"He just not a mensch", said his Rosh Yeshiva, using this one statement to explain everything. "I don't know if you can do anything for such a person." When we hear statements such as that, our hearts sink. You know it's going to be a difficult treatment process when even the fellow's Rosh Yeshiva is not able to say anything positive or optimistic about him. Whether it is individual therapy, couples therapy or family therapy, the most challenging clients are the ones that have personality disorders on top of whatever other dysfunctional behaviors they suffer from. This is because while it is possible to teach a motivated person healthier ways to respond to situations, and more adaptive ways of thinking it is much harder to change a personality. One can teach a person how to become more calm in stressful situations, and how to see himself and others in a more objective and rational manner. However, if the person has a personality that is arrogant, defensive, and/or mistrusting, it is hard to form an alliance and working relationship -- essential ingredients to bringing about change.

Families that have an individual, or individuals suffering from personality disorders must overcome enormous obstacles in order to allow for effective treatment to begin. Such individuals will tend to be so rigid and controlling, or so hostile, or insecure, that it is nearly impossible to find common ground. Even when common ground is found, the slightest insult or disappointment is enough to throw the system back into chaos. This series of articles is dedicated to the significant others who live with such persons, and to offer strategic counsel and consolation and how best to cope.

Decide Where You Stand

If you're in a relationship with someone who you believe has a personality disorder, it is important to make up your mind about what you think can realistically be achieved and what you are ready to live with. First, it is a good idea to have an understanding exactly what a personality disorder is. The Diagnostic and Statistical Manual of Mental Health Disorders DSM-IV-TR, published by the American Psychiatric Association, defines a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Some briefly explained examples of personality disorders are:

Narcissistic Personality Disorder, which is essentially a narcissistic and selfish person.

Avoidant Personality Disorder, -- a person who procrastinates and avoids people and responsibility.

Dependent Personality Disorder, -- a person who excessively relies on others to handle their emotional and personal matters.

Histrionic Personality Disorder, -- a person who uses excessive displays of emotion and can manifest physical symptoms to gain attention, sympathy or support from others.

Obsessive-Compulsive Personality disorder - a perfectionistic person who is bossy and controlling has little tolerance for mistakes (not to be confused with OCD.)

Borderline Personality Disorder - An emotionally needy and controlling person who exhibits intense mood instability and highly unstable relationships.

Antisocial Personality Disorder - A person who behaves in a criminal or immoral manner and does not seem to have feelings of remorse or conscience.

But do not mistakenly diagnose the people you know who you think have these disorders. To some degree, many of us manifest aspects of these personalities at times. The difference is that a person with a personality disorder will have a pervasive and disabling pattern which significantly impairs social and or occupational functioning. On the other hand, the rest of us may only exhibit these behaviors from time to time

A good rule of thumb to try to understand when you are dealing with a person who has a personality disorder is if you feel there is an essential lack of reasonability, and that whatever is being said is not really understood. For example, a person may be married to someone who is stingy or someone who is a spendthrift and wastes money on extravagances. Even so, though those may be personality styles, they are not necessarily personality disorders. How can you tell? If the person concedes that this is a weakness, explains his or her feelings, and can see your viewpoint as well, then this behavior is just part of how people relate to themselves and the world. However, if you find the person seems to be unable to see any view other than his or her own, you may be dealing with a personality disorder.

What makes personality disorders so challenging is that the person who has the problem rarely can see it. Like the strange but true fact that a person cannot usually detect their own poor body odor because they are accustomed to it, a person with a personality disorder is unable to notice the unrealistic, unfair or unreasonable attitudes he has in relation to others. The personality is the lens that allows people to interpret the world around them. If the lens is distorted, so is the image. Therefore, if a person grows up with a distorted lens, it is hard to convince him or her that what is being seen is not normal. For example, consider a person who is born colorblind. It is hard to explain to the person what color is. While a totally blind person would have to concede that he is missing some information, a colorblind person might have a harder time accepting this because he can still function reasonably well. So too, with the person who has a personality disorder. He or she will have a hard time accepting any shortcomings because the distorted way of looking at the world works reasonably well. In fact, in some venues, the personality disordered way of looking at the world may be even more adaptive and functional, such as a controlling perfectionistic person who works in a highly competitive environment, that does not reward collaboration but does reward thoroughness and accuracy over creativity.

