Therapy & Life w/ Elder from Hell - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Therapy and Life with the Elder from Hell

After a long lifetime filled with challenges and joys, content to go into her golden age as a respected senior, Grandma has come to live with her son, his wife, and two latency age children.  This article is not about her.  John, 70 years old has come to therapy to deal with his loss and depression following his wife’s death.  This article is also not about him.  This is an article about the elder from hell!  Perhaps, like Livia Soprano of the HBO hit series, “The Sopranos.”  Marvelously played with deliciously evil glee by the late Nancy Marchand, Livia Soprano's manipulations drove her Mafioso son Tony, a physical brute of a man to anxiety attacks and therapy.  In the process of individual therapy with elders, or with an adult child dealing with elder care issues, or in family therapy were an elder has joined the family recently, there are "normal" issues that need to be addressed: loss, the restructuring of the family with the addition of the elder, renegotiating of child-adult to adult child-elder roles in relationships, and practical and logistic issues in integrating elder's needs into the household.  There are numerous approaches and perspectives that can help the elder and the family handle the transition individually and in the family lifecycle.  Many, if not all of these approaches and perspectives work effectively.  This article is not about them!  The most logical approaches and perspectives will be stymied as with all relationships, with the presence of someone with a major characterological disorder.  All logical approaches work with logical people.  Many therapists or family members spend years (even decades) and thousands of interactions with a person with continual feedback that this person cannot be logical or reasonable.  What works with the elders from hell?  An examination of individuals with characterological disorders in individual and couples therapy prompt useful speculation for working with the elders from hell.

A fundamental sense of insecurity and vulnerability to the dangers of the world and an intolerance to one's own intense feelings of distress develops over time for some individuals, causing personality disorders to develop.  Personality disorders can be viewed from the perspective that the stress in a person’s life -- specifically, the stress that occurred in the challenges of relationships cause overwhelming suffering for the individual.  The suffering is so intense -- so invasive and instructive, that such an individual would choose characteristically dysfunctional behaviors to block, stuff, or avoid the suffering.  Characteristic flawed patterns of responses include borderline personality disorder, narcissistic personality disorder, dependent personality disorder, and histrionic personality disorder.  All of these personality disorders are difficult to treat in individual therapy.  And, personality disorders often persist throughout the life of individuals.  Which means that along with the sweet gentle granny, the spunky Nana, the distinguished gent, and the incorrigible old codger -- relatively emotionally and psychologically healthy elders, there are the borderline, narcissistic, dependent, and histrionic elders -- the elders from hell!  One of the fundamental rules from developmental theory is that under stress, individuals tend to revert or regress to earlier stages of development or immature behavior.  Inevitably, the normal challenges of elder living or integrating an elder to turn a two-generation family into a three-generation family will cause stress.  It would be no surprise that healthier adults would tend to be more healthy participants in the process as elders.  And, the more likely to have healthier adult children with healthier family systems to enter.  The other side of that is that the spawn of the elder from hell may well also have problems individually and in subsequent relationships and systems.  And subsequently, be further ill equipped to handle the demands of integrating the elder into the family.  Their need for guidance in family therapy would be great.

The Borderline Elder in the Family
The borderline personality is one type of elder from hell. Borderline personalities will over-invest (“unconditional” love for the family member) and end up being, that is, feeling betrayed and wronged (the betrayal is the cause of subsequent self-righteousness).  The pain often causes him/her to attack the other, which can be the therapist, the family member, or in the case of elders entering a family, the elder’s son, daughter, son-in-law, or daughter-in-law.  The borderline lashes out in anger but also with pain.  You can often hear the anguish in his/her voice.  Later, when calmer, he/she will then need to make up with the family member.  He/she will do so with intensity (in effect, re-seducing the family member).  Initially, the family member opens up again to the borderline’s promises and charm.  Unfortunately, the borderline personality cycles these behaviors over and over until the other gets sick of it and leaves.  This behavior might have precipitated the adult child's original departure from the family decades ago.  Such a borderline person will have a long history of such relationships.  Upon examination, the therapist may find that the individual has often run from relationships or emotionally withdrawn.  Or, he/she can also get very clingy.  Both are attempts to deal with an overwhelming sense of loss that originated in early childhood wounding by parents caused by a lack of appropriate mirroring.  The individual often experiences being alone or abandoned emotionally and/or physically.  He/she can be exceedingly and genuinely loving and kind when in need or not in crisis or feeling hurt.  After acting out, he/she will be genuinely remorseful, which leads the family member to forgive and accept only to get hurt by the borderline later.

The family member experiences an impossible expectation, that he/she provide perfect mirroring to the borderline.  Due to his/her own issues, the family member attempts to be the perfect mirror… and fails.   This is especially devastating, as many adult children feel obligated to love their unlovable elder parents.  Any acts of self-care by the family member are experienced by the borderline, as imperfect mirroring… as betrayal.  The borderline can be receptive to cognitive interventions such as discussions and working out the process with family members.  In therapy, he/she often will even accept the borderline diagnosis.  However, upon stress (an incident of “betrayal” by the family member), the borderline will revert to punishing the betrayer.  Not surprisingly, the borderline has been abandoned over and over in relationships, both in the family and outside of it.  This reality makes the borderline highly vulnerable to depression, and subsequently, to alcohol and substance abuse and other addictions in order to self-medicate.  

