By Ryan Eberst | Wednesday 3, 2024

Beyond the Label: Understanding Personality Disorders

“Personality disorder” can be an intimidating word (and a more intimidating diagnosis). In the contemporary world of therapeutic language being used on social media, it is a term that can be used without being defined. It can evoke images of toxic relationships in which the phrase “Narcissist” or “Borderline” is weaponized against others. It may call to mind one’s favorite true crime podcast or documentary, where “Sadistic” or “Antisocial” personality disorders are discussed. It even impacts the therapeutic world, where personality disorders are seen as particularly difficult cases that therapists would be better off trying to avoid and refer out to a specialist.

But the images and ideas that are listed above are largely not true. While working with and treating personality disorders does have specific considerations that therapists need to keep in mind, the working with personality disorders can be rich and rewarding. 

Before we can talk about personality disorders, we need to define a theory of personality. Ordered or disordered, everyone has a personality. A personality disorder is simply a normal human personality that has been intensified, usually in response to less-than-optimal circumstances in early childhood. So what is a personality?

From First Needs to Forming Personality: A Baby's Blueprint

We start at the very beginning. When a baby is born (and even before it is born) there already exists unique genetics, temperament, and inherent human drives for connection, aggression, and sexuality. These drives “push” to be satisfied. Early on, this is all very physical. Hunger presses on the baby, and it cries to get the drive satisfied. The infant needs its parents for survival, and not just physically. They need to be protected, attuned to, comforted and soothed, delighted in, and encouraged. The baby smiles, coos, or nuzzles to get the need for connection satisfied.

When Needs Clash: Anxiety and the Birth of Defenses

There are times when these drives are in tension with each other, or when the drive feels too overwhelming, or when the drive cannot be adequately satisfied, and the infant experiences anxiety. Defenses develop against this anxiety. As the infant grows, these defenses become more and more complex. Furthermore, the infant needs to keep the fact that the anxiety is defended against out of awareness (if the infant knows that they have defended against anxiety, then they know about the anxiety). So, secondary defenses, or defenses against defenses, develop.

Building the Blueprint: How Parents Shape a Child's Object Relations

Of course, none of this happens in a vacuum. From the beginning, the infant is physically and psychologically dependent on their primary care givers (usually, their parents). And this deep, dependent relationship supplies much of what will become the child’s personality. How the parents respond to the child, how they interact with the child, how they regulate their own emotions, how they treat each other, how they treat other children in the household – all of these interactions are internalized by the child. These different ways of relating become a map or script of sorts that the child unconsciously depends on to understand the world and themselves in the world. Psychologists use the term “Object Relations” to refer to these interactions and the scripts they develop.

From Scripts to Self: How Parents Help Children Find Themselves

As the child internalizes these scripts more and more, they are able to see themselves as a character within these scripts. They begin to experience themselves more and more in relation to their parents and others in their world. When they fall and skin their knee, an attuned parent reacts in a way that reflects their emotional reactions – fear and sadness – but does so in a way that shows that the parent is not afraid or sad themselves. Through this process, called “marked-mirroring” the child can experience themselves as afraid and sad, and experiences themselves as different from their parent. This process is repeated over and over again in every minor interaction, and the child begins to develop a sense of themselves within these scripts. This contributes to their self-esteem, sense of agency, and ability to narrate their lives as a consistent character within it.

The Interplay of Personality: From Building Blocks to Inter-Personal Styles

With drives managed by defensive processes, with internalized relational scripts that help the child to navigate their relational world, and with a firm sense of self in place, they enter into a more complex social world (daycare, school, etc.). Based on all of these processes – all of which operate mostly outside of awareness – they present themselves to their peers. They take their unique blend of 1) genetics, temperament, and drives 2) primary and secondary defensive strategies 3) relational scripts or “object relations” and 4) sense of self and present a version of themselves that fits the context, or an interpersonal style. When we talk about personality in everyday language, this is mostly what we are talking about – our specific and unique style that we present to others in our lives. But, as we now see, there are layers and layers of important processes going on beneath the surface that have a direct impact on this interpersonal style. So what happens when things go wrong?

Beyond Normal Difficulties: When Development Goes Off Track

All humans have personality, because all humans have had to adapt to difficulties in their development. Freud made it clear the difficulties related to personality development were normal and necessary, even if they produced anxiety and a need for defenses. Basic developmental markers such as weaning, toilet training, the ability to walk, and the ability to speak are all good and healthy – in fact we’re quite concerned if they’re not met by specific ages. But the necessity does not change the difficulty for the child themselves. They now have to deal with early loss (weaning), navigating issues of compliance and rebellion (toilet training), their own ability to leave their parent, which is both exciting and terrifying (the ability to walk), and how to communicate their inner world (speech). In the healthiest ranges of development, these are all difficult experiences that have a lasting impact on the development of personality.

For many people, the healthiest ranges of development are simply not possible. There are extreme cases of abuse, neglect, and trauma that profoundly impact the development of personality. But there are more subtle factors that can impact personality development as well: a parent’s lack of attunement or a failure to express delight in the child can have significant consequences for the young and developing personality. And it’s not just up to the parents: poverty and financial instability, illness (in either parent or child), cultural discrimination, and unavoidable disasters can all profoundly impact a developing child.

From Chaos to Character: How Trauma Shapes Unhealthy Scripts

If the developmental circumstances produce enough anxiety and distress in a child to have a lasting impact on personality development in healthy individuals, then in suboptimal environments normal development can be devastating. The child is required to experience these difficult stages alone, without the support of a loving parent (either due to abuse, neglect, poverty, etc.). The child needs a parent to help regulate and understand their emotions, but if that is left unavailable, the child is left in internal chaos. Defenses are used inflexibly no matter how they may distort reality, and more mature defenses are unable to develop. 

