Monthly Archives: February 2017

Personality Disorder: the other way (part two)

 

I want to blame someone. James Masterson did also, I think. He will have argued with many over what comprises a real versus a false self, or a personality disorder—whether such a thing exists with some. Were he alive today I think he’d argue with proponents of trauma model, and possibly with authors of novels like The Woman in Cabin 10. Not that these people don’t think that personality disorders exist. They simply call them something else, because mental health services, like any commodity, ultimately, is not just something to be validated by research, or—sorry—evidence-based research. It is something to be sold to the public.

For the average consumer of psychotherapy, a diagnosis of trauma, whether that trauma is episodic, chronic, the result of fatefully aberrant events or an aggregate of quaintly termed little ts that shape development (the theorized etiology of personality disorders) is simply more palatable. The word connotes victimization by an external agent, and thus a diminished responsibility for the sufferer. Treatment encourages a present identity of a survivor (very popular), with a possible future of healing. It’s a meet-them-where-they’re-at-thing. Regarding etiology, the accent is upon recent, precipitating events, with an intellectualized nod towards distant antecedents, that complex internalization of others which blurs a simplified reality.

Trauma model practitioners pay lip service to the antecedents of trauma. Prominent authors even co-opt object relations theories without crediting them, and repackage (reframe in the jargon of the field) personality disorder as something like developmental or relational trauma. A good example is featured in Barbara Steffens’ Your Sexually Addicted Spouse, whose target readership is evident by the title. In her text, Steffens describes PTSD as “something that can last a lifetime”, and that relationship trauma entails “painful coping mechanisms ingrained in personalities” Study the work of Klein, Fairbairn, Mahler, Winnicott, Masterson or Kohut and you’d hear the echo of their theories in such pop psychology literature: that psychic pain is integrated into personality over time, generating a disordered self in which such pain is habitually defended against in relationship.

But again, while trauma model educators pay lip service to old patterns, they mostly ignore it in treatment. The reasons are two-fold: A.) Treatment doesn’t last very long in this model. It’s a two week stay in a group home of some kind, or an eight-week course at your nearby hospital. B.) Discussion of problems is intellectual, academic—therapy as education. You’re given homework, even, to solidify the association with school. This is organizing, some say. Stabilizing for the unsafe person who cannot, it is presumed, manage complexity, the uncertainty of not knowing more deeply why something is happening. They are unable to weigh or contemplate their own mind alongside those of others, which are similarly complex, and implicitly dangerous. This danger is cast as objective reality, and anyone who says otherwise is “gaslighting”. Thus, treatment prioritizes affect regulation techniques and procedures, not the contemplation of self and other; it advises the practice of coping skills, self-care activities—all of which is worthy, actually, as adjuncts to growth. Meanwhile, the model’s adherents suggest that the afflicted let go of the actions, opinions, even the feelings of difficult others, while attaching labels. Fuller contemplation is put off until some ambiguously later time, when the person may be deemed ready. I think that readiness is seldom achieved. Time passes. It doesn’t so much heal as fossilize thoughts about self and other. What’s difficult to let go of are the pat understandings imparted by practitioners who recycle the same lessons in one short-term treatment episode after another.

In a longer-term therapy model, individuals inhabit their adult roles and live their lives as opposed to dropping out of society and going to school. They are challenged to do more than learn how to self-soothe or calm down, or take time-outs when mad, or to leave that bad relationship that your friends all think is wrong, only to start another one that’s similar because you haven’t learned what you got from that bad relationship. Instead, some learn (or are challenged to learn) to hang out with confusion, the grey areas of day-to-day life; to tolerate discomfort, stay with the difficult, as Masterson was once quoted as saying. Reality is learning about one’s own mind and being open to those of others, especially those that are not so easy to detach from: bosses, spouses, children; the memory of those absent but still profoundly influential.

What’s your pain today? Who or what do you want to blame, talk about instead of understand; focus on instead of yourself? Do you really know what your pain is about, what it’s backstory is—it’s underpinning? Do you think you really know the story of others? I know. It’s not what you (I’m) thinking.

 

Graeme Daniels, MFT

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Personality Disorder: the other way (part one)

 

Musing on a recent concatenation: my annual trip to San Rafael to teach intern therapists something about the late James Masterson and his Disorder of Self model; a reading of a novel that reminds me the zeitgeist is elsewhere, teaching a more palatable lesson. A student in the training, an intern in a private practice model, asked me about the fame of JM, or more specifically, about his lingering relevance. Though she’d heard of him before, she’d only known about him from others at this particular agency, she stated. The comment was a muted, polite critique, suggesting an eclipsed influence of a one-time star in the psychoanalytic pantheon.

