Tag Archives: James Masterson

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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The old scripts


A man sits in a conference room, chatting collegially with a pair of co-workers, ostensibly leading a meeting. Technically, the man is in charge, but he prefers to keep things informal, not throw his weight around. Soon they will be joined by another man—everyone’s boss—who appears to not have such reservations. As a kid, he will have been a problem, this man: if not an out-and-out bully, then maybe just a nuisance; tagged as having attention deficit disorder, and needing a good dose of meds in order to follow directives, play well with others. Today, an observing psychiatrist might say he has poor audience; meaning, a blind spot keeping him from knowing where he treads. A less generous opinion would be that he doesn’t care. He walks into a room and simply expects people to drop what they’re doing and focus on him. It’s how he got to where he is, he might say. His turn to give directives, direct play. That is, if he notices.

The first man has had a different life. Until now, his once subordination to either bullies or the inattentive has been dormant. He’d worked hard, quietly achieved a certain status within the organization, and earned his graduation to civil society, mostly spared the obnoxious company of autocrats whom he’d suffered plenty enough as a younger man. When the boss walks in he begins talking louder than anyone else, instantly turning the heads of everyone present. That other collegial exchange is now relegated in importance, which immediately stirs in the first man a dreadful anger. What is this feeling? the man wonders…later. In the moment, his thoughts go blank as his adrenaline surges, followed soon by a chill sensation. Bad, implicit memories. Anxiety. The resultant compromise between states is a halting, passive, as in barely discernible complaint: “I guess we’ll postpone our talk until later.”

In models of psychoanalytic psychotherapy, espoused by the likes of James Masterson, treatment proceeds with the following assumption: that individuals develop self and other representations, based upon an accumulation of experience of ourselves in relationship with others, which in turn forms a psychological structure that is activated in times of stress. Our explicit (conscious) and implicit (unconscious) understanding of ourselves and others is an aggregate of our object relations (experience with caretakers), derived from early development, and nurtured over time. The task of therapy is to make sense of one’s own mind and that of a therapist, even though manifest content tends to eschew focus on the therapist, especially early in the process.

Self identities—meaning, strategies of being in relationship—are often fixed and rigid by the time therapy begins. They constitute a way of getting by, but not of growing, or of being happy. A kind of quantum phenomenon collapses time, disorienting the distressed patient, who experiences new stressors with an old psychological structure, and therefore people are dimly reminded of unfinished business, though presented with fresh choices. Though I am few people’s idea of an autocrat, I might tread on toes this day, and look into fleetingly bewildered, scared eyes; hear the opening strains of quickly defended selves. I wonder what they’ll say.


Graeme Daniels, MFT

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Listening To You


So I conclude this four-part introduction to my paper on Tommy with a reference to its finale: a pop hymnal that Rolling Stone author Dave Marsh once described as “a moving passage expressing that all power emanates from the mob”. For new listeners, “Listening To You”, a refrain attached to the song, “See me, feel me”, might sound a little like the “Let the Sunshine in” passage from Hair, which ran contemporaneously on Broadway in 1969. The sentiments of these songs are indeed similar: an uplifting message of hope for the future, set against the backdrop of a circular musical theme.

The layered meaning of “Listening To You” is addressed in the second half of my paper, which traces the drama of Tommy, proceeding from the opening crisis (the murder of Tommy’s mother’s lover), which his parents cover up, which half-intentionally generates the deaf, dumb, and blind condition which in turn is a manifestation of Tommy’s dissociative withdrawal/silent protest against all that is dishonest. Living his life, Tommy finds a talent, pinball, and becomes a champion of the game and a kind of rock star. Later, as was de rigeur in 1969, he becomes something more than an exponent of light entertainment, something closer to a spiritual leader, inspiring youth in particular. In the midst of this, he is “cured” of his solipsistic withdrawal, transforming from a figure of eloquent silence to one that is socially engaged, if rather didactic in his promotion of “awareness”.

