Clinical and Moral Language: Personality, Character, and Psychopathology

 A talk given at Boston College, 4/23/23, at The Spring Meeting of the Society for Theoretical and Philosophical Psychology

 

The personality disorders create conceptual problems of social, cultural, and political relevance where clinical and moral concerns uncomfortably dovetail. In the older literature “personality” and “character” are used interchangeably as if having, essentially, the same meaning. They shouldn't and they don't. In an informal semantic differential I’ve asked, and let me ask you, in ordinary conversation do the two words carry the same moral implication? Invariably the answer is that personality is morally neutral whereas character clearly has a moral feel to it.  

 

More narrowly, I want to consider the ambiguous overlap of the moral, pathological, and social meaning of narcissism, particularly the moral and clinical dimensions of the Narcissistic Personality Disorders (NPD), especially when the subject turns to Kernberg’s 'Malignant Narcissism'.

 

In the Diagnostic and Statistical Manuals, here’s how we establish a diagnosis for NPD: A person shows at least five of these nine:

 

• A grandiose sense of self-importance
• With preoccupations and fantasies of unlimited success, power, brilliance, beauty, and/or ideal love
• A belief that one is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions
• A need for excessive admiration
• A sense of entitlement
• Interpersonally exploitive behavior
• A lack of empathy
• Envy of others or a belief that others are envious of oneself
• A demonstration of arrogant and haughty behaviors or attitudes

 

What brings people with these attributes into my office?  If they show up alone, it’s because they have failed to achieve what they believe they deserve and are depressed, anxious, panicked, and/or isolated. Or if they show up as a couple, one of them is more than a bit fed up with the other’s entitlement, lack of understanding and compassion, or pissed off due to an absence of gratifying compliance. 

 

Add to this package Malignant Narcissism’s paradigmatic core of antisocial behavior, ego-syntonic sadism, and paranoid orientation and you have a formula for someone’s misery. I’m going to focus on the problem of when they get away with it.

 

A recent American Psychologist essay “It’s time to replace the personality disorders with the interpersonal disorders" (Wright, et al) spelled out some of this: the fundamental problem of social engagement apart from personal distress.  

 

This is deeply personal given my profession as an academic clinical psychologist and practicing psychoanalyst, committed to citizenship in our fragile multicultural cosmopolitan society –– under obvious siege –– held together by attempts at maintaining often conflicting democratic norms of justice as fairness.

 

Some background.  This became a preoccupation in 2015/16 as I taught, supervised, and needed to validate the distress of my students in clinical seminar. My observations echoed during Editorial Board meetings of The American Journal of Psychotherapy. I wrote an essay for the Journal addressing some of these concerns: “Politics and Religion: Revisiting Psychotherapy’s Third Rail”. I started with:

 

“My clinical psychology trainees rarely have trouble asking their clients to explore something problematic. The point, explicitly stated or not, is to increase understanding and free up consideration of whether something might be done differently. Such inquiry is not always welcome. Questioning implies a judgment that something is questionable.  We all know this. This is why when therapy touches politics or religion, trainees are awkward and uncertain about what they should appropriately ask.  I suspect this holds true for most of my colleagues.” 

 

The case in question was a composite of a supervision of a therapist working with a racist Trump supporter.

 

Let’s take this outside the consulting room.

 

I’m going to talk about Trump, MAGA, the Goldwater Rule, and the confounding amplifications of grievance brought on during Covid isolation. Trump rallies and the Covid pandemic set my stage. Hannah Arendt, reminds us in The Origins of Totalitarianism: Totalitarian movements are simply "mass organizations of atomized, isolated individuals." As does Robert Putman in Bowling Alone: The Collapse and Revival of American Community writing, “People divorced from community, occupation, and association are first and foremost among the supporters of extremism.”

 

Regarding Covid time: 35.7 million Americans live alone. Now consider being subjected to Fox Media and clickbait fueled by algorithms governed by the psychological truism that attention gathers around feelings of vulnerability, grievance, and if encouraged, hostility to those assigned the status of problematic other. 

