Author Archives: Tracy Laramie

Part 1: The Patient

“I dread going to the hospital…I have to explain myself every time and prove to them I’m not ‘crazy.’ I’m there feeling terrible, but need to be on my ‘best behavior’ so they can see I really do know what’s happening and what I need.” – Client with cancer and schizophrenia 

A common fear for people who have both a diagnosed mental health disorder and a physical illness is that they will enter a medical setting only to have their symptoms dismissed. Clearly, there are many facets of this topic. In this article, we will focus on individuals with mental health issues who are navigating the medical system. Next time, we will discuss the experiences of medical providers and residential facilities, and the final article will discuss strategies for family members and loved ones who support an individual with physical and mental health issues. 

The client’s statement above exemplifies what studies have concluded about the experience of people with mental illness and the medical system in the U.S. The article, “Mental Illness-Related Stigma in Healthcare: Barriers to Access Care and Evidence-Based Solutions” states, “Mental illness-related stigma, including that which exists in the healthcare system and among healthcare providers, has been identified as a major barrier to access treatment and recovery, as well as poorer quality physical care for persons with mental illnesses.” Furthermore, “People with lived experience of a mental illness commonly report feeling devalued, dismissed, and dehumanized by many of the health professionals with whom they come into contact.” 

Common questions clients often wonder include: Will a doctor take my physical concerns seriously? Will they assume that it’s an issue with my psych meds? Will medical staff be watching my behavior more closely than other patients? Will doctors believe me and treat my medical issues accordingly? Essentially, patients in this situation fear that in a quick-paced medical setting, their physical concerns will be overlooked, downplayed, or go untreated. There is fear that if they speak up about a concern of being overlooked, the provider will again point to a mental health issue; that they are being “anxious” or “paranoid.” In reality, when we look at past experiences of the patient coupled with conclusions of studies which highlight the barriers people with mental health issues face in medical settings, their concerns make a lot of sense. 

How, then, can someone with a mental health diagnosis prepare to interact with medical systems? In sessions with clients who are facing medical stressors, therapists often discuss several key points: What have their previous experiences with the medical system been like? How do they feel about their current providers? What skills can they use to communicate with healthcare providers effectively? Who are the supportive people in their lives who can help? As we gain a better understanding of our experiences, both positive and negative, we get more information about what drives us and scares us. Negative experiences in the past can inform how we feel going into new experiences, even if the providers or situations are different. Mental health stigma in society, institutions, and from individuals impacts how we have been treated and how we anticipate new situations. 

Once we understand how our past experiences have affected us, we can begin to mindfully address our needs in the present. Individuals in this situation can bring to mind what they need now and what they CAN do. For instance, we can learn new communication skills to advocate for ourselves or request support to amplify our voice. We can track physical symptoms or side effects in a daily log to bring to appointments with doctors to help guide our discussions. We can purposefully seek out doctors that listen and respond to our needs in a meaningful way. Yes, each of these tasks take time, energy, and focus. We can acknowledge the difficulty of these tasks while understanding that working toward these goals together will help our overall well-being in the long run. 

It is daunting to face a large system alone. Clients in this situation are encouraged to seek out the individuals in their lives who help them feel seen. This could be anyone from a close family member or friend who could help them advocate for themselves to a friendly receptionist at their doctor’s office. When we find the good people, the individuals who make up a larger setting, then the system feels more manageable. We can focus on one good interaction at a time as a touchstone to generate more positive exchanges. We are better able to remind ourselves that we matter and that we are human beings with needs worth discussing. 

It is particularly difficult for people with mental health diagnoses to navigate the medical system for a myriad of factors. If you or a loved one would benefit from support, please reach out to WCPA to be connected with a therapist who can help. 

Is caring for your elderly parents causing tensions between you and your siblings? Have your sibling relationships deteriorated due to disagreements about care for your parents? Arguments often flare up over issues like sharing responsibility for private care, methods of care, money, inheritance, and emotional problems. Even siblings whose bonds remain strong say caring for an aging parent often takes a toll on their relationship.

These conflicts often come as a surprise. No one anticipates that they will be thrust in to emotionally charged interactions with their siblings. It is a shock to go from seeing your siblings at family dinners to navigating parents’ needs together daily. Often, long buried grievances resurface. Siblings can fall into the resentment trap, asking, “Why is this on me?” “Where is the help?”

