José Luis Carrasco, psychiatrist: ‘The keys to protecting against personality disorders are loving attention and trust’

At the end of a long, dark hallway, EL PAÍS reaches the light-filled office of José Luis Carrasco. The 63-year-old is the head of Psychiatry and the founder of the Personal Disorders Unit at the San Carlos Clinical Hospital in Madrid. Behind his desk is a large window, which looks out on a spotless blue morning sky and the green of the trees.

To the left of the desk, a large bookshelf looks strangely uncluttered. There are about 20 books on psychiatry and personality disorders, the specialty to which Carrasco has dedicated more than 30 years of his career. Among these volumes is his latest book — Personality and its Disorders (2024) — in which the psychiatrist offers readers an informative introduction to the science of personality. Just three decades ago, he confesses, this branch was “almost like science fiction.”

“In the past, psychiatry oversaw very clear illnesses: severe depression, schizophrenia, bipolar disorders... but what were called psychopathies — which were anomalous personalities — had always been considered something non-medical,” Carrasco explains.

However, in recent decades — thanks to the gradual entry of these disorders into the fields of medicine and psychiatry — much progress has been made in gaining knowledge about their causes, their neurobiology, and the psychological and familial factors that produce them, as well as the treatments that can help individuals live with them.

Question. In the introduction of your book, you write that we use the word “personality” with “astonishing naturalness, without realizing that — after God — it’s the most formidable and unattainable concept” that exists.

Answer. It’s a very strong concept. When we rate someone by their personality, it’s actually as if we’re rating their entire being, their entire essence. But when we think about it, this is as complex as the idea of God itself. And we do it quite a bit: we rate someone’s personality very easily. Just based on an encounter, a comment, or an action, we already say that “this person is neurotic” or that someone “has an obsessive personality.” We label a person’s personality based on a reaction or an act… a momentary manifestation of their personality at a specific moment and in a specific context. And, from there, we always behave with that person based on that label. That’s a mistake, because it’s a prejudice that prevents us from seeing that person in another way. Getting to know someone’s personality takes a long time.

Q. Would you dare to define the concept of personality?

A. I would define it as the characteristics, mechanisms and components of a human being, which enable them to be a person. That is, being an individual who has the capacity to make decisions, which is what differentiates us from animals. Within psychiatry, we could speak of “personality” as the tendency to be, to feel, to interpret the world and to relate to others in a certain way. But it’s a tendency; it’s not something that traps us.

Q. Can we say that personality, therefore, is fluid?

A. Today, we know that personality isn’t a fixed thing. Rather, it’s a living entity… it flows. While it’s true that it doesn’t flow from white to black, it’s still flowing. It’s not always the same, because it depends on [character] traits — which would be the foundations of the personality — but also on the interaction of those traits with the environment. We could say that genetics lays the foundations of personality… but the foundations are nothing if the building doesn’t eventually take shape via interactions with our surroundings.

Q. Do we all share the same personality traits?

A. Personality is like a temple that’s being built. We all have the same columns that act as support, which are the traits (emotional sensitivity, extroversion and introversion, thrill-seeking, impulsivity, interpersonal sensitivity, etc.), but those columns can be more or less thick, thin, tall, or short. Starting from that basis, a temple that’s built with balanced columns will have more consistency. However, if it’s built with all the thick columns on one side and the thin ones on the other, or with some columns taller than others, the temple can hold… but at the slightest storm or earthquake, it will collapse. The exact same thing is what would happen to someone’s personality.

Q. Can you offer a graphic example of this?

A. If the traits are out of place, there can be very big contradictions. For example, a person may have the trait of being a highly-developed thrill-seeker, but, at the same time, they also have a trait whereby they’re very afraid of something happening to them. This will cause this person to have an inner conflict. They may [freeze] and feel bad, [telling themselves things like] “I’m worthless” or “I’m a coward.” Or, let’s say a guy happens to be a thrill-seeker, but he also has a very strict family that tells him no, that he has to study to be a mathematician and be an orderly and well-balanced man. That is, being the complete opposite of what his biology asks of him. In the end, it’s easy for that boy to end up dropping out of school and smoking joints because he gets bored, because he hasn’t been allowed to flow [in the direction] of where he needs to go.

