There are vigorous discussions among clinicians about the need for and the relevance of diagnostic labels. Arguments are focused on the idea that utilization of diagnostic labels help clinicians develop adequate or optimal treatment plans. For instance, if one is working with someone diagnosed with Narcissistic Personality Disorder, then there are established ideas about the best course of treatment. Clinicians can find those plans and are expected to follow them or be able to justify why and how they are treating this individual in a non -traditional way. There is the supportive argument that if other medical professionals become involved, when they obtain the diagnostic label they will automatically know much about the client and the treatment the client has received because of their understanding of the label. Counter arguments speak to the concern about confusing the patient with the label. It is believed that the label will get in the way of seeing the individual as a unique idiosyncratic individual and instead, have us see them as “a Narcissist”. The label becomes the representation of the client. A supporting counter argument is that the labels become part of the permanent record and will impact the client’s ability to obtain a security clearance, a loan, life insurance, or medical insurance.
While this is an interesting discussion with right on both sides, today I want to talk about a label that is not a designated DSM label. It is not a diagnostic brand, rather it is a descriptive characterization of the adaptive behavioral and emotional skills of a client. Many clinicians will tell you that this particular type of client, no matter what their DSM diagnosis is, will be the most exhausting, draining, difficult client for them to work with. They may fit in the diagnostic categories of many DSM labels, but this description will still apply to them and no matter what their label might be. They will still fall under this umbrella categorization because of their adaptive skills. This client is called the Help-Rejecting Complainer.
If you are not a professional, you will also have encountered this individual. It might be your boss, your co-worker, your neighbor or a friend. The primary description of the help rejecting complainer is that they are emotionally an empty vacuum that attaches itself to you and sucks the life, energy and creativity out of you. When they leave you, they are full of your energy and operating on your drive and creativity, and you are left depleted and exhausted and empty. You may recognize that you are angry, but it is difficult to place the blame on any thing specific that they have done.
The help- rejecting complainer will come to you with a level of praise for your ideas, your knowledge and your importance in their lives. They will say that you are the only thing between them and death or disaster. The tension will build as they place the responsibility onto you for solving their problem, telling them what to do, answering the questions of the universe. Most clinicians are flattered by this approach because all of us like to be needed and important. Many of us went into this profession because we are good problem solvers and have many creative ideas about approaching problems and conflicts in a variety of ways that allow clients to see the problems differently or at least tackle them from a new or different angle.
The help-rejecting complainer approaches us and says, “I need you, you know what to do, and I cannot find my way. You are my last hope, my lifeline and I trust you with my future.” They say this with attentive respect and positive energy. They cheer you along as you try to come up with a solution to their problem that will fit their circumstances and resources. All is well and good as long as you remember that you cannot make their choices for them and you cannot solve their problems. What you can do is make suggestions about ways to approach a problem or try a new behavior and ask them to imagine themselves operating in these ways and to anticipate what that might feel like if they did. What becomes frustrating about these individuals is that not for one second do they consider what you have suggested. They immediately have fifteen reasons why what you have proposed won’t work. This happens reflexively and immediately and their reasons are often plausible. What they will tell you is that you are really close and they sense that you are just about to come up with the brilliant strategy, but this particular suggestion just simply cannot work because……….. They tell you this immediately, they do not have to think about it, evaluate it, or consider how what you are asking them to do might work.
These clients are very seductive because they encourage and cheer you along as you toss out the first set of suggestions and try to come up with another workable possibility for solving the conflict. While you are doing that, the client reminds you of how helpful and important you are and is waiting with baited breath for your next offering. When you make it, as luck would have it, it too, will not work. The response that identifies the unacceptability of your suggestion again comes with immediacy and without any real consideration. They will gently remind you that you don’t understand, but that the idea that you are offering is impossible because of some set of facts or some involvement of others that they cannot control, and therefore it won’t work, but it still feels just so close. They then invite you to come up with another possibility for them to consider. They continue to tell you how good you are and how much they hope that you will be able to help them. The will announce that they have spread the word of your goodness and expertise widely and that lots of new clients will be coming your way because of the help you have given them. Then they want the next installment of your energy and creativity so that they can reject it immediately as well.
Clinicians must understand that this is not intentional behavior on their part. They do not stay awake at night planning strategies to frustrate you. This is how they survive. What is going on clinically during this process is that they work like a vacuum, they are sucking your energy and creativity right out of you. They actually resupply their energy by moving from individual to individual with whom they have these relationships. They do not need a therapist in order to get these energy refills, they can get them from complete strangers or friends who have not yet worn out and abandoned them. They appear to be so good and so positive, and so troubled and wanting help. Yet, they never accept help, never embrace responsibility for change, and get their energy needs met by feeding on the energy of others. They are not hateful or aggressive; they are just exhausting and frustrating.
Clinically, when you discover you have become ensnared by this type of client, the recommendation I would offer is to distance yourself emotionally from the reaction you have been having (Anger, frustration, exhaustion, depletion). Step back and remember what is going on. The challenge for treating this client is to frustrate him/her by not giving them suggestions. Instead, reflect back to them that you understand how frustrating it must be to be in their situation and make it sound so awful that you don’t know what they can do. Add to this conversation that you care about them and commiserate with them. Do a good job of reflective listening and do not get seduced into problem solving, no matter how tempting it is. When there are opportunities, do process awareness with the client. Discuss with them how it feels to be in a room and or a conversation with them from your standpoint and ask whether or not they have heard this from elsewhere in their lives. Ask them to describe for you what they feel when you do not meet their expectation. Look for their anger, see if you can find it and get them to own it. Do not do this by designating that you know they are angry and asking them to talk about what makes them angry, or what it feels like to be angry, instead, reflect back to them the behavioral cues that “mean” anger that you are experiencing from them and ask if they are aware of displaying these cues? Ask them to pause and reflect upon the experience of being in the room with you when you don’t know the answer to their problem and see if they can feel that in the moment and to talk about how that feels.
These clients are particularly difficult for most clinicians because they are so enjoyable and seductive at first. Very quickly (at least for experienced clinicians) they loose their seductive powers. The therapist cannot play the game and buy into the manipulation and shifting of responsibility that is practiced by the help- rejecting complainer. If you are able to avoid this trap, expect to hear that you are ugly, mean, and unhelpful. If they can feel safe with you continue to invite them to exist in your space and be real, then you can help them. You will never help them by problem solving and suggesting strategies and solutions. Your job is to be in the process with them, reflect it genuinely and to communicate respect and safety to them as you experience them accurately. When these needs have been met, the client will be in a position to make positive changes and experiment with new behaviors.