Do you believe “Personality Disorder” diagnoses are pathologizing?
June 11th, 2007 |
Recently, someone asked GoodTherapy.org to include Personality Disorders within our list of Concerns Addressed (this is the list of concerns that people can select when searching for therapists and the list that all members select from when creating their listing). Our decision was a unanimous “no” and we thought it would be fair to explain why and to give our members the chance to make an argument for the use of the “Personality Disorder” diagnosis. I should say that we do support the inclusion of “personality disorder” symptoms in our list of concerns and we are currently working on translating these to fit into our list…. Please feel free to add your comments to this discussion below by clicking on the comments link directly below this post.
The following is our reasoning: We believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their personhood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very likely, if not absolutely, to produce more shame, worthlessness, and rejection in a person who probably has enough of it already. I don’t care how it is framed, normalized, or expressed: having a diagnosis called “Personality Disorder” says one thing: you are fundamentally flawed.
Please don’t get me wrong, I’m not saying I’ve never worked with people who’s inner systems fit the criteria for the DSM categories of Borderline, Narcissism, and others. The difference is that I don’t use the categorical and shaming word “Personality Disorder” to describe a person’s experience and I don’t view people as fundamentally flawed. Deeply wounded, yes, powerfully protected, yes, but fundamentally and irreparably flawed, no.
My experience teaches me that people are not fundamentally nor irreparably flawed:We are all born loving, loveable little babies. Nearly all of us come into the world fully equipped to experience peace, self-acceptance, forgiveness, calm, compassion, confidence, satisfaction, and other positive qualities. Sure, we have many temperamental differences based on genetics, but no child is born prewounded, predefended, closed-hearted, or sociopathic (though indeed there are people born with organic problems that interfere with empathy). If the caregivers and peers of our youth can nurture us adequately, we flourish; we experience joy, satisfaction, and connection to others. But because there is suffering and danger in life, because things happen to us and around us which burden us with extreme body-feelings and extreme beliefs, few of us mature into adulthood without some wounds and/ or protection. So, nearly all of us, to some degree, are part of the walking wounded. Each of us has developed different strategies, depending on how we suffered, to survive, to cope, to self soothe, to numb the pain, to escape, and to never be hurt again. For those of us, who have experienced a lot of hurt, our protective parts have a big job to do and work very hard to help us survive. For those of us fortunate enough to not have suffered too many woundings, our protectors work less intensely or frequently. Regardless of whether our protectors come in the form of addiction, self criticism, anger, depression, anxiety, avoidance, or others, these strategies or protectors are just parts of us with survival strategies, not the true Self. The true Self is the indelible core that lies unharmed and perfectly complete behind all of our defenses and wounds. And yes, this true Self exists within all of us, even folks labeled as “Personality Disordered.”
A person labeled as Borderline, for example, does not start out with such a polarized and fragile inner system, he or she was born a loving and loveable person, equipped to develop healthy self esteem, confidence, self-soothing, and other positive qualities. But significant things happened (abuse, trauma, neglect) or did not happen (attachment, connection, love, soothing) to or in proximity of such a person. The results of this are extreme feelings and beliefs which cover over and hinder access to the qualities of the true Self.
Richard Schwartz, a pioneer in the field of psychotherapy and the developer of Internal Family Systems®, a model of therapy I practice and a model of therapy which teaches therapists how to heal trauma safely, describes the Self as the “I” within the storm. I love this analogy. Imagine a hurricane. In a hurricane the outer winds reach over a hundred miles per hour and cause great destruction. This is analogous to how people feel when overtaken by their protective parts (such as anger, self criticism, addictions) or their wounds (rejection, shame, fear, abandonment, worthlessness). It’s how any of us can feel at the end of a long and stressful day when there are too many things to do and not enough time to do them all. However, just as a hurricane has a calm center where the sun shines and the winds are calm, so to do all people. Richard Schwartz and other IFS therapists have demonstrated that even the most heavily traumatized, burdened, abused, and wounded folks, with all kinds of protective and destructive behaviors, can with a bit of guidance, access the calm, curious, reflective, and compassionate core Self. When someone, even someone diagnosed with the label “personality disorder,” can shift into the state of Self, he or she has the potential to heal their wounds and in turn the defenses, which are attempting to keep the person from ever experiencing the overwhelming, awful, trauma they once did.
More curiosity and compassion helps us to see the pain beneath the protection.
Let me be more specific about how some of the protective parts of a person labeled with a “personality disorder” try to help the person to survive and avoid their exiled feelings. So for example, imagine a person named Mary who’s been diagnosed with borderline personality disorder by her mental health provider. Mary tends to “split” people in a way that people with a “borderline” constellation experience, she shifts between states of idealizing and devaluing. The devaluing part of Mary, when activated, views others as “all bad.” So, if Mary’s boyfriend does something which triggers her vulnerability, say by choosing to spend time with someone else or perhaps by expressing a criticism of her, Mary’s devaluing part, in an effort to protect her from feeling rejected, worthless, shameful, or unloved, hijacks her and manifests as anger, criticism, and perhaps even hatred toward her boyfriend. The act of lashing out at the external triger of the suffering serves the purpose of automatically and powerfully numbing Mary to those vulnerable exiled feelings, which are the real source of her suffering.
