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Dealing with the fact that some clients are just... bad people

futureapppsy2

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More of a philosophical question than a clinical one, but it's something that I think about sometimes in my work, due to focusing on both suicide (heavily grounded in the belief that all lives are inherently worth continuing) and trauma/violence (grounded in the fact that people sometimes do truly awful things)... How do we manage the fact that some of our clients may be just bad people while still treating them with unconditional positive regard and providing optimal clinical care? I'm thinking of clients with personality disorders, substance abuse issues, and maybe some mood and psychotic disorders who have just repeatedly done horrible, taxing things to other people and society and genuinely show no indications of getting better with treatment and often, no real interest in getting better period and no real remorse for anything they've done.

Thoughts?
 
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Fan_of_Meehl

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I try not to play God. Job's already taken. I see it as my job to render treatment, not absolute dichotomous moral judgement/classification of people as good/bad. If 'bad,' their own actions will eventually catch up to them. Evil eats itself in the end. Pathology is no different.
 
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More of a philosophical question than a clinical one, but it's something that I think about sometimes in my work, due to focusing on both suicide (heavily grounded in the belief that all lives are inherently worth continuing) and trauma/violence (grounded in the fact that people sometimes do truly awful things)... How do we manage the fact that some of our clients may be just bad people while still treating them with unconditional positive regard and providing optimal clinical care? I'm thinking of clients with personality disorders, substance abuse issues, and maybe some mood and psychotic disorders who have just repeatedly done horrible, taxing things to other people and society and genuinely show no indications of getting better with treatment and often, no real interest in getting better period and no real remorse for anything they've done.

Thoughts?
It seems like you're getting at couple different things here.

1. Handling your own reactions to "bad" people who are your patients.
2. Working with patients ("bad" or not) who don't seem to be getting better and don't have much interest or inclination to try to get better or even recognize existing problems.

For the latter, it may just be that they aren't ready to be in treatment and may possibly never get there, especially if they are mandated for therapy (or at least pressured by family to do so) and haven't come of their own volition.

Regardless,, the forensic-focused posters probably have some really good insight to both topics.
 
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Fan_of_Meehl

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More of a philosophical question than a clinical one, but it's something that I think about sometimes in my work, due to focusing on both suicide (heavily grounded in the belief that all lives are inherently worth continuing) and trauma/violence (grounded in the fact that people sometimes do truly awful things)... How do we manage the fact that some of our clients may be just bad people while still treating them with unconditional positive regard and providing optimal clinical care? I'm thinking of clients with personality disorders, substance abuse issues, and maybe some mood and psychotic disorders who have just repeatedly done horrible, taxing things to other people and society and genuinely show no indications of getting better with treatment and often, no real interest in getting better period and no real remorse for anything they've done.

Thoughts?
I also try to make friends with the parts of them that 'aren't bad' and strive to help them make friends with the truth. Since I don't work exclusively with psychopaths, it's not that hard to do. I work with PLENTY of people who will probably never get better (I work at the VA, so there's really no way to terminate with them and since the therapy is free, the no-shows are free, the cancellations are free, and every session is a potential audition for more money...I'm likely to work with them indefinitely).
 
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futureapppsy2

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I don’t need “unconditional positive regard” to treat a patient. Just neutral enough to provide sound medical judgement
In psychotherapy, you do need that, though, because without a reinforcing relationship with/for the client, you're going to go absolutely nowhere clinically.
 
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futureapppsy2

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Related question... are there any client populations you just refuse to work with, not on competency grounds, but on moral ones? For example, I've known a lot of people who have worked with trauma victims and said that they absolutely cannot work with perpetrators, especially perpetrators of sexual violence, because they know how much harm that they cause victims.
 
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Fan_of_Meehl

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Related question... are there any client populations you just refuse to work with, not on competency grounds, but on moral ones? For example, I've known a lot of people who have worked with trauma victims and said that they absolutely cannot work with perpetrators, especially perpetrators of sexual violence, because they know how much harm that they cause victims.
I'm not familiar with the concept of a psychotherapist necessarily refusing to work with someone on 'moral grounds.' You mean a situation in which you think your personal bias/beliefs/emotions may get in the way of objectivity such that you cannot effectively or ethically provide the clinical service?
 

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If you believe that unconditional positive regard is a necessary component of psychotherapy, and you ignore the requirements for distress, in most mental disorders... you’re gonna have a bad time.

Behaviorism and FAP can be accomplished without those.

