Understanding splitting is essential to supporting people in Borderline Personality Disorder (BPD), particularly when they are in suicidal crisis. In this episode Dr Kar Ray shares some foundational constructs as well as some practical tips that can help a health care professional or even family members provide the most appropriate support.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
Understanding splitting is essential to supporting people in Borderline Personality Disorder (BPD), particularly when they are in suicidal crisis. In this episode Dr Kar Ray shares some foundational constructs as well as some practical tips that can help a health care professional or even family members provide the most appropriate support.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
Host: Good day, this is Mahi, your host, we are on to episode 21. We have also done 6 guest episodes. I am sure you all have noticed that in our academic episodes we are sequentially covering the course content and in the guest episodes we draw out unique perspectives from mental health professionals and relate it back to the content in PROTECT. So far as guests we have had two mental health nurses, one Psychologist, one Social Worker and a Psychiatrist. Interestingly in the last episode the guests were non-mental health professionals, they were professional actors.
Expert: Yes that’s correct, to role play the case simulations in our training we do get professional actors and it was an opportunistic recording at the end of 2 days of intensive training. Tegan, Sami, Charlie and Kyra were the actors for the 7 SAFE Steps program and although they are non-mental health, they contribute so much to the course. There real time feedback as to how a piece of conversation made them feel is great for reinforcing those positive nuances that we are trying to establish in our dialogue, that is what creates relational safety.
Host: So you just took out your phone and recorded them at the end of the session.
Expert: Yea that’s about it and they were happy to play ball so we played ball, and I thought this is great content that we should share with our listeners.
Host: In 7 SAFE Steps you all have the character Sandeep that they play.
Expert: Yes, Sandeep if you a male actor and Sandeepa if you are a female actor.
Host: And what is Sandeep’s story?
Expert: Ah ha for that you have to come to the 7 SAFE Steps training I guess, we are meant to provide a story, Jill’s story today, If I delve into Sandeep we might never get to Jill today like last time.
Host: That’s true, we started episode 20 with the intention of talking about Jill and then we got taken up with personality disorders in general and never got around to Jill. Do you want to give a quick synopsis of the 3 clusters before we discuss Borderline personality disorder.
Expert: Sure, 3 clusters, 10 disorders, Cluster A includes personality disorders that are characterized by odd or eccentric behavior. They tend to experience major disruptions in relationships because their behavior may be perceived as peculiar, suspicious, or detached. The 3 personality disorders in this group are Paranoid, Schizoid and Schizotypal. Cluster B personality disorders are characterized by dramatic or erratic behavior. They tend to either experience very intense emotions or engage in extremely impulsive, theatrical, promiscuous, or law-breaking behaviors. The most common clinical presentation is Borderline Personality Disorder, that’s what its called in DSM5, In ICD the same condition is called emotionally unstable personality disorder, perhaps a more descriptive and less stigmatizing name. That’s what we will talk about today, the 3 other conditions in Cluster B are Antisocial, Histrionic and Narcissistic and finally Cluster C personality disorders are characterized by pervasive anxiety and/or fearfulness. They are Avoidant, Dependent and Obsessive compulsive personality disorder.
Host: Thank you for that summary, just to reinforce Manaan’s request not to self diagnose from the podcast or information that you read on Dr Google, if you are concerned that you may suffer from certain unhelpful personality traits that make thinking, feeling and relating to others difficult please see a professional with mental health expertise.
Expert: That’s correct, we all have parts of our personality that pose us difficulties and are not very pleasing, that does not mean that all of us have a Personality Disorder, those with a disorder they have significant difficulties and their traits are pervasive across time and settings. When people self diagnose they often have recall bias about the one or two or three instances that they may have acted in a particular way, for a diagnosis there has to be a consistent pattern. Also it is high likely that those with a personality disorder may also be suffering from depression or anxiety, treatment of those conditions may significantly help a person’s psychological pain, not to mention that sometimes the treatment for anxiety and depression if there is a co-occurring personality disorder may be different and not as straightforward as the treatment of anxiety and/or depression on its own. To cut a long story short, specialist mental health opinion and expertise is invaluable.
Host: Let’s get into it then, Borderline Personality disorder, you mentioned this is the most common personality disorder in a clinical setting.
Expert: Yes it is, in prison mental health it most probably will be antisocial personality disorder but in the community setting Borderline Personality Disorder is the most common. Around 1 in 100 people have BPD. It is believed to affect men and women equally, though women are more likely to be given this diagnosis.
Host: What is the origin of the term Borderline?
Expert: It is called ‘borderline’ because doctors previously thought that it was on the border between two different disorders: neurosis and psychosis.
Host: Who coined the term?
Expert: Now you are trying my general knowledge.
