The New Elephant in the Room: Why All Professionals Need to Learn About Personality Disorders

The New Elephant in the Room:


Why All Professionals Need to Learn About Personality Disorders


©2023 Bill Eddy, LCSW, Esq.


In 1994, a best-selling children’s book was published titled An Elephant in the Living Room, to help children learn about alcoholism—a topic that had been taboo to discuss or even acknowledge even though “at least 7 percent of the U.S. adult population is estimated to suffer from alcoholism.”[1] It wasn’t just children who weren’t discussing it, most adults hesitated to talk about it for fear of upsetting the person with alcoholism, their family, their workplace, or their community. Yet over the past few decades, our society has learned a great deal about alcoholism, including how to recognize it, set limits on it, and treat it. We are now at a similar point in history in regard to personality disorders—a topic that has been taboo to talk about or even acknowledge up to the present, even though as of 2022 the diagnostic manual of mental health professionals estimates that over 10 percent of the adult population would meet the criteria for a personality disorder, even though most have never been formally diagnosed.[2]

This has become a public health problem comparable to alcoholism in its ability to ruin the lives of those who have it, those close to them, those professionals working with them, and society at large. The time has come for all professionals, especially those involved in legal disputes, workplace conflicts, and child and family problems, to learn about personality disorders, talk about them openly, and take their significant issues into account in their work. This article provides a background on:

1. Why personality disorders are interpersonal disorders.

2. The growing societal impact of personality disorders.

3. Concerns about stigmatization and discrimination.

4. Training available from High Conflict Institute.


1. Interpersonal Disorders

There are several fundamental differences between personality disorders (hereafter “PDs”) and other mental disorders. PDs are primarily interpersonal disorders marked by interpersonal dysfunction, which means that their most difficult behavior comes out in relationship to other people, so that many more people are impacted than just the individual who has the disorder. As a major review of over 120 studies on this subject has noted:

Personality disorders are defined in the current psychiatric diagnostic system as characterized by pervasive, inflexible, and stable patterns of thinking, feeling, behaving, and interacting with others that cause significant distress or impaired functioning in interpersonal or professional domains. The importance of interpersonal dysfunction in defining personality disorders is clearly evident in their descriptive features and diagnostic criteria—each personality disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders [currently DSM-5-TR], is described by a problematic approach to interpersonal interactions, or by characteristics that are likely to interfere with adaptive interactions and relationships.[3]


Lack of Self-Awareness

Another way in which PDs are different from other forms of mental illness is that most people with PDs do not know they have a disorder or even a problem. This has been noted by mental health professionals for decades, as Aaron Beck, Arthur Freeman and Associates wrote over thirty years ago:

Personality-disordered patients will often see the difficulties they encounter in dealing with other people or tasks as external to them, and generally independent of their behavior or input. They often describe being victimized by others or, more globally, by ‘the system.’ Such patients often have little idea about how they got to be the way they are, how they contribute to their own problems, or how to change.[4]

The result of this lack of self-awareness and feeling like a victim in life can contribute to significant conflicts in families, in the workplace, and in legal disputes. They frequently claim that others mistreat them when they are not being treated badly, but simply perceive that they are. They may over-react to mild rejections or actually be rejected because of their own behavior. Of course, there are many people with personality disorders who are also victims of crimes, targets of domestic violence, those who suffer personal injuries, those who are swindled in business deals, and so forth. Therefore, handling their conflicts with knowledge and skill matters, both for the person with a PD and their targets of blame.


Lack of Behavior Change

The definition of a PD in the diagnostic manual begins with this sentence: “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.”[5] The fact that this pattern of behavior is enduring is one of the biggest misunderstandings that most people, including professionals, have about PDs. Victims of domestic violence keep wishing and hoping for a change that doesn’t come. Workplace managers figure that the person knows their behavior is inappropriate and will stop themselves, while giving second and third and fourth chances with little or no change.

Civil judges and family law judges often don’t recognize the individual’s dysfunctional interpersonal patterns and accept their stories at face value, which may be significantly distorted or knowingly false. Ironically, judges and juries are supposed to determine the credibility of a witness, without realizing that many people with PDs in legal disputes thoroughly believe the distorted statements they are making, that they are skilled at blaming others, and therefore appear very credible—sometimes even more than the true victims of their hostile behavior. For this reason, many courts get these cases backward. Legal decisions would be vastly more appropriate by understanding the true dynamics and needs of people with PDs and those around them.


Not a Traditional “Mental Illness”

Personality disorders are usually not obvious at first. Not only do people with this disorder not realize they have it, but those around them often are also unaware—until there is a crisis or they get into conflicts in a close relationship. They can be very successful in life, although many are not. They generally are considered to know right from wrong (especially under the law), but they often put a spin on their perceptions, such as seeing things in all-or-nothing terms or jumping to conclusions, which they then consider justifies their extreme actions or over-reactions.