One of the biggest reasons for sibling resentment is perceived “favoritism.” When one sibling seems to be a parent’s favorite, it can cause other siblings to become angry with the favorite child or with their parents. Adult children often internalize a perception of favoritism. Regardless of when or how this perception of favoritism comes about, it can often cause tensions and rifts between siblings in their adult years – especially when discussing care for aging parents.

Duties and roles of care for parents can also cause sibling conflicts. Some adult children might think everyone should take care of their parents, while others think that it is not their job as adult children. Some may think that putting parents in a nursing home or paying for in-home care is sufficient. Other family members might believe that adult children should provide hands-on care for their parents.

Geographical distance can add to the conflict for siblings. If one sibling lives closer to their parents, those farther away may feel less responsibility. The closer child might feel guilty if they don’t or can’t care for their aging parents. They might also experience caregiver burnout and resentment of the siblings who seem to bear less responsibility for care.

Regardless of the causes, what are some strategies that adult siblings in this situation can use?

Listen Well An excellent way to begin working together is to listen to each other. Take time to ask questions and make a point to try to understand your sibling’s point of view. Listening well can be challenging, but it is a powerful way to move forward positively. It often helps to ask, “Can you tell me more about that?” Listening can help deepen understanding and trust for all parties involved.

Find Common Ground It is also beneficial when dealing with family disputes over elderly parents to find a common ground. For example, you might all agree that none of you will personally take care of Mom and Dad. It could also be as simple as starting with a general plan of care.

Learn to Compromise Making compromises does not mean that you lose the argument, though it might mean that you will not get exactly what you want, exactly how you want it. Remember that you are seeking to do what is best for your parents, but what you think might be best may not be what your sibling thinks is best. Compromising provides a way for all parties involved to do their part.

Involve a Third Party If you can’t have productive conversations, consider bringing in a third party. The third party could be a professional mediator, medical provider, therapist, religious leader, or professional care manager. A third party could help facilitate and guide discussions while seeking to provide what’s best for your parents. Since they do not have any emotional or relational issues with you, your siblings, or your parents, a neutral third party can offer outside advice that is helpful and constructive.

In an ideal world, we’d all work together harmoniously to give our parents the best end of life in return for the love and support they gave us. It rarely – if ever – works out exactly as we would like it. But that doesn’t mean we shouldn’t try our best.

West County Psychological Associates has trained professional counselors who specialize in senior care issues. You can reach us at 314-275-8599 or see information about our therapists at www.wcpastl.com.

There is probably nothing more beautiful and intense as watching a nurturing mother look into the eyes of her infant child. There is probably nothing more critical to a child’s development than having this ongoing experience with her mother or caregiver. What the child sees in her parent’s face is a precursor of healthy or unhealthy emotional development. This can determine this child’s development style, from healthy attachment to others to avoidant and ambivalent relationships.

Psychologists like Bowlby and Winnicott tell us there are two behaviors that describe healthy attachment – mirroring and attuning. In mirroring, the child looks at the mother’s face and sees in her the reflection of himself. He also looks in her face and sees the value of himself. This is critical, because if mother (or caregiver) is emotionally distracted or unavailable because of stress, fear, anxiety, or their own inability to nurture, the infant perceives himself as being unlovable because the mother’s face doesn’t project love. In fact, psychologist Mary Ayres says that the consequence for those who miss out on being mirrored adequately is a primary sense of shame. The result of this sense of shame is a felt sense of being unlovable or somehow defective.

The next behavior is attuning. In successful attuning, the caregiver is able to emotionally join in with the child. She is matching the baby’s tone and emotion, whether the baby is expressing anger, fear, joy, or distress. Mother is conveying that she senses what the baby is experiencing. Mother does this through her words, voice, and touch. The baby feels understood. However, in order to be attuned to another, it’s necessary to be attuned to oneself. This means that we don’t negate our feelings. We don’t stay distracted so that we neglect our feelings. Through our feelings, we come to know ourselves. Attuning to ourselves allows us to become attuned to others. When we are attuned to others, we are able to tap into their emotional needs; they feel a sense of security and safety with us, and they are able to be open with their feelings.

