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Difficult Clients: Who are They and What Can We Do?

Robin M. Deutsch, Ph.D., ABPPCenter of Excellence for Children, Families and the Law

William James College

Agenda for today

� Personality traits of High Conflict clients and what interferes with resolution

� How can we manage these clients

� Significant mental health issues and parenting

� Time for modification: what to consider

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Personality Disorders

�Enduring pattern of behavior

�Onset is early adulthood

�Rigid and unchanging

�Causes significant stress and impairment

�Outside the cultural norm

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Personality Disorders� All difficulties are external to self

� Lack insight into responsibility

� Constantly responding to internal emotional events-unconscious and conscious

� Chronic internal distress

� Behave inappropriately to relieve distress

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�Cycle:

�feel distress>inappropriate behavior>negative feedback>internal stress> externalization of responsibility>inappropriate behavior

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Personality Disorder� Results of the cycle� Constant interpersonal problems� Perception as VICTIM� Lacks insight, self-reflection� Very defensive� Denies behavior and responsibility- cause or

solution� Seeks confirmation of position� All energy is focused on BLAME� Does not seek or accept treatment

High Conflict Clients� Blaming the Target � Target is close relationship� Blamed for extremely bad behavior� Seek others to advocate for their position

(distortion)� Use emotional persuasion� “Emotional facts,” fit how they feel� Feelings created by cognitive distortions, fact

feels true� Adjust facts to fit feelings, not vice versa

� From William Eddy, High Conflict Personalities

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High Conflict Clients

� Emotional Facts- emotionally generated false information, presented with intensity, requiring emergency action� Exaggeration of real facts� Out of context real facts (manipulated to fit)� Non-existent facts� Stereotyped Induction (give false impression of

target)� It is all about the narrative

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High Conflict Clients: cognitive distortions

� All or nothing thinking� Emotional reasoning�Minimize positive, focus on negative�Overgeneralization� Personalization

� From David Burns (1999)

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High Conflict Clients� Provide increased information, even if false� Aggressiveness- Drama and dominance prevail� Actions out of proportion with events� Simple Stories-creating a story in which one is

the victim, in which right and wrong are “obvious” and there is no need for facts

� Move quickly so there is no time to process� Negative Stereotyping, regardless of facts

starts process of stereotypic induction� Often sabotage self

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High conflict parents fit the court process (adapted from Eddy, 2005)

High conflict client� Externalize and blame

� All or none thinking

� Need to tell story to relieve inner distress

� Seeks alliances/allies

� Emotional, dramatic

� Avoid taking responsibility

� Punishes those who disappoint

� Get others to solve problem

litigation� Who is wrong

� Win-lose process; guilty or not

� Witness is center of attention

� Collaterals/advocates testify

� Dramatic emotional testimony

� Court can hold someone responsible

� Court can impose punishment

� Court will issue a judgment

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� Andy is 10 years old and has been diagnosed with ADHD. The parents are now separated. During the relationship the parties fought over the diagnosis and treatment for Andy. The mother was pro-active in taking Andy to various doctors and specialists. Andy was put on a strict daily routine, prescribed medication and put on a specialized diet. The father believes that the mother is over-pathologizing the child and does not follow all of the routines she wishes, feeds him whatever he wants and does not believe in medicating a child. The mother is now refusing to allow the father overnight access and is even insisting on supervised access unless he will agree to strictly follow all of the rules and routines she has in place. The father is now seeking custody as he believes the mother is harming the child by not letting him grow up to be a normal child.

� What are your concerns about Andy? About each parent?

Personality Disorders

� Cluster C : conflict avoidant� Dependent: passive, submissive, helpless,

approval seeking� Obsessive-Compulsive: over-controlled,

emotionally unexpressive, perfectionist, compulsive, defensive, indignant, overuse intellect

� Avoidant: withdrawing

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Personality Disorders: Cluster A

�Generally conflict avoidant: avoid intensity

�Schizoid: asocial�Schizotypal: eccentric�Paranoid: suspicious, fears

conspiracies

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Personality Disorders

� Cluster B Disorder (Engage Conflict)� Histrionic: dramatic, intense, prone to

fabrication, borderline traits� Narcissistic: preoccupied with self, entitled,

repression� Borderline: extreme mood swings, fear

abandonment� Antisocial: lack empathy, willing to hurt,

disregard societal rules, narcissistic

Specific disorders (Cluster B)� Histrionic PD

� Litigation provides attention!� Be careful of flirtatious, provocative behavior� Can sound persuasive – intense emotions

� Borderline PD� Conflict provides a structure� Change lawyers and retell story over and over

� Narcissistic PD� Legal action to salvage self esteem� Custody dispute will vindicate them� Only they can care for child

� Antisocial PD� Dual diagnosis� When left, feel justified doing anything to get partner back� Harassment to violence if can’t get what they want

