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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...

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