Latest / It’s All Your Fault: High Conflict People / Are Personality Disorders a Mental Illness?
Transcript
- Megan Hunter: Welcome to It's All Your Fault on TruStory FM, the one and only podcast dedicated to helping you identify and deal with the most challenging human interactions, those with someone who may have a high conflict personality. I'm Megan Hunter, and I'm here with my co-host Bill Eddy. Bill Eddy: Hi everybody. Megan Hunter: We are the co-founders of the High Conflict Institute in San Diego, California. In this episode, we'll focus on whether personality disorders are a form of mental illness or not. But first, a couple of notes. If you have a question about a high conflict situation or person, send them to podcast@highconflictinstitute.com or on our website at highconflictinstitute.com/podcast where you'll also find the show notes and links. Please give us a rate or review and tell your friends, colleagues, or family about us, especially if they're dealing with a high conflict situation. We're very grateful. Now let's talk personality disorders and mental illness. Personality disorders are pretty widespread, but not always seen as a mental disorder. They're listed in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association with the most recent publication in 2022 as the DSM-5-TR. And in this most recent edition, it indicates that over 10% of adults have such a disorder based on studies from several countries, not just the US. These are really huge numbers, yet few people know much about personality disorders and many do not see them as a mental disorder. Information found online is often misleading, but ultimately many people simply get angry with those with personality disorders, believing that they're just being difficult on purpose and that they really can control and should be controlling their behavior. Likewise, judges generally do not consider them a factor in making legal decisions because they're considered to know right from wrong. However, what we're going to talk about today is whether these views may be changing. Now, when people act strangely, we do often confront them with their behavior and tell them to "Cut it out. Knock it off. Stop what you're doing." But if they have a mental illness, we tend to give them a break or just try to avoid them. So what is considered a mental illness or disorder, Bill? Bill Eddy: The American Psychiatric Association has kind of the standard for this. They have the DSM-5 as you mentioned. Basically their definition, and you can go to their website, is that mental illnesses or health conditions involving changes in emotion, thinking, or behavior or a combination of these, mental illnesses are associated with distress and/or problems functioning and social activities, work activities or family activities. So that's a very broad definition. What people generally think of as mental illness, things like schizophrenia where the person may have hallucinations, they hear voices that aren't there. Or have delusions, they see people that aren't there. Or bipolar disorder which kind of drives someone to be manic say for two or three weeks. They're just buying things. They're not sleeping. They're high energy, it kind of drives them. And then they kind of crash into a depression. That's the other pole of the bipolar where they may be in a depression for two or three or four months. So people understand that's something driving them, that it isn't like, "Oh, today I'm going to be manic. Or today I'm going to be depressed." Likewise, depression, this is maybe the most common form of what's considered a mental illness or disorder, which many, many people experience at some point in their life. But it is included in the Manual of Mental Disorders. And people think of that as affecting their thinking. When someone's depressed, they just have a very negative outlook. You can say, "Cheer up" and they say, "What is there to cheer up about?" all of that. Likewise, anxiety. That's a really common one as well. Many people have some depression, some anxiety that resolves usually within 60 to 90 days, say if somebody passes away and you're really sad. So it's not something that sticks, but it may be a short period of time. Some people have, say a major depression, or they have a lot of anxiety. And that persists. And that may be a little bit genetic tendencies, et cetera. Then of course there's addictions. And people understand when someone's gotten addiction, they often act weird, driving drunk, just spending all their money on drugs, yelling at the people around them that they don't have a problem. So all of these we're kind of familiar with and think of as mental disorders, mental illnesses. And they're all included in the Diagnostic Manual. So when you see somebody like that, yeah, you may go, "Well, I'm going to give them a break. They got this issue they don't totally have control over," or, "I'm going to steer clear of them because they have this issue they don't have control over." So that's what people generally think of as a mental illness. Megan Hunter: Then how are personality disorders different from other types of mental illnesses? Bill Eddy: Well, this is interesting. I think it was before 2013, there was what was called Axis system that the DSM had Axis I, which was the types of mental illnesses and disorders we just talked about. And Axis II was personality disorders. Considered a disorder, but of a different type. Now it's just another chapter. They got about 50 pages in the DSM-5-TR, the TR, just text revision. So it didn't change the factors very much. But with that, what happened is personality disorders are just kind of grouped together. There's no Axis system anymore. But generally, this is one of the most common mental disorders according to the manual and yet one of the least understood