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Histrionic Personality Disorder (50% men; 50/% women, NIH, 2014)

� Excessive emotionality- often short-lived

� Excessive attention seeking: often flirtatious and flighty

� Provocative

� Exaggerates emotions and issues

� Highly suggestible, easily influenced by others

� Poor judgment and insight

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Histrionic Personality Disorder (2)� In long term relationships seen as irritable, testy,

manipulative

� Do not provide consistent structure or limits for their children

� Erratic and labile – children continue misbehavior until parents lose their temper

� Speech is impressionistic and lacking in detail

� Very unreliable reporters: fabrication is common

� ***Drive is to get attention – fear of being ignored

� May see in medical malpractice cases

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20Histrionic PersonalityClient Management

� Maintain healthy skepticism: a crisis is usually not an emergency

� Require detail, do not get sucked into dramatic claims

� Focus on tasks, set structure

� Empathize with feeling, not with alleged abuses and be wary of projections

� Be clear and specific about expectations

� Set limits on stories – return to agenda

� Avoid over-reacting to intense emotions

� Agree on consequences

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Narcissistic Personality (6% of US population)

� Grandiosity, marked by sense of self-importance, exaggerates achievement, talents, etc.

� Externalizes Blame

� Reacts to defeat or criticism with rage and retaliation

� Expects to Win: perceives only win-lose solutions

� Arrogant and envious, shows disrespect to others� NIH (2008) 62% men; 38% women

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Narcissistic Personality

� Tremendous sense of entitlement; must be first, most important, etc.

� Requires excessive admiration

� Interpersonally exploitive for own gain

� Lacks Empathy

� ***Fear of Inferiority is motivating force

Narcissistic personality and the court

� Risk takers

� Disdainful of others

� Clueless about consequences (little insight)

� Blame others

� Litigation trumps settlement or mediation

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24Narcissistic PersonalityClient Management

� Minimize idealized goals and expectation that goals can be met

� Avoid framing in win-lose terms� Avoid direct criticism� Recognize real strengths and

accomplishments� Emphasize role in decision making-benefits

of collaboration� Set limits on contacts- insist on the shared

communication loop with coparent� Explain benefits of making and following

agreements

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Borderline Personality (6% of US population

� ***Fear of Abandonment is prime motivator

� Emotional shifts that are unpredictable, rapid and very intense - mood swings

� NIH, 2008 – 53% female; 47% male� Frequent Overlap with narcissistic (40%) and antisocial (20%)

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Borderline Personality� Inconsistency in all areas of functioning

� Self-destructive, self-sabotaging

� Idealization followed by devaluation

� Needy

� Highly impulsive

� Controlling, clingy, seductive, manipulative

� Need validation, so seek enablers

� Vengeful, Rage at sense of abandonment

27Borderline Personality Disorder:Client Management

� Establish professional relationship at a distance you can maintain

� Provide realistic boundaries and expectations

� Don’t join in their anger: maintain that distance but reassure and refocus on next step

� Work with their stated goal

� Begin process of establishing children’s needs & feelings as separate/distinct from client’s re: children’s view of other parent, nature of other parent-child relationship

� Avoid over-reacting to their criticism or strong emotion

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28Borderline Personality Disorder:Client Management (2)

� Continuous reality testing of client’s contribution to conflict situations (e.g., blaming others, denial of responsibility, refusing to honor established agreements

� Expect and encourage small steps and validate as they occur

� Identify emotional facts, require details

� Offer relief from distress and more positive parent-child relationships as incentive to change

� Keep your anger in check

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Antisocial Personality� Lack of conscience, lack of remorse for hurting

others

� Disregard for safety

� Non-cooperative when no gain for self

� The ends justify the means

� May be vindictive, malevolent

� Feel above the law

� ***Fear of being dominated is the drive

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Antisocial traits� Self interest is the only interest� Lies, manipulates, exploits� Violates rules (arrogance)

� When you’re aligned - witty, charming, flattering

� When you set limits – aggression, devaluation, threat (assert power and control)

� Often characteristics of NPD, e.g. grandiosity, lack of empathy, exploitation, seeks power and importance

� BEWARE: manipulation of children common

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Management of Antisocial Clients

� Very charming – don’t be swayed and don’t bend over to curry favor

� Maintain clear and firm boundaries – a legitimate place for rigidity

� Emphasize the need to take responsibility and be accountable

� Be prepared to impose and enforce consequences

� Pay attention to your fears and protect yourself physically and professionally

� Obtain corroborating evidence and be prepared to resign

Paranoid Personality Disorder (Cluster A)

� Suspects, without sufficient basis others are exploiting, harming, deceiving him

� Preoccupied with unjustified doubts about loyalty, trustworthiness of others

� Reluctant to confide in others

� Reads hidden demeaning or threatening meanings into benign remarks

� Unforgiving

� Perceives attacks on self that others don’t see

� Quick to anger or counterattack at perceived attack to character

� Suspicious of faithfulness of partner

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Paranoid Personality Disorder (Cluster A)