Host: Well Psychiatric knowledge to be precise.
Expert: It was first used in the DSM in the third edition so that was 1980 but the term was used previously.
Host: I did a bit of research and found the name of American Psychoanalyst Adolph Stern and the year that was mentioned was 1938.
Expert: Ah so you were testing my knowledge, you knew the answer all along.
Host: Well its quite rare to get one over you, so I will savour the moment.
Expert: I have to get on to Dr Google to check our your research but in all propability you are right, it was used in the 40s and 50s to describe a group of patients that did not improve with therapy and whose symptoms did not fit into either the psychosis or neurosis classifications. You have to remember that at that time, people with neuroses were believed to be treatable, whereas psychoses were thought to be untreatable. There is a term that is not used any longer called borderline schizophrenia, but I should not be confusing listeners with a history lesson.
Host: It is interesting though, cause in ICD the term that is used is Emotionally Unstable Personality Disorder.
Expert: Yes and that is a much more descriptive term, thinking about individuals and nomenclature I think it was Otto Kernberg in the 1970s who used the term borderline to describe a personality organsation between psychosis and neurosis, people who he thought had defence mechanisms to avoid anxiety that were primitive, meaning developmentally would have early.
Host: Sorry I don’t follow, can you give examples.
Expert: You mean the defences.
Host: Yes
Expert: examples include splitting, or assigning "good" or "bad" qualities to everything, as well as projective identification or projection, or assigning your negative qualities onto someone else.
Host: Oh dear, this did not make it any easier to understand.
Expert: Sorry I guess I am trying to explain in 30 seconds what takes mental health professionals a life time to get their head around and some never do. ‘Splitting’ is common symptom in borderline personality disorder. Splitting means to divide something. It causes a person to view everything and everyone in black and white, ‘absolute’ terms. It stops them from being able to recognise or accept paradoxical qualities in someone or something and doesn’t allow for any ‘grey areas’ in their thinking. We are all shades of grey and ash, not black or white, but uncertainty is anxiety provoking, some of this stems from experiences of early life traumas, such as abuse and abandonment, so people with BPD may see a person as all good or all bad, there is nothing in between.
Host: So, they are seeing and responding to the world in these extremes, through either a filter of positivity or negativity.
Expert: Yes, but in the real world as human beings we are all fallible, but if you have been put up in a pedestal as all good, when you do something wrong that brings you crashing down.
Host: So, splitting can lead to strains or fractures in their relationships.
Expert: Absolutely, and interestingly splitting happens within staff teams particularly inpatient teams who are caring for a person with BPD, some nurses will go above and beyond and become quite drawn in and there are others who cannot find any empathy with them and finding caring for them challenging and emotionally draining.
Host: So how is such splitting in staff teams addressed?
Expert: We may end off going at a tangent but this may be relevant, it is essentially through the use of reflective practice and supervision that it needs to be addressed. On certain wards the emotions may be quite overt and staff regularly use words like manipulative in handover. The reality is that patient with BPD don’t know the first thing about manipulation, people without BPD know how to manipulate for example I have been manipulated into an agreement that I will take the rubbish bins out till the rest of eternity, not sure when I committed to that, as a man I would say that wives are very good at manipulating husbands into believing that something was there decision when it was only carefully implanted and extracted by their wife and made to sound like I decided this, if this were a text this were I would type LOL, laugh out loud, but on a serious note, people with borderline personality do not know the first thing about manipulation, there distress is so high that it is visible to everyone, there is no intent to hide anything and do anything sinister. It is almost like, I cannot deal with this my distress, so I intend to kill myself if you discharge me from the ward or do not admit me and in the making of that statement they have managed to hand over their entire distress to you, and then you are left dealing with it.
Host: you said visible to everyone, but as a lay person I can see why someone might think that such a statement is manipulative.
Expert: Perhaps you are right, to the untrained eye that will seem manipulative, but to the trained eye that is an expression of distress saying, please help me, I cannot deal with my internal world, it is overwhelming and I am worried that I might do something that I will regret. But with the right skills and knowledge, staff are able to see that such behaviour which they might class as attention seeking is really a cry for help, we spend a lot of time in the interactive exercises in the full PROTECT training to look at these issues, training this is essential to prevent malignant alienation of patients on inpatient wards or crisis teams and emergency departments where patients repeatedly present.
Host: We have been going on for a little while and we have not got to Jill yet, should we continue with splitting as this seems to be a really important topic and central to the care of patients with BPD in suicidal distress.
Expert: Well, it does overlap with the first theme of AWARE, which is anxiety and how patients with BPD may create anxiety in professionals they come into contact with, so yes by all means we can explore this further, there is always next episode for Jill. What other questions have you got.
Host: You mentioned something about childhood trauma, can you elaborate a little more?
