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This is sort of a curiosity I've had for a long time, which is the pros and cons or the good and the bad of 12-step programs. And what's been your experience in treating people? I imagine some of whom also go to 12-step programs, and where does it work for you and where does it fall off for you? What are the dangers and what are the assets to 12 steps?
Yeah, I have found 12-step programs to be invaluable to many, many people. I think they're an important support. They help a lot of people get grounded, people who otherwise seem to not be able to establish a solid position in life and abuse substances of one sort or another. So their service is important to all of us because we all know people who have had some difficulty with substances.
Having said that, sometimes the 12-step program does run a little bit at odds with some of what we might want to do in psychotherapy in the sense of having a person explore more fully their role and responsibility. Since the first step is to acknowledge that one is powerless, that leads to a position where sometimes exploration and therapy hits up against that wall and the person says, "You know, this is not within my abilities. You're asking me to do something. I'm powerless there." Sometimes we have to fudge a little bit, but I found that a person can stay faithful to their 12-step program and explore their individuality as well.
The other comment is about the higher power. I think initially the higher power was generally felt to be a god figure. As 12-step programs developed, a lot of people have been involved in those programs who don't believe in a god. Then the higher power is a moral value system, an ethical system. And as AA or 12-step programs emphasize that sharing of a value system, they help people move out of an isolation into a more common shared space under those shared values.
Do you think there could be such a thing as AA for personality disorders? I'm not sure the percentage of people who have substance abuse who sort of are also personality disorder diagnosed, um, or could be. Well, I think that many, many people who have substance abuse have also a personality disorder. Personality disorder can be understood as difficulty dealing with the complexity of reality. And reality, I don't mean just the challenges of external life, but the challenges of attending to one's own needs and desires and wishes. So to find the balance between what we want, what we desire, what we think is right, and what society allows us to do is the goal of psychotherapy. A lot of people can't find that balance and therefore indulge in the substance abuse to take them away from the anxiety of perhaps desires that they don't know how to fulfill or prohibitions that they don't know how to live up with.
Personality disorders often stem from that imbalance, that inability to combine different psychological forces and the reality within which one lives. So if you're imbalanced in that way and out is using a substance, it's understandable that a lot of people with personality disorders try to quiet one part of their mind with the substance. And therefore, I think 12-step programs provide a lot of health to a lot of people with personality disorders.
Do you think with, you know, with 12-step programs, and I'm actually, I had tried to use it for an eating disorder. It didn't work for me for that. But the aspect of spirituality and community that 12-step programs purport to offer people, is there an equivalent in therapy? Which I'm not even sure sometimes what spirituality means, actually.
Well, you know, that's a big topic. Yeah, but I think I would agree with the way you put it. 12-step programs provide a very clear set of values by which to live. Psychotherapy differs depending on which specific therapy you're talking about, but it doesn't provide that sense of community. It really helps somebody figure out what their north star is, what values they want to live by. A cliched and outdated view of psychoanalytic psychotherapy is that it's almost antithetical to anything that might have a religious tone, but it's very friendly to the notion of figuring out within yourself what you believe in, how to put it together as a harmonious system within your mind that is ethical, not too harsh, not too relax, so you don't go around hurting other people or doing things that are damaging to yourself. So the individual psychotherapy is a longer path to a more individualized version of a moral community, if you want to put it that way.
And one other thing that has interested me about AA or the one, this one step when people take sort of a moral inventory. And I read that as sort of an accountability, especially I think with personality disorders, there's an aspect of accountability that has to come into play in a person squaring with, you know, what they've done.
Um, yeah, when I think you're talking about the fourth step. I think it's the fourth step. It's a very honest moral inventory to look at what one has done, in particular in relation to others, and then to make amends. And I think that moral inventory is often the most challenging because it does, as you say, confront them with parts of themselves they don't want to think about. It goes back to that paranoid schizoid position. I don't want to feel I'm guilty. I don't want to feel I've been aggressive. I don't want to feel I've done damage. So the fourth step, the moral inventory, is very important, I think, to a person's psychological equilibrium. And if carried out well, helps somebody move into that more complex and integrated psychological organization that usually leaves somebody better fit to deal with the world around them.
What would be the equivalent therapeutically, in terms of what you're doing when you're treating people who have narcissism or BPD? Do they have to sort of do that to get better?
Well, it's less complicated in a way. It's a very basic psychological step. The moral inventory might follow, but the step I'm talking about, which to me is the crucial step in the psychotherapy of anybody with a major personality disorder, is owning one's own aggressive drives. That doesn't make you a bad person. It makes you a better person. I think that's the initial movement toward taking a moral inventory because for a lot of reasons, and we can talk about trauma, people with personality disorders can act aggressively but don't see the aggression in what they're doing or at best say, "Well, yes, I'm angry and aggressive, but only toward myself. It doesn't include other people."
When I called up my husband and said, "By the time you get this phone message, I'll be dead, but don't feel bad. You know, you did everything you could. I'm just a hopeless case." There might be desperation in that call, but I think there's also something aggressive toward the husband. My goal is to help people see that being aggressive doesn't mean being bad. Being aggressive with no awareness and control over it is generally pretty bad, but being aggressive with awareness and mastery over how to express and manifest the aggression is not so bad.
I was asked to consult on a case. In describing the case to me, the therapist showed me some images. The patient had cut herself quite deeply. There was an opening, blood tissue exposed, muscle tissue exposed. And the patient took these photos, sent them to the therapist. And I said, "Don't you think that was an aggressive action to you? To send you these photos? They're gory, they're disturbing, they're upsetting." And the therapist said, "No, no, she was just trying to say how she was feeling." My belief is she was trying to say how she was feeling, but she was also making you squirm and wince.
So what we would do in that situation is try to look right in the here and now. I'd say, "You know, I do want to hear about how you're feeling. What was there in you when you did the cut?" And then I'd be open to everything the patient said. The next step would be, "Did you think about what it's like to be on the receiving end of those photos?" "I just wanted to give you information. I thought you should have all the information." "Yes, I understand that, but think about the photos. Think about a person receiving those in the middle of an evening."
So we would try to help the person see that seemingly unbeknownst to them, there was an aggressive element. And then to say, "Okay, if there was an aggressive element, what was the aggression about? How can we understand it? What would better ways to put it into action or to express it be?" So it's a long haul, but to me, it's the central step of a therapy with a person with a severe personality disorder.