Edit: if you do a deep dive into OLD psychoanalysis literature, you’ll find the word “contemptible” many times.
 
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Fan_of_Meehl

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If you believe that unconditional positive regard is a necessary component of psychotherapy, and you ignore the requirements for distress, in most mental disorders... you’re gonna have a bad time.

Behaviorism and FAP can be accomplished without those.
And I don't necessarily interpret the mindset of 'unconditional positive regard' as equivalent to 'I like the client' or 'I approve of the client as a person.' I guess I always thought of it as a state of mind/spirit that I get MYSELF into as a psychotherapist in order to do my job competently. Most people will display aspects of themselves that I can identify with or that make it clear that they are a human dealing with the same day-to-day fears, loves, striving, pain, disappointment, grief, etc. that I've experienced also in life. I see it more as me identifying, empathizing with, and amplifying the authentic human elements of their personality. I also think it's more of a 'lovingkindness' orientation (within ME) that I try to bring to clinical encounters. Not that I'm perfect at it, but it's what I'm aiming for.
 
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cara susanna

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I try to use a DBT framework, like the patient is doing the best they can with what they have (really, it does me no harm to assume that even if it isn't true) and not viewing behaviors as "good" or bad" but effective or ineffective.
 
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futureapppsy2

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If you believe that unconditional positive regard is a necessary component of psychotherapy, and you ignore the requirements for distress, in most mental disorders... you’re gonna have a bad time.

Behaviorism and FAP can be accomplished without those.

Edit: if you do a deep dive into OLD psychoanalysis literature, you’ll find the word “contemptible” many times.
I was trained in a very, very behavior analytic program (both "traditional" behavior analysis and ACT), to the point where straight-up ABA colleagues have said "oh, you're one of us." You still need to have a reinforcing relationship with the client to make any real clinical progress--even with very young, non-speaking clients we have to pair ourselves with reinforcers to become reinforcing, and compassion for your clients is at the heart of behavior analytic thinking in that every behavior is theoretically "justified" if we understand the learning history and contingencies well enough. Maybe not unconditional positive regard in the Rogerian sense, but you still need to have compassion and empathy for your client. I guess my question is... do you ever reach a point where the client's repeated behavior, its harm to others, and the client's unwillingness or inability to change that behavior keeps you from being unable to approach that client with adequate compassion/empathy/care, and if so, what do you do? (The obvious answer is "refer out", of course, but that's not always possible and/or people don't recognize the depth of their dislike towards the client). Medical colleagues will terminate clients for non-compliance, much less harmful behavior, and we can't really do that.
 
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I was trained in a very, very behavior analytic program (both "traditional" behavior analysis and ACT), to the point where straight-up ABA colleagues have said "oh, you're one of us." You still need to have a reinforcing relationship with the client to make any real clinical progress--even with very young, non-speaking clients we have to pair ourselves with reinforcers to become reinforcing, and compassion for your clients is at the heart of behavior analytic thinking in that every behavior is theoretically "justified" if we understand the learning history and contingencies well enough. Maybe not unconditional positive regard in the Rogerian sense, but you still need to have compassion and empathy for your client. I guess my question is... do you ever reach a point where the client's repeated behavior, its harm to others, and the client's unwillingness or inability to change that behavior keeps you from being unable to approach that client with adequate compassion/empathy/care, and if so, what do you do? (The obvious answer is "refer out", of course, but that's not always possible and/or people don't recognize the depth of their dislike towards the client). Medical colleagues will terminate clients for non-compliance, much less harmful behavior, and we can't really do that.

1. This is a tough spot to be in as a therapist. I think most of us do this work because we generally find it rewarding, and when the reward isn't present it can really become aversive. I've certainly felt this with some people I work with at different points. Just want to validate that.

2. At my best, my take on it is similar to what others have spoken to, I think. If someone is coming in for therapy over and over then there is some reinforcer that is maintaining that behavior (could be my unconditional positive regard, could be concern about judgment from family members, could be fear of incarceration or legal consequences), and I would hope to leverage that in some fashion to help them engage in treatment and extinguish the target maladaptive/unhelpful/problem behaviors and shape up more adaptive/helpful behaviors. If they're coming in inconsistently and it's interfering with therapy then encourage a pause in treatment until they can return for a full course of treatment. If there's no reinforcer then they don't come and that solves that, no?
 
