About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence.
—National Comorbidity Survey Replication (Kessler et al., 2005, p. 593)
Coaches are not expected to function as psychologists or psychotherapists. It is a mistake for a coach to try to conduct therapy in the workplace, as there are practical and ethical prohibitions. Challenges in this area are described in the “Introduction” of this book, where a chart is provided to differentiate between coaching and therapy. Related issues are also discussed in Chapter 18, “Making the Transition.”
Although it is essential for coaches to understand their personal and professional limitations, it is also true that there is an abundance of psychopathology in the workplace. Although accurate epidemiological statistics are uncommon, reliable estimates imply that nearly half of us will experience significant mental illness in our lifetime. The implications of such an estimate are stunning really, as this surely means that we will all encounter problems related to psychopathology in the workplace. Many of the disorders described in epidemiology data describe disorders of childhood, and many afflicted with those disorders will never actually enter the workplace. Even so, this still leaves large numbers of generally competent people who will have to cope with a wide variety of disorders while still managing to survive or thrive in the workplace. The fact that employers often assign coaches to employees who are struggling adds to the likelihood that a coach will be confronted with client psychopathology from time to time.
This chapter describes the numerous kinds of mental disorders that coaches are likely to encounter along with the traits, patterns, and behaviors that characterize these disorders. There are more than 400 officially defined mental disorders in various medical and psychological nosologies. This chapter covers a small number of the most relevant ones. It differentiates between traits and actual disorders, and it offers advice about how to proceed when the coach is confronted with actual client psychopathology.
It is important to begin by noting the difference between traits and disorder or between personality patterns and psychopathology. We all have personalities—complex patterns of thinking, feeling, and behaving that characterize us. Many of these traits are healthy and effective, whereas other traits are the opposite: they hurt us, they set us back, or they cause pain, discomfort, or inconvenience. In short, they are self-defeating. It is impossible to imagine a person lacking in any or all negative personality qualities. The trick in coaching is to discover those traits quickly and to discern whether any are “bad” enough to warrant the label of pathology or disorder. Theoretically, this is not especially difficult to do, as there are detailed formal standards available in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association [APA], 2000), psychiatry’s bible of psychopathology. This hefty document is available at any large bookstore, and coaches trained in a mental health discipline are well aware of it. The DSM contains all of the nearly 400 diagnostic categories of disorders currently known to the psychological professions. There are detailed lists of signs and symptoms, written in a relatively jargon-free vocabulary, so that the material is more or less accessible to the lay public. The essential distinction between pathology and trait is ostensibly clear in the DSM, and it all boils down to the extent of distress and disability. If the behaviors or characteristics of a person cause significant distress or disability, they qualify for the formal diagnosis of a mental disorder. If not, that person has traits. In this model, distress refers to subjective discomfort or pain. If the emotional or psychological pain is significant, especially if it is chronic or long lasting, then one probably has a disorder. More important, if the signs and symptoms actually cause disability (an inability to do things that one previously was able to do, or an inability to do things that most other people can do, or the inability to do things required of a person in the conduct of their life), then that person has a disorder.
The concept of disorder—and the diagnostic process—can have several useful purposes. First, the naming of a set of behaviors, signs, or symptoms as a disorder might actually lead to an effective treatment. Second, a diagnosis may allow a clinician to file for health plan reimbursement to pay for therapy. Finally, many people find comfort in a diagnosis, as some of the mystery disappears and they “finally know what they’ve got.” They feel relief in that there is a name for what has been happening to them and with that name comes a sense of control and hope.
But coaches do not diagnose mental disorders. It is not their job and they are unlikely to be qualified to do so, anyway. Most coaches are not especially interested in diagnosis and find the concept counterproductive to the task at hand. Recall that coaching can be remedial (focused on “fixing” a problem or deficit) or developmental (enhancing and growing a valued employee), and a positively focused developmental coaching process has no interest in chasing after disorders. Nonetheless, coaches inevitably encounter mild, moderate, or even serious pathology in the workplace, and it would be difficult to make a case for simply bypassing these issues. Personality pathology is important because it has a way of undermining organizations and careers. It cannot be ignored.
It should be noted that most of the disorders described in this chapter affect just 1% to 2% of the general population, and the impact of symptoms often keeps sufferers out of the workplace or executive boardroom. Although 1% may not sound like a large number, such prevalence would mean that a community of 100,000 would include 1,000 such people. A business with 800 employees might include 8 to 16 people with a significant mental disorder and several others with minor, less disturbing psychopathologies. These figures might include high performers.
Coaches are likely to try to sidestep subtle or even obvious pathology if they are self-conscious or nervous about their lack of psychology skills. This reaction is completely understandable, as mental illness and abnormal behavior tend to be frightening anyway. But coaches must be able to stand up to this kind of situation and respond appropriately, partly because they may have been hired to coach precisely because of a perception that something is “wrong” with the client. Even in the best-case scenario, in the absence of disorder, negative pathological traits may be the “problem.”
There is stigma attached to mental disorders, and this creates another level of complexity and difficulty for both the inexperienced and the psychologically minded coach. People generally hide their flaws, and they specifically hide their mental health issues in the workplace. For example, those suffering from substance abuse and eating disorders are notoriously secretive and deliberately deceptive. It is wise that coaches never assume they know everything of importance about a client. We all have secrets.
It must be noted that very little of importance can be known about someone based upon his or her appearance or the way that they come across at first. You must get to know them to understand them very well, so be careful about first or second impressions. Soak up these impressions, note them and log them, but do not rely upon them. At the same time, be wary of your intuition. Although most people have an affectionate attachment to their own intuition, research is not so kind. Intuition is notoriously unreliable. Sometimes your intuition is correct and sometimes it is not. Which is it this time? There is no way to know for certain.
