BPD sibling flaring/ Health Care Worker Exhaustion

[Depression = 72% of members]

I haven’t posted in over a year, but love this site and have appreciated the great support I have found here. 

I am chief of staff of a hospital that has been hard hit by COVID. My role is 24/7.  We are coming out of our third surge and by far the worst. The last 10 months have been hard, but the last 2 months horrific.  In order to support our teams and our patients, we have had to make tough decisions, canceling surgeries, shutting down services and shifting resources, having people work in unfamiliar surroundings to build extra capacity for the unprecedented demand. The death rate is high and hitting home too often. In my role, all eyes are on me, and I have to be strong, optimistic and confident in public to keep my teams going... focusing them on all the successes and things that give us hope.  I feel incredibly proud to be a part of such an amazing team, and to have led through this very challenging time and been a part of saving thousands of lives.  I am extremely hopeful, now that things are improving and as we are able to focus on the vaccine.  But it has been intense, demanding and I am emotionally and physically exhausted.  I am a very resilient person, but this is going to take time to process and recover from. 

I am also Health care POA for my 90 yr old mother who has advanced Parkinson’s Disease ( PD).  She lives in an Assisted Living near my home and they do a great job.  Her PD has continued to progress this year and her ability to communicate dramatically worsened, concurrent with some of the quarantines and elimination of family visiting.  She doesn’t do well with zoom or face time, but until recently had been able to talk on the phone.  She has dementia, is sometimes confused and has had some intermittent psychosis.  She also has severe physical limitations and requires quite a bit of assistance with all of her ADLs.  But she still has many periods of time when she is completely lucid and incredibly insightful.  When she is lucid, it is amazing, she is inspiring, kind and grateful and proud of both of us. I had a great conversation with her yesterday. She got her first vaccine and is awaiting her second dose.  The facility is anticipating being able to come off quarantine very soon, and she is excited that I may be able to visit her soon. 

I believe my sibling has uBPD.  She was somewhat stable for a while, but the pandemic has impacted her job/income, and she has  been triggered by my mother getting worse.  She blames her deterioration on me, as well as the facility and wants to move my mom to another facility with a memory unit ( across the country close to her). I know how heartbreaking it must be for my sibling  not to be able to visit, and now to have such challenges with phone conversations.  I considered her request and if my mom was not getting great care and expressing how happy she is and how well cared for she is, I probably would have conceded just to get my sister off my back.  My mothers palliative home care team has been helpful and have been my eyes and ears since family visits have been paused.  They believe she is getting great care but have concerns that she may need additional care and might benefit from being in the memory unit (at her current facility).  My sister has repeatedly forbid me from putting her in that unit or hiring additional care givers.  I try to involve her in decisions, but when I don’t agree with what she wants, she becomes mean and accusatory .  She is  irrational, distorts and magnifies things and places blame on me and others for things that are part of the  progression of illness.  Has COVID contributed, absolutely.  Initially it was all my fault, and she said some horrible really hurtful things and made completely irrational accusations... now she seems to be focusing in on blaming the facility and the director specifically.  It changes day to day, but the one thing that is consistent, is the intensity of her anger and blame. 

As a family member, I want to include her in decisions, but I also know that what she wants is more about soothing “ her pain” and is not what my mother wants and worse could put my mothers already fragile mental status at greater risk. 

My son blocked my sibling  on my phone last week, but I forgot to block her on my iPad, so I am trying to only look at the iPad when I have the mental energy.  Every time she can’t reach my mother she goes nuts, assumes the worst and the blame cycle begins again.  She refuses to “ sign up” for prescheduled calls where they have zoom or FaceTime assistance for the residents.  She wants my mom to call her.  Its not a realistic expectation.

We have an upcoming family meeting and the care team is nervous.  I am dreading it too but also looking forward to getting it over with.  She is a “queen”, so I feel certain she will be quite charming with the team and won’t flare with them, but the aftermath will get directed at me.  She will likely distort everything they say to argue for getting out of the facility she is in. 

My therapist has been helpful and we have been talking about when my sibling would flare. I knew this day was coming, but the timing really sucks.  I know what the right decision is, and that there is no way to avoid the conflict.  She makes references to suing me, but I am not worried. There are no real grounds. I just am sick of wasting emotional energy on dealing with my sibling, when my tank is pretty much on empty already.
 

[Mommydoc]

I haven’t posted in over a year, but love this site and have appreciated the great support I have found here. 

I am chief of staff of a hospital that has been hard hit by COVID. My role is 24/7.  We are coming out of our third surge and by far the worst. The last 10 months have been hard, but the last 2 months horrific.  In order to support our teams and our patients, we have had to make tough decisions, canceling surgeries, shutting down services and shifting resources, having people work in unfamiliar surroundings to build extra capacity for the unprecedented demand. The death rate is high and hitting home too often. In my role, all eyes are on me, and I have to be strong, optimistic and confident in public to keep my teams going... focusing them on all the successes and things that give us hope.  I feel incredibly proud to be a part of such an amazing team, and to have led through this very challenging time and been a part of saving thousands of lives.  I am extremely hopeful, now that things are improving and as we are able to focus on the vaccine.  But it has been intense, demanding and I am emotionally and physically exhausted.  I am a very resilient person, but this is going to take time to process and recover from. 

