Crazy Makers

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“The Buddha’s compassion is perfectly equal and impartial.  The Buddha views all beings as his own children and strives to elevate them to attain his same enlightened state of life.  It’s not that there are no differences among people.  Rather, it’s that the Buddha, while fully recognizing people’s differences, does not discriminate among them.”

—Daisaku Ikeda

As a physician who sees almost every type of person who walks the planet Earth walk through his office at one time or another—from African Americans to Chinese to Germans to Italians; from people who never made it out of grade school to Nobel Prize winners; from the ultra-religious to the most stringent atheists; from schizophrenics to the suicidally depressed to the astoundingly resilient—I can attest to the fact that not only are there “differences among people,” but that sometimes those differences are so vast it seems impossible to imagine we’re all living on the same planet Earth.  Sometimes I feel there are almost as many “planet Earths” as there are people, their orbits separated by the immense gulf in understanding and values that separates our thinking.  And though everyone is deserving of our compassion, not everyone deserves the whole of our personal time and energy.

Some people are their own worst enemies, their attempts to handle their daily troubles so misguided that they end up causing more misery than they alleviate.  Such people often settle on strategies to help them manage their negativity that others find intolerable:  unwarranted aggressiveness and attempts to manipulate to manage insecurity; malicious gossip and even deliberate sabotage to manage jealousy; grandiosity and even narcissism to manage poor self-esteem; splitting (where everything is experienced and judged in painful extremes, all good or all bad) to manage intense emotional lability; bizarrely inconsistent approach/avoidance behavior (the classic borderline personality mantra, “I hate you, don’t leave me”) to manage self-hatred.

Often such dysfunction appears in response to injury inflicted early in life at the hands of others, and should be greatly pitied.  Yet no matter how much compassion we may feel for such damaged people, it doesn’t mitigate, no matter how much we might wish it did, the difficulty of interacting with them.  And often there comes a point at which we realize we lack the ability to enjoy our interactions with them at all.

I have a number of such people in my medical practice.  And though, in all honesty, they’re often as difficult for me to handle as they are for everyone else, I remain as committed to them as I am to my other patients.  Whenever I find myself musing about transferring them to another physician’s practice, I stop myself with one pointed question:  “If not me, then who?”  And yet medicine (and psychiatry) is sometimes as powerless to help such people navigate life more cleanly and pleasantly as are the few self-appointed heroes who often populate their personal lives and continuously try to connect them to the world in a healthier way.  Not to say that such people can’t find help—just that it’s extremely difficult.  I tell myself that my refusal to abandon such troubled people is the best treatment—sometimes the only treatment—I have to offer them.  So I continue to offer it, no matter how challenging my interactions with them may be.

And challenging they are.  A Buddha may care equally about all people as his children but in his heart of hearts still enjoy the company of some more than others.  And being a Buddha doesn’t mean lying to yourself about whatever feelings you may have—even the less-than-admirable ones.  A Buddha is still human, no matter how enlightened, and humans will always prefer some things—and some people—to others.

Which is all to say that sometimes it’s all right—even appropriate—to detach with love.  Caring about the welfare of others doesn’t by itself commit us to a lifetime of living in close proximity to them.  Some people are simply too difficult for us to endure gracefully—and leaving them in some concrete fashion may sometimes be necessary for us to preserve ourselves.  We may feel tremendous guilt and that we’re being unfair.  But we may also feel great relief to discover just how much of our stress was due to the presence in our lives of someone too toxic for us to bear.

To pretend that such circumstances—and such people—don’t exist is to take political correctness to a ridiculous, detrimental extreme.  People simply are endowed with differing degrees of mental health.  This makes the mentally ill—or the severely emotionally injured—no less worthy of the respect than anyone else, but does sometimes necessitate that we respect them from a distance.

Though in my professional life I’ve never once abandoned such a person, in my personal life—where relationships must be mutually satisfying to survive—I have.  Never with anything in my heart but concern, both for their welfare and mine, but also once having recognized my own mental health was at risk, never with much hesitation either.  This may strike some as overly harsh, but I—all of us—have lives worth protecting and enjoying as well.

