Psychotherapy of the Disorders of the Self

James F. Masterson, M.D., Ralph Klein, M.D., James F. Masterson, M.D., Ralph Klein, M.D.

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780876305331
• eBook ISBN:
  9781134849178
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Masterson Approach has evolved from 32 years of scientific inquiry, including four formal research projects, nine books, and 75 papers. this volume marks an important stage in a professional journey that has had many turnings. Clinical concern and theoretical introspection evoke a wish to share, which led to writing and teaching. The deepening of this need to build a continuing community of ideas has impelled Masterson to invite those who have learned from him to join me. This book represents their commitment and contribution to the Masterson Approach.

PART II

The Scope of Psychotherapy

The clinical evidence for the developmental self and object relations theory is derived from intensive psychoanalytic psychotherapy with personality disorder patients. Since this is the source, some therapists believe that the only use of the theory is with patients in intensive analytic work.

This section on psychotherapy demonstrates how widely the theory applies to therapeutic contacts with personality disorder patients. The extraordinarily wide ranging therapeutic activities presented all spring from the same developmental theoretical source and illustrate its scope and flexibility.

In Chapter 4 Dr. Clark, focusing on the psychotherapy of a patient with borderline personality disorder, dissects the difference between the experiencing of the abandonment depression and the “bad feelings” associated with the need to defend against experiencing the depression. In Chapter 5, Dr. Fischer describes and illustrates in detail the therapeutic management of the narcissistic personality disorder. Shorter-term psychotherapy of both the borderline and narcissistic personality disorders is described by Dr. Klein in Chapter 6. He clearly illustrates the goals of shorter-term treatment, which are far more ambitious than was thought possible years ago, as well as the different therapeutic techniques necessary in shorter-term work with the two disorders.

In Chapter 7, Dr. Orcutt abundantly illustrates the point that therapeutic technique changes as the patient's ego and object relations mature. In Chapter 8, Dr. Klein gives extensive consideration to diagnosis and treatment of those borderline patients who occupy the lower level of the borderline range and who are frequently found in the inpatient ward and the outpatient clinic. This subject, which has occupied us a great deal clinically, has not previously been reported on in such a systematic and thorough manner. In her work with a wide range of borderline personality disorders, Dr. Clark details in Chapter 9 the clinical evidence for self-activation or separation-individuation and in so doing provides rich clinical examples of what is meant by separation-individuation.

The question is often raised as to whether the Masterson Approach can be applied to psychotherapy with adolescents. In fact, it was in the area of the identification and treatment of the borderline disorder in adolescence that my clinical work had its beginnings. Dr. Orcutt in Chapter 10 demonstrates the application of the work to the psychotherapy of a borderline adolescent. In Chapter 11, Dr. Orcutt and I expand the application of the therapy to the marital treatment of a couple, each of whom has a narcissistic personality disorder.

From shorter-term to longer-term psychotherapy, whether upperor lower-level borderline personality disorder or upper- or lowerlevel narcissistic personality disorder, in work with adolescents and couples, through the making of difficult but crucial clinical distinctions, the theory ranges widely to form a solid, reliable base for both evaluation and therapeutic action with a variety of personality disorders.

J.F.M.

Chapter 4

Psychotherapy of the Borderline Personality Disorder

Karla Clark, Ph.D.

This chapter describes how the projection and acting out of the withdrawing part unit, and the depressive affects associated with it, serve to defend against the activation of the real self and the associated emergence of the abandonment depression. The split intrapsychic structure of the borderline patient is characterized by a rewarding and withdrawing object relations part unit, each with its component self and object representation. Both units reflect specific internal responses by the individual to the developmental task of separation-individuation, and both work against further separation-individuation and the activation and development of the real self.

In the rewarding self and object relations part unit (the RORU), the intrapsychic representation of the part object is powerful and “protective,” approving of and rewarding regressive behavior. There is a corresponding part self representation of being a good and compliant child. These part self and object representations are linked with affects of feeling good. This produces a false self representation which leads the person to behave in regressive and self-destructive ways and see himself as a good person when so doing.

The withdrawing self and object relations part unit (the WORU) consists of a part object representation which attacks and/or withdraws at signs of separation-individuation, linked to a part self representation which is bad, evil, and disgusting. These part self and part object representations are linked to affects of feeling defective, worthless, and loathsome. The false representation of this part unit is of a defective, bad person.

In the following case, the WORU/pathological ego alliance was projected and acted out in the form of a false, defensive self, which both hid the actual impaired real self from the view of the patient and the therapist, and prevented the real self from fully developing. A major task of the psychotherapy was to identify this false defensive self, and help the patient to understand its functions, in order to give it up and work through the resulting abandonment depression.