I am also Health care POA for my 90 yr old mother who has advanced Parkinson’s Disease ( PD).  She lives in an Assisted Living near my home and they do a great job.  Her PD has continued to progress this year and her ability to communicate dramatically worsened, concurrent with some of the quarantines and elimination of family visiting.  She doesn’t do well with zoom or face time, but until recently had been able to talk on the phone.  She has dementia, is sometimes confused and has had some intermittent psychosis.  She also has severe physical limitations and requires quite a bit of assistance with all of her ADLs.  But she still has many periods of time when she is completely lucid and incredibly insightful.  When she is lucid, it is amazing, she is inspiring, kind and grateful and proud of both of us. I had a great conversation with her yesterday. She got her first vaccine and is awaiting her second dose.  The facility is anticipating being able to come off quarantine very soon, and she is excited that I may be able to visit her soon. 

I believe my sibling has uBPD.  She was somewhat stable for a while, but the pandemic has impacted her job/income, and she has  been triggered by my mother getting worse.  She blames her deterioration on me, as well as the facility and wants to move my mom to another facility with a memory unit ( across the country close to her). I know how heartbreaking it must be for my sibling  not to be able to visit, and now to have such challenges with phone conversations.  I considered her request and if my mom was not getting great care and expressing how happy she is and how well cared for she is, I probably would have conceded just to get my sister off my back.  My mothers palliative home care team has been helpful and have been my eyes and ears since family visits have been paused.  They believe she is getting great care but have concerns that she may need additional care and might benefit from being in the memory unit (at her current facility).  My sister has repeatedly forbid me from putting her in that unit or hiring additional care givers.  I try to involve her in decisions, but when I don’t agree with what she wants, she becomes mean and accusatory .  She is  irrational, distorts and magnifies things and places blame on me and others for things that are part of the  progression of illness.  Has COVID contributed, absolutely.  Initially it was all my fault, and she said some horrible really hurtful things and made completely irrational accusations... now she seems to be focusing in on blaming the facility and the director specifically.  It changes day to day, but the one thing that is consistent, is the intensity of her anger and blame. 

As a family member, I want to include her in decisions, but I also know that what she wants is more about soothing “ her pain” and is not what my mother wants and worse could put my mothers already fragile mental status at greater risk. 

My son blocked my sibling  on my phone last week, but I forgot to block her on my iPad, so I am trying to only look at the iPad when I have the mental energy.  Every time she can’t reach my mother she goes nuts, assumes the worst and the blame cycle begins again.  She refuses to “ sign up” for prescheduled calls where they have zoom or FaceTime assistance for the residents.  She wants my mom to call her.  Its not a realistic expectation.

We have an upcoming family meeting and the care team is nervous.  I am dreading it too but also looking forward to getting it over with.  She is a “queen”, so I feel certain she will be quite charming with the team and won’t flare with them, but the aftermath will get directed at me.  She will likely distort everything they say to argue for getting out of the facility she is in. 

My therapist has been helpful and we have been talking about when my sibling would flare. I knew this day was coming, but the timing really sucks.  I know what the right decision is, and that there is no way to avoid the conflict.  She makes references to suing me, but I am not worried. There are no real grounds. I just am sick of wasting emotional energy on dealing with my sibling, when my tank is pretty much on empty already.
 

[zachira]

I hear and feel your frustration with your sister who may have uBPD. My mother had BPD. I have a brother with BPD and a sister with NPD. It hurts to be wrongly accused, especially in front of others who may be taken in by the pretending to be a nice person performance of the disordered family member. My therapist gave me some advice that has served me well when in the presence of a disordered person. She told me to focus on how I am feeling inside instead of paying attention to how badly the disordered person is behaving, and this has helped me considerably to not take on the emotional dysregulation that the disordered person is projecting on to me or other people.
I appreciate the work you are doing in health care during the pandemic, and how overwhelming it can be at times along with challenges with your sister. Take care and keep us posted on how you are doing.

[Notwendy]

Thanks for all you are doing on the front lines with this pandemic.

It's not easy being the "voice of reason" when a family member needs specific care. Your mother made you medical POA for a reason- you are the most qualified person in the family to do that. While it's understandable to be considerate of your siblings' feelings, feelings are not always facts. Your sister's feelings may feel like facts to her but you know what's really in your mother's best interests. Yes, it's hard for your sister to not be able to visit, but moving your mother far from you would make your role much harder and you would not be able to see how your mother is doing for yourself.

It's natural that these stressful situations would impact your sister's BPD behaviors. When my father was ill, my BPD mother's behaviors were exacerbated. It's understandable that such situations are stressful for anyone. Unfortunately in this situation, I did not have any POA and BPD mother was in charge of my father's medical care. This was a difficult drama triangle and when I did try to intervene on his behalf, she got angry at me and then he got angry at me too.

BPD mother also acts quite charming with outsiders and his medical care team believed he was being well cared for at home by his loving wife. What was actually happening was so distressing I called social services to see what I could do and was told I had no legal grounds to intervene.

I think you have some insight into your sister's motivations- to feel better herself and while I don't think this is with bad intent, I think it's a result of enmeshment and poor boundaries. In her thinking, what she wants must also be best for your mother, because with enmeshment the two are the same.

Unfortunately this kind of thing can divide families. If it feels like a choice between your mother's best care at this time vs your sister getting angry at you, I think you know what the best choice is and you are in the position to choose that. Keep in mind that in her more lucid times, your mother chose you, not your sister.

[wantmorepeace]

Wish I could offer some good advice, but I can only offer empathy (I get it!) and support.  It's truly exhausting dealing with a sib with uBPD and complicates what is already so hard -- dealing with the issues raised by having frail elderly parents.  I have been there.  What a juggling act!  You are doing the best you can in a hard situation.

