treating masochistic patient

[scentofpapaya]

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ok... just wanted to throw this question out there hoping that I can get some advice from more experience people....
How would you treat a patient who has "treatment resistant depression" but also has a self-defeating masochistic personality structure??
Let's say that the patient always complains that nothing works but at the same time, is not compliant with medications. How would you approach??

 

[LadyHalcyon]

ok... just wanted to throw this question out there hoping that I can get some advice from more experience people....
How would you treat a patient who has "treatment resistant depression" but also has a self-defeating masochistic personality structure??
Let's say that the patient always complains that nothing works but at the same time, is not compliant with medications. How would you approach??

I find these two books can often be helpful in regard to conceptualizing and treating personality disorders: "Overcoming Resistant Personality Disorders: A Personalized Psychotherapy Approach" and "Moderating Severe Personality Disorders: A Personalized Psychotherapy Approach."

 

[LadyHalcyon]

ok... just wanted to throw this question out there hoping that I can get some advice from more experience people....
How would you treat a patient who has "treatment resistant depression" but also has a self-defeating masochistic personality structure??
Let's say that the patient always complains that nothing works but at the same time, is not compliant with medications. How would you approach??

I know I just commented (I am avoiding doing my work and this is somewhat "work-related") but I think it may be helpful to explore the emotional needs being met through their behavior. People with masochistic tendencies tend to pull for others to take care of them by presenting as "not good enough/not competent." Perhaps at some time in their life, likely early childhood, these behaviors were adaptive and increased the likelihood their caregivers would tend to their needs. Perhaps their emotions were invalidated the majority of their life, and they worry if they "get better" then they will lose any support system they have. Noticing your own reactions to the patient can be very helpful. Are you annoyed and/or find them pathetic? Do you feel sorry for them and want to rescue them? From my perspective, it is important you don't inadvertently act in a way that confirms the patient's beliefs about themselves. One of my my main therapeutic goals is to promote autonomy, which can be difficult with patient's with dependent traits. Autonomy promotes competence and increases self-esteem, which improves psychological functioning. That being said, if I am not careful I can fall into the dependent trap by doing things for them (i.e. making appointments with psychiatrists, spoon-feeding them my conceptualization of their disorder, giving them direct suggestions). For some patients the aforementioned interventions are appropriate and helpful, but for certain patients it only reinforces their belief they can't accomplish things on their own and it shows them I care, which fulfills their emotional needs and reinforces the likelihood they will continue to use similar strategies.

Edited to add: I thought this post was in the Psychology section, sorry. I know most psychiatrists focus primarily on med management and I realize my comment may not have been helpful.

 

[whopper]

Explain to the patient that the nature of the treatment requires they be compliant or else it'll likely not work.

If the patient isn't doing the treatment to begin with explore what can be done to help the patient be consistent. E.g. Fluoxetine comes in a weekly version, family getting on-board to help administer meds, case-management if possible or appropriate to help with meds. That said do this within reason. Sometimes going out of your way to assist could enable pathological personality traits.

 

[Amygdarya]

I know I just commented (I am avoiding doing my work and these is somewhat "work-related) but I think it may be helpful to explore the emotional needs being met through their behavior. People with masochistic tendencies tend to pull for others to take care of them by presenting as "not good enough/not competent." Perhaps at some time in their life, likely early childhood, these behaviors were adaptive and increased the likelihood their caregivers would tend to their needs. Perhaps their emotions were invalidated the majority of their life, and they worry if they "get better" then they will lose any support system they have. Noticing your own reactions to the patient can be very helpful. Are you annoyed and/or find them pathetic? Do you feel sorry for them and want to rescue them? From my perspective, it is important you don't inadvertently act in a way that confirms the patient's beliefs about themselves. One of my my main therapeutic goals is to promote autonomy, which can be difficult with patient's with dependent traits. Autonomy promotes competence and increases self-esteem, which improves psychological functioning. That being said, if I am not careful I can fall into the dependent trap by doing things for them (i.e. making appointments with psychiatrists, spoon-feeding them my conceptualization of their disorder, giving them direct suggestions). For some patients the aforementioned interventions are appropriate and helpful, but for certain patients it only reinforces their belief they can't accomplish things on their own and it shows them I care, which fulfills their emotional needs and reinforces the likelihood they will continue to use similar strategies.

