How to Disarm a Borderline Part VIII Splitsville

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), and Part VII (April 30). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In today's post, I will discuss how patients with BPD get two or more other people to fight with one another, and how to avoid getting sucked into such fights.

The psychoanalytic concept of splitting has been used by analysts in a few different senses.  The different meanings of the term are clearly connected with each other, but the analysts are somewhat vague in describing in detail what this relationship actually is.  The most common use of the term, as I described in my post A Splitting Headache of 4/24/10, applies to something going on entirely inside the heads of patients with BPD. 

As I described in the earlier post, BPD patients are thought by analysts to be either unable to see both the good and the bad in anything or anyone at the same time, or do not do so because they are using splitting as a defense mechanism.

As is their wont, the analysts seem loathe to look at a mental phenomenon in terms of its interpersonal meanings withing the context of the patient's real relationships.  However, one well-known interpersonal phenomena seen with patients with BPD is often spoken about when analytic therapists converse.  This phenomenon is also called splitting.

When individuals with BPD are hospitalized in psychiatric facility, it is frequently noted that professionals will start arguing among themselves about the patient.  Two doctors, or a doctor and a nurse or social worker, will get into what are at times very heated discussions about the patient's treatment.

Sometimes the entire ward staff becomes divided into two warring camps, with one side thinking that the patient is being treated unfairly with the other side wanting to come down on the troublesome patient with the proverbial hammer.  This situation became known as the infamous staff split.

My first clue as to what was happening in these situations came with the realization that a lot of the aggravating behavior of patients with BPD is a big act that can be turned off and on at will, like a faucet, depending on who they were performing for.  The act can also be greatly altered so that they act one way with one group of people and completely differently with another group.

I was consulted on a hospital patient on a medical (not a psychiatric) floor whose medical condition was clearly being affected adversely by her stress level.  When I first met the woman, she was the sweetest, friendliest, and most pleasant of patients.  We were having a nice chat about her stress level when her phone rang. It was the patient's husband. 

Suddenly I witnessed the most amazing transformation short of a caterpillar turning into a butterfly.  She without warning turned into the nastiest, most shrill harridan one could imagine.  Her comments towards her husband were so unrepentently vicious and venomous that I began to feel sorry for him.  After a short conversation, she practically hung up on him.  As soon as she put down the receiver, however, she turned right back into all sweetness and light in a heartbeat.

Amazing.  Patients who have real mental illnesses cannot do that.  They act pretty much the same way with everyone - and even when they do not realize they are being observed.

The staff split is set up by the patient.  To one group, he or she acts like a damaged, pitiable abuse victim in need of kind understanding. To the other group, like hell on wheels.

Eric Berne, founder of the school of psychotherapy known as Transactional Analysis and author of the best selling book Games People Play, had a name for this whole pattern. He called it the game of Lets You and Him Fight. In other words, the patient acts in ways that essentially picks a fight between other people.  If this game had a professional league, individuals with BPD would be the superstars.



Eric Berne

The solution to the staff split is actually simple and straightforward.  First, staff members have to be aware of the fact that their arguments are being set up by the patient, not by the unreasonableness or stubborness of the other side.  They can then ask each other on what patient behavior they are basing their opinion, and compare notes.  They can then decide on a mutually acceptable course of action and present a united front to the patient, and voila, the patient stops trying to split them.

The relationship between the senses of the term splitting is that the patient acts all good with one group, and all bad with another group.  If pressed, the analysts would probably say that the staff split is just an incidental byproduct of the patient's tendency to see some of the staff as all good and others as all bad. 

I, in contrast, see is at a well planned, although sometimes automatically and subconsciously played, interpersonal strategy designed to create staff wars.  Once again, however, I believe such patients are ambivalent about this and down deep hope that their efforts to provoke fights will fail.  The power to play mommy off against daddy is actually very frightening for them.

When seen in individual therapy, patients with BPD will often make a damaging or incendiary accusation about an important referral source, about a colleague who is well respected or who is even a friend of the therapist, or about a nurse with whom the therapist will have to work. If therapists defend the other person without having an impartial account of what actually transpired, they are invalidating the patient.
 
However, the patient may be exaggerating what happened, making undue inferences about the motives of the accused, or discounting the role of his or her own provocative behavior in the dispute. Also, the therapist should never forget that there really are a few Nurse Ratcheds on psych wards.
 

Nurse Ratched, "One Flew Over the Cuckoo's Nest"

 
My solution: I state, "I was not there, and I have a different impression of him from my other contacts, so I am not in a position to make a judgment on this." I just refuse to take sides in the dispute, and the patient will often then drop the subject completely.

