Good Enough

It’s a holiday giveaway, these free books (almost, but not quite free if you click on the link). A year after it’s initial publication (actually, closer to a year and a half), I’m looking to stir interest in my non-fiction and memoirish work, Working Through Rehab: An Insider’s Look at Adolescent Drug Treatment. This latest giveaway comes upon the heels of a workshop I recently taught–an overview of the disorder of self model created by James Masterson, that I provided for interns at a community mental health setting. Masterson’s work, referenced minimally in most training programs these days, is referenced centrally in WTR, as a guiding set of principles for what might happen in community or residential treatment settings, especially those straining to incorporate psychodynamic perspectives.

The difficulty is outlined in one of Masterson’s final works, The Personality Disorders: A New Look (published in  2000), in which he reviews the various methods used to treat Borderline Personality Disorder, as well as concomitant conditions such as Bipolar d/o or PTSD, and bemoans the dilution of intrapsychic focus in favor of pragmatic and utilitarian approaches. Like many, Masterson points out that modern neurobiological research has determined that a child’s brain increases 2 and 1/2 times in size during the first year of life, suggesting an “experience-dependent” growth pattern tied to a dynamic between caregiver and child–that the role of a caregiver is that of regulation; regulating the immature psychological systems which influence biochemical growth.

Masterson’s contemporaries, Otto Kernberg and Heinz Kohut, suggested more or less competing models for the treatment of individuals who suffer from development dysfunctions such as BPD. Kernberg drew from ideas put forth by Melanie Klein by indicating a constitutional excess of aggression on the part of such patients, with maternal or caregiver interaction playing a less influential role in his model. Like Masterson, Kernberg recommended an expressive psychoanalytic psychotherapy in treatment, but one that favored a focus upon transference interpretations, with insight into such interactions promoting integration, and thus growth. Masterson disagreed, thinking that confrontation of ego defenses, particularly regressions designed to ward off what he termed “abandonment depression” (as in an abandonment by a primary object) was the central task of psychotherapy. In Masterson’s view, interpretations prior to containment of defenses, or the establishment of therapeutic alliances, were ineffective. Meanwhile, Heinz Kohut, in whose model I was initially trained in the nineties, recommended an approach that drew attention to patients’ so-called unmet needs. Focusing more upon Narcissism than Borderline pathology (once deemed interchangeable conditions, incidentally), Kohut taught a model which focused upon mirroring responses, with less emphasis upon transferential interaction (Kernberg), or defense analysis (Masterson). The differences are crucial, parallel to what are termed “enabling” versus “recovery-oriented” approaches in the lexicon of CD treatment. As Masterson would say, what we call defense they call the patient’s “efforts to repair”.

In  WTR, I describe the influence of Masterson in my growth as a therapist in a residential setting, as well as my movement away from the Kohut model I’d originally been taught. My rationale was as follows: the patients whom I saw repeatedly in treatment were mired in patterns of lying, self-destructive behavior, suicidal and violent tendencies, alongside a variety of other defensive habits, yet few of these patients were sociopathic. They were admitted for a treatment episode that was daily, intense,  would last over months, if not longer, and engender transferential bonds that were complex. The stage was set for a psychoanalytic treatment, yet over time, the prominence of such models diminished, in favor of derivative approaches, Dialectical Behavior Therapy, so-called Strength-based models, that focus upon symptomology versus intrapsychic, or internal change.

Change. Meaningful, lasting: everyone in the field claims to want it, and even resistant patients give it lip service.  Notions of it inform but also confound treatment plans. In dispute with Kohut, WTR mischievously contends that mirroring defenses tends to reinforce defenses. In dispute with Kernberg, I offer that a focus upon constitutional aggression ignores underlying pathology. In dispute with Masterson, I’d say that mandated referrals engender “compliance” defenses, which contaminates therapeutic alliance, enabling defenses. Such bonds, as well as defenses, are nonetheless fluid, predictable and not. But to work through rehab, as either a patient or a professional, you have to make a choice at some point as to what approach is right. Hopefully, your choice is good enough.

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