It may help to begin the search for psychopathology with a description of its opposite: mental health. If we can define what is healthy, we can compare behavior against that standard. Although clear-cut norms do not exist, most psychologists and others generally agree about a few things. First, the mentally healthy person understands and lives in consensual reality. This is called reality testing, and it implies that the person perceives things in generally accepted ways. This is a gross standard, meaning, for example, that the person does not see hallucinations, illusions, and is not bothered by delusional thinking. There are no (literal) space monsters in the bedroom (or the boardroom, for that matter). They do not hear voices or suffer paranoid or grand ideas that could not possibly be true. This standard is not conformist. It does not mean that people must be average or politically centrist or religious in the ways that most people tend to be. Mentally healthy people may think differently or even idiosyncratically, but they do not distort reality.
When reality testing goes awry, terrible things happen. However, it is uncommon to encounter clinically “crazy” people in the workplace. This is good news for the workplace and bad news for those with schizophrenia or a debilitating bipolar disorder. Although recent improvements in treatment and medications have made life and work far better for those with serious mental disorders, it is still difficult (if not impossible) to have a highly productive or satisfying career if you suffer from one of the psychotic conditions. Nonetheless, it is possible for a previously healthy and productive person to experience a break with reality. With schizophrenia this typically happens to people when they are in their late teens or early 20s; however, there is a similar disorder called a delusional disorder that tends to appear at the age of 40 or 50. However, these kinds of illnesses are uncommon (1% of the general population), but they certainly exist and have been known to derail a previously successful person.
A second essential quality of the mentally healthy person is positive energy, both physical and psychological. Mentally healthy people tend to take a positive point of view and an optimistic slant on things. If not naturally disposed toward optimism, they are able to move themselves toward a neutral or positive perspective without too much difficulty. Energy seems highly correlated to business success, and a lack of physical or psychic energy can be associated with depression. People with great physical energy have a natural advantage, as they can get more done, go to more meetings, meet more people, read more, require less sleep, and maintain a more positive attitude for longer periods. Often, they make things seem easy. It is difficult to succeed without ample energy. Although physical and psychological energies seem connected, there are often medical reasons for diminished energy. Those reasons must be investigated so that hidden maladies such as anemia, thyroid deficiency, or low blood sugar are not labeled as depression or low self-esteem.
Closely associated with energy is the capacity for engagement. Healthy people are engaged. They are busy with activities and projects and ideas that compel them. They do not sit around with nothing to do. They care about things, and they are passionate about a few of those things. They dig in and get involved. They are capable of deep concentration, and they can and do focus on tasks for extended periods, typically seeing them through to completion. They have developed a complex set of skills that require commitment and time. They apply themselves and find satisfaction in the process.
Mentally healthy people are capable of empathy, the ability to discern what others might be thinking and feeling and to care about them. This quality assumes an interest in others. The actual amount of interest can vary widely, as there are many successful people who work in relative isolation. But mental health requires the capacity for empathy when one works with other humans. Some, perhaps as many as 3% or 4% of the general population, simply do not possess this capacity (Grant et al., 2004). Others possess it in varied amounts. High empathy is required for success in some jobs, whereas other careers require little empathic capacity. The worst problems associated with a lack of empathy are described later in this chapter.
Accurate self-awareness is also associated with mental health. A healthy person is aware of what is going on inside himself or herself, and can evaluate his or her own thoughts, feelings, and reactions and respond appropriately. This self-awareness allows them to understand things more deeply and effectively and to make adjustments as a result. Emotional and social self-management is then possible. This issue is associated with psychological-mindedness and is discussed at greater length in Chapter 11 (“Emotional Intelligence”).
There are social skills required of the mentally healthy person as well, and these include the usual day-to-day interaction skills, applied in the right amount. Mentally healthy people are capable of appropriate intimacy, and they are capable of maintaining effective interpersonal boundaries. They know how to say “yes” in a superficial and deep way, and they know how to say “no” as well. They know where they start and end, and do not take responsibility for the ways that others feel. As a result, they are difficult to manipulate.
Similarly, mentally healthy people act in alignment with their own values and goals. In this way, it can be said that they possess integrity. They walk their talk; they do the things that they have decided are important. Important decisions come from within rather than from outside sources of authority.
Healthy people are flexible. They do not get “stuck” or bogged down by rigid thinking or compulsions. They are open to new ideas and are capable of change when appropriate. They are also resilient. Bad things happen to all of us, and the healthy ones bounce back as required, over and over again.
Although there are many other qualities associated with the mentally healthy person, the last (but certainly not least) on this list is the capacity for humor. Healthy people are able to see the world in funny ways, and they laugh a lot. They realize that everything in life is temporary and much of it ridiculous. They do not take everything seriously because they have acquired a sense of perspective. They know what really matters and what does not, and they do not mix up those areas. Consequently, they tend to find a healthy work–life balance and are able to manage stress comfortably.
Before describing the various important mental disorders, there are two factors that coaches must understand. First, all psychopathologies wax and wane, meaning that they get better and worse on a continual basis. Even people with the most disabling disorders experience periods of relative remission when things seem OKAY. There is an old saying in psychology that “nobody’s crazy all the time.” This means that it may be difficult to spot a disorder if you only observe a person for a short period. Those who have more experience with the person are likely to have a more accurate view.
Second, stress makes everything worse. People are often able to “maintain” for long periods and do very well. Then something stressful happens and their mental health deteriorates as a result. Stress is capable of causing any underlying psychopathology to emerge, to become florid, obvious, and disabling.
Most of the psychological disorders described in this chapter run in families. Sometimes the familial correlations are not strong ones, but often those with a disorder have parents or close relatives who have experienced a similar disorder in the past.
