Caring for Christians with Personality Disorders
ABSTRACT: About one in ten people suffers from a personality disorder, a deeply ingrained, long-standing dysfunction that forms part of the structure of someone’s personality. Although people with personality disorders often struggle to find long-term healing, the gospel of Jesus Christ, communicated by skilled counselors and patient friends, provides unique therapeutic resources that can, over time, bind up the most broken personalities.
We’ve all known people with a personality disorder. We just didn’t have a label for it.1
Ted acts like a know-it-all. He subtly informs others about his accomplishments, and he presents to the world an image of success, happiness, and confidence. But as we get to know him better, we sense a deep underlying insecurity and a strong hunger for admiration and affection.
Cindy always seems to be in a conflict with somebody at work. Although strongly opinionated and boisterous, she easily gets flustered and starts to cry when others push back. At these times, she often can be heard quietly saying to herself something like, “You’re such a jerk!”
Matt is 33 years old and has lived with his mother since graduating from college, shortly after his father died. He has a part-time job at the grocery store, but he rarely leaves the house otherwise, and he has no friends because he is devoted full time to caring for his widowed mother.
Charlotte is quiet at work most of the time, and shows almost no emotion. When she speaks, her comments don’t always correspond to what others are talking about. When others are not around, she often seems to be daydreaming. When she gets home from work, she watches television continuously until it’s time for bed.
Compared to most people, individuals like these have significant difficulties in life, but they are not so troubled that they require hospitalization. As some of the examples indicate, most have jobs, but their performance is often substandard; most also have some relationships, though typically of poor quality.
Such people are characterized by a deep and pronounced disorderedness in many core areas of their functioning: a negative sense of self, conflicted relationships, unbearable negative emotions, strong defenses, irrational thinking, and a lack of impulse control. As a result, they may exhibit inexplicable behaviors, rigidity in the way they do things, unsubstantiated beliefs about others, and unpredictable shifts in their emotions. These patterns of human dysfunction began to be identified only in the early twentieth century, and eventually they were given the label of personality disorders.
Are Psychological Diagnoses Even Valid?
Before we discuss personality disorders in more detail, it might be helpful to address the diagnosis of psychological disorders in general, since some Christians are quite skeptical of such diagnoses. The reasons for their skepticism are complex and varied. Some Christians are wary of the human sciences because they are dominated by secularism and naturalism. Some are bothered by the fact that a psychological diagnosis currently requires a fair amount of training and clinical skill, rather than being amenable to more objective assessment, like a blood test. Though genetic and brain-scan technology has made progress in detecting the genetic precursors and neurological markers of various kinds of psychopathology, we are still a long way from being able to determine a specific psychological disorder by such means.
Another concern is that the secular assumptions underlying the Diagnostic and Statistical Manual of Mental Disorders (DSM), the primary classification guide for psychiatrists, will overrule and undermine biblical truth in our thinking about psychopathology, and lead Christians to excuse their sin, rather than take responsibility for it. Furthermore, some worry that the increasing number of such disorders over the decades (currently over two hundred in the DSM-5), combined with increasing numbers of people diagnosed, is creating a massive problem of over-diagnosing psychological disorders, from depression to attention-deficit disorder.
Finally, the most important reason that some resist contemporary diagnostic categories is that very few contemporary disorders are referred to in the Bible. For those who believe that the sufficiency of Scripture entails that the Bible addresses everything of consequence in human life, extrabiblical categories of psychopathology are unnecessary, if not entirely invalid. Consequently, a number of well-meaning, conscientious Christians view the contemporary diagnosis of psychological disorders with significant suspicion.
Lord of the Sciences
The Christian community certainly needs to interpret carefully the secular diagnostic system from a biblical standpoint. But we should avoid the reaction of rejecting it entirely. Humans are more complex than any other creature in this world, so the human sciences, including the diagnosis of psychological disorders, are necessarily complex. The conclusions of the human sciences, therefore, are more contestable and ambiguous than those of the natural sciences, requiring more interpretation than simple observation or measurement can yield.