One major exception I make to this is when a patient alleges that a former therapist had sexual intercourse with the patient. (This caveat does not apply when the patient just had the opinion that the former therapist had inappropriate thoughts).  I take this allegation very seriously because, in my experience, patients rarely make unfounded allegations about this subject, and unscrupulous therapists need to be taken out of the profession.  The willingness of the patient to allow the therapist to take advantage of her in this manner is irrelevant.

The next time your friend with BPD tendencies tells a story about someone else that starts to make your blood boil - at the person being described in the story - keep these suggestions in mind and do not take sides.

Part 5 of Dr Allens Discussion About Borderline Personality Disorder The Earth Needs Rebels Show on Orion Talk Radio

Part 5 of my discussion of borderline personality disorder on Free Thinking Voice - The Earth Needs Rebels internet radio show was on live Tuesday, November 12, from 12-2 PM U.S. Central Time, and is now found on their website.    

Here is the link to the downloaded broadcast: http://oriontalkradio.com/archives.htm.  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, November 12, at 1:05 and 2:05 PM.

How to Disarm a Borderline Part IX Listen to the Lyrics Not the Tune

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), Part VII (April 30) and Part VIII (June 5). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

This post will continue describing specific countermeasures to the usual strategies in the BPD bag of tricks used by them to distance and/or invalidate you, as well as to induce you to feel anxiously helpless, anxiously guilty, or hostile.

Today I discuss statements made by individuals which sound hostile or critical but which may or may not actually be as critical or hostile as they sound.  A lot of psychotherapists recommend responding to an individual's tone of voice and body language over responding to the content of what that person actually says. 

We all have a tendency to do that anyway - most likely because tone and body language preceded verbal language in the evolutionary development of the brains of primates like ourselves.  Chimps, for example, know whether another chimp is coming to fight with them or mate with them throught the approaching chimp's posturing and the noises it makes. (And if you injure a certain part of their brains called the amygdala, they completely lose the ability to make this call).

Nonetheless, I recommend precisely the opposite: listen to the words (the lexical content) and ignore the tone and posturing, as well as any seeming insinuations implied by what is said that are not stated clearly and overtly.

If you respond only to the words, the individual with BPD will usually change to a friendlier tone.

For example, a client with panic disorder responded to my recommendation for anti-depressant medication for her panic attacks with the sarcastic-sounding remark, "Oh, so you want to mess with my brain chemistry?" It sounded as though she was accusing me of being a devious, malicious mad scientist. Some anti-psychiatry types might agree with that interpretation of my recommendation, but I digress.

I nonchalantly responded, "Yes, anti-depressants do alter brain chemistry, although we don't know exactly how they work," and went on to describe their possible mechanism of action just as one might do with any other patient. She agreed to the drug trial.  (Of course she went off the meds the very next day, but that's another issue altogether).

The structure of all human language is such that ambiguity is extremely easy to generate. Any sentence in any language can refer to a multiple of unclear attributes or objects, or can be interpreted in exactly opposite (antithetical) ways. Negative judgments can come out sounding positive and vice versa through changes in body language, tone of voice, or even choice of synonym.

For example, almost any adjective with a positive or a negative connotation has a synonym with precisely the opposite valence. An optimist, for instance, can be called a Pollyanna. People can be described as stubborn or tenacious, loyal or as being lap dogs, and so forth. A complete discussion of the antithetical nature of language is beyond the scope of this post, but can be found in my book, Deciphering Motivation in Psychotherapy.

Another trick that people with BPD are especially adept at employing is to create ambiguity through the use of unvoiced implications, as I alluded to earlier. Individuals imply something without stating it explicitly, thusly creating opportunities for plausible deniability of having made those implications at a later date.

For example, a mother may admire her daughter in some way, but make it sound as if she were critical about the very behavior that she really admires.

A good illustration of this process occurred in a conversation between a nurse and her mother. The mother was discussing the daughter’s rather assertive (some might say even aggressive) stance towards the mostly male physicians with whom the daughter worked. The mother said, “I can’t believe you talk to doctors that way!”

The patient took this to mean that the mother believed that she should not engage in this behavior. In one sense this was an accurate assessment of the mother’s view, but it was only part of the whole truth. The mother indeed was worried that the daughter might get fired. Such would have been the case during earlier times, when the mother was younger.

As it turned out, however, the mother was also expressing covert admiration for the nurse’s bravery, assertiveness, and feminist leanings. What Mom had difficulty "believing" was that the patient had the audacious nerve that the mother lacked.

