Somewhere in the notes

Somewhere in a pile of notes I found the sheets that I’d used last year for the presentation in Marin. There were several problems, and that wasn’t counting the main problem from last year: I’d taken too many sheets, overestimated, as is my habit, the size of my class. This year I’d get that part right, by taking fewer copies. But looking over a page, it occurred to me that I might not take any. First of all, the print was too bulbous and thus barely legible, the result of having been copied too many times. And the reason for that? The sheets were old, outdated. See, the top half was all about the DSM-IV.

As I groaned, I logged onto a DSM V site on my laptop, not having my expensive, thick volume with me. That’s one of those false norms, I thought, referring to the habit of placing books of presumed importance on the shelves of my office. Truth is I hardly do any reading there. My office is where I talk and listen, but not read. If I have a break or cancellation I make calls, or go for a coffee, or hit the phone and read e-mail, my favorite internet sites. I don’t read at my office, not in the old-fashioned sense at least. That I do at home, so there I was ready to read, but frustrated by an empty hand. Not for long. I found the necessary file, and soon I was scrolling down over the details of Narcissistic, Borderline and Schizoid disorders, the subjects of my forthcoming presentation. Having not bothered to review the now three year old descriptions, I was feeling precipitately sheepish, but also prejudiced. Footnotes about Schizoid personality regarding the less than 1% diagnosed with that condition had me scoffing with disdain, thinking some things will ever be missed, but the rest had me raising an eyebrow. Ten minutes later I was left impressed by the inclusion of fresh elements, or elements spoken of for years by many, but exiled from a generation by the DSM-IV edition. See, it’s now indicated in the diagnostic lexicon that Narcissistic personalities manifest an underlying vulnerability, one that has clinical utility, which is a crucial implication. Meanwhile, the new volume notes that Borderline personalities are not only labile in their relationships and emotions, but more broadly, disorganized in various aspects of their lives, and prone to fierce self-criticism.

These distinctions have been less emphasized over the last two decades as far as I can tell, and the impact upon training programs has been profound. The last time I provided a training to interns regarding James Masterson’s disorder of self model, I found that students, like my contemporaneous colleagues, tended not to observe the helplessness defense of the Borderline, or the exquisite sensitivity of the Narcissist–at least, not such that these qualities would determine the style of intervention. My biggest challenge over the next two Wednesdays is to convince relative novices not to explain too much, or to find solutions, problem solve or give ‘tools’ to their patients. It will be too late for some. Those committed to CBT, DBT, or whatever other fashionable methodology exists will want to know what to do long before they really understand who they’re sitting with. That’s the nature of our business, especially at the ground level, where everything is meant to happen quickly.

What’s meant to happen is difficult because patients in psychotherapy are largely unaware of how they block their own growth, or behave self-destructively. Therapists who think that statement disrespectful–not sufficiently positive–collude with the defensive intrapsychic structures of their patients. To the person engaged in a flight into health, proclaiming positive change in the immediate aftermath of calamity, they nod in passive support, vaguely unaware but not speaking to the patient’s likely effort to not deal with past damage. Regarding the patient who is late, not making appointments, saying “I hope you can find it in your heart to not charge”, they give slack, believing they are being flexible, empathetic, “meeting the person where they’re at”. To the person who is detached from emotion, uttering phrases like “it is what it is”, brushing off loss and pain, they are virtually applauding. Such “interventions” don’t hold people responsible for their behaviors or foster a sense of reality, and are actually disrespectful, for they don’t hold the standard or expectation of maturity.

I know I’ve thought these things for years, so I don’t really need the DSM-V to change anything with its subtly added footnotes. I just need to organize my notes.