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in accordance with social norms. And in his time, one would expect there to be a whole lot of neurosis. The Victorian era was one of the most sexually and socially repressive times in modern history. If there were a motto or slogan that would best typify the “zeitgeist” or sociocultural milieu of the time, it would be: Don't even think about it! And the patients Freud worked with suffered from all sorts of bizarre maladies that were fueled not by physiological disease but by the anxiety (and inadequate “defenses” against the anxiety) associated with the frustration and stifling of their baser instincts. These folks were literally overly conscientious and deeply repressed “nervous wrecks.” And neurosis, in one degree or another, was the defining psychological phenomenon of the era. Unfortunately Freud generalized his findings to an absurd extreme, thinking he'd discovered universal laws for human psychological functioning.
16.2 Neurosis versus Pathology: A Continuum
Whether you choose a specialty area like psychiatry where understanding and appropriately intervening with character disturbance is essential or go into family practice where you simply must take into account psychological health issues in order to provide sound overall medical intervention, you must keep in the forefront of your mind that we live in a vastly different age. The dominant sociocultural milieu is not one of massive repression but one of permissiveness and narcissistic indulgence and entitlement. If there were a motto best describing the times, it would be much like one heard in an old commercial: “Just do it!” For this reason, our populace is not as much teeming with “nervous wrecks” as it is liberally dotted with folks of impaired character. There are still neurotics among us, to be sure. But most neurosis these days is at a level most of us would consider functional. That is, the neurotics among us generally experience just enough compunction with respect to their primal urges that they make civilized life possible. By and large, the neurotics among us are functioning reasonably well (i.e. they're not suffering from the extreme and debilitating symptoms Freud's patients were) themselves and holding up society at the same time. You'll encounter neurosis, no doubt, but you'll more often encounter folks whose problems stem not so much from their neurotic conflicts but from their character deficiencies.
In Character Disturbance, I conceptualize a continuum of psychological adjustment with pure “neurosis” lying at one end of the spectrum and “character pathology” lying at the other end. Most folks fall somewhere along this continuum. And those whose problems arise mostly out of their character deficiencies are vastly different from their more “neurotic” counterparts on just about every dimension of interpersonal functioning you can imagine. This is extremely important to remember in your professional work.
In my years of private practice, I provided services to both folks who would rightfully be considered the “victims” in abusive, manipulative relationships as well as those character‐deficient and responsibility‐challenged individuals who were largely responsible for all the problems. And I quickly came to appreciate how destructive our traditional yet still dominant models of understanding human behavior really are. Victims, you see, spend a lot of time and energy desperately trying to figure out why the disordered person in their lives behaves in a manner they view as so irrational. Sometimes, they start to question their own sanity, because what their gut tells them about their manipulator goes against the popular psychology with which they are familiar. If, for example, they viewed their serial philandering spouse as “an insecure person underneath, struggling with low self‐esteem, needy of affirmation, and fearful of commitment,” they might be more likely to endure the situation, blame themselves in part for it, and strive to better understand as opposed to merely setting firm limits. But if they allowed themselves to believe what they'd always suspected in their gut – that their partner was a self‐indulgent, entitled, ravenous sensation‐seeker devoid of both the emotional maturity and the level of conscience to really love someone and not only knew it and didn't care to boot – it would be a whole different story. So, when a professional like myself finally gave them permission to trust their instincts, a whole new world opened up for them. And for that alone most were eternally grateful.
Working with neurotics is relatively easy, you see. Show trustworthiness, build positive expectations, and give them a safe place to work through issues, and all is good. Disturbed and disordered characters are an entirely different matter. They're harder to work with by nature and traditional approaches to understanding and intervening with them are virtually useless. As difficult as they are, you can work with them, especially if you're willing to adopt a radically different approach. I mentioned before that neurotics and disturbed characters are different on just about every dimension you can think of. Some of the dimensions on which the two groups differ most strikingly include the following:
Anxiety. Anxiety is like fear except it's not attached to any identifiable source. When it is, we call it a phobia. And when someone is riddled with it, almost anyone with a decent degree of sensitivity can detect it. The symptoms neurotics report and the signs they display with regard to their psychological problems are fueled by anxiety. By and large, neurotics are an overly anxious bunch; their anxiety is inadequately relieved by the defense mechanisms they employ to manage it. It's their anxiety that makes them sick. In contrast, disturbed and disordered characters are not only generally lacking in anxiety but also some even lack the kind and degree of anxiety that would be adaptive. That is, they don't experience enough internal disquiet when contemplating the actions that get them into trouble. If they had even a little of the neurotic's typical apprehension, their lives would not be such a shipwreck.
Conscience. Neurotics are generally conscientious types who have well‐developed consciences, and perhaps even overly active, oppressive consciences. That's in large measure what fuels their anxiety. Disturbed characters, on the other hand, are lacking in conscience development and maturity. They're not conscientious enough to function responsibly. And in the case of extreme character pathology (e.g. psychopathy), any semblance of what most of us would consider a conscience can be absent altogether.
Shame and guilt sensitivity. Having intact consciences, neurotics generally avoid doing things they'll feel badly about or suffer pangs of guilt or feel a sense of shame when they fall short of their internal moral standard. By contrast, disturbed characters don't have much sensitivity to guilt or shame. And they're well aware that their neurotic counterparts are very different from them, which is why “guilting” and “shaming” work so well as manipulation tactics (they only work, however, on neurotics).
Level of awareness. Freud was right when it comes to neurotics. Most of the time, they're completely unaware of the conflicts raging inside of them because their unconsciously employed “defense mechanisms” keep the emotional realities behind those conflicts out of their conscious awareness. Disturbed characters have disturbing behavior patterns to be sure, but they generally know what they're doing and why. As I like to say in workshops: “It's not that they don't see (that what they're doing is socially disdained), it's that they disagree” (with what they know are society's generally accepted expectations). Many a clinician has wasted hours of precious time and energy laboring under the delusion that if they could just get a person to “see” the error of his ways, he'd change for the better. When it comes to a disturbed character's irresponsible behavior, it's not a matter of awareness but a matter of acceptance of and acquiescence to society's legitimate expectations.
Role of feelings. The internal conflicts with which neurotics struggle are emotional in nature and most often involve feelings that have been repressed. Sorting out and working through these feelings is a principal focus of good psychotherapy. But when it comes to disturbed characters, while their feelings may be of some concern, the much bigger issue (and the reason for all the problems they have in their interpersonal relations) is the way they think about things. It's the attitudes they hold, their core beliefs about the world and how to get along in it, etc. and the problematic behaviors in which they habitually engage that are predisposed by those dysfunctional attitudes, beliefs, and ways of thinking that need to be focused on when interventions are tried.
Nature and level of discomfort. Neurotics by and large are distressed by the symptoms of their neurosis. They aren't comfortable with themselves in their unhappiness and not only seek help on their own but also tend to