Maladaptive Character Patterns: The Stuff of Survival
A different way to think about personality disorders.
Posted Jun 16, 2018
Every now and then, one of my patients asks me, “Am I a narcissist?” or “Am I a borderline?” In a way, answering could be very easy. Like most psychiatrists, I own a DSM — the Diagnostic and Statistical Manual of Mental Disorders — which contains lists of traits for personality disorders. You don’t even need a DSM to look this up — google narcissistic personality disorder or borderline personality disorder and the lists are at your fingertips. In fact, you can bet these patients looked this up before asking. Do they have the 5 out of 7 or 6 out of 9 traits that buy them a diagnosis? Maybe. But is knowing that helpful?
To answer that, let’s first think about the term “personality disorder.” The DSM says that it’s an “enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition.” OK, it sounds pretty useful to know about problematic patterns, particularly if your goal is to improve them. After all, being aware of your patterns is the first step in trying to change. Whether you are trying to improve your tennis serve or your handwriting, you have to know what you are doing before you try to do something new. And categorizing human patterns has been a psychological Holy Grail for thousands of years, with the likes of Hippocrates and Freud weighing in with potential solutions.
As a therapist, I need to understand my patients’ patterns. These patterns involve the way they think about themselves, have relationships with others, adapt to stress, think, work, and play. I learn about their patterns by hearing about their lives, listening to how they operate in the world, and experiencing their interactions with me. Recognizing common patterns helps me think about what treatment might be most helpful, predict behavior, and help people have happier and more gratifying lives. Some of their patterns feel good to them, while others cause pain. It’s the latter that generally bring people to therapy. “How can I feel better about myself?” they want to know. “How can I stop hurting people I love?”
But should we conceptualize maladaptive patterns as personality disorders? The dictionary defines a medical disorder as “a disruption of normal or mental functions: a disease or abnormal condition.” Is the tendency to avoid abandonment at all costs a disease? Are desperate measures to maintain self-esteem abnormal? Saying that people who do these things have disorders often leads to stigma, shame, and self-blame. How is that helpful?
Here’s another way to look at it: little children develop patterns to help them survive, but sometimes those patterns give them trouble later in life. Survival means more than staying fed - it means trying to develop a sense that you matter and are loved. What a task, particularly for tiny, dependent human beings who can barely walk or talk. It’s hard enough if things are going well, but try doing it in the face of neglect, abuse, domestic violence, trauma or loss. Like seeds sprouting in concrete jungles, children do whatever is necessary to feel good about themselves and believe that their caregivers love them. They dissociate during beatings, indiscriminately assume blame, deny their own needs, and attach to anyone who shows interest. These patterns are vital in childhood, but can wreak havoc when they persist into adulthood, slaying self-esteem and ruining relationships.
When people with these problems come to therapy, should we say, "You did what you needed to do to survive your childhood - and what it got you was a personality disorder"? I don't think so. They have suffered enough, both as children and as adults. It’s terrific that they have come for help. Instead, they need to be told that they are strong, that they did what they needed to do. In her landmark book, Trauma and Recovery, Judith Herman recast borderline personality as “Complex Post-Traumatic Stress Disorder” in order to emphasize the role of trauma in the development of maladaptive patterns. Marsha Linehan, the creator of Dialectical Behavior Therapy, tells patients, “You are doing the best you can, and you can do better.” These trauma-oriented therapists understand the need to emphasize the central role of early childhood in the development of maladaptive patterns, and to focus on strength over disease.
So to the patient who asks if they have a personality disorder, I say, “Personality disorder? Hardly. You did what you needed to survive. Now we need to help you find other ways to feel good about yourself and believe you are loved.” The very problems that cause them distress and shame are actually evidence of strength and resilience. To me, that’s a better place to start.
Herman, J (1992). Trauma and Recovery. New York, Basic Books.
Linehan, M (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder, New York, Guilford Press.