Comparing Psychoanalytic Psychotherapies: Development

Developmental Self & Object Relations Self Psychology Short Term Dynamic

James F. Masterson, M.D., Marion Tolpin, Peter E. Sifneos, James F. Masterson, M.D., Marion Tolpin, Peter E. Sifneos

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781134854219
• Subtopic: Mental Health in Psychology
• Index: Psychology

Based on two workshops held February 1990 in New York and March 1990 in San Francisco. Following the presentation and discussion of three clinical case histories, psychotherapists James F. Masterson, Marian Tolpin, and Peter E. Sifneos compare and contrast developmental, self, and object relations

PART I

I Case Presentations and Discussions

1

Psychotherapy of a Lower-Level Borderline Personality Disorder

Shelley Barlas Nagel

CASE PRESENTATION

Introduction

Kate was an articulate, intelligent, and charismatic 34-year-old single woman with a master’s degree. I saw her in treatment for four and a half years. She was referred by her physician; the chief complaint was depression. During our work together, major treatment issues involved her self-destructive behavior, including a suicide attempt, volatile rage, and several serious addictions.

Presenting Information

At the time of her first appointment, Kate had been out of work for six months, supporting herself with money from a trust fund. A series of unsuccessful jobs finally ended when she was fired from her last position because she had come to work with her speech slurred from tranquilizers. She hated her work and wanted to change careers, but had no idea what she really wanted to do.

She felt depressed and lost, blaming her family, previous employers, and former lovers and therapists. Kate said sadly, “I’m tired of waking up depressed and scared. Outwardly, I’m pretty and charming. Inside, there’s nothing. I hate myself.”

Family History

Kate was the youngest and least favored of four children from a wealthy East Coast family. Her father, a graduate of an Ivy League school, was a prominent attorney. She described him as brilliant, but also remote, cold, and angry. He blamed Kate, not the other children, for his problems. She felt hated by him, even as she craved his attention.

Kate described her mother, a housewife and former model, as overpowering, critical, and controlling. “She demeaned me as a human being.” Kate’s mother had significant periods of depression and often used Kate as a scapegoat. Angrily, Kate said, “I hate my parents because now I have to rebuild my insides.”

Past History

Kate’s memory of her childhood was one of feeling sad, lost, and alienated. In first grade, despite her intelligence, she was held back because of poor concentration arising from anxiety and depression. She had few interests and no hobbies. Thirty pounds overweight in grammar school, Kate continued to fluctuate in weight most of her life.

In high school, however, she lost weight and became a gregarious school leader. She earned good grades with little effort, but underneath the facade she felt a gnawing sense of hopelessness, self-hate, and anger. To deaden these feelings, she smoked marijuana, drank alcohol, and experimented with drugs such as PCP, cocaine, and LSD. This drug use continued into her late twenties. She also took amphetamines to control her weight and to give her a high; she used Valium and Miltown to “take the edge off.”

After failing the first semester at an out-of-state school, she returned home and attended a community college. Two years later, she moved away, finished her bachelor, and earned a masters degree. During this time, Kate had many brief and painful relationships with men. She was attracted to men who were emotionally unavailable, married, or abusive. Her longest relationship was with a heroin addict and drug dealer with whom she lived on and off for seven years. She went from job to job, being fired or quitting. Following graduate school, Kate had two abortions. She was raped a week after the second one.

She sought help with several therapists. The last, a psychiatrist, prescribed the antidepressant Norpramin, which Kate said never helped her. She told me that she had been drinking for many years and that her drinking and drug use had been ignored in all of her previous treatments whenever she had alluded to this behavior. Experiencing despair, rage, and self-hate, she had harbored recurrent thoughts of suicide most of her life. In fact, Kate had made five suicide attempts, the most serious occurring a year before she began treatment with me. After taking an overdose of Norpramin, she spent several days in an intensive care unit, barely managing to survive.

Treatment

Over the course of treatment, consisting of twice-a-week sessions, Kate discharged her feelings through behavior, not words. She defended against depression by using drugs and alcohol. She turned to men to take away her pain and to make her feel good. She went on massive eating binges and gained weight. She became bulimic, taking laxatives and diuretics while alternately bingeing and starving. She also acted out her rage by picking fights with coworkers and friends or by attacking me.

Kate needed to experience congruent, consistent treatment to help strengthen her reality perception, her ability to trust, and her sense of self. In the beginning of treatment, Kate tested me by missing appointments, arriving late, wanting me to see her on holidays, and asking me to prolong her sessions. Her payments were delayed and some of her checks bounced. She urged me to lower my fees and asked me to accept her as a non-paying patient when she lost a job. She tried to engage me in personal conversation, wanting our relationship to be personal rather that professional. When I did not comply with Kate’s requests, but asked her instead to explore what prompted them, she attacked me for not caring.