[Mommydoc]

Thank you wantmorepeace, Notwendy, and zachira.  Your comments and insights are so appreciated.  I appreciate your sharing your experiences and insights.  I am prepared for this to be a challenging period for us, but I also have a strong sense of commitment to my mother and my deceased father to fulfill the role they trusted me with.  I generally have a strong sense of purpose and of self, and it bothers me that I have allowed her to get to me and create self doubt.  Her feelings are her feelings but it is not my job to fix them; in fact the harder I tried in the past the more frustrated I became and it never really worked for her.  My hope is that she is able to soothe her pain but realize that is not my job, I know what my most important job is and am ready to stay the course to do it. Thank you so much for helping me get there.

[Notwendy]

Glad we could help. Post any time. Emotions are high when an aging parent is ailing. It's tough even if someone doesn't have BPD. My BPD mother was not able to be supportive- it's who she is and her own feelings are tough enough for her to deal with. You are in the best position to make the right decisions for your mom. Your sister is probably not able to be supportive.

Also don't overlook that you too are dealing with the impending changes and loss of a parent. You are also taking care of seriously ill people during this pandemic which is very tough, emotionally and physically.

Don't forget to take care of YOU too and take some time for yourself. Also if things get tough, counseling for you to as a support might help- and with so much on telemedicine, that might even work with your busy schedule.

[Mommydoc]

Thank you so much for the reminder to pay attention to my own needs.  I have so many colleagues who have lost parents in the last month and that as well as bearing witness to so many tragic stories hits home and takes a greater emotional toll.  I am so grateful my mom has survived COVID at age 90 with a severe chronic condition; everything is relative at this point for me.   

The Family Meeting went well.  The entire palliative team and I had prepped and they were aware and ready to speak to the issues we knew she would raise; they were also prepared to both validate her and reframe, and gently offer a different perspective when she made inaccurate statements.   

She seemed panicked prior to the meeting, and left me multiple messages that she needed to talk.  My husband and son told me not to return her calls, but something told me it was the right thing to do.   I ended up reaching her 20 minutes before the meeting, and was able to answer her questions regarding what to expect and by the time we got on the phone with the team she was much calmer, which I think contributed to how she responded.  We didn’t make any decisions or solve anything, and yet it was progress, as I think it really forced her to accept that my mom’s needs are best met by staying here. 

The next day was my birthday and she didn't even bother to text me bday wishes until the evening after, even then most of the text was about her.   I let her know that my mother’s facility was allowing outdoor visits and I had an appointment today ( after more than 2 months of lock down!) and she had a whole list of things she wanted me to do.   I am a people pleaser and was brought up by my parents to be her rescuer, so it takes energy to ignore her requests and just focus on myself and my mom.  I decided not to answer.

A huge burden feels lifted as it feels like the battle she has been waging for the last 3 weeks may be behind us, but I feel certain there will be another one soon or many more as my mothers condition progresses and she comes to terms with the gradual loss. 

As Hospital Chief of Staff, I frequently deal with families who are struggling with loss and anxiety, and I am able to recognize behaviors, complaints and accusations may be driven by that, while empathizing and supporting them.    I am trying to put her in the same category,  and really detach myself from her emotions and attacks so I can stay laser focused on my mother.   Our hospital is finally turning the corner and there is so much hope with the vaccine.   I am realizing I need to turn the focus back to myself, to breathe, to heal and recover so many of my exercise and self care routines, that somehow got crowded out over the last year with the chaos and demands of the pandemic. I had a an accident last summer, with multiple broken bones requiring surgery and PT.  The pandemic limited the amount of time, I felt comfortable taking off, so I experienced a lot of pain and sleep disruption for several months.  I have always prided myself on personal resilience, but this last year has truly tested me. 

So in addition to better boundaries with my sister, I am realizing it is also time to reclaim some work/home boundaries that completely eroded during the pandemic.  Appreciate any advice on navigating both of those challenges concurrently.

[formflier]

I want to join others in saying thank you for standing tall on the front lines of the pandemic.  Coupled with having to "stand tall" to manage your Mom's care...it's obviously exhausting.

I'm glad the family meeting went well.  I'm curious to know how often those happen and if perhaps they can happen more often. How long was the family meetings?  Perhaps more often and shorter.

I'm going to vote for better boundaries with your sister and I think more frequent family meetings could help.

When a long list of issues comes up, how do you think your sister would respond to..."Sounds like you have thought a lot about this.  Please raise this at the next family meeting."  Then move on to 1 o 2 issues you feel prepared to deal with in the phone call."

Best,

FF

[Notwendy]

I am a people pleaser and was brought up by my parents to be her rescuer, so it takes energy to ignore her requests and just focus on myself and my mom.  I decided not to answer.

I think looking at this aspect of yourself is a key to having boundaries with any situation- work/personal needs, dysfunctional family situations, and all relationships in general.

I have a BPD mother and my role was the rescuer, helper, people pleaser. It's ironic that I was also her scapegoat child in addition. The dynamics in my FOO were that if I was to get any affirmation it would be from my father, and to get that, I had to try to please my mother and comply with her wishes. My father was enmeshed- if mother was upset with me, he would get upset with me as well.So you can imagine I became a people pleaser.

The great part about doing this kind of personal work to change this is that it helped with all situations- boundaries with my mother, my work, and other family members.

 You are called upon to help others, but then, even medical providers need support as well. You are human. I am aware that there is a concern that a  mental health issue might  affect licensing in some areas, but this isn't a mental illness situation for you- I wonder though if it could be framed under "life coaching" or "situational support as caregiver for aging parent" "family counseling" to work with some sort of counselor on any co-dependent or people pleasing traits so that you can have better boundaries and time for yourself. I think there's more acceptance for caretaker, medical worker "burn out" these days- and so I hope there's assistance you can reach out to.

