Mixed Messages in Your Family? A Quiz You Can Take

I have been studying the families-of-origin of patients with borderline personality disorder (BPD) since the the late 1970’s. As readers of this blog already know, I discovered that the biggest and most common emotional conflict in the parents who produce offspring with the disorder is a conflict over the very act of becoming and being a parent.  As I described in a previous post, the parents think being great parents and taking care of children is the end all and be all of human existence, but secretly they wish, for a variety of different reasons, that they could be spending most of their time doing something else entirely.

Since they are conflicted about their parental roles, they constantly give off mixed messages to their children about what is expected from them. This leaves the children to try to figure out how to meet their parents’ contradictory needs to be both needed by their children and, simultaneously, for their children to just go away. The children solve this dilemma by adopting various versions of the spoiler role.

Children growing up with mixed messages from parents is, in fact, a hallmark of families producing children with any personality disorder.  The problematic mixed messages are often in regard to only certain behaviors or role functions – usually just one or two – while the parents respond to other roles and behaviors in a coherent, non-contradictory manner.

For those readers who are now adults, how does your family stack up in the continuing double messages department? My colleague Hillel Abramson and I designed an instrument to try to measure the amount and type of double messages adults perceived as receiving from their primary attachment figures, called the Family Interaction Scale or FIS.  While designed with only borderline personality disorder (BPD) in mind, it can be used more generally, and you can administer it to yourself to see what areas are problematic for your families.

But first, just a little background.

In order to see what is going on in families, one has to appreciate that conversations between family members have subtexts. A subtext is an underlying, implicit and often distinct theme in a conversation that is not perceivable if someone is only paying attention to the literal meanings of the sentences spoken. In order to understand a subtext, one also has to listen to an entire conversation before hidden meanings might become evident. Just a few sentences will not do. 

Furthermore, an understanding of the entire history of the relationship between the people having the conversation, not just the current interactions, is also required to tease out important latent themes.

Therefore, appreciating the subtexts of conversations between intimates involves thousands of variables that will be completely different for each dyad or group being evaluated. To think that subtexts of this complexity can be “measured” by standardized questions and answers on a psychological test is ludicrous. For this reasons, truly “empirical” studies are impossible.

But in today's world, one must try. Some people insist that observations of subtexts are just “anecdotal.”  They can therefore just dismiss it as an object of scientific study. To get around this just a wee bit, we chose 9 of the most common themes in the families of those with BPD that I had observed over the years, and asked four different groups to rate their parents’ ongoing, current communication in these 9 “domains.”

The four groups were patients with the disorder, those who were subthreshold for the disorder (that is, who met 3 or 4 of the criteria for BPD rather than the required 5), non-psychotic patients being treated in our clinic who did not have BPD, and normal controls who exibited no psychiatric disorders at all.

The domains are:

1.  Praise and criticism

2.  Comments to friends and relatives about the subject

3.  Reactions to advice given by the parents

4.  Blame for the parents’ problems

5.  Frequency of advice giving by the parents

6.  Degree of parent’s preoccupation with the subject

7.  Relationship of a parent’s mood to the subject’s mood

8.  Parental reactions to the subject’s work failures and successes

9.  Parental reactions to the subject’s romantic failures and successes

For each domain, we provided 6 to 7 options. Since no human relationships are completely consistent all the time, we wanted to avoid saying anything that implied that the parents were “always” one way or another.  So we asked subjects to please check only the one item in each domain rating that "came the closest to describing the parent's current behavior towards you most of the time."

For each domain, there was one response pattern that we deemed appropriate. Another response pattern we originally deemed “neglectful.”  However, in thinking about it as the results came in, it seemed to us that it would be more accurate to say that these items reflected the fact that the issue in the domain did not seem to matter at all to the parents.

There were two response patterns that we deemed polarized – the parent acted most of the time at one extreme or the other without much in between.  There were also two response patterns that were indicative of  the pattern in which we were most interested: double messages. The parents either were perceived as blatantly contradictory in their behavior, or they said one thing but seemed to mean something that was contradictory to what they said. 

In reading the items below, you should be able to easily figure out which item corresponds to which response pattern.

Subjects in the original research were asked to choose and rate up to three attachment figures from their childhoods who were still alive, still interacting with the subject in the present, and not senile.  “Still in contact" could mean in person, by phone, by letter, or even by word of mouth.