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I don’t need “unconditional positive regard” to treat a patient. Just neutral enough to provide sound medical judgement

I tend to lurk more than post but it seems like your comments are more and more intended to be inflammatory. Perhaps nothing in the clincal outcomes research has been so consistently found to be correlated with positive outcomes across modalities. It’s perhaps the most crucial of the so called common factors. You have to know that, and I’m sure that you do. Part of me wants to believe you don’t actually practice the way your posts sometimes come off, even if maybe you like to think that you do.
 
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I tend to lurk more than post but it seems like your comments are more and more intended to be inflammatory. Perhaps nothing in the clincal outcomes research has been so consistently found to be correlated with positive outcomes across modalities. It’s perhaps the most crucial of the so called common factors. You have to know that, and I’m sure that you do. Part of me wants to believe you don’t actually practice the way your posts sometimes come off, even if maybe you like to think that you do.
I’m just literal.

I need to be at least neutral. I don’t think positive regard is actually required despite the fact that I generally like people.
 
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Sanman

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More of a philosophical question than a clinical one, but it's something that I think about sometimes in my work, due to focusing on both suicide (heavily grounded in the belief that all lives are inherently worth continuing) and trauma/violence (grounded in the fact that people sometimes do truly awful things)... How do we manage the fact that some of our clients may be just bad people while still treating them with unconditional positive regard and providing optimal clinical care? I'm thinking of clients with personality disorders, substance abuse issues, and maybe some mood and psychotic disorders who have just repeatedly done horrible, taxing things to other people and society and genuinely show no indications of getting better with treatment and often, no real interest in getting better period and no real remorse for anything they've done.

Thoughts?

I personally find that life is rarely that black and white. Dig deep enough and there is a little good and bad in everyone. Coming from a learning and behavior standpoint, I try look at everyone as innately selfish and all behavior as a learned adaption. So, what kind of environment reinforced such poor behavior? Is it bad to physically harm another human being? How about if you are in prison? How about in the middle of a war? Context matters.
 
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In my short time practicing I tend to "like" the psychopaths a lot more than the typical cluster b folks. That's probably what they are hoping for though. Maybe I need to watch my back more.

Does anyone like cluster B folks? I mean part of exhibiting cluster B traits and emotional dysregulation is others hate dealing with the behavioral fallout. Psychopaths are better at manipulation and masking by definition, no?
 
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I have yet to have a patient who didn't have some redeeming qualities I could hold onto, at least enough to work with them for a relatively brief course. Had a few I didn't get to know well enough for this happen, but it generally holds true. This included doing court-ordered forensic therapy on internship. I do a lot of values work now and it dovetails nicely since it is often about finding those qualities and letting them shine (being careful not to insert myself into the process to dictate those values...but more often than not the qualities are like are also ones the clients themselves like and want to build up).
 
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BuckeyeLove

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Does anyone like cluster B folks? I mean part of exhibiting cluster B traits and emotional dysregulation is others hate dealing with the behavioral fallout. Psychopaths are better at manipulation and masking by definition, no?

cluster b practitioners?
 
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I just assumed they liked money and job security.

I dunno, some of the DBT principles are refreshing with cluster B folks. A lot of them are a lot less fragile than you think, and once you finally get rapport with them, you can really have some open and honest discussions about their behavior. Love the use of irreverence. Something that's harder to do with some other folks.
 
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Sanman

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I dunno, some of the DBT principles are refreshing with cluster B folks. A lot of them are a lot less fragile than you think, and once you finally get rapport with them, you can really have some open and honest discussions about their behavior. Love the use of irreverence. Something that's harder to do with some other folks.

A bit of irreverence, but it is not as if psychologists are striking up friendships with these people left and right outside of a work context. I don't doubt DBT can have success, but that it is hard work and the fact that we are necessary for treatment in the first place shows how off-putting the behavior can be generally and why they need help.
 

WisNeuro

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A bit of irreverence, but it is not as if psychologists are striking up friendships with these people left and right outside of a work context. I don't doubt DBT can have success, but that it is hard work and the fact that we are necessary for treatment in the first place shows how off-putting the behavior can be generally and why they need help.

Yeah, there is definitely a limit to what you can take. I never carried more than 2 individuals with prominent Axis II at any time for the most part when I did more therapy work.
 

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If we're talking about cluster B/Axis II, can we please mutually complain about the sudden lashing on lay people to the largely pseudo-scientific idea of "complex PTSD" being its own magical thing that we should never try to treat? It is... ugh.

Ugh, this thing was one of my hot button topics when I published in the PTSD world. What a clusterf*ck of terribly designed "research."
 