and talked about. And there's reasons for that. Generally, when someone just has a personality disorder and they don't have co-occurring depression, anxiety, bipolar, et cetera, they look normal. And so, if you go through your extended family, I think just about everybody has some people with personality disorders, but they may have a good job, they may be very good at something they do. But with personality disorders, it's generally close relationships that that's where that comes out and people are surprised, "Well, that's not a mental illness. They're in touch with reality. They're just a jerk." And in many ways, personality disorders are interpersonal disorders, and that's where their problems show up. So people tend to think of them as something more normal. However, they are in the manual. However, with that said, so mental health professionals say that's a mental disorder. The average person isn't so sure and thinks they're just a jerk or they're have an emotional upsets. The legal field, and a lot of our listeners are legal professionals, lawyers, judges, mediators, therapists in legal cases, it's helpful to know that the legal field has not seen personality disorders as a mental illness that should alter the kind of sentence a criminal gets or really the kind of parenting plan someone gets or anything like that in a divorce. So this is good to know as the legal field generally doesn't see personality disorders as a form of mental illness. Megan Hunter: But then are personality disorders a form of mental illness at all, or something more normal? Bill Eddy: What the legal field seems to look at is they think of mental illness as something the person really doesn't have control over. Like someone with schizophrenia, there's people that have committed a crime. Maybe they've stolen money or they've assaulted somebody because they thought they were a 300 pound gorilla when in fact it was their child or something like that, that that was a hallucination or delusion. And so they go, "Okay, rather than putting this person in prison for 10 years, we're going to give them something that maybe includes some treatment because they have mental illness. That this is a mitigating factor." And that's the term that they often use. So that a mental illness, certainly you don't have control over, so it's a mitigating factor. And in legal terms, you think of it, law professors will tell you about Mens Rea, that's M-E-N-S-R-E-A, which is that you had the thought, the intent to commit the crime. And if you have schizophrenia, they say you can't have the intent to commit the crime. But you did commit a crime so we got to kind of maybe put you into a psychiatric facility until you're better, things like that. Not guilty by reason of mental illness or insanity. That's the way it's treated by the legal field. That personality disorders, people know right from wrong, they have responsibility. They should be held liable for their bad behavior if they're in the legal system because of bad behavior. So legal systems says it's not a mental illness. Megan Hunter: Yeah, such a tricky, tricky area. Was this difference considered in a case from about 20 years ago that our listeners might remember, the Elizabeth Smart case? Her kidnapper was Mitchell. So was it even considered there? Bill Eddy: Well, what's interesting is, and this is included in our book, the High Conflict People in Legal Disputes, and we teach that at some law schools, yes, the court considered whether he was competent to stand trial. If he had a mental illness that interfered with his ability to think, communicate, et cetera, then that would be a mental illness that would make him not capable of standing trial. What's interesting in this case is they found that Brian Mitchell did not have a mental illness according to those terms. They found that he had two personality disorders, antisocial personality disorder and narcissistic personality disorder. And in many ways he was a con artist. He pretended he was a pious religious person. They would walk around the streets in white robes. He and his wife and Elizabeth Smart all covered up so they couldn't see who was who. And he pretended to be religious. But what Elizabeth said is when she had them alone away from the public, he wasn't religious at all. And so what came out in that case is they say Mitchell does not presently suffer from a mental disease or defect. And therefore they considered that he has an ability to consult with his lawyer in a reasonable degree of rational understanding so he's competent to stand trial. So they saw him not having a mental illness because he had these personality disorders instead. Megan Hunter: Wow. Bill Eddy: It's fascinating. Megan Hunter: It really is, because what's going through my mind is all of how I look at folks with this high conflict personality. I see it as an operating system that this person doesn't know they have so they're driven by something entirely different. It looks different from, say schizophrenia. But even in this Mitchell case though, walking on white robes covered up, that definitely looks a little different as well. So, interesting. How about the Unabomber case in the 1970s through '90s? Were personality disorders considered in that case? Bill Eddy: In a sense, they again saw a difference here. Now, what happened is he was evaluated by several different people. The first, I believe, psychiatrist that evaluated him said that he had schizophrenia. And therefore, the prosecution was afraid that if they prosecuted him in a trial, that there might be a reversal or an acquittal or a mistrial because of his mental illness. And so they wanted to avoid a trial if possible. What they did is they offered him life in prison instead of the death penalty if he would plea bargain and never get out, that it was life in