This devaluing part of Mary which vilifies her boyfriend and other “people/love objects” in her life has an enormous and important job to do, it’s trying to help her from feeling old feelings she’s exiled. If Mary’s devaluing part were to fail to vilify and blame others who trigger her, there would be a risk of being overwhelmed with worthlessness, shame, and other vulnerable feelings. This is why people with this sort of internal constellation have a reputation for self harm and suicide, they’re not always successful at keeping the overwhelming and hopeless feelings out of consciousness. If you or I were burdened with as much shame and worthlessness as someone like Mary, it’s likely we’d feel suicidal too.
The second protective ego state that forms the other end of the splitting polarization is a part which idealizes her boyfriend or other “people/love objects” as “all good.” The idealizing part helps Mary’s young exiled ego states, the ones that are harboring the shame & worthlessness, to have hope for redemption. If Mary’s idealizing part can worship her boyfriend and view him as the manifestation of perfection, her young parts which carry the wounds and burdens can maintain hope that someone exists who will finally love them and care for them in away they’ve always wanted; essentially redeeming the young parts inside which have felt so rejected and worthless.
What we see in the example above are protective ego states/parts in existence because there are vulnerable ego states/parts harboring and experiencing, consciously or unconsciously, some kind of old suffering, danger, or hurt. Mary is so livid and hateful toward her boyfriend at times because the power and intensity of a person’s protection is equal to the power and intensity of their hurt. She has deeply wounded parts which harbor intolerable amounts of pain which occasionally get retriggered by events.
I’ve used one symptom of the “Borderline” constellation (Splitting) to demonstrate this, but I believe it’s the same with most constellations which include protection: there is not fundamental and irreparable flaw, there are deep wounds. The whole reason someone with a personality disorder is so protective and dysfunctional is because they harbor parts that are so wounded.
Original sin? I know this term may trigger my Catholic friends, but my answer is “Absolutely not.”
If you’ve worked long enough helping people to grow and heal you become aware by experience that these wounds are not something one is born with, as I explained above, they are wounds suffered and experienced in the course of development. So, if it is true that “flaws” are the result of protective and wounded parts; true that protective parts arise in response to our wounded parts; true that wounds are not inborn but a result of experience, then we can only conclude that people are not fundamentally and irreparably flawed, but rather deeply impacted by the thing that happen. Furthermore, if you have witnessed the healing process in someone so deeply wounded you realize that, the wounds and defenses are not destined to be permanent. With the sufficient amount of time, attention, and enough Self in the room, anyone is capable of healing.Developmental psychology, as Richard Schwartz points out, was wrong to ever hold that if a person didn’t get what they needed (love, attention, etc.) from a caregiver by a certain age they were destined to suffer incomplete and deficient. Advances in modern psychotherapy have proven this once strongly held belief to be false. Because every one is already whole from birth and has what they need inside for optimal health and happiness, healing is not about giving someone something they don’t have: be it wisdom, social skills, self soothing skills. It’s about releasing the constraints that inhibit access to the true Self. This is what good psychotherapy helps people to do.~
Stay Tuned for the upcoming posts:
“Why do we use ‘personality disorder’ diagnoses anyway?” &
“What’s an alternative to the current diagnostic & classification system?”
© Copyright 2007 by http://www.GoodTherapy.org Therapist Anchorage Bureau - All Rights Reserved.
41 comments so far
I have struggled to conceptualize personality disorders in my practice….
Attachment theory, as formulated by Bowlby and others has given me the theory as well as the tools to see the more extreme presentations of personality in less pathologizing terms, and helped me approach my clients with more hope and flexibility. This has been liberating for me, and fits completely with my systems approach as a family therapist and pastoral counselor.
Lynne, Thanks for your comment. I appreciate your willingness to openly express your struggle with using the PD label. I will be putting an announcement out to our members in the next few days about this latest post. It will be interesting to see where people stand on the use of PD. Again, thanks for contributing to the blog!
I disagree. I don’t like the term itself, and it’s probably overused, but I’m sorry to say that the evidence I have experienced for myself is that some people really ARE fundamentally flawed. Many of them really MAY have had these characteristics all their lives- even newborns have different personalities. Not everyone with conditions like this has suffered abuse, and many are destructive to others.
I did not read all of your post, but you spoke asif all the problems were emotional in origin- this leaves thought disorders quite out of the picture.
I’m sure you have dealt with plenty of people in a clinic, but if you had to deal with the same people in your everyday social life you wouldn’t be so naive.
Yes : NAIVE.
Dear The Dark,
We can’t have a real conversation if you don’t take the time to read my full post. By reading it you would learn that I am not denying that some people experience significant intrapersonal disturbance, the kind which make up the various syndromes of “Personality Disorders.” I am against the use of the PD label for the reasons I mention in my post.
I appreciate where you are coming from. I’m sure that you have had experiences which have led you to believe that some people are fundamentally flawed. I used to believe the same. In my graduate training I was taught to believe that if people didn’t get what they needed by a certain age they were hopelessly flawed. I also believed, like you, that some people were just born that way. Unless I’m mistaken, the latest research shows that newborns don’t have different personalities, they have different temperaments and these temperaments are magnified by learning and experience, and particularly by abuse and neglect. I do not deny that people have genetic predispositions to develop certain syndromes, but these predispositions are largely triggered by learning and experience.
