Mood Swings

A psychiatrist surveys the mind and the wider world

On Bullying and Limit-Setting

Why limit-setting is the compassionate response to bullying.

In my prior post about blog bullies, I advocated limit-setting by deletion of comments that were purely intended to bully. Those comments generally involve invective and profanity, and provide no contribution to meaningful discussion. The only impact they have is to instill a certain reticence in the blog writer; one fears the inevitably harsh attack by the commentator.

In criticizing one particular blog bully, another commentator took offense; I should be compassionate, I was told; my anger came through and made my ideas about blog bullying suspect.

This comment is mistaken, for it assumes that limit-setting is not compassionate. This is a common error. In psychiatry and psychology, it played out a few decades ago in debates about how best to do psychotherapy with borderline personality disorder; those patients often had experienced sexual abuse and other traumas in childhood, leading to the development of a personality that was characterized, among other things, by anger and distrust. They legitimately feared others, and so they tended to strike out, being aggressive and hateful, even when unprovoked. A common target would be a psychotherapist, who, without any fault, suddently would find herself attacked. A natural human response in the psychotherapist would be anger, which is exactly what the patient, unconsciously, wished to provoke. If the psychotherapist would be unaware of what was happening, she would respond angrily to the patient, punishing the patient again, and recapitulating the traumas that caused the patient to behave this way to begin with. This is what borderline patients would do with all others in their lives; the job of the psychotherapist was to somehow break this cycle.

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"Countertransference hate" is the infelicitous phrase; the therapist hates the patient. This may not sound right; after all, all professionals should have "compassion" for their patients, shouldn't they? Of course, but does that mean therapists should "like" their patients? The therapist is not being paid to be the patient's friend; she is being paid to help the patient. It is inhuman not to feel anger at times, just as it would be to suppress other more virtuous emotions, like sadness or pity. It is a mistake to think that anger entails poor judgment; the mental health professional learns to pay attention to anger, and ask what it means - not to ignore or repress it. I never claimed not to be angry about blog bullying; it makes me quite angry, as does schoolyard bullying. What I claim is that anger does not invalidate my critique of bullying; in fact, it strengthens it, because anger is one sign that bullying is happening.

Countertransference hate is perfectly legitimate, most therapists would agree, as long as the therapist uses it to help the patient. But how? There were two classic approaches in the case of borderline personality: the psychoanalyst Heinz Kohut advocated empathy, while Otto Kernberg advocated limit-setting. Both approaches have their supporters; both have their benefits. Most therapists probably combine both empathy and limit-settings. But here is a key point: both are compassionate. Empathy is obviously so; one tries to understand why the patient feels the way she does and one accepts such feelings. But limit-setting is also compassionate; by stopping the patient from acting in certain ways that are self-injurious, one helps the patient, even if this is not appreciated at the time by the person by helped.

It is a simplistic mistake to see any approach that is not purely empathic as not being compassionate.

There are two lessons: limit-setting can be compassionate; and the experience of anger is not in itself "wrong" for mental health professionals.

We next come to a key difference between a bully and a patient. The patient with borderline personality is, in some ways, bullying the psychotherapist; she is trying to get the therapist to have a certain reaction: to get angry and punish the patient. But, at the same time, the patient with borderline personality is paying the psychotherapist to help her; she is attending weekly sessions of a certain length; she is accepting the patient role. She is seeking help. The therapist can work with her, despite her attempts to bully; the patient/bully can be treated because she is seeking treatment. There are times when this is not the case, and the therapist always has to be prepared for such outcomes; the patient may not accept the limit-setting of the therapist, and the patient can then terminate treatment. That is fine; the treatment ends, and so does the bullying, and therapist and patient go their separate ways. This is a failure in therapy, but it is not a mistake. Some patients are not ready for therapy; they have to go through multiple therapists until they are ready to accept the limit-setting or other therapeutic interventions that can help them.

A bully - whether on a school playground or on a blog commentary platform - is different than a psychotherapy patient. The non-patient bully is paying no one for help; she has not asked for any help, she is not in a treatment relationship; any help offered, especially if empathically "compassionate", will likely have no effect. Even limit-setting will have little effect for the bully, because the bully will simply go away and bully someone else. All that the teacher and school administrator and blogger can do is to employ the same techniques of psychotherapy - primarily limit-setting - so as to stop the bully from causing harm, not to the bully herself, but those who are bullied. It is the other children on the playground who are, and should be, the main focus of the teacher and principal; it is the other readers of a blog who are, and should be, the main concern of the blogger who deletes the blog bully.

Should we not be compassionate to the bully herself? Certainly, if the bully accepts the need for help. But that role plays out in a professional treatment relationship, between a psychotherapist and patient, not between a school principal and a schoolyard bully, and not between a blogger and a blog-bully. "Compassion" toward one person who is tyrannizing many others is hardly compassion; it is enabling. True compassion is caring enough about innocent human beings that one stops others from abusing them.

Lest I be misinterpreted, let me aver that I do not oppose those who wish to provide compassion to bullies - on the playground or otherwise. My point is that such compassion first needs to be extended to the victims of the bullies, and then secondarily to the bullies themselves, and only if they agree to professional treatment. To get them to the point where compassion can have benefit, though, limit-setting is a necessary prerequisite.

Too often, the bully becomes the sole focus, and the bullied are ignored. Much like criminals and their victims, everyone has rights, but those who do harm should not be treated exactly the same as those who are harmed.

 

 

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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