If we apply the colorblind metaphor to personality disorders, it also gives some insight into how this problem may be treated. Somehow, the person must go through a process that helps him get a sense that despite what he hears or feels to be true (due to his own distortions), in fact, whatever he is doing is not working. The colorblind person will only accept the existence of colors when he is faced with overwhelming evidence, such as how others seem to know when the traffic light is red or green.

For people with personality disorders, this process can come about via repeated difficult and painful life experiences, and sometimes, with some good therapy to put these experiences in perspective. Keep in mind, as miserable as you may feel living with the individual who suffers from the personality disorder, often on the inside, such persons feel lonely and insecure. Deep down, they sense they are missing out on something big (the real world of real relationships), but their distortions do not allow them to see it. Hence they have a gnawing feeling of insecurity, which may lead them to behave in even more maladaptive ways.

A person with a personality disorder often times simply cannot see or understand what it is you are saying. He or she may feel liked the wronged party and be completely oblivious to the pain that is being caused. Here are some common examples:

• An Obsessive Compulsive Personality (not to be confused with OCD) may harp endlessly about minor issues such as small budget overruns, or mild dents and scratches to a car, and minor discrepancies in child care or homemaking. The OC Personality will feel completely misunderstood. He or she may exclaim, "I don't ask for much…why is it that no one seems to care? Why can't people just remember to…screw the bottle of ketchup more tightly… …shut the light…brush off the counter etc." However, those living with this person feel beleaguered and oppressed over what they consider to be minor issues.

• A Narcissistic Personality may have unusual and unrealistic expectations that others honor and pay the highest regard and attention to what he or she says, without much regard for another person's feelings. The NP Personality may become irritated and offended when normal impingements cause others to redirect their attention, such as a baby crying or when personal or job responsibilities require action. Those living with this person will feel as if they must walk on eggshells and constantly fear insulting or frustrating this person's incredible hunger for attention and admiration.

• A person suffering from Borderline Personality Disorder will have intense fear of abandonment and therefore when people disappoint him or her in not showing the expected amount and form of love, s/he will possibly engage in self injurious acts or vent extreme and venomous rage. Such persons may alternate between intense love and idealization of people they flip to flaming and destructive hatred. All kinds of impulsive behavior ensues, usually in reaction to some real, feared, or imagined abandonment. Those who live with persons such as this feel as if they are in the presence of an emotional vacuum cleaner or tornado; a force that constantly sucks them up into a whirlwind of drama and anger. Sometimes, when you see a couple that really cannot get along and fight like cats and dogs, one or both spouses may have BPD and simply are unable to tolerate any feelings of disconnection or hurt without spiraling into an emotional nosedive.

• A person suffering from Avoidant Personality Disorder will be reluctant to take social or occupational risks, and may hide behind various excuses, but in the end the fear of being ridiculed or criticized is behind most of the avoidance. He or she may feel that others are unfair in their expectations and overly critical, but their loved ones feel exasperated and frustrated when it seems that opportunities for meaningful accomplishment are being lost daily due to avoidant behavior.

How do you live with people like this and stay sane? Is there a way to help such persons heal or must we be stuck with them as they are?

If you have made the decision to continue to live with a person who has a personality disorder, you must be prepared for a very long haul. You must also have great patience and a high degree of empathy. As we explained in previous articles, often the person with the personality disorder feels misunderstood, lonely, and uncared for. Even though most of these feelings are directly a result of their mistreatment of others, they simply cannot see it. So if you react with impatience or hostility, you will only increase their sense of outrage and disappointment at how nobody understands or cares about them.

On the other hand, caving in and catering to every single insane demand or expectation is unfair, unrealistic, and in the long run, not helpful. Imagine you are a spouse of a perfectionistic, controlling person. Even if you decide, for the sake of Sholom Bayis, to accommodate this person's demands, your children are not likely to be as charitable. This could cause serious power struggles and possibly permanently damage your child's chinuch.

