Manipulation & ‘Personality Disorder’ – Dig Deeper

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

Every now and then people are kind enough to respond to some of the things I’ve written with really thoughtful stories, ideas and comments.  I’m sharing this one.  (And feel free to let me know if you’d like me to share what you think, whether it’s complimentary or not).  It’s inspired by my most read post which is also about manipulation.  If you enjoy reading it do let @sarahjaynepalgr know.

“We all manipulate. People who tend to be diagnosed with personality disorder are just particularly bad at it”. Keir Harding (2016)

Manipulation in the context of those diagnosed with personality disorder has negative connotations. Selfish, egotistical, devious, difficult; but those assumptions refer to the intent behind the behaviour. Manipulation is essentially used for survival in whatever form is required. Our children manipulate us all the time if they feel this is necessary to get what they want and depending on how we respond some may learn that this is an effective means of survival. Forming attachments becomes a risky business when a child lacks nurturing and emotional stability. Toxic parenting, neglect, abuse or indifference (intentional or otherwise) teaches a child that human relationships are untrustworthy, painful and disappointing so the negative experience of this will be carried forward into adult life and form the basis for expectations.

Something people diagnosed with PD have in common is a lack of validation of their feelings from an early age. Many have abuse in their history, sustained trauma, complex PTSD. Receiving little or no validation of thoughts and feelings creates insecurity, fear and lack of trust as a child’s personality is forming. When emotional needs are left unmet the message is ‘you are not worthy’. Layered on top of this, any further dysfunction or trauma re-enforces the belief of unworthiness until trust is an unknown feeling. Anyone who lives in fear and cannot trust will continually test any relationship to prove their belief that no-one can be trusted. When we refer to Personality Disorder we are referring to a personality that has ‘disordered’ itself in an attempt to cope with a traumatic reality. A person has an inability to manage emotions as they have learnt their lessons in life through pain and fear not love. When a person is fearful over a sustained period of time (raw fear in a child, anxiety in an adult), the fear internalises and the chemicals in the brain remain in a permanent ‘fight or flight’ response. This heightened state of anxiety causes automatic and extreme responses to stress as any situation can trigger the fear response with no conscious control, hence creating ‘unreasonable’ behaviour which others find difficult.

Very few can empathise without having walked in a person’s shoes, however we can show human compassion and understanding and refrain from judgement. We are all unique in our ability to cope and heal and if a client is triggering you, ask yourself why and what this tells you about yourself; are you are working from your ego or your heart? To label people dismissively as manipulative, difficult or with terms such as ‘it’s behavioural’, is to ignore the core issues where the answers lie. To dismiss the cause of the condition isn’t really treating it at all but does represent the way in which we approach dis-ease in general in our culture.

It’s worth pointing out also that individuals who have had to read the moods and energy of another to stay safe from a young age are very good at sensing when they are being misunderstood or patronised. Staff should be given access to regular training sessions and examine how they manage their own health and emotions to make a positive impact in the life of another. By the time service users get the diagnosis, care plan and treatment they so desperately need it may be at the end of a very long road of confusion and suffering. To engage with staff and form a relationship takes a lot of energy and effort for someone who is crippled with anxiety and afraid of forming attachments. Whilst lack of funding and adequate resources for training can always be an issue, compassion and empathy come from the heart. If we can share this we will improve service and outcomes and enjoy better relationships with those who we have a duty of care towards.

Sarah J Palgrave @sarahjaynepalgr

Views are based on my own experiences
Professional & personal experience in mental health
Reiki & Theta Healing Practitioner

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

 

 

Forgetting inconvenient truths: A way to keep thinking.

January 2018 was an interesting month in the world of what textbooks refer to as Personality Disorder. There was the launch of the Personality Disorder Consensus Statement, an article on Personality Disorder on the BBC and the launch of the Power Threat Meaning Framework. While I haven’t read the full version of the PTFM I have read a lot about it, and there has been a lot to read. The responses were many and mixed. Some of the responses have been vitriolic, others merely critical, and others more celebratory as a high profile way of thinking about mental health and mental health problems leaps into being.

 
Some of the criticisms of the PTMF are articulately laid out here. What I want to do in this blog is lay out a basic version of what the PTMF promotes, why it’s essential that people can take this on board and what might get in the way of making some use of it.

