The Emerging Self: A Developmental,.Self, And Object Relatio

A Developmental Self & Object Relations Approach To The Treatment Of The Closet Narcissistic Disorder of the Self

James F. Masterson, M.D.

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317838906
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

At last, this much?awaited volume sheds substantial light on one of the most difficult disorders to diagnose and treat: the closet narcissistic disorders of the self. The third of a series on the disorders of the self, and the first written by Dr. Masterson since 1985, the book fills a crucial niche in his work and in the field of personality disorders. It describes not only the psychopathology and treatment of this disorder but, more importantly, demonstrates the key dynamic of the disorders of the self triad: self activation leads to anxiety and depression, which leads to defense. This is the central dynamic of all the disorders of the self, and its particular manifestations in the closet narcissistic personality disorder are described along with the therapeutic techniques required to identify and manage it. The volume succeeds in clarifying a great deal of the clinical confusion surrounding the disorder, and addresses such questions as: What does the clinical picture look like? What is the reason for the diagnostic confusion? How does one resolve it? What other disorders does this disorder mimic? How do you differentiate it from the borderline and/or schizoid disorders of the self? What are some possible etiologic factors? What precipitates a clinical syndrome? What is the intrapsychic structure of this disorder, and how does it compare with other disorders? What is the central psychodynamic? What is a mirroring interpretation of narcissistic vulnerability, and why is it the intervention of choice? What is projective identification, and why is it so important to countertransference reactions to these patients? The Emerging Self offers a clear, down to earth, hands?on presentation of interest to all therapists students, teachers, and practitioners. It will enable the therapist to identify what emotional issues are on center stage, understand how to deal with it, and also how to evaluate the results of his or her efforts. Beyond that, it will illustrate the variations in countertransference that occur as a result of projective identification. Above all, the volume will take its substantial place alongside Psychotherapy of the Borderline Adult and The Real Self as one of the three pillars of Dr. Masterson's whole theoretical approach.

PART ONE

The Oinical Picture

1

The Clinical Picture—Chameleon

A therapist baffled by a therapeutic impasse with a "borderline" patient asks for a consultation and gives a good description of the patient's clinical picture: depression, difficulty with self-assertion, clinging in relationships and with the therapist, difficulties with anger and impulse control, an inadequate sense of self, and denial of self-destructive behavior.

The diagnosis of borderline disorder of the self seemed correct, and the therapist used the appropriate therapeutic intervention of confrontation. However, the patient, rather than integrating the confrontations to develop a therapeutic alliance, instead responded either by attacking the therapist and becoming more and more resistant, or by seeming to integrate the confrontations, but without a change in affect or the therapeutic alliance.

The therapist felt more and more frustrated and defeated, and the pressure to blame the borderline patient's stubbornness or intransigence for this turn of events became irresistible as the therapist began to think, "These difficult-to-treat borderline patients . . ." How many papers on the borderline begin with this phrase! This therapist unfortunately had fallen prey to the most common diagnostic error with the personality disorders. He had mistaken a closet narcissistic disorder of the self for a borderline disorder of the self.

The first important reason why this happens is that the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) makes no provision for the closet narcissistic personality disorder. As shown in the following, the manual provides criteria for only one form of narcissistic disorder, the exhibitionist.

Narcissistic Personality Disorder

1. Grandiose sense of self-importance or uniqueness.
2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Exhibitionism; the person requires constant attention and admiration.
4. Cool indifference or marked feelings of rage, inferiority, shame, humiliation, or emptiness in response to criticism.
5. At least two of the following disturbances in interpersonal relationships.
   1. A sense of entitlement or expectation of special favors without assuming reciprocal responsibilities.
   2. Interpersonal exploitiveness.
   3. Relationships that alternate between the extremes of overidealization and devaluation.
   4. Lack of empathy.

Therefore, the clinician's alertness to the presence of the disorder is dulled.

The second important reason is that the closet narcissistic disorder of the self clinically most commonly can mimic the borderline personality disorder, but also, less commonly, the schizoid personality disorder. This book shows how developmental self and object relations theory pierces the clinical confusion and enables the therapist to identify the consistent, underlying intrapsychic structure and select the effective therapeutic approach.

The closet narcissistic disorder of the self has a consistent underlying intrapsychic structure and an equally consistent defensive theme: idealization or devaluation of the omnipotent object to regulate the grandiose sense of self. The principal emotional investment is in the object, not the self. Despite this, the clinical picture, like a chameleon, can take on the colors of other disorders. There are a number of symptomatic themes that reflect the patient's complaints rather than the aspects of the problem that the patient denies—for example, grandiosity, sense of entitlement, or lack of empathy.