Edited to add: I thought this post was in the Psychology section, sorry. I know most psychiatrists focus primarily on med management and I realize my comment may not have been helpful.

As a psychiatry resident, I thank you for posting this in the psychiatry subforum, as it's very important for psychiatrists to be aware of these issues, whether they do psychotherapy or not. Please keep posting here.

 

[LadyHalcyon]

As a psychiatry resident, I thank you for posting this in the psychiatry subforum, as it's very important for psychiatrists to be aware of these issues, whether they do psychotherapy or not. Please keep posting here.

Thank you! I just would have slightly trailored my response but I appreciate your feedback!

 

[whopper]

With psychosis and a few other disorders it's quite common for the person to not want to pursue care. Bipolar Disorder, and Schizophrenia often times are accompanied by anosognosia. In Bipolar Disorder treating the mania is often times ego-dystonic cause the patient likes the mania. Treating the Schizophrenia could fit in with the patient's delusions that someone's out to control him/her.

In substance abuse same thing with the ego-dystonic situation. Often times addicts don't want to get better on an emotional level. They can intellectually identify that being sober is the better thing but do not emotionally identify it. This has been cited in psych textbooks as intellectual vs emotional insight. Just like almost all smokers know it's bad for you, and may even want to quit but aren't committed to doing so.

Bottom line, however, is that you can only offer treatments in outpatient and can only involuntarily treat those committed against their will who do not have insight into the treatments. I've had several times where I've tried to explore getting a patient who does not want to get better in outpatient. It's leading a horse to water. They can choose not to drink even if offered. You can offer motivational therapy therapy but aside from that it's really on them.

If you offer to assist someone, say to help them stop smoking, and they don't want to quit, that's mostly on them not you. Of course, explore the situation, offer motivational therapy, remind them of what they got to lose, but once you done that what more to do?

A side of medical treatment people don't want to bring up is that you can only do so much.

 

[Crayola227]

With psychosis and a few other disorders it's quite common for the person to not want to pursue care. Bipolar Disorder, and Schizophrenia often times are accompanied by anosognosia. In Bipolar Disorder treating the mania is often times ego-dystonic cause the patient likes the mania. Treating the Schizophrenia could fit in with the patient's delusions that someone's out to control him/her.

In substance abuse same thing with the ego-dystonic situation. Often times addicts don't want to get better on an emotional level. They can intellectually identify that being sober is the better thing but do not emotionally identify it. This has been cited in psych textbooks as intellectual vs emotional insight. Just like almost all smokers know it's bad for you, and may even want to quit but aren't committed to doing so.

Bottom line, however, is that you can only offer treatments in outpatient and can only involuntarily treat those committed against their will who do not have insight into the treatments. I've had several times where I've tried to explore getting a patient who does not want to get better in outpatient. It's leading a horse to water. They can choose not to drink even if offered. You can offer motivational therapy therapy but aside from that it's really on them.

If you offer to assist someone, say to help them stop smoking, and they don't want to quit, that's mostly on them not you. Of course, explore the situation, offer motivational therapy, remind them of what they got to lose, but once you done that what more to do?

A side of medical treatment people don't want to bring up is that you can only do so much.

this bit about intellectual vs emotionally identify, can anyone expand on this or any techniques for the latter? I feel like the former just sorta happens naturally in a lot of physicians' day to day practices so I'm at a loss

 

[whopper]

It's been detailed in Kaplan and Sadock.

I found lots of jargon in K&S ineffectual. E.g. I've talked to some of the top psychiatrist in the field such as Paul Keck, Henry Nasrallah among others and the lingo used in K&S isn't in the board exams, isn't used on the field nor by almost anyone other than K&S.

But the difference between intellectual vs emotional insight I find a very significant thing. We write in MSEs one word evaluations on insight, which highly oversimplifies it. E.g. many doctors ask a patient if they can tell if they are sick and need help and if the patient says yes they'll write in the MSE that insight is "good," despite that the patient has years of non-compliance. Differentiating between the 2 in an MSE will give a much better picture with only 3-5 more words.