The diagnostic manual of mental disorders (DSM-5-TR) includes a chapter on diagnosing personality disorders for mental health professionals. However, legal professionals have not usually considered PDs to be a mental illness, which they think of as associated with someone who does not have control over their thinking or actions.

For example, in the high-profile kidnapping case of Elizabeth Smart in 2002, there was a question of whether her kidnapper was competent to stand trial or if he had a mental illness, such as schizophrenia, which would prevent him from understanding the proceedings. The court of appeals determined, based on expert testimony, that he had a narcissistic personality disorder (NPD) and an antisocial personality disorder (ASPD), but not a mental illness and therefore was competent to stand trial, for the following reasons:

Based on the evidence presented at the competency hearing, the analyses of [two psychiatrists], and the court’s analysis as set forth above, the court finds that Mitchell does not presently suffer from a mental disease or defect that impedes his rational and factual understanding of the nature and consequences of the proceedings against him or his ability to consult with his lawyer with a reasonable degree of rational understanding.[6]

This traditional interpretation may be changing, depending on the nature of a legal dispute and the jurisdiction that is ruling on a case. For example, in a landmark case in Australia in 2020, the Supreme Court of the State of Victoria found that a young woman who set many fires should get a different sentence for treatment rather than simply being sent to prison. They considered that she had a personality disorder, but not a mental illness. However, the court found that her PD did affect her judgment and behavior, so that she “should be treated as in no different position from any other offender”[7] whose mental illness could be taken into account in sentencing.


Treatment

Despite their enduring patterns of behavior, there is potential for change or learning self-management skills for some of those with PDs. It depends on which PD it is and how severe it is. For example, an effective treatment for borderline personality disorder is dialectical behavior therapy (DBT), which teaches clients skills to better manage their emotional upsets and times of extreme thinking and behavior, as well as to stabilize their relationships. DBT which can make a huge difference in the person’s life in 1-5 years of individual and group therapy, sometimes even outgrowing the diagnosis.

Some people with narcissistic and other personality disorders (there are ten identified in the DSM-5-TR), have made progress in counseling, especially cognitive and behavior therapies helping them change their thinking and behaviors. However, those with antisocial personality disorder (highly aggressive, deceitful, lack of remorse, often with criminal behavior) are generally unreachable with individual or group counseling, because their disorder may be so deeply hard-wired and/or hereditary.

Overall, few people with PDs are in treatment. The biggest challenge is that they tend to be highly defensive and psychologically unable to consider their own behavior to be a problem and therefore have no motivation to seek counseling or behavior change. When such a person also has a high conflict personality as an adversary in a legal or interpersonal dispute,[8] their fundamental preoccupation with blaming others usually prevents them from working on their own behavior patterns, so that no progress is made even if they are in treatment. (High conflict personalities—not a diagnosis—are known in the legal field for their endless high conflict behavior and prolonged cases, with a preoccupation with blaming others, all-or-nothing thinking, unmanaged emotions, and extreme behaviors.)

People with PDs also tend to have a higher incidence of other mental health problems, including substance use disorder, depression, anxiety, bipolar disorder, suicidal thoughts and completed suicides. Fortunately, these other disorders are generally treatable with medications and counseling, so that people with PDs can get benefit out of these other treatments, even though there is no specific medication for treating personality disorders themselves.


Cluster B Personality Disorders

The personality disorders most likely to come to the attention of professionals and present challenges and confusion are the Cluster B personality disorders, as described in the DSM-5-TR. The review of over 120 studies mentioned above suggests why this is:

Antisocial, borderline, histrionic, and narcissistic personality disorders, historically classified as Cluster B (dramatic-emotional-erratic) personality disorders, all showed moderate-to-large and significant associations with domineeringness, vindictiveness, and intrusiveness.[9]

This helps explain why such persons get into trouble in the workplace, often find themselves in legal disputes, and seriously impact their children and families. Research indicates that children of Cluster B parents can face a lot of difficulties growing up.

A common characteristic of persons with PDs is that they themselves most often do not consider their behavior to be problematic (i.e., the traits are ego-syntonic), yet their way of dealing with other people may represent a major stressor to persons who are close to them. Subsequently, parents with symptoms that are characteristic of BPD, ASPD, and NPD may readily see the faults and flaws in their children (and spouses) but rarely acknowledge that their own behavior or attitude contributes to any problems.

….

