Twenty years ago, the preponderance of Elaine Beckwith’s most troubling cases tended to center on substance abuse and the outpouring of near-psychotic clients cast into the general population after the onset of deinstitutionalization.
The past few years have brought a new pattern to the fore, one as pronounced as it is problematic. More and more, the Florida-based counselor is seeing signs of personality disorders running rampant among the clientele in her private practice. It seems now as if she’s dealing with 50 percent more personality disorders than at any time in her 30-year career.
“It almost feels like every time we turn around it’s, ‘Well, there’s another borderline mother,’” says Beckwith, an American Counseling Association member who is also adjunct faculty in the Palm Beach State College Psychology Department.
Though not yet quantified in appreciable detail, personality disorders appear to have surfaced at an alarming rate in counselors’ offices and on college campuses, by some accounts in unprecedented proportion.
The surge comes as the counseling profession recalibrates its approach to defining personality disorders, thanks in large part to the alternative diagnostic landscape laid out in updates to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Those two forces combined are compelling practitioners to confront a confounding yet essential dilemma: Are counselors seeing the pervasive, persistent traits of true personality disorder, or are they applying outdated norms and expectations?
“The problem is, I think we’re trying to say that these things [personality disorders] are acceptable because we’re seeing them in everybody, and there doesn’t seem to be a choice because it’s in such alarming numbers,” says Morgan Brooks, an ACA member who is an associate professor and director of the clinical mental health program at Niagara University. “It’s one of the things that confounds this issue. Should we be excluding this [behavior] as a disorder, or should we be accepting [that] this might be the normal behavior now?”
If the trend has been obvious, its causes have proved harder to pin down. Prevailing wisdom gives the apparent surge in personality disorders a generational genesis — a seeming groundswell of millennials disproportionately beset by narcissistic, histrionic and borderline tendencies.
A fact sheet from the American Psychiatric Association (APA) describes personality disorders this way: “Personality disorders are associated with ways of thinking and felling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder.”
Counselors may come across any of these disorders in their work with clients, but certain personality disorders seem more commonplace. For example, individuals with narcissistic personality disorder are obsessed with overblown notions of self-worth. Those with histrionic tendencies display impulsive and emotive behavior that seeks to attract attention. Clients with borderline personality disorder lack a sense of self and engage in intense but unstable relationships. They often have a history of sexual abuse or other childhood trauma.
The professional literature remains relatively scant regarding the surge, leaving academics and mental health practitioners to construe anecdotal accounts as to how and why so many signs of personality disorder are flooding their offices and classrooms.
“We all have theories about why this is happening,” Brooks says, “but it’s a lot harder to test those theories because there aren’t really assessments [available]. You have to really create surveys and somehow validate them.”
A popular school of thought hinges on the millennial generation’s endemic sense of entitlement that, taken to an extreme, burgeons into full-fledged traits of a personality disorder.
The advent and explosion of social media — Facebook, Twitter and the like — has also drawn scorn for its impact on the way children and teens invest their formative years online, often at the expense of engaging in genuine, real-world relationships.
Some trace the personality disorders phenomenon to a generation of parents who heaped excessive and disproportionate praise on their children — leading to deluded notions of grandeur and self-worth — and “helicopter parents” who hover over their children’s lives well into early adulthood, exerting an undue influence that stifles maturation.
Much of that line of thought builds off of the “emerging adulthood” theory that Jeffrey Arnett laid out a decade ago, in which people in their late teens and early 20s languish through a period of frequent career changes, extended education and nonmarital cohabitation. It is a period, Arnett explains, defined by instability, identity exploration and being self-focused.
The theory has gained wide acceptance among mental health professionals of every ilk, some of whom see emerging adulthood as a foundation from which personality disorders too easily spring forth.
Arnett warns that such reasoning can be overblown, citing research that shows a marked decrease in depressive symptoms and increase in self-esteem over the span from late teens to mid-20s. But he does acknowledge that emerging adulthood is a particularly vulnerable time that can pose serious developmental challenges.
Whatever their root, personality disorders are being repeatedly, and tragically, brought into the public eye as laypeople and media pundits speculate (or, conversely, refute speculation) about the purported mental health of the perpetrators of some of our nation’s worst mass shootings: Virginia Tech, Sandy Hook Elementary School, Fort Hood, Aurora, Colo., and, most recently, at the Washington Navy Yard.
Gap in the data
Brooks and four colleagues at Niagara University have tried to give shape to the nebulous phenomenon in a study of a random sampling of students, the results of which were published earlier this year. Brooks expected to see a high prevalence of personality disorders, but what the study exposed, she says, was “absolutely staggering.”
