In this post, I will continue to run down specific countermeasures for those occasions when they are trying to distance and/or invalidate you, or to make you feel anxiously helpless, anxiously guilty, or hostile.
Keep in mind that if you are someone who continually tries to fix someone with the disorder, or who keeps reacting to them out of guilt, anger, or helplessness, then they are just giving you what you seem to need. They are doing you a favor. You may need psychotherapy yourself at least as much as they do.
Also, the behaviors under discussion usually draw negativity back to the patient with BPD, so ultimately they are self-destructive.
In the last post in the series, Part VII, I discussed how to respond to ambiguous suicide threats and parasuicidal behavior. This post discusses those times when other people seem to start fighting with each other over how to respond to the person with the disorder.
The psychoanalytic concept of splitting has been used by analysts in two somewhat different senses. These 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 (see this) applies to something going on entirely inside the heads of patients with BPD.
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.
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As is their wont, the analysts seem loathe to look at a mental phenomenon in terms of its interpersonal meanings within the context of the patient's real relationships. Nonetheless, a well-known interpersonal phenomena seen with patients with BPD is also often spoken about when analytic therapists converse. This phenomenon is also called splitting.
When individuals with BPD are hospitalized in a psychiatric facility or hospitalized for a physical ailment on a medical floor, it was frequently noted that professionals would start arguing among themselves about the patient. Two doctors, or the doctors and the nurses, or two nurses will get into what are at times very heated and angry 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 while the other side wants to come down on the troublesome patient with the proverbial hammer. This situation became known as the infamous staff split.
The staff split is subconsciously 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. These seeming personality states are described in Schema Therapy, a type of psychotherapy pioneered by Jeff Young, using the concept of schema modes. A quick change from one mode to a different one is called a mode flip:
“Schema modes are the moment-to-moment emotional states and coping responses-adaptive and maladaptive-that we all experience. Often our schema modes are triggered by life situations to which we are oversensitive (our "emotional buttons") …At any given point in time, some of our schemas or schema operations (including our coping responses) are inactive, or dormant, while others have become activated by life events and predominate in our current moods and behavior. The predominant state that we are in at a given point in time is called our "schema mode." We use the term "flip" to refer to the switching of modes. As we have said, this state may be adaptive or mal­adaptive.
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The patient with BPD usually exhibits four schema modes and shifts rapidly from one to the other. One moment the patient is in the Abandoned Child mode, experiencing the pain of her schemas; the next moment she may flip into the Angry Child mode, expressing rage; she may then shift into the Punitive Parent mode, punishing the Abandoned Child; finally she may retreat into the Detached Protector, blocking her emotions and detaching from people to protect herself.” (Young, Klosko, and Weishaar, Schema Therapy: A Practitioner’s Guide, Guilford press, 2003, pp.37-41).
Now my view of this commonly-observed phenomenon is different from most therapists in that I think its nature and purpose are primarily interpersonal rather than just intrapsychic. Human beings are the most social of all organisms, so I think it is important to look at what everyone involved in an interaction is doing rather than presuming everything is taking place entirely inside one of them.
I first became aware of the phenomenon of a mode flip decades before it had that moniker. I witnessed one when I was a psychiatric consultant on a patient on a medical floor in a hospital. Her medical condition was being affected adversely by her stress level, precipitating a request for a psychiatric evaluation. When I first met the woman, she was the sweetest, warmest, friendliest, and most pleasant patient one could possibly have hoped to ever meet. We were having a nice chat about her stress level when her phone rang. It was the patient's husband.
Suddenly and without warning her entire demeanor and tone of voice changed radically; she turned into the nastiest, most shrill harridan one could imagine. Her comments towards him seemed unrepentantly vicious, venomous, and unreasonable. After a short conversation, she practically hung up on him.
Now, her husband may very well have deserved her rage and the nasty treatment. However, without knowing the entire context of their relationship, and only hearing one side of this one conversation, most people would easily start to feel sorry for the poor fellow on the other end of the line.
As soon as she put down the receiver, in literally a split second, she turned right back into all sweetness and light and continued to be like that for the remainder of the interview. Whatever the facts of their relationship might have been, what was truly striking was that her changes from “Little Miss Sunshine” to “Hell Hath No Fury” and back again were so amazingly instantaneous, radical, complete, and dramatic.
Back to the staff split. 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.
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The solution to the staff split is actually simple and straightforward. First, staff members have to be aware of the fact that their arguments may be being set up by the patient and may not be due to the unreasonableness or stubbornness of other people engaged in the conflict. They must 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. Patients with BPD can be most accomodating in that way.
Because psychiatrists have known about how to prevent staff splits for so long and have imparted this knowledge to medical and ancillary staff, we do not see this problem nearly as often as we used to.
The relationship between the two 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 it differently. I believe that the behavior stems from the job their families of origin have saddled them with – their need to play Mommy off against Daddy because Mommy and Daddy seem to need them to do this. So, their behavior is something originally designed purposely to accomplish this objective. Later, it is usually automatically and subconsciously played. Once again, however, I believe such patients are ambivalent about this and deep down hope that their efforts to provoke fights will fail. The power to play Mommy off against Daddy is actually very frightening for them.
Another related behavior involving splitting that is seen by psychotherapists is this: Patients with BPD will often make a damaging or incendiary accusation about someone the therapist might know – perhaps an important referral source or 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 or may not 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. Of course, the therapist should also keep in mind that often there really is a nasty, sadistic Nurse Ratched to be found on a psych ward. And patients with BPD make the most enticing targets for them, because many people so often will not believe them.
Nurse Ratched, "One Flew Over the Cuckoo's Nest"
My solution in this situation, in order to avoid invalidating the patient or entering into premature agreement: I state, "I was not there, and I have a different impression of that person 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 expresses the opinion that the former therapist had inappropriate facial expressions). I take this allegation very seriously because, in my experience, patients rarely make unfounded allegations about this subject, and unscrupulous therapists need to be removed from the profession ASAP. Any seeming willingness of the patient to have allowed or even invited the therapist to take advantage of her (or him) 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 try not to take sides unless and until you learn all of the facts.
In the next post in this series, Part IX, I will discuss those times when someone with BPD makes a statement that sounds hostile or critical, and therefore provokes a negative reaction, but which is actually ambiguous. It may or may not actually be as critical or hostile as it sounds.