God gave us the Bible, in part, to provide the first principles of human life — the most important truths concerning God, human beings, and salvation — themes we need to live according to his will (that is, according to his “design plan” for us). As a result, the Bible is the most valuable source of knowledge for a Christian version of any of the human sciences, an affirmation that has been termed the primacy of Scripture.2 At the same time, God clearly did not intend the Bible to be an all-sufficient scientific text. The Bible includes many genres, but God did not communicate any of his word using scientific discourse. We can thank him for that, because most humans throughout history could not have understood those parts of the Bible if he had!
Nevertheless, the omniscient Lord of creation is also the Lord of the sciences, even the most difficult ones. He who knows all things knows more about human nature and its disorders than he chose to reveal in the Bible. So we might conclude that he wants humanity to develop the sciences as part of the creation mandate (Genesis 1:26–28), in dependence on his common (or creation) grace, but basing the endeavor on the truths of the Bible. Why he made the scientific project as challenging as he did is his concern, but it is no threat to the salvific sufficiency of Scripture if we seek as much of God’s total understanding of human beings as we can.3 Indeed, that pursuit magnifies his glory all the more, so long as we use the Scriptures as our “spectacles,” as Calvin put it,4 interpreting everything in light of his scriptural revelation and incorporating its relevant content into our sciences.
If Christians have a model of the human sciences that is based on a biblical worldview, but open to all that God knows about humans and wisely critical of what secular models leave out, as well as their distortions, they should be able to develop the most comprehensive understanding of human beings possible on earth. This in turn should increase our capacity to care well for those with complex problems in ways faithful both to a biblical view of human nature as well as to the nature of their condition. That, at least, is my goal in this essay with respect to personality disorders.
What Is a Personality Disorder?
Personality is a relatively enduring, overall pattern of thinking, feeling, acting, and interacting with others that enables humans to adapt flexibly to changes in their environment, engage effectively in activities that attain fulfilling goals and accomplish life tasks, and cultivate meaningful relationships with others, including God. According to the second edition of the Psychodynamic Diagnostic Manual (PDM-2), a manual developed by the secular psychodynamic community, a personality disorder (PD) is present when people experience “difficulties with [emotion] regulation and are consequently vulnerable to extremes of overwhelming [emotion], including episodes of intense depression, anxiety, and rage; . . . recurrent relational difficulties; severe problems with emotional intimacy; problems with work; and problems with impulse regulation,” the last of which is seen in substance abuse and other addictive behaviors.5 It is estimated that about ten percent of the American population has a PD,6 and if churches are representative of America in general, that would mean that there are roughly ten people with a PD in every church of one hundred people. Think about that for a moment.
Between Reality and Illusion
According to the criteria for psychopathology developed by the psychodynamic community, there are four levels of human functioning: normal/healthy, neurotic, borderline, and psychotic.7 The healthiest among us live most of the time in the normal range. Those with mild symptoms of distress and dysfunction spend most of their time in the neurotic range, those with moderate levels of distress and dysfunction function within the borderline range, and those with the most severe kinds of symptoms (like those linked with schizophrenia) lie within the psychotic range. We bring up this helpful framework because people with a personality disorder often fit within the borderline level of functioning. The term itself is significant, because it suggests such individuals live on the border between reality and illusion (or psychosis).
Those with personality disorders, then, often misperceive and misinterpret God, themselves, others, and their circumstances, in part because their interpretive equipment (their perceptions, thinking, emotions, attitudes, and interactional styles) were shaped in family settings that were themselves conflicted and distorted. As a result, early on they developed patterns of coping and relating to others that would quickly reduce their pain and negative emotions as well as relational conflict. However, while these patterns may have served to protect them in the settings in which they developed, they are rigid and usually operate automatically, outside one’s awareness, making it difficult to engage accurately and flexibly with present reality, so they tend to cause problems in adulthood.