[formflier]

 You are called upon to help others, but then, even medical providers need support as well. 

I've been thinking about this post since I posted my first reply. 

"Everyone knows" that medical is a higher(er) stress field.  Yet...the past year is unprecedented  (maybe you have to go back to Spanish flu or...?)  Even so, the world is so much different know, I'm not sure if a comparison is helpful.

My point is:  Even those that acknowledge this has been a tough year are likely not to understand the depth of this strain.

Yet we also must acknowledge that "pandemic" is only part of the issue facing the OP. 

There is long term care (which by itself is hard...)

And there is family with BPD  (which by itself is hard...)

Combine all of that together...that's a powerful "stew" of stress (perhaps not the best word).

Please find ways to put yourself first...

Best,

FF

[Mommydoc]

Posting an update. Yes, FF, a powerful stew of stress!

Lots of positives in my life right now, with wonderful things happening with my two young adult children and my husband.I feel so blessed.   And so much hope with the pandemic slowing and making incredible progress with the vaccine. Finally all my BFFs and immediate family are vaccinated and so many “ firsts” since the pandemic.  I am incredibly hopeful.

And yet, things with my uBPD sister have fallen to the worst state in probably 5 years. My mothers Parkinson’s has progressed and she is no longer able to self feed, she is experiencing continued cognitive decline /mild dementia, and her palliative team is now recommending that she move into the memory care unit of her assisted living facility where they can provide more support.  I have seen this coming for the last 2 years and have tried to prepare my sister for it. I am the Health Care POA, so technically the decision is mine, but I have been trying to include her.  My sister had a concussion a few weeks ago and has been struggling a lot so this made the timing of this recommendation even worse.  I tried for a week to arrange a time to talk with her before the family meeting, calling more than half a dozen times; she never answered even when we had agreed on a time to talk, texted a multitude of excuses, never once tried to call me  back. I finally emailed her a summary of what was going on, and her emails quickly turned accusatory and angry.  She never committed to calling into the family meeting , until an hour before the meeting, as she claimed “her concussion” as an excuse.  ( even though she hosted a bday brunch for a neighbor over the weekend and seemed to always be out shopping without her phone when I called). 

The meeting with my mothers RN case manager, her physician and the social worker was a disaster.  She didn’t listen to anything they shared, she attacked them, she attacked me, and she hijacked the meeting with claims that they had not done their job and that this was none of their business.  She  said the meeting was a mistake and she and I should have talked before hand, denying the multiple calls and messages I had left for her.   I just listened for the first half and when I spoke, she interrupted and spoke over me.  Even when the social worker explained that the ultimate decision was mine, she claimed it was a non medial decision and that she is a 50% decision maker and that her legal rights are being denied. The meeting ended abruptly with her saying she would not agree to the transition until she had a chance to visit, in mid May.  She wants every other option considered ( moving my mother across the country to live with her or in an assisted living near her).   She texted me to call her after the meeting  which I did, and it went further downhill, she was all over the place, completely disregulated. She proposed counseling for the two of us, which I said I didn’t want to do, and her response was “ then I don’t want to be your sister” and hung up.  She then texted me to say, “ I don’t want to lose you.  I don’t want our relationship to be so contentious. Please reconsider counseling.”   I have not replied. 

We had a hospital accreditation survey going on, and as Chief of Staff, I needed to be there, but for the first time in 30 years, I left work in the middle of the day, because I just couldn’t cope with work with this situation going on.  My family was amazing, my therapist added me in for an extra visit within a few hours, and I moved forward with I coordinated arrangements for my mom to move to the memory unit with the facility director.   

My therapist ( who in many years has never told me what to do), told me that his very strong opinion was that therapy with her would be a huge mistake, told me that her behavior was abusive and that I needed to cut off or severely limit contact with her. I have been contemplating calling her one more time, to let her know what has evolved since our call, but everyone is advising me not to.  The facility has advised all of the staff not to engage with her and even the social worker told me she sees no reason to have any additional contact with her.

I can see her hurt, pain, and struggles and am  empathetic to her situation. This is very hard for me too, but I recognize that none of my efforts to include her have been successful. She claims I have completely excluded her, that I have neglected my mother and that she is better able to meet my mothers emotional and spiritual needs. 

She told the director that she is planning to visit, and yet I feel strongly that I need a break from her.  I am so conflicted and need guidance. I know both she and my mother would benefit from a visit from her, but the idea of dealing any more with her at this point, seems like a recipe for a disaster. I believe she will be very disruptive and undermine my mothers care and disrupt an already difficult transition.  Guidance please!

[Notwendy]

My father passed away after a long illness and my mother's BPD behaviors escalated during this time and she was abusive. Although I tried to help out during this time, dealing with her behavior was  emotionally difficult for me. She remained in control of his medical care and he was cognitive enough to allow this, but this situation was concerning. Still, I was not able to do anything about it.

If you think about how pwBPD manage difficult emotions, with projection, blame, denial, then it makes sense that the impending loss of a parent, or a spouse, would escalate these behaviors. My BPD mother was over the top. I didn't understand BPD behaviors well at the time and so took them personally. In retrospect, I see now that her behaviors were due to her own disordered way of managing feelings.

But I agree with your T. You don't have to be subjected to emotional and verbal abuse.

