Splitting of staff

[F0nzie]

In the books we define splitting as a defense mechanism characterized by all or none or black and white thinking but is it ever anything more than that? Is splitting ever a sick desire to emotionally injure others? Is it ever satisfaction in intentionally creating conflict and watching others fight? Is it ever about needing control or mitigating feelings of inferiority? Is it ever about having a deep loathing of others or people in general? Is it ever passive aggressiveness? Is it ever another manifestation of transference? Interested in hearing how other psychiatrists understand splitting beyond the cognitive implications of the definition, whether or not there are any deep meanings, and ways to work through it.


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[splik]

Maybe med student textbooks talk about splitting as all or none black and white thinking but that is not really what splitting is. Splitting is the basis for a whole range of defenses including dissociation, idealization, devaluation, projection, projective identification, and denial. Put simply, splitting involves some form of disavowal of feelings or psychic reality too intolerable, conflicting or overwhelming for us to experience as our own. Sometimes this involves simply the splitting off of a psychic grouping - we split off the knowledge of some form of reality (through denial or dissociation) in order for us to otherwise function. More commonly understood, this involves splitting of object representations (which is fundamental to object relations theory and our understanding of borderline and narcissistic pathology). Here parts of the self are split off and projected on others - "all good" objects that defend again "all bad objects". Freud also described splitting of the ego, which describes the simultaneous acknowledgement and disavowal of information -for example acknowledging a parent has died but simultaneously believing they are still alive is a very common experience.

Splitting is not necessary pathological. We all split from time to time. Institutions split too. One only has to watch the current political events to see splitting in action. Splitting is also the basis of many religions - as Freud pointed out goodness and evil were split into God and the Devil who were once one.

I am interested to know what has prompted this thread. I find it hard to believe that you would would have such a naive view of splitting. I think you must know the answer to most of the questions you pose is yes. It sounds like you have been dealing with a particularly narcissistic individual. I don't think most splitting is about wanting to hurt others, control others, or motivated by disdain but this certainly occurs in malignant narcissistic and psychopathic personalities.

 

[Crayola227]

In the books we define splitting as a defense mechanism characterized by all or none or black and white thinking but is it ever anything more than that? Is splitting ever a sick desire to emotionally injure others? Is it ever satisfaction in intentionally creating conflict and watching others fight? Is it ever about needing control or mitigating feelings of inferiority? Is it ever about having a deep loathing of others or people in general? Is it ever passive aggressiveness? Is it ever another manifestation of transference? Interested in hearing how other psychiatrists understand splitting beyond the cognitive implications of the definition, whether or not there are any deep meanings, and ways to work through it.


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I think like, everything you said.

I always heard it as playing two sides off each other but I never really felt like that captures it.

 

[nexus73]

It helps me to think the person doing this is sick and is not intentionally causing chaos. Otherwise I feel angry, which isn't useful. Setting healthy boundaries and potentially a behavioral plan to encourage healthier coping strategies on the part of the patient.

 

[F0nzie]

Severe staff splitting is not all that common in my experience, but then again I am still fairly fresh out of residency. Through reflection I would estimate that it has happened to me in less than 1% of my encounters? I admit that I have not done a lot of psychological research in this area.

But unlike other defenses it has created an element of mystique for me because more often than not the bridges burn faster than anyone can build them. ie. firing doctors, filing complaints, and transferring clinics in rapid succession. Other defenses on the other hand are easily tested in therapy if one has a strong alliance. Splitting, however, prevents the alliance if not aims at destroying it and thus requires a team approach to prevent the splitting. I have not seen what happens beyond this point-- maybe because it is a rare occurrence or maybe I because I need more experience.

I would like to know what I can do when I receive one of these referrals from other clinics so I can best help the patient instead of being next in line and repeating the cycle. That's why I am here to ask. Maybe "why do patients split staff" is the wrong question and beyond scientific inquiry. Although having patients tell me why certainly helps my therapy skills in formulating my hypotheses and connecting with them.