Consider Michael, whose father abandoned the family when he was a young teenager, so he had to become the head of the household, learning to become forceful and directive with his siblings, as well as a source of strength for his depressed mother. As a result, he became a leader in school, and later in work, but he never developed compassion or empathy for others, in part because he had no models for such capacities. Later, he became a harsh and unyielding husband and father, who often hurt his wife and children with his stern words and critical tone, which they later described as “mean, insensitive, punitive, and selfish.”
Conflict Inside and Out
People with a PD, Christians included, are in a relatively constant state of internal conflict. Sometimes, the conflict is obvious, as in cases of borderline PD; sometimes, it is masked, as with some versions of narcissistic PD. Typically, the lives of such brothers and sisters are hard, their relationships are difficult, and the prognosis for their getting better is not very high.
It is a truism in the counseling field that people with a PD are difficult to work with. It is sadly common, but somewhat understandable, to hear therapists talk disparagingly of folks with a personality disorder. Because these people are often so difficult for the counselor to deal with and change is so slow, some counselors doubt whether people with a personality disorder can change at all. In addition, the severely compromised relational style of some PDs — like avoidant, paranoid, and antisocial PD — explain why they are rarely seen in the therapist’s office to get help. Tragically, certain features of PDs make them particularly resistant to healing: a high level of defensiveness, lack of self-awareness, fear of others, self-loathing. By most standards, humanly speaking, those with a PD are poor candidates for counseling.
Before moving on, we should point out that someone may have tendencies towards a PD that are relatively less problematic. Such tendencies are called a style, and while problematic, they are not considered a full-blown form of psychopathology.8
Kinds of Personality Disorders
In the DSM-5, the major diagnostic system in North America, PDs are organized into three clusters. Cluster A includes paranoid, schizoid, and schizotypal PDs. Those with paranoid PD find it difficult to trust others, and are prone to sense that others are plotting against them. They read hostility into innocent remarks and may entertain conspiracy theories. People with schizoid PD just want to be left alone, and others experience them as aloof, awkward, and nonemotional. Schizotypal PD shares some similarities with schizophrenia — loose associations in speech and thought, puzzling behavior, and inappropriate emotion (including no emotion) — but without hallucinations and delusions. Many of those with Cluster A PDs come from families that are more likely than average to have such PDs as well as full-blown schizophrenia. There are strong biological influences, and medication can sometimes help.
Antisocial, borderline, histrionic, and narcissistic PDs make up Cluster B. People diagnosed with antisocial PD appear to lack a conscience. They can be ruthless, reckless, and manipulative, and in some cases are prone to aggressive behavior. Roughly three-fourths of those incarcerated in America have this disorder, and the prognosis is poor.9 Those with borderline PD have intense and difficult relationships characterized by cycles of fierce fighting followed by sorrowful and frantic recoveries. Impulsive, they view themselves negatively, a self-evaluation sometimes manifested in self-mutilation and suicide attempts (and ten percent are successful).10 People who have histrionic PD are highly emotional and refer to and seek reassurance about their attractiveness or value, sometimes acting seductively to prove their desirability or worth. Narcissistic PD manifests as excessive self-importance, a lack of empathy, and the pursuit of admiration, often resulting in disappointment, exacerbated by a sense of fraudulence and unworthiness. Many in this cluster have been found to have histories of significant developmental trauma (e.g., physical or sexual abuse, abandonment, poverty, neglect) that helps explain their relational and emotion regulation difficulties.
The Cluster C PDs are avoidant, dependent, and obsessive-compulsive. People diagnosed with avoidant PD feel very inferior to others, and are therefore severely uncomfortable in social settings and extremely sensitive to criticism. Those with dependent PD feel terribly unworthy, so they cling to others, whom they need to make decisions and take responsibility (and therefore can blame when things go wrong). They are followers who are inclined to serve. Those with obsessive-compulsive PD are perfectionists and rigid in their behavior; they can be hoarders or stingy, and others experience them as controlling. Those in this cluster often grew up in families where there was a lot of chaos, anxiety, long-term intergenerational depression, and unpredictable or explosive caregivers, sometimes called “compromised containing or holding environments,” which can help explain their counterproductive stance towards others.