We speak of these behaviors generally in terms of early child development. But they exist in relationships that go beyond early caregivers. In varying relationships, we are able to develop a healthy attachment. For example, teachers can be secondary attachment figures. Children who may not have had healthy parenting from early caregivers can feel that sense of being cared for and valued by a teacher who develops an emotional tie with his students. He cares about their emotional and academic needs. Most importantly, the students know that they are cared for. I had a French teacher in high school, Sr. Ann Francis. Besides being an excellent teacher, all of her students had the sense that she cared about us. Occasionally she would tell very funny stories on herself. I loved her stories. They made her sound very real and very human. Years later, a few of my high school friends and I decided to visit her convent in Kentucky. Of course, we were all hoping that after many years she would remember us. Not only did she remember us, she was able to tell a story about each of us that she remembered from our high school days. I know that she could not have been aware of the impact she had on our lives.

Loving grandparents, aunts and uncles, or older siblings can all be secondary attachment figures. Hopefully, we all have a few of these people who have impacted our lives. There is a beautiful Irish movie that came out recently called The Quiet Girl. It tells the story of a nine-year-old girl who lives in a harsh poverty-stricken home with an alcoholic father and harried mother and numerous siblings. She appears very quiet at home and at school. She has no friends. She barely responds when asked a question and spends most of the time by herself. An aunt and uncle offer to take her for the summer. At first, she is very quiet and withdrawn. However, from the beginning, her aunt and eventually the uncle show her consistent kindness and caring. Slowly we see the girl come into her own. It is as though her personality awakens. Throughout the movie, viewers see multiple instances where she is mirrored and attuned to.

Sue Johnson, author of the book Hold Me Tight, discusses Attachment Theory in marital relationships. She talks about the ability to be tuned into our spouse, letting the other person know that we understand them. In other words, we “get them.” Marriage can be very difficult. We often stop trying to know our spouse within a few years after the wedding. Children come and we have no time for the other. In fact, the person that we wanted to spend a lifetime with is often the person from whom we are most distant. In good marriages, each person has a sense of safety with the other. We feel that there is someone who “has our back.” That person may not agree with us, but they want to understand us; they want to know us. They’re the person who says, “I feel badly for you,” when we’ve had a bad day. They’re the person whose face lights up when we walk into the room. We see in their face the value that we have.

The therapeutic process is an excellent example of an attachment relationship. Empathy, in the form of attunement and mirroring, is the basis of the therapeutic relationship. The therapist empathetically attunes to the client by tuning into and resonating with their experiences. In the process, the therapist maintains his or her own presence and identity. It is not about becoming the other, but rather momentarily experiencing what the client experiences, whether it be emotional or physical. This implies that the therapist is attentively listening. He or she responds in a way that tells the client that the therapist is actively engaged. The client experiences the sense that they are understood. The therapist “gets” the client.

As we can see the mirroring and attunement process is critical to our well-being. Being conscious of how we relate to others can have extraordinary benefits for them and for us. The questions we may want to ask ourselves are: who have we attached to? Who has attached to us? Who was instrumental in our emotional development?

Conscious and Subconscious Biases
(Hidden Biases of Good People)

Riddle: A man and his son are driving in a car one day, when they get into a fatal accident. The man is killed instantly. The boy is knocked unconscious, but he is still alive. He is rushed to the hospital and will need immediate surgery. The doctor enters the emergency room, looks at the boy, and says, “I can’t operate on this boy, he is my son!” How is this possible? 

 Congratulations if you were able to solve the riddle. We all have biases. Some of the biases are known to us and other biases hide very deep in the subconsciousness of the brain. Because we have all been socialized differently, it is hard to imagine anything other than what we know. 

The socialization process begins when children are in their early years. Because of bias, we often give our children misinformation, missing history, and biased history that leads to stereotypes about any groups whose cultures are different from our own. This information is reinforced by people, systems, and institutions we know, love, and trust, through continued stereotypes and distortions. Some of these institutions are family, neighborhoods, education, media, government, houses of worship, economics, and class. If we do not purposefully interact with, understand, and study people who are not members of our own groups, we carry those stereotypes throughout adulthood, and they become a part of our belief system. 

The way we were socialized can influence our decisions today, producing discriminatory outcomes. How we view others who do not share the same “cultural” norms as we do can interfere with decisions we make. If we are in a position of power to hire employees, we can form opinions about who can or cannot do the job based on subconscious and conscious biases that have not been dealt with, due to the thinking of what society considers as the norm to follow. Who and what influences our social group? People who do not believe or look like us are usually left out of our social circles if we do not get to know people unlike ourselves. The way we were socialized could keep us in our comfort zone, which causes us to make mental judgments about all others who do not “fit” within our social group. 