Kate acted and reacted without thought of the consequences of her behavior. She wanted a quick fix—to numb and deaden her feelings. After an eating binge or a drinking episode, she felt remorseful and depressed, but continued her destructive cycle through further abuse of drugs and food. Each episode eroded her self-respect and self-image and reinforced her self-hate.

I can only speculate, based on my own work with patients with addiction problems, that Kate may have experienced physical and/or sexual abuse as a child. Childhood abuse appears to create a vulnerability to later problems with addiction. She had no clear memories of such abuse, but her intense acting out served to block many feelings and early memories.

From a neutral, yet empathic, stance, I brought to Kate’s attention what she was not aware of: destructive behaviors harmful to her best interests. I made her present behaviors unacceptable to her by introducing conflict into her defensive system. At the basis of my confrontations was the conviction that Kate had the capacity to think, to stop herself from acting on impulse, to contain her feelings and talk about them in the sessions, and to act in a self-supportive manner.

By identifying her addictive and self-destructive behaviors, I followed the basic principle that priority be given to the process of stopping such actions—an issue that takes center stage in this type of treatment. Kate’s patten of compulsion, loss of control, and continued abuse in spite of adverse consequences from drugs, alcohol, and food were addictions that could result only in a downward spiral. I confronted Kate’s denial of her drug use. I asked, “Why are you hurting yourself with drugs and seeking an artificial high? I’d think you’d want to experience what you’re feeling and be aware of your problems so that you could then solve them.” Gradually, she internalized these questions and began asking them herself. She threw the amphetamines away. “I’m sick of the struggle,” she said. But when she went through a period of withdrawal, she became depressed again and increased her drinking and use of tranquilizers.

Kate denied that alcohol was a problem, claiming, “I only take a few drinks. It makes me feel good. After all, I’m just a social drinker.” I further confronted her denial by pointing out she had lost a number of jobs because of her drinking. Eventually, she showed signs of identifying with my perceptions and of integrating my confrontations by making efforts to cut back. Then, the arena of her conflicts shifted, and she engaged in a variety of defensive behaviors, including overeating, compulsive shopping, and verbal attacks on me.

Kate said to me, “I’m mad at you, I’m mad at this therapy. I feel like I’m under a microscope.” Confronting the projection by putting it back in her head, I said “You have some choices: You can face your problems and feel some pain or you can deny your problems and dump your anger on me.” She responded, “Looking at myself is hard. It’s easier to focus on you, but I guess that doesn’t help me much.” “Right,” I echoed.

I made it clear to Kate that using alcohol and drugs was at odds with coming to therapy. I said, “If you take alcohol for your pain, then you can’t use treatment.” I wondered if she had thought of going to Alcoholics Anonymous. She angrily responded, “That is the most obnoxious idea I’ve ever heard. Those people are disgusting creeps, and I’m mad you brought it up.” I answered, “I don’t know why you’re getting so upset. You’ve told me of your problems with drugs, your years of drinking, the loss of control, the blackouts and hangovers, the preoccupation and remorse. I’d think you’d want help.” One of the main focuses throughout Kate’s treatment was encouraging her participation in Alcoholics Anonymous—a necessary and important adjunct to her psychotherapy. Therapy alone would not be sufficient to manage her addictions. I did not see very much hope for her recovery without her involvement in AA.

Several weeks after she began treatment, Kate started attending AA meetings. At first, she had several bouts of drinking coupled with a few days of sobriety, followed by rationalizations, excuses, and attacks on AA. Then came efforts at self-control and limited drinking, but the limited drinking eventually gave way to heavy drinking. Kate ultimately realized that once she began drinking she could not stop. She hit bottom emotionally and she became hopeless and despairing. But, with her improved reality perception of these problems and their destructive consequences, she began to view her drinking and drug use as intolerable and unacceptable. She now turned to AA and to her therapy sessions to deal more honestly with her painful feelings about herself and her past.

At the same time, I was also confronting her lack of self-activation regarding her career. I said, “I’m wondering how it is you’re not taking steps to look for work, so that you could have some structure to your days. I know it’s a painful time, but you go to bed rather that push yourself to take some action that would make you feel better about yourself, instead of worse.” I stressed her lack of functioning. Coping was crucial.

My confrontations and Kate’s attempts at self-activation stirred up her depression and feelings of helplessness. Now she wanted me to take care of her and make things easy so that she would not have to take responsibility for herself. She said, “I can’t do this, I don’t know what to say next. Can’t you help me and give me some direction?” I avoided resonating with her projection by not being drawn into the role of care-taker. With the underlying expectation that she could manage herself, I asked, “I’m wondering why you’re feeling so helpless. How is it you feel you’re not able to generate your own direction?” She said, “I can’t do it. I feel so alone. The loneliness is unbearable.” She started to cry, expressing despair.