This latter development, to which I had listened casually for years prior to writing my paper, led me to consider other aspects of Tommy’s psychology beyond the effects of early childhood trauma while retaining consideration of that early history. In the service of this task, I turned to the writings of James Masterson and Harry Guntrip, two figures from the psychoanalytic family tree who, like John Bowlby, were writing about things like attachment and loss, schizoid withdrawal, and/or schematics of intrapsychic structure around the same time that Tommy was being made.  Drawing upon Masterson’s model of intrapsychic structure of self disorders, I played with the idea that Tommy Walker emerges as an adult displaying the features of Narcissism and Schizoid personality disorder (the combo presentation is more precisely delineated by Guntrip).

To explain, Masterson’s model is one of so-called object relations units, featuring representations of self and other, which constitute an individual’s false self (a kind of strategic way of being in the world, consisting of an aggregate of experience). According to Masterson, a person’s representations of self and other are nuanced depending upon the nature of their disorder: Borderline, Narcissistic, and Schizoid are the three main personality types his model outlines. Tommy’s Narcissism is exhibited in several ways: initially, his preoccupation with his image in mirrors seems the most obvious indicator; he is lost in himself. Later, he seems grandiose in his emergence as a star, in  his upbraiding of followers, and in his general sense of himself as a “sensation”. Like a tragic hero, he seems destined for a fall. It happens in the penultimate song, “We’re Not Gonna Take It” in which disillusioned (kids?) rebel against the restrictions of the rather farcical “holiday camp” and revolt against Tommy’s leadership. The lyrics bring to mind the kind of scenes that might have happened had fans of Woodstock not tolerated sitting in down-pouring rain, suffering lack of food, overcrowding and poor hygiene conditions for days upon end. Meanwhile, Tommy seems like an aloof figure: essentially withdrawn, somewhat paranoid and alienated, still fearful of being appropriated for others’ needs. His lingering schizoid dilemma is that of seeking attachment while protecting himself from harm, real or imagined.

The hopeful conclusion suggests a resolution of such conflicts, a transcendence of false self strategies such that Tommy and his followers can listen more intently to both outside and internal voices, integrating complex experiences of self and other instead of merely reacting against fate. More plainly, the finale promises that artists and their listeners can learn to move on from trauma, grow up, and deal with life’s triumphs and travails. If that all sounds rather trite or precious, then it may be, but at least it’s more positive or mature than “hope I die before I get old”. Then again, the opera’s libretto (if I may use that term) suggests more or less the same as what “My Generation” did four years prior to Tommy: that The Who would bond with its audience (the mods of the mid-sixties), and reflect their values, dreams, including the nihilism; their love and their hate. So Tommy ends with a refrain that you can sing in the shower, sing from behind the wheel of your car; sing by yourself or sing amongst a crowd. Take your pick, but while you sing, listen:

Listening to you, I get the music

Gazing at you, I get the heat 

Following you, I climb a mountain

I get excitement at your feet

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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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The Roots of Prejudice

The scarier prejudices are those that don’t recognize themselves, followed closely by those that don’t apologize. The second category, if it is malleable, calls for individuals to see reason, be open to contrary experience, which is difficult enough; that is, hard work for anyone. But challenging such a blockade is still easier than calling out the prejudice that isn’t even understood as one.

There are plenty of words representing ideas that are invoked to protect prejudice. Take the word trauma for example. There’s a word which is used on a regular basis to explain reactions to a past event, or set of events. Look up the diagnosis of PTSD (Post Traumatic Stress Disorder) in the DSM (diagnostic standards manual of the American Psychiatric Association) and you’ll find reference to numerous symptoms, falling under three sub-headings: re-experience, avoidance, and increased arousal. When an individual is faced with a stressor, he or she experiences flashbacks, bad dreams, the desire to avoid certain places, people; hypervigilance and agitation in stressful situations. When the trigger is the pace of traffic for a car accident survivor, or the turmoil of a returning soldier, then the assessment of trauma seems appropriate, the prescription of avoidance seems natural, even common sense.

