Portrait of a Personality Disorder, Part 3: Cognitive Distortions in Cluster B Personalities

We all distort things in our heads.  If you're honest with yourself, you know you do.  We all have distorted memories of relationships and disagreements.  We all have distorted ideas about ourselves.  We all have distorted ideas about other people and other people's motives.

But here's the thing . . .  Some people distort more frequently and to a greater degree than others.  Some people cannot or do not acknowledge their distortions and do not even seem aware they might be distorting.  Like all disorders, Cluster B personality disorders are identified, not by unique traits or behaviors, but the frequency, severity and impact of certain traits and behaviors.  The cognitive distortions seen in Cluster B personalities have a direct impact on how an individual relates to other people.

Human relationships are, by and large, reciprocal phenomena.  There is give and take.  And, there is a feedback loop.  I say something nice to you, you say something nice to me, and we both feel good.  Or, I say something mean to you, you return the favor, and we both feel bad.

With Cluster B personalities, the feedback loop is broken.  The short circuit is a defense mechanism in which the individual unconsciously or semi-consciously edits their awareness of their own behavior in such a way to protect their perception of themselves.  The result is an individual who sees themselves as always the victim (as in Borderline Personality) or always the better person (as in Narcissistic Personality).  Perceptions of other people are not anchored in objective observation but, instead, are wildly changeable based on how the other person makes the personality disordered individual feel at any given time.

Lucy's distorted perception of the same interaction?

Lucy of Peanuts provides us a nice illustration of the principle of distortion and the effect it has on relationships.  Now, how about we look at a real life example, say, a recent example?  Here is an excerpt from Thursday's presidential news conference:

QUESTION: . . . You said that the leaks are real, but the news is fake. I guess I don't understand. It seems that there's a disconnect there. If the information coming from those leaks is real, then how can the stories be fake? 

TRUMP: The reporting is fake. Look, look . . .And I'll tell you what else I see. I see tone. You know the word "tone." The tone is such hatred. I'm really not a bad person, by the way. No, but the tone is such -- I do get good ratings, you have to admit that -- the tone is such hatred. . . .But the tone, Jim. If you look -- the hatred. The, I mean, sometimes -- sometimes somebody gets...Well, you look at your show that goes on at 10 o'clock in the evening. You just take a look at that show. That is a constant hit. The panel is almost always exclusive anti-Trump. The good news is he doesn't have good ratings. But the panel is almost exclusive anti-Trump. And the hatred and venom coming from his mouth; the hatred coming from other people on your network. . . I -- I think you would do much better by being different. But you just take a look. Take a look at some of your shows in the morning and the evening. If a guest comes out and says something positive about me, it's -- it's brutal. . . .Tomorrow, they will say, "Donald Trump rants and raves at the press." I'm not ranting and raving. I'm just telling you. You know, you're dishonest people. But -- but I'm not ranting and raving. I love this. I'm having a good time doing it.But tomorrow, the headlines are going to be, "Donald Trump rants and raves." I'm not ranting and raving.Go ahead. . . . 

QUESTION: Just because of the attack of fake news and attacking our network, I just want to ask you, sir... 

TRUMP: I'm changing it from fake news, though. 

QUESTION: Doesn't that under... 

TRUMP: Very fake news. 

QUESTION: ... I know, but aren't you...(LAUGHTER) 

TRUMP: Go ahead. 

QUESTION: Real news, Mr. President, real news.. . . But aren't you -- aren't you concerned, sir, that you are undermining the people's faith in the First Amendment, freedom of the press, the press in this country, when you call stories you don't like "fake news"? Why not just say it's a story I don't like. 

TRUMP: I do that. 

QUESTION: When you call it "fake news," you're undermining confidence in our news media (inaudible) important. 

TRUMP: No, no. I do that. Here's the thing. OK. I understand what you're -- and you're right about that, except this. See, I know when I should get good and when I should get bad. And sometimes I'll say, "Wow, that's going to be a great story." And I'll get killed.I know what's good and bad. I'd be a pretty good reporter, not as good as you. But I know what's good. I know what's bad. And when they change it and make it really bad, something that should be positive -- sometimes something that should be very positive, they'll make OK. They'll even make it negative.. . . as an example, you're CNN, I mean it's story after story after story is bad. I won. I won.

