The Mastersonian approach to the Borderline disorder of self
Our contemporary clinical landscape has been particularly interested in the intra-psychic, interpersonal and behavioral difficulties of a group of patients described as ‘borderline’. Historically a midway diagnosis – a ‘disorder’ somewhere between neurosis and psychosis – various theorists have, over the last five decades, explored and explicated coherent structural approaches to aid clinicians in identifying and understanding the immense psychological turmoil borderline patients face on a daily basis. The current paper will explore the psychoanalytic psychotherapeutic approach of Dr. James F. Masterson (1926-2010) and his colleagues at the now International Masterson Institute. Emphasis will be on the intra-psychic development of the disorder and how the clinician can access and successfully understand and treat the internal life of patients facing the borderline dilemma.
James F Masterson and the borderline adolescent
In carefully reviewing Masterson’s original research projects (1955-1972), it is evident that his major theoretical approach as a young psychiatrist was to understand the various developmental difficulties adolescents face, and the fact that, contrary to the prevailing scientific and clinical attitude of his day, many adolescents did not grow out of their difficulties even though they received some measure of symptom relief with once-a-week psychotherapy and family intervention. Masterson’s main clinical task was to understand the intra-psychic genesis of adolescent acting out and he was given an unparalleled opportunity to do so when he was asked to become head of an adolescent inpatient unit at the Payne Whitney Clinic in New York. This led to various scientific publications and follow-up studies all carefully tracing the inner world of what today is referred to as the borderline dilemma. Succinctly, Masterson found that given the hospital setting and its emphasis on containment of acting out, it soon became evident that the process of containment resulted in the adolescents becoming increasingly depressed! The latter remains a living clinical example of Freudian theorizing where it is held that as certain painful developmental trauma cannot be experienced or remembered and thus worked-through, behavior per se seems the only viable conduit for it; those that cannot remember, repeat. The latter also paved the way for Masterson to conceptualize borderline acting out as a developmental expression of a failed separation–individuation (SI) process. Masterson became increasingly aware that as the adolescent patients contained their acting out and became more depressed, they started talking about historical difficulties relating to their mother (and father) rather than paternal and maternal difficulties as experienced in the here and now. Developmental failures and the resulting intra-psychic and interpersonal vicissitudes could now be explored theoretically as well as clinically.
The central dilemma of the borderline adolescent
Theoretically and clinically immersed in the developmental model of Mahler and her colleagues (Mahler, Pine, & Berman, 1975; Mahler, 1979, a & b), and working within an analytic frame with borderline adolescents, Masterson soon came to understand the importance of maternal libidinal availability in supporting the evolving self of the child. Masterson came to view the borderline adolescent’s dilemma as one in which the adolescent, from an early age, related a form of mothering, that due to her own separation failures, fostered clinging relatedness at the expense of the child’s unique individuality and SI needs; “My mother always tried to help me – or so I thought. I think I always knew she actually wanted to control me, and when I expressed myself she would scream and rant and cry.
I think I knew that to stay connected to her I had to do it her way or be exposed to her anger and rejection”. That is, the earliest mother-child dyad was structured and regulated through a specific rewarding and withdrawing paradigm that comes to dominate the inner world of the borderline. It is held that the mother’s need for the child to be a certain way, and relate in a specific fashion, interferes with the child’s natural imperative to separate and individuate. More tragically, not only is the natural SI interfered with, but such parenting actually also supports dependency and withdraws supplies if the latter bond is not upheld. It is important to note however that many of the behaviors to be shortly described can be found existing on a continuum – at times obvious, but mostly unconscious and unintentional and the product of trans-generational developmental difficulty. Furthermore, and although conceptualized by Masterson in the 1960s, it is currently a well researched reality that maternal affective availability remains vital for continual ego development and is regulated by, and regulates, our most basic neurobiological systems (Greenspan, 1989; Kernberg, 1975, 1976, 1980, 1982, 1984; Masterson, 1972, 1976, 1981, 1983, 1985, 1988, 1989, 1995, 2000, 2004, 2005; Schore, 1994, 2003a, 2003b). In short, excluding obvious maternal neglect, the borderline dilemma is a subtle developmental phenomenon that becomes obvious over time in acting out behavior and may be given another opportunity at growth in the therapeutic encounter.
The split internal world of the borderline disorder of self and the warding off of the abandonment depression
Given the internalization of a withdrawing-rewarding mother Masterson furthered his project in conceptualizing an internal world characterized by both a split ego and split object relations unit. That is, through the use of splitting, the young child and, later, the borderline adult, tries desperately to keep separate two contradictory primitive affective states with itself and object representations. The units can be described as the withdrawing object relations part unit (WORU), and the rewarding object relations part unit (RORU) and is represented by the figure below.
