Monday, August 29, 2011

TREATMENT ISSUES FOR PASSIVE AGGRESSIVE PERSONALITY DISORDER


TREATMENT ISSUES

Outcomes for clients with Passive Aggressive Personality Disorder (PAPD) can be good with treatment.  However, treatment is usually difficult mostly because the person with PAPD is resistant to believing that they have the disorder and often leave treatment claiming that it didn’t do any good.  Also, the effectiveness of therapies for PAPD are not yet proven—(so they may be right in saying that this disorder does not exist--but I doubt it)!

It is difficult to get them into treatment because they don’t believe they have the problem—YOU do.  They live in fear and don’t trust others’ opinions.  They believe they are constantly dealing with stupid people who don’t understand as much as they understand.  They often start therapy with Marriage/Couples therapy.

The person with PAPD feels pressured by therapist to perform.  The client wants to please consciously, but can’t succeed.  Clients sometimes look for the therapist to tell them what to do and then sabotages it.

(Some experts say that PAPD may be one of the hardest and most miserable patterns of behavior to deal with.  But keep an open mind!)

Cognitive Therapy:  Can help clients to understand that they expect the worst from others and then proceed to behave in such a way that brings out the worst from these same people.

Challenge Their Most Common Thinking Errors (Faulty Thinking)

  • I must avoid an argument, fight or conflict at all costs.
  • I never “win” in confrontation.
  • There is no use in opposing them; they are much more powerful than I am.
  • I must please people by telling them what they want to hear.
  • I never get anywhere by showing my anger openly.
  • It’s bad to get angry.
  • No one wants to know how I feel.
  • No one will understand how I feel.
  • My problems are unique; I need to hide them since no one would understand.
  • I am a loser and failure anyway; why try to defend my position?
  • I enjoy seeing people get blown away by my agreeing with them and then my doing the opposite of what I agreed to do.
  • I’d rather back down right away to minimize the damages a fight could bring rather than tell people how I really feel about things.
  • It’s so hard to be honest with people about how I feel when what I feel is counter to what they want me to feel.
  • It’s important for people to like and accept me and I say anything just so long as they like me.
  • It’s not what I do or how I act that is important to people, it is what I say that influences them.
  • People will never know I’m angry and disagree with them.
  • I hide my feelings well from others.
  • Feelings don’t count.  It is better to deny my feelings than upset another with whom I am in disagreement.
  • I’d rather lie than get into an argument with someone.
  • If I lie about how I feel, others will never know the truth.

Psychodynamic Psychotherapy:  Helps clients to understand root of anger and pattern of early relationships.  Can bring out client’s anger at you (somewhat dangerous—The clinician must be VERY skilled to do this!).

Behavioral and/or CBT:  PAPD’s are ambivalent and express this in behaviors that vacillate between negativism/autonomy and dependency/conformity.  Fluctuations between deference and defiance, between obedience and aggressive negativism, explosive anger or stubbornness and periods of guilt and shame.  Behavior can be either overt or covert.

TREATMENT GOALS TO ADDRESS ARE:

  • survival kills and self-care
  • substance abuse
  • other treatment providers
  • psychosocial history
  • mental status
  • coexisting anxiety/depressive disorders
  • medication evaluations for antidepressants
  • identification of typical PA maneuvers
  1. Challenge passive aggressive behavior and point out the inconsistency between their words and actions.
  1. Pay attention to their actions rather than their words, then give them feedback as to what their actions tell you about their feelings.
  1. Ask for their true feelings reassuring them that there are no right or wrong feelings, and that it is OK to share negative feelings.
  1. Ask them what has them so intimidated that they fear sharing their feelings.
  1. Have them explore their feelings toward authority figures and how these feelings came to be.  Help them resolve these issues.
  1. Help promote development of a positive self-concept.
  1. Avoid criticism—promote positive feedback for positive behaviors.
  1. Help them realize how their behavior affects how others react to them.  Help them be more effective thereby reducing their anger and guilt.
  1. Explore triggers to PA behavior.  (Usually situations where the person’s performance will be judged--or they think they will be judged.  Authority figures and powerful people.)
  1. Reassure them that they can reach a “win-win” solution if they are willing to compromise.
  1. Remain open to any negative feelings they have and let them know this.
  1. Help them recognize how their desire to be competitive affects relationships negatively.  Teach them how to respect how each of us feels.
Help them to see the benefits of eliminating passive aggressiveness.