Mental health professionals cannot afford to take a chance of not understanding their clients or students “whole selves.” Understanding our own biases will ensure we are able to assist with the healing aspect of those whom we serve. 

For mental health professionals and school mental health professionals, cultural competency is the ability to provide mental health services that can acknowledge cultural differences between the client or student and the professional. The more the clinician knows about clients’ or students’ culture, ethnicity, or background, the more likely clients and students will feel comfortable in therapy. When the professional is culturally competent, having prioritized their understanding of a client’s or student’s background, gender, abilities, sexual orientation, ethnicity, religious or nonreligious beliefs, and other factors, and connecting this important knowledge to mental health services, it enables clinicians to accommodate and respect differences in opinions, values, and attitudes. At the same time, it is important to be aware that no group of people is monolithic. 

The book, Blind Spot: Hidden Biases of Good People, written by Mazarin R. Banji and Anthony G. Greenwald, talks about “mindbugs.” These are ingrained habits of thought that lead to errors in how we perceive, remember, reason, and make decisions. The eye receives, the brain registers, and the mind interprets visual and audio information. If we don’t bring these ingrained thoughts to the conscious level, they lead to negative stereotypes capable of oppressing certain cultural groups. For example, mindbugs can get in the way of mental health professionals’ ability to help in a crisis if they are unfamiliar with a client’s or student’s religious or non-religious beliefs. Therefore, mental health professionals must understand their own cultural biases to become culturally competent professionals. 

There will always be differences within the same cultural group. However, culturally competent mental health professionals are continually working on their own subconscious and conscious biases to support all their clients and/or students. We begin to understand the richness and beauty of the tapestry when the world connects, and we get to know and appreciate each other. 

By the way, what was your first thought about the riddle? Remember, we ALL have biases. 

“I only do what I want to do.” That sounds incredibly selfish, doesn’t it? Most of us would feel guilty saying that to ourselves, let alone to another person. Many of us were taught to be self-sacrificing. Do for the other person and not ourselves. People are praised for thinking of others first and putting their own needs aside. Years ago, I found that there was a fallacy in this thinking. As I was doing what others wanted, I did not give myself permission to do what I wanted – and I resented it and eventually resented them.  

The first time that this occurred to me was when I was in my thirties, married with three adolescents, working full-time as a teacher, and going to grad school. Our psychology professor had recommended that if we were going to be in the counseling profession, we should have the experience of seeing a therapist. At that point, I was feeling frantic. It was two weeks before Christmas, and I was finishing the academic semester. The house wasn’t decorated. No gifts were bought. And there were numerous discussions among family members about who was doing Christmas and Christmas Eve dinners.  

I was referred to a young therapist (a doctoral psychology student doing his residency). I remember spewing out my anxiety and confusion. I felt that I was being torn in a thousand different ways and I didn’t know how I could please everyone. After listening to this, he asked me a very simple question. “What do you want to do?” I felt as though no one had ever asked me that question. I am sure I had never asked myself, “What do I want?” It was always about what others wanted from me and for me. The question literally changed my life. I made the decision that seemed reasonable, doable and would make me happy without adding a burden onto other people. Everyone seemed fine with what I chose. I had a great Christmas. Most importantly, I also decided that I would never spend another holiday not doing what I wanted. All of these years, I’ve kept that promise to myself. 

After this, I discovered two things. The first was that, in pleasing myself, there were no resentments. I enjoyed what I was doing and I enjoyed others with whom I was with. Resentments are toxic to a relationship. How many times do we do things essentially to please another person but end up resenting them in the process because this is not what we want to do. For example, if I would have gone ahead and had Christmas or Christmas Eve dinner to please my mother, I’m afraid my resentments would have spilled over into our relationship. We see this in relationships all too often. One party tends to give to the other regularly and eventually builds a wall of resentment. After years of this resentment, the couple finds themselves in a therapist’s office because, in time, this behavior has destroyed the relationship. The less I resent someone or something, the more willing I am to do what others ask of me.

The second thing I learned was that I could make choices for myself as long as my behavior didn’t negatively impact the other person. For example, in the case of the Christmas events, I told my mother that I would have a very difficult time doing Christmas or Christmas Eve dinner because of the time crunch, but I would love to do New Year’s Day dinner with my family and my cousins, whom I really enjoy. Everyone seemed pleased and we had a great holiday. If I had offered no solution to the Christmas dinner dilemma, it wouldn’t have been fair to the other family members. My rule of thumb is that as long as my decisions do not negatively affect others, it is my choice to make. For example, if I go dress shopping with a friend and she insists that I buy a dress that I’m not really happy with because she loves the way it looks on me, I have the right to say that I appreciate her opinion but I much prefer the other dress. If I were to buy the dress that she chose, it would be to please her and not myself. 