The Most Disabling Mental Disorders
Although any psychopathology can be disabling, depending upon its nature, severity, and the demands faced by a person, there are three that tend to be the most disabling. The first is schizophrenia. It is the disorder most commonly associated with the term crazy, as people with this disorder can seem quite strange. People with schizophrenia suffer from “psychotic” symptoms including hallucinations, delusions, and illusions that are often bizarre in nature. They see things that are not there, hear voices, misinterpret stimuli, and hold beliefs that could not possibly be true. Many homeless people are psychotic, medicating themselves with alcohol. The hallucinations are often frightening and disorienting, and they cause people to reside in a world of their own, trying with all of their might to solve the riddles of their symptoms. Schizophrenia typically afflicts a person when they are in their late teens or early twenties. It often begins with prodromal indicators, odd behavior that is not itself disabling or terribly distinctive. People often do not take notice, especially when the afflicted is a teenager. When the disorder becomes full blown, others are shocked and terribly dismayed. The person whom they knew disappears forever, replaced by a stranger who now lives in a different and incomprehensible world. Medication is available, and it can be relatively effective. But antipsychotic medications typically bring side effects that are troublesome and disabling themselves. Sometimes the medication does not work very well, and all too often, the psychotic person is unwilling to start or continue to take medication. Schizophrenia is a lifelong disorder and no one has a definitive explanation of its cause or a comprehensive understanding of the biochemical mechanisms. Roughly 1% of the world’s population is thought to suffer from schizophrenia.
Bipolar disorder is a second, highly disabling disease, and it is often called manic-depressive illness. Although onset can occur at any age, it often begins at the age of 20 or so. The onset is usually disruptive and damaging. It is a recurrent disorder, as it comes and goes, characterized by periods of mania and/or depression. The DSM–IV–TR (APA, 2000) describes manic episodes in the following way: “a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood.” That mood is accompanied by grandiosity, decreased need for sleep, pressured (intensely forced) speech, flight of ideas (thoughts that seem to race through the mind without control), and increased energy to be devoted to tasks that often do not make sense to others. Bad (terrible) judgment is usually a problem, as the person acts on decisions that are extremely risky or even ridiculous. Families of people with bipolar disorder have sad stories of how the afflicted person impulsively refinanced the house to bet on a horse or a new invention, only to quickly lose all of the money. People in a manic phase stay up all night and drive others crazy. They are very difficult to be around. They can be a danger to themselves, and suicide or reckless physical behavior, including risky sexual activity, is always a possibility. Depression is often present, and some people with bipolar disorder only experience hypomanic episodes or no mania at all. Hypomania is a milder, less dramatic form of mania that is not nearly as bad. Medication is likely to be the only remedy for a bipolar disorder. Even so, the available medications are not yet highly effective, and they all come with unattractive side effects such as dry mouth, stomach upset, and acne. Lithium, a traditional medication for bipolar disorder, is so toxic that treatment requires ongoing blood testing to make sure that dosages are safe. Although gentler, more effective medications are increasingly available, people with this disorder typically do not continue taking medication until they learn—through difficult trial and error—that they simply must. This process can take years.
The third highly disabling mental disorder is dementia, a sudden or gradual loss of mental abilities. There are many kinds and causes of dementia, and people lose the ability to remember things, to name things, to order things, even to make sense out of daily life. For example, people with dementia might not recall the name of common items such as keys or coffee cups. They might not be able to remember the names of familiar people. They might not recognize family members. They might leave the house with their underwear on the outside of their clothing. They get lost in familiar places and have to be escorted home by the police. They cannot balance their checkbook or do their taxes. They might forget to turn off the gas burner on the stove.
When the onset of dementia is sudden, it is usually the result of a physically traumatic injury (such as a car crash or a mugging) or a stroke (when a blood vessel in the brain is clogged or bursts). Such sudden dementias can be massive or small; they can be permanent or temporary. When the onset is slow, it is sometimes the result of a series of tiny strokes, called multi-infarct dementia, or the result of a disease process such as Alzheimer’s disease or AIDS or alcoholism. Medications can prolong memory capacity, but none can “cure” the underlying problem or the loss of function. Experts predict an epidemic of new Alzheimer’s cases in the next couple of decades.
Although dementia is associated with older people, it is, for the most part, not a natural function of the aging process. When dementia is present, it signals a pathology (something is “wrong”). A small loss of cognitive function is typical in many healthy older people, but dementia is not. All of us know someone who is quite old and has not lost a step. It is important for coaches to know that dementia is not limited to older people. Several of the various causes can occur in youth, such as car crashes, fights, ski accidents, and even strokes. Strokes can be quite silent and undramatic, leaving the victim with a vague sense of disorientation and a mild, mysterious, perceptible loss of function.
The Most Common Psychopathologies
There are four disorders commonly found in the workplace. First, and foremost, is anxiety. There are a number of anxiety-based diagnoses, and taken together they form the most common set of disorders in the general population. These include generalized anxiety, panic disorders, agoraphobia, social and specific phobias, posttraumatic stress disorder (PTSD), acute stress disorders, and obsessive-compulsive disorder. Anxiety is defined by apprehension, fearfulness, uneasiness, distress, worry, and tension. Fears are typically irrational and unresponsive to rational, corrective input. Anxious people cannot be talked out of their worries. Some anxieties make sense to others, as they derived from traumatic experiences. Others are mysterious and inexplicable in their origin. Since there can be physical causes such as hyperthyroidism, mitral valve prolapse, and food allergies, medical conditions must be ruled out early on. Sometimes people are anxious because their parents raised them to be afraid, sometimes people are anxious because they think in frightening ways, and sometimes people suffer because they are perpetually tense and stressed, with a nervous system that is continuously on fight-or-flight.