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[splik]

But unlike other defenses it has created an element of mystique for me because more often than not the bridges burn faster than anyone can build them. ie. firing doctors, filing complaints, and transferring clinics in rapid succession. Other defenses on the other hand are easily tested in therapy if one has a strong alliance. Splitting, however, prevents the alliance if not aims at destroying it and thus requires a team approach to prevent the splitting. I have not seen what happens beyond this point-- maybe because it is a rare occurrence or maybe I because I need more experience.

there is NO alliance. you cannot develop a therapeutic alliance with severe narcissistic or borderline patients. Problems usually arise when the therapist mistakenly believes there is one, or tries to establish one. Gerald Adler wrote a famous paper describing the alliance with these patients as a "myth"

Team-based approach as you say is the key. Unfortunately these patients are a very good test of how strong and unified the team really is. It is also to remember that completely eliminated splitting is neither possible nor desirable. Patients need their defenses. What is important is that all team members have an awareness of what is going on and anticipate that splitting will happen, are monitoring their own countertransference and not enacting the transference projections, and feel comfortable to discuss their feelings (including murderous feelings) in a non-judgmental supportive environment with the rest of the team. Not making any decisions without discussion with the team can help. These patients should not be given the choice of switching their team or psychiatrist. Any complaints about a staff member should be discussed with the patient present with both the devalued staff member and an idealized one. If they don't like their doctor or whoever, they should be discharged from the clinic. Splitting based defenses should not be interpreted, but neutralized in other ways. If the patient idealizes you, you should tell them "I am glad you think so highly of me, but you know, it's inevitable that at some point I am going to do something to upset you."

I should point out that if you are dealing with a severely narcissistic individual, then their aim may be to wreak havoc and pit staff against each other, and attempts to manage this will enrage the patient who will ultimately abandon the treatment. which is fine as they are probably untreatable anyway.

 

[birchswing]

In the books we define splitting as a defense mechanism characterized by all or none or black and white thinking but is it ever anything more than that? Is splitting ever a sick desire to emotionally injure others? Is it ever satisfaction in intentionally creating conflict and watching others fight? Is it ever about needing control or mitigating feelings of inferiority? Is it ever about having a deep loathing of others or people in general? Is it ever passive aggressiveness? Is it ever another manifestation of transference? Interested in hearing how other psychiatrists understand splitting beyond the cognitive implications of the definition, whether or not there are any deep meanings, and ways to work through it.


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On the one hand, some of the new-age thinking would say you've never judged anyone but yourself (you being the patient in this case). New-age thinking can be self-centered, but it might be helpful in looking at patients as it detaches you from the equation. On the opposite end of the spectrum, I don't really buy into new age thinking all the way because I think people need each other. From what I know about this type of splitting, it starts from bad attachment with caregivers, and what is a psychiatrist but another caregiver. I've never done this, known anyone who's done it, nor do I know much about it, but when I took a psych class the idea of limited reparenting stood out to me as rather interesting and I wonder if it could be apropos to the situation you and your patients are in:

https://en.wikipedia.org/wiki/Schema_therapy#Limited_reparenting

It seems like the parallels between bad attachment to parents and caregivers are there. Both are authority figures. And with multiple staff, just like multiple parents, there can be confusion. The idea of *going* with the patient's automatic orientation that all people are like their initial caregivers and using it to the practitioner's advantage makes sense to me. Although, it does raise interesting questions. Actual children can't choose their parents or leave them. So should a practitioner practice limited reparenting with a patient's permission and awareness or subtley? The Wiki article says dropout rate is low, so I guess people find enough value that they opt-in to an experience that in its original form (being born to parents) is not an opt-out experience.

