Removing the Mask of Kindness Diagnosis and Treatment of

the Caretaker Personality Disorder

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To my beloved Mother, who lived for her children-until one day, in her
later years, she discovered ceramics.
 CONTENTS

Preface IX

Acknowledgments

PART I THE INBORN ABILITY TO PROTECT

THE SELF
Psychological and Emotional Survival 3

2 The Benign and Pathological Use of Masks 19

3 Factors in the Choice of Protective Strategies 31
4 From Identity to Catastrophe: When Masks Fail to Protect 43

PART 2 KINDNESS AS DECEPTION 61

5 Diagnosis of the Caretaker Personality Disorder 63
6 Caretaker Personality Disorder and Other Clinical States 81
7 The Psychotherapist with Caretaker Personality Disorder 101

PART 3 TREATMENT 117

8 Obstacles toward Discarding the False Self 119

vi i
vii i CONTENTS

9 Treatment and the Shift toward Self-Focus 135

10 Observing and Measuring Indications of Change 157

Appendix A: Glossary 175

Appendix B: The Selfless Personality Scale 179
Bibliography 181
Index 187
About the Author 195
 PREFACE

Within the recesses of our conscious mind is the belief that "it is better to
give than to receive." The Great Commandment from the New Testament
is to love God and thy neighbor as thyself. Giving to others is not only spiri-
tually rewarding but also sOcially and interpersonally redeeming, psycholog-
ically palatable, and perhaps even phYSiologically beneficial. There are indi-
viduals who seemingly take the concept of giving to extremes as if
self-gratification is selfish and, even worse, a sin. Psychotherapists have ob-
served many of the consequences of pervasive selflessness that include feel-
ings of deprivation, emptiness, and the experience of living in an existential
vacuum. As a consequence of this observation, particularly over the past two
decades, therapists more readily encourage their patients to seek balance in
their relationships and develop a healthy self-interest while also being re-
sponsive to the needs of others, in other words, to love thy neighbor as thy-
self but not to the exclusion of the self. Perhaps as a precursor to this con-
temporary emphasis on a give-receive balance, Fromm stated his view of the
Significance of self-affirmation: "If an individual is able to love productively
he loves himself too; if he can love only others he can not love at all."l Spir-
itual leaders are beginning to espouse that even for the giver, charity is as
much about getting as it is about giving and that spiritual self-interest is an
appropriate action.
In spite of the increasing awareness that it is not always better to give
than to receive, for many individuals receiving is extremely uncomfortable

ix
x PREFACE

and is usually deflected. These individuals will buy expensive gifts for oth-
ers, inconvenience themselves to do favors for them, and nurture others
back to health while neglecting their own health. Ask them what they would
like for a birthday gift, and the typical response is, "Thank you, but I don't
need anything." Saying yes to kind gestures from others engenders guilt
feelings that lead to such responses. On the other hand, saying no to re-
quests for favors from others evokes anxiety and even panic in this person-
ality type. This imbalance in give-and-receive responses contributes further
to interpersonal and intrapsychic problems that range from adjustment dif-
ficulties to life-threatening depression.
Whether or not we are in the helping professions or have special talents
or skills, most of us find giving a joyful experience. We admire people who
give more than their share. We do not suspect their motives as political or
manipulative for some personal gain, and we usually do not have to be wary
of the gifts they bare or the favors they offer. Generally, these are reason-
able, well-intentioned people. On a surprising number of occasions, we as
therapists do encounter those individuals whose selflessness is transformed
from a benign, admirable character trait into a pathological condition. Pre-
viously the cornerstone of their apparently stable existence, kindness as a
coping strategy begins to fail them, and they are likely to require profes-
sional help.
Why would someone adopt a lifestyle that provides limited need satis-
faction and a diminished capacity for joyful experiences? One "benefit"
might be that the reluctance to receive keeps others at an emotional dis-
tance, which limits closeness and the possibility of repeating prior traumatic
interpersonal experiences. Being in this position provides the other-focused
person with the follOwing advantage: "If I take what you offer, you may get
the impression that I need you. I prefer it the other way-that you need me
most of the time, if not all of the time." This give-receive imbalance, in
many cases, ironically can lead to the very responses that selfless types were
seeking to avoid that include rejection, abandonment, and hostility from
others. Bach and Goldberg wrote that nice guys can wreck lives, including
their own. 2 The beneficiaries, subliminally sensing emotional distance from
the giver, usually feel controlled, manipulated, and smothered and tum
away from them. This consistent deference to others not only damages re-
lationships but can ultimately lead to loneliness, isolation, and suicidal
thoughts. These are but a few of the dire consequences that can result when
selflessness becomes an obsessive lifestyle.
Gale, a psychiatriC nurse in her forties, came for help and presented that
she was physically exhausted, lonely, and emotionally drained. She was known
PREFACE xi