In relationships, the other including the therapist becomes the betrayer and often is “punished.”  Some therapists recommend remaining as consistent, accepting, and nurturing as possible, letting the client work through the transference with the therapists.  These, however, are often the same therapists that say the borderline drives them crazy!  The therapeutic process that I prefer is to attempt to teach borderlines how to express pain and loss without attacking.  I also clearly and assertively take away the borderline’s self-righteousness claim that he/she is entitled to hurt the betrayer.  In couples or family therapy, I reinforce the partner or family member setting limits on hurtful behavior by the borderline when he/she is hurt.  Borderlines assert that they cannot suffer and survive.  When they suffered as young children, their parents were not there to hold and contain the pain, nor to foster the resiliency that one needs to draw upon to endure it.  Pain was not a moment of distress, but would draw them into an abyss of terrifying abandonment and loneliness.  Their compulsive acting out (hurtful stabs at their family members and family members) is an attempt to jump from the intolerable abyss.  They are not conscious of the consequences (especially, long-term consequences) of their behavior; or at best, are only semi-conscious and are unable to restrict their behavior.  However, suffering occurs in relationships; great suffering occurs in intimate relationships.  It is unavoidable.   The therapist or family member should teach the borderline that he/she CAN suffer and still behave appropriately… in fact MUST suffer, even embrace suffering to be able to survive and grow.  The therapist needs to attack the basic mythology of frailty, and interrupt the cycle that leads to depression and anxiety in people, and specifically, to vengeance by borderline personalities.   

The therapist must enlist both the borderline and his/her family member in the borderline’s healing, in order for there to be hope for the relationship.   The borderline’s ability to self-monitor and self-regulate his/her pain and acting out is very limited.  The borderline needs to empower both the therapist, but especially the family member to help him/her in the process.  This asks him/her to be vulnerable to those who can hurt him/her the most.  The therapist needs to help both the borderline and his/her family member understand the psychodynamic and family of origin issues, as well as the current challenges of integrating the elder into the family, that cause the vulnerability, hurt, and neediness AND subsequent need for vengeance.   This may allow the borderline to accept the therapeutic interventions to facilitate growth and change.  And, will allow the family member to have the compassion to tolerate the borderline’s process of healing as an individual and in the family relationship.  The family member needs to recognize the borderline dynamics, refuse to be abused, yet be able to nurture the elder when the pain underlying the anger precipitates the abuse.   

When the borderline reacts explosively, the family member needs to recognize it well enough to refrain from retaliating (or running), and respond differently.  “What you just did hurts.  Right now my instinct is to attack back or withdraw, but I’m trying to hang in here.  Are you trying to hurt me because I hurt you?   I will not accept being abused.  However, I also want to know how I hurt you.  Help me understand what I did and what it meant to you.  Tell me how I hurt you.”  The family member has to be insistent on staying with this process and avoid the habitual responses.  When the process expresses itself in the session, the therapist’s ability to stay focused on identifying and validating the underlying issues will interrupt the process, and model for them both how to do it themselves.    The therapist can both prompt the new process and model it.  

This is a long-term process.  Getting the family to stay committed to the process is critical.  One way is to require an immediate commitment from the family (but especially, the borderline member… you probably can recognize the personality by the middle of the session) at the end of the first session for a specific number of sessions, with a specific IN SESSION process if one or the other wants to terminate therapy (no telephone terminations).  Explain that the commitment serves to avoid any family member using attendance at or the continuation or not of therapy, as another weapon in the family's battles.  Predict to both that one of them may threaten to stop coming to therapy to manipulate or intimidate the other family members.   One of the primary ways a borderline deals with anxiety is to run; running from therapy, running from the therapist is very likely.  By anticipating it and making a prediction, a paradoxical intervention addresses this probable response.  Paradox works to either reveal (expose) the habitual dynamic, thus facilitating insight; or as the client resists the prediction, causes behavior to change.  It also removes the threat of running from therapy for the therapist, who otherwise would be disabled in his/her interventions if the thrust of therapy becomes keeping the individual or family in therapy.  