 

[smalltownpsych]

Lots of staff splitting is usually a sign of unhealthy dynamics in the staff more so than the patients problem. In fact, blaming patient is splitting. Not saying you did that, but I'm sure you've seen it. As far as treatment goes with the patients who have the pattern you are describing, the basic premise is that you need the me the stable object in the relationship. I have found Linehan great for some basic strategies that are also very helpful for the team and Kernberg to be helpful for conceptualizing and broadening my own understanding. Both of them emphasize the importance of maintaining a strong therapeutic frame which is my point about being the stable object in the room. Linehan is great for helping you to learn what those boundaries be and how to establish them.

 

[F0nzie]

Lots of staff splitting is usually a sign of unhealthy dynamics in the staff more so than the patients problem. In fact, blaming patient is splitting. Not saying you did that, but I'm sure you've seen it. As far as treatment goes with the patients who have the pattern you are describing, the basic premise is that you need the me the stable object in the relationship. I have found Linehn great for some bqsic strategies that are also very helpful for the team and Kernberg to be helpful for conceptualizing and broadening my own understanding. Both of them emphasize the importance of maintaining a strong therapeutic frame whoch is my point about being the stable object in the room. Lineman is great for helping you to learn what those boundaries be and how to establish them.

Staff are always sicker than the patient.


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[PikminOC]

Fonz, what type of complaints?

 

[F0nzie]

Fonz, what type of complaints?

"He said she said" on steroids. ie. She said you would, he said he would, he said you should, he did this, she did that, he said you didn't know, etc. Sometimes having more staff to observe the interactions and enhance communication works to meet the patient's needs... Other times it just results in the whole team getting fired and the pt ends up rolling through to the next team like a red hot fireball. I am interested in learning more about the composition of that flame.


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[smalltownpsych]

"He said she said" on steroids. ie. She said you would, he said he would, he said you should, he did this, she did that, he said you didn't know, etc. Sometimes having more staff to observe the interactions and enhance communication works to meet the patient's needs... Other times it just results in the whole team getting fired and the pt ends up rolling through to the next team like a red hot fireball. I am interested in learning more about the composition of that flame.


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You gotta read Kernberg's Psychotherapy for Borderline Personality. Understanding how pathological internalized object relations works can go a long way towards understanding what is going on with these patients and how they are able to replicate their internal world from their past into the current world. Part of the split introjects is that if one person is the victim, then someone else has to be the victimizer. Either directly or indirectly through projective identification, the patient places her anger and hostility into others, who then begin fitting into whatever their comfortable pattern of responding is. Mine is to avoid conflict and make wisecracks. When I find hurtful sarcastic jokes at peoples expense coming to mind, that is a good sign I'm getting caught up in an enactment. The best advice I can give is to interpret the patient's underlying hostility. If you can get them to speak their anger more directly, it won't leak out all over the place. When I say speak their anger, I'm not talking about their petty gripes. Those are just part of the enactment. You have to get deeper. "So when the staff did that it made you feel like no one cares about you. It must be awful to be at a place where people are supposed to care and feel like they don't. Kind of like when you're mom did drugs instead of caring about you?"

 

[F0nzie]

@splik. Thanks for the article. Definitely puts things into perspective although I do think alliance is on a continuum and that there is probably a point of no return.

@smalltownpsych. You make a good point about the unity of the team. This is particularly challenging in CMHC where staff turn over is so high.


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[F0nzie]

After reading and reflecting on these responses I started thinking about my 3 year old son. For example, if he is naughty and he gets into trouble he will run to mom and say "daddy hit me mommy". (I have never laid a finger on my child) Flat out lie! Inside I'm like...how dare you make such a horrible accusation. At first my wife looked at me with suspicion until he did it to her and accused her of hitting him. (I swear we don't hit our child). It's not just the things that he says verbally but his behaviors and actions may also expose our weak points in parenting. So it makes sense that splitting can be understood as lack of stability and failure of parenting to get the child past this point. If you have an unreliable team perhaps that triggers early traumatic/neglectful childhood experiences that result in regression. Maybe we see it more often than we should since a lot of us work in the type of system that lays the groundwork for us to observe it.


