1. health and fitness
2. therapy

Difficult People:
Difficult Patients
A Framework for Intervention, Stabilization and Recovery
41st Annual School of Addiction
and Behavioral Health
Anchorage, AK
May. 2015
Bruce Carruth, Ph.D.
San Miguel de Allende, GTO, Mexico
Difficult People
Bruce Carruth, Ph.D.
Difficult People
have
Difficult Lives
Bruce Carruth, Ph.D.
Difficult People
have
Difficult Lives
And become our
Difficult Patients
Bruce Carruth, Ph.D.
Some characteristics of
difficult people
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
Bruce Carruth, Ph.D.
Characteristics (continued)
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
We’ve all had “worst” times in our lives and
behaved in “difficult” ways
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
Bruce Carruth, Ph.D.
Most of us in early childhood develop core
psychological assets and attributes
Centeredness
Self-esteem
Potency
Integrity
Self-support
Generosity
Perseverance
Curiosity
Trust
Competence
Self discipline
Self-soothing
Empathy
Self boundaries
Capacity to bond and attach
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
Negative reinforcement cycle in adolescence and
young adulthood
Life skills deficits and developmental lags
Lifelong adaptive
coping to wound
increases
rigidity
Developmental
trauma and ongoing
retraumatization
More wounds to self
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
A drug or coping behavior evolves to quell the
core deficits
Some adaptive coping patterns
• CHRONICALLY ANXIOUS
phobically anxious (fearful)
obsessively anxious (obsessive and “locked down”)
core anxiety
• 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
Bruce Carruth, Ph.D.
A drug or coping behavior evolves to quell the
core deficits
• ADDICTION as an effort to adaptively cope
• Control dynamics
• Emotional blunting
• Living in crises
• Shame & guilt
• Aloneness
→Addiction builds “disconnects” in primary relationships
Increasing the alienation / shame / insecurity
→Addiction obscures underlying problems & deficits
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
Common characteristics (con’t)
• 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
Bruce Carruth, Ph.D.
Common characteristics (con’t)
• 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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
IMPLICATIONS FOR TREATMENT
• 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.
Bruce Carruth, Ph.D.
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)
Bruce Carruth, Ph.D.
breakdown
(where difficult people live)
(where other people live)
Range of adaptation
Limited adaptation
A Recipe for a “Nervous Breakdown”
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
“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”)
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
DRAGONS
• Think of the
wounded self as a
dragon …
an internal,
invisible dragon
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
3 options for coming to grips with dragons
1. Hide them
2. Feed them
3. Make friends and tame them
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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 reexperience their wounded self and begin
healing
Bruce Carruth, Ph.D.
Feeding dragons
Life experience
Feeds dragon with:
• Lonely
• Aloneness
• Inadequate / insecure
• $, fame, accomplishments
• Abandonment
• Surrounds self with others
who will never leave
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
What tames dragons?
• Loneliness
• meaningful connection
• Inadequacy
• self validation
• Abandonment
• belonging
• Empty
• meaningfulness
• Guilt / responsibility
• self acceptance
Bruce Carruth, Ph.D.
What tames the dragon (con’t)
• Vulnerability
• self (internal) strength
• Suspiciousness
• safety / trust
• Neediness
• fulfillment
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
Stages of therapy
Engagement
Telling the Tale
Working Through
Integrating
Bruce Carruth, Ph.D.
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.
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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!
Bruce Carruth, Ph.D.
Muy importante!!!
People with character
neurosis don’t come to
therapy to change.
They come to therapy to
get the dragon fed
Bruce Carruth, Ph.D.
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”
Bruce Carruth, Ph.D.
Early treatment strategies
1. Abstinence (for addicts)
2. Lots of emphasis on building connection:
offering hope, belief in possibility of change,
acceptance, good listening
3. Compassion, but not sympathy
4. Support, but not “sides taking”
5. Responding to the presenting crisis
6. Listening for the core dilemmas but not
confronting them
Bruce Carruth, Ph.D.
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 change
9. Final stages of early treatment are:
Beginning to delve into history and its meaning
Beginning to build a road map for recovery and
ongoing treatment
10. And throughout early treatment, keep an eye out for
dragons and how they operate!!!
Bruce Carruth, Ph.D.
2nd phase of treatment
telling 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.
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
2nd phase of treatment (con’t)
Telling the tale
• 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
Bruce Carruth, Ph.D.
2nd phase of treatment (con’t)
Telling the tale
• 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
Bruce Carruth, Ph.D.
2nd phase of treatment (con’t)
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
Stage 3: working through the swamp (con’t)
• 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
Bruce Carruth, Ph.D.
Stage 3: working through the swamp (con’t)
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
Bruce Carruth, Ph.D.
Stage 3: working through the swamp (con’t)
• 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
Bruce Carruth, Ph.D.
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.
Bruce Carruth, Ph.D.
Stage 4 (con’t)
• Difficult people come to therapy having created difficult
situations in their lives:
→primary relationships
→work and education
→physically
→in their families
→legally
→spiritually
• It takes years to reconcile past with present.
• Recovery is a process, not an outcome
Bruce Carruth, Ph.D.
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
Bruce Carruth, Ph.D.
For more information or follow-up
Bruce Carruth, Ph.D.
brucecarruth@gmail.com
brucecarruth.com
US telephone: 713-589-3250
MX telephone: (52) 415-121-1169
Bruce Carruth, Ph.D.
Bruce Carruth, Ph.D.
Bruce Carruth, Ph.D.
Bruce Carruth, Ph.D.
Bruce Carruth, Ph.D.
Bruce Carruth, Ph.D.