You probably need little direction when it comes to your mother's medical decisions. But in this case, you are also a family member, and while you cognitively understand what is happening with your mother, you still have the feelings of any other family member at a difficult time. Perhaps at this time, you can draw on the expertise of your mother's health care team. Surely your sister isn't the only family member with emotional/mental health problems they have encountered. I don't know if you have sat down with them to discuss the situation. If they have determined your sister is too disruptive for them to interact with, that's between them and her. They may need a restraining order. You don't have to be the boundary here.

I also agree with your T, counseling with your sister could just turn into a blame session.

[zachira]

I have a sister with NPD with strong borderline traits and a brother with BPD. It is so normal to want to have a close loving relationship with a sister, to want to include her in the care of your mother in the ways that would be possible if your sister were capable of putting the needs of others ahead of her own. Sadly, the problems with your sister's behaviors due to her BPD, give you no choice but to find ways to protect yourself, your mother, and your mother's caregivers from your sister's chronic self centeredness and emotional meltdowns. My heart goes out to you, knowing you do not want to give up on having  some kind of relationship with your sister, you do want to include her in your mother's care in some ways while being well aware she can't have any legal powers as a decision maker as that would not be in your mother's best interests. In my experience, it hurts so deeply to have to give up on a dysfunctional family member, because there really is no hope for things to ever improve and for the toxic meltdowns of the family member with BPD which affect the wellbeing of everyone around them to ever end. You are in therapy and trying to do what is best for everybody. Be extra kind and compassionate with yourself as you find ways to balance out your needs with what is best for everybody concerned: your mother, your sister, and your mother's caregivers. Above all being patient in accepting there is no hope for a disordered family member to ever get better, is a life long sorrow even as we are less overwhelmed with the sorrow with time.

[formflier]

Hey... ...please get yourself a favorite beverage and take a couple deep breaths.

I need to talk to the "triage doctor".

You've been around the medical world enough to realize that you don't always have the capability you need to save the patient(s).

Here is the situation

You are in the emergency room.  You have 3 patients...you have the  resources to provide ethical, compassionate and medically sound care to two of those patients.  There are no additional resources that you control...to bring to bear.  It is what it is.

Patient 1:  It is "possible" that you may marginally improve the life of one of the patients, however...the vast majority of medical expertise says it is "unlikely".  Life expectancy measured in decades if left alone.

Patient 2:  It is "possible" and "likely" that applying your medical knowledge/abilities to this patient will result in a prolonged and higher quality life for this patient, likely measured in years if you apply your skill.

Patient 3:  It is "possible" and likely" that applying your medical knowledge/abilities to this patient will result in a higher quality life/extremely productive life for this patient, likely measured in decades.

Where would you expect your trauma team to place their efforts, which patient gets left out of treatment?

Why?

Best,

FF

[Mommydoc]

Thank you NotWendy, Zachira and FF. Your posts reinforce what I already know, help strengthen my resolve and give me a strength and energy to face this situation without taking it personally.  My sister absolutely flared with my fathers death, and my mothers deterioration will likely be worse. It appears that she is beginning to realize that she may be losing me.   I love the triage analogy FF, and yes, I know that my energy and attention is best directed towards my mother, self, the rest of my family, my friends and work.   

This week, I  have a short trip planned with my daughter to help her with a very important transition in her life.  I am looking forward to focusing completely on her and recognize how fortunate that I am the one who she wants to be with her for this.   Truly a gift.   

The pandemic drained me, and yet, I am so grateful for the role I was able to play and that my mother was in a place that kept her safe and that she survived it.  I am so grateful that I can visit her and spend time with her.  Yesterday she told me she had dreamed that she had died, and I asked her what it was like.  She couldn’t elaborate, but she told me that it made her think and that she decided that she wants to live a little longer and isn’t ready to die.   Despite her cognitive decline, my mother has incredible insight and is able to express gratitude, joy and her insights are a helpful guide.

Both the facility and the care team have dealt with difficult family members and have been very supportive. I used to be embarrassed and apologize for her behavior, but now I realize they get it, and though I still apologize, I feel more comfortable just accepting it.  My sister is usually very charming and charismatic and this used to only happen behind closed doors.  With her current dysregulation, it is obvious to everyone involved, which actually makes it easier for me.   She told the care team, “ I am not a mean person, even though I sound like it”. Since she lives across the country, a restraining order is likely not necessary, but it is a good idea to have in mind, if my sister becomes disruptive when she visits, which is my greatest fear, and I love the idea of “ let them deal with it”.  Perhaps one of the best things about the memory unit, is that it is locked entrance and she will not be able to just walk right in.   

I appreciate the reminders for self care.   As we emerge from the pandemic, as a physician leader I am concerned about PTSD,  increased nurse/ physician burnout and suicide risk.   As I have been reading and learning, I have become intrigued with post traumatic growth.  This morning I did a guided meditation and it walked me through an exercise to find the gifts and growth opportunities in adversity and challenges.  I am so grateful for the support as this journey is heartbreaking in many ways.  It is clear, but very sad, that my sister and I can not support each other, but I am very clear where my priorities and attention need to be.  Perhaps my freedom and well being as a priority for once is the first gift of this experience. 

thank you!

[Notwendy]

Yes, take care of you!

My BPD mother's behaviors really escalated at the time of my father's illness. I had to have boundaries with this. I was grieving too. She would say awful things like " your father hardly has a daughter" and then walk back on it- like your sister is doing. At one point she'd say horrible things and the next time, be all teary.

This is a tough time for both of you and you don't need to be her punching bag. You have had enough as it is with the pandemic.

