Difficult People: Difficult Patients A Framework for Intervention, Stabilization and Recovery 41 st...

Difficult People: Difficult Patients

A Framework for Intervention, Stabilization and Recovery

41st Annual School of Addiction and Behavioral Health

Anchorage, AKMay. 2015

Bruce Carruth, Ph.D.San Miguel de Allende, GTO, Mexico

Difficult People

Bruce Carruth, Ph.D.

Difficult People


have

Difficult Lives

Difficult People


have

Difficult Lives

And become our

Difficult Patients

Difficult people have difficult lives — They make lots of bad decisions — Their life is full of crises and struggles — There are never enough internal and external resources

Difficult people are hard to get along with — They ask too much from others — They don’t give much back — They are inconsistent in relationships


Some characteristics of difficult people

Difficult people don’t easily learn from experience So they keep making the same mistakes

Difficult people aren’t inherently “bad” but their behavior leads others to judge them harshly

Difficult people often end up getting what they most fear: Rejection Impotence Vulnerability Shame Isolation Loneliness Hurt Chaos Failure Abandonment Abuse Alone


Characteristics (continued)

• Difficult people (more often than not) end up as victims, with life centered around their “trauma drama”.

• Every family has a few (and sometimes more than a few) difficult people

• Difficult people tend to raise difficult children and pass along the problems generationally


Characteristics (continued)

And many of us are difficult in context or at times in our lives

But some people are difficult MOST of the time and across contexts

And the harder they struggle, the more difficult they can become


We’ve all had “worst” times in our lives and behaved in “difficult” ways


Most of us in early childhood develop core psychological assets and attributes

Centeredness Self-esteem Potency Integrity Self-support Generosity

Perseverance

CuriosityTrust

CompetenceSelf disciplineSelf-soothing

EmpathySelf boundaries

Capacity to bond and attach


These capacities can be hindered by early developmental childhood experiences

• Rejection and abandonment• Physical, emotional & psychosexual abuse• Degradation and shame• Exposure to violence• Developmental failures• Pervasive poverty• Physical illness / physical trauma / birth defects• Poor parental nurturing / loss of a parent


These traumas contribute to inhibiting essential life skills development

• Interpersonal / relational skills• Problem solving skills• Conflict management skills• Needs management skills →meeting self needs →recognizing the needs of others• Work / study skills• Self care skills• Skills in planning and organizing


Negative reinforcement cycle in adolescence and young adulthood

Life skills deficits and developmental lags

Developmentaltrauma and ongoing

retraumatization

Lifelong adaptive coping to wound

increases rigidity

More wounds to self


A drug or coping behavior evolves to quell the core deficits

Some adaptive coping patterns • MANIPULATIVE ORIENTATION suspicious and mistrusting conning and manipulative self aggrandizing / entitled self effacing seductive •. HOPELESS AND DESPAIRING dysthymic / chronically depressed pervasively dependent counter-dependent isolation • WOUNDED and UNSAFE wounded / trauma orientation angry victim



Some adaptive coping patterns • CHRONICALLY ANXIOUS phobically anxious (fearful) obsessively anxious (obsessive and “locked down”) • CORE ANGER aggressive and attacking (everyone else is an idiot) passive aggressive (disavowed overt anger) • WITHDRAWN AND ISOLATED lives within self highly defended and interpersonally distant can acknowledge disconnection but is clueless about how to connect • SOMATICIZING chronically sick or impaired being sick is a/the primary way of connecting, getting love and support



• ADDICTION as an effort to adaptively cope

• Control dynamics • Shame & guilt• Emotional blunting • Aloneness• Living in crises

→Addiction builds “disconnects” in primary relationships Increasing the alienation / shame / insecurity

→Addiction obscures underlying problems & deficits


Initial response in treatment is similar to other clients

• Not drinking / using is going to make everything OK

• Identification with others in treatment

• Relief to have found a solution

• Positive support from others


But soon, difficult people start doing what they have always done

• Magical thinking

• Manipulating and alienating people

• Over / under reacting to the environment

• Over and under emoting

• Creating crises

• Withdrawing


Common characteristics of people with character neurosis (character pattern disturbance)

• Don’t learn from experience Confuse learning and intellectualizing

• Under stress are either rigid, inflexible & compulsive or are underbounded and impulsive

• Often look very self centered, low on empathy

• Low tolerance for frustration


Common characteristics (con’t)

• Feedback may feel threatening – get too defensive to hear feedback about behavior even positive feedback

• Perception of self as victim, – not accepting responsibility for own feelings and behavior

• Fragmented sense of self – distortions of self-perception



• Often poor interpersonal skills – tend to manipulate others to get needs met – other people feel manipulated in interactions with difficult people

• Efforts to get needs met are often exaggerated and self defeating

• Feelings are either repressed, over expressed or distorted



• Often one feeling (sadness, anger, anxiety) is used to express all feelings

• Often see the world in “black and white”, dogmatic, “all or nothing” terms


IMPLICATIONS FOR TREATMENT

• Treatment is all about the relationship

• Treatment has to begin with building safety

• Confrontation has to be attuned to what the person can hear and integrate

• Treatment is an opportunity to build new living / relating skills



• The counselor has to articulate what the client can’t. “Let me check this out with you…”

• Non-judgmental & empathic connection of past and present experience

• The therapist has to adapt their approach and stance over time to the needs of the client.