Here, like Lucy, we have an individual who sees himself as a victim and simultaneously better than, a clear sign of a narcissist (more on that later). And, like Lucy, he is seemingly oblivious to his part in any contentiousness. You can see the distortions all serve to bolster, not just the image of the man, but more specifically, his self-image.

This is a clear and beautiful example of a neurotic process expressed publicly and recorded by worldwide news outlets.  It is less an argument than the man's internal process expressed outwardly, for he is not attempting to convince his audience of his greatness and their badness so much as his argumentation serves to reinforce his internal beliefs.  By stating his distortions externally, they become more real for him internally.

And, this is exactly what is so challenging about relating to and attempting to have a reason-based conversation with someone with a Cluster B personality type.  There is no real give and take.  The disordered individual is simply having an argument with himself or herself, and, while you may be the target, you cannot meaningfully take part in the manner you are used to if you are expecting a reciprocal give-and-take relationship.

More on Borderlines and Crime

In January I posted on Borderline Personality Disorder, Crime and Responsibility.  More recently, I came across an interesting literature review on the topic of BPD and its association with crime and incarceration.  “Borderline Personality and Criminality,” by Randy and Lori Sansone, was published in Psychiatry in 2009.

In this paper, the authors review multiple studies that have looked into the rates of Borderline Personality Disorder among the incarcerated and the criminal.  They acknowledge that it is not a comprehensive review and they did find a wide discrepancy in findings probably related to differences in methodology as well as peculiarities of different sample populations drawn on from penitentiaries.

Their overall conclusions:

According to the findings of the majority of studies in this area, compared to rates expected in the community, BPD is over-represented in prison populations.  This finding may be particularly evident among female prisoners.  Rates vary, depending on the methodology, but generally appear to be in the range of 25-50 percent.

This is a considerable difference from the rate in the general population that has been measured at between two and six percent. 

They continue:

Factors that may be associated with the presence of BPD among criminals include being female, having a history of childhood sexual abuse, committing an impulsive and violent crime (e.g., murder), having antisocial personality disorder traits, and perpetrating domestic violence.  given this association, clinicians in both mental health and primary care settings need to be aware of the possibilities of such histories in their patients with BPD.

Gender:

It is well known that BPD has a higher rate among women than men.  This holds true in prison populations as well.  Rates among incarcerated men range around 5-6%, very similar, but maybe slightly higher than men in general.  Now where it gets interesting is with women.  Studies varied significantly in their findings.  On the low end, one study found 11.5% of incarcerated women to have BPD but another study found as many as 42.9%!  This last study was conducted in Germany using structured interviews.  Overall, not only do imprisoned  women have a higher rate of BPD than men, but also significantly higher than women in general.

It has often been speculated that the overall gender imbalance is due to biases in the formulation of the disorder criteria or biases in the act of diagnosing.  The authors mention this question in passing but do not offer any speculations.  (In my own, non-scientific, observations from the world of practice, I believe that because we expect to see BPD in women it leads to over-diagnosing among women where any kind of Axis II behavioral problems tend to result in a BPD label while, in contrast, BPD traits in men often go unnoted or misinterpreted as anti-social features.)

Childhood sexual abuse:

As with the general population, incarcerated people with BPD had a higher rate of childhood sexual abuse.  Not surprisingly, history of childhood sexual abuse was even higher for incarcerated women who were both sex offenders themselves and met the criteria for BPD.

Violent offenses:

Overall, data supports an association between BPD with higher rates of violence (toward others) when comparing prisoners with and without BPD.  One study found that women prisoners who had committed crimes related to major violence were four times more likely to meet criteria for BPD than women who had committed minimally violent crimes.  Another study of men in British prisons for murder found 49% of their subjects had BPD traits.

Some studies looked at violence in association to subtypes of BPD.  One study found serial murderers to be associated with a strongly manipulative subtype of BPD.  Another study relates rage-based murder with an “over-control” subtype of BPD.  The authors conclude that “the majority of current data and impressions indicate an association between BPD and the impulsive, rage-fueled murder."