Her critical tone of voice obscured the admiration. The actual lexical content of the comment has no positive or negative valence at all.  She was merely expressing surprise. The nurse perhaps should have responded, "Well, is that a good thing or a bad thing?"

On the Borderline

I was gone last week. Sometimes that happens. Between the day job and the writing and the family ... blogging sometimes gets relegated to the things I wish I could do but can't. Only sometimes, though. But! I have a few updates:

• I am working on Book 3 in The Guards of the Shadowlands series! My editor loved Book 2, and I'll be doing revisions on it soon, but for the moment I'm trying to crank out a first draft of Book 3. I'm hoping to have that draft by the beginning of June, but with everything else that's happening,  I wonder if that's too ambitious. I'll let you know.
• I received cover proofs for SANCTUM and oh, oh, oh, they are gorgeous. I can't wait to show you guys the cover. When I first opened the file, I started crying. There was just something incredibly emotional about seeing a visualization of my story concept. More updates on that very soon!

And now ... today I thought I'd discuss yet another personality disorder. I've already posted about Schizoid Personality Disorder and Obsessive Compulsive Personality Disorder, and you can find my quick-and-dirty primer on personality disorders here.

Borderline personality disorder can be found in approximately 5-6% of the population (that's from the study I link to in this paragraph, which was a pretty thorough one, but other estimates put the prevalence at only 1-2%). A relatively recent epidemiologic survey study (of over 35,000 people) found that there's no gender difference in the prevalence of this disorder, which was previously thought to be more common in women. The study did show that the disorder is associated with more general mental and physical impairment in women, however.

The symptoms, according to the DSM-IV: Like with all personality disorders, BPD is a pervasive pattern (meaning it occurs across relationships, situations, and settings) of impairment. With BPD, that impairment occurs in interpersonal relationships, with self-image, emotion, and impulsivity. To be diagnosed with the disorder, someone must show five or more of the following symptoms:

1. "Frantic" efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships in which the person alternates between idealization and devaluation (often referred to as black-white thinking or splitting)
3. Markedly and persistently unstable self image or sense of self (in other words, you like yourself one hour, and despise yourself the next, in a really extreme way)
4. Impsulsivity in at least two areas that are potentially self-damaging (like spending, sex, alcohol/drug use, binge eating, or reckless driving)
5. Recurrent suicidal behavior or self-mutilating behavior
6. Intense mood reactivity (extreme emotions in response to situations)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Stress-related paranoia or dissociative symptoms

Individuals diagnosed with this disorder account for a disproportionately high percentage of mental health care dollars. In other words, BPD causes a lot of impairment and suffering. Research shows that people who have been neglected or abused (particularly sexually abused) in childhood are more likely to be diagnosed with this disorder, especially if they have a problematic home environment and/or a certain kind of temperament (e.g., high levels of negative emotion).

source

Interestingly, a few psychiatrists have diagnosed fictional character Anakin Skywalker as having BPD, and even used him as a teaching example. There's a great article on that by Dr. Carolyn Kaufman here.

There is an effective treatment for BPD called Dialectical Behavior Therapy (there's no drug that helps, not really).The developer of DBT, Dr. Marsha Linehan (who, by the way, has had a long and productive career in psychology, and has helped a lot of people), disclosed recently that she was actually diagnosed with this disorder as a teenager--and if you want to read a truly inspirational story, go read this article about her. I promise you will not regret the time you spend on it.

Just a note about this disorder: the label "borderline" comes with a whole lot of stigma, so when I hear "I think this person has borderline personality disorder" (or worse: "I think this person is borderline"), I tend to interpret it as code for "I'm not sure how to help this person, so I'm using a label to neatly categorize him/her in a way that allows me to feel less guilty about it." (Hey, it's a complex code.) I'm definitely not saying all mental health clinicians do this, and I certainly don't believe any do it on purpose. But I am saying that my ears perk when I hear the phrase, and I start asking A LOT of questions.

In general, I think our diagnostic system is really useful, and helps us develop more effective treatments for problems that cause a lot of suffering. However, I think these terms are always at risk for being used in ways that dismiss complex human beings or add to the stigma, and of course, that bothers me. <end of rant>

Aaand because it's Monday, go check out Lydia's Medical Monday post, and Laura's Mental Health Monday post (zombies! yipes!).