Some relationships, of course, resist abandonment, most notably relationships among family members, the breaking off of which usually carries far more significance and causes far more pain.  And though the bar for choosing to break off such relationships must be higher, such a bar still exists.  This remains always a personal decision, but one that remains all right to make—and must, in fact, sometimes be made.

This is a difficult topic, for it risks legitimizing the notion that the more dysfunctional among us deserve the pain they create for themselves.  In no way do I mean to suggest this.  Instead, my intent was to legitimize the notion that our compassion must sometimes be pointed preferentially at ourselves.

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  • Dr. Alex —thank you for giving voice to this topic. Knowing when to remain engaged and when to compassionately detach—ah, such a difficult line to neatly define. It has helped me to review the points you made in your blog on character vs. personality to help me make some important distinctions. And now, with this post, I will try to remember your point that sometimes, the compassion “must be preferentially pointed at ourselves.” Thank you…

  • I respect that you have never removed a patient from your practice because of the differences you discuss, but I think the bar exists there as well as in our non-medical lives. Since I would guess that there are some folk in your practice that may cause way more “making you crazy” than anyone in your personal life, I think, with compassion and self care, it is sometimes necessary to move them on. Sure, one might be able to be more detached in the office, but a fine person with BPD can easily dominate and intrude in ways no relative could do. I applaud your way of seeing your relationships, and I think it has to apply rarely to the office practice as well, in order not to be made crazy by the crazy makers.

  • Very helpful post, Alex! At the support group I run for folks with bipolar disorder, depression and their loved ones (, we occasionally attract folks w/borderline personality disorder, which is not our expertise. Usually what happens is they will attend a meeting and commandeer all attention to themselves and so upset the group that benefit accrues to no one. I usually talk kindly to the person afterward—or telephone them—and explain I have a resource better than ours (a treatment center or a support group for BPD) to help them. They’re usually grateful.

  • Thanks for your thoughts on this, Alex. I find it difficult to detach with love…it’s the with love part that escapes me sometimes. Members of my family are toxic, and though I know I’ve done the right thing by detaching, I still resent them for the things they’ve done that cost me so much. For example, I spent years of my life depressed because of childhood trauma, and I didn’t even know I was depressed until, in desperation, I started seeing a therapist. Those years I spent under the cloud of depression, the years I spent working through it with a professional, the thousands of dollars it cost me, not to mention the countless opportunities for happiness I missed…I don’t know if I can honestly say I love them much if at all. Having said that, I do feel guilt about it because I know they suffer from character disorders. I used think there was something I could do to change that, but there isn’t. I’ve accepted this.

    I’m happily free of depression now. I’m in a loving relationship, and I run a successful business.Two of my siblings and I have highly functional and fulfilling relationships with one another. All of this goodness has come to me despite the presence of those toxic people in my life, and NOT in any way because of them, and it likely would have come sooner had they not been there in the first place. Maybe one day I’ll be able to say I love them, but at present it feels like a lie.

  • Dr. Alex,

    Your post as always was written with sensitivity and acknowledgement of the pitfalls (blaming dysfunctional people for their pain). However, I find the value of sharing the necessity of discernment in our personal and professional relationships valuable. I have found that if in my relationships I am so overwhelmed with aversion towards another, my intellectual intention of lovingkindness doesn’t help either of us much. Not only am I trapped in such a relationship, but so is the Other, by my continual reinforcement via my aversive reactions to their behavior.

    It’s also important how you noted the professional and personal difference. We may not have the choice in which individuals seek our assistance in helping professions, but by choosing this type of career, I think there is an obligation to serve others with lovingkindness towards the vulnerabilities they bring us in trust that we will respond ethically to the best of our ability.

