We live in interesting times in the United States. Over the past two years, we have seen on the political stage countless examples of behavior, attitudes, statements, and reactions that have led us to question the psychological suitability of those holding political office. For instance, articles have been written about the psychological stability of Donald Trump, and a myriad of mental health professionals have spoken about concerns centering about his having a personality disorder, mostly focusing on narcissistic and/or antisocial personality disorders. There also have been concerns raised about early signs of dementia or cognitive processing deficits. Other disgruntled Americans question the judgment and reasoning of many holding political office. Congressional politicians—both nationally and locally—have been in the news for years, with accounts of reckless spending, illegal sexual behavior, affairs, and illegal or questionable use of monies. Americans are pretty disgusted, regardless of where they land politically.
Politicians are not the only ones who behave badly and make us wonder what is happening in this modern era. The events of Charlottesville and countless other cities have shown us that not only are racism and xenophobia alive and well, but they act in ways to hurt and kill others. Attitudes which many find questionable have crossed into a new level in which the destruction of life and the promotion of aggression and violence are normalized in some circles. We question what would make someone act in this way, and this is a good question. Many answers have been given, and they are intriguing. The moral decline that these actions bring clearly suggests that we have segments of society and the political world who have considerable challenges in acting morally, ethically, and legally. As the rector of my Episcopal parish recently wrote, this problem is a spiritual sickness that has infiltrated the ideas and actions of white supremacists. I believe there is something quite crucial to understand in these ideas, regardless of where one's religious ideas and values lie.
However, I see some of these challenges in the modern era as an indicator of another type of problem—that is the problem of disordered personality. By definition, personality disorders are enduring patterns of thoughts, feelings, behaviors, and impulses that are relatively stable and cause distress and maladaptation in the context of the individual’s culture. While these problems have been typically classified as distinct disorders, DSM-5 is encouraging clinicians and researchers to understand personality pathology along various dimensions. The first set of these dimensions is pathological personality traits, which are broadly organized into five broad domains – Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Also part of this dimensional presentation is the understanding of personality problems by the ways in which oneself and others are understood and enacted. This latter component is referred to as Levels of Personality Functioning (LFP). Self LPF is characterized by problems in self-directedness and in having a clear sense of one’s own identity. Other LPF is characterized by problems with being empathic and developing intimacy.
If we were clinicians asked to assess these individuals who act in these troubling ways, we no doubt would find that many might be considered to be highly antagonistic and detached. Some may be motivated by strong levels of negative affectivity (such as depression, fear, or anxiety), while others might also be relatively detached from society and their own culture, thus fearing the kinds of problems one might have by associating with others who are different. And finally, more psychotic ways of thinking might govern the way in which the world is perceived and experienced, thus leading toward hateful and aggressive acts and fears. Within the LPF framework, we also would likely find individuals who feel very challenged in taking charge or their lives (i.e., low in self-directedness) and thus act in ways that are dramatic and extreme, only to achieve greater mastery. Some might have their identity so rigidly defined that they cannot view themselves or their actions in any other ways that might allow more constructive dialogues and exchanges with those are different or disagree with them. From an interpersonal (other) perspective, we can certainly see how empathy fails to be expressed in a number of these politicians and citizens, and we might easily envision how they are challenged in having intimacy with others who are not exactly like them. And even then, if they do have more close and caring relationships, if deficits in empathy exist, for instance, then it could be the case they strike out against those who go against their own ideas.
I am not suggesting we start diagnosing everyone who acts in these troubling ways with personality pathology. Ethical and competent assessment dictates a careful evaluation of a patient (not a random citizen or politician) from a licensed clinician, who appreciates the complexity and nuances of how information and data about a patient combine to produce a compelling and accurate narrative about how he or she functions. For instance, cognitive declines, head injuries, anxiety, depression, and trauma (just to mention a few) can affect judgment and behavior. Nevertheless, I do not believe it is a far stretch to envision that personality pathology may exist in a number of these individuals, when their actions are so publicly and regularly recorded.
The National Institute of Mental Health has not funded research on personality pathology in recent times, and treatment of personality disorders or pathology has suffered a similar fate. Clinicians, too, are reluctant to diagnose personality pathology, in large part due to the stigma and the perception that personality disorders are untreatable. Many providers offer piecemeal approaches to personality pathology (e.g., treating an impulse control problem) without conceptualizing how the specific problem is set into the context of the person’s personality. And then there are many psychiatrists and physicians who take mainly a psychopharmacological approach to these problems—again treating symptoms and not underlying personality structure and processes.
It is time that the mental health community put personality and its pathology back into the equation when patients are assessed. Funding agencies and professional societies need to take a closer look at these problems and how they are manifested. Offering healthy amounts of funding for carefully designed assessment and treatment studies will be a good start. Because I value the understanding of human personality in psychological treatment, I have moved into the role of president-elect of the International Society for the Study of Personality Disorders, (www.isspd.org). The ISSPD is committed to working at the international level to promote the importance and value of understanding personality in its complexity – traits, LPF, disorders, structure, and processes. We also are committed toward enhancing treatment to make people’s lives better.
Personality and its pathology does matter. It is time to start thinking about our challenges this way.