Sunday 1 September 2013

PD - The Elephant in the Room

All humanistic therapists are suspicious of labels for people. The infinite complexity and marvel of a person can't be captured in any word, label or concept. Labels can easily also freeze time and imply that people can't change;  attract judgements and create hierarchy. However, the skilful use of words can help us to understand ourselves and others and communicate some of this understanding.
There are three related words which can be very helpful and are often not understood; particularly in the world of personal development. They can easily be lost into the world of psychiatry or clinical psychology. They are neurosis; personality disorder and psychosis and I want to briefly write about each.

Neurotic behaviour is simply when someone seems to not be able to learn from their experiences. They do the same unhelpful thing over and over again with the same unhappy results. Everyone makes many mistakes in their lives; neurosis prevents us from learning from them. It has a stuck and repetitive quality. Something is behind the behaviour and the failure to learn, which is not fully known and operates in the background - the subconscious. It is likely to be past fears and needs that now are not fully conscious. Neurotic behaviours simply doesn't work very well at making a life of relaxation, pleasure, intimacy, creativity and ease. All basic requirements of human beings.  Some behaviours can be seen as addictive but are fairly easily acknowledged as unhelpful. Often it is seen as "just the way I am" ; as if people can't change. But people can always change, neural pathways in the brain can be re-wired. Neurosis is almost always accompanied, and may be primarily signalled by either anxiety or, often the long term effect of constant anxiety; depression. Anxiety is "fear spread thin"; a sense of vigilance and arousal as if there is some immediate danger. The danger is unknown and the anxiety can often move from one focus to the other. Sometimes the anxiety itself is pushed in to the body and becomes physical illness. About one in ten people will have anxiety and a similar number depression at some time in their lives. People with a lot of neurotic behaviours can easily be labelled, but I hope not dismissed, as neurotic.  At its heart neurosis is a failing attempt to manage discomfort and dis-ease; some feedback and reflection can often allow the person to acknowledge the neurotic aspects of themselves and begin the process of healing; by the twin paths of removing the traumas that are behind the neurosis and learning and practising new behaviours which help them get more of what they really need in life.

Psychosis by contrast involves parts of the person which are not in contact with consensual reality and which either create fear or lead to behaviours which are ineffective or unhelpful to the person. They cannot be easily confronted by new information or feedback and are more deeply buried in the unconscious rather than the subconscious. They often have a quality of dominating a person's life leading to dramatic changes; though sometimes they have a contained psychotic part with an unshakable belief which does not usually totally dominate their life. As all people have different parts of their whole personality it is possible to have a psychotic part which can be contained. People who are actively psychotic need sanctuary; safe places where they are protected, supported and loved until the parts more able to deal with the ordinary world can get stronger. Rarely, they may benefit from some medication. Unfortunately in our society; the idea of an asylum; a safe place has largely gone and been replaced by chemical prisons which may sometimes be the only option but which often block any process of healing and re-connection. There are one or two conditions (perhaps schizophrenia and bi-polar disorder which each affect about 1% of people) where there may be an organic component and medication may be the best; just as a diabetic may need insulin to function.

The most interesting third term is personality disorder. This is the elephant in the room; the hidden iceberg which is all around us. Some studies suggest up to one in ten people have a personality disorder.  There are about ten recognisable varieties of personality disorder. Many are characterised by withdrawn, detached, fearful or eccentric behaviours and may be distressing for those who have to try and relate to them. However there are some personality disorders characterised by lack of empathy for others and severe disturbance in interpersonal functioning. The two largest of these are Narcissistic and Borderline Personality Disorders. They, like most personality disorders, are egosyntonic which means that nobody goes to a therapist and says that they have a personality disorder. Friends or a partner may push them to a therapist. Anyone who has worked, particularly in industries like finance, law, the theatre, politics will have come across people who are almost impossible to deal with and leave a trail of wounding and destruction behind them. It is very unconscious and has some of the characteristics of a psychosis in its disconnectedness from aspects of consensual reality and their unavailability for feedback and discussion. It is as if their relating is completely beyond all reflection. Unlike neurosis, they often are not troubled by high levels of anxiety or depression. In fact it is a sign of progress in therapy when they feel such things.

Our society rewards financial and career success so some forms of personality disorder can get considerable rewards for the effects for their personality disorder. One study found higher levels of three personality disorders in executives than in patients in Broadmoor secure psychiatric hospital. This is likely to be true for, for example psychopathic personality disorder, as being ruthless in business is likely to lead to success, at least in the short to medium term.  In some ways all personality disorders exist between neurosis and psychosis but they are a different to both while containing elements of both. Some, like borderline personality disorder have overt anxiety but often they do not. They exist with a degree of certainty which eliminates anxiety. This certainty and the interpersonal behaviours that it promotes, is damaging and confusing for those around. One of the best books on living with someone with Borderline Personality Disorder is subtitled "walking on eggshells" from the experience of what it is like being around someone with sudden and violent mood swings and an unstable sense of self.  Those around someone with Narcissistic Personality Disorder are being called on to admire and/or serve the other. Being an admirer or a servant is never very satisfying if you actually want intimacy; you are always either a resource or a threat as a narcissist lives mostly in their own world and can never really see or emphasise with another. For narcissists, ageing is often particularly difficult and they are prone to develop addictions later in life if the possibility of success is no longer enough of a drug.  For borderline personality disorder the intensity of their dramas exacts a big price on their body and they burn out or have to quieten down. Both are living with a weak ego which is always threatened by the world and swings between fear of abandonment and fear of engulfment and annihilation.

Personality disorder is the elephant in the room; an elephant which may be trashing the furniture. I'd rather such labels didn't exist but the disorders certainly do with varying degrees of severity.  At one end of the scale of severity is idiosyncrasies and interesting personality types and character structures; at the severe end are desperate people unable to function at all in the world of other people and of real relationships.  Psychotherapy certainly works with personality disorders but it is more or less impossible unless they can come to the realisation that they have one and it is often slow, steady work.