There is an important distinction between the stress of a workplace and the stress that people feel. One is a condition of the external work setting, the other is an internal perception. These terms are mixed and used synonymously, but some people are sensitively reactive to the stress of the workplace and others are not. Some are overwhelmed by it. Some bring anxiety disorders into the workplace and try as hard as they can to hide them. It can be difficult to succeed when troubled by the symptoms of anxiety such as disordered sleep, mental distraction, specific phobias and generalized fears, stomach upset, and constant muscle tension. Whereas some people suffer from a generalized anxiety disorder and feel nervous and troubled all the time, others experience unpredictable and immobilizing panic attacks. Anyone who has ever had a panic attack will tell you that it is one of the most horrible experiences imaginable. Emergency rooms and cardiologists often are the first to diagnose panic attacks, as people truly believe that they are dying. These sudden attacks can include heart palpitations, a feeling that you are choking or smothering, chest pain, dizziness or body tingling, derealization (a sense that things are not real), a fear of losing control or losing your mind, and a profound impression that death is imminent. Frequently, repeated panic attacks turn into a panic disorder and can even lead to agoraphobia, when a person attempts to avoid future attacks by avoiding situations that are associated with previous attacks. The lifetime prevalence rate for panic disorders is about 2% of the general population.
Anxiety disorders can be extremely disabling, but most are amenable to a combination of medication and psychological treatment. The side effects of modern medications are not typically disruptive or sedating, and many people are able to function at high levels of productivity while taking medications for anxiety disorders. Cognitive therapy, described in Chapter 6, involves training in thought management and is often quite helpful to people with chronic anxiety.
The second common disorder in the workplace and general population is depression, and it is sometimes difficult to distinguish from anxiety, as many people suffer from some vague combination of anxiety and depression. When the condition is seriously disabling it is called major depression; when it is milder and less disabling it is called dysthymia. The dysthymic person is the chronic worrywart, the person who generally sees things from a negative and gloomy point of view, has low energy, and experiences little joy. Many fully functioning workers and executives suffer from dysthymia, and they suck it up, work hard, and make the best of it, never really enjoying the ride but discharging their responsibilities fully.
Major depression is another matter, and it is significant. The lifetime prevalence rate (the percentage of people in the general population who will experience depression during the course of their lifetime) is figured to be 5% to 12% for men and 10% to 25% for women. A major depressive disorder is quite disabling, and some people are actually bedridden by it. People with major depression cannot think clearly or focus adequately to work. They suffer from anhedonia, the inability to experience joy. They distort things in the most negative possible ways and cannot be talked out of their negative thinking. They eat poorly and sleep inadequately. Sometimes they drink to try to find relief, and the alcohol makes everything worse. They become irritable and annoy people who are close to them. They are difficult to be around. They need to exercise, but simply cannot find the energy.
Some people respond well to the right medication, and side effects are often minimal or tolerable, especially relative to the unpleasantness of the depression. It may require a lengthy period of medical experimentation to arrive at an optimal pharmacological regimen, but medication in combination with cognitive therapy can be quite effective to many (but not all) depressive people.
The fourth disorder common to the workplace is ADHD, attention deficit/ hyperactivity disorder. Although ADHD is traditionally considered a childhood disorder, clinicians have recently noted that many suffer from symptoms well into adulthood. The disorder can include either inattention (attention deficit), or hyperactivity and impulsivity, or both. The disorder is often associated with specific learning problems, especially with reading. Signs and symptoms of inattention include distractibility and difficulty in maintaining attention or focus, forgetfulness, disorganization, trouble following through with tasks to completion, and difficulty with attention to detail. People with inattention often do not seem to be listening when you speak to them, as their mind may actually be wandering or they may be focusing on several things at once. Symptoms of hyperactivity include difficulty in sitting still for extended periods, excessive talking, fidgety motor activity, and feelings of restlessness. People with impulsivity often blurt out answers before questions have been completed and they tend to interrupt speakers and have difficulty waiting to speak or waiting their turn. They sometimes seem insensitive and can be unpopular with peers. Although children with ADHD often do poorly in school, symptoms usually abate as they get older. As a result, a person may not be left with a full-blown disorder but may still suffer from the difficulties that these symptoms create. ADHD affects about 2% of males in the general population and a smaller percentage of females. Effective medication is available, typically in the form of a mild speed such as Ritalin or Aderall. Side effects are often mild and tolerable.
Personality Disorders
Personality disorders is a family of difficult and problematic disorders that tend to be lifelong. They are called “personality” disorders because they represent a structural problem in the organization of a person’s basic, distinctive character. Personality is best understood as the pattern of thinking, feeling, behaving, and coping that characterizes or defines someone (Millon, 1981). In many ways, you essentially are your personality. Personality is a pervasive, comprehensive set of qualities that are present across all aspects of one’s life. It is present during morning, noon, and night, and when you are with others. Your personality is present when you are at home, and it goes with you to work. Everyone notices it and must deal with it. Millon points out that people with personality disorders tend to think and behave in ways that are inflexible. They find it difficult to adapt to new interpersonal situations and have a limited number of alternative strategies. Their thinking tends to be rigid, and stress is hard on them. They often organize their lives in ways that enable them to avoid new or challenging situations. They tend to think and behave in vicious circles. Narrow and distorted thinking constrains them and causes them to repeat their mistakes, even when it should be obvious that they are not getting anywhere. They tend to experience the same difficulties over and over without insight. They are fragile and lack resilience. When things get difficult or when their dysfunctional coping mechanisms fail, they tend to distort reality to try to cope.
Again, it must be said that all of us have personalities and personality characteristics. The difference between characteristics and a disorder has to do with the extent of distress and disability present. With some personality disorders (specifically those in Cluster B, see following list) it is often other people who experience the distress rather than the person with the disorder. The level of distress and disability must be significant in order to diagnose a disorder rather than just a set of traits, and they must have an impact in two of the following areas: thinking, feeling, impulse control, and interpersonal functioning. Presently available medication does not seem to be of much help with these disorders.
The DSM–IV–TR (APA, 2000) lists 10 personality disorders organized into three categories or clusters:
Cluster A
Paranoid
Schizoid
Schizotypal
Cluster B
Antisocial
Histrionic
Borderline
Narcissistic
Cluster C
Avoidant
Dependent
Obsessive-Compulsive
Cluster A
People with disorders in Cluster A tend not to do well with other people and tend not to enter the workplace or last very long there. Paranoids are characteristically distrustful without justification. They are suspicious without warrant and they fear exploitation. As the old saying goes, they think that “everyone’s out to get them.” They are preoccupied with unjustified suspicion about the motives and behaviors of others. They personalize everything.
