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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