Expert: When a baby enters the world, they experience the things within it as either good or bad, or as all or nothing. As the baby develops psychologically, they begin to understand that the world isn’t just good or bad. They become able to integrate the idea that good and bad can be held in the same object.
Host: So, this integration of good and bad in the same person is lacking?
Expert: If one has experienced childhood trauma and really struggle to trust someone, you can see how difficult it is for them to think that a person that they feel close to may have some bad in them along with all the good. That uncertainty is extremely anxiety provoking for someone who has gone through significant trauma. How can good and bad co-exist in the same person, this would be way too overwhelming emotionally.
Host: So, splitting into good or bad allows the person to tolerate difficult and overwhelming emotions by seeing someone as either all good or all bad, idealised or devalued.
Yes, this makes it easier to manage the emotions that they are feeling towards another person, which on the surface seem to be contradictory as it puts extreme strain on the relationship as it is only a matter of time before the person who is idealised will turn up short.
Host: What do you mean by turn up short?
Expert: Well short of their expectations and then they go from all good to all bad. Such a split might often be caused by an event that might seem harmless or small to people without BPD, but they may in some way relate to previous trauma. The past trauma also creates an entire world view that its only a matter of time before they will be let down, so people with BPPD are often testing out both personal and professional relationships, again this testing behaviour stems from fears of abandonment, separation or severe anxiety. And it’s only a matter of time that it becomes a self-fulfilling prophesy.
Host: Can you elaborate on the self-fulfilling prophesy?
Expert: Say for example you are feeling anxious about an upcoming job interview and you start thinking there is no way I will get the job, you keep ruminating over it and make yourself so anxious that you make a mess of the interview and you don’t get the job and then you say I knew it all along that I wont get the job. That’s an example of a self full-filling prophesy
Host: Ok but how does that relate to relationships?
Expert: Let’s say you start believing that someone does not like me, so you behave in a way with the person that is distant or a bit rude and you know what the other person notices that and mirrors your behaviour and before you know they don’t like you because of the way you have been behaving. So the way we behave turns a belief into reality.
Host: Ok much clearer and how would that relate to someone with BPD.
Expert: Let’s say someone with past trauma has started to get close with another person, but because of their past traumatic experiences they are struggling to open up or trust the person, they might push them away through their actions that relate to not letting them in and the person does not persevere, actually in those living with BPD the converse is often true due to trauma, they class the person as all good and an intense relationship begins, they are all in, before you know something happens and doubt creeps in or because of past trauma they start doubting that this is too good to be true and they start testing out the relationship, either by being too possessive or putting unrealistic expectations from the person, when they are not met, they give rise to arguments and anger outbursts and before you know they have managed to prove to themselves that this was too good to be true, everyone lets me down, no one should be trusted – all part of a self fulfilling prophesy.
Host: So, the splitting, all good or all bad which on the surface makes it easier to deal with relationships, it becomes a huge deterrent to maintaining long term relationships.
Expert: Yes, a person with borderline personality disorder may use splitting to class people as ‘perfect’ or ‘evil’, something will ‘always’ or ‘never’ go right, someone will ‘always’ or ‘never’ be loving. A person may hold onto these black and white views permanently. For others, their opposing views can fluctuate over time, where they switch from seeing someone or something as entirely good to entirely bad, or vice versa.
Host: So, is there any other impact of splitting?
Expert: A common symptom of BPD is emotional dysregulation – this is where a person is less able to manage their emotional responses than individuals who don’t struggle with a personality disorder. Therefore, when a person with the disorder splits and perceives something or someone to be entirely good or bad, they are likely to respond in a way that falls outside what would be expected. These extreme emotions can be exhausting, both to the person with BPD and those who are closest to them.
Host: And this relates to what you were saying about being on a pedestal and coming crashing down?
Expert: Yes, when seeing someone or something as entirely good, this can leave the person with BPD vulnerable to harm and danger as they are unable to see associated risks. So they may get taken advantage of which then feeds into that cycle of abuse and trauma. Also, when believing a person is completely perfect, this can also lead to co-dependency, where they rely on that individual for all their wants and needs. This can be harmful to both parties, and a draining responsibility.
Host: And this is what you said, we are all fallible and shades of grey and ash?
Expert: Yes, when a real or perceived slight is then experienced by the person with borderline personality disorder, this can cause them to feel disappointed, betrayed, unloved or abandoned, and view the other party as entirely bad. The individual may then become angry or withdraw entirely. They may also become incredibly angry with themselves. There are techniques to manage anger during this time which is taught in Dialectical Behaviour Therapy program.
Host: If you are a mental health professional how do you navigate splitting and continue to care for the person with BPD, I know you mentioned reflective practice and supervision, what will they do in supervision?