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Ollie123

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Is there even a generally-accepted definition for complex PTSD? I used to think it specifically referenced cases with multiple index events (which seems legit enough on the surface as something we would want to study and understand, albeit not inherently deserving of being its own diagnostic entity) but that is clearly now how it is used in common parlance. I now mostly just see it used to refer to basically "People who have had crummy lives." Oftentimes BPD by another name. Occasionally PTSD + Axis IV issues.
 
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futureapppsy2

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Is there even a generally-accepted definition for complex PTSD? I used to think it specifically referenced cases with multiple index events (which seems legit enough on the surface as something we would want to study and understand, albeit not inherently deserving of being its own diagnostic entity) but that is clearly now how it is used in common parlance. I now mostly just see it used to refer to basically "People who have had crummy lives." Oftentimes BPD by another name. Occasionally PTSD + Axis IV issues.
Nope, and yep, that's been my frustrating experience as well, plus the idea that we shouldn't treat "complex PTSD" (or even PTSD in general), because treatment is invalidating and victim-blaming. Sigh.
 
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cara susanna

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"Complex PTSD" is my hot button topic! I can rant for hours about how there's no empirical support for it as a distinct diagnosis or diagnostic subtype . Everytime I see it mentioned in the mainstream I shudder and try to decide if it's worth going on said rant (I usually decide that it isn't).

Is there even a generally-accepted definition for complex PTSD? I used to think it specifically referenced cases with multiple index events (which seems legit enough on the surface as something we would want to study and understand, albeit not inherently deserving of being its own diagnostic entity) but that is clearly now how it is used in common parlance. I now mostly just see it used to refer to basically "People who have had crummy lives." Oftentimes BPD by another name. Occasionally PTSD + Axis IV issues.

Generally it is defined as PTSD plus interpersonal and emotional dysregulation. It used to be called PTSD DESNOS. But one criticism that people make of C-PTSD research is that the definition is inconsistent and always changing. Plus there's "complex" symptoms, as I just described. But then there's also what we would consider "complex" trauma which is what you described, e.g., prolonged and repeated sexual abuse. The fun thing is that those two things don't line up at ALL. Okay, I'm starting to go on my rant now so I'll stop.

Edit: Actually, I should say that it's one of my two hot button topics.
 
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Does anyone like cluster B folks?

I love working with BPD, NPD, and HPD! Not ASPD so much. I'm a somewhat introverted person, so the cases I feel the most stuck with are reserved, depressed people who have "nothing" to talk about. It can be difficult for me to "hook" them in. But I am so good at holding boundaries in the face of drama! Borderline people can be so passionate and creative which makes me really enjoy them. And narcissistic people are always doing a lot of work in therapy (even when they're saying they're "fine" and being resistant, they just can't stop giving you a ton of material to work with). With Cluster B's, I never have to pause and ask myself "what are we even doing in this treatment?". Yes! Come in and scream at me! I don't take it personally, and I'd much rather work through that with someone than fish around for goals.
 
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Is there even a generally-accepted definition for complex PTSD? I used to think it specifically referenced cases with multiple index events (which seems legit enough on the surface as something we would want to study and understand, albeit not inherently deserving of being its own diagnostic entity) but that is clearly now how it is used in common parlance. I now mostly just see it used to refer to basically "People who have had crummy lives." Oftentimes BPD by another name. Occasionally PTSD + Axis IV issues.

Right, so what should we call these people? Clearly there is this observable outcome cluster of dysfunctional personality/insecure attachment/poor coping skills that is associated with early life adversity/inconsistent caregiving. It's not quite BPD, though highly overlapping, because there are a fair number of people with BPD whose childhoods objectively weren't so terrible, and also because many people who had difficult childhoods are insecurely attached and have grossly dysfunctional interpersonal relationships without having the hallmark chaotic life trajectory, suicidality, and subjective emptiness of BPD.

We haven't done a very good job of naming something that is pretty clearly a thing. I feel like complex PTSD is as good a label as any. Or you could call it something else, but really, why isn't it in the DSM? I see it way more than I ever saw things like 'schizoid personality disorder'.
 
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cara susanna

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Right, so what should we call these people? Clearly there is this observable outcome cluster of dysfunctional personality/insecure attachment/poor coping skills that is associated with early life adversity/inconsistent caregiving. It's not quite BPD, though highly overlapping, because there are a fair number of people with BPD whose childhoods objectively weren't so terrible, and also because many people who had difficult childhoods are insecurely attached and have grossly dysfunctional interpersonal relationships without having the hallmark chaotic life trajectory, suicidality, and subjective emptiness of BPD.