These figures had to have served in the parental role when the subjects were between the ages of 5 and 15.  We provided the following list:

1.  Natural Mother

2.  Natural Father

3.  Adoptive Father

4.  Adoptive Mother

5.  First Stepfather

6.  Second Stepfather

7.  First Stepmother

8.  Second Stepmother

9.  Father's Father (only if he lived with you)

10.  Father's Mother (only if she lived with you)

11.  Mother's Father (only if he lived with you)

12.  Mother's Mother (only if she lived with you)

13.  Brother at least 5 years older than you

14.  Sister at least 5 years older than you

15.  Other (Specify)

Here were the test items:

DOMAIN 1

1.  This person consistently praises me no matter what I decide about how I run my life

2.  This person consistently criticizes me no matter what I decide about how I run my life.

3.  This person consistently goes back and forth between praising and criticizing me for the same decisions.

4.  This  person is consistently fair in praising and criticizing me for my decisions.

5.  This person rarely  praises or criticizes my decisions about how I run my life.

6.  Regarding my decisions, this person consistently says one thing but really                  means another.

________________

DOMAIN 2

1.  This person consistently brags about me to their friends and relatives.

2.  This person consistently bad mouths me to their friends and relatives.

3.  This person says contradictory things about me to friends and relatives.

3.  This person is consistently fair in making remarks about me to friends and relatives.

5.  This person consistently does not talk about me with their friends and relatives.

6.  This person consistently says one thing about me to friends and relatives but really means another.

________________ 

DOMAIN 3

1.  This person acts happy only if I follow their advice.

2.  This person acts happy only if I ignore their advice.

3.  This person consistently acts unhappy with my reaction to their advice no matter if I follow or ignore it.

4.  This person accepts my reaction to their advice even if I disagree with it.

5.  This person consistently does not react to how I respond to their advice.

6.  Regarding my reactions to their advice, this person consistently acts one way but really feels another.

________________ 

DOMAIN 4

1.  This person consistently blames themself for their own problems even when they are not at fault.

2.  This person consistently blames me for their own problems even when I'm not at fault.

3.  This person consistently goes back and forth between blaming me and themself for their problems.

4.   This person is fair in assigning blame for their problems.

5.   This person consistently blames others rather than me or themselves for their problems.

6.    This person rarely blames anyone for their own problems.

7.     In assigning blame for their problems, this person consistently says one thing but means another.

_______________ 

DOMAIN 5

1.  This person almost never tells me what to do, even if I ask for their advice.

2.   This person almost always tells me what to do.

3.  This person consistently goes back and forth between telling me to make my own  decisions and telling me what to do.

4.    This person usually tells me to make my own independent decisions but will offer advice if asked.

5.   This person is unconcerned with who makes the decisions in my life.

6.    Regarding telling me what to do, this person consistently says one thing but really means another.

________________

DOMAIN 6

1.   This person  consistently expresses worries  about how I am doing even when they know I'm doing well.

2.    This person never expresses worries about me even when they know I'm in trouble.

3.     In expressing worries about how I'm doing, this person goes back and forth between expressing worries and saying nothing.

4.    This person is consistently reasonable when expressing concerns about how I'm doing.

5.    This person doesn't even bother to find out how I am doing.

6.    In regards to worrying about how I'm doing, this person consistently says one thing but really means another.

________________

DOMAIN 7

1.    This person only acts happy when I am happy.

2.     This person only acts happy when I am miserable.

3.     This person goes back and forth between acting happy when I'm happy and acting happy when I'm miserable.

4.     This  person shows sympathy with how I feel but their mood does not depend on how I am feeling.

5.     This person almost never reacts to how I am feeling.

6.      When I'm happy or unhappy, this person  consistently acts one way  but really feels another.

_________________ 

DOMAIN 8

1.     This  person does not act happy unless I am succeeding in my career.

2.     This person usually acts unhappy about my career accomplishments and relishes in my failures.

3.       This person goes back and forth between acting happy about my career successes and relishing in my failures.

4.      This person expresses satisfaction with my career successes and sympathizes with my career failures.

5.      This person almost never reacts to my career successes and failures.

6.      When reacting to my career successes and failures, this person consistently acts one way but really feels another.