If you can't accommodate, and you can't fight back, what is there left to do? The answer is, you will need to set rather firm personal boundaries, while at the same time, being as patient and accommodating as possible from an emotional perspective. In other words, you will not allow yourself to be bulldozed or pressured into accommodating the distorted and unreasonable demands of this person. However, you will be empathic and emotionally responsive to the feelings of this person. Below are some examples of how to do this.

If you are dealing with a person who is extremely rigid and perfectionistic, and gets upset when certain things are not neat and in order, you might say: "I understand that you get very nervous when the house is not neat. I see that you become irritable and uneasy." Do not make any attempt to accommodate this need if it is truly unrealistic and out of proportion. If the person pushes you, or challenges you why you are not doing what he or she demands, you should once again respond to the emotions. Let the person know that you feel terrible about how much distress this causes him or her. Invite the person to tell you more about how hard it is. But at the same time, without antagonism and without losing your patience, let the person know that you are not able to accommodate this demand.

As another example, if you are in a relationship with somebody who is highly insecure, and demands a degree of availability and connection that is impossible for you to meet. Perhaps this person calls you an unreasonable number of times when your work demands that you not carry on extensive phone conversations with family members. Once again, respond with patience and empathy. Let the person know that you understand how anxious and lonely he or she feels when you are unable to connect. Invite the person to tell you more about it when you are able to listen. However, all the while that you are responding emotionally to the person, on an action level maintain realistic boundaries. Meaning, that if indeed you are unable to be on the phone to the degree that this person needs, and it really is an unfair expectation, let the person know that you simply cannot do it.

In both of the above examples, the person with the personality disorder will not take this lying down. He or she will likely become antagonistic, aggressive, offensive, and possibly abusive. You must do the best you can to stay calm, respond with genuine empathy about the person's emotional state, but still hold your boundaries. This will not happen quickly, but in time to person will learn to respect these boundaries, and also appreciate your patience and your sensitivity. It also is likely that you'll be goaded into losing your temper, and then the other person will have good rationalizations for why you are wrong. He or she will think, "Look at the terrible way I am treated. " Therefore, it is advisable to stay patient and emotionally available.

Once again, it is your choice to stay in such relationship with a person like this. The other choice, of course, is to end the relationship. However, such a choice is fraught with its own difficulties.

People with personality disorders rarely come to the realization that they have problems without experiencing years of confusing and hurtful interactions with people. And only then, a rare few are able to have the emotional honesty and integrity to make the leap of faith that somehow, the problems are of their own making. If you are in a relationship with such a person, you will need to draw a line where you simply will not tolerate certain behavior. The trick is to draw this line without hostility or emotional reactivity, while still remaining genuinely empathic. When you draw this line, you draw it firmly. Without assigning blame, or becoming overly critical, you let the person know that you are unable to live under the current circumstances. It is likely that you will get hostile and antagonistic responses. However, if you stick to your guns, and remain calm but also empathic, your message might eventually get through. Even if your message does not get through, the person still might accept the limitations of the situation. It is important to point out that this limit setting will not work unless the other person is completely convinced that you will not continue in the relationship if the problem is resolved. The limit setting cannot be an empty threat. It must be a fair and objective statement about how you will need to end the relationship if the problem continues. Once again, don't go down this road unless you see no other viable option.

Try to think from the other person's perspective. It's going to seem to the other person as if you are the one making an unreasonable demand, so it is helpful to be kind and perhaps even apologetic while you are still setting a firm limit. To a personality disordered spouse you might say something like:

"I'm sure that you feel that what you do is reasonable. I don't think that you're able to see how hurtful your behavior is. So, I'm trying not to resent you. However, whether it is my fault, or it is yours, I'm unwilling to continue living in this situation. You are welcome to study the problem, together with me, with a therapist or a rabbi whom you trust, but if this problem won't change within the next few months, I need to find a different way to live."

Although the typical personality disordered spouse will at first react with much hostility to such a challenge, if you remain emotionally connected and emotionally honest, and you take great pains not to cause any additional hurt, this might be just the wake-up call that the person needs. Progress may be slow, so you need to be patient as long as you see that there is a will to change and there is progress.

Ó 2009 Rabbi Simcha Feuerman, LCSW Chaya Feuerman, LCSW 718 793-1376 [email protected]. Material may be copied and distributed freely provided that the articles are printed in their entirety and this note is printed on all pages.