What has helped me is to not react to my mother's moods emotionally. It's been several years since my father died, and it was awful. I also yelled at her a few times, out of exasperation, and her response was to escalate and retaliate. I found that anger at her was ineffective. After my father died, a wise person advised me to call her on a regular basis- which ever was most comfortable for me. I don't get into anything emotional with her. If she gets verbally abusive, I just calmly say " I will speak to you later" and end the call. She got the message that I don't want to deal with this. She also though has the assurance I am not disconnecting with her by calling her on some schedule regardless of her actions or moods.

if she does  insist on visiting your mother, it might be best for her to visit without you there and also not unsupervised but with staff watching her. Just have them tell her it's policy ( it might be already). This takes away the triangle with you if you are not there. I also would not be alone with her before or after- have your husband or someone come with you. PwBPD tend to hold it together better when others are watching.

Lean on the staff and let them handle it. Surely they have dealt with issues like that. Glad you are taking care of you.

[formflier]

Hey there hospital administrator!  I'm glad the analogy worked.  Can you confirm you are a MD but primarily "treating a desk" these days (older naval aviators complained about having to "fly a desk" later in there career...trying to make another connection).

Anyway...I had two shore commands, which meant that at the end of the day..I was really the hospital/clinic administrator.  So glad I had good staff...the amount of detailed paperwork and inspections to "accredit" (if I remember the right terms...tried to block them out... ) was daunting.

Imagine the rules and changes to become accredited to store and administer the anthrax vaccine.  It couldn't be kept anywhere near other meds or vaccines...complete pain in the azz...

OK...back to the topic at hand.

From time to time I have opinions 180 out from "most" on these boards.  I often find that the best way to "fight" BPD (sorry for military analogy) is to do the unexpected...agree with them and insist they are 100% right...and you are 100% onboard.  

Basically...instead of you reacting to them...you agree with them and they are then in the position of reacting to you...and BPDs will then be forced to discredit themselves...or do something healthy.

Buckle up...

I think you agree to counseling.

"Hey sis...I've been able to give your counseling idea some thought...and I think you are so wise to bring in mental health professionals for advice."

(set up 2 times where your T can be part of the call and then let her know.)  I can call you to discuss logistics of this on X or Y.  Which works best for you?

Then...discuss nothing else with her until counseling with you, your T..her and her T.

Under no circumstances do you get on the phone/video..whatever with a T that has not been fully briefed in by your T...and frankly...I think your T should be there for at least the first session or 2.

Do I actually expect your sister to follow through.  Nope.

You need "cover" or "self justification" to move on and leave your sister to her own devices.  (I see lots of my own past thinking in your posts..)

And on the off chance she agrees...she will either stick with it..and have a healthy outcome...or run away.

With two Ts involved...the likelihood of you soaking up verbal abuse in session is very low.

Best,

FF

Very important that if/when you agree to counseling...that is the only topic you discuss with her outside of counseling.

Perhaps wise..perhaps..to send logistical and big picture updates about your Mom on a schedule.  But no details..no discussion...outside of counseling.

[missing NC]

Mommydoc,

I am sorry for what you are going through but admire your thoughtful approach in thinking through the contingencies ahead of time.  My brother and I went through a horrific time with my BDP/NPD sister when my late mother developed dementia and terminal cancer.  One of the things I did wrong was that I failed to interpret her behavior through the lens of trying to meet her needs.  Consequently, I failed to validate her feelings with disastrous results.

I agree that attempting joint therapy with your sister will be at best an extraordinarily painful exercise.  However, it may be worth considering whether her proposal to engage in joint therapy might be a strategy to meet an underlying need - perhaps maintaining or improving her relationship with you.  It may be worth expressing how much your sisterly relationship means to you and pointing out that you too would like to be closer and that, while you don't have the emotional bandwidth for joint therapy at this time, you hope she can join you and the kids - or cousins or aunts - for a virtual game night in a couple of weeks...While that scenario may or may not fit, it is imperative to think about the underlying need she is trying to meet and, even if you cannot meet it, to honor that need.  You might also consider saying you recognize how scary and stressful your mom's illness is for her.   

You are in an extraordinarily tough spot between your mom, your sister and the pandemic/work.   It sounds like your propensity to think through the issues before they come up has served you well.  Best of luck moving forward. 

[formflier]

I agree that attempting joint therapy with your sister will be at best an extraordinarily painful exercise.  However, it may be worth considering whether her proposal to engage in joint therapy might be a strategy to meet an underlying need - perhaps maintaining or improving her relationship with you.  

And...you have to spend less time on "the sister" and more time on "the other patients".  You just have to.

This is a pathway to take the pain and pack it into a session a week..or biweekly...

Or if she refuses therapy, even though it was her idea...well...

Seriously...what do you do when a patient refuses treatment?  How much attention do they get in your hospital?

Best,

FF

[Notwendy]

However, it may be worth considering whether her proposal to engage in joint therapy might be a strategy to meet an underlying need - perhaps maintaining or improving her relationship with you.

This is hugely helpful. Often the "issue" and requests aren't for the actual request but to meet an underlying need.

I grew up terrified of my mother. She had so much power and control. One of her main ways of controlling me was that she was able to enlist my father to be angry at me too. I was more attached to him, it would hurt my feelings.

With Dad gone, the dynamics changed. She knew I wanted some sentimental items of his. She refused to let me have them. While this seemed very cruel, I realized that I think her main fear was that if she didn't have something I wanted, I would walk away from the relationship. At that point, I could have if I wanted to. Her behavior was abusive and Dad was my main emotional connection. But I didn't feel right with that choice. The calling her on a regular basis addressed that feeling.