For the first time, subclinical levels of Borderline, Antisocial, and Narcissistic PD symptoms in parents have been documented to predict behavioral and emotional difficulties in their children as early as the preschool age. When parents were not cohabiting, the variance of the children’s emotional problems explained by parental symptoms increased more than six times.[10]

In other words, when parents have separated and a more balanced parent is no longer in the household, it is much harder on the child when alone with the parent with a PD. The authors of this study focused on parents who had subclinical levels of these disorders, meaning that they had some of the traits but not fully diagnosable personality disorders. They concluded: “Child service providers need to have knowledge of those deviant personality traits in parents that may represent a possible peril to their children’s mental health, even when parental PD is not diagnosable.”[11]

In short, personality disorders cause much internal distress to those who have them and can cause significant suffering and confusion to those around them, especially in their families, at work, and in legal disputes. However, what evidence is there that this is a growing public health problem affecting society at large?


2.  Growing Societal Impact

Over the past forty years, personality disorders have had an increasing impact on our society, especially in the areas of mental health, workplace conflict, and legal disputes. The following describes the growing awareness of problems and needs in these areas.


Mental Health Field

In 1980, the American Psychiatric Association published its third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3), for the first time identifying personality disorders as a specific category with specific criteria for diagnosis and treatment. (I was in training that year as a clinical social worker when two members of the DSM committee came to our clinic to train us in using the DSM-3.) Today, the DSM-5-TR is used worldwide to help identify and treat those with any mental disorder, including personality disorders.

In 1990, Aaron Beck and Associates published the highly regarded Cognitive Therapy for Personality Disorders, which applied new cognitive therapy methods for treating those with these disorders. Such methods were designed to help those with personality disorders, who were previously discriminated against and not thought to be treatable. Key lessons they taught were to steer clear of emotional venting and instead focus on changing their negative self-talk to more realistic and positive self-talk.

In 1993, Marsha Linehan published her landmark book Cognitive-Behavioral Treatment of Borderline Personality Disorder. The name of her new method was Dialectical Behavior Therapy (DBT), mentioned above, which is now the most researched and recognized treatment for borderline personality disorder, which is present in approximately 6% of the adult population according to the largest study of personality disorders in the United States. DBT completely changed treatment of this disorder. Instead of focusing on insight, the past, and feelings, this method focused on teaching clients personal self-management skills. Clients don’t have to be diagnosed to be treated with this method, although many are. It can help anyone, especially those with a PD.

In 2004, a major study was published by the National Institutes of Health examining the prevalence of personality disorders in the United States. The authors described the reason for this study:

Personality disorders have been associated with several adverse consequences in the general population, including marital difficulties, occupational dysfunction, and criminal behaviors…. Clinical studies have shown that personality disorders complicate the course of some [other] psychiatric disorders and are associated with increased likelihood of relapse and treatment dropout, greater global impairment, and decreased psychiatric functioning among substance abusers.

….

Knowledge of the prevalence of personality disorders contributes to the assessment of the mental health of the nation and determines the scope of those disorders confronting the nation. For policy and prevention efforts, accurate information on prevalence and the identification of vulnerable subgroups of the population might highlight the need for focused planning at both the national and local levels.[12]

Unfortunately, this significant study received very little attention, although their statistics for the various personality disorders were listed in the DSM-IV and are currently mentioned in the DSM-5-TR.

In 2012, a study of over 900 children showed the impact of having parents with symptoms of personality disorders. The study’s conclusions:

The PDs that appear to be most strongly associated with hostile behavior and that may affect children are Borderline Personality Disorder (BPD), Antisocial Personality Disorder (ASPD) and Narcissistic Personality Disorder (NPD). These disorders are characterized by features such as difficulty controlling anger (BPD, ASPD, NPD), impulsive and aggressive outbursts (BPD, ASPD), rage when being criticized (NPD), irritability (BPD), aggressiveness and physical assault (ASPD), being tough-minded, exploitive, and non-empathic (ASPD, NPD), lack of reciprocal interest and sensitivity to the wants and needs of others (ASPD, NPD), extreme sarcasm (BPD), being indifferent to having hurt another (ASPD), sudden and dramatic shifts in their view of others (BPD), emotional coldness (NPD, ASPD) and disdainful, arrogant behavior (NPD).

….

For the first time, it is documented that parents’ self-reported symptoms of Borderline, Antisocial, and Narcissistic Personality Disorders at a predominantly subclinical level had a strong effect on their children’s psychiatric symptoms, especially when the biological parents were not living together.[13]

In short, personality disorders are clearly different from most mental illnesses in that they are primarily interpersonal disorders affecting the mental health and welfare of numerous people, including their children, who are society’s future.