Many people have a few of the above symptoms (which helps explain why students studying PDs often conclude they must have one). What distinguishes a full-blown PD is that these patterns are long-standing, deeply ingrained, and often rigid and unyielding, forming part of the structure of their personality. We might consider a PD to be a malformed personality that, as noted above, originally developed as a set of protective responses to difficult family settings — patterns that are not helpful in adulthood because they distort perceptions of present reality, including God, self, and others. We should also point out that people often have features of more than one PD. Christians will identify some of the above ways of living and relating as sinful, and this leads us to a more explicitly Christian interpretation.
A Holistic Christian Analysis
Because the Bible gives us the first principles of human life, we need it to get as close as possible to God’s understanding of problems like PDs, as well as their remediation, and distinguish a Christian approach, in some key respects, from that of modern psychiatry and psychology, which are based on the worldview of naturalism. The Bible gives us three perspectives on matters related to psychopathology: sin, suffering, and weakness.11
Sin, Suffering, and Weakness
Scripture obviously refers to sin the most. Though created for God, humans now are characterized by a fundamental opposition to God at the core of their being, which contaminates everything they do. Theologians have termed this orientation original sin, with which all humans are now born (Psalm 51:5; Romans 3:11–18; 7:11–25). As a result of this tendency, humans commit various kinds of personal sins — actions of thought, speech, or other behavior that violate God’s design plan for human life and signify that their desires and loves are disordered. Both original sin and personal sins constitute what we might call ethicospiritual psychopathology (ethical and spiritual disorder). Because sin alienates us from God and others, we should consider it the worst form of psychopathology. The work of Christ is the remedy for sin and sins, resolved in divine forgiveness, which is obtained through faith and repentance (Romans 3:21–26).
Suffering comes from many sources, including physical pain; deprivation; maltreatment, rejection, or neglect; and personal failure. Suffering can also be acute (short term) or chronic (long term), and negative (unpleasant) emotions are usually involved (e.g., sadness, anxiety, anger, shame, guilt). Suffering provides another perspective on psychopathology because it can contribute to the development of psychopathology. Biblical teaching on suffering, therefore, can help us better understand psychopathology and its spiritual transformation.
According to the book of Job, God allows suffering, in part, to test our devotion to him. Complementing the teaching of Proverbs, Job teaches us that suffering is not necessarily tied to personal sins. Indeed, children may suffer for a while before committing personal sins (Deuteronomy 1:39), as we have already suggested, while their psychological capacities are developing. At the same time, suffering can be a catalyst for virtue (Romans 5:3–5; Hebrews 5:8–9; James 1:2–4). The Psalms contain many expressions of suffering to God (see, e.g., Psalm 13; 22; 88), as do the Prophets (e.g., Jeremiah 8:18–22; 12:1–4), which theologians have termed lament. These passages encourage contemporary believers to take their suffering to God and “pour out your heart like water before the presence of the Lord” (Lamentations 2:19). Isaiah also reminds us that God is deeply touched by the suffering of his people: “In all their affliction he was afflicted” (Isaiah 63:9).
Weakness in the New Testament refers to a variety of deficient human conditions, including poverty (Acts 20:35) and biological limitations like illness and sleepiness (John 5:7; Matthew 26:41); compromised psychosocial functioning, like an unimpressive personal presence (2 Corinthians 10:10) and poor speaking abilities (2 Corinthians 11:6, 21); as well as spiritual deficits like religious scrupulosity (Romans 14:1–4). Conceptually, we are warranted in extending this rich biblical concept to any kind of biological or psychosocial damage — from genetic abnormality to many kinds of psychological malformation, including autism, PTSD due to combat, and emotion dysregulation that has resulted from chronic child abuse.