Isolation is a hotbed of misogyny, racism, antisemitism, and anti-intellectualism. Covid Culture constantly offered reminders of contamination: the themes of Mary Douglas’s “Purity and Danger” morphing to a primitive torch parade chanting “Blood and Soil”. 

 

Not terrified enough, in 2016 I wrote "A Note on American Reactionary Politics:

Sanctioned Transgression and Uncanny Dread." Something from that posting:

 

"Here's my un-nuanced sense of the abused and aggrieved core of the GOP, a group of maybe 20-25% of the overall electorate. Not enough to win the presidency without additional support, but more than enough to make national life ugly. What turns white conservatives, reactionary? Their perception that too many nonwhites are getting a piece of their pie. This is the heart of Trump's base. What makes religious conservatives reactionary? An uncanny and confused confrontation with the sanctioned transgression of enfranchised gays, uppity women, and gender benders feeling it's time to come out of the shadows. Cruz country. Trump and Cruz's core supporters overlap and share a hyper-defensive us violated by them. They finally chose Trump, the bigger bully, the entertaining clown, who encouraged impotent whites to share his narcissistic desire to tower. They're going to get screwed again, but more organized and rankled with neo-fascist frustration, entitlement, and aggression. We're in for a very dark rough ride."

About Sanctioned Transgression: 

 

"Sex, gender, race, and family relations have always been subject to religion and state attempts to limit what people are permitted to feel and do. Sanctioned transgression concerns enhanced social or legal protection for behaviors and relationships a dominant group has previously kept forbidden. When legal protection is sought or offered for these "transgressions", taboos are less hidden, even celebrated. This doesn't sit well with the deeply defensive. It is especially problematic when it evokes a person's suppressed urges now openly exhibited in others. Freud called this the return of the repressed. It should come as no surprise that anxious dread surfaces in people unprepared to manage these feelings; nor is it a surprise these feelings are treated as provocation to assault the source of threat. So why Trump over Cruz? I suspect it's because Trump encourages attack, a position of strength that feels better than Cruz's creepy discomfort." 

 

Trump’s MAGA rally provided unity and celebration; and thanks to Hilary Clinton, an identity politics of “Deplorable Pride”. And along with these poorly educated aggrieved whites, the Nazi scum and Nazi curious were invited to slither out from under the rocks. 

 

None of this bodes well for a citizen wanting vibrant democratic cosmopolitan communities. 

 

What does this have to do with the clinical encounter, diagnosis, moral dialog, and the Goldwater Rule? Do you remember the Goldwater slogan “In your heart you know he’s right”, and the wry response, “In your guts you know he’s nuts”? Whether nuts or not, his platform invited psychiatric critique and the American Psychiatric Association's reaction in the form of a rule that, “a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

 

In 2016 and 2017 various psychiatrists and psychologists publicly ignored this claiming Trump displayed "an assortment of personality disorders marked by a lack of empathy, grandiosity, exploitive behavior, and malignant narcissism.” 

 

Defending their public diagnosis as a duty to warn, they followed with the claim of an ethical responsibility to alert the public about Donald Trump's “dangerous mental illness”.

 

Let’s return to NPD and Malignant Narcissism. Think about the meaning and semantic differential of the word, "malignant".  Malignant breaks into two domains, social and medical.

1. The Social: Malevolent, spiteful, hostile, malicious, malign, evil-intentioned.

2. The Medical: highly virulent or infectious, invasive, lethal.

 

The social use of malignant is medically evocative of cancer’s invasive infiltration of the Body Politic. 

 

Otto Kernberg described Malignant Narcissism as a component of a narcissistic personality disorder in people with sadistic dispositions. Kernberg employs "malignant narcissism" and psychopathy interchangeably. The malignant narcissist wantonly disregards the rights of others by endorsing violence with an absence of remorse, coupled with chronic lying, disregard of law, and the like. 