Realistically, however, there are many things that we do that we feel we should do. I would suggest that if we could take the word “should” out of our vocabulary we would be much happier. We all have activities in our life that we don’t particularly want to do, but we know we need to do them. Very few of us enjoy mopping the kitchen floor, washing clothes, or paying bills. I may not enjoy these activities, but I know they are necessary in living an ordered life. I do want the peace of mind that comes when I’ve taken care of daily living activities, so I choose to do these things. I do not enjoy going to the Funeral Home, but I choose to pay my respects to my friend’s husband. While I may not enjoy doing this, it is something that I choose to do. This is not a “should” but rather a “want.” It is made out of an expression of choice.

The key word in this theory is “want.” What do I want? Many of us have spent much of our lives doing what others expected of us. We live and make our choices based on what others want. Many of us either have never asked the question of ourselves or, if we have, we don’t know the answer. Sometimes we don’t know because we’ve not allowed ourselves the question. This is either because of the guilt in putting the emphasis on what we want or no one was ever really interested in what we wanted. We didn’t know we had the option.  

I find that asking clients what they want is a key factor in helping their emotional growth. When they can’t identify these wants, we concentrate on what they feel. We can start by asking ourselves what is important to us. Is this activity worth my time or energy?  Is this something that I would choose to do? If they can start identifying their feelings, they’ll soon come to a recognition of what they want. Most of my turmoil that Christmas was that I knew what I didn’t want, but I hadn’t asked myself what I did want. I honestly didn’t know that that was an option.

What I’ve discovered through these years is that I have more choices than I thought. In some cases, when I no longer enjoyed an activity that I regularly participated in, I found ways to eliminate it from my schedule. I have also found that having a conscious awareness of the people that I value in my life allows me to be more proactive about spending more time with them. Acknowledging what I want allows me to make more definitive choices in my life. It has also forced me to look at how my choices affect others. All in all, knowing that I have the freedom to choose has given me the opportunity to experience a well-lived life. For that, I am very grateful.

Marriage through matchmaking was the original form of courtship, recorded as far back as the Bible, but the concept of finding a loving partner and getting to know them through dating before marriage has only been in existence since the late 1800’s to early 1900’s. This shift from parental and community decisions about who we spend our lives with to allowing freedom and exploration has never been as apparent as it is in this current era with online dating.

Dating online has had an interesting journey from the humble beginnings of paying for matchmaking services through match. com to its current state of freedom, hype, and confusion. Back in 2001, when match. com merged with love. aol, individuals paid $24.95 per month for a membership to take a survey and be matched with other singles with similar interests and values. Now people can hop onto one of countless, free “dating” apps, which all provide different ends. Most dating apps advertise as a way to help singles meet and find a life partner, but anyone who has ever explored them discovers they often have very different purposes. Certainly, there are a few people who meet their partners through these apps, but the more prevalent experience is that the apps provide some users with false hope and others with stories of frustration and even violation. 

For many Gen X-ers, Gen Z-ers, and other millennials, it has become obvious that the transition from meeting people at school, work, clubs, and bars to meeting them on the smartphone has had deleterious effects on the way we interact with potential partners. People are not only utilizing apps more, but they are becoming more averse to the “old fashioned” way of meeting others. Many younger people talk about the great risks inherent to meeting people at public places and saying things such as, “Well, they’re a complete stranger. Who knows what they may be like? I’d rather get to know someone first [via online chatting].”  

This change has impacted our public interaction in a way that has almost encouraged social phobia. The mentality that we can only feel safe meeting a potential partner if we text them for weeks in advance has led countless people down the rabbit hole of endless conversations that never led to an actual in-person experience. Contrarily, this behavior pattern has led many others down a dangerous path of false security with individuals who are pretending to want a connection when all that is desired is a sexual experience, are presenting as one person when they’re an entirely different individual, or the all-too-friendly bot profile which tries to trick app users into sending cash. 