This has an impact on how object relations, or the relational script, are written down in the memory of the child. In the experience of overwhelming emotion, the child struggles to relate to others as complex individuals, instead seeing them as all good or all bad. The scripts are composed of flat characters who play simple roles that have no nuance – roles that are determined by the child’s current emotional state. And the child experiences themselves as the protagonist in these scripts, with roles that are just as simple and unnuanced. In extreme cases, they may not even be able to identify what character they are, confusing themselves for others. 

The child then takes these scripts and acts accordingly. They enter interpersonal relationships expecting all good and all bad characters. They may enter a new relationship expecting an all good ally and savior, which initially makes the other person feel great, but eventually leads to feelings of resentment, stress, and the pressure to live up to unrealistic expectations of a role they can’t play. This leads to disillusionment in the individual, as this new character who they thought was all good is not actually all good, and therefore can only be all bad. The disappointment, anger, rage, or fear is so overwhelming that they react explosively, and the other person retaliates or abandons, reinforcing the scripts. And the show goes on over and over again. The actors change, the roles never do, and the entire show is directed by extreme emotional states.

The Therapist in the Play: How Personality Disorders Impact Treatment

People with personality disorders are not the only people who struggle, but they do struggle in a particular way. Someone with a healthy personality may experience extreme depression, anxiety, addiction, trauma, or any number of other difficulties. But, typically, when these individuals experience these struggles, they recognize they need help, they enter into therapy, and they experience the therapist as someone who can help (but not all good), but is also imperfect (but not all bad). 

But when development has been suboptimal, and personality has developed in a disordered way, a therapist will be experienced as the various roles within the scripts that were written in these suboptimal experiences. The therapist may be seen as an all-powerful savior, a vicious attacker, an incompetent fool, or an exploitative manipulator – they may be experienced as all of these roles in a single session.

The Unconscious Play: Why Personality Disorders Can Be Challenging to Treat

Humans have a strong tendency to “play” or “act” with others. When we are being treated in a certain way, when we are being recruited into certain roles, we tend to play them out. Roles are comfortable for all of us; they tell us who we are and we are doing in the moment in any given relationship. So when we are being asked to play a particular role in a particular moment, we typically go for it. 

It should be noted that this all takes place unconsciously. There are no auditions to play roles in the lives of the others in our lives. In interpersonal relationships we are dropped into the play, regardless of whether we wanted to be or not, whether we are aware of each other’s scripts or not, and usually without even being aware that the play is being performed.

When a personality has developed in a disordered way, the pull to play the roles is especially strong. The under-developed defensive processes tug on the very young and under-developed parts of others (which we all have), and we often find ourselves in the same play again, with the same roles being performed by different actors.

Breaking the Cycle: Therapy for Personality Disorders and the Therapist's Role

This is where the treatment of personality disorders differs. It requires that the therapist not only work on the symptoms as one would with other individuals (the depression, anxiety, addiction, trauma, etc.), but also, and often first, attend to the roles that are being played out unconsciously. This is why it is crucial for therapists who are working with disordered personalities to have their own therapy; they have to be aware of their own scripts, their own character, their own defenses and drives, and their own interpersonal style. In other words they have to have a relationship with their own unconscious, so that they can be aware of their impact on their patients, and how their patients may impact them. 

But being aware of one’s own unconscious doesn’t save therapists from unconscious processes in the moment. Therapists may have a better idea of how they react when they play certain roles, and how their own scripts recruit others to play roles in their lives, but they still find themselves “caught up” in playing roles they didn’t audition for. Often, this awareness is vague – I know I am playing a role, but I am not sure which role. In other words, therapists need help.

The Necessity Of Consultation

In order to effectively treat patients, and especially those struggling with disordered personalities, therapists need to have consultation with other therapists. In consultation, the therapist presents the case (always without identifying information to protect the privacy of the patient) to other therapists to help gain an understanding of the drama, the roles, and the scripts, as well as the director (emotion) that is driving the show. 

Other consulting therapists can reflect back the drama that is being played out unconsciously. They speak courageously about how they experience and feel the patient and the therapist, and the relationship that is unfolding to uncover the unconscious truth of what is happening. The therapist can then begin to speak courageously to their patient, telling them how they are experiencing the drama, the roles, the scripts, and the emotion. The drama becomes conscious, and the patient and therapist can start to work together to rewrite the scripts, rework the roles, and foster a healthier relationship with the emotional director.

Beyond Diagnosis: Rehearsing New Stories at Aletheia

At Aletheia, all of our therapists are specialized in treating personality disorders. This is because, at Aletheia, we have high value for relationship and consultation. We come together weekly to discuss cases and consult with each other. And our model of consultation is focused on bringing to the surface the unconscious dramas that are being played out with our patients. By focusing on our own emotional states in consultation, we become aware of the emotional states that are directing the plays in our offices. We collectively think about these states and the roles and scripts that they are directing. And we rehearse together, trying on new scripts and roles so that we can begin to relate with our patients in new ways. 

When we’re able to identify and discuss these unconscious dramas, therapy becomes improv. The patient and therapist begin to rewrite the dramas that were laid down in early childhood. The therapist and patient both begin to “play” with the roles, experimenting and trying own new ways of relating to each other. Together, the patient and therapist find more spontaneous and flexible dramas with more nuanced characters and a more robust sense of one’s self in the drama. In short they re-write the dramas together. 

The goal is never to change from one play to another. Therapists are not trying to change someone from one personality to another. Rather, the goal is to “edit” the scripts, deepen the roles, and flesh out the characters. We’re not in the business of exchange one personality for another, but rather for ordering a disordered personality that already exists. The end goal is that the patient can develop healthier defenses, more flexible and realistic scripts, and a more solid and stable sense of self.