prison with no chance of parole, because of their fear that a trial with his mental illness would blow up and he might go free. Megan Hunter: Oh. Bill Eddy: So what happened is he accepted their offer and therefore he's in prison for life now. But what's interesting is some other psychologists also interviewed him and said he doesn't have schizophrenia, he does have control, and that he probably has paranoid personality disorder because what they said is his multi decade bombing spree, because he's over 18 years, he was sending these bombs in the mail, says, "was a product of measured consideration" not uncontrollable impulses. And statements he made showed that he thought that this violence was appropriate and that technological progress was evil and therefore he was going to try to help stop that. But he had many years... He was very organized. If he had schizophrenia, there saying he wouldn't have had control, he would've had impulses that were more short term, but this showed he had time to think about this and he had rational thoughts and that he knew what he was doing was legally wrong. Megan Hunter: Wow. I'm absorbing and thinking. It's just such a big topic. I started thinking about problem solving courts and mental health courts, and should there be personality disorder courts. It's- Bill Eddy: It's coming in a sense because I think as personality disorders get more attention, people are starting to go, "Well, wait a minute. This does affect their thinking." I mean sending bombs through the mail because you don't like technological progress, there's something wrong with that thinking. And yet it's not like he didn't think they were a 500 pound gorilla. He knew they were people and they were getting injured and he had a plan. So I think what you're talking about, problem solving courts and stuff, it really do make sense with people who have some of these thinking problems, but in many ways are effective people, they can hold jobs. They can have relationships. They have difficulties in close relationships. But they can learn skills. I mean, that's a lot of what we do, is teach skills so that people can have good relationships even if there's some of this in the family. Megan Hunter: Yeah. And it brings to mind medication as well. I guess it might be a sort of a built-in assumption I guess that a mental illness can be treated with medication. Where with personality disorders, the treatment is not medication. It is skills as you said. So I think that would probably go against the legal system, viewing someone with a personality disorder is truly mentally ill. Yes? Bill Eddy: Yeah. In other words, people with schizophrenia, they go into, say a psychiatric hospital or a psychiatric prison, and take medication and suddenly they're more reasonable and cooperative and such. Well, that doesn't happen with personality disorders there. It's like learning a whole new language and culture for them to change. It isn't a chemical imbalance as much as the ingrained habits, patterns, thinking. And that's why like DBT, dialectical behavior therapy for borderline personality. It can be so effective, but only over time. People have to learn new ways of managing their emotions and changing their thoughts about things and treating anger proportionally, because people with borderline tend to be all or nothing with anger, and learning what's a smaller amount what's appropriate to the situation. So people with personality disorders can learn in many cases. But someone with schizophrenias, the issue's pretty much chemical and medications is the primary treatment for that, not even counseling. Counseling may help manage daily life, but it's not a treatment for schizophrenia where it can be a treatment for some personality disorders. Megan Hunter: Mm-hmm. Okay. So kind of something has happened in the past couple of years that was a big departure from the norm, which is a landmark case in Australia. It came out in 2020. That really may indicate a change in thinking about personality disorders in criminal cases, not in all legal cases, but at least in criminals. So I recall it had to do with, I think, someone with a borderline personality disorder diagnosis and a fire. So what was that case about and what did the court of appeals decide there? Bill Eddy: Yeah. So this is really the first big case that I've seen that takes this new approach, and this is from 2020. And for our friends in Australia, this is the Brown case, which my law students in Australia know well because some of them have written about it in their papers. But the Brown case, Brown was a young woman, who she was an adult. She was 19. She'd been in a treatment center and liked being in the treatment center, but she aged out. And so what she did is, one, I think it was a Sunday morning, she went around... And this might have been Melbourne because Melbourne's in this state of Victoria and it was the Victoria Supreme Court that made this decision. So she went around, maybe Melbourne, and started fires. She started fires in buildings that were... No one was there, no one was hurt. But the last place she started the fire, she just sat in front of it and waited to be arrested. And what she wanted was to be arrested and sent back to her treatment center. And so there's a logic in that I suppose, but it's that distorted logic that people with personality disorders have. They put a spin on things. So they're kind of in touch with reality, but see it in more extreme way. So she was arrested and convicted. I think was supposed to get like an 18 month prison sentence. And the judge said, "That's just not right. That's not what this person needs. She has a personality disorder. She doesn't have schizophrenia. She doesn't have a bipolar disorder apparently. She has a personality disorder." And I think you may be right that it