In addition to these hazards, dating apps have enabled those who suffer from social anxiety to fully envelop themselves in a world where they never truly need to take social risks. They can gain the minimal social interaction they desire by interacting through apps, without ever actually meeting another person. They may feel socially fulfilled, but what they are truly doing is enabling their anxiety. Those who experience social phobia fear the scrutiny of others through social interactions, like meeting unfamiliar people, being observed while eating or drinking, performing in front of others, and acting in a way that is embarrassing. Meeting unfamiliar people, eating and drinking together, and risking embarrassment through personal exposure are all key elements of early dating. As exposure therapy has evidenced, engaging in behaviors that make one nervous, over time, lessens anxiety. Therefore, engaging in dating behaviors, safely and appropriately, inherently will help a socially anxious person gain control over that aspect of life and have more fulfilling life experiences. 

This is not to say that dating apps are all bad. They have merit in connecting others in ways unimaginable to past generations. If a single person wants to date and find a partner for life, dating apps can certainly be one option. However, users can be mindful not to spend too much time chatting online. Connect with a potential partner, find a safe public place to meet, and meet them. Daters can get to know potential partners in real life and make sure to set clear expectations for what is wanted out of the relationship. In short, today we can use technology to enhance dating, not to replace it.

Other options exist besides dating apps, though. It’s still possible to use more traditional routes of meeting a partner. If meeting at bars feels scary, singles can try connecting with a classmate or coworker – someone we can take our time getting to know, flirt with, and develop something special with in a structured environment. This may lead to building social skills, such as boundary setting, empathy, and cooperating, as well as reducing social anxiety. 

Finding a significant other in the real world can boost confidence. Real-life dating partners can see us for who we really are, not merely our internet identity, and this can feel incredibly validating. On the internet, we have time to come up with clever responses and confident self-statements, but in person we may be awkward and fearful that people will not take the time to get to know the real person that we are; this is understandable. But as we worry about deficits in our competence, we likely also under-appreciate what virtues and talents we actually possesses that may be attractive to a partner. By avoiding in-person relationships, daters can make ourselves inaccessible to growth opportunities, preclude further maturation, and becomes more dependent on the apps.

As daters, whether we choose to try dating apps or to engage with the people in our everyday lives, we must put our personal boundaries and respect first. To be sure, some people will be inappropriate partner options; they just aren’t the right fit. Others may actually be manipulative, deceptive, or simply unkind. But this does not mean we are unlovable or deserve mistreatment. Dating requires that we find the qualities in ourselves that make us unique and bolster them; bring them to the surface and show them proudly to the world. If we choose, we can promote this self-expression first through dating apps and maintain it throughout the process of making a real-world connection. Dating takes courage. Finding someone we want to spend our life with can take time – but this is OK. Though social media comparisons make us feel like there is a timeline for life, there is no rush.

I recently listened to a podcast in which a doctor referred to Attention-Deficit/ Hyperactivity Disorder, or ADHD, as a gift that needs to be unwrapped. As we come out of the holiday season, it’s hard to imagine such a gift being as popular as the ones that arrived from Amazon deliveries or trips to the mall. It’s certainly not a gift that anyone places on their list. But it’s important to remember that ADHD isn’t gifted only to those who were naughty rather than nice. It’s a gift that does not discriminate – despite prevailing myths, such as, “Only kids get it,” “People just need to try harder and get organized,” and “I don’t have it because I can stay focused for a long time when I watch my favorite shows on Netflix.” The true gift in realizing that you have ADHD is in the knowledge that you can do something about it to help you better control its effects on your life. 

What exactly is ADHD, and what does it look like? 

Attention-Deficit/Hyperactivity Disorder is a neurodevelopmental disorder. It’s caused by genetics and other biological causes, not bad parenting, too much screen time, or food additives. Not enough dopamine is produced in the prefrontal cortex, which leads to problems with executive functioning, impulse control, and emotional regulation. According to the DSM-5, there are three types of ADHD: inattentive, hyperactive-impulsive, and the combined type. 

Features include problems with paying attention, impulsiveness, and overactivity. Other traits include poor executive functioning, difficulties with organization, and struggling to stay on task or pay attention in meetings. Then there is cognitive hyperactivity, meaning that the mind has trouble winding down. You might have a difficult time relaxing and feeling that you’re always on the go, in overdrive, restless and impulsive. 

ADHD may also manifest itself through poor activation, or procrastination. You may get easily overwhelmed and shut down, especially when the activity is not in your wheelhouse or else seems hard or boring. Other ill effects include a poor working memory, a struggle to shift focus (especially when hyper-focused on something interesting) and poor emotional regulation – that is, frequent outbursts due to low frustration tolerance. 