The Narcissistic Elder in the Family
Narcissists will assert superiority over the other person.  He/she will cruelly punish the other for “sins” with great self-righteousness.  The narcissist is created by the lack of mirroring (considered to be even more severely inadequate than what the borderline experienced) from his/her parents.  The wound is created either by severe emotional neglect (with the implicit message that “you don’t matter”), or over-indulgent parents (who promise perfect mirroring such that the infant and child will not experience any pain or anxiety, and then inevitably fail, thus creating a fundamental terror of his/her vulnerability in the world).  The narcissist responds to this existential terror by seeking to prove his/her worth through extreme competence and control (which includes manipulation).  Narcissists tend to be highly successful academically, professionally, and financially.  Anyone who the narcissist perceives as inferior is dismissed.  However, the narcissist will respect anyone who unequivocally proves or establishes his/her superiority.  However, any competitor is perceived as a threat to that alpha competence which then is also perceived as a threat to his/her basic worth.  And, the narcissist will respond with ego-syntonic self-righteous intensity… even cruelty to the perpetrator.  Hence, Livia Soprano who used all means possible including guilt to manipulate family members to serve her continued domination – even manipulating Uncle Junior into instigating an assassination attempt on her son, Tony Soprano.

Normally, the narcissist will not normally present for therapy, or as part of a couple or family for therapy unless in an extreme crisis mode.  Coming to therapy, in itself, is an admission of vulnerability, the narcissist normally cannot make.  The crisis usually is threat of loss of job, marriage, or other extreme consequence (including repeated severe substance abuse and effects).  In the case of a family, this may be a threat to the narcissistic elder that he/she may be soon ejected from the family and placed into institutional care. The narcissist will try to assert superiority over therapist and everyone else including family members.  If therapist is passive (unconditional, agreeing, seeking to facilitate without offering substantive feedback), he/she will be dismissed.   You should expect questions …even challenges about your credentials and experience, and arguments about your interpretations or interventions.  If you try to please the narcissist, or accept his/her superiority, you will be dismissed.  Humanistic existential therapists are highly vulnerable to this, since they present themselves as equal partners in a caring helping process.  The narcissist DOES NOT want the therapist to be an equal.  As an equal, you will be perceived as a rival, dangerous to his/her need to feel superior.  And, you will be attacked.   Ironically, I believe they are more receptive to more classic psychoanalytical styles that place the therapist in a superior mode IF the therapist can establish clearly superior credentials.  His/her energy is to make you “wrong” all the time.  When the therapist experiences these criticisms and attacks, he/she is having the same experience the narcissist’s family member continually has.   A common therapeutic approach is for the therapist to be the unconditionally attentive and nurturing parental figure for the narcissist to work through his/her issues.  My therapeutic preference is to assert superiority as the therapist in the realm of relationships and psychology!  Although, the narcissist will attack a rival and, dismiss an inferior, he/she will defer to and respect a clear superior.  The therapist’s realm of superiority in relationships is clear and obvious, just as much as the narcissist’s inferiority is clear and obvious; if the narcissist/client is so intellectually and otherwise superior in these areas, then what is he/she doing in therapy!?  Being in therapy is a de facto deference to the therapist.  However, the therapist must assert this.  

If the therapist finds him/herself caught up in proving oneself, he/she should step back and comment on the process as a third person observer.   The therapist moves him/herself into a new “objective” position that surveys and assesses the interactions.  He/she is asserting his/her professional competence (superiority) in this domain—assessment and evaluation of interpersonal processes integrating a three-generation family.  Sometimes, a less rigid narcissist is able to defer to this and is able to benefit from the feedback and use it in the relationship.  Or, the narcissist may not agree and continue to argue, but the family member gets to see the dynamic with someone else being an antagonist to the narcissist for the first time.  Comment again on the process (arguing and superiority) and refer to the family member for confirmation (“He/she does this to you too?” “Do you find him/her making you wrong all the time too?” “Is this just me, or do you see him/her interacting with others like this too?”)  Switch to the family member and process his/her frustration and other feelings dealing with this.  Ask the narcissist, if he/she is aware how he/she affects the other person… do NOT ask, “Is this what happens?”  Asking the narcissist what happens allows him to argue the interpretation of reality.  What the family member feels is existentially unarguable (a powerful stance by the therapist).  That he/she should or shouldn’t feel this way is also (for the time being) placed out of bounds by the therapist.  Ask how he/she feels about hurting, dismissing, etc. his/her family member.  He/she will respond by explaining.  Interrupt the explaining and ask again, how he feels about hurting…  Repeat as he/she avoids.  Repeat again as he/she avoids.  Feed back observation that he/she seems to have real problems with acknowledging the harm to and the hurt in the family member.  Switch back to the family member to ask what he/she feels about his/her feelings being ignored.  Continually use the family member as affirmation of the basic therapeutic evaluations… the power of the therapist and the family member together makes it more likely that the narcissistic person will (begrudgingly) accept the feedback.  Before the session ends, bring therapist-narcissist relationship to the table for discussion.  Ask directly, if the narcissist is mad at you.  Predict that since you disagreed and challenged him/her, that based on his/her dynamics with the family member (and others discussed) that he/she would either dismiss you as incompetent (or worse!) and terminate therapy, or be angry at you.  Before he/she responds, ask the family member what he/she thinks the narcissist will do or feel (again, using the family member as a “therapeutic family member”).