The progression from (1) identifying and working with the affects of the false defensive self to (2) challenging the patient to give up the false defensive self to (3) the subsequent emergence of the affects of the abandonment depression is a common, expectable clinical sequence. However, in the case to be presented (as in many others that have come to my attention), the normal task of working with the set of depressive affects associated with the WORU/pathological ego alliance as prelude to working through the abandonment depression was complicated by the ease with which the affects associated with the one could be confused with those of the other. This occurred because the patient experienced and described both sets of affects as “depression” and failed to distinguish between them.

Such confusion may lead to failure to manage the defensive depression adequately, which in turn leads to treatment complications and failures as the abandonment depression itself, then, fails to emerge in a clearly identifiable form. In the case to be discussed, the crucial point for the psychotherapy was to identify and distinguish one of these forms of depression from the other.

In order to address the questions of (1) the identification and management of the WORU/pathological ego alliance, (2) its projection and acting out expressed as a false defensive self, and (3) distinguishing it from the underlying abandonment depression, one must first consider the defensive function of splitting and the effect of such splitting on the development of the real self.

Splitting is used defensively in order to maintain and protect “good” images of self and other from being overwhelmed by “bad” images, which the individual fears would threaten and destroy the good (Kernberg, 1975, p. 25). When splitting leads to the development of a false defensive self, the implications for the individual's development of his real self are far reaching and grave:

In the borderline personality disorder . . . those impaired by this disorder are unable to use the real self to react to reality challenges with supportive realistic self-assertion, but run instead to a false defensive self—a product of the alliances between the pathological ego, the rewarding unit relations part unit and the withdrawing object relations part unit. This leads to avoidance, passivity, denial, and preoccupation with fantasy, thus further feeding their lack of self-esteem.

Their defensive self representations—based mostly on fantasy rather than reality—consist of two equally unrealistic fantasy images: that of a helpless child who is loved or rewarded for not asserting himself and an inadequate, evil, bad self which impels the mother to withdraw. (Masterson, 1985, pp. 31–32)

It is perhaps easy enough to see why a borderline individual would fail to consciously question a compliant, clinging, and non-self-activating false self representation, when by so representing himself he feels “good” in both an absolute and a moral sense. But why would an individual embrace a false, defensive self representation that is based upon his feeling that he is “bad”?

Fairbairn makes the point that, having initially internalized bad objects, an individual may also defend himself from knowing about their existence by seeing himself as bad. Fairbairn believes that the patient does this because he prefers to see himself as a bad person in an essentially good universe rather than as an essentially bad person in a bad and malignant universe (Fairbairn, 1986, pp. 109–110).

To extend Fairbairn's premise, seeing oneself as bad in a bad universe is felt as preferable by some borderline individuals to repudiating the bad introject altogether, thereby loosening one's defensive affective investment and experiencing the feelings of loss of the abandonment depression. The projection and acting out of the WORU/pathological ego alliance (henceforth to be referred to as the WORU defense) thus forms a barrier to the even more painful feelings that lie beneath it. The patient sees himself as being bad and disgusting. Frequently, he will describe this self experience as “being depressed,” and in fact he may be acting or feeling depressed: tearful, lethargic, subdued, or flagrantly suicidal. He then compounds this by resisting any challenge to this view of himself because of his unwillingness to face the abandonment depression beneath.

Experiencing oneself as bad and malignant in a bad and malignant universe, and behaving badly in order to justify the feeling, are therefore two levels of defense against calling the entire self representation into question. One can think of the very existence of the WORU false, defensive self representation as the most basic, primary defensive configuration in these cases. The defenses against seeing that the WORU self representation is a false self representation are a secondary defensive maneuver. These secondary defenses must often be worked through before the primary defense is either identifiable or workable.

The first key to distinguishing all of the affects associated with the withdrawing part self and part object relations unit from those of the abandonment depression proper is the quality of moral badness, or self loathing, associated with the WORU defense. This quality can be easily distinguished from the affects associated with working through the abandonment depression. The latter includes feelings of helplessness and hopelessness, emptiness and void, separation anxiety, depression, rage, and guilt over separating (Masterson, 1976, p. 39). All of the latter affects share the quality of feeling abandoned and alone but lack the feeling of moral badness and defectiveness of the WORU false self depression.