We learn from the Bible that God is especially concerned for those with weaknesses (Deuteronomy 24:19; Psalm 82:2–4), and the apostle Paul remarkably reframed weakness as a site where God’s glory can shine the brightest (1 Corinthians 1:27–31; 2 Corinthians 11:16–12:10), since it shows “that the surpassing power belongs to God and not to us” (2 Corinthians 4:7). He modeled boasting in weakness, knowing “that the power of Christ may rest upon me” (2 Corinthians 12:9), and he taught that its presence should affect our treatment of others: “Encourage the fainthearted, help the weak” (1 Thessalonians 5:14). We may infer, then, that Christianity promotes the care of those with biopsychosocial damage; accepting, even boasting about one’s damage; and interpreting it as a site where God can especially manifest his glory.
Healing in Three Dimensions
This three-dimensional approach to psychopathology provides a more comprehensive framework for understanding PDs than that provided by the reductionism of secular psychology or a moralistic focus on sin alone. Research, for example, has found that genetic vulnerability makes certain psychological liabilities found in PDs more likely to develop, triggered by exposure to severe suffering of various kinds (e.g., the trauma of abuse and neglect), particularly when encountered in childhood.12 As a result, we can safely assume that those with a PD have usually suffered a fair amount, from an early age, resulting in their specific biopsychosocial disabilities. Knowing this should dispose Christians to view those with a PD with compassion and care. Part of their Christian healing will likely involve lamenting to God and coming to terms with their suffering, past and present, as well as their biopsychosocial damage, and gradually learning to reinterpret it all as a story of glory, being woven into the drama of Christ and his life, death, and resurrection, as they are slowly being raised from the dead of their dysfunction, due to their union with Christ (Romans 8:1; Ephesians 1:3–11; Colossians 3:1–4).
As we have already noted, however, the specific kinds of damage seen in a PD can include poor self-awareness and self-regulation abilities, an elaborate defensive structure, a rigid relational style, and a poorly integrated self.13 Such liabilities undoubtedly contribute to the commission of personal sins and the formation of vices that have been woven into their character. As a result, PDs are best understood as a hybrid condition, composed of biopsychosocial weakness and ethicospiritual sinfulness termed fault.14 According to Paul Ricoeur, the term “fault” connotes personal responsibility (“It’s his fault”), compromised by deterministic influences (“A fault is a fracture in the earth’s crust”).15
The Bible refers to such hybrid conditions. Poverty, for example, is sometimes considered a consequence of irresponsible behavior (Proverbs 10:4), yet the poor are also to be cared for and their rights protected (Proverbs 19:17). Perhaps most relevant is that sin itself is referred to as a weakness (Hebrews 5:1–3). Personal responsibility as well as the impoverished biopsychosocial background due to early suffering need to be considered in the assessment, pastoral care, and treatment of those with a PD. When genetically vulnerable children suffer severely through poor parenting, their ethical and spiritual capacities in adulthood will be compromised. Rather than providing an excuse for sin, these influences help us understand why some people maintain rigid patterns of counterproductive behavior, that is sinful to a degree that only God knows.
Savior of the Broken
Part of counseling those with a PD involves sitting patiently with them, empathically connecting with their suffering, and addressing their formative experiences and their personal responses to them in light of Christ’s redemption, while helping them see that the coping mechanisms and defenses they developed in childhood are now getting in the way of their ability to receive the love of God and others in order to obtain the healing they need.
The sins and vices (sinful action tendencies) of those with a PD can be fairly obvious to others (especially the PDs of Cluster B: antisocial, narcissistic, histrionic, and borderline). It is perhaps natural, therefore, that healthier Christians tend to treat people with a PD like they treat themselves — hold them accountable, encourage them to choose the right course of action, and challenge them to repent when they sin — only to become frustrated with them when they fall back into their sinful patterns. In some such cases, church discipline may seem like the only recourse.