    Sadly, the one difficulty I see in personal relationships is how we will tolerate injustices/atrocities that would not be otherwise acceptable from another person, and by maintaining the relationship our intention for lovingkindness may inadvertently reward cruelty. As the statistics bear out, it’s most often not a stranger who harms us, but someone we know well. So, for myself this is one criteria where I have, and will cut off a personal relationship—even family. Another often unused alternative to complete shutout of a dysfunctional family member is a period of time out —days, months or years.

    Perhaps the trickiest relationships are those that span both professional and personal life. While they may be easier to avoid, at other times we do find ourselves working with lovers or family members. The challenge comes when for good reason, one part of our relationship with them (either the personal or the professional) is severed. Then it’s a question of how to still be compassionate within the leftover relational context.

    Thanks again for the wise, inspiring comments!

  • You really got me with this post, Alex. This is the most difficult terrain my life has given me to navigate. Where are the guidebooks? Where are the maps? It is—for me—the most difficult thing in life to see where the compassion slips over into something more like self-sacrifice. Of course it is easier, as you suggest, in professional life as opposed to personal life. But as each individual—Buddha or not—has individually calibrated capacities for endurance of what is difficult to endure, each instance must be reviewed with scrupulous attention and honesty. A full-time job for some of us!

    rdp: It’s hard for all of us, I think.


  • One of the crazy makers in my life is my sister-in-law. She’s always been manipulative and sows discontent. Now that she has cancer, her behavior is worse. She’s angry and bitter. I know she is in pain, I know she may not have long to live but for my own preservation, I have to detach. My spouse thinks I’m being too hard on her which to me means I should be hard on myself so it can be easier for her…

    Maxine: A tough one.


  • Thank you for again holding humankind to a higher standard.And for helping to clarify that compassion is a strength that includes the capacity to detach with love. People trapped in dysfunction came into this life as we all do; innocent, helpless and loveable. They don’t choose mental illness. Those of us who are fortunate to have reasonably healthy functioning should be grateful, non-judgmental, and not victims. A tall order.

  • I wholeheartedly agree with your statement: “Sometimes our compassion must be pointed at ourselves.” According to the Pali Canon, the Buddha set out a three-part test for deciding if we’re about to engage in wise speech: Is what we’re about to say true, kind, and helpful? I’ve taken to applying that test to myself when I’m considering to what extent I should should continue to engage with difficult people. I ask if it would be true, kind, and helpful to myself, meaning true to my deepest values, kind and helpful given my own limitations and instinct for self-protection.

    Some may think this is selfish, but I’ve found that the better care I take of myself (which may include disengaging from some people), the more I can be fully present for other people.

  • Thank you for sharing this. I’ve struggled with eliminating toxic relationships because I do feel guilty. I used to make excuses for those types of people, but after many years was running out of excuses and getting tired of the abuse, I broke free. I still feel guilty to this day, but it’s nice to not have someone belittling me to make herself feel smart or arguing with me because she should be the center of the universe.

  • I can relate to the comments here. I wanted to share the work of Marsha M. Linehan of the University of Washington, creator of a treatment used worldwide for severely suicidal people derived in part from Buddhism. Dr. Linehan recently came out of the closet about her own struggle with BPD and subsequent transformation. Here’s the link. At the end of the story is another link with the NY Times article and a brief video interview.

  • Sometimes we have to make a choice and save ourselves, as all the compassion in the world won’t save those from whom we must detach. There’s nothing noble about going down in flames with another person out of loyalty—but people do it all the time.

  • […] […]

  • Thank you, Alex, for your honesty in discussing this topic and to everyone for your comments. I particularly found illuminating your concise description of the strategies people use to manage their insecurity, their jealousy and their poor self-esteem. As I was reading along, it brought to mind the necessity of recognizing and honoring one’s personal boundaries. In this, you can act from self-respect and with more compassion.

    This is an article I want to reread and reflect more on because it spoke to me in a valuable way about choices and behaviors in this area of life. Thank you.

  • After enduring a fair amount of verbal and even physical abuse from a family member for many years, I finally realized I needed to limit my interaction with them. I know that they are suffering terribly, and I feel tremendous sorrow because of that, but it was a question of self-preservation.