3d doctor
Within traditional psychiatry signs and symptoms that occur together are named as a diagnosis. The PTMF encourages us to shy away from diagnosis and illness and instead explore a person’s difficulties and distress in terms of:
 What happened to you?
 How did it affect you?
 What sense did you make of it?
 What did you have to do to survive?

 
From the questions above we can then discover a narrative around why someone does what they do. We can see how their behaviour makes perfect sense given their previous experiences. In an ideal world we can then think about what might help and at a minimum consider how to avoid replaying some of the person’s most negative experiences.

 
For difficulties such as insomnia the framework might not be that helpful. For other areas I suspect clinicians and service users should use it if they both agree it’s useful. For the people who get labelled with Borderline Personality Disorder this kind of thinking is vital.

 
Why is it vital? There was a time that I didn’t think that it was. I was happy to join in with a roll of the eyes and a “typical PD” comment. I could understand that someone was self-harming because they had a personality disorder. Times when I felt attacked or criticised it was easy to label everything as the product of a disordered personality – this left me as a flawless clinician with merely a faulty patient to contend with.
As the years ticked by my experiences in work got me thinking of people with a diagnosis much more as simply people. My work became about helping staff who thought in the way that I used to, to unpick their ideas and see someone in a more empathic way. What I tended to find was that a list of diagnostic criteria had absolutely no impact in how staff thought about and responded to the people in their care. When we could move away from the descriptive (and fairly judgemental) criteria and think about the experiences that people had lived through that might inform how they behaved, then it felt like some empathy could arise.

 

Two examples:
1 Looking through someone’s notes I read “Mandy went to her room and was self harming due to her diagnosis”. It frustrated me that someone’s thinking could begin and end with that sentence. There was no sense of what was going on in their head. No indication of or curiosity about what they might be feeling. No indication of how people around them responded (apart from the implication that it was dismissed and pathologised). How can we help people if our sole understanding of their behaviour is that they do it because of a particular label?

 
2 I was in a group and someone recounted something that they’d done “because of my BPD”. We spent a decent amount of time exploring how their feelings and responses were entirely appropriate, especially given their early traumatic experiences. The description of overwhelming emotion and the desperate urge to feel something different made a lot more sense and contained more potential for change than “because I’ve got BPD”.

 
It would be easy to say that the above examples are simply people using diagnosis badly. While this is true, there is something that happens in this area of work that means that traumatic histories are forgotten and staff see risky or troubling behaviour purely through the lens of their own experience.

 
“I feel manipulated” = They were manipulating me
“I don’t know why they did that” = They were doing it for attention
She cut herself after ward round = She’s trying to sabotage her discharge

 
To an extent this is understandable (understanding does not mean approval). I was very poorly trained to work with people who had lived through trauma and my understanding is that undergraduate training hasn’t changed significantly. With no knowledge base, the students of today tend to learn from those who also had little training so learned on the job. Combine this with people who cope in ways that can be dangerous (the results of which staff might be blamed for) and you have an environment full of confused, anxious clinicians. This seems to lead to a situation where toxic ideas can flourish with little opportunity for people to learn anything different. A new cycle of treating people as if they were manipulators begins, with people reacting to that hostility and then having their reactions explained by their diagnosis.

 
This doesn’t happen everywhere but it does happen every day. Any tool we can use to stop the thinking shortcuts of “They’re just…” and focus on an empathic understanding of why someone does what they do seems essential for maintaining compassionate care. We can’t validate someone with personality disorder, but we can validate someone whose thoughts feelings and actions make perfect sense given their experience. The PTMF may not be product that means we never use diagnosis again, but let’s not boycott the restaurant because there are a few dishes we don’t like.

 

Keir provides training, consultancy and therapy via www.beamconsultancy.co.uk

Why are people with Personality Disorder so manipulative?

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

Those diagnosed with personality disorder are manipulative.  This is a fact.  At least, you would think it was a fact if you heard it as many times as I have coming from the mouths of people in the caring professions.  Whenever I’m doing training on personality disorder, there is rarely a session where this fact isn’t voiced at some point.  When it does come out, it isn’t spoken in a timid, tentative way, but with the full throated confidence of someone speaking a truth universally acknowledged.  It is a fact as certain as death and taxes, and because people are so assured that it is a fact, the presence of a service user with a diagnosis of personality disorder in the room does nothing to encourage them to censor their views.

