more consistent in attending their treatment sessions and completed the course much better than others.
So here we have clear evidence of the benefit of personality disorder. It is fair to add that most other studies suggest that personality disorder is a hindrance to success,5 but this may be because nobody has thought of using the personality disturbance positively before. I have certainly been aware of this in my own practice for years. Sometimes the best treatment combination for a medical condition is a complicated one involving several drugs or other forms of therapy, taken at precise times during the day. When my patient is a highly conscientious person, often extending into the personality disorder range, I am confident that the treatment regime will be followed exactly as prescribed.
If you, or someone else you know well, has mild or moderate personality disorder the strategies for dealing with it can involve the same approach as for personality difficulty, but with rather more effort. The main form of management is nidotherapy (see Chapter 9). The other, somewhat neglected, way of managing the problem is to use your personality strengths to compensate for the negative effects of the disorder.
This is the first time that the words ‘personality strengths’ have been used in this book. This may seem odd. The trouble is that in all the learned expositions on personality disorder there is virtually nothing on personality strengths. I have also been guilty of not taking this into account in my own work on personality disorder. In the first chapter of this book I described my own personality in terms of its difficulties. I did not dwell on personality strengths as they were not relevant to my attempted illustration that personality both changes and stays the same, in different ways, during the course of life. But without a description of my personality strengths nobody can really make an overall judgement of my personality.
Personality strengths are present even in those with significant personality disorder. I am sure you will be able to remember occasions when a person whom you know well rose to an occasion and behaved in a much more positive and affirmative way than they would have done normally. These are often big occasions like giving a speech at a wedding, arguing with a celebrity at a public meeting, impressing people at a job interview or coping with the loss of a loved one. It seems people are able to draw on reserves of strength at times of adversity and stress. So why are they not able to do this routinely? The simple answer is that they can’t. The habits of personality disorder too often inhibit the enterprise that is in us all. Let us take one example from my own experience.
Maureen was excessively shy and could not tolerate social situations or large groups of people. She was always extremely anxious in these situations and so did everything possible to avoid them. This anxiety had affected her work, where she generally underperformed as an office worker and was felt to be a bit of a wimp by her superiors.
But she was not a wimp, and she had her wits about her. She noticed at work that some of her senior colleagues never seemed to be around even though they were supposed to be working full time in the office. Four of them appeared to be involved in covering for each other when they were not around. As a consequence, other more junior staff such as Maureen had to do greater amounts of work and were blamed if they faltered in these tasks and made the occasional mistake. Maureen had mentioned it to her immediate supervisor, who merely told her not to be a troublemaker and to get on with her own work.
Despite Maureen’s fear of large social occasions she felt the only way forward was to go to the top. Strictly speaking, it was not her preferred idea at all. It was just that her father, a former trade union representative, had convinced her that this was the only way forward. So at the company’s Christmas party, where all the senior management sat at the top table, Maureen had her opportunity.
She went straight to where the managing director was sitting.
‘Excuse me, sir,’ she said, blushing, but this was not going to stop her. ‘I do not want to spoil the occasion but I have something very important to say to you. It will only take about two minutes.’
‘Yes, my dear. But this is not a time and place to discuss such matters – come and see me in my office during working hours.’
‘But I am not allowed to leave my office during working hours and would have no chance of seeing you then. I promise you it will take a very short time and it is in your interest to listen to me [her father had stressed this line to her in advance].’
In the end she was persuasive enough to get him to leave the table, retire to a corner of the room, and tell him about the shenanigans in the office.
She was not at all sure that he had taken this in and returned to her seat at the back of the hall in some confusion, not least because by this point everyone was looking at her, which increased her social anxiety. But it worked. An internal investigation was carried out and three of the four conspirators were dismissed. Maureen was looked upon in a new light and shortly afterwards achieved promotion. When others said how astounded they were at the way she had been so brave in conquering her anxiety, she replied, ‘You may not realize, but I feel like this most of the time, so an extra notch up on my fears does not make much difference.’
There are other ways of using your personality strengths. Those that are strong and positive can be used to reduce stress in your life6 so that you choose where you will be most comfortable. Other people can also use their personality strengths to deal with others who have personality disorder. One of the other books in the Sheldon series, How to Love a Difficult Man,7 illustrates this well. By adapting yourself to fit in with the foibles and difficulties of others you reinforce yourself. You can draw a parallel with haemophilia and the regular injections of the clotting agent. When in personality difficulty, give yourself an injection of personality strengths.
When it comes to the other end of the personality spectrum – severe personality disorder – I am much less confident. The proportion who seek treatment is relatively low and, as you might expect, most of them are in the borderline category. They may respond to one of the psychological treatments described in the previous chapter but they may also break off and go their own way.
For many others, especially those who show their personality abnormality in the form of aggression, it is very difficult to find any form of treatment that has long-lasting benefit. This is partly because so many in this group refuse to engage in any form of treatment. The only light at the end of the tunnel is the increasing evidence that with advancing age these personality features get less, and many have lost their most difficult personality problems by the age of 55.
My patient Melanie, whom I rashly said would improve by the age of 50, is now a little better and no longer creating chaos in the centre of London. But I think the main change has just been the passage of time, not the many attempts to intervene over the years. ‘You’ll never be able to change me, Peter,’ she once proudly said, ‘I am incorrigible.’
What does concern me over the current management of those with severe personality disorder is the excessive use of coercion. This is perceived simply as punishment, and whatever else psychology has taught us about personality disorder in the last 50 years, the main conclusion is that reward works and punishment fails. This is the area we need to be working on.