  • Dear Dr. Alex Lickerman

    I find your post very interesting and somehow controversial. Having a background in Psychology, I do agree that early childhood experiences has a great impact on certain dysfunctions in life, however these fixations should not be pitied, rather, it should addressed to cater personal growth.

    As a reader, I consider your writing to be a great example of a quality and globally competitive output, and it would be a great thrill and honor if you could share your genuine ideas and knowledge to our community, Physician Nexus.

    We would love for you to visit our community. With this you can gain 1000 physician readers from over 62 countries on Nexus. It’s free, takes seconds, and is designed for physicians only—completely free of industry bias and commercial interests.

    Ruby Jean Abarcas
    On behalf of the Physician Nexus Team

  • Hello Alex,

    The post title grabbed my attention and couldn’t help but to respond or simply add, hopefully, relevant information, for I see the notion of “compassion” as a fundamental tenet of Nichiren Buddhism, and it is critical that it is understood clearly, particularly by people of other faiths.

    The statement, “The Buddha does not discriminate among them,” has more fundamental relevance to life itself than more superficial ones, like personal “preferences” or “likes and dislikes” that can or cannot be detached with love.

    “The Buddha and the Common Mortal”—Living Buddhism July/August p. 28

    In the Lotus Sutra, Shakyamuni Buddha states, “At the start I took a vow, /hoping to make all persons/equal to me, without any distinction between us.” (The Lotus Sutra and its Opening and Closing Sutras, p. 70) This is the “compassion” Daisaku Ikeda speaks of. The effort we make for ourselves and the help we give others to realize this same is the “compassion.”

    Nichiren clarified that there was no distinction between a Buddha and an ordinary person other than one’s own delusion that such a distinction in fact exists. This delusion causes ordinary people to perceive a gap that cannot be bridged between the Buddha and themselves (or themselves and others)…. Buddhism teaches that though we have an inherent tendency toward ignorance and disbelief in the “innate dignity and nobility” of human life, we also possess the original potential for Buddhahood. Instead of being “originally sinful” we are originally enlightened.

    My personal feeling is that this message by Daisaku Ikeda isn’t about “liking everyone” and spending time with everyone equally as a sign or show of one’s compassion; rather, it is about a fundamental question we ought to ask ourselves about how we view life. More specifically, do we believe one person’s life is more “valuable” or “dispensable” than another’s; if yes, what makes one life more valuable? Do you think that there is an “intrinsic value/worth” to life, to any human life? If not, who and what dictates and determines the value? Let’s make it even more specific: what about the children in our own city’s urban communities? People in Africa or Middle east, or in Gaza vs. our own life or our family members’? Is life equal? Who’s deserving and not deserving? Those are the fundamental questions Buddhism forces us to ask ourselves about life, beyond the visible dysfunctions or differences we see. And Nichiren answers clearly and absolutely those most fundamental questions. He challenges us to become “truly human” or “awakened humans.”

    According to Nichiren, it is essential we realize this true nature of life, if we seek to become absolutely happy ourselves in this life time and in this world.

    My apologies for the long post. 🙂

    Peace & Love!

  • Alex,
    Your post on compassion is interesting and I admire your professional devotion to taking care of “crazy makers.” Truly compassion begins with ourselves and we should respond to others’ needs based on self-respect and not self-sacrifice. Having said that, I believe that there is a great deal more to be said about the subject of compassion because it is the basis for motherly love and through the use of our “mirror neurons” we learn how to behave through imitating our caretakers—the beginnings of learning and education. From a Buddhist point of view you are missing a very important point and that is that you can extend the hand of friendship to a crazy-maker and offer them options—a new way of dealing with the world through recognizing their Buddhahood . If the time is right, they take this opportunity. Many people have transformed their lives because at the right time an enlightened person believed that even a cave that has been in the dark for countless years can be lit by the right torch. So it’s not just a choice between professional caring or personal flight from a crazy-making energy-sucker. There are more than two options, and the Buddha understood this.