A Recipe for a “Nervous Breakdown”

• Chronic, repetitive stress

• Limited coping skills for stress

• Rigidity, Lack of adaptability

• Limited environmental supports (family, partners, money, health, shame)


A Recipe for a “Nervous Breakdown”

breakdown

Lim

ited

adap

tatio

n

(where difficult people live)

(where other people live) Rang

e of

ada

ptati

on


Withdrawing and Reacting

• In a crisis, we all tend to either withdraw or become reactive to our environment

• The “good side” of withdrawing is it gets us grounded, back in ourselves, more stable

• The “good side” of reacting is that we take charge of the situation, take action, work for solutions.

• The “downside” of withdrawing is we get immobilized, forces outside of us take over, opportunity to change passes by

• The “downside” of reacting is we get out of control, just reacting to the situation and often alienating us from other supports


“Difficult People” just exaggerate this pattern

Good treatment is helping the individual do the opposite of where they get stuck: in reacting or withdrawing.

• To be more responsive, support coming out, making a plan, taking action, seeking support of others

• To be more grounded with self, sit still, let others take charge, do grounding exercises (e.g. meditation / relaxation), be with others who are making efforts to get grounded (“I need a meeting”)



• Treatment is all about the relationship

• Treatment has to begin with building safety

• Confrontation has to be attuned to what the person can hear and integrate

• Treatment is an opportunity to build new living / relating skills


DRAGONS

• Think of the wounded self as a dragon … an internal, invisible dragon


And what do we know about dragons?

• They are scary and we don’t like to see them

• They have the potential to hurt people

• They live a long time

• They take up a lot of space


What we know about dragons (con’t)

• They tend to alienate others

• Dragons want what they want when they want it

• Get angry quickly and over little things

• Don’t think they are at fault


3 options for coming to grips with dragons

1. Hide them

2. Feed them

3. Make friends and tame them


Hiding dragons

→Hiding the dragon is an attempt to deny / repress the wounded / deficient part of self.

→The problem is that it takes a lot of emotional energy to hide a dragon and they tend to pop out at the wrong times


Feeding dragons

• Feeding dragons are the coping behaviors to cover / hide or co-opt the wounded part of self.

• Well fed dragons just demand more food “Feed me, Seymour, feed me!!!”

• Feeding dragons is shooting self in foot: rewounding


Making friends and taming dragons

The more effective solution is to meet the dragon, make friends and ultimately tame the beast.

One meets their dragons by having the courage, safety and support to re-experience their wounded self and begin healing


Feeding dragons

Life experience Feeds dragon with:

• Lonely • Aloneness

• Inadequate / insecure • $, fame, accomplishments

• Abandonment • Surrounds self with others who will never leave


Feeding dragons (con’t)

Life experience Feeds dragon with:

• Empty • hire people to love us

• Guilt/responsibility • caretaking / martyrdom

• Hurt / vulnerable • safety at all costs

• Suspicious • self reliance / don’t trust

• Neediness • hiring caretakers


What tames dragons?

• Loneliness • meaningful connection

• Inadequacy • self validation

• Abandonment • belonging

• Empty • meaningfulness

• Guilt / responsibility • self acceptance


What tames the dragon (con’t)

• Vulnerability • self (internal) strength

• Suspiciousness • safety / trust

• Neediness • fulfillment


4 stages of treatment

1. engagement and stabilization: placating the dragon

2. Telling the tale and getting the story straight: meeting the dragon & sizing up the swamp

3. Working through the developmental trauma and developmental deficits/lags

finding new ways to embrace the dragon(s) having the corrective emotional experience

4. Integrating and healing: Building a new life coming out on the other side of the swamp


Stages of therapy

Engagement

Telling the Tale

Working Through

Integrating


Some problems in getting started with difficult people

1. Difficult people often don’t respond to conventional cognitive-behavioral therapy. CBT needs to be moderated to be less confrontive, less “heady” & with more focus on emotional support

2. Difficult people often get “worse” in early stages of treatment (after an initial honeymoon) , especially when the therapist is not feeding the dragon.


Problems getting started (con’t)

3. Difficult people are often crisis driven and drop out of treatment when the crisis abates

4. Difficult people tend to use the therapist and treatment environment in inappropriate ways and the therapist may feel manipulated

5. The difficult client’s neediness can feel like a bottomless pit


Problems getting started (con’t)

The transference of difficult people will often lead to inappropriate expectations of the therapist and their role in the therapy

Especially early in treatment the transference can be difficult to track. One day the client thinks you are great and the next you don’t know anything!


