Upside Down Medicine

The Arc of Psychotherapy: What is Personality? What Are Personality Disorders?

Most people are not familiar with the process of psychotherapy. To non-professionals, psychotherapy may look like a lot of hocus pocus with little clarity or focus. Because of this I thought it would be useful to publish a series of case studies in several therapies that I've been privileged to perform. I will outline, in clear and concise detail, the specific problem which generated the therapy, the treatment course(the "arc"of therapy), and the therapeutic outcomes.  I  will comment on some of the theory and techniques employed in psychotherapy. I hope, thereby, to demystify an otherwise arcane process, and to demonstrate how it can lead to important changes in thoughts, feelings, and behaviors.

But first, some basic understanding of the underlying biology of personality. We are all born with differing temperaments. When I was a medical student at NYU, our attending, not a psychiatrist but an OB/GYN, took us to the newborn nursery, where we were to make observations of the 10 or 12 little ones hot out of the oven. Some were placid, mostly asleep. Others were fussy and crying, while still others were alert, curious, looking around for visual stimulation. These characteristics, arguably, represent their varied inborn temperaments. These proclivities are built into the genetically determined structures of their little brains. As  adults, the placid ones will remain laid back, the fussy ones likely will present as anxious, and the curious tots will grow up to seek intellectual and other kinds of learning.

Our personalities,  however, are not only a product of temperament, but also of experience. I liken the child's brain to wet cement: any impression, any experience, it encounters will be forever incorporated into that  brain as the cement hardens.The brain, much like wet concrete, progressively "solidifies" over the first twenty to twenty five years of life. This is why personality disorders are not diagnosed until, essentially, adulthood. Behavioral problems in childhood are still subject to change so long as the "cement" has not hardened. Change is much more difficult in adulthood. Luckily, the brain, even in adulthood, is said to be "plastic" and still subject to changes. Perhaps it is not solid stone, but rather more like hardening putty. 

The "impressions"left on the developing brain take the form of unique neural networks that are relatively permanent in adulthood. Psychologically, these quasi-permanent patterns are called "internalizations. " They are added atop and alongside the individual's inborn temperament to produce what we call personality: relatively stable and predictable patterns of behaviors, thoughts, and feelings which, because they have been "cemented," will repeat themselves repeatedly and predictably over the lifetime. What we refer to as personality is therefore temperament+cemented internalizations.  I like to talk about these regular patterns of feelings, thoughts, and behaviors as the individual's "player piano program," because he and she will be repeating their unique tunes again and again over their lifetimes. 

When the player piano program is adaptive, serving the best need of the individual and those around him, the personality is a healthy one by definition. But when the patterns are maladaptive to a significant degree, the person is said to have a personality disorder. The individuals are not much bothered by their personality traits. Generally, these behaviors tend to cause pain mostly to those who interact with them. A good example of these destructive behaviors can be found in the daily descriptions of one of our current prominent leaders. Others, however, are in some pain themselves as a result of their repetitive personality traits. These person's problems are more technically called "character neuroses."  Whereas the pure personality disordered individual experiences her repetitive behaviors, though destructive to others, as "ego-syntonic("There's nothing wrong with me! It's you who has the problem."), the character neurotic is in some pain,  and recognizes that something, though inscrutable, is amiss about their behavior patterns. It is these people who seek out professional psychotherapy to alter patterns of behavior, thoughts, and feelings painful  to others and to themselves. The truly personality disordered person is in no pain and therefore finds little need or desire for therapy.

The Arc of Therapy: Robin

Robin was a single, attractive nurse, in her mid-thirties. She came to treatment for her depression, and improved significantly in terms of her mood disorder after being placed on a selective serotonin reuptake inhibitor. Nonetheless, she continued to present in a manner she'd demonstrated since she began treatment. She came across mildly and chronically whiney, "sour," clearly unhappy. I drew her attention to the way she was coming across. She conceded she felt unhappy most of the time. I invited her to begin talking about her dissatisfactions. We extended our monthly medication monitoring sessions to a full 45-50 minutes to allow for further elaboration and understanding.