There are, of course, times when the misbehavior of those with a PD must be publicly addressed. Criminal activity, sexual aggression, and child maltreatment warrant a firm societal and ecclesial response. At the same time, we must never lose sight of the image of God in all people and our familial relation with other Christians, no matter how terrible their behavior. A holistic Christian framework allows for a multilayered approach to the care of souls with a PD. This entails rejecting the common tendency to look down on them. We all have original sin, so everyone falls short of God’s perfect standards in their heart (Romans 3:10–23).
Moreover, Christ taught us, “Blessed are the poor in spirit, for theirs is the kingdom of heaven” (Matthew 5:3). He also came as a physician to those who were sick (Luke 5:31–32), and he associated with the most sinful and broken in his culture — undoubtedly, many of them with a PD. Most importantly, we must never forget that it was the Pharisees who sought Christ’s crucifixion, not the most obvious sinners. The central place of the Pharisees in the Gospel narratives teaches us that the healthiest among us are those who are the quickest to see and acknowledge their own sins and limitations, and who are the most compassionate toward the least healthy.
Care for Those with Personality Disorders
We have already noted that the prognosis of those with a PD is relatively poor, particularly when compared with depression and anxiety, for example.16 Strong defenses, a harsh moral sense (whether conscious or unconscious), relational fear, and a high degree of shame tend to make it unusually difficult for those with a PD to identify, own, and address their sinfulness, suffering, and weaknesses.17
Peace with God and Others
The gospel of Jesus Christ provides unique therapeutic resources that in principle can help this process immeasurably. To begin with, in Christ all of our sin — original, personal, and vicious, including its shame and guilt — was resolved and absolved by God on the cross. Christ was also “crucified in weakness” (2 Corinthians 13:4), and his life and death show us that God willingly entered into solidarity with us in our suffering and human vulnerabilities. All believers — including those with a PD — can therefore appropriate more deeply and healingly their forgiveness and perfection in Christ (Romans 5:1; 8:1; 2 Corinthians 5:21), knowing they are co-sufferers with Christ (Romans 8:17) and personally accepted and beloved by God in him (Romans 8:1, 31–39; Ephesians 1:5–6; 3:17–21).
People with a PD can also learn how to commune better with God in prayer, Bible reading, and meditation, as well as commune with others, perhaps particularly those especially trained to work with PDs. Ideally, the church would provide a safe place for those with a PD to grow in communion and experience concretely the compassion of Christ. A commitment to be such a church, however, will require great patience and the willingness of pastors and small group members to tolerate the volatile emotionality, stubborn defenses, and poor relational styles of those with a PD. Part of God’s treatment plan for those with a PD involves his people modeling his love, even with those who are unable right now to reciprocate.
By experiencing these accepting divine and human relational contexts, PD sufferers can learn to better tolerate and accept their conflicted internal world, process and regulate their negative emotions more productively, build a new self-understanding based on their union with Christ (Colossians 3:9–10; Ephesians 4:22–24), and cultivate improved relational skills and capacities. Confession and repentance are basic Christian counseling concepts that facilitate these tasks, since they involve self-awareness; acknowledgement and ownership of sinful thoughts, attitudes, and actions; and a turning away or disavowal of them, without denial or dissociation (the New Testament’s word for repentance, metanoia, literally means change of mind). In addition, Christians with a PD can grow in acceptance and surrender of their past and present suffering and weaknesses, mindful of Christ’s continual loving presence, to which they can return, again and again, without fear of rejection.
