Wednesday, May 9, 2018

Someone who makes you feel like you are "crazy"

It's spring here in Colorado and I have been very busy with so much - just not blogging. So... I had better write something, right? Well, I am seeing and getting a lot of questions about something that therapists used to refer to as "Axis II issues," when we had that sneaking suspicion that there was more going on than simple depression or anxiety. Axis II refers to a disability, such as a cognitive delay that compounds mental health issues. Axis I is the primary mental health issue, Axis III is the medical concerns or diagnoses, Axis for is the level of stress, and Axis V is the Global Assessment of Functioning (GAF) score. Zero means your dead, 100 is frankly impossible. Most people who come in for therapy fall between a 45 (outpatient level) and 65.
Many years ago I took a training with Dr. Greg Lester who lives here in Colorado. I saw him teach in New York and I have since been to a keynote speech he did at a local conference. The title of this post is from the manual I still keep from that first training. Someone with a personality disorder can make us feel like we are crazy. The DSM IV and prior (the big psychiatric "bible") used to break down personality disorders by type and title - the immature types, the anxious types etc. The DSM V, the most current publication, just lumps them into Personality Disorder. Similar to how the authors renamed autism and put it all under one title - Pervasive Developmental Disorder.
The aforementioned training was probably the most useful one I had ever attended. It broke down all of the types and behaviors, gave clear examples -mostly using TV and film characterizations, and how to treat and manage these clients, and perhaps even "cure" them of these dysfunctional patterns of interacting with others.
People who have personality disorders create drama. Drama is used a lot when we find ourselves talking about disagreements we might have with people, or sometimes even just referring to someone who has strong feelings. Clinically, drama is the creation of issues that are not initially present. The person might take on a role of victim and seek help. However when the help is not given or not viewed at helpful, they switch roles. They then take on the role of persecutor or rescuer. This switch of drama creation is the hallmark of every type of personality disorder. People who come into treatment who say they do not respond to any treatments or "always" have felt a certain way most likely also have a personality disorder. The clinician often needs to draw upon their own feelings for information - does this client make you anxious? Or angry? Do they attempt to bait you into discussions, redirect you, confuse you? These are big indicators that it is NOT you. If you are a family member, your feelings will also guide you. It's helpful to recognize these behaviors and most importantly, NOT engage with them.
This last part is extremely difficult to do. We as social creatures are hard wired to engage in debates, justify ourselves, become defensive, and want to make things work out for the best. When you are being led around through another's drama, you will feel crazy.
When someone is smart, it is harder to manage this, as a therapist. Often the treatment looks one sided. The client simply talks and talks while the therapist does not engage. This will be a very different experience for the client as most friends, relatives, and anyone else who comes into contact with them will naturally engage, defend, justify, argue. They will suddenly find themselves in a new territory that forces them to use other skills. Dialectical Behavior Therapy (DBT) is a good modality for this - the clients learn about mindfulness, what boundaries are, general social skills. Once the client becomes genuine, an engagement can happen. This is the real person after all, undefended and wanting to make a real connection despite how frightening that can be. When clients are lower functioning and very disabled by trauma and a resulting personality disorder, setting limits, learning skills of daily living and problem solving are essential.
There isn't a complete explanation of how these behaviors and traits come to be. Sometimes there is abuse, and the personality developed as a way to survive childhood. Sometimes it is a general lack of being held accountable for many years, the narcissist believes he or she is special, perhaps because they were always told this and that they could do no wrong.
Some examples of TV and film characters with Personality Disorders (just for fun) and might help you, if you are a clinician, learning to be one or just curious:
Sheldon - The Big Bang Theory (schizoid)
Hugh Grant - About a Boy (schizoid)
Nicole Kidman - To Die For (narcissistic)
Pheobe - Friends (schizzotypal)
The entire cast of Amelie (paranoid, avoidant, histrionic, borderline etc)
Mary Tyler Moore - Ordinary People (obsessive compulsive)
Michael B. Jordan - Black Panther (anti-social)
Mel Gibson - Conspiracy Theory (paranoid)

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