Q. You mentioned that personality flows in harmony between a person’s biology and their surroundings.

A. Exactly. The thing is that, if there’s no harmony and a child, for example, doesn’t reach the expectations that he feels his parents have, it’s easy for him to begin to get overwhelmed. That’s when the personality gets sick. You have to let the [personality trait] flow, because the trait is never bad. The bad thing is when you try to put a dam on the trait and make a person be different from who they are. It happens a lot with impulsive kids. Maybe they have a brother capable of studying for 10 hours straight, but they can’t be like that. As parents, we have to understand this and let them be. They may be good at many other things, but you cannot try to make them have a trait that they don’t have.

And what happens if we force it on them? Well, the child will begin to think that they’re a disappointment, that they’re worthless. Their self-esteem will begin to fall and they may end up developing a personality disorder.

Q. To what extent do parents affect the personality development of children?

A. The emotional nourishment provided by parents [or guardians] is essential. In the end, the essence of personality-building is the experience of oneself: the image that I have of myself, the esteem that I have towards myself. And this has been created through the eyes of parents: through their smile, [or through] what the world gives us in response to our actions.

It’s in this exchange that we craft our image and our self-esteem. If we haven’t generated a semi-consistent self-image and self-esteem — because there’s a lot of disparity between what we are and the ideal that we feel our parents expect — we’re approaching a personality disorder. That’s why one of the key recommendations of my book is that we must help the [personality] grows towards where it needs to grow. If it can be improved a little, that’s fine. But for example, [parents or guardians] shouldn’t compare a son with his brother or with his friend, because that sends a message that we would like them to be different. The key to protecting against personality disorders is [providing unconditional] loving attention and trust.

Q. Where is the line between a very impulsive, narcissistic, or hypersensitive personality and an actual personality disorder?

A. Basically, a person with a personality disorder cannot function independently. They need a kind of crutch, a protective figure. The case of an emotionally hypersensitive person who can succeed academically and professionally, who can have a partner and who — although they may suffer somewhat — is autonomous, we wouldn’t classify them as having a disorder.

Another key aspect is that the identity of a person with a personality disorder isn’t formed. When we explore [their condition], we realize that they’re people without purpose. They’re going nowhere and are getting tangled in interpersonal situations, [which need to be] dealt with.

Q. The pandemic caused an outbreak of mental health disorders. Has this also happened when it comes to personality disorders?

A. There’s been an exponential increase. In general, this has happened with all disorders that have to do with behavior and personality. We don’t know exactly why this is. It’s partly due to the lockdowns, which forced kids to spend a lot of time with their parents, without the disconnection that relationships with peers entail. And then, [young people] were also probably affected by the universal feeling of meaninglessness. Feeling that they had no prospects, many became discouraged, or entered in symptomatic loops of self-harm.

Q. There’s also a lot of talk about social media affecting personality development.

A. Social media isn’t bad, per se. But when it’s in the hands of vulnerable people, it can do a lot of damage. Think about it: we have kids forming their self-image in comparison to the ideal images they see on social media.

Q. One’s surroundings also play a role in the development of personality disorders. Can they help in the recovery process?

A. Yes. Invalidation of the patient’s discomfort is very common. Since these disorders don’t have very bizarre symptoms — such as delusions or hallucinations — it seems that they’re just troubles in life, that they’re not diseases. One tends to think that the person is forcing the situation a little, or that they don’t want to get out of it. But this isn’t true. The patient is the way they are because they cannot be any other way… but it’s more difficult for family members and society to understand them. That’s why it’s easy to invalidate discomfort with comments like “nothing’s wrong with you,” or “with everything we’ve done to make you happy, how can you do this to us?”

Q. Do we lack empathy with people who suffer from personality disorders?

A. Yes. [These patients] produce a kind of automatic reaction of rejection and annoyance in others. We must be taught to identify the disorder, to empathize [with the person struggling] and to accept them as they are. When someone afflicted with personality disorder is well-received, they automatically have less of a personality disorder. And, over time they stop being [afflicted with the condition]. Care greatly improves the disorder, at least in people with borderline personality disorder, which is the most common one.

Translated by Avik Jain Chatlani

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