The second key to the distinction between the depression of the WORU defense and the working through of the abandonment depression is to be found in whether the patient is focusing, through his depression, on keeping the relationship with the old internal objects alive or trying to give them up. When the abandonment depression proper is at the center of the patient's awareness, the relationship to the old part objects is absent or subordinate. In contrast, affects attached to a false defensive self refer to an internal relationship between the part self (or selves) and still dominant internal objects, the self being subordinate. In the latter case, the WORU defense depression, for example, is characterized by affects of feeling bad, worthless, and otherwise invalid vis-à-vis an internal object who is attacking or withdrawing. The depressive affects experienced in this context are reactive rather than active, i.e., “I am bad because ‘it’ thinks I am. This makes me feel awful.” Clinically these depressive affects are a barrier to (defense against) self-activation and maximally interfere with adaptation and function. These affects must be distinguished from the abandonment depression itself, which is associated with loss of the object, not the threat of loss, in consequence of one's own attempts to take the initiative to separate and individuate, i.e., “I feel hopeless of ever receiving support for separating from the object and must give up and go on. This makes me feel empty, terrified, guilty, etc.” The affects associated with the abandonment depression refer to the individual's efforts to give up the old ties to destructive part object representations. Thus they are active rather than reactive. Clinically they are the result of self-activation and minimally interfere with adaptation and function.

Once the clinician can distinguish between the WORU defense and the underlying abandonment depression, the question arises as to how to manage or work through the WORU defense. The defensive expressions of the false defensive self (or selves) are managed in precisely the same manner as are other defenses of the borderline: through confrontation.

The technical principle is the same for confronting secondary defensive manifestations of either the RORU or the WORU. The patient must learn to identify their presence and view their projection and acting out as antithetical to his best interests, and therefore learn to control them. When confronted, a patient may be able to control his impulse to act in such a way as to verify his internal view of himself as wrong and bad. He may thus learn to call into question the thought that he is wrong and bad before ceasing to experience the feeling of being bad.

A variety of options open at that point. The patient may stop there, saying that he knows that he feels like a bad person (especially when experiencing separation stress) and that that feels awful to him, but that he knows that these feelings do not reflect a true picture of what he is like, and that he is not going to allow the feelings to stop him from functioning.

If, however, the patient then goes on in therapy to repair the split by working through the abandonment depression, the following three stages unfold: (1) The hope of support for separation-individuation from the objects is given up and is replaced by self-acknowledgment. (2) For this group of patients, this leads to withdrawal from the internal objects and increased attention to the self, with subsequent abandonment depression and separation anxiety. (3) Finally, after the tie to the internal object has been given up, the personality is reconsolidated based upon whole self and object representations.

The case presentation that follows will illustrate this process.

CASE ILLUSTRATION: MR. E

Presenting Complaints

Mr. E is a single man in his early forties.¹ He entered therapy with complaints of depression, low self-esteem, and feelings of social isolation. He had recently changed careers (from recreational program director to lawyer) and was having problems on the job. He felt that the job itself was poor, and that the administration of the firm was unprofessional and inadequate. He was in trouble with his immediate supervisor, a woman, whom he felt unfairly criticized his work.

Mr. E had other difficulties in managing his daily life. He reported a good deal of past and present drug and alcohol abuse. He suffered from financial problems. He had no permanent living arrangement, because he had constant fights with his roommates. He saw himself as exploited and victimized, the other as selfish, abusive, and exploitative. He would move on, only to repeat the process elsewhere. He seemed to have no friends.

He had had five years of weekly individual psychotherapy with a male therapist. He complained, however, that he still felt depressed— perhaps more so than ever. More important, for him, he had been unable to develop any lasting relationship with a woman. He wanted to marry and to have children and hoped that seeing a woman therapist would help him to achieve this.

As we began treatment once a week, I noticed several things about him that appeared problematic to me, but of which he was unaware. Certainly, these traits interfered with his stated goal of meeting and marrying a woman. He had allowed himself to become noticeably overweight (although not truly obese). He dressed in unkempt, illmatched clothing. Often he appeared for sessions in dirty denim overalls and a smelly tee shirt. His long hair was frequently dirty and uncombed, and he often had a powerful body odor. His expression was chronically angry, aloof, and disconnected.

There were contradictions and inconsistencies in this picture of Mr. E, some of which were apparent at once and some of which did not appear for some time. These contradictions and inconsistencies were signs that the picture he presented was a false, defensive self. I happened to know from other sources that he had a reputation as a highly creative and innovative recreational program director. His story of the way he left his job, in contrast, left out his achievements and job satisfactions and emphasized his quarrels with fellow staff. He presented himself as little better than a bum, certainly as though he were incapable of achievement or taking himself seriously. In contrast, he had graduated from a good college, had some graduate training in art history, and had now finished law school, where, as he revealed when I inquired, he had done quite well scholastically. Additionally, Mr. E was an artist of considerable talent, who had achieved some recognition for his work. He revealed this in s...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• The Authors
• Prologue: Evolution
• I The Masterson Approach
• II The Scope of Psychotherapy
• III The Art of Confrontation with the Borderline Personality Disorder of the Self
• IV Countertransference
• V New Perspectives
• Index