I’m going to spend some time thinking about manipulation, what we might mean by it and whether this is another way of interpreting behaviour in a way that might help carers keep caring.

 Most definitions of manipulation use the terms like clever, skilful or artful, implying a conscious use of talent on behalf of the manipulator. Based on this definition, we all manipulate the people in our lives in that we consciously try to get them to do what we want.  Being good manipulators, we hope to do this while keeping people liking us.  This is the skill.  It is not the forcing of our will onto others but being able influence people while keeping them on our side.  The problem that people with personality disorders have is that they are awful manipulators. Very often in my life women who are older than me tend to mother me.  If I look a bit flustered or helpless, they will frequently step in and do things for me that I’m perfectly capable of doing myself.  At the end of it, we all tend to like each other a bit more.  I’m in their debt and they feel they’ve been useful.  You can argue that this is a skilful bit of interaction, but based on the definition above, you could also argue that I’m manipulating people.  Let’s contrast this with me walking into the office and shouting “If someone doesn’t give me a lift into town, I’m going to fucking kill myself and it will be your fault.”  I have no doubt that the people in the office would indeed take me into town.  Whether they would ever want anything to do with me in the future is another matter.  Again, lets have a think about what might be the actions of a skilful arch manipulator, and what might be someone with really ineffective ways of getting their needs met.  A good manipulator gets what they want and people like them.  A bad manipulator gets what they want and people resent them.

It wasn’t a million years ago that I shared the ‘personality disorder = arch manipulator’ view. I used to work in a team where at least once a week a man would phone to tell us he was suicidal.  What followed would invariably be a 30 minute phone call where I desperately tried to get him to tell me he would be ok.  He rarely did.  Every suggestion of what to do had already been tried.  Every option had been explored and found wanting.  It said on his careplan to phone when he was suicidal and here he was phoning.  Now what was I going to do about it?  The answer was always nothing particularly useful.  While I was being berated for my incompetence I tended to feel powerless, useless and for someone who came to work to make people better, pretty bad at my job.  It would be fair to say that I hated the way he ‘made’ me feel and I know that many of my responses on the phone were far more about me trying to ‘win’ than they were about trying to provide care.  Because he had phoned weekly for years, I knew the actual risk of him committing suicide was pretty static and that the phone calls didn’t reflect a significant change.  In my head this guy was sat at home planning different ways that he could torture me.  I saw him rejoicing in my discomfort, raising his fist in the air (as I did) when he felt he’d refuted an argument and hanging up the phone after a particularly vitriolic exchange happy with a job well done.  My team were very helpful in supporting me with my view of him and we would have many conversations that built up a picture of someone whose sole pleasure in life was my misery.

It’s hard to be particularly caring to someone who at best, I wished would leave me alone.  Because I took the majority of his phone calls, I sought out some supervision to help me manage what I viewed as a cruel individual.  The supervision was not an enjoyable experience as rather than help me to manage a trouble maker, the supervisor started pulling apart the foundations of the power crazed manipulator I had built up.  He asked me what the service user was looking for when he called and what in his life might explain the way he interacted the way he did.  He got me to see how unhelpful the picture I had of the client was and even worse, how I might be exacerbating and maintaining some of the very things that did my head in.  That was the first time that everything I thought I knew about ‘personality disorder’ had been challenged and now I reflect on it, the first step towards me choosing this area for my career.

The point of the above is that I can sympathise with the view that people diagnosed with personality disorder are manipulators and it’s a view that I’ve held myself.  Now let’s try a different way of looking at things.

Within DBT (Linehan 1993) manipulation would be viewed as poor interpersonal effectiveness.  Most of us come from a background that helped us to be effective.  We know how to get our needs met while keeping people on our side.  We know that when we raise the intensity of our communication by being more assertive or even hostile and rude, we run the risk of damaging the relationship with that person.  We generally know that if we need help someone will do something and that we can say no to requests that are unreasonable.  People who tend to be diagnosed with personality disorder haven’t come from the same background and as a result, they don’t have the same skill set as the average person in the street.  They might have come from a background where your needs were only met if you screamed blue murder.  They might have come from a background where people modelled that threats and violence were the only way to get people to do what you want.  They might have only been cared for when they were physically hurt or they might never have been taught to put their feelings into words.  They might….and on and on.  The gist of this is that we will see peoples past relationships in their present ones if we look for them.  If we look hard enough, we can see how people have been taught to interact the way we do.  If we’re being brutally honest with ourselves we might see how what we do keeps some of these problems going.  If we only spend time with people when they’re in crisis, if we only increase input when they self harm or we reduce our contact as soon as they’re ‘doing well’,  we can be playing a big part in keeping some of the more difficult to manage behaviours going.