I’m certainly open to the idea that people are born with personality disorders, but in my clinical experience every person I’ve ever worked with who would be labeled with a PD diagnosis, has undergone some from of emotional abuse or neglect. For those who have suffered PD whom I’ve been able to successfully guide toward more inner balance, the healing has involved resolution of their trauma. A handful of these people resolved trauma that didn’t even seem to be of this life. Perhaps just screen memories, but when the trauma was unburdened from the nervous system the symptoms reduced or ceased. So in these cases, I’m very open to the idea that some people are born with stuff they’ve been harboring from other places… be it reincarnation, genetic memory, collective unconscious, or other. What I’m trying to get at is the idea that at our core we are all good, loving, and, no matter what covers are good stuff over, we are capable of healing it.
I’m not here to debate thought disorders. Frankly, I don’t know enough about them.
Fourth, I feel a bit jabbed by your comment that I am naïve. Concluding that someone is naïve because their experience is different from yours is unfair. I find a funny parallel between you, concluding I’m naïve because you disagree with me, and those mental health practitioners who label their clients with PD because they feel powerless and not good enough to help. I will say more about this in my next post which is on the topic of why our profession uses the PD diagnosis.
Noah
I agree with your nonppathologizing orientation.
At the same time, it is important to add that there are alternatives to the notion, which fits for some but by no means all borderline and narcissistic folks, that the problem is too much childhood suffering and pain. Too much success, especially success at getting one’s way by ignoring others’ concerns while expecting others to respond to one’s own, can create these disorders with or without what we usually think of as emotional injuries.
What folks sometimes refer to as “spoiled” kids, emotional kids who always get their way because they have overpowered their parents with their intense emotional storms, are at risk for becoming borderlines. Special kids, at the same time, are at risk for what I call “tall man syndrome, i.e., becoming narcissists. They are at risk for feeling so talented or tall or smart that what they want seems to them, and often to others as well, as far more important than what others want.
In other words, borderline and narcissistic injuries are patterns of response to situations in which what they want feels sacred and what others want, irrelevant.
This model of personality disorders, based on conflict resolution theory, (see From Conflict to Resolution by Susan Heitler) leads to a practical treatment response. Teach narcissists and borderlines to listen and become responsive to others’ concerns, teach them win-win conflict resolution, and they will learn to function with emotional health and even personal maturity.
A key part of the skill set narcissists and borderline personalities need to learn, in order to do win-win conflict resolution, is emotional self-regulation. After years of pitching fits to get what they want, they typically need much coaching to learn to recognize anger as it begins to arise, remove themselves from the situation, self-soothe, and then return in a calm problem-solving mode to find win-win solutions.
This kind of treatment approach requires first that the therapist become an expert in conflict resolution, and then that the therapist become a great coach for conveying the skills to clients. For a free download on Therapist as Conflict Resolution coach, go to http://www.therapyhelp.com.
In sum, with enough confrontation on their old ways of powering over others, plus coaching in win-win skills, borderlines and narcissists who want to grow up can become great folks with normal to excellent potential for partnership.
woops, please change one wrong word.
In the fourth paragraph, please change “borderline and narcissistic injuries” to “borderline and narcissistic syndromes.”
It should read:
In other words, borderline and narcissistic syndromes are patterns of response to situations in which what they want feels sacred and what others want, irrelevant.
If the APA tried to take a position like this, it would be worrisome. But for goodtherapy.org to do so is appropriate. It seems totally in line with this site’s mission statement to take stands like this one.
DSM diagnoses are nothing more than time-dependent symptom chiecklists. A person either has the requisite symptoms in the given time frame, or does not. PDs are, by definition, chronic. There is no more “pathologizing” in diagnosing a personality disorder than there is in diagnosing adjustment disorder. Some people believe it is like hanging a scarlet letter on someone to diagnose a personality disorder; I do not.
I personally believe the DSM system is valuable, but limited. The best way to arm a a patient against shame and humiliation is to tell them, “Here are your symptoms. You’ve had them for many years. We call this a personality disorder. Here’s what we’re going to do about it.”
I am very concerned about this idea that we are somehow protecting patients by hiding their diagnoses from them. Any of us would be deeply disturbed if we went to a physician for a chronic illness (say, diabetes) and were told something like, “Well, let’s not worry about what this is labelled, let’s just say we’re going to do the best we can. Do as I say, and don’t worry yourself over the name of your illness. I don’t want you to feel like there’s something fundamentally wrong with you.” Patients should be told their diagnosis, and should be empathically held such that they feel empowered by the knowledge, rather than shamed by it.
-padrenurgle
Hi. That’s a thoughtful article. I agree in principle. In fact all labels can have that shaming effect. Yet, people will certainly come for help who were subjected to being labelled if they had received help from previous practitioners who were required by insurance companies to submit a diagnosis.
On the more hopeful side, sometimes a personality disorder diagnosis can be helpful for a client. I am thinking here of people I have seen who had difficulty controlling emotional outbursts who had believed they had a bipolar disorder, normally more of a biochemical and a lifelong issue. When in fact they had borderline personality disorder. Knowing that gave a great sense of relief and hope since it is simply a learned pattern from a long history of invalidation, and as such can be unlearned, for instance with DBT. And even without DBT, it tends to improve over one’s life. I think there is no easy answer here. I wish there were no labels. And I know sometimes diagnoses can feel shattering. But knowing the symptoms, the etiology, and the related treatments is also the road out of that hell for many people. What do you think?
