Hearing and Talking with the Rejected Self

Review of Candace Orcutt’s The Unanswered Self: The Masterson Approach to the Healing of Personality Disorders (London: Karnac Books, 2021), ISBN: 978-1-913494-32-2, 269 pages, paperback, $60.

Psychoanalysis was once considered non-viable for those with personality disorders—a condition judged to be ingrained within the self. James F. Masterson was a pioneer in psychoanalytic psychiatry who, like other innovative contemporaries such as Searles, Kohut, and Kernberg, was determined to establish understanding and effective treatment for these “disorders of the self,” as Masterson later came to call them. In the 1970s and 1980s, a paradigmatic shift was taking place in the evolution of psychoanalytic thinking: from a focus on the symptom to the whole patient and from a near-exclusive emphasis on the inner workings of the individual mind to a more inclusive concern with the relationship between the self and others.

In her comprehensive new book, The Unanswered Self: The Masterson Approach to the Healing of Personality Disorders, Candace Orcutt presents an expert review of Masterson’s contribution to this historic shift in the therapeutic approach. In theoretical detail, with extensive case studies that comprise a third of the book, Orcutt describes Masterson’s unique approach to the treatment of the borderline disorder, together with his dynamic synthesis of the treatment of personality disorders as an overarching concept. Orcutt is a former associate of Masterson’s and serves on the faculty of the Masterson Institute in the U.S., Australia, Canada, South Africa, and Turkey. This considerable experience has well-equipped her to systematically review, expand, and update Masterson’s work—a model focused on identifying and addressing developmental deficits of the self. Masterson’s healing of these deficits, as reflected in the title of Orcutt’s book, rests on the clinician’s capacity to listen, acknowledge, and attune to the unanswered needs of the preoedipal self.

Orcutt devotes the body of the book to delineating the schizoid, narcissistic, and borderline disorders as focal and interrelated in Masterson’s model. A full chapter is given to each and is succinctly narrated with lucid clinical examples that enhance the read-

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er’s understanding of Masterson’s approach: of work with psychopathology based on the developmental deficit and its idiosyncratic manifestation in interpersonal and relational difficulties.

As the book unfolds, we learn how Masterson forms his therapeutic approach by combining Margaret Mahler’s developmental studies with the “inner working models” of relationships proposed by object relations theory. He theorizes that a child’s healthy developmental subphases may be overshadowed and distorted by unmet attachment needs, and thus possibly internalized in faulty psychic models of self, other, and relationship. Consequently, these subphases are internalized in faulty concepts of self, other, and relationship.

Masterson’s clinical approach centers around the concerns of preoedipal psychic development. His techniques aim to provide reparative interventions and relational experience directed to the healing of specific types of personality disorder—pathology arising from unmet developmental tasks at specific stages of psychic growth. Specialized communication is clinically structured to allow the arrested part of the self to feel heard and seen: acknowledgment for the schizoid, mirroring for the narcissist, and containment of contradictory points of view for the borderline. In Masterson’s approach, the therapeutic transformation largely relies on an experiential congruence between patient and therapist.

A chapter on Masterson’s concept of Abandonment Depression explores a central impediment to the healing of personality disorders that has historically defeated therapeutic attempts with these patients. Counter to expectation, such patients appear to become intensely worse just as they seem to be getting better. Instead of accepting this as a failure of therapy, Masterson sees this characteristic negative reaction as part of the ongoing psychic process. He understands that the patient must face and work through the ingrained and faulty assumption that the risk of losing love is always in tandem with the desire for individuation. With therapeutic support and strengthening of the self, the patient can nonetheless continue to cycle toward new understanding and increasing health. This clinical phenomenon is sometimes casually referred to as “two steps forward, one step back,” but the backward step in personality disorders can seem so disastrous that therapists, as well as patients, are often discouraged by it.

Masterson first evolved the concept of Abandonment De-

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pression in his groundbreaking work with the borderline, which established his standing in the field. His formulation of the underlying psychic process, which he calls “the Triad,” is: “self-activation leads to fear of separation, which leads to renewed defense.” He sees the resolution of Abandonment Depression as transformational. It makes possible the capacity to mourn as described by Freud, the ability to achieve the reparative depressive position as described by Klein, and the attainment of the capacity for developmental mourning as posited by Kavaler-Adler.

Orcutt’s closing chapter deserves close reading as it proposes the carrying forward of  Masterson’s theory into current issues of trauma, dissociation, and self-states, as proposed by Bromberg and foreshadowed or echoed in the work of Fairbairn, Winnicott, Khan, Schore, Putnam, and van der Kolk. The concept of trauma was originally introduced into Masterson’s work by Orcutt, and here she suggests that a trauma mechanism may underlie the creation of a personality disorder itself and is implied in an extension of Masterson’s developmental model.

The Unanswered Self is a must-read for beginning therapists and a welcome one for seasoned clinicians. The book combines theoretical concepts with effective clinical techniques especially relevant to today’s caseloads. It is written in a clear, accessible style, and the compelling clinical illustrations bring Masterson’s achievement to renewed life.

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