I have been pondering this issue for a while, particularly in Australia, where debates around public disability services have become highly politicised. In public discourse, psychosocial disabilities are often viewed as less impairing than physical or intellectual disabilities. However, a person with a severe physical or intellectual disability who is likeable, easy to get along with, and able to communicate their needs and concerns clearly and respectfully will generally have a much easier time accessing help and services than someone who is demanding, rude, belligerent, and—as you put it—“exasperating”.
People will go out of their way to help someone in need who is likeable. And despite the idea that we are an increasingly individualistic society, the ability to engage respectfully and effectively with others remains essential to living well in society—particularly when someone needs to interact with services on a regular basis. When I discuss these cases with others and point out that a person’s support needs are high because of their difficulty relating to people, the immediate response is often that the person needs to “learn” to ask for help in appropriate ways, and that services and support should be withheld until they do. But if natural consequences were sufficient for this individual to learn socially acceptable behaviour, it would have worked by now. They cannot learn social norms through natural consequences—that is precisely why they are disabled. It would be akin to suggesting that a paraplegic could get around better if people stopped “enabling” them by providing wheelchairs or assisting with transfers.
This article will probably attract some criticism (but hey, what else is new!), yet I think it is the most important and timely piece you have written. We have to talk about this issue, because ignoring it does not solve anything and, in many ways, is making things worse. I recently read a study that found that just 0.1% of callers to a suicide crisis phone line accounted for over 60% of calls received, with these frequent callers receiving an average of 160 hours of counselling per year (https://journals.sagepub.com/doi/full/10.1177/00048674251361753). I can’t help but think that if those hours were delivered as focused, intentional, long-term psychotherapy, the burden on crisis services might be reduced—although getting people to engage in regular therapy instead of repeated crisis-line use is a challenge in itself.
In any case, thank you for highlighting this issue. I work with clients who fall into this category, and supporting them requires an honest and realistic acknowledgement of their difficult interpersonal style, compassion for their struggles, compassion for the challenges faced by carers and service providers, hope that change is possible with time, perseverance, and resources, very clear boundaries, and a good sense of humour.
This piece made me think a lot about a number of things. There are gradations among the people you talk about- those who are violent and commit actually crimes, others whose personalities make dealing with chronic illness more challenging for those around them.Those whom we really fear and those whom we would prefer not to deal with.
I think a fundamental question you raise is not being able to treat someone as a moral equal. I think when we get to that point, as clinicians or family members, we have a problem both for ourselves and the ill person. Not being held morally accountable and not being a full partner leads to a power imbalance, to shame for the patient and resentment for the clinician or other party. And Psychiatry does people a disservice if we deliver the message that mental illness implies a lack of accountability.
Donald Winnicott's paper "The Use of an Object" comes to mind- the idea that the job is to withstand the attempt to destroy the other person- but then to circle back later and say, "hey, you know you almost destroyed us." Clare Winnicott wrote about her experience working with evacuated children in Britain in WWII, and described having to put a violent child outside the door until he could get himself in control. (Face to Face with Children: The Life and Work of Clare Winnnicott.)
This may be an ideal, but it seems like when someone is this difficult the thing to discuss is how difficult they are, and how alienating that is. When we can't do that, or our countertransference gets the better of us, at least to part with the message of how we see the problem, and try not to inflict harm.
I read this essay with a lot of respect and recognition. The exhaustion you name is real. Where I feel uneasy is when that exhaustion begins to feel like a foregone conclusion rather than a signal of systemic failure. The category of “the insufferable” makes sense interpersonally, but I worry about what happens when it stands in for the predictable outcomes of under-resourced systems. The limits of psychiatry are real, but they don’t have to be the limits of our collective imagination. Here's my response: https://undergroundtransmissions.substack.com/p/talking-back-to-what-do-we-owe-the
“The interpersonal issues at the individual level are a different beast entirely”. My mother in law is uBPD. I know un-credentialed people are not supposed to diagnosis people, but this seems like a rather odd social mandate to me, as most family members of “insufferable” people never wanted to know half as much as they now know about their exasperating (putting it mildly) family member’s possible mental illness. They go in search of answers out of desperation, know the way their family member behaves isn’t how non—disordered adults generally act. Couple that with the fact that it seems many clinicians aren’t willing to diagnosis a patient with something like borderline personality, I assume because of social stigma. I’m not even sure the regular clinical environment would provide enough interpersonal stress to cause someone suffering from undiagnosed BPD to act out in the same ways they do privately within their interpersonal relationships. I would think that resources play a huge role in how much contact health care providers have with people suffering with a mental disorder. If they can amass enough negatives advocates in real life and in the absence of self harming behavior or criminality they probably don’t come into contact with hospitals or jails, perhaps until old age when their family members need help caring for them. Thank you for this article. It very succinctly puts into words the conflicting emotions people have when dealing with these types of people.