- Fred
These are important ideas. We must remember that the so called “Personality Disorders” are among the least valid or reliable in the current nosology. The DSM-V will likely make some radical changes in the way they are conceptualized. In Integral Psychotherapy we address the self-system and the proximate self (what is generally regarded as “I” versus the rest of the Kosmos) is demarcated by a “self-boundary.” This proximate self is synoymous with Loevinger’s “ego.” In cases where the proximate self boundary is fragile and easily overwhelmed from within or without we may see styles of psychological engagement similar to what is called “Borderline PD.” We can conceptualize the symptoms of other so-called Personality Disorders similarly with the idea of the self-system and self-boundary.
The self boundary that is proximate (ego) is typically syntonic (”that’s just how I am”). To tell someone though that the very things they identify as “I” are disordered is damaging and not at all helpful. Better to refer to a psychological style that arose likely for good reasons but is no longer helping the person get what they need or want in life. This way of describing the situation lends itself to a pretreatment discussion and, if the client then wants to engage, therapies like DBT where what works in a person’s “personality style” can be balanced with elements the person can change to reduce suffering.
I really agree with your article concerning everyone does have a core of goodness which is often hidden by layers of different types of painful abuse. My issue is that it takes time to help one to heal and in this day and age, as counselors we are not allowed to do the longer term work that is needed if insurance has to be used.
What a lovely, thoughtful, well worded piece. Dick’s way of looking at humans is so much more useful than labels like PD which, I think, only serve to scare people.
Thank you.
Joanna Lawson
I believe that all disorders as labeled are a starting point…and not the whole story. For example, I am a woman, a Jew, a “six” on the Enneagram, a Capricorn, a native New Yorker…and I am none of these things exclusively or even forever. (I could convert to Catholicism, I could have my sex changed, I am a Californian now, I’ve learned how not to be fearful all the time, I don’t relate to Capricorn horoscopes even though I was born in January, etc.)
I was (repeat “was”) depressive. Every therapist I had said so, and that’s what went on the insurance forms. The treatment I received for more than 20 years (from several different therapists) got me out of bed in the morning, sometimes, but never took my whole self into account. Instead I was treated as a bundle of beliefs: Depressives need therapy and medication until they die. Depressives are sick. Biology (depression on both sides of the family) is destiny. None of this turned out to be true for me.
Until I found a way to address the depressing issues as apart from me, rather than to see myself as depressive, depression continued to have power over me.
II am not a therapist, and I don’t practice therapy…but having worked with people with all kinds of “disorders”, and witnessed how their lives change when neither they nor I attach to their diagnoses, I propose we see PD diagnoses as helpful pointers while not putting people in diagnostic boxes.
Carol
Hi Dr H, Thanks for sharing your perspective. I agree with what you’re saying about “spoiled” kids and “tall man syndrome” However, I do believe that these folks are generally injured by subtle forms of neglect and by early childhood attachment disturbance. My experience with people who fit the borderline constellation leads me to disagree with your notion that the borderline syndrome develops as “patterns of response to situations in which what they want feels sacred and what others want, irrelevant.” That is what I would describe as a symptom or result of the underlying causes. Perhaps I’m misunderstanding your analysis, but my sense is what you describe may play a role, but it’s disregarding the significant impact of neglect and abuse that these folks suffer. Anyhow, that’s my feeling based on my experience. What do others think? Noah
Dear Padrenugle, I loved what you wrote about the APA. It motivated me to “keep on trucking.” I definitely savor the role of “rebel with a cause.” I’m aware that my intentions with creating GoodTherapy are a bit grandiose, but I really hope to influence the mental health system to treat people better. I disagree with your statement that “there is no more ‘pathologizing’ in diagnosing a personality disorder than there is in diagnosing adjustment disorder.” I think that if you were really to step into the shoes of a client you would feel that there is a difference. An adjustment disorder says that we’re experiencing difficulty adjusting, whereas a personality disorder says that our personhood is disordered. There is a difference. Actually the best way to arm a patient against shame and humiliation is to throw out the label personality disorder altogether. And focus instead on the parts of the client and to appreciate how these parts, such as anger or splitting, or entitlement, etc, help them to survive and cope. It’s not about hiding a diagnosis from someone, it’s about being careful and sensitive enough to not use a label that has potential to shame and blame when we could provide better treatment without labeling. I’m all for the use of diagnostic labels that are rational and non shaming. My post aimed to show that PD diagnoses are both shaming and irrational. I’d prefer a label that more adequately describes in a non shaming way the underlying psychological processes that occur as a part of PD. See what I mean? Noah
Elliot, I appreciate your response and agree with your statement that it’s “Better to refer to a psychological style that arose likely for good reasons but is no longer helping the person get what they need or want in life.” Thanks, Noah
Hi Pat, I totally agree with you about the time it takes to heal. My post can be interpreted as me saying the work is easy or happens fast….. Here’s the GoodTherapy.org view and my view on our power and limitations to help:
“We are limited. We greet our clients with great hope. We have spent countless hours studying or trade, doing our own inner work, mastering our technique, and learning to “Be” with our clients. We have parts of ourselves that want to do good work. We are compelled to help others release burdens and cope with suffering because we know how good it feels to do so. Yet, there are times when we can’t. We believe a good therapist never gives up hope that a person can heal in this lifetime, but also recognizes that he or she may not be the one to help, that the time may not be right, the client not ready, and that, for whatever reason, one may never do the work we envision them doing. To good therapy it helps to let go of expectations and outcomes for ourselves and for the people we work with; though without giving up.”