Clinical Themes

The impaired self can be consciously experienced as bad, inadequate, ugly, incompetent, shameful, or weak, or as falling apart. A prominent complaint is difficulties with intimacy or a close relationship. A real, healthy close relationship would interrupt the patient's narcissistic defenses and expose the patient to his or her impaired self and abandonment depression, and so the patient must form relationships based on narcissistic defense. The permutations and combinations of these relationships are endless. The complaint can vary, for the narcissist with a detachment defense, from having no or few relationships, to a lack of responsiveness on the part of a partner (failure to mirror perfectly), to being attracted to people who are not in reality available—for example, having an affair with a married person or with someone who lives far away or travels a lot, with the distance providing the necessary defensive protection.

A seemingly inconsistent picture appears with persons with devaluing narcissistic disorders, who seem to be devoted either to partners whom they consistently attack and devalue or to partners who attack or devalue them. They undergo recurrent experiences of instantly "falling in love" based on sexual attraction, and then being disappointed and falling out of love as the relationship matures. Also, attracted by the other person's money, power, beauty, or sexual appearance (narcissistic supplies), they may evince a genuine feeling for the person that quickly leads to disappointment when the quality that attracted them disappears.

Narcissistic rage emerges at the partner's failure to meet entitlement needs without awareness of the entitlement.

Problems with sexual functioning arise that derive not from a specific sexual conflict, but from the need to defend against the anxiety and depression produced by the emotional pressure for intimacy that occurs in a sexual relationship. One can be sexually competent with a partner with whom one is not involved, but when one is involved, one has to detach affect to function sexually.

The difficulties with real-self-activation also vary widely, from the patient's not knowing what he or she wants to do to the patient's being able to identify it but not being able to initiate it, or being able to initiate it but not being able to follow through. Or the patient is able to activate only through a relationship with an idealized other, but if he or she becomes separated from the idealized other, the ability to activate deteriorates.

The difficulty with self-activation also causes patients to take jobs in which they can function quite successfully, but where they feel no sense of meaning or satisfaction—for example, a lawyer who really wants to be an artist. Or they may initiate a career based on their latent talent and being able to identify what they want (real- self-activation), but find that success so frustrates their closet defenses, thus bringing them onto center stage, that it exposes them to such severe anxiety that they have to avoid following through in order to relieve the anxiety. Often the need to relieve the anxiety can lead to alcoholism or drug addiction. Workaholism as a defense against intimacy and/or the anxiety associated with selfactivation is common. The structure of the work partakes of their emotional investment in the idealized object, and while they work long hours, they feel an emotional equilibrium, and the loneliness, isolation, and burnout involved are denied. This difficulty with real-self-activation can extend to difficulties in taking good care of personal needs, such as diet, weight control, exercise, rest, and proper grooming. On the other hand, some patients can spend inordinate time on taking care of themselves.

There can be problems with affect regulation, with either detachment and too little affect or too much affect and outbursts of narcissistic rage. Unlike with the exhibitionist, there is a constant repetitive experience of the disorders-of-the-self triad: selfactivation leads to anxiety and depression, which lead to defense. Under separation stress, the depression is full blown and the patient may become suicidal. Otherwise the depression is better defended against and of a lower grade.

There may be a host of neurotic symptoms, from anxiety to phobias, compulsions, and hysterical symptoms. Somatic symptoms are particularly common as the patient experiences the impaired real self as "the body's falling apart." In some patients, acting-out symptoms arise, with sexual promiscuity, alcoholism, or drug addiction. In others, the symptomatic picture can be that of an eating disorder, most commonly bulimia, but also anorexia nervosa. For the adult patient, there may also be a current, ongoing enmeshed relationship with the mother or father, or both, with the patient feeling caught up in the role of psychological caretaker and unable to free himself or herself from that role.

Separation stresses commonly precipitate a clinical syndrome: separation from the idealized or devalued object and/or a loss of narcissistic supplies, such as power, money, beauty, or appearance.

Clinical Examples

The following examples present brief descriptions of patients who will be discussed in greater detail in the chapters on psychotherapy.

Case of Ms. A.

Ms. A., a tall, blond, slender, divorced, 40-year-old homosexual woman who owned a business and had two children, complained of her difficulty in interpersonal relationships. She had had her first homosexual relationship while in college. Later she fell in love with a man, married him, and in so doing, she said, "I lost my sense of self. I became all things to my husband and children." She was married for 10 years, during which time there were no homosexual relationships.

She reported, "After 10 years, I realized that I had no self, nor did I have any intimacy with my husband. I started to drink, and as I had a low tolerance for alcohol, I became an alcoholic and had blackouts. I drank for three years, until last year, when I joined AA and started an affair with a woman.

"During the three years that I was drinking, I had two relationships with women and one with a man. All of them were difficult and conflictual. I tended to sell out to women who were attracted to me. I have great difficulty acknowledging myself. I feel I have no self. I have trouble asserting myself."

