“I can't stand it, I know you planned it”
Sabotage, The Beastie Boys
People with a diagnosis of personality disorder self-sabotage, This is a fact. How do I know it’s a fact? Because health care professionals regularly tell me this when I ask them about their associations with a “personality disorder” diagnosis. It is a very annoying thing when somebody makes a considered, deliberate attempt to undo anything good but it’s always worth wondering if that is the exact thing that is going on. Just imagine what it might be like to be told that everything that has just gone wrong is the result of your deliberate action? That the mess around you is what you intended. That regardless of how much you are inconvenienced or suffering, it is exactly what you wanted and strived to achieve. What might that do to your sense of self? What might you think about the person telling you this? Let’s have a think about the term sabotage and see if we can up with some other ways of understanding what people do.
Oxford Languages (googles first result) defines sabotage as to “deliberately destroy, damage, or obstruct (something), especially for political or military advantage”. The key word here for me is “deliberate”. Moby tell us that things fall apart, like they always do. What I tend to find is that if a personality disorder diagnosis is involved, the reason for things falling apart will be placed squarely on the shoulders of the person with that diagnosis. Sabotage will be talked of, and any other explanations with be thrown to the wind. Let’s have a thing about what, in the absence of a personality disorder diagnosis, some of those explanations might be.
Marsha Linehan, the creator of Dialectical Behaviour Therapy and someone who identified with the diagnosis of “BPD” herself asks us to work and think by the following principle
“All things being equal, we agree to search for non-pejorative or phenomenologically empathic interpretations of our patients', our own, and other members’ behaviour. We agree to assume we and our patients are trying our best, and want to improve. We agree to strive to see the world through our patients' eyes and through one another's eyes. We agree to practice a non-judgmental stance with our patients and one another”
Now I’m going to suggest that it is impossible to follow the above direction while saying that people self sabotage, that they “deliberately destroy, damage, or obstruct” their own wellbeing.
Lets have a scenario that lots of people will be familiar with. A young woman (it’s always a young woman) is on a hospital ward after being admitted due to escalating self harm and suicidality. Things have settled. The MDT think it’s time for discharge but they don’t tell her in case she “sabotages” the plan. She is told at lunchtime that she needs to be gone by teatime. She self harms in the toilet. She isn’t discharged that day. Everyone agrees that she has sabotaged her care and people are so confident about this hypothesis that the patient is told this is what they did. How do I know? I was there. This is a true story (stories – happened all the time).
Lets have a think about some other possible interpretations of what went on.
I’ve worked with some people who like fixed and concrete plans. A sudden change of plan is massively unsettling. A way to deal with massive upset is to self-harm. The behaviour might have stopped discharge, but that wasn’t the intent.
I’ve worked with others whose primary aim is to stay safe and their firm belief is that an inpatient ward is the place to do that. Some of those people know self-harm will keep you on a ward. If they disagree that discharge is best, it makes sense they will do what they can to stay safe. Is this then sabotage of care or an attempt to maintain care? If people have different goals to their MDT, is it sabotage for them to pursue their goals?
I’ve worked with people who hate themselves. “Discharge in 4 hours” sounds a lot like “We don’t like you, you can fuck off now” especially when delivered out of the blue. It would make sense that people validate their self-hatred by hurting themselves. Is this a deliberate attempt to destroy their care or is it nothing to with destruction, it just happens to have the effect of changing other peoples plans even though that wasn’t even considered.
I’ve worked with people who have had every aspect of control and autonomy in their lives taken away. The only thing they have in their lives that brings them into people’s thinking or influences what people do is the danger they place themselves in. When they are told X is happening and they don’t want it, Y is often the only way to push back. The only way to have any control. Is that a deliberate attempt to wreck their long term goals or again, does it change the plans of others?
Are you thinking that there might be some other reasons that I haven’t mentioned? You’re right. There are millions. The best answers will be the ones we elicit from the patients themselves but if not, “deliberate self sabotage” should be the last option on our list.
I’m going to give another example. We were working with Sarah (all my pseudonames are Sarah) who had a huge drug problem. We got really involved. We helped her move to a new area. We got grants and bought her some basics for the new flat. We celebrated her first night alone in her new place. We cursed her for sabotaging all our efforts when she sold her basics and bed linen to buy drugs. What I realise now is that whatever I wanted, Sarah’s priority in that moment was to be away from whatever was in her mind, as it had been for the months before. We hadn’t tackled the things that made Sarah want to be unconscious, we just helped her take those awful thoughts to a new place. Sarah didn’t sabotage anything. We lost sight of the fact that our goals and Sarah’s were different, we didn’t talk about that with her and when she went with her goals rather than ours we got annoyed with her rather than considering why our goals were more important than hers.
I’ve made a lot of impulsive decisions in my life, some of them have taken me away from my long term goals. Even at my most critical, self-eviscerating moments I would struggle to define those times as a deliberate attempt to rip my life apart. When we look people in the face and tell them that their actions are a deliberate attempt to tear down anything good in their lives we will almost certainly be re-enacting the part of somebody who has hurt them. ‘You asked for this’. ‘You’ve got what you wanted’. “It’s all your fault”. We, those who are supposed to care, will be telling them that they are the authors of their misery and that this is what they wanted all along. That the whole mess is of their creation and of their desire. If we are replicating the words of somebody’s abuser, we’ve probably stopped providing care. We will never be struck off for saying people sabotage, but the reasoning behind such a statement is surely outside all of our codes of practice.
So should we celebrate an event that brings plans crashing to the ground? Absolutely not. It’s incredibly frustrating but before looking to diagnosis to give us a stigmatising explanation, lets exhaust every possible empathic explanation first. We can still be annoyed, angry, frustrated and feel useless. As Linehan would again remind us, the result of behaviour is often not the deliberate intention. We can feel all these things without blaming the patient for deliberately eliciting them.
Before we end, I have worked with those who have told me that they wanted to tear things down. It was all they could do. In a world where they were nothing, they were only something in the minds of people when they validated their sense that they were beyond help. They inspired a great deal of sympathy from others, but also a lot of resentment and anger. The important thing to remember is to let go of the self-centredness and narcissism that we as a staff member can hold – much of what we take personally in work isn’t about us.
I don’t think the term sabotage has a place in the empathic, relational model of working most people agree is the foundation for helping people in their lives. It locates all problems in the one person who probably has the least influence over what is taking place. Let’s always strive to empathically understand why people do what they do and, if risks escalate at a time when we know things are more stressful, perhaps if we change the plan in response we are the ones who might be sabotaging something.
Keir helps people work with complex mental health difficulties through beamconsultancy.co.uk