E.g. for a chronic smoker who doesn't want to quit
Insight: Intellectual-good, Emotional-poor.

 

[clausewitz2]

this bit about intellectual vs emotionally identify, can anyone expand on this or any techniques for the latter? I feel like the former just sorta happens naturally in a lot of physicians' day to day practices so I'm at a loss

I would avoid the distinction between intellectual and emotional "insight" in this case in favor of thinking about different kinds of motivations and incentives. Understanding why someone persists in an apparently destructive behavior despite being able to name reasons they shouldn't when asked about it should prompt you to think about what the function of the behavior really is for them.

They would not keep doing it if it was doing something for them. Perhaps they have learned that planning for the long term is futile because their lives have always been very chaotic so better to take pleasure when you can. Perhaps they do not attach as much value as you do to physical longevity. Perhaps they are fiercely independent-minded and resent being pressured to change their behavior. Perhaps some of the way they eat is an important part of their culture and changing that is losing part of their identity.

Presuming that the values of our guild are the only rational ones makes it difficult to having a working relationship with people who don't fundamentally accept that.

 

[FlowRate]

I know I just commented (I am avoiding doing my work and these is somewhat "work-related) but I think it may be helpful to explore the emotional needs being met through their behavior. People with masochistic tendencies tend to pull for others to take care of them by presenting as "not good enough/not competent." Perhaps at some time in their life, likely early childhood, these behaviors were adaptive and increased the likelihood their caregivers would tend to their needs. Perhaps their emotions were invalidated the majority of their life, and they worry if they "get better" then they will lose any support system they have. Noticing your own reactions to the patient can be very helpful. Are you annoyed and/or find them pathetic? Do you feel sorry for them and want to rescue them? From my perspective, it is important you don't inadvertently act in a way that confirms the patient's beliefs about themselves. One of my my main therapeutic goals is to promote autonomy, which can be difficult with patient's with dependent traits. Autonomy promotes competence and increases self-esteem, which improves psychological functioning. That being said, if I am not careful I can fall into the dependent trap by doing things for them (i.e. making appointments with psychiatrists, spoon-feeding them my conceptualization of their disorder, giving them direct suggestions). For some patients the aforementioned interventions are appropriate and helpful, but for certain patients it only reinforces their belief they can't accomplish things on their own and it shows them I care, which fulfills their emotional needs and reinforces the likelihood they will continue to use similar strategies.

Edited to add: I thought this post was in the Psychology section, sorry. I know most psychiatrists focus primarily on med management and I realize my comment may not have been helpful.

FYI In my residency and area of the country psychiatrists also do a lot of psychodynamic work, so I find this post directly helpful to my practice.

But the difference between intellectual vs emotional insight I find a very significant thing. We write in MSEs one word evaluations on insight, which highly oversimplifies it. E.g. many doctors ask a patient if they can tell if they are sick and need help and if the patient says yes they'll write in the MSE that insight is "good," despite that the patient has years of non-compliance.

FWIW we're encouraged to actually describe insight and judgement (patient recognizes they have problems with XYZ but does not think Q is an issue; patient prefers to use reiki and herbal cleanses to treat their psychosis instead of medications). I think there are two reasons this doesn't happen very often: first, you've often described some form of this elsewhere in your note and second, people are lazy and psychiatric notes are already long AF.

 

[LadyHalcyon]

FYI In my residency and area of the country psychiatrists also do a lot of psychodynamic work, so I find this post directly helpful to my practice.

I definitely consider myself to be an interpersonal/dynamic clinician, especially in regard to my conceptualization. I think having a good conceptualization is essential for treatment, whether pharmacological treatment or more traditional talk therapy. I have an uncle who is a psychiatrist in NYC and does a lot of therapy, but he has been practicing for at least 30 years, and NY is notoriously dynamically focused. Do psychiatry residencies focus on conceptualization/therapy or is it primarily med management? I suppose it likely depends on the residency.

 

[FlowRate]

I definitely consider myself to be an interpersonal/dynamic clinician, especially in regard to my conceptualization. I think having a good conceptualization is essential for treatment, whether pharmacological treatment or more traditional talk therapy. I have an uncle who is a psychiatrist in NYC and does a lot of therapy, but he has been practicing for at least 30 years, and NY is notoriously dynamically focused. Do psychiatry residencies focus on conceptualization/therapy or is it primarily med management? I suppose it likely depends on the residency.