Consequences of this approach include the therapist being an ally for the family member who has always been made wrong.  Consequences (potentially…hopefully) for the narcissist are that he/she will accept you as an authoritative person and be willing to defer to you.   Don’t be deceived, however, they will still try to take you down or test you over and over.  You need to stay one step ahead… keep them off balance… keep them on your territory.  Re-assert a territory they are unfamiliar with… one they must (relatively) unequivocally defer to you.  And, that, again, would be the therapeutic realm, or the realm of healthy relationships.  For therapists who are egalitarian, this runs counter to their instincts.  However, narcissists, who will not feel valued or reciprocate with respect since their issue is superiority, will eat up egalitarian therapists!  The key is that rather than using the authoritative stance to dominate, the therapist uses it to respect his/her needs.  Gently but firmly affirming the underlying need to be valued and respected, addresses the original wounding of the infant/child (rejection or failed attempts to be a “perfect mirror” by parents).  Remember, you are the therapist and the narcissist is there because of his/her failure to do relationships well.  Those who are careful not to pathologize clients are reticent about asserting this position.  It is a difficult choice.  However, since narcissists tend not to present themselves in therapy of any sort, that they are there means that they are vulnerable and in crisis and more open than they normally would be.  On the other hand, often clients may not be true narcissists, but have narcissist tendencies that can be effectively addressed with these techniques.

The Dependent Elder in the Family
Dependent personalities will look to their family member (and, to the therapist) for affirmation that they are “right” or OK.  They are unable to do this for themselves.  Early domination (emotional and psychological neglect or abuse, if not also, physical and sexual) was likely.  It was dangerous to assert oneself in relationships within their family of origin.   Dependent personalities continue this dynamic with new relationships or in renewing old family relationships.   They have many experiences being made unimportant, being silenced, and being disempowered.  They have extremely low self-esteem.  Unable and inexperienced to confirm for self, his/her basic worth, they are always looking to others for confirmation.  However, when they get confirmation, they are unable to retain any lasting sense of self-worth.  Therapists’ or family members’ praise is only (if then) momentarily effective.  Feedback to the dependent elder that they seem unable to take praise is useful.  As with other personality disorders, the therapist needs to reveal the underlying early childhood mechanisms (stress, trauma, and abuse) that fostered this personality style as an important foundation to change.  The dependent personality was developed in order to survive as a fundamentally disempowered individual in a dangerous world.  From this perspective, it is not a pathology, but rather, a logical response to extreme conditions.  It “works” for the individual.  This attacks the basic mythology of helplessness of the dependent personality.  Many of the issues described for the victim personality are relevant to the dependent personality.

Family members get tired of this neediness and will often become rejecting, which they may have a hard time justifying.   The therapist should ask family member how it is to be trapped and/or manipulated by dependent’s constant need for reassurance and permission (and thus, expose the dynamic).    The dependent personality often is super-nice… super-sweet.  Being super-nice/sweet is his/her “thing” or methodology to gain some control of life.   By being sweet, others will like them and will tend to do things for them and will cut them a lot of slack.   Ask the family member how it feels to be trapped and manipulated by dependent’s niceness (expose this dynamic as well)!  The dependent personality tends to do more passive aggressive behavior than overt behavior.  He/she is often able to drive family members crazy with passive aggressive behavior!  Name and reveal this, in addition to other dependent processes in the family in therapy.  Revealing the dependent personality’s passive aggressive behavior puts the all the family members on equal footing—all may be purposely attacking and hurting the other, although they are doing so with different styles.  Establishing this equality, allows for more empowered negotiations between family members.  

The elder is very apologetic when her son complains about her using his tools and not putting them away.  She subverts his righteous indignation, by being meek and self-deprecating.  She asks meekly for him to tell her what he wants her to do.  She’ll do what he asks.  It works to disable him.  He becomes more frustrated as he is aware that he seems more and more of an asshole in front of the therapist if he continues to insist on his issues, when his mother is so deferential and beating up on herself.  He comments about this trap, “I’m always the bad guy!  She makes me feel like a jerk when she does that.  But then she keeps on doing the same stuff anyway!  I tell others about her, and they tell me I’m unreasonable!  She has my brothers and sisters on her side!”   My intervention is to agree with him but taking it to a deeper level.  “You’re right… she’s got it made.  Her ‘niceness’ really screws you up.  Where do you think she learned this?” The family member is often aware of the family of origin dynamics at the origin of personality of his/her mother.  To her, I ask,

”This works pretty well.  Being nice is a great way to ‘get’ him!  Where did you learn this?”  In a short time, it is revealed that being nice and sweet was the only for females to get any semblance of power and control in her family.  Overt attempts were considered too aggressive or not feminine, and were punished severely.  Continuing to work with her individually while her son watched, I asked, “What were the consequences of doing life this way?  What was the downside?”  Usually, the individual is quite aware of the negative consequences having lived them all her life.  At this point, the personality will still re-assert itself when she says, “Oh, I’m so messed up!  What should I do?  Tell me what to do?”  Pointing her to other people and personalities can be a way to promote change while not falling into the same pattern of dependency.  “What would so and so do?  What would the angry part of you do?  What would the strong part of you do?  The powerful part?”  Enlist the son or other family members in her process, “You would like her to fight back, huh?  It’d be better than all this sweetie sweetie stuff, wouldn’t it?”  Often, the family members would confirm this, “At least she’d be real, instead of being all fake about it.”  At this point, you can train her (and him) how to “fight” in the session.  Have her repeat provocative and emotionally charged phrases that have her experience ownership of her feelings; say: “tell him, you’re pissed that he…”  “tell him, you hate that…”  “tell him, you can’t stand…” As the therapist, you need to be aware that the dependent personality will continually attempt to revert back (like all the personality disorders) to habitual communication and behaviors, and identify and then deny the invitation to join in the old relationship.   

