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Just Too Mean for Psychotherapy?

Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states ...Read More

Dr. Richard A. Friedman MD, a psychiatrist, wrote an article in the Tuesday, February 6th 2007 edition of the Science section of The New York Times. In the article, Dr. Friedman makes the point that when nastiness is a personality trait, it does not necessarily mean that there is a psychiatric condition. In other words, some people are just plain nasty and not ill.

Evidently, the catalyst for Dr. Friedman’s article was the fact that one of his psychiatric residents was loudly scolded and criticized by a patient for being incompetent. Dr. Friedman met with the patient and, after listening to his litany of complaints, told him that it is no surprise that people treat him badly if this is the way he treats others. In the article, Dr. Friedman then explains that this man was being treated for obsessive-compulsive disorder but had responded well to medication. Dr. Friedman goes on to write that this patient, apart from his diagnosis, was just "mean spirited." He points out that there was no history of trauma or abuse in the patient’s history that might cause his behavior to fit into some diagnostic category. He gives examples of several other cases to further support his contention that being nasty is not necessarily a psychiatric condition that can be treated. Another way of saying the same thing is that some people are just not very nice. He is careful to separate these individuals from those who have a personality disorder or who suffer from another psychiatric condition.

With all due respect to Dr. Friedman and his expertise as an experienced psychiatrist, I do not agree with him. The fact that this patient has been treated for an obsessive-compulsive disorder for ten years indicates that there is more there than meets the eye. This patient succeeded in alienating a psychiatric resident and, then, Dr. Friedman. In fact Dr. Friedman was so angered (and understandably so since patients can provoke rage in the best of therapists) that he wrote The New York Times article in which he has the "last word."

In terms of psychodynamic or psychoanalytic parlance, the infantile rage and sense of entitlement of this patient provokes counter attacks from other people who then mistreat him. Is it really true that, as Dr. Friedman contends, this patient, who acts out in public, attacks those who are trying to help him, and alienates his doctors to the point where they counter attack and reject him, is simply mean spirited and not afflicted with a personality disorder or with behavior that leads to his self destruction?

It seems to me that if, as therapists, we are treating the whole person, we must examine all behaviors and not isolate those behaviors that may not fit conveniently into a DSM IV category.

Today, when we live in high pressure times and constantly hear bad news about crime, war, mass destruction of human lives, global warming, viruses with the potential to wipe out millions, terrorism, economic problems…..(well, you get the point) many people suffer the effects of stress, which is manifested in the form seen in the patient just discussed. In other words, many people react irrationally and emotionally due to the effects of stress. There are those of us who are healthy enough to cope with this stress and there are those of who suffer from a psychiatric condition and cannot cope with all of this.

My point is that the patient in question is not simply "mean spirited" but is having great difficulty coping with his life and behaving is socially acceptable ways despite the fact that medication is helping reduce his obsessive-compulsive condition.

It is my contention that we are psychiatrists, psychologists, and social workers because we want to help people improve their coping skills, and that includes those who do not come across as "nice guys!"

What is your opinion?

Keep Reading By Author Allan Schwartz, LCSW, Ph.D.
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