Personality disorders difficult, sometimes impossible, to treat

Comedian Ron White is setting up a joke about visiting some 3,000 soldiers on a military base. A female heckler shouts from the audience, “Yeah, well every one of them is (unsatisfactory in bed)!”

White pauses, his face frozen in that collision of droll and impish that has me laughing already. “Wow,” he ponders aloud. “You’d think after 2,037 or so (unsatisfactory experiences in bed) the average person might think, ‘Hmm, maybe it’s me!’ “

And again I’m reminded: Only the truth is funny. After I finish laughing, I start thinking. White’s spontaneous aside to a heckler makes me think of a population of people with whom I struggle both professionally and interpersonally. Professionally, because these people are difficult and sometimes exhausting to treat in therapy. Personally, because these people are difficult and exhausting in interpersonal relationships.

White makes me think of people with personality disorders.

Let me borrow a bit of colloquial brilliance from M. Scott Peck’s book “The Road Less Traveled.” He defines “neurotic” as the prevailing tendency to assume too much responsibility for the perceptions and behavior of others toward oneself. Conversely, he defines “personality disordered” as the prevailing inability to accept sufficient responsibility for the perceptions and behavior of others toward oneself.

Broadly put, a neurotic person overly interprets the perceptions of others to have to do with oneself. The personality disordered person rarely imagines anything to be a consequence of oneself.

Western civilization is a “neurosis factory.” So utterly common is the outcome of neurosis in human development that it’s considered ordinary in my profession. A therapist referring a patient to me will often include in the background and clinical history the very words “normal neurotic.” Meaning, about as neurotic as most people.

About as neurotic as me, for example.

Personality disorders represent a much smaller population. Research estimates float between 9 percent and 15 percent of the population. This number spikes dramatically in populations of chemical addiction and other compulsive behavior, the homeless, and, not surprisingly, prisons.

Regardless of type, individuals with personality disorders tend to have two things in common:

* Rigid oblivion. This is a more pernicious problem than garden variety denial or even delusion. Personality disordered people make no ready connection between their behavior and the reactions of others. They are sincerely shocked when they are fired on a Thursday for not showing up to work on a Wednesday. Their firing does not confront them with themselves; rather, it provokes umbrage and entitlement.

I don’t know if these folks can’t look at themselves, or if they won’t. But, chronically, they simply don’t.

* Passive absence of reciprocity/passive presumption of entitlement. Now, the word “passive” there is so important. Us normal neurotics can, on a given day and in a given moment, foreswear reciprocity in relationships and we can decide to behave in entitled ways. But, for personality disorders, this is more a default assumption. Truly their worldview. Acts of kindness, generosity and other interdependent gestures never oblige them in relationship. A shocking absence of quid pro quo coupled with a petulant expectation that the world owes them something.

Two observations dominate my view of personality disorders: People with personality disorders are desperately unhappy, though, in some cases it seems they are the last to be aware of their own unhappiness. And, people who try to forge filial/familial bonds with these individuals find themselves quickly depleted of emotion, spirit and vitality. It’s like having the life sucked out of you by Count Dracula. Makes you feel crazy.

I admit I don’t have a lot of confidence in talk therapy as an effective means of helping people with personality disorders, though it does help some. More often I see two things helping these people:

* Suffering. Until they are surrounded by a critical mass of folks with consistent boundaries — and by boundaries here I mean an abject refusal to tolerate the absence of reciprocity and the demands of entitlement, the willingness to surrender these people radically to the consequences of their behaviors — I don’t hold out much hope they will look at themselves. Ever.

* External containment. For example, prison. Personality disorders often thrive in prison. Become trustees. Become well-liked by the prison guards. Or, as in an adolescent facility, when the youth is put on “strip room” for 90 days. Or when they join the Army. Or when a borderline marries a high-functioning narcissist. Any external structure that presents a fierce, consistent, authoritative, external “rule.”

And, of course, this doesn’t always work. Sometimes these folks just don’t get well.

Steven Kalas is a behavioral health consultant and counselor at Clear View Counseling Wellness Center in Las Vegas. His columns appear on Sundays. Contact him at

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