    If you consider the present plight of the world, it is precisely lack of compassion which is leading us over the abyss to global warming and warfare.

    Keep writing your fine blog.


    Dennis: Couldn’t agree more. Even when we detach with love from a crazy maker, we can continue to care about their happiness and remain open to them in specific ways, e.g., to helping them into therapy, or to helping them practice Buddhism, or anything else we think might be of genuine benefit. In such cases, we might consider changing the “rules of engagement” in our relationship with them—that is, the kinds of interactions we’ll allow—rather than detaching from them altogether.


  • Alex, your title seems harshly disparaging, even as your article conveys the opposite.

    I am surprised that neither you nor any of your responders linked your ideas to divorce.

    Last, what if it is true that your expansive tolerance, never turning away a patient, actually attracted such people/patients? What if any of us who are open came to suspect that we actually ATTRACT such difficult people? What would we/should we do??!!

    Chris: Good points. First, in Buddhism, there is the idea that we tend to attract certain types of people into our lives by virtue of our own character traits and behavior, that people in our intimate environment mirror us in some way. And sometimes it’s true that the very things that bother us most about others are issues we struggle with ourselves. But not always. For example, the need for control is a basic human want, so to conclude we also are overly controlling because we have so many overly controlling people in our lives might be a mistake (if you toss a rock into a crowd of people, chances are whoever you hit will be overly controlling). On the other hand, we’re always served by asking what contribution we ourselves might be making to any relationship conflict in which we find ourselves. It often opens the door to change within ourselves that stops us from attracting people we wish we didn’t.

    When the relationship is professional, not personal, and especially relationship between a health care provider and a patient, the rules of engagement are different. If doctors only admitted people they liked into their medical practices, far too many people would be forced to go without care! I’m not saying there don’t exist circumstances in which it would be best for a doctor to terminate a professional relationship with a patient, but in my view a difficult personality isn’t one of them. Finally, regarding divorce, yes, it’s an obvious context to apply the idea (in my mind, included in the “family” section).


  • We made a vow to appear, at this time, in this place, so we could lead others on the path of enlightenment. We are all the same. What we learn from each other is what matters. In the end, it is all we have.

  • Hello Dr. Alex,

    Thank you for all your posts. I read them often in PT and here on your website. This one is very interesting and I have found it to be so necessary to put distance between myself and difficult people in my own life, my mother, some siblings and some friends, yet we are not seen as accepting unless we put ourselves in the situation where we have to put up with the difficult people to prove that we love and accept them just as they are and take everything that they decide to unload on us even if it’s difficult to bear and bad for the spirit. Thank you, thank you and please keep writing on all the variety of topics you do.

  • Hello again Dr. Alex–

    I read this when it first posted and twice more before I now post. I am confused. I wrote a lengthy and difficult (for me) response to a post of yours entitled “When Someone You Love Is Unhappy.” I understand that in the present article you are not necessarily discussing persons that you have been in love with, be it a relative, a close friend, a spouse or life partner. But is there a difference in how one should act in the set of circumstances set forth here as opposed to the earlier article?



    Steven: I don’t think so. In that previous article my last suggestion was to detach with love when in your judgment the calculus of staying doesn’t add up. It’s so difficult to suggest guidelines about this. People can change, can pull themselves out of spiraling depressions, but on the other hand a repeated history of failing to do so does to some degree predict a future history of failing to do so. The idea, it seems to me, is to maintain a heart of compassion both towards a difficult person and yourself, and remain fluid in your decision making. The cutting off of someone needn’t be complete or permanent. In a sense, the decision to so might best be made not once and then never revisited but made anew every day depending on changing circumstances.