_________________

DOMAIN 9

1.     This person does not act happy unless I am having a successful romantic relationship.

2.     This person usually acts unhappy about my successes in romantic relationships and relishes in my failures.

3.     This person goes back and forth between happy about my romantic successes and relishing in my failures.

4.     This person expresses satisfaction with my romantic successes and sympathizes with my romantic failures.

5.     This person consistently does not react to how I am doing in romantic relationships.

6.     When reacting to my love life, this person consistently acts one way but                   really feels another.

_________________

The results of the study were published in 2005 in the psychiatric journal Comprehensive Psychiatry, volume 46, pages 340-352, and were highly significant and in line with most of our predictions. The fact that they were so significant was even more impressive considering the fact that the number of subjects in each subgroup was relatively small. Discovering small differences usually requires larger samples, so this means that the differences were probably quite large.

We found there were significant differences between groups in regard to appropriate and contradictory responses for the first attachment figure rated. BPD patients endorsed fewer appropriate responses than did the patient controls (p=.001) and than did the normal controls (P=.011). There were no other significant differences among groups regarding appropriate responses for the first rated individual.

BPD patients reported significantly more contradictory responses than did patient controls (p=.004) and normal controls (p=.003). In addition, Subthreshold subjects reported more contradictory responses than did patient controls (p=.009) and normal controls (p=.005).

Contrary to prediction, there were no significant differences in the mean number of polarized responses among any of the groups. The polarized responses were indicative of something called splitting: the tendency of people to think of others as all good or all bad.  BPD patients are thought to be unable to see shades of grey, but they were no more likely to endorse polarized response patterns than anyone else. In other words, this was evidence that patients with BPD do not split, at least when thinking about these issues. This was also shown in another way described below.

There were also no significant differences in what we first called neglect responses among any of the groups. This was a bit of surprise since neglect is often present in the parenting styles of those with BPD.  However, even when prominent, it tends to oscillate with overinvolvement.  But if these items measured lack of interest rather than neglect per se as described earlier, the fact that the parents of subjects with BPD were not characterized as uninterested should have been no surprise. That is because-  clinically - even when parents of future BPD patients are neglectful, they tend to blame it on the child!

When chronic unhappiness (dysthymia) was controlled for in comparisons of subject groups, the pattern of significant effects remained the same.

The number of subjects rating two parental figures (N=59) was considerably smaller than the number of subjects who rated at least one (N=93). No significant overall effect between the groups on the way they responded to the FIS regarding person B was found – possibly because of the much smaller sample size. However, the trends were the same.

Normal controls reported significantly more appropriate responses than did BPDs (p=.002), Subthresholds (p=.004), and patient controls (p=.024). BPD patients reported significantly more contradictory responses than did normal controls (p=.002) and trending toward reporting more than did patient controls (p=.064), while subthreshold subjects reported significantly more than did normal controls (p=.038). There were no significant between group differences in polarized or neglect responses.

Every contradictory item on the questionnaire was endorsed for person A by at least two of the BPDs (5%) with a range of 5% to 32.5%. The most commonly endorsed contradictory item was, “This person consistently goes back and forth between praising and criticizing me for the same decisions.” 

When we examined the FIS by domains, the most commonly endorsed domain in which either contradictory response was endorsed by BPDs for person A was domain 1, with 40%. The corresponding percentages were domain 2, 27.5%; domain 3, 25%; domain 4, 20%; domain 5, 32.5%; domain 6, 22.5%; domain 7, 20%; domain 8, 27.5%; and domain 9, 20%.

The fact that the pattern in the various domains was all over the place within the BPD sample also indicates that each item was considered separately and there was no pattern of items being  rated globally in one consistent way. Such global ratings might be expected in "splitting" subjects who were unable to look simultaneously at both good and bad characteristics in an individual.

Furthermore, although the mean number of contradictory responses of BPD subjects within the varius domains was considerably higher than the mean for patient controls for person A, it was still quite small—only 2.24 (range 0 – 8 out of a possible 9). The mean for the normal controls, however, was only 0.46.  In other words, the normal controls perceived almost NO double messages from their parents. 

So readers, go ahead and use the FIS to rate your own families on how often they drive you to distraction with double messages. You don't have to share the results with anyone unless you want to. But please feel free to share your general reactions to the FIS items in the comments section.

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.