The Histrionic Elder in Therapy
Histrionic Personalities tend to be very flamboyant attention grabbers.  While they often have the same emotional wounds as those suffered by other personality disorders such as Borderline Personalities, the Borderline gets into angry disruptions and self-destructive behavior in relationships resulting in deep feeling of emptiness, whereas the Histrionic is very expressive and dramatic, charming and flirtatious.  The need for the affirmation of attention is very profound and the Histrionics’ behavior can be inappropriately sexually provocative and seductive.  They are often initially experienced as very charming, fun, and attractively passionate.  Upon further experience, others will find that the Histrionic is shallow.  They lack the depth of personality that would hold someone’s attention or affection over the longer term.  Although, the presentation is dramatic, the underlying logic or rationale he/she presents is usually vague or ambiguous.  The intent is not to convince the other of the logic of the idea or issue, but to use the idea or issue to draw attention to the Histrionic.  Histrionics are also easily influenced by other’s opinions.  Agreeing with another tends to have the person attend to you as a supporter or ally.  They also tend to easily trust people or quickly find deep emotional connection to the point of having romantic fantasies about people who do not perceive as deep a relationship.  Conversely, they do not offer enough depth for relationships to move along, thus creating problems developing deeper intimacy.  The need for attention is compulsive and unrelenting.  When they were younger, they may have trouble keeping friendships since their need for attention may cause them to be flirtatious with friends’ boyfriends or girlfriends inappropriately.  As elders, they will also be perceived as charming and fun -- as really neat and cool old people by those who do not have to live with them.

The Histrionic has trouble sharing the stage; he/she will do something immediately to draw attention back to him/herself.  After the initial attraction, others experience their own self-worth being ignored through the Histrionics’ behavior.  The Histrionic is not interested in others… their lives, stories, feelings, or thoughts, but are interested in others only for the attention they can give him/her.  A family member to a Histrionic consistently finds his/her needs or feelings being over run by the drama of the Histrionics’ attention hogging activity.  Such a family member often will get tired of counting only as the audience (with little audience participation!) and not mattering.  When others are no longer interested in him/her… attending to him/her, the psychological void the Histrionic experiences, becomes overwhelming.  As opposed to classic existential question-- the tree in the forest that falls and no one hears or sees it fall, then does it exist or did it really happen? for the Histrionic, he/she becomes desperate with fear that he/she doesn’t really exist or count unless someone sees or feels him/her.   He/she is then likely to engage in extreme behaviors to gain an audience again.  Through it all, the Histrionic appears to be unaware of the quality of his/her behavior. The therapist should help the Histrionic become aware of his/her process and the underlying needs.

The Histrionic may love being in individual therapy; he/she is getting the undivided attention of the therapist.  He/she will “perform” the entire session.  However, the therapist will also experience the shallow quality of the Histrionic.  If the therapist attempts to focus the Histrionic on his/her inner feelings and thoughts, the Histrionic will offer quick and easy explanations while continuing the flamboyant style.  In couples or family therapy, however, the Histrionic has to compete with his/her family members for the attention of the therapist.  If allowed, he/she will dominate the session, keeping both the family members and the therapist as the audience.  When the therapist speaks to him/her, it is tolerable because the communication is directed towards him/her.  However, if the therapist speaks to a family member or a family member is speaking, he/she will become uncomfortable without the focus on him/her.  Even when interrupting, he/she will be able to do it in a charming manner that obscures the fact that it is an interruption.  The Histrionics’ family member tends to be accepting of his/her behavior.  People who are more critical and demanding of their own needs being met would tend not to get into a long-term relationship with a Histrionic (and, therefore not likely to present themselves in couples therapy).  However, family members are born into the relationship. The Histrionics’ family member can be attracted to the drama and flamboyance of the Histrionic; enjoy being in the “glow” of the Histrionics’ “light;” vicariously enjoy his/her activity; and may have sufficiently low self-esteem to be satisfied being secondary to the Histrionic needs.  The therapist should help clarify for the family member what he/she gains or can gain from the relationship.  Long-term relationships (including jobs) are often sacrificed for the excitement of something new for the Histrionic.  It is unlikely that the Histrionic will be the instigator of couples or family therapy.  He/she is more likely to move on to some other activity or relationship where the minimal requirements of attention would be met.  On the other hand, his/her family member may instigate the therapy.  As an elder who has become dependent on the family member, the Histrionic may not have the option of moving on, perhaps for the first time.

