Tag Archives: DSM V

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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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.


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A Day in Symposium, Part Two

As I listened to several speakers champion the apparently threatened cause of drug treatment at the 2nd Annual Addiction Symposium in San Francisco, I wondered to what degree I was hearing cutting edge opinion. Conventional wisdom is that drug treatment should be thriving, with Parity Laws, Affordable Care Acts, and so on paving the way for expanded services: more spaces in outpatient programs; increased number of beds in hospitals. Third party payers must now think of addiction, or substance use disorders (as they are termed in the APA’s DSM V), as a disease, and therefore pay accordingly for its treatment. But programs aimed at specific professionals, such as doctors and nurses, are under threat, apparently. At least so-called “diversion” programs are threatened, though speakers thought the term “diversion” ought to be threatened (for reasons I didn’t really understand, I should add). Meanwhile, I wondered about the implications for a particular corner of the drug treatment industry, one in which I worked for fifteen years: namely, adolescent residential treatment.

When speaking of access to treatment for doctors, airline pilots, nurses, as well as adults in the general public, advocates tend to speak against discrimination issues: the problem of individuals being discharged from treatment programs because they relapse on drugs, or because they otherwise break program rules, fail to comply with medication regimens; because they exhibit the symptoms of their disease. The mocking that is directed at such intolerant discharges—the would you turn away a heart disease patient who has a heartattack? arguments—remind me of the similar yet more detached observations of journalist/physician Lonny Shavelson in his book Hooked. He likewise decried the strict rules of Therapeutic Communities, and lauded drug courts for working more flexibly with society’s most difficult cases, its most inveterate users. However, it’s strange to me that given the ubiquity of sanguine opinion at the level of medical leadership, that principals of adolescent programs, especially residential programs, don’t weigh in with some counterarguments: most notably, that relapsing substance users don’t just disaffect themselves as they continue to use drugs or refuse to take pills or go to therapy. Sometimes they spread drugs in a program, or threaten people, physically hurt people; harass people, verbally abuse people, staff and peers. Problem? Of course it’s a problem—a problem of safety. And it’s not a problem that can be resolved with a brief course of motivational interviewing, and so discharging—that “discriminating” act against the incorrigible—is not only appropriate for some, it’s necessary.

This issue of how to make treatment safe for everyone (especially kids) is one of the most important topics in my book, <em>Working Through Rehab: An Inside Look at Adolescent Drug Treatment</em>. Who am I to offer opinions? Who do I need to be? I am not a physician. I’m not a recovering drug addict, nor am I a long-suffering parent of a troubled teen. But I am a psychotherapist, and I worked for fifteen years in this complex rehab business that defies soundbites, pat summaries of phenomena. I compiled memories and opinion, and now offer for a concerned readership a nuanced view of what really happens in an average drug rehab.

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