Antisocial personality:

Both BPD and Antisocial Personality Disorder are associated with higher rates of violence.  Antisocial individuals tend to engage in more property crimes and are more calculating and planned.  Borderline individuals tend toward episodes of aggression and violence.

Where BPD and APD co-occur, there are significantly higher rates of anger, impulsivity and aggression resulting in a higher score of psychopathy.  (Personally, I've often felt there is a significant overlap between these two categories but the authors do not give any additional insight on the topic.)

Domestic Violence:

Multiple studies have found a very solid association between BPD and both male and female batterers.  Many batterers have a history of experiencing trauma themselves, and this, in turn, is also associated with development of BPD.  One study found that 27% of women arrested for domestic violence met the criteria for BPD.

Overall it seems there is a very clear link between BPD and both violence and criminality in general.  The strength of that link varies quite a bit from study to study, however.  The authors offer no causal speculations.  Make of it what you will.

Reference:  Sansone, Randy; Sansone, Lori (2009).  “Borderline Personality and Criminality.”  Psychiatry; 6(10):16-20.

Borderline Personality Disorder, Crime, and Responsibility

On the topic of mental disorders and responsibility—of late, I’ve been hearing several therapists repeat a couple things that bother me:

1) Borderline Personality Disorder is just as serious as Schizophrenia and sufferers of BPD should be given just as much clinical attention and services.

I have to say, no, BPD is not the same as schizophrenia and should not in fact be treated the in the same manner.  Should medical professionals be told they need to treat sunburn the same way they treat cancer?  I think not.  Furthermore, I don’t know why we treat so many people whose primary presenting problem is BPD in the public mental health system intended for people with severe disabilities.  The bulk of the empirical research seems to show that BPD is best treated in the community with an established and effective therapy such as Dialectical Behavioral Therapy or similar.  Placing people with BPD in residential facilities for the severely disabled will only be detrimental for both the client and everyone else who lives or works at the facility.

2)  People with BPD who behave manipulatively should not be blamed or expected to change because their behavior is avolitional.

I will agree that “blaming” the client is in no way helpful, nor will expecting someone with BPD to instantly change result in anything but frustration.  However, it is simply false to say that someone with BPD has no ability to modulate mood or behavior.  No human behavior short of reflexes or seizures are avolitional.  Making false statements of this kind, even in apparent defense of people with serious disorders, only serves to increase the divide in understanding.  It also takes away from the agency and empowerment of the client that we are trying to help.  Someone with BPD is not helpless to change.  Change can happen with trust and support as long as there is a real desire in the person to make a change.  Setting clear but respectful limits helps too, because we all know that, like it or not, life has limits.  It is not at all helpful to give the BPD patient the message that anything they do is okay just because they have a diagnosis.  Such a message can be devastatingly harmful.

It might help to illustrate this issue.  Take a look at this excerpt from a recent news article (well, it's news-ish, I guess, it's from The Sun):

A WOMAN has been jailed for cruelly imprisoning three young children in a disgusting room without clothes, food or water.

Jan. 25, 2011.  Sick Daniella Henderson left the youngsters in the squalid conditions and their ordeal only ended when the kids were seen hanging out of a window desperate for help.

When police arrived at the house they found the bedroom they had been left in all day stank of urine, had no beds or furniture and had a bucket as a toilet.

The grandfather of one of the children today slammed sick Henderson's 15-month jail term as too lenient. . . .

Penny Moreland, defending, said: "Most people will find this shocking and distressing. This has not borne out of pure malice or badness.

"She was deteriorating mentally and has a borderline personality disorder [sic]."

The defense attorney here is presenting what a certain ilk of therapists are trying to put out there, that someone with BPD cannot be held responsible for their behavior. I would say, yes, it is distressing.  The defense states that the behavior was not malice or badness and seems to imply that the behavior cannot be malice or badness as long as the behavior is “explained” by a mental health disorder, in this case BPD.  It seems to be an underlying tacit assumption that the categories of malicious behavior and symptomatic behavior are mutually exclusive. At the risk of blaming people with BPD for their own behaviors, I have to question the validity of this assumed dichotomy.  Is it possible that someone’s behavior might be driven by BPD and that person is acting with malice?