This is one of the reasons that I don’t file insurance any longer. Noah
Thanks Joanna for summing it up so succinctly. Noah
All diagnostic labels do is guide therapists to use the right tools with the right client. Not educating mental health professionals on some mental health problems is like not educating some doctors on some medical problems. Instead of limiting the flow of information on these categories, we need to address the concerns noted in article as the concerns are quite valid.
Hello R Wells, Thanks for the comment. I certainly agree that mental health professionals should be educated on syndromes. I do not want to limit the flow of information about these categories. In fact, I’d like to better educate people about these categories and I’m advocating the use of less pathological labels for PDs. Thanks, Noah
On this issue, I feel very strongly alligned with Noah. I have an obligation to my clients to provide the best possible therapy in order to improve the quality of their lives. If we do that, then we have done our job. For me, the issue with personality disorders is that out of the many clients I have seen since licensure,there has been no one stating their presenting problem is a personality disorder. They come to therapy because of symptoms and/or
behaviors that are bothering them. With the stigma regarding mental health , and the difficulty many clients have over deciding whether or not to try therapy, I do not see using pathological labels is in the best interest of our clients. Yes, in our educational interests, but who is asking for help, here.
I found 2 issues in your post, and am primarily addressing the initial one of should PDs be listed as a concern that a person can select.
I do think that it is important to list “personality disorders” as one of the concerns that people can select when looking for a therapist – specifically because some people have been diagnosed, whether by another clinician or self-diagnosed, and are looking for someone who is comfortable working with their “diagnosis” or symptoms.
There are therapists who will not work with clients that they find difficult or have specific issues such that could result in someone diagnosing a PD. It seems to me that not allowing someone to specifically look for a therapist that will more likely work with them despite the behaviors or relational issues that can result in a diagnosis of PD, sets the client up for another hurt or “failed” relationship.
I enjoy working with clients who may meet the diagnostic criteria for a personality disorder, but other kind and skilled clinicians do not – and may not be able to be the clinician that can or will help a person that meets criteria for a PD. By not allowing those searching for a therapist to look for the clinician who can best serve them, and wants to work with them, it seems that a disservice is being committed.
I do think that the name “personality disorder” sounds horrible – especially when thrown about in the lay community. And I think that it is wrongly and carelessly diagnosed by clinicians way too often. However, in its correct form, the diagnosis does serve to identify and make sense of a collection of symptoms that otherwise do not make sense.
Thanks Murray, I appreciate the support and I really like how you distinguish between psychotherapy and education and how the purpose of education and science may, at times, conflict with the purpose of psychotherpay & healing. Noah
I would like to add to the point about “spoiled” kids and “tall man syndrome”, that in my opinion this is a valid description of a behavior pattern that often causes frustration and anger, and, I believe, not necessarily caused by childhood hurt or neglect per se, but rather by the assumption made by the adults that they should be able to be good enough to prevent anything bad from happening to the kids. This in turn, causes the adults to feel guilty if anything bad happens to their kids. Consequently, the kids expect and feel entitled to a “perfect” world, which of course never happens. As a result, the kids, now adults, can’t understand why they can’t control things and people, so they conclude that people are stupid, irrational, demanding, etc… My point is that we should be cautious about implying that the main source of problems/dysfunctions is hurt or neglect from childhood. This assumption could easily and is often understood to mean that good parents are those who strive to control the environment for their kids, and assume that their kids are going to be damaged if the world is not perfect for them. They feel guilty if they can’t provide such an environment. This is just as damaging for their children, causing them to feel entitled and frightened that they will not be able to survive if they are not able to control their environment.
I feel that today there are just as many problems/dysfunction caused by parents feeling guilty or inadequate for not providing a perfect environment, or by parents feeling entitled to control the environment to protect their kids, as there are problems caused by parents being abusive (I am using these simplistic terms to amplify the contrast.)
On the issue of PDs as damaging labels I mostly agree with Noah, although I have heard a colleague telling me that a client of hers was relieved to know that there was a term describing exactly what she had, and therefore felt that she was not a “hopeless” case.
Finally, on the issue of diagnosis in general I believe that any type of diagnosis is often counterproductive, because it causes people to focus on what is wrong, and does not help them see that the main part of them is healthy, resourceful, whole, and that they have the power to heal themselves. However it is helpful to acknowledge that they feel “bad”, “sick” etc… as their feelings are the indication of a discrepancy between what they want and where they are at. If a diagnosis could be formulated as a way to know in what direction to point/focus, then that might be helpful.
Finally, I am interested to know if anybody is using the teachings of Abraham (Esther Hicks, The Law of Attraction) in their practice, and if so, how they do it. I am willing to share as well about my understanding so far. I hope it is OK to start on another subject.
Hi Erin, Thanks for your thoughtful response. I think you raise an important point about how some people get rejected by therapists who don’t want to work with them because their symptoms are outside one’s scope of practice. And I see how having a name which communicates the syndrome can be useful for both therapists and clients. I’m not against having a name. I just think we need a name that is both rational and non shaming. My post aimed to show that the PD label was both irrational and shaming.