People with a schizoid personality disorder have little or no interest in other people. They have no interpersonal relationships and infrequent interactions. They are interpersonally cold and engage in solitary activities.
People with a schizotypal personality disorders are extremely eccentric and odd. They have very unusual thoughts and behaviors, but not so different that they qualify as bizarre. Their disorder is likely to exclude them from the everyday workplace.
Cluster B
Cluster B contains personality disorders that haunt the workplace and make life difficult for everyone. They are of significant relevance to the coach and the business organization. Coaches will encounter people with significant traits, if not the full-blown personality disorders found in this cluster. They tend to share narcissism, a dysfunctional self-centeredness as a central dynamic, and they tend to be highly manipulative of others. They are all about themselves, fragile, and resistant to change or influence. They lack empathy and are interested in other people only insofar as those others can help them get what they want. They are difficult to be around for very long, and they do not have deep or enduring friendships. They feel empty, but hide their real feelings behind charm and superficial extraversion.
The defining characteristic of the antisocial personality disorder is chronic disregard for other people and their property. The term sociopath is synonymous with antisocial personality. People with this disorder do not conform to social norms of honesty, fidelity, and integrity. They tend to be charming, dishonest, and unreliable. They were probably in chronic trouble as a child. Their charm gets them into organizations, and when they are clever, they are able to sustain a career, especially if that career rewards the personality characteristics that they possess. They can be finaglers and hustlers. Successful politicians and operatives often have antisocial traits, as do some salespeople. They are good at doing whatever it takes to get ahead, especially in the short term. Progress and career success are limited by their lack of integrity and absence of empathy. Although people find them highly attractive at first, most eventually figure them out for what they are: an exploiter. Those with antisocial personality disorder may actually engage in illegal activities to get what they want. Millon (1981, p. 474) estimates that 75% of those in prison have this disorder, whereas only 3% of American males have it. They are unstable and unreliable and have poor behavioral self-control. Coaches are likely to be recruited to help them, and they will superficially engage with a helpful coach at first, doing whatever seems necessary to get out of the immediate trouble. People with personality disorders are unlikely to change very quickly or very much. People sometimes “grow out” of these disorders to some extent over long periods, but this takes too long to satisfy an organization, bosses, or colleagues. The prognosis is poor. Sociopaths tend to do better in situations with a clear, forceful structure (such as military service) if they can tolerate it.
People with a histrionic personality are excessively emotional and always on stage. They are gregarious and dramatic but vapid. They are constantly on the search for attention, craving it, and deeply and frantically afraid that they might not get it. They are uncomfortable when they are not the center of attention, for when they are not, they fear that they might just collapse into a deep caldron of nothingness or simply disappear. They require constant social approval. They seem full of life and charm, and are often seductive. They are the life of the party. They might use sexual evocativeness to inappropriately commandeer attention. They dress and groom carefully and deliberately to attract attention, and they speak in dramatic, excessive ways, full of flair. They are likely to be highly influenced by the latest trends or fads and are extremely sensitive to the moods of others. Their emotions are expressed emphatically, often to the puzzlement or embarrassment of others, and emotions seem to be turned on and off quickly. They are likely to overestimate and overstate the quality or intensity of their personal relationships, assuming that their relationships have a depth that others do not share. Paradoxically and sadly, they are interpersonally shallow. They are wary of real interpersonal closeness, as such closeness might allow others to discover the truly fraudulent nature of their personality, as this is how they perceive themselves. Histrionic people are not prone to introspection. Inactivity can be threatening because such periods can allow awareness of the deep emptiness.
The borderline personality disorder is notorious in clinical psychology. The term borderline is a somewhat unfortunate label, as it does not accurately describe this disorder. The term seems to have evolved as earlier clinicians viewed people with this disorder as being on the boundary or border between neurosis (chronically self-defeating) and psychosis (out of touch with consensual reality). The term was also used when doctors were uncertain about a diagnosis that did not seem severe enough to be viewed as definitively psychotic. Millon (1981), in his important text on personality disorders, notes that labels such as “erratic” or “unstable” or “cycloid” or “labile” would have been a preferable choice, but his recommendations did not prevail.
Clinicians have been known to dread meetings with “borderlines,” as they can be extremely difficult to deal with. These clients have a fragile sense of self and an unstable identity that is papered over with a false grandiosity. They feel empty inside and seek to use others to fill the void. As a result, they are exquisitely sensitive to rejection, which they experience as a deeply primal sense of abandonment. The DSM–IV–TR (APA, 2000) refers to this phenomenon as “frantic efforts to avoid real or imagined abandonment.” The thought of being alone can be terrifying. The sense of who they are shifts suddenly and unpredictably. They can quickly shift the focus of hostility from self to others and back again. Their relationships are unstable as they jet back and forth between idolization of another person (who shows potential to fill them up) and hostile rejection of that same person if shown the slightest sign of disagreement. Others experience them as oddly flattering, suddenly hostile, and overtly angry. Clinicians use the term splitting to describe this characteristic black-to-white thinking and behavior. People with a borderline personality disorder sometimes cut or mutilate themselves, either for attention or as a distraction to fill the emptiness and prove to themselves that they are “real.”
Coaches are unlikely to encounter people with this disorder in the workplace, but they almost certainly will run into those with borderline traits. Even when relatively mild, such traits are typically problematic and difficult to understand or change.
The narcissistic personality disorder is closely associated with the borderline, as it shares qualities to some extent. Narcissism is interesting and important to any discussion of coaching because of the prominence of narcissism in many powerful and successful business leaders. Narcissism has been the focus of several highly regarded studies of American corporate and entrepreneurial leadership (Maccoby, 2000; Rosenthal & Pittinsky, 2006).
