The truism, “It is better to give than to receive,” is a cliché that reflects a pro-social character trait, selflessness. Selfless individuals, caretaker personalities, invariably place the welfare of others before their own. They are typically pleasing and accommodating and at least at first blush others view them with respect if not adoration. Those in our surround are taken aback when such admirable qualities are transformed into an addiction to please, the signpost of The Caretaker Personality Disorder (CPD).
Pursuant to the formulation of the disorder in 2006, one of my colleagues said, “I have always had patients like that as part of my caseload and now I know what to call it.” These patients are typically nonprofessionals but also include helping professionals such as therapists, nurses, physicians, religious leaders and others.
Their diagnosis has eluded us in the past perhaps because chronic pleasers give the appearance of being capable, strong and well adjusted. If left undiagnosed their tendency to give with the minimum of receiving creates an emotional imbalance that wreaks havoc upon relationships and in more cases than many practitioners might suspect, leads to depression and suicide. Clearly in these cases it is not always better to give than to receive.
Dr. G, a physician, was so dedicated to one of his patients that he spared him the indignity of signing himself out of a hospital when in Dr. G’s opinion his release was premature. The patient’s physical condition deteriorated and he filed a malpractice suit claiming the doctor should have demanded he remain in the hospital. Already addicted to amphetamines that had damaged his kidneys and stunned by his patient’s action, he spiraled into a deep depression and “allowed” himself to die while attached to a dialysis machine. His wife was convinced that the presumed accident was actually a suicide. Months after his death I reviewed Dr. G’s file and reflected upon his biography. It occurred to me that his history contained certain dynamics that were strikingly similar to those of other patients I had treated.
Eventually I was to discover that 5 percent to 6 percent of my practice for more than a decade included these types whose lives were controlled by guilt and their inability to say, “No.” Consistently their childhood experiences included faulty parenting that was exacerbated by various traumata; most often trauma associated with abandonment and its vicissitudes (including neglect) and sexual assault.
Most patients with this illness do not recognize the cause of their suffering. They begin therapy with the usual concerns: (a) their most important relationships are falling apart, (b) they are suffering from fatigue and emotional emptiness, relentlessly attempting to keep pace with meeting the needs of others, (c) they are puzzled why others keep rejecting them when their actions toward them are so kind, (d) psychosomatic complaints without insight as to their cause and (e) they are recovering from one or more suicide attempts. A hopeful sign is when during the middle phases of treatment the patient begins to notice the dangers of overly benevolent behavior.
The diagnosis of CPD is complicated further when the practitioner is donning the Mask of Kindness. Anti-therapeutic interventions abound! The overly accommodating therapist allows patients to control his/her schedule, avoids confrontation and is unable to help the patient embrace past-present connections, such as the influence of faulty parenting and neglect that contributed to the formation of the pleasing coping style in the first place. Further, the therapist’s “blind spot” derails the treatment contract including fees, missed sessions and insurance obligations.
Below are some comparisons between CPD and other personality patterns and syndromes:
- Compulsives and narcissistic personalities are self-absorbed; pleasers are other-focused to the exclusion of their own interests, joy and pleasure.
- Codependents are predominantly female who enable dependent types who cling to them, whereas caretakers, both male and female, provide (unsolicited) help to dependent and independent individuals who eventually reject them.
- Care addiction is akin to narcissism in that behavior is deceptively self-serving and grandiose. CPD and borderline personalities have in common chronic feelings of emptiness and an obsessive need for object constancy; however for the pleaser the appearance of these needs is unconscious and remains unnoticed by observers.
The personality disorders listed in the DSM rarely escape detection by the practitioner. By contrast, CPD has gone undetected and undiagnosed by the mental health community.
The treatment of CPD is daunting primarily because a successful outcome is dependent upon overcoming the patient’s resistance to giving up the many benefits of what has become emotional sanctuary. Among these compromises are: the presumed guarantee of contact from others who need them, self-esteem enhancement whenever they “save the day,” the admiration and “love” (albeit shallow and short-lived) from others for being so kind.
Other challenges include grasping the idea that being good can be bad, being able to distinguish self-focused from selfishness and anticipating that their beneficiaries often will not be receptive to their progress because they (others) will have to fend for themselves in the future.
Recovery becomes possible when these patients begin to experience that their needs, wishes and desires and their sensitivity to others can coexist. At that juncture a better balance of give/receive is no longer an unattainable abstraction.