  • Alex,
    Although I understand what it is you mean by detaching, especially for safety reasons, it is not always that easy, especially when you truly love that person inside that is fighting to stay, yet is over run by the exterior demon who will prevent any help and healing at all costs. This is not just a figment of their imagination; they are not just “crazies,” and I thank the few people who seem to understand this, for their encouraging comments, especially Michael, Dennis and Michiko, who’s comments I can truly relate to. I haven’t read enough of your site to know how you go about treating your patients; however I know that medicating them is not the answer, and will more than likely cause adverse reactions, not to mention opening them up to a psychic attack. A fractured soul is not an easy task to take on, especially those physicians who think these people are just “mentally ill.” Carl Jung was the closest I’ve seen to understanding and treating anything of this kind. His Archetypes theory is fascinating, and as the aforementioned poster’s hit on, it is through enlightenment and love that the soul can be brought back together. Also with hypnosis and Shamanism a soul can be retrieved. The comment made about the enlightened person lighting the torch, so true, and that we are here to lead others to enlightenment, also true. Natural state of perception and vibration will be restored. The self is fighting against the poisons of those that wish to enslave. So when in a relationship with someone who is not always “one,” yet you know that one and love that one, have seen the desperation for help and love, not to allow the demon to return, only then can you understand how it can be tolerable. Sometimes it isn’t, sometimes it is very very difficult to maintain that compassion and unconditional love, but it is this love and compassion, and not to give in to the doubt and frustration that is the cure. Not easy at all, and a lot of hurt, however, lessons learned, intuitively seeking guidance bit by bit the self emerges and strengthens. I know this would probably sound like I am one of those very “crazies” mentioned here, I assure you, I’m not. I live this, I see them, and I am a lot of the time alone; after all, who would possibly understand? Only those who know. Love and light,

    Samantha 🙂

  • Dear Doctor,
    Sincerity is everything when it comes to authentic living and exchange of energy. You can not make it your duty, through much “oriental approach,” to like people and be their friend—without judging them. Nobody expects that. People are not equal; they are born very different, even when quite “functional,” and friendship requires special spice—respect. So help people out of respect—for them and for life in general, even when they are “not functional.” To make a person better, you must provide proper therapy and that person must make an effort with so many details, starting from philosophy, and ending with cuisine and fashion. It is a full time job to be crazy. And even more effort is needed to stop being “dysfunctional.” What is required from you is good knowledge of medicine and pharmacology, “eyes of compassion,” and persistent support to make your clients ambitious to make real friends. Being a doctor and a friend at the same time is too much to expect, unless it really happens. Professionally you communicate with the humanity as such, it is a matter of choice; intimately you communicate with the chosen few, regardless how “normal” they may be. Exclusivity is a virtue. It is the right of spiritual aristocracy, shared by other humans and crazies. Help your patients find God, not just you in the bar or at a social gathering. It does not require any apology. It is just modesty. Some of them must work more to reach leisure and pleasure. And some may turn out to require more than you can provide with all the best intentions. Maybe it is a good idea to occasionally let the patient meet more doctors and let him/her choose. Teamwork with heavy cases is also a good idea, including consulting the patient. If the symptoms resist, not only that your pills are not a good option, you may be the wrong choice, also. All people need “a hand to hold.” If you are not really there, help them find somebody who would be interested in giving it a shot. We all must find the right kind of people, not just “a friend.” Please, help the “dysfunctional” you are so generous with get to another colleague. And yet another. Untll the crazy maniac starts working on himself and taking responsibility. There is “a heart of mercy” for everyone; you are just out of the light of your understanding. Save your energy, get assistance. Your patient deserves that kind of respect. Humans can not give understanding and health as a gift, even gifts of love; we all fight for that. If your patients are not fighting along with you, they must find a focal point to build a center of gravity towards functionality. What you have to awake the patient for is self responsibility for one and only life. It is so much more important issue than the triviality of socializing. Sorry, I do not believe in reincarnation. It is more intensive than that. Your question is simply, “Will you lift the sword for the benefit of your crazy patient?” That Buddhist talk is a bit evasive.

    With kind regards,


  • OUTSTANDING post. This is so affirming, Alex. I don’t know why I didn’t see this when it came up? I’ve been following you for a couple years. Maybe I wasn’t meant to see it until today, when I really needed to read it. Thank you. 🙂 -Molly