Comment

This patient's defense of idealizing the object helped her to manage for many years, as long as she denied the cost to her real self. However, as she got older, this defense began to fail with her narcissistic husband. She divorced him, but, on her own without a close object to idealize, she became an alcoholic in order to deal with her abandonment depression, and she started psychotherapy. When the psychotherapy did not help, she came to therapy with the complaint that her lifelong idealizing of the object had not worked, and that she was aware of its cost to her real self.

Case of Mr. B.

Mr. B., a 55-year-old bachelor, in the setting of the death of his closest male friend, conflicts in his relationship with a woman friend, and increases in his asthma symptoms, became anxious to the point of panic for fear that he might have a coronary occlusion and die, as several members of his family had died of heart attacks. He checked his blood pressure and pulse four or five times a day. He denied depression, but the affect was probably absorbed by his somatic preoccupations. He also felt a lessening of his interest and energy and sense of excitement in his work.

He complained of difficulties in his relationships with women, both in the present and throughout his life. He had a close relationship with a 35-year-old woman, whom he liked and to whom he was attracted, but, he said, "She wants emotion and commitment, and I mostly want sex, and I get angry at her demands. As much as I like her, when she's not around and I'm alone, I don't miss her and I feel fine."

Comment

As a child, this patient's abandonment depression had been powerfully reinforced by severe physical illness that threatened death. He had defended by detaching affect from the self and the object and idealizing it, and by performing to receive adulation. The loss of the friend, the pressure of intimacy, his age, and the recurrence of his asthma overcame his defenses and reinforced and precipitated the childhood panic that he would die.

Case of Mr. C.

Mr. C., a single 38-year-old architect, had a chief complaint of "latent heterosexuality, homosexuality, social isolation, depression, and anger and self-destructive behavior." He described himself as a workaholic who worked 16 hours a day. He lived by himself and was socially isolated. He had great difficulty tolerating his feelings when alone in his apartment, and when he was not working, he drank at home or went out to gay bars, either just to observe and be with people or to seek one-night sexual stands. He found it difficult to access his feelings, and so felt detached a good deal of the time, and although he wished to have relationships, he had few friends and felt isolated and lonely. "I couldn't bear to have anything good happen to me," he said. "I don't deserve anything. When anything good happens, I turn around to attack myself. I spend my time observing. It's frightening to get close to people."

Comment

This patient's impaired real self was so fragile that his defense of performing for the idealized object to regulate his grandiose self was not sufficient, and thus he also required detachment of affect from the object and workaholism, and possibly alcoholism, to deal with the profound abandonment depression. It was the failure of this entire defensive system to manage his depression and isolation that brought him to psychotherapy.

Case of Mr. D.

Mr. D., a 50-year-old married businessman, came for psychotherapy after a heart attack with a chief complaint of: "I'm hanging onto a bad marriage because I'm afraid of being abandoned. I've been in codependency groups for years and have read widely, including several of your books. I abdicated to my mother, and since then to two wives. I feel chronically depressed most of the time. I feel lost, with no sense of an identity or of self. My business is successful, but I am a workaholic. Many years ago, I was an alcoholic. However, I've been overeating and am still 25 pounds overweight after my heart attack."

Comment

The patient's heart attack impelled him to come for psychotherapy after a number of previous therapeutic failures. The difficulty with the sense of self, the dependence on attacking women, suggests that his defenses go beyond the usual focus on the object to an internalization of the aggressor defense that requires an external aggressor to reinforce it. This defense suggests the possibility that the parental negative attitudes may have included physical and/or sexual abuse.

Summary

The diversity of the clinical picture—difficulties with self-image, with affect, with relationships with others, with overt symptoms, with impulse control, as well as workaholism and alcoholism— seem to defy organization, and, therefore, the development of a carefully thought-through and considered therapeutic approach. The advantage of the developmental self and object relations perspective, described in Chapter 2, is that it sifts through this clinical diversity to reach the underlying, enduring, unchanging intrapsychic structure. It allows the therapist to organize the clinical material according to this structure, which then informs the therapist as to what is on the center stage of treatment and how it must be dealt with, and also how to evaluate the results of the efforts to deal with it. In other words, it provides not only a point of view, but also a tool with which to conduct an ongoing evaluation of that point of view.

2

A Developmental, Self, and Object Relations Theory

The term narcissism has become so associated with disorder that it is important to differentiate between healthy narcissism, which is essential to life, and pathological narcissism.

Healthy narcissism, or the real self,² is experienced as a sense of self that feels adequate and competent, a feeling derived mostly from reality, with some input from fantasy. This sense of self includes appropriate concern for others, and its self-esteem is maintained by the use of self-assertion to master challenges and...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Acknowledgments
• Contents
• Introduction
• Part One: The Oinical Picture
• Part Two: Psychotherapy
• Part Three: Countertransference and Projective Identification
• Summary
• References
• Index