Permission to use given by Zeig-Tucker and Thiesen (2012)
In the WORU the object representation (OR) is one of a maternal part object which is experienced as critical, hostile, angry, and rejecting. Subtly, and at times not so subtly, the child experienced (in reality) a withdrawing of support and libidinal supplies when he or she asserted the wish for separation and individuation. The part self-representation (SR) of the WORU is characterized by feelings of inadequacy, helplessness, guilt, and emptiness. The linking affect is frustration, chronic anger and resentment that mask the underlying abandonment depression.
In contrast, the RORU is characterized by the opposite, that is, by a maternal part object (OR) that is loving, approving and supportive of both regressive and clinging tendencies. The part SR is of being a good, compliant and passive child. The linking affect is of feeling good and being gratified (linked with the pathological ego) and stimulating the wish for reunion. Masterson empathically stated that the emotional upheaval experienced by a withdrawing or punishing mother cannot be truly articulated in technical terms, and defenses should be viewed as desperate inherent survival strategies against unthinkable anxieties and affect storms, ‘activated’ especially during separation stresses and/or individuation strivings and stressors. The latter is most obvious to therapists as borderline patients are frequently in need of therapy after a loss (of a relationship), but not so clear to many clinicians is the fact that when borderline patients ‘activate’ themselves, that is, state their needs and wants and separate – individuate – they face many anxieties as well. Given Masterson’s model, one is reminded that getting better means to ‘move out’ or rely less on the RORU, but that would entail facing the WORU. Many patients in therapy state this when they say, for example;
“To say no (self-activation) to my husband/partner (mother) would mean that I am wrong, bad (WORU SR) and they will leave me (abandonment fears) – it’s hopeless”.
One can now appreciate the paradox of therapy and progress in general for the borderline patient – that in all actuality it evokes the dilemma the borderline tries desperately to avoid. Defense mechanisms, although very effective in the short run, will compromise the central capacities of the self. Masterson described these as follows: (a) spontaneity and aliveness of affect, (b) healthy self-entitlement due to feelings of mastery, (c) self-activation, assertion and support in managing one’s own wishes and supporting them in reality, (d) acknowledgement of self-activation and maintenance of self-esteem, (e) soothing of painful affects, (f) continuity of self, (g) commitment, (h) creativity, and (i) intimacy, without constant fear of engulfment or abandonment.
The basic therapeutic approach to the borderline patient according to Masterson
Clearly evident in various written works, psychotherapeutic intervention remains a challenging and difficult endeavor with most borderline patients. Despite these difficulties, the psychoanalytic psychotherapeutic frame, with its inherent neutrality, is held to be an effective treatment modality wherein the split units and the abandonment depression can be effectively addressed and worked through. How is this achieved? Initially by the following:
- Setting very clear and definite therapeutic boundaries
- Clarifying the level of borderline organization (higher or lower level borderline)
- Establishment of clear therapeutic goals (as articulated by the patient) so as to allow for the process of clarification and confrontation
- Containment of the activated split-units due to the analytic frame and the process of confrontation and clarification
- The working-through of the abandonment depression, and
- supporting the emergence of a ‘Real Self’ through a process called communicative matching.
Most importantly, given the reality that the borderline relies on the RORU to ward off the WORU, its destructiveness needs to be addressed early in the therapy. It is argued that the central therapeutic focus in the beginning phases of therapy (which could last for years) is on making the alliance between the RORU and the pathological ego ego-dystonic through means of confrontation and clarification. Succinctly stated, the therapist remains actively interested in the various ways the patient works against his own self-interest and needs. A composite example, although simplistic, may prove beneficial:
A 35 year old female writer (Nancy) came for therapy for her alcohol problems, relationship difficulties (currently involved with two men) and difficulties in writing. The first few sessions were spent carefully listening and supporting Nancy in stating her therapeutic needs which were as follows: “I would like to manage and understand my drinking and my self- sabotaging relationships with men – it is as if I fear being alone but end up with crap relationships. And my work is going nowhere!” Clearly, from this description Nancy shows promise as many borderline patients cannot even state what they need, and thus defensively rely on therapists to tell them what to do (RORU behavior).
An example of confrontation and clarification:
Nancy: “This week I screwed up – drank a lot – and told Greg to go away (separation stress), started feeling depressed (leads to negative affect) and called Frank (clinging) and that just worsened things! I am a screw-up ain’t I! My mom (OR of WORU) said I will result in nothing (SR of WORU)”.
Therapist: “Could you tell me more about what happened, it seems you had a tough week…”
Nancy: “Well just that – what more do you want me to say! It’s hopeless (abandonment affects) – just want to drink, what should I do? (focus on therapist for advice) – should I stay with Frank or Greg? – what do you think..?”
Therapist: “They are good questions Nancy, and I am reminded of your therapeutic need – that you said you would like to manage and understand your drinking and your relationship with men as you fear being alone but end up with difficult relationships. Do you see link here?” [help focus on self – for now try not to play into the RORU by being directive]. Or more direct: “Nancy, those are important questions; I am not sure how you will understand your relationships better if I tell you what you need to do, as if I would know better.” [The focus here is to support the patient to focus on themselves and their therapeutic need and by-pass the tendency to focus on the other at their expense].