Heavily residency dependent. To make very broad generalizations, residencies in the Northeast are likely to have the strongest focus on this as are residencies in major cities with psychoanalytic institutes. As pointed out in other threads by members who are more knowledgeable about residency curricula than myself, we're technically required to be proficient in CBT and Psychodynamic PT but this has been interpreted as anything from having had many cases of each for years to basically just having a few lectures on the topic.

 

[clausewitz2]

FYI In my residency and area of the country psychiatrists also do a lot of psychodynamic work, so I find this post directly helpful to my practice.


FWIW we're encouraged to actually describe insight and judgement (patient recognizes they have problems with XYZ but does not think Q is an issue; patient prefers to use reiki and herbal cleanses to treat their psychosis instead of medications). I think there are two reasons this doesn't happen very often: first, you've often described some form of this elsewhere in your note and second, people are lazy and psychiatric notes are already long AF.

A major teaching point I emphasize with medical students is that if you are not specifying exactly how or in what sense judgement/insight is impaired, it's just, like, your opinion, man. It is not useful information anyone else can rely on.

 

[splik]

ok... just wanted to throw this question out there hoping that I can get some advice from more experience people....
How would you treat a patient who has "treatment resistant depression" but also has a self-defeating masochistic personality structure??
Let's say that the patient always complains that nothing works but at the same time, is not compliant with medications. How would you approach??

This patient sounds more help-seeking help-rejecting than masochistic. the distinction may be subtle since masochistic patients may reject the helpful suggestions of others, and may not respond well to the interventions of the therapist or psychopharmacologist, but I think the underlying motivations are different. my psychoanalytic supervisor in residency used to say we are all masochistic (i.e. that everyone at some point has some need to surrender, even sadists) and in my experience, masochistic patients (who believe they are unworthy, deserve to suffer, hold up their suffering as intrinsically good) are a joy to treat and can do very well in psychotherapy. there are obviously different types of masochism, but I find masochists do their homework! help-rejecting complainers not so much.

help-rejecting complainers may have masochistic elements to them, but it is more likely they are borderline, paranoid, or covert narcissists. Typically, they need validation for being "the most difficult patient" and a "hopeless case." It is only when you gratify their need for recognition as experiencing the most intractable suffering you have ever seen and when you question your ability to even help them, that you can make some traction with treating them. In contrast, I would conceptualize the underlying motivation of the masochist to be to demonstrate their moral superiority (what Freud called moral masochism), or to maintain attachments (if the patient believes the only reason others show interest in them is because they are suffering).

It is also important to remember that even with all the other bogus personality disorder diagnoses in the DSM the concept of self-defeating personality disorder never made the cut, and for good reasons. psychoanalytic notions of masochism can be useful but feminists in the 70s and 80s were quick to point out that there was the potential to blame victims for their abuse. Thus even if you find it helpful to formulate patients in this way, I would not put anything in their medical record re: masochism.

 

[LadyHalcyon]

This patient sounds more help-seeking help-rejecting than masochistic. the distinction may be subtle since masochistic patients may reject the helpful suggestions of others, and may not respond well to the interventions of the therapist or psychopharmacologist, but I think the underlying motivations are different. my psychoanalytic supervisor in residency used to say we are all masochistic (i.e. that everyone at some point has some need to surrender, even sadists) and in my experience, masochistic patients (who believe they are unworthy, deserve to suffer, hold up their suffering as intrinsically good) are a joy to treat and can do very well in psychotherapy. there are obviously different types of masochism, but I find masochists do their homework! help-rejecting complainers not so much.

help-rejecting complainers may have masochistic elements to them, but it is more likely they are borderline, paranoid, or covert narcissists. Typically, they need validation for being "the most difficult patient" and a "hopeless case." It is only when you gratify their need for recognition as experiencing the most intractable suffering you have ever seen and when you question your ability to even help them, that you can make some traction with treating them. In contrast, I would conceptualize the underlying motivation of the masochist to be to demonstrate their moral superiority (what Freud called moral masochism), or to maintain attachments (if the patient believes the only reason others show interest in them is because they are suffering).