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[smalltownpsych]

After reading and reflecting on these responses I started thinking about my 3 year old son. For example, if he is naughty and he gets into trouble he will run to mom and say "daddy hit me mommy". (I have never laid a finger on my child) Flat out lie! Inside I'm like...how dare you make such a horrible accusation. At first my wife looked at me with suspicion until he did it to her and accused her of hitting him. (I swear we don't hit our child). It's not just the things that he says verbally but his behaviors and actions may also expose our weak points in parenting. So it makes sense that splitting can be understood as lack of stability and failure of parenting to get the child past this point. If you have an unreliable team perhaps that triggers early traumatic/neglectful childhood experiences that result in regression. Maybe we see it more often than we should since a lot of us work in the type of system that lays the groundwork for us to observe it.


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Right on the money. I like the term primitive defense mechanisms because it captures the fact that they are normative at certain stages of development. Our patients get stuck there for a variety of reasons. A little more advanced stage is when the kid starts actively plotting to get what they want by pitting parents or other adults against each other. I used to run an adolescent program so got to see plenty of that dynamic play out.

 

[randomdoc1]

After reading and reflecting on these responses I started thinking about my 3 year old son. For example, if he is naughty and he gets into trouble he will run to mom and say "daddy hit me mommy". (I have never laid a finger on my child) Flat out lie! Inside I'm like...how dare you make such a horrible accusation. At first my wife looked at me with suspicion until he did it to her and accused her of hitting him. (I swear we don't hit our child). It's not just the things that he says verbally but his behaviors and actions may also expose our weak points in parenting. So it makes sense that splitting can be understood as lack of stability and failure of parenting to get the child past this point. If you have an unreliable team perhaps that triggers early traumatic/neglectful childhood experiences that result in regression. Maybe we see it more often than we should since a lot of us work in the type of system that lays the groundwork for us to observe it.


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I swear my toddler splits too. But I guess, what can I expect, they don't have mature coping at this point. Neither me nor my husband lay a hand on him. However, I am more stern with boundaries and my mother is definitely a pushover with my son. So naturally, he favors daddy and grandma more. Kind of hurts . Guess I'm not the not as fun parent when it comes to mom and dad.

 

[Salpingo]

After reading and reflecting on these responses I started thinking about my 3 year old son. For example, if he is naughty and he gets into trouble he will run to mom and say "daddy hit me mommy". (I have never laid a finger on my child) Flat out lie! Inside I'm like...how dare you make such a horrible accusation. At first my wife looked at me with suspicion until he did it to her and accused her of hitting him. (I swear we don't hit our child). It's not just the things that he says verbally but his behaviors and actions may also expose our weak points in parenting. So it makes sense that splitting can be understood as lack of stability and failure of parenting to get the child past this point. If you have an unreliable team perhaps that triggers early traumatic/neglectful childhood experiences that result in regression. Maybe we see it more often than we should since a lot of us work in the type of system that lays the groundwork for us to observe it.


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It relates to the severity of trauma and consistency in parenting. Its hard enough to understand that the person who punishes you is the same person that nourishes and cares for you, that the person you totally depend on is also completely fallible. That developmental hurdle can become insourmountable when there's sexual abuse or volatile behavior (one minute they're your best friend and cuddle buddy, the next they're terrifyingly angry). There are some behaviors that are just totally irreconcilable with the image of loving, stable parent.

Biologically, there's also a need for empathy and attachment (which is why the original studies on antisocial PD looked at war orphans). Your son may want to express to the other parent that he is being hurt, or that he's powerless and want someone to come to his defense. But when he is old enough to put himself into your shoes, and realize how damaging it would be if someone accused HIM of being abusive, he'll be able to take a more nuanced look.

Like splik mentioned, the split itself isn't necessarily pathological. However, the response to the split is. If we perceive someone as the "bad parent", how do we react? Do we lash out angrily? Do we punish them? Do we try to repair the relationship? Do we assume we deserve that bad parent for something wrong we've done?