But what happens when fear of a stressful event is conflated with fear of the events’ principal figures, especially if those figures represent distinct social groups? Currently, I observe a disturbing trend in my work, as well as in my community: the prerogative to disparage police, lawyers; representatives of “broken” systems, medical and administrative. I notice that when threatened, individuals launch into fierce diatribes, reducing people in these professions to caricatures, while paying thin lip service to the possibility of error (“I know there are some good cops”, said a man I listened to recently). You might think this constitutes that small space for understanding, as I suggested earlier. But I don’t think so. At least, when there is such awareness, it seems fleeting, and more importantly, outwardly-directed—the worry about what others might think, but not so much an integration of feedback.

A broader understanding of trauma, or its cousin prejudice, lies beyond the medical dimension, within the theoretical realm of the unconscious. In asserting this, I am aware of leapfrogging the conscious derivatives of prejudice, that which is attributed to socialization over time. While I don’t dispute the impact of calculated teaching, or “modeling” as it is also dubbed, I rather think that the roots of prejudice lie in a capacity for splitting, as Melanie Klein first conceived (building upon the writings of Freud) in the 20s and 30s, and in the strange vicissitudes of psychic energy, which call for binding. Splitting is a primitive defense: a habitual impulse towards segregating love and hate that is innate, thus creating a template for good and bad, which provides humankind with both a moral lens, but also a harsh, distorting, discriminating eye. Latterly, modern theorists like Masterson devised maps of intrapsychic structure, which delineate the pathways taken as a result of splitting. Within such maps individuals can potentially see who is who (in terms of what is experienced affectively) in the equations of relationships, and begin to question a presumed reality.

Present-day mental health services addresses social prejudice in an oblique way: by urging separation, boundaries; “tools” for people to use, to enable calming, the quickest paths to safety. Ironically, the oblique path is more accessible for the average sufferer; the methods of choice are more utilitarian. They speak past the core traumas, prejudices, leaving well enough alone lest its practitioners offend those who have already fixated on truth. Therein lies some kind of cycle, I think, which is difficult to interrupt. That’s scary also.

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An Argument for Depth Therapy in Drug Rehab