During her graduate school internship in the late 1990s, the issues Brooks counseled college students on typically amounted to little more than dorm-room disputes, homesickness or a need for career advice. Only on rare occasions did she see full-blown, clinical-level instances of personality disorder.
That all changed around the middle of the first decade of the new millennium, when Brooks was working in Niagara University’s counseling center.
“It was incredible. It was all of a sudden. It was just a marked shift,” she says. “There was nobody coming in and saying they were homesick. There was nobody who just had a roommate problem. Nearly everyone — I would say nearly 90 percent of people — walked in already suspecting they had a disorder, or already having a name for a disorder that they’d been given by a previous therapist, or were continuing therapy from high school, if not further back than that.”
The surge of students on medication was so pronounced, she says, that the university hired a psychiatric nurse practitioner to keep up with the demand.
“They were coming to campus with these issues already, with the diagnoses, on the medications,” Brooks says. “There were real and serious issues going on.”
To quantify the explosion of personality disorders, Brooks and her Niagara colleagues screened 351 voluntary participants at the 2,700-student school.
With a 1 percent to 3 percent threshold thought to be the norm, the study unearthed an “unprecedented prevalence” for the 10 kinds of Axis II diagnoses laid out in the DSM-IV, with the most striking figures coming for histrionic personality disorder and narcissistic personality disorder, at 29.6 percent and 21.1 percent, respectively.
Even more distressing, the study — published in the International Journal of Education and Culture — found no significant statistical difference in the prevalence of eight of the Axis II disorders between clinical participants and those who had never been in a therapeutic setting. The data offer a startling indication, Brooks and her co-authors write, that personality disorders may be vastly more widespread among college populations than previously suspected.
“We’re seeing this across the board,” Brooks says. “If you’re on a college campus, you hear this stuff from everybody. We are all seeing these things and all wondering, ‘How are these people going to succeed in life?’ So it surprises me that more people aren’t looking at this, to be honest.”
A mother’s legacy
The 13-year-old girl who sat in Beckwith’s Palm Beach office that day in 2009 bore all the hallmarks of borderline personality disorder: A childhood defined by a tumultuous home life. Arguments, screaming, name-calling, a litany of self-destructive behavior and emotions that would get the best of her. Promiscuity, self-mutilation and declarations of a desire to kill herself. An inability to maintain friendships and a constant craving for a boyfriend to make herself whole. On top of that, Beckwith suspected the girl had been exposed to domestic violence.
The client’s careening behavior reached its breaking point when her parents caught her in bed with an 18-year-old and decided to bring her in for counseling.
Those borderline traits, as well as a history of depressive episodes, revealed themselves before the first session was complete. And over three ensuing years of counseling sessions and therapy, the case emerged as perhaps the most extreme instance of borderline personality disorder Beckwith has ever seen. “It was right out of the textbook,” she says. “Every symptom was there.”
The cause traced quickly and clearly to the girl’s mother, who from one moment to the next vacillated between smothering affection and “annihilating rage,” Beckwith says, while also showing jealousy over the daughter’s relationship with her father. The mother would insist that the daughter get help, then would turn around and undermine Beckwith’s efforts to provide that help.
“Mom would tell her, ‘I would have been better off without you. I want you out of my life.’ And the next minute she’d be hugging her and crying, ‘Oh, I love you,’” Beckwith says. “The daughter was totally, totally abandoned emotionally. She was rebellious and would constantly seek attention and love from just about anybody else. You could see how much the daughter was just trying to get mom’s love and support, and how much mom just could not come out of her own needs.”
Beckwith turned to the 2002 book Understanding the Borderline Mother by Christine Ann Lawson and conducted weekly sessions of trauma outcome process therapy with the girl. Sessions focused on the girl’s hypersensitivity and the cascading physical reactions — quickening heart rate, anger-induced blackouts and various anxieties — that were triggered anytime her mother flew into a rage. As a result of those episodes, the girl’s emotions would get mixed up, conflated and confounded into a sort of numbness and sense of disassociation, Beckwith says.
Much of Beckwith’s work was aimed at helping the girl empathize, understand boundaries, socialize better and grasp societal norms, and forge and maintain healthy relationships. Beckwith provided her with a sampling of psychoeducational literature to take home, which the girl had to make copies of and sneak into her backpack to conceal from her undermining mother.
“What was amazing is, I sat down with [the girl], I took it right out of the DSM and explained to her what a borderline personality is,” Beckwith says. “And when I pointed it out, it’s like a light went off in the daughter’s head, and it started making sense to her.”
Over time, the girl’s appearance started to soften. Her wardrobe featured more pastels. She grew more relaxed, centered and self-assured. She was coming into her own, emotionally, academically and socially, Beckwith says. She cultivated positive friendships and even started dating in what Beckwith saw was a healthy way. She was flourishing as an artist and began looking to apply to colleges.