Parasitism as Psychotherapy

There is a lot of literature and professional discourse in the area of transference and counter-transference.  It is a staple of clinical supervision and represents some core concepts relevant to quite a few therapeutic models.  Anyone providing, or claiming to provide, psychotherapy must be aware of, and have at least a modicum of training on these core concepts.

So, why is it then, in the public mental health system, there is so much confusion and ignorance on such basic concepts?  Is it because graduate counseling and social work schools are vocational factory farms intended to get people in, take their money, then move ‘em out with their rubber stamp degrees?  Is it because the public mental health system attracts mediocre and failed therapists (I don’t think so because private therapists are hardly any better)?  Is it because of the confusing eclectic din of contradictory theories and “evidence based” practices that make it impossible for directors, clinical supervisors, and therapists alike to develop any kind of coherent vision of what they are doing?  Is it simply due to lack of oversight and supervision that individual professionals gradually drift into their own personal comfort zones, un-self-aware, and motivated by their own emotional needs?

Do I sound too harsh a critic?

I see it every single day in the field.  Every day.  The same dramas get played out endlessly with every possible variation, yet always the same.  The client with the borderline personality or complex PTSD or dysfunctional patterns of meeting their needs, whatever you want to label it, it plays out the same anyway.

On the one hand you have professionals who are frustrated at being manipulated and lied to by their client; cynical at dealing with clients who have no interest in working on their  issues or getting better but seem to only want to suck as much as they can out of the mental health system; and angry at colleagues who blame them while covering up, making excuses, and enabling the client’s manipulations and anti-social behaviors.

On the other hand you have professionals who, with great self-importance, take up the cause of these poor misunderstood individuals.  Somehow these professionals develop a shameless belief in their own “special” ability to connect and understand.  They quickly conclude and profess that all the client’s problems stem from the negative judgments of others, including judgmental mental health professionals.  They seem to believe that the “cure” is to empathize and sympathize with their client, while never questioning their client’s beliefs or behaviors.

I have news for you.  If you find yourself falling into one of these camps, you need to stop what you are doing and step back to find some objectivity.  Psych 101:  if you are emotionally enmeshed or reacting strongly to your client, you are not going to be able to provide any kind of real therapy.  And that is exactly how it plays out.  Clients who get this kind of dual reaction/enmeshment treatment don’t get better.  The reactors just play out the role of perpetrator, thus reinforcing the client’s belief in their own victimhood and allowing the client to dodge any responsibility for their own behavior.  The enablers do just that, they cover up for their client and enable them to continue with their dysfunction.

The enmeshed enablers are probably the worst of the two, simply because they will continue the “therapeutic” relationship for years and years and years regardless of the complete lack of progress.  What develops is a sort of emotionally symbiotic parasitism that’s paid for by Medicaid.

On the one side of the symbiotic relationship is a client whose dysfunction has led them to get all of their emotional needs met through therapy and the mental health system.  In other words, therapy is an end in itself.  The negative and positive relationships they develop with professionals feeds their emotional need for drama and attention and emotional enmeshment.  There is no desire for actual improvement.

On the reverse side of the symbiotic relationship is a professional who is hungry for attention and recognition and a feeling of efficacy.  As long as the therapist stays on the client’s good side by joining them in their denials, rationalizations, and reification of their victimhood, the client will return the favor by singing the therapist’s praises and generally playing to their ego.  The bigger the ego of the therapist, the more susceptible to this they seem to be.  These arrogant professionals believe they are somehow immune to counter-transference and ignore clinical best practices.  The result is they feed their client’s pathology without end and seem to be oblivious to the fact that their client never gets better.  It doesn’t seem to matter because both client and professional are getting their emotional needs met by the relationship and Medicaid pays for it all without question.

There does not seem to be any end in sight to this pattern.  It has been a major problem in the mental health system since it was first identified in the mid 20^th Century.  But in spite of the mountain of literature and treatment guidelines, professionals continue to make the same mistakes time and time again.  How can a therapist help a client face their hard-to-face issues when the therapist isn’t willing or able to face their own issues and seriously look at how their counter-transference impacts their efficacy?