A family came into therapy upon the instigation of the family member—the daughter-in-law who was getting tired of being pushed aside by the elder and her husband because of her histrionic behavior.  Her mother-in-law had moved in two years ago.  When I asked the son what he thought about his mother's attention grabbing behavior, he responded that he was kind of used to it.  The mother added that her son was such a sweetheart. Then I asked more directly if his wife's upset with his mother bothered him.  The mother interrupted that she was just trying to be part of the family.  He said that he had reassured his wife that there wasn’t anything negative intended.  When I fed back to him, that he still had not answered my question, he said it was difficult, because he loved both of them.  She started to interrupt again, but I told her to hold on until I finished with her son.  During this subsequent exchange, she seemed to become fidgety.  When the focus switched to her, she visibly lit up.  She gave shallow evasive answers, but with a definite flair.  Her affect was animated and she spoke rapidly.  There was little space for anyone to get in.  When confronted with the inconsistency between her expressed commitment to her son and daughter-in-law and her behavior with her daughter-in-law, she minimized the issues with a wave of her hand.  She seemed to enjoy my continued challenges to her -- she stayed in the spotlight.  I fed back to her these observations.  She was able to acknowledge their validity.  When asked where the behavior may have come from, she began a dramatic story of her childhood.  After a while, I stopped her and instructed her not to speak for 10 minutes while I talked to her son and daughter-in-law.  I told her just to focus on her own feelings during the 10 minutes so she could report on them later.  I proceeded to purposely ignore her.  She couldn’t stand it, and interrupted within a minute.  I repeated the instructions—hushing her, and continued with her son and daughter-in-law.  She became more fidgety and began to frown.  Again, she interrupted, lasting two minutes this time.  She started to say that she didn’t like just listening.  Again, I hushed her to stay with the experiment.  In another couple of minutes, she interrupted again—this time with definite annoyance.  I fed back to her that she couldn’t stand not having the attention on her.  I asked her daughter-in-law for confirmation.  She agreed but her husband tried to minimize it.  I confronted him with his acceptance of the minimal attention he got from her.  I confronted the elder with her need to keep the attention on herself.  Neither the mother nor the son liked these revelations.  I repeated this over the next three sessions.  They stopped coming to therapy.  

It is also possible (perhaps, probable) that this family broke up eventually (a different living arrangement), when the daughter-in-law decided she was worthy of more and demanded more in the relationship; or, when the son decided that his relationship with his wife was more important than maintaining the dysfunctional relationship with his mother; or, when the mother found her son and daughter-in-law less attentive and needed a new fresh audience and found a way to get one (perhaps, in the staff of an attentive care facility!).  Or, the most unlikely outcome, that she recognized her histrionic behaviors and began working on her growth to stay in the relationship or some subsequent relationship.

The Paranoid Elder in Therapy
Many aspects of the borderline personality or the narcissistic personality can be seen in the paranoid personality: the intense anger and sense of being betrayed over seemingly incidental and minor transgressions, extreme self-righteousness of the position held, and the brutal lashing out in vengeance for harm experienced.  As in other developmental disorders, the origins of the paranoid personality disorder lay deep within the individuals’ formative childhood experiences and may not be accessible in the present to them or the therapist.  Similar to the narcissistic personality, the paranoid personality experiences his or her world perspective as ego syntonic -- it all makes sense to him or her.  However, whereas the narcissist in a narcissistic rage tends to go to an ostensively cool nonemotional place that justifies every cruel act of revenge to him or her as logical, the paranoid tends to go to an intensely emotional place of rage. Similar to the borderline personality, the paranoid personality is deeply hurt by others’ acts. However, whereas the borderline, once the pain has subsided has deep regret for what he or she then recognizes as inappropriate and abusive behavior, the paranoid stays in the pain and does not ever have either regret nor awareness of his or her behavior having been inappropriate (or the regret or awareness is only momentary or superficial).  While the borderline can move from the anger and the narcissist will deny his or her anger, the paranoid stays in the anger.  Individuals with stimulant abuse and dependency issues such as methamphetamines ("crank," "speed," "crystal"), crack or cocaine and alcohol will often present in the same manner as the paranoid personality.

In family and couples counseling, the underlying and overriding thrust and goal of the paranoid personality is to prove the righteousness of his or her perspective, and to prove the corrupt and evil intent and behavior of his or her partner or other family member.  Any discussion about an incident or an interaction always goes to how the partner or other family member maliciously and purposefully violated the paranoid.  To engage in such a discussion about what happened, when it happened, what one person did or the other person did, what precedents and history are involved, and whatever details that are supposedly relevant is essentially fruitless.  The paranoid's goal is not to get clarity about what happened, to understand what the underlying motivation or intent may have been (it was obviously "evil" intent!), to achieve resolution or compromise, to improve communication, or to heal or to achieve greater intimacy.  There is often little or no insight as to how vicious his or her behavior is or has been, nor how damaging it has been to the other or to the relationship.