� Driving force is distrust of others and fear of betrayal

� Not schizophrenia, which is characterized by out of touch with reality and paranoia beyond their control

� Self control and conscious decision making characterizes Paranoid PD

� Violate court orders in name of protection of children

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Management of Paranoid Clients

� Do not personalize – normalize procedures, cite the law or policy

� Always assume you are being misinterpreted and overexplain and clarify

� Ask for their thoughts, answer questions BE TRANSPARENT

� Put everything in writing

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How to handle any high conflict client (from Bill Eddy)

� Bonding� Be consistent, balanced� Anticipate crises and respond calmly- do not overreact� Keep your distance� Validate person, not complaint� Focus on person’s strengths

� Structure� Set and maintain boundaries� Clarify expectations and roles� Think teenager: choose your battle, contain emotions, reflect

their feelings� Maintain focus on tasks (for their advocates as well)

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Handling high conflict clients (2)

� Reality-testing� Go back to cognitive distortions and maintain healthy

skepticism� Confront outright lies with evidence� Dash legal fantasies that are unrealistic

� Consequences� Court orders need to identify future consequences� Specific treatment orders: for whom, what kind, markers of

success� Markers for behavior change � Financial consequences/penalties� Follow up

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What about the others?

� Family

� Friends

� New partners

� Lawyers

� Therapists

� Tribal warfare

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� Back to 10 year old Andy: Father is refusing to follow food, structure, medication protocol; Mother is insisting on supervised access and Father is seeking custody

� What are next steps in attempting to resolve the conflict and the parenting arrangements?

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Mental Illness

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Mental IllnessFactors include:� Type (major disorder or not)� Level of severity and duration (chronicity)� Amenability to and compliance with

treatment (psychotherapy/medication)� Level of support (family, community)� Co-occurring conditions� SES

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Analyzing parenting capacity/functioning

� Mental illness linked to strengths and difficulties

� Mental illness alone does not predict poor parenting

� Need assessment of nature of parent’s disorder and its implications

� Differences between major mental illnesses, chronic and more temporary, psychosis and personality disorders

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DISORDERS

Result in dysfunction in one or more areas of living:

� interpersonal relations

�work or education

�self-care

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Considerations� Parenting abilities – mediating variable� Level of parenting stress� Nexus between the illness and parenting

� Child Variables�Child’s age at onset of parent illness�Child’s temperament, behavior�Child’s exposure to inappropriate

parental behavior� Linkage between psychiatric condition,

parenting, and child adjustment

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Substance abuse and potential effects on parenting

� Physical caretaking� Food, clothing, shelter� Hygiene, cleanliness� Routine and structure� Safety/supervision

� Discipline� Punitive or permissive

�Ability to meet special needs of child: energy and focus on consistency

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Substance abuse and potential effects on parenting

� Relationship with children� Emotionally disconnected/disengaged� Emotionally over-reactive� Potential violence� Role reversal� Unpredictability

� Social/community involvement� isolation

� Association with violence� High overlap

***Higher rate of abuse and neglect

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Emotional and Behavioral Consequences for Children

� Poorer developmental outcomes

� At risk of substance abuse themselves

� More depression and anxiety than children from non- addicted families

� Attention and focus problems –affects academics

� Self-esteem issues

“why can’t I get him/her to stop?”

But not negative effect on all children

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Patterns of substance abuse� How predictable is usage?

� Intermittent or binge?

� Does parent know when he/she is going to binge?

� Can children be protected from intermittent or binge usage?

� What is commitment to recovery? � For co-occurring disorders, No evidence that

treatment under 90 days is effective� What matters is duration, whole person

approach, methods used, and degree of social support and external pressures

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Evidence-based treatments for alcohol disorder with adults

� Behavioral Self-Control

� Cognitive Behavioral therapy Coping Skills

� Community Reinforcement Approach (contingency management)

� Motivational Enhancement Therapy

� Relapse Prevention Therapy

� Pharmacologic Therapies: Acamprosate (Campral) and Naltrexone

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Change in circumstances

� Step-up planning

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� Tina is 8 years old. Assume that the parents did not live together and the father had only a sporadic relationship with Tina but on several occasions he had overnight access. Both parents blame each other for the lack of a consistent contact. The mother begins a court proceeding for child support and the father then seeks an order for specified access. The court orders supervised access and the supervised access reports are very positive. The mother then agrees to unsupervised day access to be gradually increased to overnight access. Before overnight access is to begin, Tina refuses to see her father. The father alleges this is a pattern with the mother interfering with his relationship with Tina. The mother alleges Tina has bad memories of overnight access with her father when she was little and raises concerns about the father drinking and she is worried about who else is living in his home.