You might think that drug treatment with adolescents and psychoanalysis are terms that don’t go together, and you’d be right…sort of. Actually, a psychoanalytically-derived therapy is precisely what James Masterson, considered by many the father of adolescent psychiatry in the United States, intended for a residential treatment of troubled youth. His 1967 book, The Psychiatric Dilemma of Adolescence, offered the view that troubled kids do not “grow out of” problems of anxiety, depression, and acting out behaviors, as many of Masterson’s contemporaries appeared to assert. In this review, Masterson found that upon five years upon initial evaluation, over 50% of the adolescents previously treated in hospital settings for psychiatric conditions remained severely impaired. Although symptoms of anxiety, depression, and delinquent behaviors achieved modest reduction, some psychiatric disorders, such as pathological character traits, had not been touched upon in treatment at all.
Subsequently, Masterson was invited to take charge of adolescent inpatients at the Paine Whitney Clinic connected with Cornell University, which later resulted in his seminal text, Treatment of the Borderline Adolescent, in 1972. This book introduced the stage progression system of movement through a long-term residential program, intended to mirror the child development stages of separation-individuation as observed by Object Relations theorist Margaret Mahler. In this book, Masterson describes an initial “testing” phase of treatment in which patients relentlessly break rules or challenge staff, testing the limit-setting capabilities of staff, substituting them as parents (alloparenting, some call this), unconsciously determining who cares enough about them to maintain said limits and thus provide safety. The job of the therapists in such a setting is to convert patients from “actors and non-feelers” to “feelers and talkers”. Twenty years after this text was published, I began my career working in the field of adolescent drug treatment, though it was a further ten years before Masterson’s ideas really sunk in.
During my early years at Thunder Road in Oakland, a Therapeutic Community whose structure once bore a distinct resemblance to that described at Payne Whitney, I adapted to a cohesive treatment structure that more or less supported the Masterson approach (though few referenced him specifically), while adhering to the psychodynamic underpinning. Staff commonly used terms that were of psychoanalytic pedigree, such as “containment”, “splitting”, and “failure to thrive”; interns such as myself were repeatedly encouraged to observe transference (feelings in present relationships that are unknowing reflective of past relationships) meanings in the behaviors of patients, and more importantly, to attend to countertransference feelings in ourselves that may impinge upon therapeutic goals. Even staff not trained or educated in psychoanalytic concepts appeared to observe unconscious process in patients; in confrontation groups, counselors would routinely call out the negative behaviors, tease out the secrets of “acting out”. Then, upon the dropping of defenses, staff would zero in, often compassionately, sometimes not, upon the deeper meanings, the unacknowledged feelings.
For many in treatment this seemed not only fruitful, but also necessary, even exciting. They appreciated feeling understood. Furthermore, it seemed like common sense, this in-depth approach. Firstly, the adolescents lived in the facility and were kept clear of substances (at least, much more so than they otherwise would have been). There was clearly an opportunity for multiple therapy sessions per week, in various formats: individual, family therapy, and group. Even daily meetings were possible, and so the table was set for an in-depth therapy to occur. But the truth is that psychoanalytically-derived therapies, which call for an exploration of attachment patterns, links between family of origin memories and latter day behaviors, is frowned upon in many community mental health settings, even rehab settings wherein the intensive structure would seem tailor made for an in depth approach. There are several reasons for this, in my opinion: most concern either expediency or cost, but other reasons constitute a pronounced, if subtle devaluation of not only adolescent capacities, but also the dedicated staff that typically comprise drug treatment teams.
One assumption is that shorter term therapeutic orientations, solution-focused or cognitive behavioral therapies, for example, are easier to train to newer professionals. Their elements are easier to bullet point, sound-bite, and thus install into memory, left-brain functioning, versus the more unwieldy task of integrating a fuller experience. This is why many patients leave rehab centers armed with jargon, making glib pronouncements as to how they’ve changed; promises that all too often they cannot sustain. Often, these patients haven’t changed—not really. They’ve learned some “tools”, can parrot some phrases, maybe a few 12-step slogans. But their complex feelings haven’t about themselves and others haven’t changed, much less their understandings about those feelings. A second reason for the proscription of in depth therapy is that it is presumed to be cost-ineffective. But short term methods mean short-term outcomes, in my opinion, while short-sighted research conceals long-term effects, the attrition of growth that leads people back to rehab without understanding why earlier lessons didn’t stick. Reading this, a proponent of brief models would likely break out the sales pitch language and declare short term models “evidence-based”, and imply that psychodynamic models are not. This is untrue. Don’t believe me? Check out University of Colorado professor Jonathan Shedler’s comprehensive, 10-year meta-analysis research of over 70 studies upon the efficacy of psychodynamic models. It was published in the March 2010 issue of American Psychologist. It’ll open your eyes.
Regardless, especially in my latter years at Thunder Road, I experienced the unfortunate devaluation of psychodynamic models of care, and heard that similar things were happening at other programs. Managers began making philistine comments in staff meetings, deriding psychodynamic models as “that Freud stuff” while unknowingly using psychodynamic terms to reference current and longstanding practices. Few around me seemed to know or remember who James Masterson was, much less perceive his legacy within adolescent psychiatry. Borrowing models concurrently used in schools, clinical managers began using language connected with the Strength-based movement, which presumes a normative population of youth as the focus of care, emphasizes encouragement of adolescents’ strengths versus what is disparagingly termed a deficit-based approach. Thankfully at least, short-term models with worthy methods are coming to the forefront, muscling into the competitive arena of ideas. Most notable are the mindfulness-based therapeutic approaches, which are teaching affect (affect roughly corresponds to feeling) regulation skills (Important note: addiction is increasingly understood as a problem of affect dysregulation, not faulty cognition!), which draw their principles from advances in the area of neurobiology.


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Remember the Big No

ImageMasterson criticized Kohut’s theory of an independent line of narcissism, his idea that the self matures from infantile forms to mature forms through the self-object functions of parents (mirroring and idealizing) who, once again, don’t exist so much as separate individuals as much as they represent functions in a strictly vertical line of development. In Kohut’s model, which would appear to have influenced the latter day Strength-based movement which is aimed at kids in schools (and also kids in special needs programs), the individual seeks mirroring and idealization in an effort to correct prior deprivations. These ‘efforts to correct’ reframe the discussion of therapeutic intervention. They de-pathologize the defensive actions of the narcissist, in keeping with a positivist, ‘non-judgment’ ethos, and the reader might consider the shadow side of this bias.