I also agree with Murray who wrote in his comment to my post that in his practice, “there has been no one stating their presenting problem is a personality disorder. They come to therapy because of symptoms and/or behaviors that are bothering them.” Likewise, very few people have come to me using a PD label, the handful that have were given that label by their former therapists who were unable to help them.
I haven’t posted on this subject yet, but I believe there is an alternative classification and diagnostic system which would prevent shame and simultaneously allow for providers to communicate. Such a system might also prevent the rejections you are concerned about. I will post more about this later. Until our diagnostic and classification system change, the best that I feel I can do on GoodTherapy.org is to provide clear cut concerns, worded in common everyday language, so people can more easily identify the symptoms they’re experiencing and adequately share these with their provider. This is a project that we’re in the process of now. When we’re finished we’ll update our list of concerns with more of these psychological based symptoms translated into easy to understand language. I believe this will prevent the rejection you’re concerned about.
I also want to say that a part of me thinks that anyone and everyone in a mental health role would benefit from learning how to work with people who have deep wounds and strong protectors. I don’t think we can easily avoid contact with people who are deeply wounded and defended, especially as clinicians.
Lastly, I think it’s a therapist job to prescreen his clients, to ask questions which will determine if the persons “stuff” is beyond their scope or know how. But I agree that even then it can be hard to tell and much of the “stuff” doesn’t show up until some time down the road anyhow. Noah
Hi Fred, I really like the example you gave. A few years back I experienced a similar thing and helped the person to have hope for healing because what they were experiencing was not genetically based bipolar, but the symptoms of something else entirely. Rather than labeling it as a PD, I helped the person to get to know the parts of him involved in his mood swings. Doing this was just as helpful and provided just as much relief and hope without saying to him that he had a syndrome called PD. Rather we could develop respect, curiosity, and even compassion for the collection of symptoms which form the syndrome. That’s my thought. Noah
Lots of great discussion here. I think earlier, Noah asked what else are we apart from our personality – perhaps I have misquoted. I think we are a lot more than personality – in psychoanalysis the term character is generally used , to indicate the unconscious parts of the interacting self, where ‘personality’ generally is associated with consciousness, or self consciousness. padrenurgle suggests that psychotherapy participants have a right to know their diagnosis, in the same way as medical patients do – I agree with Elliot, the terms, symptom lists, and conceptions in the DSM will change, and already differ from other diagnostic systems – they are not ‘facts’ but a system for communicating with other practitioners in a ’systematic’ and ‘consistent’ method, and tools for aiding treatment planning – which should also be collaborative. Remember the term borderline was first used to indicate a practitioners’ uncertainty about whether someone was neurotic or psychotic – so historically it pertains to the practitioner, not the experience of the client/patient.
I agree with Erin, prior diagnoses can be traumatic and can be the initial material that the participant wishes to or needs to deal with, and so it may be worthwhile for a practitioner to
indicate a level of comfort or familiarity – a gesture of welcome.
Finally, I agree with Noah, that most of the PD categories are strongly associated with attachment systems -
primarally resistant/preoccupied (C) and disoriented/disorganised (D). Looking at the research around incoherent parent discourse in the AAI – and how this predicts the child’s attachment scoring – is very compelling. Therefore a therapy that promotes the mutual construction of coherent discourse and narrative makes sense.
I tend to think of people who fit some of the PD diagnoses as experiencing levels and registers of relational and representational distress, and salient, hostile or dismissive everyday responses from others – related to past trauma, sure, but not always identifiable, and more to the point, generating ongoing trauma – which such stigmatising terms often contributes to.
Cheers,
DF
Recently trained as an IFS therpist, i generally agree with the article above. But i work in world where diagnoses are a matter of course, and so here is how i handle it.
In the spirit of empowering my clients, i view all diagnoses in the same light. I allow my clients to decide how useful or irrelevant it is to their treatment. When/if a client asks about a diagnosis, I use the metaphor of a Band-aid. I say, “Diagnosis are like band-aids. Sometimes a band-aid can be useful to isolate a wound from the environement, to help keep it clean and promote healing. Other times, band-aids can actually cause a wound to fester and worsen, because it hinders the person’s ability to create the conditions for healing. In the end, the band-aid itself has little or nothing to do with your actual process of healing. If it is useful for you to have a name for your experiences or to know that there are enough other people who struggle with the same kinds of things you are struggling with, for there to be a band-aid/label created for it, then use the Band-aid. If it hurts to have a label, or creates obstacles to your healing, then disregard it. Remind yourself that it is only a band-aid, a way doctor’s came up with to isolate something so they could learn to heal it. The label is not the wound. Nor is the label the process of healing. Use a band-aid if it helps, but if it causes the wound to fester, toss it in the trash.”
I worked with a teen who was deeply wounded from a long trauma history, before I knew about IFS. Somewhere she heard someone refer to her as “borderline personality disorder.” She called me between sesssions with anxious questions. She wanted to know what it meant. I read her the symptoms from the DSM-IV. She could identify with many of the symptoms listed. Then, i explained the band-aid metaphor and healing. And I added, “if i had been through what you have been through, i also would fit some list in this book. It may not be the same list because each person responds differently, but i guarantee you, that your experience is human. The psyche splinters to protect itself; it is just what the mind does in response to trauma. None of your experience is outside of humanity. You are 100% human.” i asked her was this useful information, she said, “yes”.