After several months of sobriety, she talked about losing her sense of self when she was around her family. She said, “When I get around my family, I get so disoriented and doubtful about myself. I can’t fight them.” I asked her why she had such trouble supporting herself. She answered, “I need to figure out a way of being myself against them or how to process their input. I always got real depressed and would use drugs when my sisters and mother would say the family would really love me if I’d only open my heart. It was always as if I were the problem. Lately, I’ve had to shut down to come to grips with it.” I pointed out that shutting down wasn’t coming to grips with it. She responded, “I feel overwhelmed, and I start wondering if I’m crazy.”

I suggested that, under her family’s negative input, she conceded her judgment of reality to them, rather than sticking to her own. She replied, “My heart tells me if I don’t protect myself against them, I’ll end up dead. If I expose myself to them, I’ll doubt myself. If they were in here, they’d swear they loved me.” I answered, “You keep switching from your reality perception to their distortion as if it were reality.” She answered, “It’s hard to see the truth.” She began crying and said, “I feel so uncomfortable talking to you about my family. I think you think I’m crazy or don’t believe me.” I answered, “You have been talking about giving up your own reality perception to your family’s perception. Now you’re doing the same thing. You think I’ll see you the same way your family saw you. Do you notice you’re doing this now with me?”

Kate began to see a relationship between her feelings and her behavior and to observe herself. Her self-image gradually improved, but, in reaction to her positive feelings, she criticized and attacked herself. She said, “I’m a jerk … spoiled … nothing but a failure.” I responded, “You were just acknowledging your pride in your efforts, and now you’re attacking yourself. You call yourself names and beat up on yourself, rather than attempt to understand the way you feel.” She started to acknowledge her positive efforts. But, her compassionate acknowledgment triggered feelings of anger and she then attacked me, accusing me of criticizing her. Reflecting her projection, I asked, “How is it you don’t experience what I’m saying as being helpful? Instead, you think I’m attacking you. I’m pointing out how what you do in your life doesn’t support you. How is that criticism?” She replied, “I guess what you say is helpful, but it’s painful; being nice to myself is just not familiar.” Again she wept and said, “The vicious attacks in my head are from my mother; that’s how she talked to me.” Kate expressed a sense of betrayal and sadness that her mother did not protect her from her father’s abusive taunts, choosing instead to side with him against her.

After a year and a half of treatment, Kate’s functioning had improved markedly. She no longer worked at minumum wage jobs beneath her ability. She relied more on herself, rather than on others. In her sessions, she was dealing with her feelings, not testing me as much or making me the target of her rage. She showed signs of treating me as an ally, rather than as an adversary, illustrating the strengthening of the therapeutic alliance.

But as she relied more on herself, she also felt depressed. She said, “I’m feeling worse than I’ve ever felt in my life.” I replied, “Yes, I know you’re feeling worse. It’s because, as you’re controlling your behavior, you’re actually feeling more.” I told her, “For you, feeling worse is good, not bad. Before, when you were using drugs and alcohol, turning to men, using sex to numb your feelings, and hating yourself, there wasn’t any hope. You weren’t going anywhere except down. You’ve been miserable most of your life. Now there’s some purpose to your pain. Now it’s possible to get to the bottom of it and to resolve your conflicts.”

Kate mourned the wasted years of self-abuse and cried over the painful relationships with her parents and the love and support she had missed. She viewed her family with increasing clarity. She talked openly about her feelings of being left out as the unloved and least favored child. Kate saw her mother more realistically as a woman with emotional problems of her own and began to realize that she herself was not the cause of all her family’s problems. She saw that her chaotic behavior and acting out were ways to hurt herself and were often compulsive, ritualistic repetitions of actual childhood scapegoating situations. However, after two or three sessions where she expressed sadness and rage about the past, she came to her sessions completely detached, with little memory of the previous sessions. I confronted the detachment by saying, “When you cut off feelings, you remove the possibility of being able to work them out.” After tracking for several months this pattern of affect followed by detachment, I had to accept that Kate was not able to consistently experience feelings of rage, anxiety, and depression associated with self-activation and separation experiences without at times being overwhelmed. She intermittently lost the ability to think and to observe herself, and she detached affect. She returned to food binges and withdrew from her friends and AA.

In order to help Kate handle these feelings, I created a more supportive, focused therapy environment and turned from the goal of working through to the goal of ego repair during once-a-week sessions. Kate further developed the ability for self-observation and introspection. She realized that she was resisting the responsibility of growing up, a process that she associated with feelings of self-loathing, loneliness, and hopelessness. As time progressed, she identified with my perception of her as a competent, worthwhile person. However, the pattern of shifting behaviors continued, although to a much lesser degree. Kate initiated steps to activate herself positively, but then often retreated into despair; yet, she eventually came out of it. She learned to utilize concrete methods of coping with her depression. She listened to music and AA tapes, attended meetings, and maintained a long list of positive activities to do when she felt bad. And as ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Introduction
• PART I. Case Presentations and Discussions
• PART II. Workshops
• PART III. Overview
• Bibliography