Years ago I created a different kind of drama centered around the so-called unempathetic mother. In The Big No, Jill Evans, my first and only female protagonist, is living a protracted separation/individuation from her mother, a Romanian immigrant now living in Northern California. Jill’s mother is religious, somewhat narcissistic in her own right, and protective of a secret past. From within Jill’s disturbed sleep the reader glimpses a world parallel to her own. Her recurrent ‘Cinderella’ dream plucks beta elements from her everyday life and posits her as a step-child of a controlling mother, and an absent and/or abusive father. Ugly sisters are jealous and venal, and the father is a humiliated failure with sinister, exploitative friends. The dreams, like Chris Leavitt’s shadows from Crystal From The Hills, portend the future, or else they call out the guilty in the present. Like the culpable mothers that informed Masterson’s theory, Jill’s mother has maintained libidinal availability as long as Jill has been dependent. As the story begins, Jill has returned home after a relationship failure and a job transfer, with her tail between her legs. But it’s her dogged unconscious combined with later efforts to uncover family secrets that bristle against the family order: the mother’s comfortable old-maiden-like existence, living in proximity to Jill’s two conformist sisters; the secure knowledge that the past has been stashed, and that everyone is safe. A confrontation ensues, creating casualties out of each character’s false selves, their stifled existence. Society must set limits on some things, and liberate others. Everyone has something or someone they must covet. Everyone has something to fight against.

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Working Through Rehab: Growing out of it


In Masterson’s The Psychiatric Dilemma of Adolescence, published in 1967, the problem of treating kids in the psychiatric setting is exhaustively examined. Noting the tendency of clinicians to dismiss diagnoses of clients, saying “he or she will grow out of it”, in reference to a plethora of acting out and mental health problems. Meanwhile, Masterson recounts that social scientists in the 60s were attempting to organize the phenomena they studied, rather like researchers of the physical sciences, and thus methodology changed; so-called objective research, focusing upon variables like validity, reliability, and statistical analyses, were coming to the fore and changing the ways clinicians addressed problems. Masterson, however, grew conflicted about the differences between the social science methodological point of view, and his and others’ clinical observations.

Masterson found after his twelve year study, that 50% of the adolescents he studied did not “grow out of problems” upon five year follow-ups, and that while symptoms like anxiety, depression, and acting out (with sex, drugs, or violence) did diminish, but that which brought the most difficulty, in terms of sustaining meaningful relationships, activating healthy goals, ambitions, accessing creativity and self-care–their pathological character traits–had not been touched upon in treatment…at all.

As much as anything, my reflections in Working Through Rehab: An Inside Look at Adolescent Drug Treatment, are derived from Masterson’s implied warnings about the costs of a superficial treatment approach. I recall working with a young lady in my private practice–a late teen–who was supposedly drawn to relationships with boys “from the wrong side of the tracks”. Much thought, encouragement, argument, and time had been put into making her see reason, re-think her “choices”, and make “rational” decisions. The cognitive dissonance was pervasive: she wanted safety and “respect”, but was drawn to men inclined to hurt her. She wanted independence, but ended up feeling anything but. She was drawn to the bohemian, the pull of rebellion, and found separation in rejection of her family’s fears. Little did she know how conflicted she was with herself, not others, and how long the conflict would last if she did nothing about it. In my first novel, Living Without Blood, I presented the consequences for a family living by the rule, “time heals all wounds”. The Metcalfs  discover that time passage without conscious intrusion does little more than fossilize understandings, generating alienation.

In Working Through Rehab, I depict therapeutic environments that are either forgetting, actively disregarding, or plainly ignorant of Masterson’s now forty year old caveats. Programs working with kids are operating upon the assumption, “they’ll grow out of it”, seeking to emphasize kids’ positive traits in the hope that their deficits will fall away under the power of love. Or, they’ve taken a subtly defeatist tact, thinking the wounds are too great, the fossilization too hard and too widespread, such that the roots of problems are impenetrable.

