Treatment for Psychological Splitting
Long-term psychodynamic psychotherapy is the most effective treatment for psychological splitting, focusing on integrating polarized perceptions and developing more nuanced views of self and others. 1
Understanding Splitting as a Defense Mechanism
- Splitting is a borderline defense mechanism where two aspects of one's emotional life are experienced as independent from each other, creating an inability to integrate positive and negative qualities of self and others 1
- It manifests as "black and white thinking" where people and situations are viewed as all good or all bad, with sudden shifts between these extreme perceptions 2
- Through projective identification, individuals unconsciously project split aspects of themselves onto others, recreating their internal object world in their external relationships 2
First-Line Treatment: Psychodynamic Psychotherapy
- Long-term, open-ended psychodynamic psychotherapy is indicated for splitting as it addresses entrenched conflicts, developmental interferences, and maladaptive personality traits 1
- Treatment goals include:
- Reworking conflicts to relieve constricting defensive patterns 1
- Developing flexible thinking and access to fantasy life 1
- Stabilizing psychological functioning by increasing expression through words rather than impulsive actions 1
- Enhancing flexible use of defenses and age-appropriate assessment of realities 1
Specific Therapeutic Approaches
- Interpersonal psychodynamic therapy helps patients recognize and integrate split representations of self and others 1
- Cognitive Behavioral Therapy (CBT) addresses the cognitive distortions that underlie splitting by challenging black-and-white thinking patterns 1
- Therapists should interpret splitting episodes within a psychodynamic framework to aid integration of self-representations and improve control over emotional responses 3
- Treatment should follow a structured phase-based approach:
Managing Splitting in Clinical Settings
- Clinicians should recognize when splitting occurs in treatment settings, where staff may be divided into "all good" or "all bad" camps 2
- Continuity of care is essential, with treating clinicians remaining constant for at least the first 18 months of treatment 1
- Therapists should resist the temptation to "give in" to patients to forestall emotional outbursts, as this reinforces splitting 3
- Regular team meetings and supervision are crucial to identify and address splitting dynamics within the treatment team 2
Medication Considerations
- Pharmacotherapy should be considered as an adjunct to psychotherapy, not as a primary treatment for splitting 1
- Antidepressants and benzodiazepines should not be used as initial treatment for depressive symptoms unless a clear depressive disorder is present 1, 4
- If psychotic symptoms are present alongside splitting, atypical antipsychotics may be considered for their better tolerability 5
- Anxiolytics should be used with caution and only as part of a comprehensive treatment plan 4
Potential Complications and Pitfalls
- Transitory deteriorations (regressions) in functioning may occur during treatment, including acting-out behaviors 1
- Complications in the therapeutic relationship are common, including excessive dependence on the therapist 1
- Distinguishing pathological splitting from healthy developmental splitting is important; not all splitting is maladaptive 6
- Reactive rather than preventive care approaches should be avoided as they miss opportunities for better outcomes 1
Family Involvement
- Families should be provided with ongoing support and information in a partnership that involves the patient, family members, and treating clinicians 1
- Multi-family groups with a psychoeducation focus can be beneficial 1
- Early warning signs of problematic splitting behaviors should be discussed with both patient and family 1