The thrust of couples or family therapy in this situation include (similar to working with a couple or family with a borderline) the therapist clearly asserting that no member of the family has the right or the permission to be abusive no matter how righteous or entitled they feel.  The paranoid will not like this boundary, nor be readily able to follow it.  In this case, this boundary is more for the other to hear and feel reinforced and validated.  It would serve the other and the therapy for the therapist to name the paranoid's dynamic- that he or she is intent on proving the other's corruption.  And, then for the therapist to label that unacceptable.

Jane who is seventy-eight years old and Benjamin, her son in his early fifties present for therapy after 10 years of a very difficult co-habitating elder care relationship.  Jane came to live with Benjamin and his teenage daughter about ten years ago shortly after her husband (Benjamin’s step-father) died and after Benjamin’s divorce.  There are issues about chores and supervising the teenager and some financial issues that affect their relationship.  Benjamin is flabbergasted as to the vehemence that Jane attacks him with continually.  She is relentless.  Not only does she bring up transgressions in the present, but she has a whole history from the last 50+ years.  Rather than just list the things that she feels he has done to her, she spices the narrative with frequent ugly stares and what is obviously intense hatred.  When I challenge her that she seems to hate Benjamin, she snaps back with another list of him failing as a son.  When I asked Benjamin if he feels the hatred, he acknowledges it.  When I asked him how it feels, he says it beats him down but he has gotten to the point where he shuts her out because it is too overwhelming.  Jane jumps in here to condemn him again that he emotionally abandons her and shuts her out.  Her jaw juts out, her face is red, the veins bulge out in her neck, and fire darts out of her eyes.  She is fuming. Benjamin sighs and states rhetorically, "So, I guess I am the worst most ungrateful son in the whole world!"  I challenge her that much if not all of her comments in the therapy have been to prove that Benjamin is the "worst most ungrateful son in the whole world!"  Her response is to give further proof that he is the worst most ungrateful son in the whole world.  I prompt her as to what positives she has experienced with Benjamin.  She begins with some experiences when he was a baby and then quickly and determinedly moves to show how he subsequently betrayed her.  I prompt her as to why she stays or has stayed with Benjamin.  She responds about how he can be caring and then gives more examples of how he hurts her.  I feed back to her again, that her responses seem to always go to proving that he is the "worst most ungrateful son in the whole world!"  This is where Benjamin jumps in and exclaims, "That's why I don't try to talk to her anymore.  It's always about me being the big ass hole!"  He goes on to describe walking on egg shells around her but still failing and get ripped over and over.  I asked her again why she stays with him.  She becomes sullen and says she does not know.  She makes some excuses about finances that prove to be untrue.  I asked her if she could stop abusing him (it is important to clearly label this process as abuse).  She responded with further justification for her abuse, "If he didn't..., then I wouldn’t..."  I commented that it sounds like she was unable to stop abusing him.  I asked her how her anger and attacks have been affecting Benjamin.  She initially says he must not like it, and then moves immediately into justifying why she does it and how he deserves the anger.  

This seemingly futile therapeutic process is actually clarifying to me as the therapist that Jane has major paranoid issues and possible paranoid personality disorder (or a substance abuse issue that creates paranoia).  A borderline can acknowledge the other person's pain as he or she can step away from his or her own pain in a calmer moment.  The inability to have empathy is a characteristic of paranoid personalities.  Such people are so immersed in their own pain that they cannot empathize with someone else's pain.  They experience the request to connect with someone else's pain as a denial of their right to have their own pain, and subsequently will resist empathizing and deny the other person's pain.  The narcissist also is unable to acknowledge or empathize with the other person's pain, but his or her rage is deeply buried out of his or her own consciousness.  In fact, whereas the paranoid will be in rage but also in pain (owning and acknowledging his or her own pain), the narcissist not only denies the other person's pain but his or her own pain and rage.  The other person who can gain clarity from this process, is the paranoid's partner or other family member -- in this case Benjamin.

I prompted Benjamin, "It seems that any so-called discussion between you and Jane ends up being Jane trying to get you to confess to being the worst most ungrateful son in the whole world.  Is that right?"  Benjamin acknowledged that it was.  "Are you the worst most ungrateful son in the whole world?"  Benjamin acknowledged his faults and his mistakes, and he also acknowledged how he sometimes strikes back at Jane when her attacks were relentless or particularly nasty.  And, he acknowledged that he was wrong and it was abusive.  However, he asserted, "But, I am not the worst most ungrateful son in the whole world."  I challenged him, that if he wasn't the worst most ungrateful son in the whole world and the totality of the process with Jane was consistently about proving him to be the worst most ungrateful son in the whole world, that his continued participation in such a series of discussions seemed to be masochistic.  He acknowledged this.  I challenged both of them, that Jane seemed to be unable to stop trying to prove that Benjamin was the worst most ungrateful son in the whole world and that Benjamin seemed to be willing to have Jane continue to try to prove it to him forever.  I implied that they were doomed to continue forever in this vein.   At this point (in response to the paradoxical intervention), Benjamin's body rose out of its defeated slumped position and he stated emphatically but calmly, "I'm done.  I don't deserve this and I am not taking it anymore."

