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How Family Caregivers Can Manage Aging Adults With Personality Disorders

Strategies include staying calm during outbursts and balancing loyalty with limits

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Kubkoo

“My mom has narcissistic personality disorder,” one of my psychotherapy clients said to me. “She is unaware of my feelings as her caregiver.” “You wouldn’t believe the tantrums my mother throws when she doesn’t get her way,” said another. “I think she has borderline personality disorder.” “My father doesn’t feel guilty about hurting anyone’s feelings because of his antisocial personality,” said a third.

It sounded a little odd to hear people who aren’t clinical professionals applying mental health diagnoses to their family members, but psychiatric and psychological terms have always found their way into regular jargon. Thirty years ago, I heard psychotherapy clients say they were afraid they were “codependent” because they relied too much on others’ approval to feel good about themselves. Ten years ago, clients asked me if they were “bipolar” because they reacted to caregiving stressors with up-and-down moods. Nowadays I’m hearing more references to “personality disorders” when describing some care receivers.

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I don’t think this is being disrespectful. Caregivers have always struggled to understand why some family members they are caring for are argumentative, demanding or all-around difficult. It is sometimes easier to think of those relatives as having some condition beyond their control that affects their behavior rather than seeing them as personally hostile to the caregiver. “My mother doesn’t mean to ignore my needs,” a caregiver son or daughter might say, “but her narcissism prevents her from understanding what I’m going through.” That’s also a way for caregivers to protect themselves from disappointment by lowering their expectations that care receivers might change.

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So, what is a personality disorder? And how can caregivers best work with a care receiver who has one? Here are some ideas.

A personality disorder is generally a lifetime mental health condition

To understand what a personality disorder is, we must first understand how psychologists define personality: as a stable set of characteristics or tendencies that make up a person’s distinctive way of interacting with others throughout their lives. We may say that someone has a gruff personality when they always seem a bit grumpy, and a cheery personality when they are mostly upbeat, smiling and friendly. For someone with a personality disorder, that consistent set of characteristics tends to be off-putting, even offensive to many people. We’re not talking about the personality changes that often come with dementia. Instead, a personality disorder is part of the way he or she has always interacted with others. The person with the disorder is almost always unaware that something about their behavior rubs others the wrong way. When those others then get upset or distance themselves, the person with a personality disorder hasn’t a clue why and often feels victimized or abandoned by them.

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Self-centered and angry

What role do personality disorders play when it comes to caregiving? Imagine an aging father who has always acted as if he were the center of the universe and now seems incapable of understanding or appreciating the sacrifices his caregiving adult children are making for him. The more his children do for him, in fact, the more entitled he seems to feel that they should do even more, regardless of how it disrupts their lives. When they try to set limits on how much they do, he flies into a rage. The father is a lifelong narcissist who has been tolerated and humored by his children. Now, as his narcissism becomes more pronounced through his years of decline, they resent his many demands and avoid him as much as they can.

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Remaining calm, firm and empathetic

Being avoidant, however, is a luxury many caregivers can’t afford. To be true to their own values of caring for vulnerable people, they are committed to remaining engaged with even those care receivers they find obnoxious. Nonetheless, there are general strategies that can help.

Assume that a perennially difficult person will be difficult during the caregiving years. They may resist all help or insist on more. They may never give thanks. Their often-provocative behavior will be easier to take if the caregiver expects it.

 Respond to their displays of high emotion with resolute calm. Speak softer, not louder. Repeat back to them the concerns they’ve expressed to demonstrate that their message has been heard. This in and of itself often helps care receivers calm down.

 Balance loyalty with limits. Say you will be there for them, but then define what you are able and willing to do. If the care receiver pushes back or becomes irate, calmly hold your ground. Giving in to their anger will only encourage them to use it again to control you and the situation.

Never lose compassion. People with personality disorders are often unhappy. Even when they are taking out their frustrations on others, you should never lose sight of their suffering. Empathize with their suffering and help them within limits you set without agreeing to suffer yourself.

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