Legal Professionals

A comparison of the number of appellate court cases addressing the issue of a “personality disorder” over the past forty years shows the following increase:

1980 to 1990 = 2,058 cases

1990 to 2000 = 5,548 cases

2000 to 2010 = 10,000+ cases

2010 to 2020 = 20,000+ cases

(Lexis Advance Research Timeline statistics retrieved on December 30, 2022, from: https://advance.lexis.com/search – a subscription data base service for lawyers.)

The field of family law in particular has noted the apparent increase of cases involving personality disorders over the past forty years. In the 1980s, the term “high conflict” became common in describing divorce cases in family courts, which could devolve into “tribal warfare” as family members defended one spouse and attacked the former spouse in disputes over the children which often lasted years. In their 1988 book, Impasses of Divorce: The Dynamics and Resolution of Family Conflict, the authors described the inability of some parents to resolve their divorce and custody conflicts:

Typically, parents manifesting these patterns of behavior have borderline personality disorders. Often, they split off and project unacceptable feelings onto others in their social world and then struggled in conflictual relations with those others… In mediation they are willing to negotiate one day and feel furious and betrayed the next. Settling their custody dispute is tantamount to giving up part of themselves…. They are friendly, talkative, gracious at one moment; screaming, and stubborn the next.

….

Mr. A waxed poetic about the wonders of parenting and his children’s “infinite capacity to love and forgive.” At other times, he became tense, morose and irritable and neglected them or became harshly punitive. In fact, one night he severely beat his son for not living up to his expectations and lost custody.[14]

In a 1997 article, two mental health professionals who had extensive experience as counselors, mediators, and custody evaluators, described the primary source of difficulty in their work:

While performing our duties in all of these roles, we have found that clients who engage in protracted adversarial processes, whether personal or litigious, show a high percentage of personality disorders. They make up a significant population of the descriptively difficult clients who consume an inordinate amount of time and energy of family lawyers and the family court system.[15]

Yet widespread and open discussion of personality disorders in family law cases has been slow to come. As a survey of lawyers and judges more than twenty years later in 2019 explains, the lack of understanding and training in addressing these high conflict personality disorders still persists:

As we have seen, when litigants with high-conflict personalities enter the family law system, disputes are prolonged, courts experience backlog in their dockets, and collateral damage results to parties, children, attorneys, the court, and even, indirectly, taxpayers. The advice most consistently heard in our interviews and from our collective review of the literature about these cases is that the best way to respond to high-conflict personalities is to recognize the pattern of behavior and to disengage from the conflict. It will take training to learn to recognize and disengage from conflict-driven litigants. Toward this end, our research elicited a series of pragmatic solutions. Our proposals fall into two broad categories: education and training for lawyers in terms of managing these individuals, whether as clients or as opposing parties, and education and training for judges about how to facilitate settlement in cases involving individuals with high-conflict personalities.[16]

In 2008, I co-founded High Conflict Institute, LLC, with Megan Hunter, MBA. At first our aim was to educate primarily family law professionals about Cluster B personality disorders and ways of managing their cases more effectively, in court and out of court. Our efforts were recognized in the 2019 research above:

For insight into the impact of these cases on family members and others in the legal system, there is the work of Bill Eddy, a social worker and a lawyer, and the co-founder of The High Conflict Institute. Eddy has authored several books offering tools and advice for managing high-conflict personalities in the legal setting. His work offers rich insight into how and why the default structure of our family law system inevitably activates the traits that are the hallmark of those with high-conflict personalities. Eddy’s central message draws on his observation that the dominant trait of a high-conflict personality is to view relationships as adversarial.[17]

 While the focus of our work with High Conflict Institute has been on training legal professionals, we have also been inundated with requests for this knowledge and skills for professionals in all settings, including human resources, employee assistance professionals, managers, and administrators in healthcare and education.


Workplace Professionals

With the DSM-5-TR estimating that over 10 percent of adults in the United States meet the criteria for a personality disorder, it’s not surprising that they show up a lot in the workplace. Having a personality disorder does not prevent most people from working, it just causes the person to get into frequent conflicts with those around him or her, and/or those in positions of authority.

In 2000, the book Toxic Coworkers: How to Deal with Dysfunctional People on the Job was published, bringing attention to the impact of personality disorders in the workplace:

Our own study of personality factors and stress in the workplace showed that over 80 percent of our sample worked with at least one individual whose behavior was a significant source of stress for them (Cavaiola & Lavender 1999). Moreover, when asked what types of problems these coworkers, bosses, and subordinates caused, the type of characteristics people found most troublesome were similar to or identical to many of the personality disorders described in this book.

               Personality disorders are a special group of psychological disorders of which the general public and most workplaces are unaware. They are distinctly different and potentially more malignant than other types of disorders, such as depression or anxiety.[18]

….