More than two years into therapy, as the girl neared her 16th birthday, she started talking about seeking emancipation to free herself from the toxic relationship with her mother. She showed Beckwith an intricate budget laying out the income from her two jobs and the cost of rent, food and expenses. Beckwith knew the girl was no longer simply acting out; she was becoming stronger and who she needed to be.
“I was afraid to say to myself, ‘Could she be getting better? Could she actually be getting healthier?’” Beckwith says. “But things really were falling into place.”
It was, for Beckwith, one of the most personally rewarding cases of her career. The success she experienced is in stark contrast to what many counselors face when working with clients who have personality disorders — particularly borderline personality disorder. This population of clients can be notoriously difficult to treat. “They just suck your emotions dry,” Beckwith says.
Not ‘doomed forever’
Counselor burnout was part of why Marsha Linehan devised dialectical behavior therapy (DBT) 30 years ago, a landmark shift that made headway in treating some of the most intransigent disorders and dysfunctions. With its central tenet of a perpetual exchange between acceptance and change, DBT has become the standard-bearer for treating borderline personality disorder.
The technique proved particularly apt for Cheryl Hamilton’s work at a community mental health agency in Columbus, Ohio, and in her counseling of juvenile clients in the local county court system. Over the course of six years — until Hamilton went on maternity leave this past spring — more than half of her client caseload showed traits or had a full diagnosis of borderline personality disorder.
Hamilton’s tact adhered as closely as possible to the archetypical DBT model, with its specific targets, hierarchy and modes of service delivery: individual psychotherapy, group skills training, phone consultations and a team consultation.
The community mental health center where Hamilton worked asked clients to commit to DBT therapy for a year. Therapeutic work in the initial stages included group sessions to develop the client’s skills in mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness.
What makes DBT effective, for both client and counselor, is its explicit structure, says Hamilton, a member of ACA. “I found that when other counselors referred clients to me, the clients felt like they had been in so much chaos in their [previous] therapy if they weren’t using a structured model,” she says. “With DBT, you know what the target is. There are no surprises. I knew where we were going [and] they knew where we were going. It kept us moving instead of being stuck. Compared with not using DBT, it always felt like there was movement and progress and a goal. What it does is get them to apply those skills so they can decrease their emotional suffering and all that chaos.”
Many of Hamilton’s clients would come directly from a hospital after a suicide attempt or some other self-destructive behavior. Originally developed to treat clients with a history of parasuicide attempts, DBT is one of the few treatments empirically proved to achieve significant improvement.
“Unfortunately, I’ve had a lot of clients who would meet criteria [even] after treatment for borderline,” Hamilton says. “But I’ve also had a lot of clients who wouldn’t. Some of the traits of that personality might still be there — some of that vulnerability, some of that emotional intensity — but not necessarily meeting diagnostic criteria. So, I definitely think there’s hope that someone isn’t doomed forever to have the disorder.”
In his work with students at Hiram College, a liberal arts school outside Cleveland, Kevin Feisthamel has developed a style that folds in elements of DBT with a handful of other techniques. The director of counseling, health and disability services at Hiram, Feisthamel places emphasis on having clients improve their situational self-awareness and mindfulness of all their senses. Sometimes, he asks clients to keep a journal detailing specific behaviors. He also integrates elements of positive psychology and motivational interviewing techniques along the lines of the Stage of Change model conceived by James Prochaska and Carlo DiClemente.
Meditative therapies have been of particular interest lately to Feisthamel, a member of ACA. “I know it’s relatively new here in the Western world, but all the research I’ve seen regarding meditation has been very positive, even with personality disorders,” he says.
Millennials struggling with personality disorders tend to lack any deep emotional attachment, Feisthamel says, but because of their relative youth, they are also generally less entrenched in their disorder and thus more able to internalize and implement change.
“Those habits can be changed, which is important for students to hear, because so often they don’t think there’s any change that can come,” Feisthamel says. “It’s about making them aware of, ‘Now you’re not 10 years old anymore. You had no choice when you were 10, but now you’re a grown adult, and here are some choices you can make for yourself.’ With the young kids of today, having them feel comfortable and safe — to be able to talk about specific issues in their life and how to function better on a daily basis — a huge part of that is working on it with them together. That client-counselor relationship is the No. 1 predictor of change in all the research, and forming that relationship is huge.”