Some gift! So now what do I do?

Remember, knowledge is the gift! If you identify with any of these behaviors and think that ADHD could be the reason, don’t panic. A good place to start is with your primary care physician. Along with assessment, lab work is often ordered to rule out thyroid disorder. Often, doctors recommend psychological testing to help rule out other possible causes of your symptoms.

If the diagnosis is clear, you could ask a psychiatrist to do a psychiatric evaluation to clarify the need for medication. Stimulant medication, such as Ritalin or Adderall, is not recommended for everyone, but is often worth trying, when you have a doctor that you trust to work with you to find the right medication and dosage. There are also many non-medication treatment options available, such as behavior modification, nutritional recommendations, and therapy, to name a few. A therapist who specializes in ADHD can help individualize a treatment plan that targets decreasing problematic symptoms, while increasing more positive habits and practices.

Treat yourself to this gift!

Without treatment, negative messages such as, “You can’t pull it together,” or “You’re such a bad parent!” can continue to imprint on your mind, leading to feelings of inadequacy, low self-esteem, anxiety, and even depression. So get help if warranted and “unwrap the gift” of knowledge about your attention deficit. Realize that your brain works in a different way, and with it come strengths, including the ability to think outside the box, be creative, multitask, be laser focused on what you’re passionate about, and be empathetic.

Life would be so much easier if everyone just got along, but at some point, each of us encounters individuals who behave in a manner that evokes anger, fear, humiliation, or a sense of powerlessness. This is especially challenging when the person is a colleague, supervisor, neighbor, client, or family member with whom we have to interact on a regular basis. Of course, behaviors that one person may find difficult may not be such a big deal for another. Whereas one person may have a strong negative reaction to an individual who behaves in a pushy, bossy, critical, or intimidating manner, another may get stirred up talking to someone who expresses strong religious or political beliefs with which they disagree. We may be able to sometimes avoid or decrease interactions with these individuals, but it helps to increase our ability to effectively navigate them.

Goal Setting

Our goals and objectives for challenging encounters depends on the nature of the relationship and what we want to accomplish. For a one-time interaction with an individual who is known to become volatile, our objective may simply be to communicate something important and obtain compliance without making the situation worse. With a family member who expresses very different viewpoints in a manner that makes us upset, our goal may be to remain calm, grounded, and curious, and to express our beliefs without expecting endorsement. We do not have to like the other person, we do not have to agree, and we do not have to change their mind or elicit an apology. We should try to resist the urge to judge or put the person in a single category according to something like politics or religion, because that can make things worse. Sometimes our goal is to acknowledge to the difficult person that our own view may be but one legitimate viewpoint among many. At other times, our objective may simply be to remain quiet, redirect, or distract rather than confront, or to restrict interactions with the person.

Planning Ahead

If we anticipate that a person will act in a provocative manner, it is important to choose the right time and place for conversations, and troubleshoot potential challenges in advance. Ensuring physical and emotional safety, maintaining the person’s privacy, and treating him/her with maturity, dignity, and respect are very important. Encounters can be planned to ensure built-in opportunities to take a break if needed. It may be important to ask a co-worker, supervisor, friend, or family member to be present during an interaction as an observer or participant, to increase our comfort level and assist if needed. It may be necessary to plan interactions in public areas, or keep our back to the door in case we need to exit quickly. During the conversation, it is OK to end a meeting quickly in a polite and respectful manner. We should avoid trying to reason with someone who appears to be under the influence of a mood-altering substance. Emotional abuse, including deliberate humiliation, threats, or derogatory name-calling, should not be tolerated. If at any time we feel unsafe, we should consider involving law enforcement, Human Resources, or other authority figure who can ensure safety.

Self-Awareness

It may be helpful to increase self-awareness of why a certain person evokes strong emotions, and what we may be inadvertently communicating to that person in our response. Sometimes an individual reminds us of a previous painful relationship when we felt the same fear, anger, shame, or sense of powerlessness. In situations where a person is difficult because he/she has very different viewpoints, it may help to remember that it is natural to have a strong preference for our own values and belief system because they help define our identity and what is important to us. Sometimes it is hard to acknowledge the different ideas of others in part because our strong emotions may interfere with logical or rational thinking, in the same way they may block reasoning for the other person. Talking about contentious issues in our highly polarized social environment is incredibly hard and complicated. Seeking support from a trusted confidant to process thoughts, feelings, and reactions, can help in gaining perspective.