The narcissistic personality disorder is defined by the DSM in the following ways. The essential quality is a grandiose sense of self-importance complicated by a fragile self-concept that is constantly in need of support. Narcissists are preoccupied with powerful fantasies of unlimited success but are at the same time burdened by deep feelings of inadequacy. They sense that they might actually be a fraud, and their response to this possibility is to seek constant and excessive confirmation from their apparent successes and admiration from those around them. They are hypersensitive to the tiniest criticism. In spite of their sensitivity to their own feelings, they are ignorant of the feelings of others, essentially unable to accurately guess at what others might experience. In fact, they are not all that interested in others, unless that other person can add to their feelings of grandiosity and entitlement. They lack empathy. They are manipulative users who need others to support their fantasies of personal superiority and power. They can be quite charming, as necessary, but punitive when someone threatens them by daring to disagree. They are typically poor listeners, and can be paranoid and downright hostile when they feel threatened. They do not make deep friendships, and others eventually see through their charm and grow to fear and avoid them. People with this disorder are typically male, and they are present in the general population at the rate of about 1%.
The rate of narcissists in the population of charismatic and entrepreneurial corporate leaders is probably much higher, however. Maccoby (2000) and Rosenthal and Pittinsky (2006) have argued that narcissism is a double-edged sword, and that narcissistic qualities are rather frequently found in important and successful leaders. They point out that narcissists are charming, charismatic risk takers, driven in part by fantasies of grand success. They are hypercompetitive, with big ideas, and they can mobilize others especially in times of fear or stress. They step into the breach and seem fearless when others are more wary. They are highly motivated to achieve personal power, success, and the accompanying admiration. They make excellent first impressions and can inspire confidence in their organizations, at least temporarily. Narcissists typically thrive in chaos but do not do well in times of organizational stability.
The critical issue is whether a narcissist has a full-blown disorder or just narcissistic traits. All of us need some narcissism to leave the house in the morning. We need to feel important enough to assert ourselves and to ask for things that we want. The distinction between healthy self-confidence and narcissism is crucial. Rosenthal and Pittinsky (2006) point out that healthy narcissists have some insight into their own self-centeredness. They are aware of their own tendencies and able to step back, monitor, and manage it all, often with a gentle sense of self-deprecating humor. They are stable rather than unstable, and they do not insist on uniformly fawning feedback from others. Even though it might not be natural or easy to do, they find ways to get outside of themselves and pay genuine attention to others.
Deeply narcissistic leaders face two insurmountable problems. First, they inevitably alienate those who have to work with them. Rather than cultivating loyalty and admiration (which they desperately seek), they end up with followers who silently dislike and distrust them. Their arrogance and egocentricity create inauthentic relationships. Those followers who can no longer tolerate such a personality find a way to leave when they can. Those forced to remain become bitter and careful. Second, the ambition of the narcissist’s fantasy eventually outruns market reality. They risk too much, and refuse to listen to those who caution them, taking the organization too far, often causing great harm to the company and its employees. They then move on, unable or unwilling to incorporate negative results into their internal concept of self. They blame others and learn nothing from the experience.
As much as narcissists could benefit from coaching, they are insulated and interpersonally isolated; not all that interested in coaching, especially if the enterprise is to include honest or critical feedback. They are liable to feel threatened by a coach who might be able to see through their fragile and fraudulent sense of self-esteem. They are also likely to be suspicious of a coach. Should they submit to coaching, the coach–client relationship is likely to be challenging, typified by disruptions that could derail the process at any moment. A coach should expect to be tested and rejected at the slightest hint of disagreement. Even then, it would be the rare narcissist who seeks and embraces help, and as Rosenthal and Pittinsky (2006, p. 626) note about the activities of a coach, “It is far from clear that they are the types of practices to which any narcissist would be amenable.” Nonetheless, Rosenthal and Pittinsky speculate the possibility that “without such ego-driven leaders, we would live in a world relatively devoid of bold innovation and social change” (p. 630).
Cluster C
Cluster C includes people who are pathologically anxious, tense, and controlling. People with an avoidant personality disorder crave interpersonal, interactional interaction and relationships, but are too frightened to do anything social. They are extremely hypersensitive and dread criticism. They take almost no social risk, feeling deeply inferior. People with this disorder are likely to avoid any work situation that might involve contact with people or the possibility of social error, disapproval, embarrassment, or rejection. They are occasionally able to form interpersonal relationships, but only when they feel safe, and usually under conditions of “assurance of uncritical acceptance” (APA, 2000, p. 718). For the most part, they remain socially invisible.
The dependent personality disorder is typified by extreme passivity and interpersonal dependence. These people desperately fear separation and are pathologically submissive and clinging. They are unable to tolerate aloneness or independence. They need constant reassurance, and are unwilling to take responsibility for much of anything. They will go to great lengths to secure support and strongly prefer to be told what to do rather than to initiate action. They are unlikely to start projects or to carry them out without consistent supervision and reassurance. They are typically indecisive.
There are two disorders that include obsessions and compulsions, obsessive-compulsive disorder, and obsessive-compulsive personality disorder. Obsessions are thoughts; persistent, recurrent ideas that cannot be controlled. These thoughts are intrusive and inappropriate and irrational, and they tend to dominate one’s thinking. Compulsions are repetitive actions or behaviors carried out in an attempt to reduce anxiety or anticipated distress.
When obsessions and compulsions are prominent, a diagnosis of obsessive-compulsive disorder (OCD) is appropriate. OCD is an anxiety disorder that is relatively common (2.5% lifetime prevalence) and can be quite disabling. Compulsions can be complicated and can profoundly interfere with essential life activities. It might take hours to complete regular daily functions such as meal preparation and eating. Obsessions commonly focus on fear of contamination, loss of order or control, and doubts (for example, “Did I leave the stove on?” or “Did I leave a light on?” or even “Did I run someone over with my car on the way home tonight?”). This disorder can actually get worse as one gets older, and prevalence rates are thought to be greater in those with higher IQ or social class (Morrison, 2001).