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

In my post about the family dynamics of Borderline Personality Disorder (BPD), I describe the role of the spoiler. A child or adult child of a family that exhibits the family patterns described in my posts on this subject begins to behave in ways which turns things around. The child invalidates the parents' efforts to "help" or "take care of them" in nasty ways. He or she essentially responds to invalidation by making comments that invalidate the parent right back. 

The reason the children do this is because they believe the parents need a child to be a target for their anger, and volunteer for the gig. They give the parents just cause by behaving in unreasonable and infuriating ways.

When it comes to the people who make comments on my posts on this and similar subjects, it always fascinates me how parents usually think I am putting all the blame on them for the family problems, while the adult children with the disorder react to the exact same post by thinking I am putting all the blame on them! 

Family systems therapists used the term punctuation to describe these types of reactions. People take something that is an ongoing problem created by continual reactions to feedback from two people with each other, and look at just one isolated segment of it - thereby breaking up a process artificially into misleading cause and effect relationships. They then react accordingly.

Of course, there are readers who do see the whole of the patterns in their lives but still do not know how to put a stop to them. In many cases the problems continue in spite of honest declarations of personal responsibility and even apologies -because there continue to be underlying issues that remain unaddressed.

I have reproduced two comments and my replies which illustrate these phenomena quite well. The first comment doubles as a description of spoiling behavior which illustrates it far better than I ever have.

The Blame Game

Submitted by A Mother of a Possibly BPD Child on November 6, 2016 - 11:39am

Regarding blaming the parents for "invalidating" feelings: I think it's a dangerous idea that all feelings are valid. Does anyone truly believe this?

When you are dealing with someone whose thinking is so distorted that they misperceive all your motives and react to your natural withdrawal as abandonment after they have been screaming abuse at you for an hour, you will just distort your own thoughts if you try to get into their head. If I say to my daughter "When you told me X it hurt my feelings," she often perceives that as an attack and starts to mock me: "Oh did that hurt your feelings? POOR YOU!" This can often escalate, and soon she is telling me what a horrible parent I am. That she is in so much pain that she'd lash out at me like this (again) does *not* mean I was abusive to her. She did not learn how to talk that way from us. We would never say something like that, even though she tells other people that's how we talk to her, and she probably believes we do. We did not cause that pain. Her mind did.

And this is the crux of the matter: just because someone perceives something as hurtful does not necessarily mean it's time to blame someone for hurting them. If someone trips and falls on you, and you scream, and they get mad at you for hurting their ears and making them feel ashamed with your tears of pain, should you feel sorry for them, since they honestly feel hurt by what you did? Should you feel mortified at yourself for inflicting such a nasty guilt trip on them with your tears? Some feelings *are* invalid! We invalidate our own feelings all the time. We *have to* if we don't want to be complete narcissists. A non-BPD person might feel a flash of anger at the ear-pain, but they would quell it, and then feel sorry they fell on you, sorry they hurt you accidentally. And if the screamer is non-BPD, they will probably be furious for a second at being fallen on, but then accept the apology and understand that it was an accident, perhaps even apologize for the loud sound they made - and everything will be fine afterward.

But if it isn't like this, the non-BPD screamer might reflect that they shouldn't have screamed and they certainly shouldn't have cried, since that just escalated things with the BPD person. But they were just behaving the way they would to anyone who fell on them. The reason they might think they shouldn't have screamed though, was because it made things into a conflict they didn't want, and they knew they could have avoided it.

This is CRAZY-MAKING.

And here's something else that's important: if (in the scenario with the falling person being BPD) the screamer pretends nothing bad happened afterward and tries to be loving again as if the falling person had been apologetic and understanding, are they *enabling* this bad behavior? Spoiling a tantrum-thrower? And if the falling person is the screamer's child, is the screamer not providing a terrible role model for the child? Should the *child* learn to tolerate this kind of behavior in other people? Should they not stand up for themselves and have high standards for their own behavior and that of other people?

Parents want to teach natural consequences, encourage empathy, and model the way one should behave in certain situations. BPD totally warps this. You start to think it's impossible to teach anything useful. You start to think that *ANY* response you have is doing irreparable harm to the BPD person. Walking on eggs to reduce conflict, or refusing to tolerate bad behavior - it's all bad. So what would be *good* for a BPD person? How would we recognize it?

As parents, we are not mind-readers. However we respond to behavior, it should teach something (how to respond, how not to respond, natural consequences, etc.) If the behavior is terrible and entirely lacking in empathy and remorse (just self-loathing, which doesn't do a darned thing to enact change), and if normal parenting only makes it worse, that cannot be - and is not - our fault for not knowing what would set the kid off this time. Of course we guess, of course we suspect - but we don't *know*. If we knew, we would necessarily be mentally ill too!