The therapeutic process can be about improving communication, insight or awareness, or healing.  Improvement and progress in these areas lead to growth and change hopefully.  Sometimes, the therapeutic process is essentially and even totally about setting boundaries.  The direction of couples or family therapy when there is a paranoid personality is toward getting the other person to set the boundary that abuse is unacceptable.  That continued participation in the relationship will not happen if abuse continues.  As noted earlier, the paranoid personality disorder individual functions essentially in the same manner as certain individuals with substance abuse and dependence issues.  Substance abuse and dependence treatment gives guidance to working with the paranoid personality.  Much of addiction treatment is based on a behavioral model with very clear and very firm boundaries.  In many therapeutic models, the therapist tries to facilitate or prompt change in insight, in awareness, in thinking, in emotions (emotional reactivity), in spirituality, and so forth which will then facilitate or prompt change in behavior (from dysfunctional to functional behavior and life).  Many substance abuse and dependence treatment models have a reverse therapeutic process -- change the behavior and there will be eventual change in insight, awareness, thinking, emotions, spirituality and so forth.  Much of the direction of the change in behavior is about asserting and establishing clear boundaries of acceptable and unacceptable behavior.  The maintenance of the treatment is focused on those boundaries.

For Benjamin and Jane, the assertion of the boundary by Benjamin removed permission for Jane to continue to abuse him.  The logical consequence of this if Jane is unable to change, is that Benjamin will remove himself from the relationship – practically speaking, removing Jane from his household (or, possibly decide to keep letting himself be abused -- if not accepting that he is the worst most ungrateful son in the whole world, then that he is the biggest idiot or biggest masochistic in the whole world!).  As far as the individual with the profoundly dysfunctional behavior, only when the drinker is finally able to acknowledge and accept that he or she is unable to drink and be functional, will the drinker even begin considering changing his or her behavior.  Only if Jane is finally able to acknowledge and accept that she cannot be abusive and keep this relationship (live in this house), will she even begin considering changing his or her behavior.  And, some people continue to drink, lose everything until they eventually die.  And Jane may also continue, lose everything until she eventually dies… alone.

Unreasonable People
Sometimes the honesty of the therapy is intolerable for families, couples, or individuals too deeply invested in their dynamics.   The therapist should not collude in the maintaining the dysfunction of the relationship, in order to maintain the therapeutic relationships, that is, the therapy.  If the relationship is clearly harmful to all members, while it is not the responsibility of the therapist to end the relationship (that is the clients’ decision), it is his/her responsibility to reflect back as accurately as possible his/her assessment of the relationship.  This is not to say that any particular personality disorder is impossible to treat.   Personality disorders are by definition, pervasive deeply ingrained patterns of dysfunctional behavior.  And, as such are extremely difficult to treat.  And, impossible to treat if the client is too immersed and too fragile or invested in the disorder.  In the case with the paranoid elder, this was true.  It is also possible (perhaps, probable) that this family broke up eventually (a different living arrangement), when the son finally decided he didn’t have to suffer the continual abuse; that taking care of his and his daughter’s mental health didn’t make him the worse most ungrateful son in the whole world; that keeping himself available to be abused by his mother did not serve her either; that Jane would never be the mother he wanted and needed; and that his mother was incapable of being happy.  Or, the most unlikely outcome, that she recognized her paranoid behaviors and began working on her growth to stay in the relationship or some subsequent relationship.  Treatment and change may also be impossible for other personality disorders as well.  In "The Sopranos," Livia Soprano would never even consider that her behavior was in any way inappropriate.  For this elder from hell, her values and behavior were completely ego-syntonic.  Tony finally comes to the realization that his mother (a narcissist, if not a sociopath) can never be the loving nurturing mother that he desired, and that she is evil incarnate.  He gives up on the impossible.  He declares to the rest of his family, "She's dead to me."  On my website, the mini-poster "On Unreasonable People" says

Far too much energy is spent on trying to get unreasonable people to be reasonable.

It takes anywhere from a few minutes (or seconds) to a few interactions
to determine if a person can be reasonable.

Some people cannot be reasonable because of
developmental issues, alcohol or drug influences, and/or deep emotional or psychological pain.

Reason works with reasonable people.

Boundaries and consequences work with unreasonable people.

The work with the family with an elder from hell -- with an unreasonable elder may not be able to produce the kind of growth and change that is necessary for the family to exist in health.  Individuals with personality disorders are difficult to work with and to live with at any age.  When they are elders, when there are additional emotional, psychological, social, physical, and environmental stressors, the dysfunctional characterological patterns of behavior may not be amenable even to the best therapy and to the best intentions and energy of family members. In such situations, boundaries and consequences, which are the only things that work with unreasonable people may be necessary.  Among such boundaries and consequences would be the elder from hell, but not in your home!

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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