Dealing With Difficult Relatives
CLASSIFICATION OF MENTAL DISORDERS
Most mental health professionals use the list of mental disorders provided in the Diagnostic and Statistical Manual (4th Edition), published by the American Psychiatric Association in 1994. It is known as the DSM-IV. This book devotes a chapter to each of the major categories of mental disorders. Examples include substance related disorders (like alcohol dependency), anxiety disorders (like generalized anxiety or obsessive-compulsive disorder), mood disorders (like major depressive disorder or bipolar disorder), schizophrenia and other psychotic disorders, etc.
PERSONALITY DISORDERS
Many people are not aware that another chapter in the DSM-IV deals with personality disorders. Unlike the mental disorders that most people are familiar with, a personality disorder (PD) does not come and go. Personality disorders are, by definition, virtually lifelong, meaning present since adulthood. Further, they are, by definition, maladaptive, meaning that they cause either distress or impaired function in the person’s life. Finally, the behavioral traits that make up the disorder are generally demonstrated by the person in most areas of their life. The DSM-IV lists ten specific PDs. Some of the better known personality disorders are narcissistic PD, antisocial PD, dependent PD, and paranoid PD. The DSM-IV closes the chapter on PDs by including a sort of left-over category called “personality disorder, not otherwise specified.” This label is used for individuals who meet the criteria for a PD, but do not meet the criteria for any of the ten specific PDs.
How common are PDs? Overall, they are quite rare. Surveys indicate that perhaps 10% of adults ever qualify for the diagnosis of any PD. There are small gender differences in the rates of PD. To a small degree, women are more likely than men to show borderline, dependent, or histrionic PD, and men are more likely than women to show antisocial, paranoid, schizoid, schizotypal, narcissistic, or obsessive-compulsive PD.
PERSONALITY DISORDER NOS AND ITS CONSEQUENCES
In my practice of clinical psychology, I have been very impressed with the number of my adult patients who describe a loved one, often a parent, who has, for decades, shown a very stable pattern of extremely difficult and unpleasant behavior to their closes relatives. I have adopted the label “personality disorder, not otherwise specified” for these individuals. I write it: PDNOS.
What are they like? Why do I label them in this way? The behavior of these individuals is routinely described as:
- Mean, hateful, rude, critical, demeaning, insulting;
- Arrogant, insensitive, selfish;
- Domineering, controlling, pushy, demanding;
- Opinionated, outspoken, sarcastic, negative, complaining, impossible to please;
- Inconsistent, irrational.
Further, these individuals, when confronted with their uniquely unpleasant behaviors, often claim convincing excuses for behavior, such as illness, pain, loss/grief, disappointments in life, etc.
It is characteristic of PDNOS that they usually, if not always, behave appropriately, even charmingly, with authority figures or strangers.
INEFFECTIVE COPING STRATEGIES
The following responses to PDNOS behaviors seem completely reasonable, and usually work with other people, but consistently fail with PDNOS. Nevertheless, relatives often continue to attempt these repeatedly.
First, reasoning with the PDNOS relative consists of explaining why you wish they would behave differently, asking them to behave differently next time, revealing how their behavior makes you feel, etc. These approaches all rely on an assumption that the PDNOS relative respects and uses logic in their own thinking and decision making.
Second, confrontation with the PDNOS relative consists of angrily describing their own behavior to them, and demanding they change, and often threatening some consequence if change does not come. This approach relies on the assumption that the PDNOS relative has insight into themselves, and the emotional maturity to try new behaviors.
Invariably, neither reasoning nor confrontation leads to improvement in the PDNOS relative’s behavior. The results are generally nasty arguments followed by increased frustration in my patients.
EMOTIONAL EXPERIENCE OF CAREGIVING ADULT CHILDREN OF ELDERLY PDNOS
PDNOS individuals, as parents raising small children, routinely use parenting styles (demeaning, insulting, sarcastic) which are now commonly labeled psychological abuse. PDNOS individuals, as elderly parent requiring assistance, present a thankless and punishing experience to their adult children. I find these adult children are often ambivalent. They are torn between (1) love, affection, desire to do the right thing, and (2) a long list of unpleasant emotions, such as:
- Anger, hurt feelings,
- Frustration, feeling helpless and inadequate because help is rejected or criticized.
- “Guilt,” i.e., feeling of wrongdoing in having unloving feelings toward a parent,
- Grief/sadness over unfulfilled yearning for a loving parent who would appreciates and validates the child.
CYCLE OF PAINFUL INTERACTION WITH A PDNOS RELATIVE
A. PDNOS shows a provocative act or statement.
B. Relative is shocked/outraged/hurt.
C. Relative tries to correct/reverse the act/statement by reasoning, explaining, confronting, as though PDNOS’ actions
were considered, rational, voluntary.
D. PDNOS denies or escalates, but does not change.
E. Relative feels even MORE resentful, angry, hurt, guilty, confused.
F. Relative suppresses these unpleasant feelings, and resumes hoping for a future filled with normal behavior from PDNOS.
G. Cycle soon repeats.
VIII. LEARNABLE SKILLS FOR COPING EFFECTIVELY WITH A PERSONALITY DISORDER NOS RELATIVE
A. Recognize the psychopathological element.
B. Grieve the lost dream of having a loving relative.
C. Reconceptualize caregiving as a choice, not a duty.
D. Learn to avoid confrontation.
E. Master the appropriate use of the “therapeutic fib.”
F. Set appropriate goals.
G. Develop caregiver self-care skills.
H. Develop good visiting skills.
I. Use formal services, like a psychologist.
J. Use psychiatric medications when appropriate.
Most mental health professionals use the list of mental disorders provided in the Diagnostic and Statistical Manual (4th Edition), published by the American Psychiatric Association in 1994. It is known as the DSM-IV. This book devotes a chapter to each of the major categories of mental disorders. Examples include substance related disorders (like alcohol dependency), anxiety disorders (like generalized anxiety or obsessive-compulsive disorder), mood disorders (like major depressive disorder or bipolar disorder), schizophrenia and other psychotic disorders, etc.