The staff becomes split when there's projective identification -- people believe that they are the saviors, experience the hopelessness/helplessness of the situation, or feel angry at being held hostage. Your experience as a parent should help in that case, realizing that you have a shared agenda with fellow staff members just as you have a similar agenda with your wife: get this destructive little creature safely out of your house and capable of fending for itself before it sets something valuable on fire.

 

[Ceke2002]

I think consistency is key in these situations whether it's one on one, a hospital, clinic, or group situation, you all have to be on the same page with one another or else you're not doing the patient any favours. Thankfully I've never been hospitalised myself, but visiting at least one friend (we'll call her 'L''), with a disrupted attachment pattern, and suspected BPD, in hospital, and seeing the types of splitting behaviour that @F0nzie and @smalltownpsych have described, that was always the one feeling I came away with every time, like "wow, forget about being on the same page, none of you guys are even reading the same book", and in the meantime L would be acting out her defense mechanisms from one end of the ward to the other and getting nowhere fast. It was damn near the same script being played out every single time - L would hit one of her thrice or so yearly crisis points (bulimia plus severe self harming), agree to voluntarily enter a two week program to try and stabilise her eating and reduce/stop self harming, and no matter who was working what shift on the ward there always seemed to be a Nurse: 'Let's be friends' and a Nurse: 'Tough love' amongst them. Not surprisingly L would always immediately gravitate towards Nurse 'Let's be friends', because when you've been through a situation of abuse you do tend to want to immediately align yourself with the one person in the room you think is going to do you the least harm - and Nurse 'Let's be friends' would end up being the idealised object on the ward for a while, because she was the one who was perceived to 'really get it', and didn't make L feel threatened (even going as far as to align herself with L against Nurse 'Tough love' by quietly disparaging Nurse 'Tough love' behind her back, and telling L things like "I don't even know why *she* bothered going into a caring profession if she's not going to care"). Now fast forward a few more days and invariably Nurse 'Let's be friends', in her apparent zeal to align herself with the patient by trying to be their newest BFF, would slip up and do something to shatter L's idealisation of her (usually by doing something like making what they thought was a light hearted joke to a bulimic along the lines of how they needed to 'start getting ready for bikini season' and *giggle, giggle* 'so tell me what the secret is'), and all of a sudden Nurse 'Let's be friends' would go from idealised to threatening object, and Nurse 'Tough love' would take over the idealised object role (because now they were the one who was seen as being 'right all along', and all Nurse 'Let's be friends' had done is wasted valueable time by not having the guts to challenge L when that's what she *really* needed). So now watch the roles switch when Nurse 'Let's be friends' starts to resent the way this patient has turned on her, after 'all she's tried to do', so she ends up taking on the role of Nurse 'Tough love', and in the meantime Nurse 'Tough love' is gloating to herself, because of course they knew all along that you have to be tough with these patients and not let them walk all over you, and 'look, now see, I'm the one who's finally gotten through to the patient' and suddenly Nurse 'Tough love' would find themselves cast into the same role as Nurse 'Let's be friends' by a patient who was basically acting out defense mechanisms learned from prior abuse situations - except of course now in L's desire to align themselves with the person they thought would be the least likely to hurt, or abandon them they would start internalising Nurse 'Tough love's' attitude towards patients to an extreme degree and start not only talking about how she needed to 'toughen up' and 'get honest with herself', but also denigrating herself as 'ungrateful' and 'unworthy' and 'insert more self defeating negativism'). The entire end result of this being L would come out of hospital worse than what she went in; behaviour wise she might have been stable for a while, but emotionally she'd be a complete mess and then the entire cycle would just end up repeating itself the next time she crashed and burned and ended up back in yet another crisis state.



Footnote: L did finally get herself into a good treatment program, one where the staff were on the same page and she got the same balanced and empathetic response from everyone (and any ruptures that occurred were dealt with quickly and appropriately), and she's doing really well now - well enough to have completed a masters in counselling and now be working as a youth counsellor for a government funded agency.