Individuals with personality disorders often cause their organizations to run in a highly inefficient manner, potentially costing the corporation millions…. Workers with personality disorders often cause corporations to pay millions in damages to victims of their behavior. But bear in mind that this problem is two pronged. Not only do corporations often have to pay for the damage PD (personality disordered) people have wrought against others, but they must often pay for the damage that workers with PDs believe has been done to them.[19] (Emphasis in original)

These authors itemized each of the ten personality disorders and how they often appeared in workplace difficulties. They were surprised that little had been researched or written about this subject up to that time. Yet, many years later there has still been little open discussion of the impact of personality disorders in the workplace.

 In 2015, a study by Harvard researchers Michael Houseman and Dylan Minor titled Toxic Workers concluded that it saves a company approximately $5300 to hire a superstar employee but saves a company approximately $12,500 to avoid a toxic employee – either by firing them, not hiring them in the first place or by “converting them to an average employee.”[20] While they did not use the term personality disorder, their descriptions of such workers are similar to those in the Toxic Coworkers book about PDs in the workplace. Their idea that you can convert some of these workers into “average employees” fits with the reality that some people with PDs or PD traits may be able to be taught skills that can help them manage themselves to become more positive employees.

Also in 2015, I co-authored a book with L. Georgi DiStefano, LCSW, on managing personality disorders in the workplace: It’s All Your Fault at Work: Managing Narcissists and Other High Conflict People.[21] We won an Axiom Business Book Award in the category of Human Resources / Employee Training. We even received an endorsement from Ken Blanchard, the coauthor of the One Minute Manager, the most successful business management book of all time. He recognized the importance of this subject:

This book belongs in every leader’s library. Although I believe there’s a pearl of good in everyone, some people’s pearl is hard to find. You may not be able to change a high conflict personality, but by using Bill Eddy’s and Georgi DiStefano’s techniques, you’ll be able to keep the focus on solutions rather than arguments.[22]

Many workplace trainings and consultations have arisen out of this book. However, proportionately few people in the workplace have been trained by us or others in regard to personality disorders. Much more training needs to be done in this important, but barely acknowledged, area in the years ahead.


Mediation Professionals

In 2020, I was approached by the American Bar Association (ABA) to contribute a chapter to a new book on mediation ethics. In 2021, this book, Mediation Ethics: A Practitioner’s Guide, was published and included my Chapter 8: “Dealing with Difficult Parties.” I reported behaviors mentioned in a variety of published legal cases defining difficult parties, “exaggerated emotions, adamant directives, attacking and demeaning behavior, difficulty compromising, a preoccupation with blaming others, repeated interruptions, bad-faith participation,” and so forth. I said that they may need a different approach:

However, any realistic approach to the mediator’s role must recognize that mediation parties cannot always be treated the same. For example, the Model Standards state in Standard VI, Quality of the Process, that “[i]f a party appears to have difficulty comprehending the process, issues, or settlement options, or difficulty participating in a mediation, the mediator should explore the circumstances and potential accommodations, modifications or adjustments that would make possible the party’s capacity to comprehend, participate and exercise self-determination.[23]

Also in 2021, my book Mediating High Conflict Disputes was published, co-authored by Michael Lomax, a Canadian mediator with both family and workplace mediation experience. It included over 100 tips and tools for helping difficult clients remain in mediation, stay calm, and resolve their disputes.

Legislatures and courts are increasingly requiring mediation over litigation for a full range of disputes. This means that people with personality disorders are participating more and more in mediations, so that professional mediators need to be prepared to understand their unique dynamics and methods for assisting them to completion of the mediation process. Failure in mediation often means that the parties proceed to litigation, which is in many ways much worse for those with personality disorders. While courts are supposed to be an adversarial process of conflict resolution, those with personality disorders (at least Cluster B) often don’t accept court decisions, as they tend to be stuck in conflict without resolution because of their own endlessly adversarial thinking.


3.  Stigma and Discrimination

The goals for educating professionals about personality disorders are quite different from those for educating the general public. By educating professionals, the goal is to be more effective at working with these clients rather than avoiding them, which results in less stigma and discrimination. In educating the public, the goals are to teach such people methods of managing their relationships more effectively with difficult people and also learning how to avoid becoming someone’s target of blame—possibly by limiting engagement with these individuals.

The reality is that their dysfunctional interpersonal behavior already draws attention to them. Most people in relationships with PDs have a fear or caution about how to interact with them and are already “walking on eggshells.” With Cluster B, as described above, their behavior tends to be dramatic, emotional, or erratic, and domineering, vindictive, and intrusive. Many people already avoid them because of these social impairments.