People with PDs will especially benefit from counseling designed to address their unique challenges. Generally, progress can occur only after a strong therapeutic bond has been formed between counselor and counselee, depending on the compassion and skill of the therapist, and even then, only when guided by the capacities and willingness of the counselee. A pastor or counselor who chooses to form such a bond with someone with a PD must be prepared for the counselee’s disruptive actions that may arise and threaten the relationship. Providing a “holding environment” for the person with a PD, through gentleness, kindness, and patience (2 Timothy 2:24–25), where both the conviction and comfort of the gospel can be artfully applied, can help foster the trust needed to sustain the therapy through difficult seasons.
Given the challenges facing people with a PD, we have to be realistic about the obstacles between them and significant healing in this life, but we can still be hopeful, given brain plasticity and Christ’s desire and power to heal. Though progress may be slow, we now know that, contrary to their reputation, people with a PD can gain some measure of healing when using the best secular models.18 We also have seen people with PDs get healing through gospel-based, Christ-centered relational therapy. Published research on distinctly Christian treatments for PD, though currently lacking, would revolutionize the field, help legitimate Christian therapy for insurance companies, and contribute to a Christian apologetic aimed at a scientized, therapized culture. Such investigations would publicly validate what believers already know: Jesus Christ is the great physician of souls, even of those with PDs.
Hospital for the Poor in Spirit
The church of Jesus Christ is the most important soul-care institution in the world. Along with its other major callings of worship, preaching and teaching the word of God, administering baptism and the Lord’s Supper, and doing evangelism and missions, the church is a hospital for the poor in spirit. The church is on the cutting edge of the Christian mental health system, ministering to the basic needs of its people and referring as needed. It is time that she become as holistic and sophisticated as she can be in her understanding of the disorders of the soul. In the past decade, we have seen a number of church leaders who fell into sexual sin or demonstrated poor leadership, for which they lost their positions. With a Christian understanding of PDs, we can make better sense of some of these situations and perhaps learn better how to handle them in the future. (It may also help us understand better the extremely polarized political culture of our day.)
What does it take to be a pastor who can grow a church? The strengths of people with some PDs may make them strong, charismatic leaders (e.g., those with a narcissistic PD), and for a time, others may follow and admire them. But the significant liabilities of such PDs eventually become evident. Sometimes dismissal is the only option — for example, in cases of sexual abuse (though even then the church can continue to minister wisely and compassionately to all parties). But it would be even better if we could figure out how to identify such people problems before they reach a state of crisis, and if we could help our brothers and sisters address their problems through appropriate counseling, perhaps relieving them of some of their responsibilities for a time, both so they get the help they need and to role model for the entire church that we really are committed to the entire body of Christ, no matter how troubled.
Every situation is different, and some become so relationally toxic that a parting of ways is necessary. (We recall that even Paul and Barnabas separated!) But understanding and accepting the category of PD might make it easier for churches and their leaders to talk about and work through such dynamics without stoning anyone. Churches with robust counseling ministries that combine biblical wisdom and clinical understanding will likely be the best equipped to help those members and attenders who have histories of trauma and the unique configuration of sin, suffering, and weakness, that we call a PD. Unfortunately, in most major cities today, it is still hard to find Christians trained to treat PDs from a Christ-centered standpoint that makes use of the best available science.
A special challenge is ministry to marriages where one or both partners have a PD. Helping spouses accept the weaknesses of their partner, as well as their own, can promote patience, self-control, and compassion. Holding the highest standards for Christian marriage requires us to recognize the difficulties involved in marriages that include a severe PD in one or both partners. At times, the church has to help people make hard decisions regarding the safety of a spouse or children, while also exercising charity toward those who make hard decisions that we may disagree with.
Safest Place on Earth
People with PDs should not be referred to by their diagnostic label: “She’s a borderline”; “Watch out for narcissists.” Such labeling is dehumanizing, alienating, and self-righteous. Perhaps our motto could be, “People with a personality disorder are still people,” and even better, “Saints with a personality disorder are still saints.” Moreover, the diagnosis of psychopathology is reserved in our culture for those with the training to do so. Suggesting that a brother or sister has a PD without the requisite training is surely poor manners, if not downright slanderous. Even if accurate, we are not honoring them as Christ among us: “As you did it to one of the least of these my brothers, you did it to me” (Matthew 25:40). The healthier and more mature God’s people become, the more they develop the capacity to be a container for the psychopathology and dysfunction of others. How amazing would it be if the church developed a reputation for being the holiest, happiest, and safest place on earth? There is a reason Jesus attracted broken sinners and repelled the “healthier” self-righteous.