Your footnotes are especially important and could lead to a whole article on which types of psychological theories and therapies are actually equipping care providers to work with the patients you describe. I agree that (in different ways) Comprehensive DBT, with its required DBT consultation team that provides support, relief, and reality checks to the clinicians involved, as well as really well delivered and supervised psychodynamic treatment are the only types I know of that make a consistent showing in this regard.
Sometimes people DO experience something like being invaded by an external enemy when they go mad. But very often, they don't. I've published about my own psychotic behaviour in the past, which wasn't violent towards other people, but I would wake up friends in the middle of the night and demand all their attention to a degree that was definitely exhausting for them, and terrible to endure.
I had close friends cut off contact eventually, and I have no hard feelings against them, I understand completely. I'm SAD that I lost them, but I can see that they really did their best, and eventually, it was just too much.
And they were dealing with ME. Not with some reified "mental illness" taking over and running me like a puppet.
I think you gotta find some balance, in your own case too, between holding yourself responsible to a degree, while also taking your difficulties fully into account and not being too hard on yourself. It's difficult but honest, whereas "it wasn't me, it was the illness" often isn't.
It's also interesting, what you write, about likeable vs unlikeable patients.
I think I'm pretty likeable, but also FUN. And this has helped me as a patient. I've got this whole fantasy-horror-show going on. It's more entertaining than many other mental health issues that clinicians deal with.
Also, as you note, this isn't just a psychosis issue. There are people with conditions like ASD or ADHD, far off from any psychotic spectrum, but who think they're entitled to endless patience from other people when, for instance, they're ALWAYS late and ALWAYS forget stuff. But at the end of the day, this, too, becomes impossible for other people to deal with and endlessly adapt to. Having a life, needing to plan ahead, having limited energy and flexibility - that's just being a mere mortal, not being ableist.
This also an important issue for communities of care and faith communities to consider. How do we love and support people with serious and disruptive mental health challenges while still maintaining an ethos of welcome and belonging? How do we support and love people with serious and persistent needs and issues when we ourselves (institutionally and individually) have limited capacity?
That is impossible, I think, without talking "out loud" both to the person and the commnunity so that it is not a dirty secret and everyone is knowing so as to not inadvertently set up the next unknowing member for a similar experience so they can set their own uncomfortable but necessary out loud boundaries. Collective knowledge and collective respect with collective boundaries.
You've put a light on one of our taboos. Money has been another one, but that's for another day, though I suppose enough money makes insufferable people a little easier to tolerate. [excellent but a bit dated book - The Last Taboo: Money as Symbol & Reality in Psychotherapy & Psychoanalysis by David Krueger]
I'm also thinking of a paper by Buie, decades ago, called "countertransference hate in the treatment of borderline patients." Very gutsy to use "hate" in the title, but also spot on.
I've read little about psychiatrists who fire patients, though that is usually (unless due to nonpayment of fees) relabeled as a poor fit, just not making progress and "time for a fresh pair of eyes" or similar, but it's often an iatrogenic manipulation because of the insufferability problem.
Few insufferable people will own being so. They'll acknowledge they can be demanding or oppositional at times, but not as a mainstay of their personality. Rensin is almost an
admirable exception and it -from a distance - makes him a little more likable! I wonder if I could bond with him in some way using that in a humorous or ironic way. I'm glad I don't have to make that offer for real.
Being with someone like this is akin to handling a porcupine. You are going to get stuck frequently and part of it is damage control. You want to punch the thing but you'll be the one to bleed more,, and even trying to put it down hurts.Pretty hard to find something about it you like. We're supposed to find something likable in everyone, and if we can't it's not automatically some version of countertransference.
It has helped me in my work to sometimes think, "jeez, and there are people who are with this insufferable person for hours on end." A bit of consolation.