 

Notice I just shifted from the clinical diagnostic NPD to “the malignant narcissist”, moving from clinical language to the moral language of indignation and condemnation. This is the public polemic the ethnomethodologist Harold Garfinkel described as essential in Degradation Ceremonies: public rituals that removes or restricts a person’s standing in community. 

 

A key feature of moral condemnation in classical Degradation Ceremonies is the act of identifying the foundational values a community member failed or betrayed, denouncing them publicly as having acted in true character, and in so doing, effecting a judgment that the person in question is no longer fully one of us. They are not one of us now and perhaps never were. Harsh and punitive. Here the language points its finger at bad character. Depraved whether or not deprived.

 

Let me ask: What can the professionally informed clinician/citizen do when encountering people whose interests and power directly threaten the integrity and survival of the communities they most value? (The question that plagued my students and supervisees).

 

Now back to clinical and moral language. Let’s turn to the different intent in clinical and moral appraisals starting with something from Philip Cushman’s “Psychotherapy as Moral Discourse”.

 

“Because the therapist's professional identity and economic livelihood

are contingent upon being viewed as a neutral observer, putatively cut loose from or at most minimally influenced by moral allegiances and the corruption of politics, therapists are uncomfortable with conceiving of their work as a discourse about the definition of the good and the determination of what is proper or improper behavior. Yet when one studies the history of various schools of psychotherapy with a hermeneutic eye, the moral frameworks and political consequences of these theories seem obvious. The self and its ills, the healers, and their technologies, are historically contingent, socially constructed, politically active, and morally constituted.”

 

Clinical language generally concerns the dynamics of the individual especially in reference to their symptoms, deficits, and suffering.  Medicalized, “nonjudgmental”, and morally neutral, when correctly employed has the noble aim of avoiding a clinical encounter from becoming a Degradation Ceremony. Consistent with compassion and care, psychotherapeutic engagement attempts affirmation and empathy, a stance of I to Thou. Clinical language and practice provide, at least temporarily, the patient-client with the breathing space of being off the hook. Apart from whether this respects the person as agent, when should the hook be applied?

 

Moral language's foundation is the engagement with others; how the other suffers or is damaged, enhanced, protected, and so on. Moral language involves the Utilitarian's greater social good and happiness along with the Deontological “oughts”, the choices morally required, forbidden, or permitted. The Deontological and the Utilitarian can clash. The oughts good for the goose might make the gander unhappy. Sometimes it matters which side you are on.

 

We might offer corrective empathy, we can care for the narcissistically disappointed struggling with depression, panic, and envy. We can be compassionate. But what should we do when they inflict harm? Worse, far worse, what of the privileged narcissist: successful, charismatic, in a position of power, who gets away with it by appealing to the envy, grievance, and pain of the vulnerable?  And in doing so creates a political community defined by a cultivated hatred of the people and norms of the cosmopolitan society I embrace and defend. 

 

We don’t need clinical language when the cause of alarm is the open celebration of a charismatic and malignant narcissist; a destructive, entitled asshole deserving degradation.  And as psychologist and citizen, I've an obligation to point this malignancy out. I don’t need to diagnose psychopathology. Instead, I can rail against an evil character; not an illness deserving healing and compassion, but a vileness requiring removal. 

Arendt, H. (2017). The origins of totalitarianism. Penguin Classics.

Kernberg, O  Malignant Narcissism and Large Group Regression, The Psychoanalytic Quarterly, 2020, 89:1, 1-24

Putnam, R. (2001). Bowling alone. Simon & Schuster.

Douglas, M. (1966). Purity and Danger. London: Routledge and Kegan Paul. 

Schwartz W. Politics and Religion: Revisiting Psychotherapy's Third Rail. Am J Psychother. 2022 Dec 1;75(4):177-180

Wright AGC, Ringwald WR, Hopwood CJ, Pincus AL. It's time to replace the personality disorders with the interpersonal disorders. Am Psychol. 2022 Dec;77(9):1085-1099.