Good cop vs. Bad cop – Splitting in medicine

Photo by Skyler Ewing on Pexels.com

I continue to have this rather unsettling experience with an allied health colleague in my team. While meeting a patient together for the first time, she would interrupt the interview during my segment to tell the patient, either directly or indirectly, that I am interrogating the patient, I am being invalidating, the information I am collecting is not important, etc.

The funny thing is, I happen to know her outside of these interviews and she is quite lovely, which is why it shocks me every time she does this.

This behavior where one tries to intentionally or unintentionally cause the person of interest to see one party of the triangle in an idealized manner (e.g. good cop, usually the one doing the splitting) and the other party as an aggressor/ perpetrator/ incompetent member (e.g. bad cop) is called splitting. Splitting behavior is often associated with patients with borderline personality disorder or other cluster B disorders, and is thought to originate from childhood experiences that made them feel invalidated and devalued, causing the child to develop this particular way of relating to others to regain some sense of control. This behavior is hugely stigmatized in the mental health field and often labelled as the patient being “manipulative”.

I am not saying that this particular colleague has a personality disorder. In fact, I am not sure if she recognizes that what she is doing can negatively impact rapport building with a patient. I had a similar experience with a patient who split the team in half, with those who were put in the idealized role constantly fighting with those who were put in the perpetrator role over medical decisions relating to this patient. Residents are often victims of such splitting behaviors because it can be easy to put them in the role of an incompetent provider/ perpetrator, since they do have less experience and confidence to be able to appropriately defend themselves. I was surprised, however, to find that residents often fall victim to such behaviors performed by other members of the healthcare team as well. Bringing up such issues with supervising physicians can mark the resident as a “bad team player”, putting a permanent scarlet letter on his/her scrubs.

After getting sick of feeling bad for myself, I tried to put an objective lens (more or less) on this matter. Why are certain allied staff members motivated to split the patient against residents or doctors in general? Upon reflecting on how splitting behaviors originate in patients with personality disorders, the answer became clear. Patients are much more familiar with the role of a doctor than the role of say, a social worker, occupational therapist, or a nurse, even though each member forms a critical part of the circle of care for this patient. Patients are also taught from a young age that doctors are authority figures who they should lean on for guidance. Because of this, the patient can, unconsciously or consciously, act in a way that make allied health members feel like they are less valuable or important. After experiencing this on a day to day basis, they may have formed this way of relating to patients to regain a sense of control and value in the workplace.

I spent some time reflecting on this to end this blog on a positive note – how can one navigate this environment in a way that prevents such splitting behaviors from developing in the first place? I feel that this situation has gotten so large that it has become a global issue – demonization of doctors and distrust in the medical system, with serious implications for public health especially during this pandemic. Unfortunately, my conclusion was that there are no easy answers to this. How do we protect residents, allied health professionals, and patients so that they do not perform or fall victim to splitting behaviors?

I look forward to the day when I read this blog and feel grateful that such interactions are a thing of the past. Until then…. ??

I don’t know.

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