I have been pondering this issue for a while, particularly in Australia, where debates around public disability services have become highly politicised. In public discourse, psychosocial disabilities are often viewed as less impairing than physical or intellectual disabilities. However, a person with a severe physical or intellectual disability who is likeable, easy to get along with, and able to communicate their needs and concerns clearly and respectfully will generally have a much easier time accessing help and services than someone who is demanding, rude, belligerent, and—as you put it—“exasperating”.
People will go out of their way to help someone in need who is likeable. And despite the idea that we are an increasingly individualistic society, the ability to engage respectfully and effectively with others remains essential to living well in society—particularly when someone needs to interact with services on a regular basis. When I discuss these cases with others and point out that a person’s support needs are high because of their difficulty relating to people, the immediate response is often that the person needs to “learn” to ask for help in appropriate ways, and that services and support should be withheld until they do. But if natural consequences were sufficient for this individual to learn socially acceptable behaviour, it would have worked by now. They cannot learn social norms through natural consequences—that is precisely why they are disabled. It would be akin to suggesting that a paraplegic could get around better if people stopped “enabling” them by providing wheelchairs or assisting with transfers.
This article will probably attract some criticism (but hey, what else is new!), yet I think it is the most important and timely piece you have written. We have to talk about this issue, because ignoring it does not solve anything and, in many ways, is making things worse. I recently read a study that found that just 0.1% of callers to a suicide crisis phone line accounted for over 60% of calls received, with these frequent callers receiving an average of 160 hours of counselling per year (https://journals.sagepub.com/doi/full/10.1177/00048674251361753). I can’t help but think that if those hours were delivered as focused, intentional, long-term psychotherapy, the burden on crisis services might be reduced—although getting people to engage in regular therapy instead of repeated crisis-line use is a challenge in itself.
In any case, thank you for highlighting this issue. I work with clients who fall into this category, and supporting them requires an honest and realistic acknowledgement of their difficult interpersonal style, compassion for their struggles, compassion for the challenges faced by carers and service providers, hope that change is possible with time, perseverance, and resources, very clear boundaries, and a good sense of humour.
This piece made me think a lot about a number of things. There are gradations among the people you talk about- those who are violent and commit actually crimes, others whose personalities make dealing with chronic illness more challenging for those around them.Those whom we really fear and those whom we would prefer not to deal with.
I think a fundamental question you raise is not being able to treat someone as a moral equal. I think when we get to that point, as clinicians or family members, we have a problem both for ourselves and the ill person. Not being held morally accountable and not being a full partner leads to a power imbalance, to shame for the patient and resentment for the clinician or other party. And Psychiatry does people a disservice if we deliver the message that mental illness implies a lack of accountability.
Donald Winnicott's paper "The Use of an Object" comes to mind- the idea that the job is to withstand the attempt to destroy the other person- but then to circle back later and say, "hey, you know you almost destroyed us." Clare Winnicott wrote about her experience working with evacuated children in Britain in WWII, and described having to put a violent child outside the door until he could get himself in control. (Face to Face with Children: The Life and Work of Clare Winnnicott.)
This may be an ideal, but it seems like when someone is this difficult the thing to discuss is how difficult they are, and how alienating that is. When we can't do that, or our countertransference gets the better of us, at least to part with the message of how we see the problem, and try not to inflict harm.
I read this essay with a lot of respect and recognition. The exhaustion you name is real. Where I feel uneasy is when that exhaustion begins to feel like a foregone conclusion rather than a signal of systemic failure. The category of “the insufferable” makes sense interpersonally, but I worry about what happens when it stands in for the predictable outcomes of under-resourced systems. The limits of psychiatry are real, but they don’t have to be the limits of our collective imagination. Here's my response: https://undergroundtransmissions.substack.com/p/talking-back-to-what-do-we-owe-the
“The interpersonal issues at the individual level are a different beast entirely”. My mother in law is uBPD. I know un-credentialed people are not supposed to diagnosis people, but this seems like a rather odd social mandate to me, as most family members of “insufferable” people never wanted to know half as much as they now know about their exasperating (putting it mildly) family member’s possible mental illness. They go in search of answers out of desperation, know the way their family member behaves isn’t how non—disordered adults generally act. Couple that with the fact that it seems many clinicians aren’t willing to diagnosis a patient with something like borderline personality, I assume because of social stigma. I’m not even sure the regular clinical environment would provide enough interpersonal stress to cause someone suffering from undiagnosed BPD to act out in the same ways they do privately within their interpersonal relationships. I would think that resources play a huge role in how much contact health care providers have with people suffering with a mental disorder. If they can amass enough negatives advocates in real life and in the absence of self harming behavior or criminality they probably don’t come into contact with hospitals or jails, perhaps until old age when their family members need help caring for them. Thank you for this article. It very succinctly puts into words the conflicting emotions people have when dealing with these types of people.