PERSONALITY DISORDERS
Many people are not aware that another chapter in the DSM-IV deals with personality disorders. Unlike the mental disorders that most people are familiar with, a personality disorder (PD) does not come and go. Personality disorders are, by definition, virtually lifelong, meaning present since adulthood. Further, they are, by definition, maladaptive, meaning that they cause either distress or impaired function in the person’s life. Finally, the behavioral traits that make up the disorder are generally demonstrated by the person in most areas of their life. The DSM-IV lists ten specific PDs. Some of the better known personality disorders are narcissistic PD, antisocial PD, dependent PD, and paranoid PD. The DSM-IV closes the chapter on PDs by including a sort of left-over category called “personality disorder, not otherwise specified.” This label is used for individuals who meet the criteria for a PD, but do not meet the criteria for any of the ten specific PDs.
How common are PDs? Overall, they are quite rare. Surveys indicate that perhaps 10% of adults ever qualify for the diagnosis of any PD. There are small gender differences in the rates of PD. To a small degree, women are more likely than men to show borderline, dependent, or histrionic PD, and men are more likely than women to show antisocial, paranoid, schizoid, schizotypal, narcissistic, or obsessive-compulsive PD.
PERSONALITY DISORDER NOS AND ITS CONSEQUENCES
In my practice of clinical psychology, I have been very impressed with the number of my adult patients who describe a loved one, often a parent, who has, for decades, shown a very stable pattern of extremely difficult and unpleasant behavior to their closes relatives. I have adopted the label “personality disorder, not otherwise specified” for these individuals. I write it: PDNOS.
What are they like? Why do I label them in this way? The behavior of these individuals is routinely described as:
- Mean, hateful, rude, critical, demeaning, insulting;
- Arrogant, insensitive, selfish;
- Domineering, controlling, pushy, demanding;
- Opinionated, outspoken, sarcastic, negative, complaining, impossible to please;
- Inconsistent, irrational.
Further, these individuals, when confronted with their uniquely unpleasant behaviors, often claim convincing excuses for behavior, such as illness, pain, loss/grief, disappointments in life, etc.
It is characteristic of PDNOS that they usually, if not always, behave appropriately, even charmingly, with authority figures or strangers.
INEFFECTIVE COPING STRATEGIES
The following responses to PDNOS behaviors seem completely reasonable, and usually work with other people, but consistently fail with PDNOS. Nevertheless, relatives often continue to attempt these repeatedly.
First, reasoning with the PDNOS relative consists of explaining why you wish they would behave differently, asking them to behave differently next time, revealing how their behavior makes you feel, etc. These approaches all rely on an assumption that the PDNOS relative respects and uses logic in their own thinking and decision making.
Second, confrontation with the PDNOS relative consists of angrily describing their own behavior to them, and demanding they change, and often threatening some consequence if change does not come. This approach relies on the assumption that the PDNOS relative has insight into themselves, and the emotional maturity to try new behaviors.
Invariably, neither reasoning nor confrontation leads to improvement in the PDNOS relative’s behavior. The results are generally nasty arguments followed by increased frustration in my patients.
EMOTIONAL EXPERIENCE OF CAREGIVING ADULT CHILDREN OF ELDERLY PDNOS
PDNOS individuals, as parents raising small children, routinely use parenting styles (demeaning, insulting, sarcastic) which are now commonly labeled psychological abuse. PDNOS individuals, as elderly parent requiring assistance, present a thankless and punishing experience to their adult children. I find these adult children are often ambivalent. They are torn between (1) love, affection, desire to do the right thing, and (2) a long list of unpleasant emotions, such as:
- Anger, hurt feelings,
- Frustration, feeling helpless and inadequate because help is rejected or criticized.
- “Guilt,” i.e., feeling of wrongdoing in having unloving feelings toward a parent,
- Grief/sadness over unfulfilled yearning for a loving parent who would appreciates and validates the child.
CYCLE OF PAINFUL INTERACTION WITH A PDNOS RELATIVE
A. PDNOS shows a provocative act or statement.
B. Relative is shocked/outraged/hurt.
C. Relative tries to correct/reverse the act/statement by reasoning, explaining, confronting, as though PDNOS’ actions
were considered, rational, voluntary.
D. PDNOS denies or escalates, but does not change.
E. Relative feels even MORE resentful, angry, hurt, guilty, confused.
F. Relative suppresses these unpleasant feelings, and resumes hoping for a future filled with normal behavior from PDNOS.
G. Cycle soon repeats.
VIII. LEARNABLE SKILLS FOR COPING EFFECTIVELY WITH A PERSONALITY DISORDER NOS RELATIVE
A. Recognize the psychopathological element.
B. Grieve the lost dream of having a loving relative.
C. Reconceptualize caregiving as a choice, not a duty.
D. Learn to avoid confrontation.
E. Master the appropriate use of the “therapeutic fib.”
F. Set appropriate goals.
G. Develop caregiver self-care skills.
H. Develop good visiting skills.
I. Use formal services, like a psychologist.
J. Use psychiatric medications when appropriate.