Muy importante!!!

People with character neurosis don’t come to therapy to change.

They come to therapy to get the dragon fed


Muy importante!!!

“Tell me I’m not crazy”

“Tell me it’s not MY fault”

“Tell me I’m lovable”

“Tell me I’m a victim”

“Tell me I’m good enough / wonderful”

“Tell me I’m right / I’m all right”


Early treatment strategies

1. Abstinence (for addicts)2. Lots of emphasis on building connection: offering hope, belief in possibility of change, acceptance, good listening3. Compassion, but not sympathy4. Support, but not “sides taking”5. Responding to the presenting crisis6. Listening for the core dilemmas but not confronting them


Early treatment (con’t)

7. Responding to, but not directly confronting, ego defenses (we tend to directly confront in addictions treatment)8. Gaining a commitment for long term change9. Final stages of early treatment are: Beginning to delve into history and its meaning Beginning to build a road map for recovery and ongoing treatment10. And throughout early treatment, keep an eye out for dragons and how they operate!!!


2nd phase of treatmenttelling the tale and getting the story straight

• As the individual stabilizes, develops a commitment to therapy and bonds with the therapist, there is a natural unfolding of the telling of the tale.

• The role of the therapist is to be the observer, embracer and integrator. Interpretation / confrontation invites defense and makes telling the tale dangerous.


2nd phase of treatment (con’t)Telling the tale

• The tale evolves in pieces, in stories that may be stimulated by current experience

• What happened isn’t as important as what it means

• History is only important in terms of current meanings. The only reason to tell the tale is to understand what it means to the person today



• Trying to “remember everything” is futile

• Everything in history is perception. The past isn’t real, isn’t right or wrong, or true or false.

• Our tales are told in metaphor. Our story may not bear much resemblance to the reality of others



• Getting the story straight is like constructing a jigsaw puzzle. Pieces get laid out, then begin to fit together to form a coherent image & the missing parts begin to become more obvious. “What is the theme here”

• The wounds are often the last part of the story to be seen and told

• Words aren’t always the best vehicle for telling the tale



• You don’t have to tell the WHOLE tale

• You know the tale has meaning when emotion is attached (tho the emotion may be hidden). Part of the therapist’s role is to help identify the affects

• As the story evolves, mourning will begin and the swamp will become better defined


2nd phase of treatment (con’t)

• It is scary to meet dragons. As dragons emerge, we do what we’ve always done, revert to lifelong coping patterns. A big job of therapy is to build the capacity to do something different.

• Dragons aren’t events. They are our experience of the event


Stage 3: embracing and working through the self deficit and wading through the swamp

• The swamp is the affects, beliefs and schema and memories of prior experience, reinforced over the years

• The entry point for experiencing the wounded self is through emotion (affects)

• We tell the tale, embrace and experience the affect, experience the past, observe our schema (truth) as it emerges


Stage 3: working through the swamp (con’t)

• The goal of this phase of treatment is for the person to be able to experience the wounded self through the eyes of who they are today and be able to embrace and accept that wounded part.

• Out of this acceptance grows new beliefs about self, enhanced self-efficacy, improved inter-personal relationships, and an ability to experience a range of formerly disavowed emotions



• This experiencing (of the self) occurs in the therapy environment, but also “outside” in ordinary life. The freshness of the new insight allows the person to confront an environmental stimulis in a new way, with different understandings, different behaviors and different results.

• Relationships outside of therapy become fertile ground for the self/other experience



The goal of therapy is to reinfoce the changes and build an environment where a person can:

> continue to experience their self > experience the range of affects that arise when the self is touched > embrace the wounded part and > as a result, alter behavior in the present



• In stage one of therapy, people come to get the therapist to feed the dragon

• In stage two of therapy, people want the therapist to slay or fix the dragon

• In stage three of therapy, people use the therapist to try out new approaches to embrace the dragon


Stage 4: Integrating a new life

• The goal of the final stage of therapy is to integrate changes into a new way of life

• The therapist is now more of a collaborator. The transference is diluted by less frequent visits, by being in group rather than individual therapy, or by other growth efforts on the part of the client.

• The therapist becomes a “check in” point, to be called when needed.


Stage 4 (con’t)

• Difficult people come to therapy having created difficult situations in their lives:

→primary relationships →in their families→work and education →legally→physically →spiritually

• It takes years to reconcile past with present.

• Recovery is a process, not an outcome


Healing is sufficient when:

→We can confront and resolve problems as they arise on a day to day basis

→When we have a network of people around us with whom we can truly be our SELF

→When we know who we are in relation to our environment

→When we can rejuvenate our SELF on a regular basis: Physically, emotionally, intellectually, interpersonally & spiritually


For more information or follow-up


[email protected]

brucecarruth.com

US telephone: 713-589-3250

MX telephone: (52) 415-121-1169

Difficult People: Difficult Patients A Framework for Intervention, Stabilization and Recovery 41 st...

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