A Splitting Headache

In my blog post of March 11, 2010, I described what I believe to be an absurdity that has been promulgated by the mental health profession about patients with borderline personality disorder (BPD). These individuals were said by theorist Marsha Linehan to have “apparent competency,” by which she meant that they appear to have certain abilities in some contexts which they in fact do not possess. I wondered how they were able to demonstrate competencies through performance that they actually lacked, and I opined that it is much easier to fake incompetence than competence. Perhaps it is the incompetence that is more apparent than real, and is in fact a highly-motivated but well-hidden choice.

Another popular idea in the field about patients with BPD is that they engage in something called splitting. Anyone who has treated a patient with the disorder in psychotherapy has ample eyewitness evidence that they often talk about other people as if they were, in their essence, either Gods or complete piles of horse manure, with nothing in between. This is splitting behavior. The fact that they sometimes act this way is an extremely valid observation, but what does it mean?

First of all, “splitting” others into “all good” and “all bad” categories was originally presumed by psychoanalysts to be a defense mechanism. A defense mechanism is a mental coping maneuver meant to both partly express and to ward off any feelings that a person might experience, as well as any accompanying impulses, that they find unacceptable in themselves. For example, a person who does not like to think of himself as angry at his father might “take it out” on someone else. This is an example of a defense mechanism called displacement.

Whenever we are faced with someone who does something heinous or who inspires us, we all have a tendency to “split,” or think of the person as all or mostly good, or all or mostly bad. This is completely normal. Many of us feel that child molesters, to take a common example, are monsters with no redeeming qualities whatsoever. Mother Teresa, on the other hand, is viewed by some as a true and flawless saint.

What happens in a situation in which someone else does something wonderful one day and something absolutely heinous the next, or vice versa? For example, what if your own father raped you one day when you were thirteen, and bought you a pony the very next day? (This actually happened to a patient I know of). Even therapists have trouble putting something like that together. Some therapists even accuse patients of making things like that up. Is it surprising that our patients might have to think about these characteristics separately in order to avoid severe cognitive confusion?

Along came a psychoanalyst named Otto Kernberg. He began to talk about “splitting” not as a defense mechanism but as a deficit. He believed that patients with BPD literally lacked the ability to see both good and bad in others or themselves simultaneously. According to his theory, future patients with BPD failed to negotiate a childhood developmental stage called rapprochement, which, according to the theory, takes place around the age of two. “Normal” two year olds supposedly then develop the ability to integrate good and bad images.

The problem with this formulation is that social psychologists have actually studied children to find out when normal children develop this ability, instead of just sitting around theorizing about it. In fact, three different studies using three completely different methods [Donaldson, S., & Westerman, M. (1986). Development of children’s understanding of ambivalence and causal theories of emotions. Developmental Psychology, 22(5), 655-662; Harter, S. (1986). Cognitive-developmental processes in the integration of concepts about emotions and the self. Social Cognition, 4(2),119-151; Selman, Robert. (1980). The Growth of Interpersonal Understanding. San Diego: Academic Press] all came to the same conclusion. Normal children do not begin to develop this ability until they reach the age of about eleven and a half. They do not get especially good at it until they are about fifteen years old.

Of course, analysts never read social psychology, so they are unaware that their theory is utter nonsense. They also ignore evidence from their own observations which should cause them to doubt the veracity of their “ego deficit” theory. They will readily acknowledge that patients with BPD are master manipulators. The patients with BPD know how to size anyone up in a very short time in order to best figure out how to make him or her personally feel either helpless, guilty, or angry in dealing with them. How could they do this so well if they were not able to gauge other people’s strengths and weaknesses simultaneously? This is an easy question to answer. They could not.

I once mentioned to an analyst that when any of my patients with BPD are in the right mood, they are easily able to list other people’s good and bad points at the same time. He responded that this observation does not prove that they are really able to see good and bad qualities simultaneously! I wondered: how on earth could a patient ever prove to this therapist that he or she is capable of anything?

Another point about splitting that applies to everyone, not just patients with BPD, is that when you are absolutely furious with someone else, you never feel like bringing up all their best qualities. Likewise, if you wish to butter someone else up, bringing up all of their faults is not in your best interests! Heaven forbid we should think of any of our patients as smart enough to know this.

In my opinion, splitting is only sometimes a defense mechanism, and it is never an ego deficit. It is rather an interpersonal strategy designed to elicit specific reactions from other people in the patient’s important relationships.