What a start, I thought. It was the beginning of a six-hour training, so I’d be up against it, hoping to disabuse this woman and others of some chestnut assumptions, biases reinforced by institutions, medical and cultural, as well as academia to some extent. The pressure wasn’t great–mostly self-imposed, I think–but subtle. What is my obligation or prerogative to instruct about the Masterson model? To advocate for an outmoded, if (in my opinion) far more thoughtful take on the concept of personality disorder? Not much, actually. And six hours is a lot, you might think, to shed light on a few things, offer a different way of thinking about an old problem.

Anyway, Disorder of Self is a term Masterson coined towards the end of his career, to provide an alternative to the embattled Personality Disorder label, which is described via a medical lens in the diagnostic standards manual (DSM-V) of the American Psychiatric Association. The term references a syndrome of characteristics, ‘pervasive’ in nature, cutting across contexts and time. For many, it’s not a popular term. It pathologizes, stereotypes, and reduces, mostly because of the way these terms are used, which indeed pathologizes, stereotypes and reduces. The most commonly used terms, Borderline and Narcissist, have seeped into commonspeak like rain spilling over a dam. It wasn’t meant to be, but it’s not surprising  given the flood of opinion. I remember when I was in graduate school, when I was first introduced to the nomenclature. The word Borderline was a byword for difficult client; it denoted (and still does) someone who is volatile in mood, and therefore in relationship; it means someone who is often suicidal, or otherwise self-destructive. They make demands, flood the boundaries of novice therapists. They overwhelm. Narcissists do something similar, only with more self-importance, so-called grandiosity, and conceit.

James Masterson followed the psychoanalytic tradition, cast PDs not so much as a syndrome of behaviors or glibly-described personal styles as a complex map of self and other representations–a dynamic between self and other, not self versus environment per se, as DW Winnicott opined. Following the lead of Melanie Klein, WRD Fairbairn, and Margaret Mahler, Masterson cast Borderline and Narcissistic disorders as derived from intrapsychic structures comprised of interactions between projections and introjections, those experiences of self and others. He mapped out these experiences in object relations units, states of mind activated by splitting defenses, representing false ways of being, strategies of how to operate in relationship, on an unconscious level. My task in these introductory trainings was to read passages from cases, snippets of exchanges between myself and clients, illustrating these states of mind. The utility? To show how a mind works in commonplace ways, basically.

The students were struck by how familiar the exchanges seemed, and by how apt the conceptualizations ultimately seemed as they were described and then depicted in case scenarios.

Someone asked about trauma, a word often used to combat the notion of PDs in some circles, and subtly join with the paradigm in others. We note the ubiquity of the word trauma to denote victimization, the externalization of problems, attributable to fate or social forces and not so much an aggregation of developmental phenomena. It suits us to connect dots, but to do so expeditiously, to indicate identifiable, as in consciously understood and remembered events. And it is a familiar, almost comforting idea, especially for those who don’t know what projections are—who might find it maddening to ever wonder whether thoughts and feelings come from the self versus another, or between an elusive self and other.

Fiction, not so strange fiction, can reinforce this facile prejudice. Ruth Ware’s latest thriller, The Woman in Cabin 10, for example, features a main character who has suffered a home break-in at the outset of the story. This event serves as a backdrop for the subsequent misadventure, in which she sees and hears evidence of a murder, but is gaslighted by a pernicious crew of a luxury cruise-liner, who are protecting a villain in power, and discredit her because she is shaken, prone to depression–on medication, it is discovered. For some portion of the book, the reader is teased by the possibility that the protagonist is an unreliable reporter, filtering her drama through both recent events and a plethora of self and other representations, accumulated over time, and manifest in a reactive personal style.

Alas, the story abandons the tension of such an unknown and quite readily sides with its designated heroine, linking her terror to her recent misfortune, and only thinly to anything pre-existing. Disappointing, I thought, though the story was still gripping. Oh well, I’m back at work tomorrow, and thankfully not dealing with anything as serious as murder, but still following stories with protagonists that will grip my interest beyond a taut 75,000 words. I just have to figure out who the people are that I’m sitting with. That’s their job, ultimately.

Graeme Daniels, MFT

 

 

 

 

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