Some clients have parts that feel better having a label for their experience. It allows them to feel power over, gain distance from, feel relief or bring more awareness to what feels like an out of control life. Others find it stigmatizing. Whatever the case, I trust the person’s system to tell me what is most useful for their healing process. I generally do not discuss diagnoses with a client without being asked about it. I also get many questions, as i also work with children who are in residential treatment, who come to our agency already bearing a list of diagnoses. While the kids never ask, parents need a lot of information about labels. Many of our families have adopted children who carry a wound of separation from the biological mother as well as severe trauma histories, which greatly impact the child’s ability to be in relationship. In these cases, the whole family must heal together, and the parents must be willing to engage in a lifelong healing process for and with the child. I give them the same band-aid metaphor. Some parents thank me for seeing the their child as a unique, valuable being, others use the labels because it helps them understand and realize the issues are not always about how they are parenting.
So, I unabashedly use whatever promotes healing for the client(s).
Hi Diana, Yeah, I too believe we are more than our personality. Personality being the parts (ego states) of us engaged with the world and there are states of consciousness we can tap into which transcend the personality. I was using the statement “what else are we other than our personality” as a way to express the impact of being labeled as PD. Personality is generally used to describe the sum total of who we are. Thus if our personality is disordered, the “sum total of who we are” is tainted. I hope I have made a good argument for the fact that people are not irreparable tainted or flawed. Given enough time and attention/intervention people have the potential to heal. The difficulty is that we often don’t have enough time and many people have parts which are so dug into their protective stance for the purpose of survival that they resist the pull to wholeness. Noah
Hi Monique, I’m open to the idea that that entitlement can be developed without injury. However, I do believe there is an injury which happens to children who are given everything they need and coached into selfishness. Parents who focus on providing every possessions and gratification to their children can create entitled kids who learn to judge others who have less. But these parents often lack in providing unconditional love and connection to their children. Although generally unconscious of it, children raised this way can lack the experience of deep loving attachment. This is not trauma, but it is a form of neglect which is passed down by parents who themselves did not realize what they were missing. This experience does burden the child. I think that person with a narcissistic wound doesn’t know what he or she is missing and to compensate for the Self-to-Self connection values the material and the external more than the average bear. I’d love to hear what others think about this. Noah
Hi Kendra, I really like your balanced approach to using diagnoses in your work. You and a number of others who posted were able to demonstrate situations in which diagnostic concepts were valuable and helpful to people. I want to clarify that I’m not against using diagnoses. I am however, in favor of a diagnostic system which more adequately describes human beings in non-shaming terms. I believe “Personality Disorder” is often a harmful term and can be replaced with words which provide more adequate definition/understanding and accomplish everything positive that a diagnostic systems intends to. I‘ve really enjoyed this forum and want to thank all of you who took the time to share your ideas! Noah
Hi Noah,
I thought the article was really excellent.
You might like to check out forthelittleonesinside.com
It’s Robyn Posin’s website; very unpathologizing, and deeply humanizing.
All from a fairly radical woman’s point of view. However, I have plenty of men in my practice who have bought her deck of “Rememberances” cards and find them extremely helpful.
If you do look at it let me know what you think.
Peace,
Nicole
I need to rant…
I am so tired of therapists and doctors labeling clients PD then in essence giving up on them. I had a recent incident with a client that I have worked with for 6 months. She attenpted to get more help by entering a day treatmnt program for her ED and was told by the MD, who has only read her chart that with her “PD” and SI was too severe for the program.”
Of course the client calls after 3 hours of Binging and Purging saying “What PD???” Uggg!! I talked to the MD and she was so cold, compassionless, and in my opinion irritated by the client! Well, if you think she is PD (x3 BTW) then the last thing you shoud be is irritated.
I can recall working in several inpt. tx centers as a mental health tech before I got my MA and hearing the staff talk poorly about the patients, esp. the BPD ones. If someone walked in with a BPD dx, you might as well hang a target around their neck! Where is the COMPASSION? If BPD is so difficult to manage as a therapist, imaging how hard it is for these people to live with! It is not a choice…neither is bulimia, binge eating or anorexia BTW.
If you are burnt out, get out!
I love my job!
[...] Post is a promised follow up to a post from two weeks ago called “Do you believe “Personality Disorder” diagnoses are pathologizing?“ I was motivated to finish it this morning when I read a passionate comment posted [...]
As a professional mental health therapist AND also a survivor of severe depression and anxiety who endured over 30 ECTs, I can say without a DOUBT that defining ANYONE by a diagnosis in counterproductive and hurtful.
As far a personality disorders go, I agree with you 100%! No one is a borderline or even a depressive.
As a mental health professional, I am disheartened by the profession’s useage of 3rd person language… ie.. a BD, a schizoprehnic..etc. Again, NO ONE is a diagnosis.
The concept you are utulizing.. empowerment.. actually has been around for sometime and came from the peer movement. Various peer and family mental health organizations have to stand up and take a bow for using their leverage to graciously impart the concept of empowerment and respect to professionals, who sadly enough usually took the “medical model” route of thinking about mental health clients.
I have had the privilege of working at a mental health linic in Denver, that is maintained in a partnership of clients and professionals who believe that empowerment is of utmost importance, in helping individuals gain quality of life.
As trauma survivor of debilitating depression and anxiety, I found stabliization via the appropriate medication. However, it was through empowerment oriented suppport groups and organizations, that I found my calling – helping others to acheive the same qaulity of life – via becoming an empowerment mental health professional.