Expert: Well, help the professional get into the person’s shoes, the whole idea of empathy in action.
Host: And that is the challenging part.
Expert: Extremely challenging for those with a severe borderline personality disorder. I will share one of the most evocative description of what it is like to live with a severe BPD, a word of caution for our listeners, the response you may have to this is quite visceral, so if you are eating, please do not listen to the next minute or so of the podcast. What I am sharing relates to a discussion about feelings of disgust and how a patient with severe BPD described what it felt like to be her, here goes, imagine, a dog has just pooped, the poop is still soft and warm, using your bare hands you pick it up, you open your mouth and you put it into your mouth, the way you feel right now multiply that a 100 fold, that’s how it feels like to be me every day.
Host: Oh my gosh that definitely gives a visceral response.
Expert: Absolutely, our life experiences are so far removed from those of a person who may have been systematically sexually abused by their primary care giver from an early age say of 5 or 6, that does not matter how hard we try, it is very difficult if not impossible to walk in their shoes. That does not mean we do not try, it means we try harder and harder and suspend all judgement, as we say in the protect training, mind open mouth shut and listen up, listen to their pain from up close and personal, close enough to feel their darkness but not so close that you get overwhelmed.
Host: You do cover empathy in action in a fair bit of detail in the values of relational safety in the CORE module, but the scale of this challenge is something quite different. Are there practical things that people whether they be professionals or family and friends can remember to do?
Expert: Remember that splitting is a symptom of borderline personality disorder - while it can be difficult not to take their words and actions personally, remember that the person is not intentionally trying to hurt you. Splitting is something that they are doing unknowingly. Think about how you respond to the person who is splitting - try to remain calm and if you find this difficult, give yourself an opportunity to cool down by postponing an important conversation. Show the person that you really do care - a person with BPD is likely to be dealing with feelings of abandonment, isolation and loneliness. Therefore, try to show the person that they are cared for and that they are heard. Set healthy boundaries to help manage behaviours – work with the person with BPD to set limits so that they understand the behaviours that you won’t tolerate, such as throwing objects or violence. While these boundaries may be unintentionally challenged at times, make sure that you carry out the pre-determined consequence, which may include walking away from the situation. It is also important for you to encourage the person to receive the right treatment, and be an advocate of it when they do so.
Host: That’s quite a helpful summary of how to navigate splitting, I just realised that we have been talking about BPD for so long and we have not even systematically looked at the criterion for diagnosis.
Expert: I think we should begin the next episode with it and then I promise we will get around to Jill. I do think we have laid a solid foundation for the BPD case simulation discussion. Understanding splitting is central to caring for people with borderline personality, so this is time well spent.
Host: Just like episode 20 we never got around to Jill our case study as we ran out of time, but we promise to talk about Jill next time and how the AWARE factors relate to Jill. Manaan do you promise as well.
Expert: I do indeed, we will get there, patience is a virtue and good things happen to those who are patient, I am sure our listeners realise how important this topic was.
Host: We will look at all the symptoms of Borderline Personality Disorder or Emotionally Unstable Personality Disorder in the next episode. In today’s episode we have covered in depth the why, how and what of splitting and some really evocative imagery of what it feels like to have a severe borderline personality disorder.
Expert: The strong sentiment of disgust towards oneself will relate back to the self harming that is very prevalent in people with BPD.
Host: Pause and think about your clinical practice and what challenges you face with Borderline Personality Disorders. Have you thought of people with BPD as manipulative or attention seeking. Have your views changed in anyway after listening to the podcast. What changes will you make to the interactions you will have with patients with BPD. If you have specific questions please do email us at admin@progress.guide. Share your musings with us. Tweet your thoughts and tag #GuideProgress. It helps get the word out about the podcast to more professionals and support progress to practice. You can access all the transcripts at www.progress.guide. You can connect with Manaan on Linked in, or follow our linked in page by searching on linked in for progress.guide. We are also on twitter and YouTube. Our twitter handle is @GuideProgress. As usual please do follow the podcast, there will be weekly episodes every Friday and share it with your colleagues. Your ratings will help get the word out so please don’t forget to rate us on Spotify, apple podcasts or audible or whichever channel you are listening on. Challenges in supporting people with Borderline Personality Disorder is a common knowledge and skills deficits. Given severe borderline personality disorder has a standardised mortality rate of 45.1 it is a critical area for suicide prevention. Helping healthcare professionals fine tune their practice in this area is an essential step in creating a workforce that delivers high quality care for people in suicidal distress. Remember together we can make a difference. Tune in next Friday and we will explore how the AWARE factors relate to Jill, our case simulation of Borderline Personality Disorder. Thank you for joining us today and keep spreading the word.