We haven't done a very good job of naming something that is pretty clearly a thing. I feel like complex PTSD is as good a label as any. Or you could call it something else, but really, why isn't it in the DSM? I see it way more than I ever saw things like 'schizoid personality disorder'.

It's probably just traditional PTSD. The link between BPD and trauma isn't as strong as people think it is.

Also, as mentioned above, the main issue with C-PTSD is that people think it's harder or even impossible to treat than straight PTSD. The argument is that we need to build up interpersonal and emotion regulation skills in these individuals prior to engaging in trauma-focused work (this is referred to as the step-based trauma treatment approach). Research does not support that argument--"complex" trauma and symptoms are not related to worse trauma treatment outcomes or dropout, and building skills prior to trauma work doesn't improve outcomes or retention--and so we just end up delaying care. Or, worse, people don't seek it at all because they're under the impression that their trauma is too complex and will never get better.
 
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It's probably just traditional PTSD. The link between BPD and trauma isn't as strong as people think it is.

Also, as mentioned above, the main issue with C-PTSD is that people think it's harder or even impossible to treat than straight PTSD. The argument is that we need to build up interpersonal and emotion regulation skills in these individuals prior to engaging in trauma-focused work (this is referred to as the step-based trauma treatment approach). Research does not support that argument--"complex" trauma and symptoms are not related to worse trauma treatment outcomes or dropout, and building skills prior to trauma work doesn't improve outcomes or retention--and so we just end up delaying care. Or, worse, people don't seek it at all because they're under the impression that their trauma is too complex and will never get better.

But the clinical picture is totally different than classic PTSD. People with chronically crappy childhoods rarely seem to present with re-experiencing or avoidance, and often not with hypervigilance either. Some of the DSM symptom descriptors for PTSD can't even apply to this population because they stipulate a change from pre-trauma baseline.

Instead they often have the opposite pattern:a chronic unrecognized compulsion to seek out life partners who recapitulate the rejecting or violent behaviors these patients came to expect from their early caregivers.

And it is harder to treat, because they have no previously healthy baseline to compare themselves to. Someone with classic adult onset PTSD from a military exposure or sexual assault has a healthy pre treatment baseline and a pretty clear understanding of the difference. People with histories of early life adversity often don't even have a clear picture of what more functional interpersonal relationships would look like.

There are multiple publications that document worse response to both pharmacological and psychotherapeutic treatments in people with histories of early life adversity. I don't think this is a point that could possibly be under debate, though I'll link some relevant papers anyway.

Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: a meta-analysis
Valentina Nanni, Rudolf Uher, Andrea Danese
American Journal of Psychiatry 169 (2), 141-151, 2012

Childhood trauma predicts antidepressant response in adults with major depression: data from the randomized international study to predict optimized treatment for depression
Leanne M Williams, C Debattista, AM Duchemin, Alan F Schatzberg, Charles B Nemeroff
Translational psychiatry 6 (5), e799-e799, 2016

Childhood maltreatment and differential treatment response and recurrence in adult major depressive disorder.
Kate L Harkness, R Michael Bagby, Sidney H Kennedy
Journal of consulting and clinical psychology 80 (3), 342, 2012
 
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cara susanna

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But the clinical picture is totally different than classic PTSD. People with chronically crappy childhoods rarely seem to present with re-experiencing or avoidance, and often not with hypervigilance either. Some of the DSM symptom descriptors for PTSD can't even apply to this population because they stipulate a change from pre-trauma baseline.

Instead they often have the opposite pattern:a chronic unrecognized compulsion to seek out life partners who recapitulate the rejecting or violent behaviors these patients came to expect from their early caregivers.

And it is harder to treat, because they have no previously healthy baseline to compare themselves to. Someone with classic adult onset PTSD from a military exposure or sexual assault has a healthy pre treatment baseline and a pretty clear understanding of the difference. People with histories of early life adversity often don't even have a clear picture of what more functional interpersonal relationships would look like.

There are multiple publications that document worse response to both pharmacological and psychotherapeutic treatments in people with histories of early life adversity. I don't think this is a point that could possibly be under debate, though I'll link some relevant papers anyway.

Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: a meta-analysis
Valentina Nanni, Rudolf Uher, Andrea Danese
American Journal of Psychiatry 169 (2), 141-151, 2012

Childhood trauma predicts antidepressant response in adults with major depression: data from the randomized international study to predict optimized treatment for depression
Leanne M Williams, C Debattista, AM Duchemin, Alan F Schatzberg, Charles B Nemeroff
Translational psychiatry 6 (5), e799-e799, 2016

Childhood maltreatment and differential treatment response and recurrence in adult major depressive disorder.
Kate L Harkness, R Michael Bagby, Sidney H Kennedy
Journal of consulting and clinical psychology 80 (3), 342, 2012

So these are all depression studies, not PTSD studies. I am talking about PTSD, not depression. If someone has PTSD symptoms but is missing a cluster e.g. hypervigilance, other specified trauma or stressor-related disorder captures that just fine. There's no need to come up with a new diagnosis that has no empirical support for it. Additionally, I am referring to evidence-based therapy for PTSD when I refer to treatment. As I mentioned, studies demonstrate that type of trauma (including childhood sexual abuse), number of exposures, and age at exposure(s) do not predict PTSD treatment outcome or drop out rates. Even if it's true that childhood trauma predicts worse outcomes, there is no reason for complex PTSD to exist as a diagnosis and definitely not with separate treatment recommendations. As I mentioned, studies that do examine the step-based trauma treatment approach thus far have not found any benefit.


 
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But the clinical picture is totally different than classic PTSD. People with chronically crappy childhoods rarely seem to present with re-experiencing or avoidance, and often not with hypervigilance either. Some of the DSM symptom descriptors for PTSD can't even apply to this population because they stipulate a change from pre-trauma baseline.

Instead they often have the opposite pattern:a chronic unrecognized compulsion to seek out life partners who recapitulate the rejecting or violent behaviors these patients came to expect from their early caregivers.

And it is harder to treat, because they have no previously healthy baseline to compare themselves to. Someone with classic adult onset PTSD from a military exposure or sexual assault has a healthy pre treatment baseline and a pretty clear understanding of the difference. People with histories of early life adversity often don't even have a clear picture of what more functional interpersonal relationships would look like.

Sounds like PTSD mixed with some Cluster B to me. Which is what the proponents of "complex PTSD" have repeatedly failed to reliably differentiate in trying to claim that it is a distinct disorder. Also a reason that DBT seems to work pretty well with these patients.
 
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So these are all depression studies, not PTSD studies.

Right, which makes sense, of course, because the whole problem is that we don't have a diagnostic category or specifier for "bad childhood and consequent dysfunctional relationships". So these people get dumped into other categories. For classic adult-onset PTSD, an MDD-like picture can also be part of the presentation ("pervasive alterations in mood"), but because of the "better explained by" criterion, we rightly don't diagnose both together. For "complex PTSD," since the appropriate category is not in the DSM, they get called lots of other things and pile up a string of partially-applicable diagnoses that could be more perspicuously dealt with if we had a real name for the syndrome.

I am talking about PTSD, not depression.

OK but my point is that we need a name for the thing that people are calling "complex PTSD." I am in full agreement that it bears little relationship to classic PTSD, although the parallel diagnostic structure of exposure+clinical syndrome makes sense to me. But the criterion A would be different, the clinical symptoms are different, and most importantly, the age and chronicity of exposure would be relevant.

If someone has PTSD symptoms but is missing a cluster e.g. hypervigilance, other specified trauma or stressor-related disorder captures that just fine.

But usually people who go into these other/NOS categories go there because they are oddballs, are missing a criterion or whatever. It doesn't make sense to me that a very common syndrome with obvious prognostic importance wouldn't have its own DSM label.

There's no need to come up with a new diagnosis that has no empirical support for it.

Really, there's no empirical support for the assertion that people with messed up childhoods have messed up adult relationships and relatively intractable mood/anxiety symptoms compared to people with loving, supportive childhoods? For real?

Additionally, I am referring to evidence-based therapy for PTSD when I refer to treatment.

I don't think it makes a lot of sense to apply, for example, exposure-based interventions to people who had messed up childhoods, and expect that to fix their dysfunctional interpersonal schemas. Do you?

As I mentioned, studies demonstrate that type of trauma (including childhood sexual abuse), number of exposures, and age at exposure(s) do not predict PTSD treatment outcome or drop out rates.


This study does not appear to have examined age or chronicity of exposure at all, just symptom clusters. (Also it included only 58 individuals with self-reported CPTSD sx and examined only the possibility of PTSD vs PTSD+CPTSD, not the possibility that someone could have CPTSD without PTSD.)
As I am certain you are aware, other studies, some of them cited by the one you linked, which doesn't appear to be an improvement upon them, have found support for the CPTSD diagnosis.


