Author: Maria Yang, MD

Categories
Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (II).

Another reason to stop talking in the midst of a difficult clinical interaction[1. I focus on clinical interactions here, but this arguably applies to any difficult interaction we have with our fellow human beings.] is to recognize what you are thinking and adjust the language accordingly. The words we use to describe events, even if only in our heads, will influence both our emotions and behaviors.

Here is an example. Who would you rather work with?

Person 1: This is a 28 year-old woman who is manipulative and immature. She will do anything to get attention; she’s so dramatic. She never takes responsibility for what she does and everyone else has to clean up the messes that she makes.

Person 2: This is a 28 year-old woman who struggles to deal with emotions she feels like she can’t control. She has difficulties with relationships, but she’s doing the best that she can with the skills she has to get her needs met. If she knew how to work with people more effectively, she would. She might also have fears that if she tried harder, she might fail. No one likes to feel shame.

These descriptions could be of the same person. However, your reactions to each description might be noticeably different.

Some may argue that this is an exercise in semantics or, worse, indulgence in delusion. “But, Dr. Yang, she really is manipulative….”[2. Like I noted here, we manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.]

It’s our job to be more flexible than our patients. That’s why we get paid to do what we do. Yes, you could argue that these are just word games. However, would you rather be helpful or would you rather be “right”?

If describing patient behaviors in neutral, if not generous, language will help you maintain your professionalism and deliver quality care, then give strong consideration to what words you choose.

Please note that you can still use neutral language even when you feel angry or frustrated:

She’s screaming and trying to bang her head against the wall right now because that’s the best that she knows how to cope with the situation. I’m getting really annoyed with this… and if she could do something different right now, she would.

What is happening and how you feel are both “true”.[3. Using neutral language in your head during difficult interactions can have the added benefits of making you slow down and reducing the intensity of your emotions.] Remember, you feel what you feel. Own it.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself.

One more reason to follow before we all resume talking.

Categories
Nonfiction Observations

Contrast.

She was a petite woman. She thrust her shoulders back and her dark hair cascaded down in waves towards her slender waist. Her burgundy and white dress gently bounced with each step she took in her four-inch heels. Her arms and legs had the girths of tree saplings. A designer handbag swayed on her left shoulder and pearl-accented earrings dangled from her ears.

It was crowded at the buffet. With purpose she walked past the glistening hunks of prime rib, the pink slabs of baked salmon, the heaps of bacon, the blobs of scrambled eggs, the bowls of romaine lettuce and spinach, the rounded cubes of honeydew, pineapple, and cantaloupe, the bundles of fried egg rolls, the vats of noodles, the pot of egg drop soup, the bowl of quivering red jello, the trays of walnut brownies, lemon cake, and chocolate mousse pie, the racks of barbecue ribs, the oozing discs of pepperoni pizza, the rows of chocolate chip cookies, and the limp triangles of French toast.

She carried her plate with both hands, her fingers tightly gripping the edges. Her eyes scanned the buffet, but she was not looking at the food. The only item on her plate was one roasted red potato.

Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Personality Disorders to Difficult Interactions (I).

I successfully delivered my talk on personality disorders recently. The second half of the talk strayed from personality disorders to a discussion about how to manage difficult interactions with people. The two topics are peripherally related, as you will recall that individuals with personality disorders often have difficulties with interpersonal relationships.

To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.

Think about the last time you had a rough day. It is within the realm of possibility that, during that slice of time, you behaved in ways that suggest you have a personality disorder. It may not happen often, but it happens to all of us at some point.

Most of us rely on “gut feelings” to identify when we’re having difficult interactions with people. There are behavioral cues, though, that can serve as “red flags” to alert you that an interaction isn’t going well:

1. There are frequent interruptions. The other person keeps interrupting you… and you keep interrupting the other person.

2. There is a lot of repeating. You keep saying the same thing over and over again… and the other person keeps saying the same thing over and over again.

3. Many words are spoken, but nothing is really said. The literature describes this as “disengagement”. You’re just saying things to end the conversation. (e.g., “There’s nothing else I can do. Sorry. There’s nothing else I can do. Sorry.”)

Though emotional cues are valuable, sometimes it is easier to recognize these behavioral cues. We may not realize how we’re feeling until it reaches an uncomfortable intensity.

Once you recognize that you are in the midst of a difficult interaction, what can you do?

A useful first step is to stop talking.

The reason why it is important to stop talking is because when you stop talking, you can then self-reflect. I know that sounds “woo woo”. Hang in there with me.

Acknowledge the emotions you are experiencing. If you do not recognize and acknowledge what you are feeling, those emotions will likely manifest themselves in behaviors that you may not like.

If I refuse to acknowledge that I feel angry with someone, I might speak in a tone of voice that sounds sarcastic and condescending, give an icy glare, or say something biting and rude. Acknowledging what I am feeling gives me the opportunity to adjust my behavior accordingly. It gives me choices as to how I want to proceed.

To be clear, people aren’t stupid, so the other person probably knows that I feel angry. Acknowledging my anger, though, can cue me to take a deep breath, relax my face, or do something else to prevent the situation from getting worse. If I’m not paying attention to how I feel, I won’t do any of those things.

