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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 appreciate it greatly when they get it. Impaired characters are generally quite comfortable with all the signs of their character disturbance. They generally come to the attention of professionals under pressure from someone else. They're happy with who they are and how they operate. The symptoms of their dysfunction primarily cause distress to those around them. There's an adage in clinical circles: If they're making themselves miserable, they're probably neurotic. If they're making everybody else miserable, they probably have a character disorder. There's a lot of truth to that adage.

 Response to adverse consequence. Neurotics question themselves and strive to make changes when things go wrong. They tend to become unnerved easily and to blame themselves all too readily. Disturbed characters, by contrast, tend to be relatively unfazed when their actions invite negative consequences, and even if they are perturbed to some degree, it's generally a short‐lived reaction. Some of them more severely impaired characters even become more emboldened and determined in their manner of coping as consequences mount. They blame others, not themselves when things go wrong anyway, and as a result, they don't appear to profit from experience.

 Nature of self‐presentation. The traditional conceptualization of personality as a “mask” a person wears to hide the true (often unconscious) self is still a reasonably valid perspective when it comes to understanding and dealing with neurotics. And for far too long, all personality styles have commonly been considered, as David Shapiro aptly titled his landmark book, “neurotic styles.” But certain personality manifestations tend to lie more toward the character‐disturbed end of the neurosis – character disturbance spectrum, so it's not only inaccurate but sometimes even dangerous to view such individuals within the neurosis framework. For example, the ego‐inflation associated with narcissism has been commonly viewed as an outward and unconscious “compensation” for underlying feelings of inadequacy and deficient self‐esteem. We used to think similar things about bullies as well. But research is proving these assumptions mistaken most of the time. There are folks who are just exactly as they appear. When such folks act like they're all that, it's because they really sincerely believe they are. It's neither an act nor pretense. Sometimes, there's some objective basis for their beliefs about their greatness, and sometimes there's not. But even when there isn't, that fact isn't necessarily proof that the person must be “compensating” for anything. Some people simply tend to overestimate their value regardless of the objective realities. Even those narcissists with substantial resumes will still tend to believe they know more than they actually know or can do more than they actually can do. When you're dealing with character disturbance, most of the time what you see is what you get. If they're presenting a façade, it's usually done consciously and deliberately as part of the game of impression management or some other confidence scheme.

 Needs in therapy. The emotional conflicts causing neurotics distress are mostly unconscious to them. In insight‐oriented therapy, we establish a trusting relationship that facilitates mindful reflection to help bring these conflicts into greater conscious awareness. Neurotics both need and generally benefit from insight‐oriented interventions. Character‐disturbed individuals need something entirely different in any therapeutic encounter. Already having insight but lacking in motivation to change course, they need “confrontation” and therapist‐facilitated “correction” of their maladaptive ways of thinking, attitudes, and behavior patterns. And if change is ever to occur, it will happen in the here‐and‐now moment of interpersonal interaction when the therapist benignly but firmly shines a light on a dysfunctional attitude, way of thinking, manipulation tactic, or other responsibility‐avoidant behavior and both proposes and reinforces appropriate alternatives.

Now, there are many, many more dimensions on which neurotics and disturbed characters differ, and in my book Character Disturbance, I outline several more than I've mentioned here. But there are even more than the additional ones I mention in the book, and it would be fair to say that just about everything you've ever learned about what goes on inside a person and why folks do the kinds of things they do probably doesn't apply when it comes to dealing with an impaired character. Narcissists, antisocial personalities, covert‐aggressors, and other manipulators are simply a different breed for the most part, and the rules for dealing effectively with them are very different, too. It's when folks (professional and lay persons alike) refuse to accept that fact that they put themselves at a distinct disadvantage in any encounter with such individuals.