Rigid perfectionism is the hallmark of the obsessive-compulsive personality disorder. People with this disorder do not suffer from actual obsessions or compulsions, but their personality is organized in an obsessively, compulsively overcontrolled way. They are preoccupied with order and completely inflexible. Control is the central theme of their character structure. They may be devoted to work and to efficiency, but they overdo it and cause more harm than good by excessive attention to unnecessary detail and by driving everyone around them crazy. They can also be indecisive, unable to commit unless and until all conditions are perfect. They can turn any activity into a tedious, odious task. They cannot relax. As expected, they do not delegate well, as others do not have the requisite level of high standards. They may be stingy or miserly, and they may turn into packrats, accumulating too much clutter. They are poor team players and do not appreciate having to carry out someone else’s plan, and if they express affection, it is in a controlled, conventional style.
Intermittent Explosive Disorder
Intermittent explosive disorder might fit several general categories, as it involves impulse control, anger, and aggression. It is often associated with substance abuse as well. Some feel that this disorder is not actually a discrete disorder but merely a sign of other disorders such as an antisocial personality (Morrison, 2001). Coaches may encounter this problem and should be aware of it in any case. It is characterized by repetitive, uncontrolled, sudden outbreaks of explosive aggression. This is a person with unpredictable, frightening temper tantrums, a reaction grossly out of proportion to the events at hand. The disorder has not been well studied, but is more common in men than in women. The episodes are felt to be uncontrolled by the person manifesting them, and they are extremely distressing to all involved. The disorder has been known to cause job loss, school suspension, divorce, hospitalization, legal problems, and career derailment. Those with this disorder are amenable to treatment, but the treatment process can be quite difficult and frustrating. They are likely to be motivated for treatment after experiencing several devastating and embarrassing incidents.
Somatoform Disorders
The word somatic means “body-based.” There are several challenging disorders in the somatoform category. People with these disorders seem to have physical or medical problems that cause significant distress or disability, but medical consultation cannot fully explain things.
With somatization disorder people experience at least eight physical symptoms in various parts of the body prior to the age of 30, and at least one of the symptoms must be sexual in nature. Patients with this disorder are more likely to be female than male, and it tends to run in families. Physicians become frustrated, as they are not able to provide comprehensive or effective treatment.
When chronic pain is disabling and psychological factors are thought to play an important role in the onset, maintenance, or worsening of the pain, a pain disorder is diagnosed. This happens to women more often than men, and it can follow an accident or previous medical condition. This disorder is known to cause significant career impairment and can be quite disabling, physically and emotionally.
When emotional conflicts or problems are converted into physical conditions, the diagnosis is conversion disorder. The conversion process and conversion symptoms are common. As much as one third of the general population has experienced a physical symptom resulting from an emotional or psychological problem. Who has not gotten a stress headache or felt a stomachache when faced with a frightening situation? People break out with rashes, they get acne, and they suffer tightness in their chest. Their mouth gets dry. But when these symptoms convert into actual medical conditions that a doctor cannot explain, a conversion disorder may be the cause.
When a person systematically misinterprets physical signs or symptoms to mean that they have a serious illness that does not exist, they may be experiencing hypochondriasis. This is a disorder characterized by preoccupation with the fear that one has a serious or life-threatening medical disease. Medical consultation and reassurance do not help and do not change the sufferer’s mind. Their belief is irrational and refractory to evidence.
One last somatoform disorder that might be encountered by the coach is body dysmorphic disorder, a peculiar form of self-focused obsession. People with this disorder are powerfully preoccupied with an imagined deficit in appearance, most often in the face, hair, breasts, or genitals. This problem can be devastating, especially when people with the disorder can find cooperative plastic surgeons. The lore and literature of psychotherapy is littered with stories of people who ruined their facial appearance with multiple redundant cosmetic surgeries (Tignol, Biraben-Gotzamanis, Martin-Guehl, Grabot, & Aouizerate, 2007). People with this disorder commit suicide at significantly higher rates than the general population (Phillips & Menard, 2006). Sufferers spend significant time inspecting their imagined flaws, grooming, and compensating. They are likely to avoid activities that would expose others to their perceived ugliness. This disorder can severely impact any career that requires frequent contact and interaction with others.
Traumatic Events
Nearly everyone is exposed to the harshness of unexpected pain or loss. Few escape at least a modest amount of trauma. After a difficult life event, such as a divorce or the loss of a loved one or a serious career or financial setback, it takes time for humans to return to previous levels of happiness and functionality. This is normal. When a person does not “bounce back,” when they continue to be depressed or listless or when they do not reengage in life’s activities, there is a diagnostic label for them. If the trauma was severe, such as in war or earthquake, fire, kidnapping, or serious sexual abuse, some people are left with PTSD (posttraumatic stress disorder). When this happens, they may experience recurrent and intrusive memories or dreams of the event, they may become phobic about traveling to places that remind them of the event; they may become numb, detached, and estranged; and they may have difficulty sleeping and concentrating. They may have persistent anxiety and an exaggerated startle response. This disorder requires significant professional help.
When a person suffers from exposure to an extreme trauma and the symptoms resolve within 1 month or so, the diagnosis of acute stress disorder is appropriate. If those signs and symptoms linger, PTSD is the more accurate diagnosis, and PTSD can last for years, perhaps even a lifetime.
On the other hand, when someone is subjected to a less traumatic event, such as a divorce or job loss or other significant setback, they may experience emotional or behavior symptoms such as depression, anxiety, odd behavior, or substance abuse. When this reaction is in excess of what would generally be anticipated, a diagnosis of adjustment disorder may be appropriate. In this disorder the symptoms are expected to resolve within 6 months of the time that the original stressor ended.