Even if it's true that childhood trauma predicts worse outcomes, there is no reason for complex PTSD to exist as a diagnosis and definitely not with separate treatment recommendations. As I mentioned, studies that do examine the step-based trauma treatment approach thus far have not found any benefit.

Sure, I think the best way to approach the chronic-childhood-adversity/adult-relational-dysfunction presentation is absolutely a question that requires further active investigation. As we know, this is a difficult-to-treat group, and the phased approach you mention may not be the answer. Like WisNeuro above, I usually send them to DBT, which is often helpful (as it is often helpful for many people with emotional dysregulation/poor coping skills who don't fit classic BPD criteria). Although I kind of think DBT does a better job of addressing the immediate issue of coping skills but maybe not such a great job of addressing the larger problem of interpersonal dysfunction. DBT is so focused on putting out emotional-lability fires that there's not a lot of space to work on the relational piece.

But I think ignoring the existence of the syndrome and pretending that it is equivalent to adult-onset PTSD will preclude us from being able to do the research that is necessary to answer this question.
 
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cara susanna

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Right, which makes sense, of course, because the whole problem is that we don't have a diagnostic category or specifier for "bad childhood and consequent dysfunctional relationships". So these people get dumped into other categories. For classic adult-onset PTSD, an MDD-like picture can also be part of the presentation ("pervasive alterations in mood"), but because of the "better explained by" criterion, we rightly don't diagnose both together. For "complex PTSD," since the appropriate category is not in the DSM, they get called lots of other things and pile up a string of partially-applicable diagnoses that could be more perspicuously dealt with if we had a real name for the syndrome.



OK but my point is that we need a name for the thing that people are calling "complex PTSD." I am in full agreement that it bears little relationship to classic PTSD, although the parallel diagnostic structure of exposure+clinical syndrome makes sense to me. But the criterion A would be different, the clinical symptoms are different, and most importantly, the age and chronicity of exposure would be relevant.



But usually people who go into these other/NOS categories go there because they are oddballs, are missing a criterion or whatever. It doesn't make sense to me that a very common syndrome with obvious prognostic importance wouldn't have its own DSM label.



Really, there's no empirical support for the assertion that people with messed up childhoods have messed up adult relationships and relatively intractable mood/anxiety symptoms compared to people with loving, supportive childhoods? For real?



I don't think it makes a lot of sense to apply, for example, exposure-based interventions to people who had messed up childhoods, and expect that to fix their dysfunctional interpersonal schemas. Do you?



This study does not appear to have examined age or chronicity of exposure at all, just symptom clusters. (Also it included only 58 individuals with self-reported CPTSD sx and examined only the possibility of PTSD vs PTSD+CPTSD, not the possibility that someone could have CPTSD without PTSD.)
As I am certain you are aware, other studies, some of them cited by the one you linked, which doesn't appear to be an improvement upon them, have found support for the CPTSD diagnosis.




Sure, I think the best way to approach the chronic-childhood-adversity/adult-relational-dysfunction presentation is absolutely a question that requires further active investigation. As we know, this is a difficult-to-treat group, and the phased approach you mention may not be the answer. Like WisNeuro above, I usually send them to DBT, which is often helpful (as it is often helpful for many people with emotional dysregulation/poor coping skills who don't fit classic BPD criteria). Although I kind of think DBT does a better job of addressing the immediate issue of coping skills but maybe not such a great job of addressing the larger problem of interpersonal dysfunction. DBT is so focused on putting out emotional-lability fires that there's not a lot of space to work on the relational piece.

But I think ignoring the existence of the syndrome and pretending that it is equivalent to adult-onset PTSD will preclude us from being able to do the research that is necessary to answer this question.

But if you read the study above, there are people with "complex" symptoms that also have a single trauma and adult onset. So how can we claim it's the same thing? By all means, study this topic, but claiming that it's a separate diagnosis and related to childhood trauma when there's no clear and consistent relationship demonstrated between said symptoms and trauma type is to me a huge issue.

My other big issue with C-PTSD is that the cart is now before the horse. If you think that it exists, fine, but it's now take as a given fact when the diagnosis is at the very least disputed.
 
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But if you read the study above, there are people with "complex" symptoms that also have a single trauma and adult onset. So how can we claim it's the same thing?
By all means, study this topic, but claiming that it's a separate diagnosis and related to childhood trauma when there's no clear and consistent relationship demonstrated between said symptoms and trauma type is to me a huge issue.