It might also be worth thinking about splitting, where “people with personality disorder ‘play staff off against each other’ and form special relationships with particular carers”.  Splitting in teams certainly happens but I wonder if us staff ignore the part we play.  Instead we blame the client and think of them as an evil puppet master, pulling strings that ‘make’ us act.    Now I come from a background that taught me I was loved and valued.  Despite this I tend to gravitate towards people I perceive as warm, friendly and interested in me.  People labelled with personality disorder have the same tendency.  When in a frightening place it makes sense for them to particularly attach to staff who show the most warmth or have some characteristic that feels safe.  It makes more sense to strengthen that relationship by giving gifts, telling secrets and ‘being good’ for them.  Those staff care.  They need to be hung on to.  The relationship can also be strengthened by distancing yourself from people who are more cold, apathetic, hostile or just different.  By being difficult for the ‘other’ ones or only working with the special ones the special relationship is emphasised . This isn’t a cold, calculated endeavour to cause chaos, but a natural response from someone whose early experience of carers was different to our own.  In The Ailment, Tom Main (1957) gives the example of a baby crying in a room full of people.  They will compete to sooth it and some will succeed.  In an innocent way the baby evokes some rivalries in the people around it.  It might become distressed by these rivalries and might even make them worse in the quest for comfort.  While the baby hasn’t caused the rivalry (or split), its behaviour which draws in some while pushing away other inflames them.  The baby (fairly understandably) is pretty poor at managing the people around him but he does the best with what he has.  The split isn’t his fault. 

We can also think about what gets called personality disorder as a difficulty in managing strong emotions.  Often people with this label were never taught to manage their emotions, they had people in their lives who modelled ineffective ways of coping or they learned that only intense expressions were effective.  When on the receiving end of these powerful emotional communications it’s important to remember how well we are able to think when we are at our most frightened and angry.  When working with those who have been taught that the world is out to hurt them or those who are terrified at the prospect of being left alone, it is understandable that strong emotional responses will be a part of many of our interactions.  When angry or afraid we all want to manage the immediate threat and pay less attention to what happens in the long term.  If we can view people as feeling threatened or terrified, if we can understand why they might do all they can to achieve a short term goal again, it is harder to keep that picture of a skilful arch manipulator. 

We started with a picture of people diagnosed with personality disorder as calculating master manipulators.  We’re now at a place where we might see that some behaviours are exaggerated natural responses while others are the product of poor interpersonal skills.  We might substitute the idea of people intentionally causing chaos with people doing the best they can with what they’ve got.  Holding this in mind is essential for keeping some care in the caring professions.  It is nigh on impossible to care for someone who you think is deliberately trying to hurt you simply for the pleasure it will give them.  If we can ask ourselves why the client communicates in this way and find an explanation in their past then we can keep empathy.  While we have empathy, we can show compassion.

We live and work in busy times.  There is little time to search peoples records for clues from their past.  Action is valued, reflection looks a lot like doing nothing.  We do little good for our clientele when we act without empathy and yet the pressure to act on what is in front of us is immense.  Perhaps next time we feel that pressure to act we might do it with a person who has missed out on some of the skills we have in mind.  We can notice the sense that we’re being manipulated and wonder what that might mean in the context of an unskilful person trying to get their needs met.  It doesn’t mean that our actions will be different but it might mean we might communicate in a more caring way.

We all manipulate.  People who tend to be diagnosed with personality disorder are just particularly bad at it. 

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

Linehan, M. M. (1993). Cognitive Behavioral Treatmentof Borderline Personality Disorder. New York: Guilford Press.

Main TF. The Ailment. Br J Med Psychol. 1957; 30:129-45.

 

As ever, all of the above is just an idea to play with.  Don’t take it as fact.  Other ideas are available...