Habit Disorders and Addictive Behavior
Another important and common set of problems is that of addiction. Taken together, the number of people in the workplace who are addicted or dependent overwhelms all of the other psychological problems described so far (APA, 2000; National Center for Health Statistics, 2007). Tobacco, alcohol, marijuana, and prescription drugs are an undeniable feature of the modern workplace. The so-called War on Drugs has been a colossal failure, and American professionals and workers use and abuse drugs at high rates (National Center for Health Statistics, 2007; Tracey, 2008; Walter, 2008). The Economist recently reported this astonishing fact: Marijuana is now by far California’s most valuable agricultural crop (“Home Grown,” 2007). Coaches are certain to have to deal with clients who are either addicted or struggling with excessive or counterproductive alcohol or other substance use. Recent research on the typology of alcoholism (Moss, Chen, & Yi, 2007, p. 155) describes a “functional subtype” comprised of “generally middle-aged, working adults who tend to have stable relationships, more education, and higher incomes than other alcoholics. They tend to drink every other day, often consuming five or more drinks on drinking days.” This group makes up about 20% of all alcoholics.
Shame and embarrassment are commonly associated with alcohol and drug use, and most heavy users keep their habits to themselves. Much of the addictive behavior found in or around the workplace is secretive, but it can still be the cause of significant disruption, dysfunction, and loss of efficiency. Consumption of alcohol and other substances on the job is an obvious problem. Issues related to substance abuse after work are less obvious but just as important. Addicted people typically deny or minimize difficulties and are often unaware of the losses they suffer. This adds a level of difficulty to the coaching challenge. It is entirely possible for a coach to completely miss the fact that a client is addicted, and that the addictive behavior (or its consequences) is an important part of the overall picture. Unless there is a very special rapport along with a clear promise of confidentiality, clients are unlikely to share this important information with a coach. The unknown addiction can result in a mysterious spinning of wheels as nothing changes and no one can discern underlying causes for the inertia.
Addiction can be to an astonishing variety of substances and experiences. The following definition is useful here: Addiction is a compulsive and pathological relationship to a mood altering experience that has life-damaging consequences (Peele, 1985).
In this view, it is easy to see that coaches will encounter clients who are addicted to experiences such as work, gambling, sex, food, caffeine, exercise, Internet porn, and others too numerous to mention. They will also suffer from obsessions (constantly repeating thoughts they cannot shake) along with compulsions (irresistible urges toward repetitive behaviors designed to reduce anxiety or stress). They will, most likely, disguise and hide these thoughts, urges, and behaviors to avoid seeming weird to those around them. Some clients will be troubled by a compulsive need to do things perfectly and, perhaps to demand that quality of behavior from others. Others will be bulimic, eating compulsively and then secretly “purging.”
The good news is that treatment for addictions is widely available and can be inexpensive. The bad news is that addicts typically “bottom out” or suffer terrible consequences prior to entering treatment. Coaching would be of enormous value if it could help a client avoid tragedy by entering treatment before disaster strikes.
It bears repeating that coaches are not psychotherapists or doctors. They are not usually trained in these areas, and therapy is not their job. The differences between coaches and therapists are described in detail earlier in this book and depicted in the “Introduction” in Table I.1. The coach has a performance focus rather than a therapeutic orientation. It is not the coach’s job to help fix personality problems. That task is outside the scope of coaching. Coaches must resist any temptation to attempt therapy.
Nonetheless, it is essential for coaches to be familiar with the traits and disorders described in this chapter. They should not be too surprised or caught (too much) off guard when confronted with psychopathology. Coaches can potentially be of great help to clients and organizations when they recognize traits and disorders, label them in an appropriate way, and help clients decide what to do. “What to do” might include a referral for a more definitive diagnosis or a recommendation for effective therapeutic help. It might include discussions about how to minimize the impact of traits in the workplace and career.
It is also possible that coaches may encounter clients who have psychological disorders and are already engaged in professional treatment. Many successful people have acknowledged psychological issues and gotten treatment. Many are taking psychotropic medications with a good effect. There are large numbers of people in the American workforce who are in a successful, ongoing recovery from substance abuse problems. In those cases it may be important for coaches to be able to understand relevant disorders and coordinate coaching with therapy. Coaches should take care to discern whether psychotherapeutic treatment is “public” or confidential from the point of view of their client.
Coaches ought to wonder about hidden psychopathology when things do not “add up.” If there is mystery, if something does not quite make sense, or if it seems that the coach is “missing something,” it is a good time to wonder about the possibility that addiction, depression, disordered thinking, dementia, an eating disorder, or some other secret problem lurks. Recall that psychopathologies wax and wane, meaning that they get better and worse periodically. You may have met your client during a “good” phase and did not notice symptoms at first. He or she may later phase into a more difficult period. His or her colleagues have seen this person in several phases and are likely to have a more comprehensive view. It is a coach’s job to effectively and accurately integrate third-party information into the assessment, and this can be a challenge. One must be careful not to allow a global positive impression to cause a coach to distort reality. It is entirely possible for a coach with good client rapport to discount negative data points or observations when it makes a favored client look or seem “bad” or “sick.” Also, recall that stress tends to bring out pathology and to make self-defeating traits worse. When stress builds, observe clients to see the impact.
Remember that many people succeed by effectively managing negative traits or psychological disorders. Modern medication, when properly prescribed and taken can work miracles, especially when combined with consistent, appropriate psychotherapy. Psychotropic medications represent a profit center for drug companies and are constantly improving. It is reasonable to anticipate that clients with a serious psychological disorder could—with help—manage or transcend their difficulties and continue to thrive.
It seems important that coaches consider who is the client when psychopathology appears. Is the sponsoring organization the client or is the client the client? Is it appropriate to hide pathology from an organization that is paying a coach? Is it necessary to reveal pathology to that organization, and if so, under what circumstances? To whom does the coach owe which obligations? These can be difficult questions indeed.
Finally, it is important for coaches to “step up,” notice, and address psychopathology when it is present. The temptation to ignore a problem, to politely sidestep it, or to minimize it will be attractive. Psychological disorders are disruptive, confusing, embarrassing, and frightening. Coaches can potentially add enormous value by responding courageously and appropriately when pathology emerges.
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