was borderline. Most people with borderline personality disorder are not setting fires and doing things like that. So it's important people know that. There's a whole kind of range. So this was pretty extreme. But the judge said, "I want to see her in something that has some treatment included." And so he went against a many year standard when criminals had been openly told that a personality disorder that they had was not going to be considered in their sentencing. And so they got harsher sentences and no treatment. So the Victorian Supreme Court upheld that judge's decision and basically overturned the precedent of not considering personality disorders. And here's what they said. They basically concluded that an offender diagnosed with a personality disorder "should be treated as in no different position from any other offender," relying on an impairment of mental functioning as a mitigating sentence. Now it's a case by case and they often want mental health testimony. So not everybody can come back and say, "Okay, well I have a personality disorder. Change my sentence." It's more of like, "Yeah, if you really have the right situation." And treatment may be appropriately part because there's people with like antisocial personality disorder where treatment just may not be in the picture at all and they just really need to be locked up with society protected from them. But this is a shift. I haven't seen it yet in the US, but I have a law school class in the US so they may find if this changes one of these days. I think personality disorders are going to be something people start understanding more. Megan Hunter: Wasn't there some research that came out of California, I think, family courts about narcissism? Narcissistic personalities? Bill Eddy: Yes. Yes. I'm glad you brought that up because in family courts, they don't like to hear about personality disorders because they just want to know how's this person's parenting. And so if you say, "Well, my wife's got borderline personality disorders. She should never be around the kids" or, "My husband's got narcissistic personality disorder. He should never be around the kids," they don't want to consider that. However, this study was done and published in Family Law journal saying that narcissistic personality disorders were driving a significant number of family law cases. And that professionals, lawyers, judges, et cetera, need to start looking at how to treat them differently. And so this is now another area where we're looking at that. And I forgot about that one, so I don't have it at my fingertips, but Rosenfeld was the lead author in that article, in that study. I think family law may be getting closer to considering personality disorders just to understand them. Not to make the decisions particularly different. But a difference would be if they realize someone has a personality disorder, you can't just give them a lecture and have them behave differently. And that's, I think, where family courts need to go, is they need to understand who can change and who can't change. And that's usually a pattern of behavior. And if people present the pattern of behavior that goes with a personality disorder, they don't even need to say the personality disorder. They can just say, "Your honor, this behavior's continued uninterrupted for the last 10 years. A lecture is not going to make it better and this parent needs to have far less time than a parent that shows flexibility and reasonableness." We'll see. Megan Hunter: Yeah. And you think about the return on that would be, I think pretty significant in terms of how the children fare throughout the co-parenting years and if their parents could get some skills. Even though they're divorced, right? Even if they had these skills and could improve their parenting, it would have a ripple effect throughout society really. Well, this has been really fascinating, Bill. I know you've done just so much research in this area and read everything there is to read out there. So it's really great to have this conversation. Now, this is the part where we usually announce next week's topic. However, we have an announcement to make. We are actually going to take a little bit of a break, a hiatus for a few weeks to get some vacation time and self-care in. We both work pretty hard, as I'm sure all of you do as well. But we'll be playing our most popular episodes during our hiatus. So just keep listening. We're not stopping. We'll just have a few of those ones that are pretty popular played again. And then when we start the new season, we'll have some very interesting surprises in store, and it's just going to get better and better. Keep on sending your questions. We'll keep answering them and maybe we'll answer even more next season, Send those questions to podcast@highconflictinstitute.com or submit them to highconflictinstitute.com/podcast. And tell all your friends about us. We'd be grateful if you'd leave us a review wherever you listen to our podcast. The reviews I've seen so far have been really fantastic and we're grateful, very grateful for those, and grateful for you, our listeners, to take the time to learn about what we have to talk about. It is really important for humanity, in our opinion. So until we're back from hiatus, have a great summer if you are in our part of the world, and have a great winter if you're in the Southern hemisphere. And keep learning about high conflict behavior so you can manage it in your life and keep striving toward the missing piece. It's All Your Fault is a production of TrueStory FM. Engineering by Andy Nelson, music by Wolf Samuels, John Coggins, and Ziv Moran. Find the show, show notes, and transcripts at trustory.fm or highconflictinstitute.com/podcast. If your podcast app allows ratings and reviews, please consider doing that for our show.