It is also important to remember that even with all the other bogus personality disorder diagnoses in the DSM the concept of self-defeating personality disorder never made the cut, and for good reasons. psychoanalytic notions of masochism can be useful but feminists in the 70s and 80s were quick to point out that there was the potential to blame victims for their abuse. Thus even if you find it helpful to formulate patients in this way, I would not put anything in their medical record re: masochism.

"In contrast, I would conceptualize the underlying motivation of the masochist to be to demonstrate their moral superiority (what Freud called moral masochism), or to maintain attachments (if the patient believes the only reason others show interest in them is because they are suffering). "

This! I find many of these patients believe they will not receive support if they improve. That also plays out in their relationships with providers. I have found it helpful to ask questions about how their emotional needs were met as a child (i.e. How did you mother soothe you when you were upset?; How did you you convey your pain and suffering as a child? How did people respond when you would express your pain Etc....). If they described their home environment as being invalidating, I often will use some sort of analogy: If someone broke their leg they would at first tell their parents something like "my leg really hurts". If that doesn't get their attention, it would make sense to talk more about the pain in a persistent manner. If that didn't work a person may then choose to fall to the ground, start screaming and escalate their behavior as a way to get their needs met. Yes the pain is real and yes their leg is broken. Often framing things in this way will both validate their pain and their choice to keep focusing on the pain/bringing the attention of others to the pain.

 

[nitemagi]

Explore if they could think up any benefits to not getting better. Or if they have fears of actual improvement -- basically giving voice to the sabotaging side to walk about what it gets out of sabotaging.

It's useful in conceptualizing patients to imagine them as parts that are competing, rather than a solitary "I." Each part is them, and each part needs to be addressed.

 

[Georgit]

I would avoid the distinction between intellectual and emotional "insight" in this case in favor of thinking about different kinds of motivations and incentives.

This distincion is another way to say that sometimes beaviour of people value more feelings and sensations than rational thinking.
Sometimes psychiatry verges on reinventing the wheel...

To say something more clever: rational thinking can be wrong, as much as your guts. When someone else called it "delusions", usually it is wrong.

 

[scentofpapaya]

thanks for all the feedback here. I feel that it is very exasperating to treat patients who actually do not want to change. I've realized that some people just thrive in playing the "victim" or "martyr" role and although they are suffering, their suffering is strangely very ego-syntonic. As a clinician, I feel that my time is just wasted or being used to perpetuate their "illness" and the "patient role." sometimes I feel that just ending the treatment might be more therapeutic for some of these patients. I do recognize that "blaming the victim" might be a problem, but I also do think self-defeating behavior is something that is real. Maybe I've just hit that point that I'm just jaded and become cynical....

 

[clausewitz2]

thanks for all the feedback here. I feel that it is very exasperating to treat patients who actually do not want to change. I've realized that some people just thrive in playing the "victim" or "martyr" role and although they are suffering, their suffering is strangely very ego-syntonic. As a clinician, I feel that my time is just wasted or being used to perpetuate their "illness" and the "patient role." sometimes I feel that just ending the treatment might be more therapeutic for some of these patients. I do recognize that "blaming the victim" might be a problem, but I also do think self-defeating behavior is something that is real. Maybe I've just hit that point that I'm just jaded and become cynical....

It might be worth asking very frankly what their goals are for treatment and highlight where relevant things they have done that aren't really consistent with that. I mean, it's a hard conversation to have, but you can either think this question very loudly and get increasingly frustrated and try not to seethe when treating them or actually address the elephant currently perched on your desk.

And who knows, they might actually identify treatment goals that take things in a whole different direction.

 

[LadyHalcyon]

I have found this approach to be helpful with these patients. Basically having a frank discussion about your feelings and perceived lack of progress. It can be uncomfortable but it can also "break the cycle" and improve treatment effectiveness/adherence.

It might be worth asking very frankly what their goals are for treatment and highlight where relevant things they have done that aren't really consistent with that. I mean, it's a hard conversation to have, but you can either think this question very loudly and get increasingly frustrated and try not to seethe when treating them or actually address the elephant currently perched on your desk.

And who knows, they might actually identify treatment goals that take things in a whole different direction.