Over a few months, Robin helped me to understand that her unhappiness and complaints stemmed directly from her social life: No man seemed to want her. She remained single, with no husband and no children, while her girl friends were all now married with families. She had occasional dates, but nothing much seemed to materialize from these. Meanwhile, she performed well at work, but she  did not demonstrate great passion for it, and certainly she didn't derive sufficient satisfaction to compensate for  her empty social life.

In subsequent sessions, we explored her prior relationships. What emerged was the revelation that she'd had 3 prior long term relationships in her adult life. She terminated each of these, giving "good reasons" for the first two, though an admittedly weaker explanation for ending the last one, This man was quite in love with her, and apparently she with him, but she nonetheless found a flimsy reason or ending it, something she now regrets. She had no "good reason" for terminating this bond, and now he was already involved with another woman. All of this accompanied by the mild whining addressed earlier. 

Further exploration of her childhood upbringing revealed the following : Father was a pleasant man, but passive. On the other hand, mother was exceptionally intrusive in her life as well as in her father's,. Mother did not hesitate to tell her how she should best manage many aspects of her lie. She told Robin how to dress, how to fix her hair, what to study. In particular, she emphasized how vital it was to marry early and have children, and made her feel small for not achieving these goals.. It soon became evident that Robin had moved to Pittsburgh from another city to be away from her parents' influence.

When we discussed her current life, I learned that she had bought her first home during the initial stages of our treatment, which consisted of monthly sessions stretched over two and a half years, for perhaps a total of 30 treatment "hours." It was over this town house that Robin was the most 

passionate I had ever seen her.  She loved nothing more than spending alone time in the unit, painting and decorating it herself. Indeed, she preferred this to dating and getting together with her girl friends.

At this point I began to connect the dots in her life story, and to uncover her pathological internalized program: Above all else, above friendships, relationships, and boy friends, Robin cherished her autonomy. Mother had been so domineeringly intrusive in her life that Robin needed to protect her sense of her own self primarily. Relationships of any kind, and especially close and intimate ones, threatened her sense of self much as mother had done in her younger years, and were to be avoided. However, she could not admit to herself that she chose autonomy over marriage; this would fall short of mother's now-internalized expectations of her and make her feel small in mother's, and her own, eyes. Instead, she projected the problem onto the men in her life. You don't want me is preferable to the psychological truth: I don't want you. You threaten my autonomy, my sense of self.

I interpreted these conclusions to Robin. We came to the same conclusion on multiple occasions, examining her life from  many different perspectives. Robin found it difficult not to internalize these new understandings, given the burden of evidence. She soon stopped whining. She began dating again. She met a professional who proposed marriage. She was ambivalent. We talked openly about the decision. I pointed out to her there is nothing amiss about living alone and protecting her sense of self, any more than there was something wrong with marriage. The choice was hers. Either one would be both "right and wrong." In so doing, I affirmed her autonomy in making this critical decision. Robin chose to marry, though she was still somewhat ambivalent and  not head over heels in love. 

Interestingly, she moved back to her native city with her new husband, not far from her parents. I rook this as confirmation she had grown strong enough in her "self" to tolerate her overbearing mother's greater presence in her life.

I present the major "chunks" of data which led to the denouement  in her healing as if they were derived in some linear fashion. This was not, and never is, the case. Therapy involves establishing a warm and trusting relationship. It involves detective-like inquiry(without, in Robin's case, being experienced as overbearing and intrusive), clarifying many disparate threads of data, confronting defenses, and bringing Robin along with me to jointly explore her unconscious but nonetheless internalized program. What she does with this knowledge is up to her, now better armed with new understanding about herself. Therapy is indeed the art of "disclosing man to himself.."