Professional Education

Today’s education of professionals about personality disorders helps them to avoid shying away from working with them and to be more effective in this work. Without this knowledge, many professionals have already been avoiding clients with PDs on their own, as the following example demonstrates:

At one of my trainings a lawyer came up to me during the break. She said: “I took one of your trainings a year ago and learned that I could handle cases that I previously avoided. Right after your training, I went back to my office and pulled a letter out of the outgoing mail. I had written that I was going to terminate this client because she was so difficult. Instead, I kept working with the client and last week we successfully settled her case!”

With greater understanding and training, professionals gain confidence and methods that reduce stress and help their clients to be more successful—and easier to work with.

Likewise, by adopting more effective mediation approaches, mediators can help clients participate more effectively and reach durable agreements, rather than having their mediations blow up and clients walk out. While many people in mediation can become able to talk about their interests, discuss the past, have insights about their own behavior, and process difficult emotions, those with personality disorders tend to become emotionally overwhelmed with those approaches. Instead, they tend to be much more successful when mediators focus them on narrow problem-solving thinking activities in the present which help them steer clear of self-sabotaging emotional reactions.

With professionals, the question of screening comes up, such as screening for domestic violence before conducting a family mediation for divorce or child custody issues. What is important here is that mediators are screening for behavior, not for the presence of a personality disorder or other mental illness. Based on the specific history of aggressive or violent behavior, a mediation may be adapted to fit the situation (such as separate rooms, virtual mediation, presence of lawyers) or not conducted at all.

It’s not unusual to hear that some experienced lawyers and mental health professionals already attempt to screen out “difficult” clients at the start of a case (such as the example above), but we discourage that and instead encourage learning how to effectively manage such clients. If experienced professionals do not take their cases, then they will often end up with new professionals who are ill-prepared to manage such clients while also learning their new profession. Education about the dynamics of personality disorders can usually make a huge difference in helping all professionals manage their cases effectively even with clients with likely high conflict or difficult behavior.


Educating the Public

Education of the general public is also in the interest of people with personality disorders, just as it has been for those with alcoholism and other addictions. People become more compassionate when they understand that a person with a PD may not have self-awareness of their challenging or aggressive behavior. Those around them, such as friends, family and co-workers often wonder if they have done something wrong. Family members and supervisors may wonder if they can fix the person. It helps to learn that personalities develop in childhood as a result of heredity, early childhood experiences, and the behavior modeled by the larger culture the child grows up in— none of which a child has control over. This can help build empathy for someone with a PD. But it is understandable that it is not always possible to have compassion when one is trying to figure out how to protect oneself from someone else’s aggressive behavior.

It is important to acknowledge that the reason that people tend to avoid individuals with PDs is because of their behavior, not because of a diagnosis of a mental illness, which they probably are not even aware of. For those on the receiving end of dysfunctional interpersonal behavior, it can be quite distressing and confusing.

Of course, people are responsible for their own behavior. Awareness in the general public about personality disorders may motivate some with possible PDs to get help for themselves. We have had people contact High Conflict Institute asking for help in overcoming some of their own extreme behaviors in order to preserve a job or close relationship. However, so far this is uncommon as it generally takes negative consequences to motivate change, just as in motivating people with alcoholism or other addictions. Then it takes a program of change, such as a year or more of DBT, if change is even possible.


High Conflict Personalities

It’s important in educating the public (and professionals) to know that not all people with personality disorders have Cluster B behavior that is potentially domineering, vindictive, and intrusive. In fact, not everyone in Cluster B even has those behaviors. For example, some people with borderline personality disorder just blame themselves; some of those with narcissistic personality disorder are simply self-centered without targets of blame; and some people with antisocial personality disorder just engage in financial scams without blaming any individual.

When interacting with people with personality disorders it’s more effective to focus on behavior rather than on a mental health diagnosis. About half of those with personality disorders appear to have a high conflict pattern of behavior that includes: 1) a preoccupation with targets of blame; 2) a lot of all-or-nothing thinking; 3) unmanaged emotions; and 4) extreme behaviors. If this pattern is seen as repeating a lot, it indicates that they have high conflict personalities. This term is helpful as a term of art and avoids the need for anyone to diagnose others in a conflict, as it describes behavior, rather than labeling the person, and is not a diagnosis in the DSM-5-TR. The goal is to find the best balance between respecting those with high conflict personalities while protecting those around them from their high conflict behavior.

It is also important to note that not all people with high conflict personalities have personality disorders. Some have more flexibility and some ability to engage in self-awareness, rather than an enduring pattern of dysfunctional behavior. These are important points taught in all of the trainings of High Conflict Institute.