Nancy: “I just feel that when I say to Greg that I need space to write (self-activation) he says I am selfish and then storms out, tells me to choose (borderline dilemma – choose between self or loss!), then I say ‘Fine, go!’ but after a while I feel lonely (self-activation leads to anxiety), how will I manage without him? I start getting anxious and then drink and phone Frank. I think I should stick to Frank and let Greg go. What do you think? Maybe I should give more attention to Greg, his needs. Stop being so goddam selfish! My mom always said I was a selfish little brat – always wanting to do my own thing!”
Here we can clearly see many ‘borderline’ realities: when Nancy activates herself, she was met in her history that she spontaneously gave (her mother’s reaction to her) with active threat of loss (WORU). This is repeating with her chosen object relationships in the present and, in turn, activates abandonment fears that she manages by numbing herself with alcohol, clinging to another relationship (RORU), turning on herself, subverting her needs to Greg, and asking the therapist for direction. The therapist, given the process, can decide how and where to intervene; he can do so supportively to strengthen the ego (when seeing the patient once a week), or bring to her attention (when seeing the patient more than once a week) the various realities she is trying to evade as a way to ward off the WORU affects. Masterson’s work gives many examples of interventions given in once-a-week therapy as well as those found in longer-term therapy.
It should also be mentioned that ‘confrontation’ remains an art and very reliant on the therapist’s “capacity for empathy, introspection, creativity – and understanding and knowledge” (Klein, 1989, p.216). The aim of confrontation is as follows (Klein, 1989, p. 220):
- Limit setting
- Reality testing
- Clarifying the consequences of maladaptive thoughts, feelings or behaviors, and
- Questioning the motivation for maladaptive thoughts, feelings, or behaviors.
The latter is always done with care and forethought and is clearly expected to communicate inherent and respectful trust in a patient’s ability to take responsibility for “identifying and containing feelings, verbalizing them through sessions, and behaving in an adaptive and realistic manner” (Klein, 1989, pp.219-220). We trust, until proven otherwise, that borderline patients have capacity and potential; their failure to demonstrate this should not be met with anger or scorn but an exploratory, supportive, non-judgmental and reflexive attitude and, more importantly, the facilitation of further self-examination and defense analysis. However one must anticipate that self-examination and defense analysis will reactivate the WORU which in turn can be expected to reactivate the RORU as a resistance; and so the work progresses slowly but surely through cycles of exploration and resistance. During this arduous work the therapist will also come to see clearly the concept of the borderline triad which can be summarized as follows: all self-activation (SI and feelings of competence) leads to anxiety/depression that will lead to defense as in:
“I have been doing better (self-activation), then I suddenly become aware – can I do this (leads to anxiety)? What if I change – will my partner like me? Will I be able to do it alone? Then I get so anxious I just let it go, it is easier to just keep your mouth shut and say nothing (leads to defense)…but I can’t keep on doing this! “
As the patient continuously works through these difficulties one will start seeing the flowering of the Impaired Real Self, that is, true needs and desires and capacities of the self that will support the patient moving forward. It is especially, and only in such states, that the patient and therapist may rely on communicative matching. As the patient becomes able to tolerate the activation of individuation strivings, it is of great importance to support the Impaired Real Self as it remains vulnerable. During the initial conceptualizations of ‘communicative matching’ Masterson returned to the work of Eric Erickson, and especially Mahler, to understand this clinical dilemma. The main aim is in providing an individual with the required closeness and acceptance as well as emotional acknowledgement of the person’s unfolding self (evident in self- activation). This is again done with much sensitivity and without the therapist taking over for the patient. The therapist remains alert to the activation of further defenses, the return of old patterns, and continuously acts as a guardian for the real self. With time and patience one can truly see the unfolding of a person less reliant on the RORU and better able to manage, if not worked through (partially and otherwise), the destructive nature of the WORU.
It was the aim of the current paper to describe the psychoanalytic approach of James Masterson to the borderline dilemma. The borderline patient is conceptualized as having a unique intra-psychic split characterized by a rewarding and withholding paradigm. This paradigm can be translated into a self and other experience dominated by clinging and distancing phenomena as desperate attempts to ward off earlier abandonment experiences. Although seemingly effective, it is at the expense of true vitality, creativity and a feeling of uniqueness.
Loray Daws is a registered clinical psychologist in South Africa and a registered clinical counsellor and psychotherapist with the British Columbia Association of Clinical Counsellors (BCACC) and the Canadian College of Professional Counselling and Psychotherapy (CCPCP). He has more than 15 years’ experience of working with various psychiatric disorders. Loray has also completed the New York based Masterson Institute’s three-year post graduate training program in psychoanalytic psychotherapy for the treatment of the personality disorders. Loray serves on various directorates and faculties and has lectured and published internationally in the areas of personality, eating and psychosomatic disorders.
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Image: Journey into a nightmare by Giara