  • Have deeper, more honest, and longer lasting relationships.
  • Feel less stress, anxiety and depression in dealing with others.
  • Learn to be clear and consistent about their feelings.
  • Stop resorting to lies about their feelings.
  • Develop self-respect, self-confidence, self-esteem, and self-worth.
  • Have more energy because they would no longer be defending themselves from people they consider to be powerful and intimidating.
  • Have clarity of focus and purpose, working on the things they want rather than what others want for them.
  • Have fewer people venting their rage on them.
  • Experience a sense of harmony in their lives.

So what do you do if you are having issues with someone you suspect is PA?  Well, the following is practical advice for clinicians, however, I think the average person can take info from and apply it.

This information can also be very helpful in understanding the process and give support, if your loved one is in therapy.

WARNING:  DO NOT ATTEMPT TO TREAT SOMEONE YOU SUSPECT HAS PAPD UNLESS YOU ARE A CLINICIAN AND ARE NOT RELATED TO THE CLIENT!

SOME QUESTIONS TO ASK:

   WARNING!!  Some PA clients react very negatively to being asked questions.  Use empathy and interpretation in those cases.

  • What is your usual response when I disagree with someone who intimidates you?
  • How do you feel when you are angry or upset with someone who intimidates you?
  • How often do you agree with these people rather than confront them just to avoid conflict?
  • What benefits do you derive by avoiding confrontation?
  • What are your feelings after you have backed down from someone who intimidates you?
  • Under what circumstances do you resort to passive aggressiveness and why?
  • What are the negative results of passive aggressiveness?
Homework/Exercise


        WARNING!  It is dangerous to give PA clients homework or advice.  They usually forget about it or otherwise fail to do it successfully in order to defeat the authority figure (therapist) and preserve autonomy.

        Write a detailed story about incidents during which they acted passive aggressive and a sequel to those stories detailing what they did differently, how they confronted feelings, how they were consistent and gave others permission to call them on inconsistencies.  Include resolutions, impacts on relationships and benefits of being direct and assertive.

Assertiveness Training:  They must learn these skills in order to heal.

Anger Management Groups/Classes:  Anger is at the root of their negativity and sabotage.  They need to get others to express the anger they cannot by their PA behaviors.

Individual Therapy

Group Therapy:

  • Members often become angry and frustrated with the PA client.
  • Provides opportunity for them to learn how to manage their hostility.  Group leader can help them to process what they want or need and then rehearse appropriate behaviors in the group.
  • They do not do well unless they accept responsibility for their hostility and do not alienate other group members.
Couples Therapy:  Often the starting point in therapy:  The partner in the couple is the one who drags the PA client to get help.

TREATMENT GOALS SHOULD INCLUDE:

    1. providing clients with a benign experience with authority figures
    1. addressing control issues and teaching them that they can get one type of control by giving up another, maladaptive type of control
    1. helping PA parents lessen the destructiveness of their over controlling, unpredictable, and hostile behavior with their children
    1. addressing behavior in all relationships, e.g. contrary, stubborn, devaluing
    1. helping them give of their agenda of suffering and work toward achieving and sustaining contentment and efficacy.
Clients with PAPD cannot achieve a personality style that does not fit them temperamentally.  Try to encourage leisurely personality style traits such as:

  • the belief that they have a right to enjoy themselves on their own terms in their own time
  • the inclination to deliver what is expected of them and no more
  • resistance to exploitation; comfortable refusal to meet unreasonable demands
  • relaxes attitude toward time
  • resistance to feeling awe toward authority figures.
These are functional behaviors and are compatible with basic attitudes and beliefs of PAPD clients.

OTHER COMPLICATIONS FOR PAPD CLIENTS:

  • Stunted career development despite good intelligence (i.e., underachievement)
  • Substance abuse or dependency
Countertransference Issues For You:

  • Frustration and anger at inability to help and being defeated.
  • Feeling incompetent because can’t help client.
PA CLIENT BEHAVIORS OFTEN ACTED OUT IN TREATMENT:

  • intrusive and unnecessary phone calls
  • role reversal with evaluation of therapist—discussing good and bad points with emphasis on the bad
  • projection of anger and then criticism of anger
  • absorbing nothing:  in denial, minimizing, changing subject, or denying hostile motivation
  • absorbing everything and refusing to apply it
  • doing opposite of what therapists expect
  • using insight against both themselves and therapists


SEE POST:  WHAT IS PASSIVE AGGRESSIVE PERSONALITY DISORDER?

2 comments:

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Anonymous said...

Issue here is that PA hasn't been recognized since 1994. It is not listed on the DSM-V. IT was removed because it has, and I quote in part, "to broad a range" and was to "vague"