The other important aspect about acknowledging your emotions is that it grants you permission to feel what you feel. People sometimes have this idea that you must like all of your patients (or clients or customers or…). However, you won’t like all of your patients. That’s okay. That’s not the expectation. The expectation is that you show respect and provide the best care you can to them. That doesn’t mean that you have to like them.

You feel how you feel. There may be days when you feel anger towards people you like. And that’s okay. You will be much more effective if you acknowledge how you feel to yourself because you will be giving yourself choices. Those choices can give you significant influence over the rest of the interaction.

This is one important reason why you stop talking. More reasons to follow.

Categories
Observations

Personality Disorders (intermission).

Forgive the lull in posts here about personality disorders. I am scheduled to deliver my talk this Friday. I’m directing my efforts towards creating a visually pleasing presentation and discussing the information as coherently as possible.

It doesn’t matter how many times I’ve presented something in front of a large group of people. I still feel nervous before every talk.

Categories
Consult-Liaison Education Medicine

Personality Disorders (IX): Definition and Etiology of the Dependent Type.

There is very little data about dependent personality disorder. Psychoanalytic theorists have discussed their ideas about how this condition comes about, but there are few papers that discuss the reasons why it develops and what to do about it.

We’ll go through the DSM-4 criteria for it first:

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Yikes. Would you have ever guessed that “clinging” would become a diagnostic criterion?

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

The thought is that the person will make the “wrong” decision or that the decision will displease other people. The decisions, though, may not appear complicated to most people. (“Which cereal should I eat? You’re not going to be mad if I eat the Cookie Crisp, right? But maybe I should go with Lucky Charms. Which do you think will taste better?”)

(2) needs others to assume responsibility for most major areas of his or her life

Again, this suggests a lack of trust in oneself to make the “right” decisions. (“Which job should I apply for? Where should I live? What kind of food should I eat?”)

(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.

Perhaps this is also a fear of abandonment (see borderline personality disorder). Also note that this criterion includes a caveat about excluding “realistic fears”, whereas in borderline personality disorder, the excessive efforts apply to either “real or imagined” abandonment.

(I suppose it is noteworthy that this criterion refers to “expressing disagreement” and the borderline criterion refers to “excessive efforts”, though both are driven by “fear”.)

(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

Insecurity is all a matter of degree. Again, this difficulty with initiative must impair function, affect relationships, etc. Conversations like

“Where do you want to eat?”
“I don’t know, where do you want to eat?”

don’t count.

(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

“Doormat” is not a clinical term, but this is what often comes to mind.

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

This is an interesting criterion because it comments directly on emotions rather than behaviors. Sometimes we think people feel uncomfortable or helpless, though they actually feel neither. Sometimes people do feel uncomfortable and helpless, though their behaviors don’t suggest this at all.

(7) urgently seeks another relationship as a source of care and support when a close relationship ends

This criterion, as with the last one, should be taken in conjunction with the other criteria for this diagnosis.

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Fear underpins this diagnosis and drives the behaviors that seem like “clinging”.[1. One must be careful when assuming intentions from behaviors alone. You might see me eating a sack of cookies (behavior) and assume that I lack control (intention). I might actually be eating a sack of cookies (behavior) because I hadn’t eaten all day or I don’t want to share my cookies with other people. Maybe the sack is no longer full of cookies, but I am eating quickly because I am running late. The sack may not have cookies inside. You get my point.]

Here is a paper that reports some studies that describe possible etiologies of dependent personality disorder. Some authors found a relationship between “infantile feeding experiences and later dependency”, though the data is inconsistent and subject to the mothers’ reporting bias.

When people studied interactions between infants and parents and parenting styles, they found that parents who are overprotective and authoritarian may have children who ultimately develop dependent personality disorder.

The author correctly notes that parental behavior may actually reinforce dependent behaviors in children and vice versa. If the parent derives some benefit (psychological or otherwise) from a child who shows dependent behaviors, the parent may actually increase the authoritarian and overprotective behavior because the parent “likes” the reactions. This may drive the child to demonstrate even more of these behaviors. And on and on it goes.

These observations are in direct contrast to other hypothesizes about dependent personality disorder (for which there is no data, but only speculation): Some argue that children who lose their parents at an early age (due to death, adoption, etc.) are more likely to develop dependent personality disorder. Others argue that children who have chronic physical illness are also more likely to develop this condition.

One major component to consider is “fit”.[2. To learn more about “fit”, read about attachment theory.] We don’t choose our parents or our children. Sometimes, there just isn’t a “good fit” between parents and children. Some parents are anxious, which leads to overprotectiveness and authoritarian behavior. This may increase the likelihood that the child will develop dependent personality disorder or traits. If the child had different parents, he might have a different temperament as an adult. To be clear, many children do have anxious parents and never develop this condition.

And that’s all I got for dependent personality disorder. Next up is how to manage (not treat!) these conditions in settings like shelters and supportive housing. I shan’t let that task daunt me.