My father was the "glue" that held our family together. After he died, several extended family relationships broke apart. I wonder if your sister fears this. Regardless of what is escalating your sister's behavior, you do not have to tolerate abuse. But she may also fear that without your mother, you won't have anything to do with her. You can choose that if you wish- it's always your choice. But if not, working out some way to stay in contact with her might help.

[Mommydoc]

Yes, FF,  confirming I am a physician, but have been in a full time physician executive role for about 9 years.  ( 25 years of full time clinical practice with progressive leadership roles prior).

I appreciate the idea of exploring her request and the underlying need.  I am struggling with how to meet her needs and my own.

I am very clear that the abusive behavior, constant undermining is dysfunctional and not deserving of my energy and attention. What I need is a break from all of that.  I am struggling to see the value of doing therapy with her.  I don’t think my therapist would agree to work with another therapist or her therapist, (and it would cost twice as much).  I know my sister would manipulate a new therapist and it would probably be quite agonizing for me, with out any  gain. And I agree, she would eventually re-nig.   I agree that figuring out a way to assure her that the relationship is of value to me, and that I will continue to commit to it, and invest in it, could potentially meet her underlying need. I like the idea of some family zoom sessions with  her son/husband, my husband and kids.  Family is important to her. She definitely would not behave like she does with me in front of my kids.  I just don’t know if my family would agree to it, as they are pretty angry with her right now.  

I am still processing right now.  I feel a bit of pressure to let her know my decision to transition my mother.  My therapist and family feel it would be fine to just email her and be clear about it.  Do I include this stuff about our relationship or not.  Frankly I can write the best email in the world and the minute she sees that I am moving forward with the higher level of care, and not considering her alternative options, she won’t see or process any of the other stuff.  

[zachira]

If you decide to do therapy/zoom sessions/family meetings with your sister and I can understand the many reasons why you would decide to not do so, you are right on in thinking that you will need family members that your sister wants to look good in front of, to prevent contact with her from becoming ways for her to act terribly with nothing accomplished. With my mother with BPD, I often managed my stressful times in the summer house with her, by inviting people to stay there that she wanted to impress with how great she was and with whom she would have been ashamed to have a meltdown in front of. It seems that your sister does not care how she is perceived by your mother's professional caretakers and this may be because she sees them as you, and they are not family members.

[GaGrl]

Mommydoc, prior to the pandemic, my next door neighbor retired from her COO position at our university hospital, and she is very frank that she could not have taken the stress with her heart problems -- so kudos to you for what you've been dealing with.

As to the health directive...my 95-year-old mother is now bed-bound, receiving home healthcare, and I am working with her healthcare providers to make the decision to move to home hospice care. I am the only surviving child, which at least makes the decisions clean -- although I would certainly be happy to have my emotionally healthy sister back with us to share the caregiving with me! I can not imagine the pain and upheaval that comes with a mentally and emotionally UN-healthy sister interfering with and questioning your health directive decisions.

Bear in mind, always -- your mother, in possession of all her faculties, named YOU to make healthcare decisions, and she did that for a reason.

As to decisions to be made soon, can you go ahead and have your mom moved to the next level of memory care, and only then inform your sister that the move was necessary? Your sister is going to blow up, no matter what, but am least the decision would be made and your mom will be in a protected and secure care situation.

Joint therapy? I doubt it would be accepted by her under any condition that would work for you. A sincere note of love and caring might be what she needs to hear.

[formflier]

 I am struggling with how to meet her needs and my own.


And I agree, she would eventually re-nig.  

 

You need a break.  Agreeing to joint therapy..and having a boundary to only discuss "the mom care situation" with a therpaist...gives you the break you need.

Is she backs out..her choice..not yours.  You get a break from her either way.

And..on the odd chance that she goes ahead with it...perhaps things improve.

Do you see this is really about your needs...and getting those by agreeing with her.

Best,

FF

[missing NC]

I feel a bit of pressure to let her know my decision to transition my mother.  My therapist and family feel it would be fine to just email her and be clear about it.  Do I include this stuff about our relationship or not.  Frankly I can write the best email in the world and the minute she sees that I am moving forward with the higher level of care, and not considering her alternative options, she won’t see or process any of the other stuff.  

In the past, I recall spending an hour (at work) writing a detailed logical email to my sister on why I as the trustee of her estate (at the time) would not agree to withhold money from her children in the event of her death in the expectation that her ex-husband would give them up and (according to her plan) they would be separated.  She freaked out over my response because her children's welfare was of no consequence compared to her desire to punish her ex-husband. So you are right that spending time on logic and eloquently explaining how moving your mom to the memory care unit at her current facility is best for your mom will not circumvent a blow-up.  Bill Eddy, an attorney and former therapist who specializes in dealing with high conflict individuals, has written extensively about how to mitigate that blow-up through EAR - empathy, attention and respect and BIFF - communications that are brief, informative, firm and friendly - when communicating with them. It sounds like BIFF is what your therapist and family are recommending. Here is a decent short summary on BIFF:  https://www.psychologytoday.com/us/blog/5-types-people-who-can-ruin-your-life/201809/biff-4-ways-respond-hostile-comments/

Good luck!

[Mommydoc]

I would love feedback on this communication...trying to follow BIFF but not sure it is brief enough?

“___ thank you for your last text. “I don’t want to lose you as a sister. I also don’t want our relationship to be so contentious. I hope you will reconsider family counseling.”

I thought about it a lot. Our relationship means a lot to me and I want to continue to invest in it.  For now, we need to focus on our individual healing and recovery, and some time and space will benefit both of us. I am hopeful that we could benefit from counseling in the future. Perhaps in the meantime, we can set up some family to family zoom calls with our immediate families to help strengthen the bonds among the cousins and our spouses.  We are a family and we could benefit from those connections.  