Strengths-based interventions that increase our self-confidence may also lead to improved relationships. For example, making a list of our interpersonal strengths, coping abilities and past successes in interacting with difficult people, may help empower us. We can recall an experience in which we handled a challenging interaction in a way that made us feel courageous and self-confident, and then soak in and savor those pleasurable feelings immediately before we have to talk with an angry customer or co-worker.

If an interaction leads to us feeling rejected, criticized, or disrespected, these feelings may be reflected in our tone of voice, facial expression, or body language. We may avoid eye contact, scowl, or display irritation on our face, perhaps leading the other person to think we do not like him/her. We can increase awareness of how we come across to others and learn to modify our responses so they do not contribute to worsening of an individual’s provocative behavior.

Interpersonal Skills

Active listening, without being so overly focused on our rebuttal that we miss the message, gives people a sense of being seen, heard, and understood, which can be calming. As we listen, we can re-state the individual’s main point and validate his/her viewpoint or feelings. Validation simply means that we recognize and acknowledge where the person is coming from, even though we may not agree. Our instinct may be to try to calm the other person down by telling them to lower their voice, putting our arm on theirs, or some other similar gesture that may be appropriate in other contexts. But if someone is already upset, it may be better to avoid directives or physical touch, as it might be misinterpreted. Also, telling someone who is upset to be quiet and calm down may make the person angrier. Allowing some degree of ventilation as long as the person does not become emotionally abusive, may be helpful.

There are many considerations to help make decisions around when to avoid conversation, change the subject, or stand up for what needs to be said. It is helpful to build coping skills for tolerating distress and managing strong emotions so they do not cloud our thinking or interfere with our response. To delay responding immediately to an angry person, we can focus on taking slow, deep breaths, or using a mindfulness strategy of shifting our attention away from negative thoughts to the here and now.

Assertiveness skills such as asking for what we want, setting boundaries, and saying no when appropriate, help us take care of ourselves while effectively communicating our needs. Utilizing these skills during interactions with someone who exhibits bullying or intimidating behavior can be very challenging and requires practice. It is OK to limit conversation duration, frequency, and content, or to say, “That’s an interesting idea and I’d like to hear more but I have to leave now.” In some circumstances, it is preferable to use messaging or email communication, rather than face-to-face, although one has to be careful with wording, to prevent misinterpretation. At any time, after weighing out the pros and cons, it is OK to end the relationship.

Understanding Difficult Behavior

Using negative labels such as “arrogant” or “idiot” to describe a difficult person can narrow our perspective and contribute to emotional distress. It is more helpful to focus on the behavior and resist the urge to cast judgment with negative labels. There are great variations in the reasons why people behave in a provocative manner. The individual may have a mental health or substance abuse problem, or be reacting to life stressors such as loss of a job, divorce, death, financial setback, or other events. They may have a history of painful life experiences such as being bullied, victimized, rejected, or abandoned, and have developed a sense of having been wronged and a desire to blame others for those wrongs. 

Our understanding and empathy for how a person reacts to life experiences does not mean we are making excuses for bad behavior. We may still need to prioritize holding the person accountable for his/her behavior. But understanding can increase our empathy, compassion, and forgiveness, if those are our objectives. Forgiveness does not have to interfere with the pursuit of justice if harm has been done. However, it may help us to stop obsessing about past wrongs so we feel less angry or bitter about the other person.

Sometimes it is helpful to identify goals or interests that we share with the person, such as a sports team, a hobby, or type of music, which are all great neutral topics to discuss. Finding something we can agree on is a better place to start than jumping right into a disagreement or difficult topic. Acknowledgement of mutual goals can help build rapport and resolve conflicts, even if each of the parties have different ideas of how to achieve those goals. For example, an angry and volatile parent may share the same goal as a teacher: for the child to do well in school. Maintaining this focus during interactions may dilute the intensity of a challenging interaction.

Closing

Getting along with a difficult person often requires extraordinary effort and emotional energy, but can be managed successfully. Seeking therapy or consultation from a professional counselor can help you identify thoughts and feelings, gain perspective, build coping skills, and implement a plan for managing a relationship with a difficult person. If you are interested in getting connected with a compassionate and experienced therapist, please contact West County Psychological Associates at (314) 275-8599.