A line in the sand
Beckwith sets the case of her teenage client with borderline personality disorder squarely within the context of the unsettling rise of personality dysfunction she is seeing both as a counselor and as an adjunct professor. She says her classrooms are rife with students who feel disproportionately privileged and who think that because they’ve paid tuition, they are owed an easy A and deferential treatment. “So many young people these days, they feel so entitled that when they don’t get what they need, they simply cannot handle it,” Beckwith says.
The seeming deluge of personality disorders has called their very definition into question, prompting leaders in the field to reevaluate how mental health professionals face the issue. During development of the DSM-5, proposals were made to eliminate several categories of personality disorder. This proposal was ultimately voted down, and the same 10 personality disorders from the DSM-IV were retained. However, an alternative hybrid dimensional-categorical model for diagnosis is included in Section III of the DSM-5.
As detailed in a personality disorders fact sheet published by APA, “The [Personality Disorders] Work Group’s first revision represented a significantly different approach to diagnosis. It attempted to break down the concise models of personality disorders, which sometimes are too rigid to fit patients’ symptoms, and replaced them with a trait-specific method. Using this model, clinicians would have determined if their patients had a personality disorder by looking at the traits suggested by their symptoms and ranking each trait by severity.
“As evidenced by the field’s reaction, this new model was too complex for clinical practice. … The result was reflected in a second proposal, a hybrid model that included evaluation of impairments in personality functioning (how an individual typically experiences himself or herself as well as others) plus five broad areas of pathological personality traits. Although this hybrid proposal was not accepted for DSM-5’s main manual, it is included in Section III for further study. … APA hopes that inclusion of the new methodology … will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.”
Ideally, that hybrid alternative will push mental health professionals to think of personality disorder less in black-and-white terms and more in nuanced shades of gray, says Feisthamel, who presented a standing-room-only session on understanding personality disorders in the DSM-5 at the ACA Conference in Cincinnati this past March.
Having had time now to delve into the since-published DSM-5 and consider its approach to personality disorders in greater depth, Feisthamel has found merit in some of its suggestions. Perhaps the greatest positive, he says, is that the alternative model in the DSM-5 suggests breaking out the characteristics of personality disorder so that practitioners can document a collection of traits “instead of giving that full-blown diagnosis of personality disorder.” And instead of the “not otherwise specified” designation that Feisthamel says too easily became a catchall under the DSM-IV, the “Trait Specified” diagnosis encourages practitioners to pick and choose facets of disorder.
It’s a framework that jibes well with Feisthamel’s approach to counseling undergraduates and in teaching future mental health professionals to be more guarded and judicious before doling out a diagnosis. “We’re always very cautious of assigning the [old] Axis II disorders — especially the personality disorders — because it is a lifelong punishment,” he says. “Those are labels for life.”
The prevalence of personality disorders at Hiram doesn’t seem as dire to Feisthamel as the reports he hears from some of his peers on other college campuses. He has seen the surge of personality disorders firsthand, however, especially when he worked in community mental health centers earlier in his career, where he says prevalence rates were as high as 85 or 90 percent.
“It’s a big change in the culture of our country,” he says. “I do think there is a change in people’s behaviors and individuals being raised where you do have those people feeling entitled. There are a lot more people in need and who need that access [to counseling].”
Feisthamel believes some of the apparent increase is due to the public’s growing comfort with talking about mental health issues. He points to Hiram’s chapter of Active Minds, a student-run nonprofit that advocates for mental health awareness. The organization focuses its efforts on establishing a more open dialogue that educates students and encourages them to seek help when needed. Since incorporating 10 years ago at the University of Pennsylvania, Active Minds has spread to more than 400 schools nationwide.
“I think we’re doing a good job of decreasing the stigma,” Feisthamel says. “I find myself being on a college campus where individuals are more knowledgeable about seeking services, which I think is excellent. So maybe it’s that more people are aware of the signs and symptoms and they are getting in for treatment at that moment.”
Just as understanding of the autism spectrum has evolved within the mental health fields and the public at large, Feisthamel says, counselors need to adapt their definition of “personality disorders” to keep pace with shifting cultural norms.
But at some point, Brooks says, mental health practitioners must be mindful to stand their ground about what constitutes a willingness to be flexible versus what constitutes clearly delineated personality disorders.
“These are not adaptive skills,” she says. “No matter what generation you’re in, or what time, if you can’t have a face-to-face conversation, if you can’t sit down for an interview without rolling your eyes or crossing your legs or looking bored, or you can’t get to class on time — or you don’t bother to come at all — no matter who you are and whoever your boss is, I can’t imagine anybody is going to be able to keep a job or a healthy relationship. Maybe we will all adapt to that, but that to me would be a very sad world. What would happen to us if everybody just didn’t show up to work, to school, or know how to function in a relationship? We’d completely fall apart. And I think we’re moving more and more in that direction.”
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