After your call to the executive director on Thursday, she agreed to allowing mom spend time during the day in the neighborhood for meals while staying in her current room.  Thank you for suggesting that to her. She emphasized with me that this is a trial not a long term solution.  I was able to spend several hours with mom in the neighborhood on both Saturday and Sunday. I  was impressed with how well she did with the extra prompting the staff provide there.  I will continue to provide regular updates to you via email.

I  am glad you are continuing to improve and I want you to focus on yourself and your recovery.  We both know we love each other and want to support each other and mom.”

[missing NC]

I thought about it a lot. Our relationship means a lot to me and I want to continue to invest in it.

This is lovely - both the thought you have given to her email and your commitment to the relationship. 

For now, we need to focus on our individual healing and recovery, and some time and space will benefit both of us.

The reference to "space" may be misconstrued as
distancing yourself from her.

I am hopeful that we could benefit from counseling in the future.

Leaving the door open can work well.  If you do actually pursue joint counseling in the future, you may be able to find a therapist who is versed in DBT, especially the Distress Tolerance section.  This may be an out-there idea, but if she is really keen on doing something together to strengthen your relationship/improve your communication and you have the bandwidth and interest, taking a Zoom class together on Nonviolent Communication (NVC) might meet that goal without the angst of therapy. 

Perhaps in the meantime, we can set up some family to family zoom calls with our immediate families to help strengthen the bonds among the cousins and our spouses.  We are a family and we could benefit from those connections.  

Your honoring of family connections really comes through.  If you do a family game night, Scattergories (the board game) works really well via Zoom as does https://skribbl.io/.  Both are really good at setting a light mood and generating some laughs.  If you want to do a family movie night, both Netflix (Teleparty) and Amazon Prime (Watch Party) offer the option of watching a movie together so that it's synchronized and you can type comments to each other during the movie.  Lighter fare like comedians work well for such banter during the set.  But regular movies work well too for just having a shared experience.   

After your call to the executive director on Thursday, she agreed to allowing mom spend time during the day in the neighborhood for meals while staying in her current room.  Thank you for suggesting that to her. She emphasized with me that this is a trial not a long term solution.  I was able to spend several hours with mom in the neighborhood on both Saturday and Sunday. I  was impressed with how well she did with the extra prompting the staff provide there.  I will continue to provide regular updates to you via email.

This is really positive and very reassuring.  :-)  I am not seeing the part about moving your mom to memory care and wonder if that will be another communication. 

I  am glad you are continuing to improve and I want you to focus on yourself and your recovery.

I am not sure what this means and wonder if it might come across as parental.  Does the recovery refer to dealing with her feeling about your mom's condition?  If so, would it work to say that you feel/share/understand her sadness/fear/anger or whatever the feelings are?    

We both know we love each other and want to support each other and mom.”

The closing line is very validating. Your sister is lucky to have you. :-) 

[Mommydoc]

Thanks for the feedback on the email.  My mom has been spending time in both the assisted living and in the memory unit. She isn’t happy about it but told me today it was “acceptable” which is progress.  The director of the unit spent time with both of us this afternoon and I am feeling a lot better about it being the right thing.  She is definitely engaging more and eating better when there, but she doesn’t like the “idea of it”.   I am trying to get to the point where my mom has truly transitioned and is doing well, before announcing the decision to my sibling so I can say she is doing really well, we are getting there. The director says it can take a few weeks, it has only been a few days. Since it was my sisters idea to have her spend a few hours daily  there, my brief communication is intended to honor her “idea” and help her accept the next part which I plan to communicate next which is I have decided to move her there permanently.  (truthfully this is hard for me too, especially since my mom is not so happy with it, so I  am trying to take the time I need some time to transition too... they will start charging us the increased rate on 5/1 regardless of when we fully move her). They aren’t rushing us.

I want to be firm that I do need some space, but that is not goodbye, it is I need my space.  I think she needs it too.  Interested in others thoughts. The old me, would refrain from saying that but I want to be clear and assure I am saying what I need. I also need her to respect my POA role, but saying that will trigger hero’s Ieft it out.

So my plan is to send this email, let her explode and see if she takes me up on the time with our families.  I love the ideas about  movies and activities and it will be great to do when my daughter moves, as she will welcome the virtual “company”.  Then next week, I will calmly proceed with my decision to move her permanently to the memory unit.

My sibling suffered a head injury a few weeks ago, which is what my reference to her recovery is. I will probably make that more specific to avoid her misinterpreting it. 

Thanks again!

[formflier]

Can you give us a day to edit the email and send it tomorrow..or the next day.

I think it would be much more effective with about 1/3 to half of the words.

I agree you take your space...but I think you need to communicate it differently.

I hope to have time to edit a proposed response...maybe in a hour or two.

There are lots of landmines we can remove...plus several implicit messages you want to insert.

Such as "Thanks so much for the suggestion about Mom's care.  It's very helpful to have solid backup." (or something like that).  What is the implicit message in there?

Best,

FF

[Mommydoc]

Absolutely, FF, I truly appreciate the help. I am resisting the urge to send as I want to keep her informed ( I have a problem with being hyper- responsible, serves me well in most aspects of my life, but not here). 

I am headed to meet my daughter and really want to focus on her.  I am fine waiting to send until after your edits.

I added recovery from your “ concussion” and a thank you for her taking the lead in coordinating the rental of a property in my mom’s trust, as we have been corresponding on that.  But agree it is way too long.   

Thank you soo much!