Your footnotes are especially important and could lead to a whole article on which types of psychological theories and therapies are actually equipping care providers to work with the patients you describe. I agree that (in different ways) Comprehensive DBT, with its required DBT consultation team that provides support, relief, and reality checks to the clinicians involved, as well as really well delivered and supervised psychodynamic treatment are the only types I know of that make a consistent showing in this regard.
This was a great read and I agree with so much.
Sometimes people DO experience something like being invaded by an external enemy when they go mad. But very often, they don't. I've published about my own psychotic behaviour in the past, which wasn't violent towards other people, but I would wake up friends in the middle of the night and demand all their attention to a degree that was definitely exhausting for them, and terrible to endure.
I had close friends cut off contact eventually, and I have no hard feelings against them, I understand completely. I'm SAD that I lost them, but I can see that they really did their best, and eventually, it was just too much.
And they were dealing with ME. Not with some reified "mental illness" taking over and running me like a puppet.
I think you gotta find some balance, in your own case too, between holding yourself responsible to a degree, while also taking your difficulties fully into account and not being too hard on yourself. It's difficult but honest, whereas "it wasn't me, it was the illness" often isn't.
It's also interesting, what you write, about likeable vs unlikeable patients.
I think I'm pretty likeable, but also FUN. And this has helped me as a patient. I've got this whole fantasy-horror-show going on. It's more entertaining than many other mental health issues that clinicians deal with.
Also, as you note, this isn't just a psychosis issue. There are people with conditions like ASD or ADHD, far off from any psychotic spectrum, but who think they're entitled to endless patience from other people when, for instance, they're ALWAYS late and ALWAYS forget stuff. But at the end of the day, this, too, becomes impossible for other people to deal with and endlessly adapt to. Having a life, needing to plan ahead, having limited energy and flexibility - that's just being a mere mortal, not being ableist.
This also an important issue for communities of care and faith communities to consider. How do we love and support people with serious and disruptive mental health challenges while still maintaining an ethos of welcome and belonging? How do we support and love people with serious and persistent needs and issues when we ourselves (institutionally and individually) have limited capacity?
That is impossible, I think, without talking "out loud" both to the person and the commnunity so that it is not a dirty secret and everyone is knowing so as to not inadvertently set up the next unknowing member for a similar experience so they can set their own uncomfortable but necessary out loud boundaries. Collective knowledge and collective respect with collective boundaries.
You've put a light on one of our taboos. Money has been another one, but that's for another day, though I suppose enough money makes insufferable people a little easier to tolerate. [excellent but a bit dated book - The Last Taboo: Money as Symbol & Reality in Psychotherapy & Psychoanalysis by David Krueger]
I'm also thinking of a paper by Buie, decades ago, called "countertransference hate in the treatment of borderline patients." Very gutsy to use "hate" in the title, but also spot on.
I've read little about psychiatrists who fire patients, though that is usually (unless due to nonpayment of fees) relabeled as a poor fit, just not making progress and "time for a fresh pair of eyes" or similar, but it's often an iatrogenic manipulation because of the insufferability problem.
Few insufferable people will own being so. They'll acknowledge they can be demanding or oppositional at times, but not as a mainstay of their personality. Rensin is almost an
admirable exception and it -from a distance - makes him a little more likable! I wonder if I could bond with him in some way using that in a humorous or ironic way. I'm glad I don't have to make that offer for real.
Being with someone like this is akin to handling a porcupine. You are going to get stuck frequently and part of it is damage control. You want to punch the thing but you'll be the one to bleed more,, and even trying to put it down hurts.Pretty hard to find something about it you like. We're supposed to find something likable in everyone, and if we can't it's not automatically some version of countertransference.
It has helped me in my work to sometimes think, "jeez, and there are people who are with this insufferable person for hours on end." A bit of consolation.
So well said.