Do you think this, my would-be reader? Are you a mental health practitioner? A consumer of services. Who are you that you might be interested in this topic? Who do you need to be? Who am I to make pronouncements on trends that flit in and out of fashion, some sticking, some not. Who do I need to be?



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August 13, 2013 · 8:57 pm

Letter to a therapist friend


Hi, sent you a message a few nights ago, haven’t heard back, which isn’t like you. I’m not taking that personally (unless I should be?), but I thought I’d reach out again, imagining you may still be feeling hopeless, as you were last month, mostly because of work. 
I hope this doesn’t sound self-serving, but I think my modest, self-published book about drug rehab and community mental health as a whole does provide hope to those who work in this business. Many like yourself are smothered by the platitudes of directors, administrators, and so on while otherwise feeling technocratic shards of glass pierce into their sides. I felt in your reaching words something(s) unachieved in our world: passion, bravery; risk inflected with humility. I could feel it in your depiction of that unsatisfying exchange with your manager. A “nice” man, you said. It reminded me of something an old SN once said to our group of supervisees in the three-year program: “there’s nothing nice about being nice”–it was in response to a fellow student who was struggling to manage frame issues, and justifying a lack of confrontation by declaring that confrontation was…well, not nice. In my book I am scathing, I think, about rigid adherence to procedure–the tyranny of the HR manual–when not just common sense, but common thoughtfulness, decency, but above all realness, is called for.
There are times when I think that the Masterson model can truly be distilled into these qualities. I reflect on my caseload at any one time and I think, with whom  do I feel spontaneous? who do I really know? what connections feel real to me? More often than not, the best work feels like a jazzy, flowing sense of knowing…something that feels right. That may sound a little soft, and a lot unreliable. It certainly doesn’t sound very “evidence-based” or scientific, or “quantifiable”. But the thing is this: it sounds reliable to me. The reason? I trust myself, whether others do or not. Doesn’t that sound wonderful? Doesn’t it sound like a gift, or a real achievement, if I’m to give myself the credit for doing the work. I’m not saying I’m getting it right with all my patients. I’m saying I can tell who I’m getting it right with, and who I’m not getting it right with.
I agee that being in the quadrants is tantamount to being unsober. I think this was the basis for our original discussions about blending the Masterson model with a 12-step program. I’m working on myself as I flit in and out of defenses; my therapist is fighting me, I think–thinks me defeatist in my self criticism. Among other things, I defend the hard but fair pronouncements that KS made of me last year. I realize that his cool yet cutting approach stirred something vigorous yet frightened in me. It all lingers, the hurt. I was surprised to read that you “identified” (with being seen? or the “bad” experience you referenced), as I specified being seen in a manner that felt menacing, even sadistic. Did I misunderstand you? Were you writing of being scrutinized, and by KS in particular?
You wrote of vulnerability in your last e-mail, “to the toxic foolishness”. I identify with this vulnerability, though I think I have some of the detachment you crave. I’m not entirely free of bad systems. Indeed, there are one or two that are threatening to ensnare me in a fight currently (perhaps more on that in a later e-mail). But TR is nearly two years in my rear view mirror, and completing the book has been, dare I say, cathartic. Anger is draining, despite the sneery, superior tone sometimes evident in the book and especially within this accompanying blog. Whether a handful of people read it (the book), or hundreds more do so, I have cleaned my own internal system of the toxic entity that once dogged me. I have gotten some peace. Like a Schizoid personality, I also have a fantasy, which I’ll share with you: you see, in the future, I imagine achieving a modest, measured (compromised?) fame for my lengthy missive to my peers. I’ll be asked what I think should happen in drug rehabs for adolescents; perhaps what should be happening in all community mental health settings. On the specifics I’ll defer, I think, as I choose to disentangle from Gordion Knots, practice something like a second step, and wait for help from those on the inside. I don’t want to abandon. I don’t want others–least not people like yourself–to give up hope. I just think I need back-up. I need the real selves to present in numbers.

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