I think that the optimal designation of symptom clusters to achieve maximal separation from other DSM diagnoses is still a matter of study and debate; recognizing, of course, that all of the existing DSM diagnoses also have some overlap among themselves at the edges, and that inter-rater reliability for DSM diagnoses is pretty poor across the board.

My other big issue with C-PTSD is that the cart is now before the horse. If you think that it exists, fine, but it's now take as a given fact when the diagnosis is at the very least disputed.

I'd say it's a given fact that chronic exposure to adversity in early development tends to create a lifelong set of mental health problems. This has been established through multiple lines of human and animal research spanning decades.

I think that whether the specific name and symptom clusters that have been suggested as CPTSD is the best way to capture this or not is definitely up for debate. But the fact that we currently have no diagnosis or specifier to indicate exposure to early life adversity is a huge lacuna in the DSM, and one that has important consequences both for treatment choices and the formulation of research questions.
 
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Mindfulpsych22

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Although I kind of think DBT does a better job of addressing the immediate issue of coping skills but maybe not such a great job of addressing the larger problem of interpersonal dysfunction. DBT is so focused on putting out emotional-lability fires that there's not a lot of space to work on the relational piece.

This a bit of a deviation but just couldn’t let this go. This a huge misrepresentation of DBT. If this is your view of DBT, what you’ve been exposed to seems like non-adherent, low quality DBT. DBT has an entire skills module devoted to interpersonal skills. Interpersonal behaviors with the therapist and therapy team are targeted within the therapy all the time! In fact, they are often targeted within “therapy interfering behaviors” which is the second most highly prioritized treatment target, second to life threatening/self-injurious behaviors. The initial sessions of DBT are almost entirely focused on establishing a collaborative relationship and making specific commitments to each other and the therapy. A well-trained DBT therapist is thinking of skill building and generalization constantly and uses every interaction with the client as an opportunity to enhance interpersonal skills. DBT therapists talk about the therapeutic relationship often and give the client honest feedback about how their behaviors impact the therapist. Even phone coaching in DBT is set up in a manner to help the client with learning how to seek help from others in a more functional way rather than through dysfunctional means that burn people out (passivity, helplessness, hostility/complaining, emotional escalation, etc).

Furthermore, DBT is much less about “putting out” emotional fires with distress tolerance skills than working on long-term change by targeting patterns of reactivity and working to change those through solid cognitive work, exposure, behavioral activation, and problem-solving. An important part is often working on skills to reduce dysfunction in interpersonal relationships. DBT also often tries to facilitate functional friendships between DBT clients to reduce social isolation and enhance social support.

We can certainly discuss which treatment targets DBT seems to do better or worse at improving in the research studies, but I personally think “interpersonal functioning” is a very hard outcome to operationalize and capture. Furthermore, it is often embedded in or inextricably linked to other treatment targets/outcomes in a way that may not be straightforward to detect. For example, MDD may improve during a course of treatment because a client goes from being lonely and isolated to actually building and sustaining meaningful relationships. That level of complexity is poorly captured by an outcome measure of remission of MDD or change in BDI scores. I personally believe that because interpersonal conflict is often a primary antecedent for self-injury and suicide attempts in DBT clients, the reduction in hospitalizations/suicidal and self-injurious behavior is often an indicator that the client is improving at reducing, reacting to and working through interpersonal conflict. Given that DBT clients have often dropped out of previous treatments because of anger/relationship problems with the therapist, the relatively low drop out rate in DBT may be an indicator that DBT improves a client’s interpersonal functioning with their therapist. Teasing this out is so hard because relationship functioning has a highly transactional influence with emotion regulation (if I use coping skills to better manage anger and don’t blow up on people, then I hang onto more friends, then my beliefs about being unlovable start to change, then I become less afraid of others leaving, then the next time there is a conflict, it is perceived as less of a threat and evokes a less intense emotional response which makes it easier to act effectively and maintain the relationship, etc). Like I said, I think it’s very hard to isolate “interpersonal functioning” as easily studied treatment outcome separate from other outcomes.
 
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WisNeuro

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Agree with mindfulpsych here, DBT has huge components that deal with interpersonal/relational issues, both within and without the therapeutic relationship. What was described earlier as DBT that focuses on immediate issues, does not sound like any of the DBT I was trained in. I'm sure there are some watered down versions out there. But, it sounds like you need to find a new DBT referral source if that's all you're getting.
 
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