If we as parents caused this escalation by "invalidating" some feelings that originated in a distorted version of reality, or if we offended the child by refusing to be her punching-bag, that means LIFE itself would have provoked the same outburst. We just happen to be here trying to get her to have some self-knowledge and resilience. We are trying to help her learn how to deal with the real world. The real world will never be as careful as we are trying to be. The real world will never ask itself "Should I try not to take this personally, since she's clearly in so much pain she doesn't know what she's saying, or should I just react the way I normally react, since those are the natural consequences??"

The real world will react to BEHAVIOR. Often wrongly, often nonsensically, often (sad to say) maliciously. We are supposed to prepare kids for this! And as parents, we are supposed to train our kids to control their behavior and take responsibility for their actions. But what if, despite our best efforts, they don't learn this?

Many of the families that seem to shun someone who stops behaving so abusively were probably put through hell and just can't take any more. It's like they were holding up the car out of sheer adrenaline, and now the car is gone, they are burned out and need a break. Castigating them for shunning the person is asking way too much of them. Those were the natural consequences. Natural consequences usually teach non-BPD people how to control themselves and take responsibility for their actions. But what works with BPD people?

Parents of BPD kids need support and skills, not blame. They need tools to cope with a situation that is literally crazy - and quite possibly crazy-making.

·report

blame game - my response

Submitted by David M. Allen M.D. on November 6, 2016 - 4:21pm

Hi A Mother of a Possibly BPD Child,

"Blaming" and finger pointing are counterproductive, but all adults - both parents and adult children alike - have to take responsibility for their part in the family dynamics if these dysfunctional patterns are ever going to stop.

What you have written is a beautiful description of spoiling behavior by a child (or an adult child) with borderline personality disorder. It is designed on purpose to invalidate YOU. The child thinks for various reasons that you need them to do that, believe it or not.

For an explanation of how this seemingly crazy situation may arise in families even if there is no obvious abuse, see the posts

http://www.psychologytoday.com/blog/matter-personality/201109/the-family-dynamics-patients...

http://www.psychologytoday.com/blog/matter-personality/201205/borderline-personality-disor...,

and

http://www.psychologytoday.com/blog/matter-personality/201205/borderline-personality-disor...

Communication to Estranged Children

Submitted by Ria on November 12, 2016 - 2:10pm

I am so grateful for the comments of adult children on this page. It gave me insight in the feelings and minds of adult children who cut off parents. My daughter has cut me off a year ago - it happened a few times before she had children, I always reached out and tried to mend the relationship, but now the grandchildren are used as pawns. Although I am broken with the loss of my daughter as well as grand children, I have decided it is final this time. I was not the perfect mother, not even a good one. At 64, after many years of therapy, after two marriages, I understand that. 

I know my daughter is angry and anxious and use this cut-off defense after irrational anger outbursts - this time in front of the kids, which was the final straw for me. But you cannot cut off love and wipe out precious memories. I wonder all the time if she is happier without me in her life. Perhaps she has a better chance of growth, sorting out her own anger and pain without me. I want her to be happy and content within herself. It saddens me even more when I read of the bitterness and pain adult children express here and I cannot help to think: is there anything more I can do for her? Can I help her? Or is letting go the better option? I know no one can really answer, but let's talk about this. I know there are really evil people, but many parents were simply damaged as children. When they have children, usually when they are very young, they have no skills or boundaries or knowledge of parenting to care emotionally for their young, especially 38 years ago when information and education was not a given. The result is emotional abuse, neglect, and / or physical abuse. The horrible old cycle - how do we break it?

Communication - my response

Submitted by David M. Allen M.D. on November 12, 2016 - 2:42pm

Hi Ria,

Of course I can't say anything about your situation in particular, but in general, of course it is best for parents to acknowledge their problematic behavior in the past, explain what they had experienced with their own parents, and apologize.

However, if the parent then goes on to continue to feel too guilty and beat themselves up for their past flaws, that may backfire. The adult child may then start to think that the parent is better off without them - just as you say you wonder about your kids being better off without you - because the child sees that his or her presence makes the parent feel really bad. In response, they may continue to avoid the parent so as not to add to the parent's burden. 

Additional point not in my original reply: Alternatively, they may act nasty to feed the parent's guilt because they think the parent wants to be punished for various sins - or they may go back and forth between the two depending on whether the parent seems to need to be punished or then starts to feel too guilty.