I am interested in sharing with others my experiences and theirs in addition.
Yes, labels can be “pathologizing” [sic]. All labels! But that’s the state of the art as we have to live with. I would prefer to just deal with a “person with problems”. Why not object to the use of “major” depression or “generalized” anxiety? Open the DSM to any page. Almost all mental health conditions are an expression of some arbitrary decision to determine that, on a continuum, this set of symptoms goes beyond some perception of normalcy or acceptable behavior. Placing any label from the Diagnostic and Statistical Manual of MENTAL DISORDERS is, de facto, defining a problem as pathology
I rarely use a PD Dx, but, if I agree to accept insurance reimbursement, I must also accept the tool (DSM) that they and the APA have made part and parcel of that agreement.
Until the APA and the insurance industry change the DSM, I say let practitioners list PDs.
Hi Chuck,
I disagree that all labels are equally pathologizing. If you read my post you will see I argue that the term “Personality Disorder” is uniquely shaming and unnecessary. Being told by a therapist that you have depression, anxiety, or some other diagnosed condition, is nowhere near as potentially hurtful as being told that your personality is disordered. I have no problem using certain labels from the DSM and I don’t think all labels are necessarily shaming. There are many good labels we attach to ourselves and others.
Also, I want to reiterate that to practice nonpathologizing therapy does not require one to believe that pathology doesn’t exist. Non-pathologizing means viewing a person as greater than their problems. It does not mean problems do not exist, it means NOT viewing the problems as the whole person or the whole person as the problems. In nonpathologizing therapy we try to “do no harm” and because the PD label is often times harmful and at least unnecessary for treatment, we don’t use it.
Noah :)
I agree that it’s harmful to diagnose people with a personality disorder and take it a step further. I have co-facilitated a DBT group for people diagnosed as having Borderline Personality Disorder and saw that the group and the exercises we did helped the participants get better control over their emotional lives, I also saw them use their diagnosis as an excuse for not changing, saw a hopelessness set in, even as we worked with them to find a way out. I also remember doing a group project on Borderline Personality Disorder in my Treatment of Mental and Emotional Disorders Class. One classmate’s task was to interview counselors working in the field about how they made the diagnosis. Although there are some instruments that are designed to measure the symptoms, most practitioners in the field that my classmate interviewed admitted that they usually reserved the label for clients who were “pains in the butt.”
And, it seemed to me that the diagnosis got in the way of their being able to find therapists who were willing to work with them because of the negative reputation people who have such a label have, no matter where they are in the process of healing and self-transformation.
Finally, as a psychodramatist, I find it more useful to work with people in terms of the roles they play and the role choices they make because this allows us to experiment with different ways of playing roles than seem important and drop the roles that they find no longer serve them.
[...] are some recent topics you can comment on, click on any of them to read the post and to comment:Do you believe “Personality Disorder” diagnoses are pathologizing?Why do We Use Personality Disorder Diagnoses Anyway?How to Choose a Counselor or TherapistWhat are [...]
I absolutely and completely agree. So-called personality disorders are signs of extreme childhood trauma or neglect, and as such they can be worked with. I hate labels: they tend to be prisons.
Currently I have a 38 year old male client. He has been lumbered with various labels including sociopathic personality disorder, DID, schizophrenia and antisocial personality disorder.
He IS none of those things, although he used to exhibit behaviours that fit the diagnostic categories of all of these except schizophrenia. He does have multiple personalities, and until about 6 months ago, when the ‘8 year old boy’ was in charge, he was murderous.
You’ve guessed it. He became a street kid and marijuana user at 8 years of age.
All the same, he, and everyone he knows him are surprised that nowadays the rage is rarely triggered. When it is, he can almost always control it.
All these labels actually give very little useful information. The question is NOT the particular pattern of behaviours a person exhibits, but the strengths that will allow him/her to learn new ones and overcome the old habits.
The term personality disorders has been so overused it is often used as a “trash can” diagnosis for clients that push our buttons, are difficult, or don’t respond well to our treatment. The symptoms we see in these diagnoses are the result of a number of developmental, biological, and emotional issues that can often be helped. Whether learned or genetically tranferred, some people have a difficult time with affect regulation, distress tolerance, and other skills that help most of us to manage daily conflicts, emotions, and stress. Labels like these are not very useful except for the need to classify a condition of behavioral, emotional, and psychological challenges. Clients need to believe in themselves and make sense of why they are having such difficulty. With support, a good therapist can help such clients to access their own selves, learn, and practice the skills that were once blocked or absent due to trauma in one’s early development.
I recently sought help for MD and was diagnosed with PDNOS. When the therapist told me the diagnosis, I immediately felt shame and protested it. However I deferred to her expertise and accepted that the diagnosis was more than likely accurate. I always suspected I had a neuroses, whose underlying conflict I could uncover and work through. PD has me dejected and confused. It seems to me the distinction has to do with whether successful attachment with my mother took place. It seems trauma can be overcome if attachment was successful. What confuses me further is that a new therapist I am seeing, told me that PDNOS is a diagnosis that is given out when the doctors are not really sure what the problem is. I suspect he was trying to assuage my concerns about the extent of my damage. My question to the practioners is if they have ever succeeded in helping a patient recover to a stable state of calm, vitality and self-acceptance.