Avoid Unnecessary Labeling

There is a wide range of severity of behavior for those with personality disorders and high conflict personalities, so publicly using these labels isn’t really helpful. Saying “You’re a narcissist” or “You’re a high conflict person” may be intended to motivate the person to behave better, but it actually makes things worse. It triggers defensiveness and can unnecessarily lead to stigmatization and discrimination. We strongly discourage that. What is more important is to understand the specific behaviors and patterns of behavior that the person has.

For example, in a family court case regarding child custody, it can help to explain to a judge that a parent has a long-standing pattern of yelling and throwing things at the children or repeatedly lies to healthcare professionals about the child’s healthcare needs. Perhaps that parent has borderline or narcissistic or antisocial or histrionic personality disorder, but what is most effective is describing these specific patterns of behavior and what decisions are necessary to protect the child in a shared parenting situation.

Likewise, in the workplace when there is a difficult employee it is more helpful to identify what their specific behavioral difficulties are. For example, if a middle level manager displays frequent arrogance and demeaning comments in their emails toward their employees, it can help to have them get some coaching in writing emails, such as using our BIFF Communication™ method. If their behavior improves with this coaching, then it may be possible to retain the manager.

However, if you think it would be helpful, you can develop your own private working theory about the person’s pattern of behavior so you can adapt your own behavior to be more effective. For example, if you think that the person has a borderline personality (whether disorder or just traits doesn’t really matter), then you might emphasize having empathy and clear boundaries for the person. If you think they have a narcissist personality, then you might focus on using words that show respect, avoid insulting them even if they insult you, and emphasize setting limits by explaining policies so they don’t feel you are personally criticizing them.

You can keep all of these thoughts private and remain open to the possibility that your theory may be wrong. If necessary, you may discuss your private working theory with a team of people—such as in a law office or doctor’s office—so long as the goal is to help the person.


4. Training with High Conflict Institute

Over the past fifteen years, we estimate that our trainers with High Conflict Institute have taught our knowledge and methods to approximately 250,000 professionals. This includes live trainings in person and on Zoom in 40 states and 15 countries, and On Demand trainings on our website. Yet this is a drop in the bucket for what society needs at this time. As we have experienced a significant increase in demand for our trainings, we are adding more speakers and more On Demand trainings for professionals and more self-directed classes for the general public. The following are some of our key trainings to help as many professionals as possible and ordinary people understand what is happening to them in their work, relationships, and legal disputes, and what they can do about it.

Trainings for Professionals

New Ways for Families® – Counseling and Coaching

We provide 12-hour training for professionals in these two skills-training methods to assist parents in potentially high conflict separation and divorce cases. We license counselors to use our method which includes six individual counseling sessions and three parent-child counseling sessions. We license coaches (counselors, lawyers, mediators, and parent educators) to work with our online class (12 self-directed units) in three coaching sessions.

New Ways for MediationGeneral and Family

We provide 12-hour training in our breakthrough method of mediation with potentially high conflict clients, based on our book Mediating High Conflict Disputes.

New Ways for Work™ Coaching

We provide 12-hour training in this workplace coaching method designed for employees who are potentially having difficulty at work or want to strengthen their conflict resolution skills. This is based on our New Ways for Work Coaching Workbook and Manual.

Certification Training

We offer two certification trainings for professionals who wish to apply our knowledge and methods in many settings:

Certification: Conflict Influencer™

This 10-hour certification training is applicable for professionals to be a positive conflict influencer in their workplace, educational setting, organizational administration, and other settings. This includes 8 hours of self-directed pre-recorded training and 2 hours of live lab with a coach to practice these special skills, which is a unique feature of our trainings.

Certification: High Conflict Legal Dispute Resolver

This 10-hour certification training is applicable for lawyers and other legal professionals who want to be a legal dispute resolver in their practice. 8 hours of self-directed pre-recorded training and 2 hours of live lab with a coach to practice the special skills offered, which is a unique feature of our trainings. (This training is focused on litigation and negotiation. For mediation training see New Ways for Mediation above.)

Continuing Legal Education Courses

See numerous On-Demand courses ranging in length from 1-12 hours, which qualify for California MCLE credits and other states which recognize these, including:

  • Understanding and Managing High Conflict People in Legal Disputes (3 hours)

  • Dealing with High Conflict People in Family Law Cases (7 hours)

  • Conversations on Domestic Violence in Family Law with 16 Experts (6 hours)

  • Personality Disordered Parents and Alienated Children (3 hours)

Live Lab

A creative lab experience with our Live Lab Coaches for learning Conflict Communication Skills, such as BIFF Response and EAR Statements.