Could you have a personality disorder? Though never diagnosed, I (Eric) am fairly certain I had narcissistic PD in early adulthood, at least to some degree, and that is still a sort of default orientation that characterizes my old self. Emotional lability, relational conflict, trauma in one’s family of origin, marriage problems, poor work history, or addictions may be indicators of a PD. If you recognized yourself in any of the above discussion, you might consider having a conversation with your local pastor or a skilled counselor. Just know that nothing can separate you from the love of Christ — not even a personality disorder.
I (Eric) am indebted to Warren Watson for providing insightful feedback and significantly shaping the content of parts of this essay. ↩
See Eric Johnson, “Properties of Scripture and Its Relation to Other Texts,” chap. 5 in Foundations for Soul Care: A Christian Psychology Proposal (Downers Grove, IL: IVP Academic, 2007). ↩
Johnson, Foundations for Soul Care, chap. 4. ↩
John Calvin, Institutes of the Christian Religion, ed. John T. McNeill, trans. Ford Lewis Battles (Philadelphia: Westminster Press, 1960), 1.6.1. ↩
Nancy McWilliams and Jonathan Shedler, “Personality Syndromes: P Axis,” in Psychodynamic Diagnostic Manual, ed. Vittorio Lingiardi and Nancy McWilliams, 2nd ed. (New York: Guilford Press, 2017), 21. ↩
Mark F. Lenzenweger, “Epidemiology of Personality Disorders,” Psychiatric Clinics of North America 31, no. 3 (September 2008): 395–403, https://doi.org/10.1016/j.psc.2008.03.003. ↩
McWilliams and Shedler, “Personality Syndromes,” 20–24. ↩
McWilliams and Shedler, “Personality Syndromes,” 17. ↩
James Morrison, DSM-5 Made Easy: The Clinician’s Guide to Diagnosis (New York: Guilford, 2014), 542. ↩
Allen Frances, Essentials of Psychiatric Diagnosis, rev. ed. (New York: Guilford, 2013), 131. ↩
For an extended discussion of these matters, see Eric Johnson, God and Soul Care: The Therapeutic Resources of the Christian Faith (Downers Grove, IL: InterVarsity, 2017), chapters 8–11. ↩
John F. Clarkin and Mark F. Lenzenweger, eds., Major Theories of Personality Disorder, 2nd ed. (New York: Guilford, 2004); W. John Livesley, ed., Handbook of Personality Disorders: Theory, Research, and Treatment (New York: Guilford, 2001); Joel Paris, “Psychosocial Adversity,” in Handbook of Personality Disorders: Theory, Research, and Treatment, ed. W. John Livesley (New York: Guilford, 2001), 231–41. ↩
McWilliams and Shedler, “Personality Syndromes,” 21–23. ↩
Johnson, God and Soul Care, 283–87. ↩
Paul Ricoeur, Fallible Man, rev. ed. (New York: Fordham University Press, 1986). ↩
Livesley, Handbook of Personality Disorders (New York: Guilford, 2001). ↩
McWilliams and Shedler, “Personality Syndromes,” 15–74; June Price Tangney and Ronda L. Dearing, Shame and Guilt (New York: Guilford, 2003). ↩
See, e.g., Jon G. Allen and Peter Fonagy, Handbook of Mentalization-Based Treatment (Hoboken, NJ: John Wiley & Sons, 2006); Marsha M. Linehan, DBT Skills Training Manual, 2nd ed. (New York: Guilford, 2015). ↩