For General Public

  • See our website for on-demand courses at Conflict Playbook

  • See our coaching and consultation options here

  • Inquire about the Live Lab here


Conclusion

This article has been a call to recognize that personality disorders are as big of a public health problem as alcoholism and other addictions. PDs are interpersonal disorders which mostly do not change. Yet they continue to be misunderstood and treated as a taboo subject, while ruining the lives of many of those who have these disorders, those close to them, those professionals who work with them, and society at large. These are not dramatic terms, but rather a description of the reality of our modern world. Understanding personality disorders helps explain many of today’s problems, from domestic violence and child abuse to workplace harassment and sexual assault, and other social problems.

PDs cause many more people problems than just the person with the disorder, so that educating professionals and the general public is necessary to successfully manage these problems. Not all people with personality disorders cause others significant distress. The difficulties come primarily with those who also have high conflict personalities who are preoccupied with blaming others. Therefore, we must have compassion for those with personality disorders while also educating as many people as possible in order to protect them from becoming targets of blame. PDs are at least 10 percent of the adult population. All professionals who work with people and the general public need to learn about these disorders. We can no longer ignore this new elephant in the room—and everywhere in the world.

 

[1] Jonathan Segal, “Elephant in the Living Room,” HR Magazine, March 1, 2012. Retrieved on December 28, 2022, from: https://www.shrm.org/hr-today/news/hr-magazine/pages/0312legal.aspx

[2] American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022, 734. (Hereafter DSM-5-TR)

[3] Sylvia Wilson, Catherine B. Stroud, and C. Emily Durbin, “Interpersonal Dysfunction in Personality Disorders: A Meta-Analytic Review,” Psychology Bulletin, July 2017; 143(7): 677-734. doi: 10.1037/bul0000101.

[4] Beck, Aaron, Cognitive Therapy for Personality Disorders, (New York: Guilford Press, 1990), 5-6.

[5] DSM-5-TR, at 734.

[6] US v Mitchell (2010), 706 F. Supp. 2d, 1148, 1227.

[7] Brown v R 62 VR 491 (Victoria, Australia)

[8] Bill Eddy, High Conflict People in Legal Disputes, 2nd Ed. (Scottsdale, AZ: Unhooked Books, 2015).

[9] Wilson, “Interpersonal Dysfunction,” 20.

[10] Turid Suzanne Berg-Nielsen and Lars Wichstrom, “The mental health of preschoolers in a Norwegian population-based study when their parents have symptoms of borderline, antisocial, and narcissistic personality disorders: at the mercy of unpredictability.” Child & Adolescent Psychiatry & Mental Health. 2012; 6:19. doi: 10.1186/1753-2000-6-19, pp. 18-19 of 24.

[11] Id. at 19.

[12] Bridget Grant, et al. “Prevalence, correlates, and disability of personality disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.” Journal of Clinical Psychiatry 65 (7): 948–58, 948-949.

[13] Berg-Nielsen, “The Mental Health,” 2.

[14] Janet R. Johnston and Linda E. G. Campbell, Impasses of Divorce: The Dynamics and Resolution of Family Conflict (New York, NY: Simon & Schuster, 1988), 119-120.

[15] Rhoda Feinberg and James Tom Greene, “The Intractable Client: Guidelines for Working with Personality Disorders in Family Law,” Family and Conciliation Courts Review, Vol. 35 No. 3, July 1997, 351-365, 352.

[16] Esther Rosenfeld, et al, “Confronting the Challenge of the High-Conflict Personality in Family Court,” Family Law Quarterly, Vol. 52, No. 1 & 2, Spring/Summer 2019, 79-118.

[17] Id. at 85.

[18] Alan A. Cavaiola and Neil J. Lavender, Toxic Coworkers: How to Deal with Dysfunctional People on the Job (Oakland, CA: New Harbinger Press, 2000), 3.

[19] Id. at 11.

[20] Toxic Workers – Working Paper No. 16-057 (Harvard Business School, 2015 – available from the authors Michael Houseman and Dylan Minor).

[21] Bill Eddy and L. Georgi DiStefano, It’s All Your Fault at Work: Managing Narcissists and Other High-Conflict People, (Scottsdale, AZ: Unhooked Books, 2015).

[22] Id. on back cover.

[23] Bill Eddy, “Chapter 8: Dealing with Difficult Parties,” Mediation Ethics: A Practitioner’s Guide (Chicago, IL: American Bar Association, 2021), 115-127, 116-117.

 

Bill Eddy headshotBILL EDDY, LCSW, ESQ. is the co-founder and Chief Innovation Officer of the High Conflict Institute in San Diego, California. He pioneered the High Conflict Personality Theory (HCP) and is viewed globally as the leading expert on managing disputes involving people with high-conflict personalities. He has written more than twenty books on the topic, developed methods for managing high-conflict disputes, and has taught professionals in the U.S. and more than ten countries. He is also co-host of the popular podcast, It’s All Your Fault, and writes a popular blog on Psychology Today.

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