as 'Wonder Woman" by her peers because of her boundless energy and un-
wavering commitment to patients. She had felt embarrassed when she cried
in the presence of a supervisor when a patient on the hospital unit died. In
her mind, shOwing emotion represented an unacceptable display of weak-
ness. Unaccustomed to openly expressing feelings, she believed she was hav-
ing a nervous breakdown. In the beginning phase of treatment, she spoke al-
most exclusively about the people in her life and avoided discussing herself
directly. She proudly stated that her family, friends, and patients needed her
and that, in spite of feeling overwhelmed at times, she made herself available
to them. When I asked her what she needed, she seemed startled by the
question and had difficulty responding. After several minutes, she replied, "I
don't recall anyone ever asking me that question," and she began to cry. She
expressed her appreciation that someone asked her-about her-and as an
expression of gratitude referred a physician to me whom she had known from
her work at the hospital. Although centered primarily on his work, the physi-
cian also suffered from a preoccupation with the welfare of others and the
concomitant neglect of his own interests and need states.
John, a forty-five-year-old cardiologist, had reverted to an amphetamine
habit that began in medical school. Trying to keep pace with his caseload
and making certain of his accessibility to patients, he succumbed to addic-
tion and entered a drug treatment program. He developed a serious kidney
problem as a result of the drug abuse. The combination of not seeing pa-
tients for nearly a year (the core of his identity) and his dependency on dial-
ysis treatments led to depression and persistent suicidal thoughts. In the
early phase of treatment, he stated in a noticeably unemotional manner that
he was concerned that his relationships with his wife and two children,
strained prior to his addiction, were worsening. He admitted that it was not
his idea to come to a psycholOgist and that his wife insisted that he do so.
Following the completion of a drug rehabilitation program and after begin-
ning therapy, he returned to work. Almost immediately, his boundless en-
ergy was restored, and he reestablished his devotion to his practice.
After three years of progress in therapy and with renewed support from
his wife and children, John appeared to have made a satisfactory adjust-
ment. Concerned that he could relapse into "the old workaholic trap," he
decided to give up his practice and teach at a medical college. He began to
exercise, make new friends, and plan more vacations with his family. At the
end of his last therapy session, he stated that he felt happy for the first time
in his life. By mutual agreement, his treatment ended.
Two weeks before leaving his practice to begin his teaching career, an in-
cident took place that caused John to relapse and yield to his addiction once
xii PREFACE

again. A patient who had been under his care for more than fifteen years
wished to return home after a prolonged hospital stay following heart sur-
gery and complications from pneumonia. John recommended that he re-
main in the hospital three or four more days. Adamant about returning
home, the patient, in opposition to his doctor's recommendation, decided
to sign himself out. John wanted to spare his patient the indignity and the
paperwork involved in such an arduous process. He put his self-interest
aside and without hesitation released the patient. The patient contracted
pneumonia, nearly died, and filed a malpractice suit against John for giving
in and releasing him from the hospital too soon. John felt betrayed and dis-
illusioned, and although he did not revert to his former habit, he spiraled
into depression and returned to therapy. In less than a year, he managed to
recapture the optimistic spirit he had prior to the lawsuit and continued to
enjoy his new career and a wholesome family life. Unfortunately, three days
before his fiftieth birthday, his wife telephoned me and told me that he died
on a dialysiS machine.
My professional and emotional reaction to this case led me to prepare a
seminar for physicians at Fair Oak Hospital in Summit, New Jersey. When
I told the audience about the case, they reacted with silence that, at the
time, I experienced as stunned disbelief infused with intense anxiety. The
majority of the audience seemed to convey an attitude of concern and vig-
ilance about their own mental state and overall well-being. However, dur-
ing discussion, one physician commented in a rather stoic manner that self-
sacrifice is part of the job and that physicians know that when they enter the
field. That noble but dispassionate remark, I believed, served as a counter-
point to my presentation and minimized the danger of the self-neglect that
I had sought to emphasize. The comment also reinforced in my mind the
enormous challenges ahead for myself and my colleagues regarding the
treatment of professionals and nonprofessionals so steadfastly devoted to
the lives to others.
How can accommodating, sacrificing, and giving special attention to oth-
ers-such SOcially redeeming, spiritually rewarding, admirable behavior-
become transmuted into a lifestyle that ultimately can lead to misery, emo-
tional isolation, emptiness, and, in more than a few cases, suicide?
Observers are usually shocked when the person whom they have viewed as
strong, independent, and self-sustaining suddenly appears vulnerable, de-
pendent, and depressed.
The propensity toward selflessness is characteristic of individuals who
enter the helping professions. Nurses, phYSicians, psychotherapists, charity
workers, teachers, clergyman, rabbis, and others are expected to subordi-
PREFACE xii i

nate their needs and desires to the people they serve. Nonprofessionals may
also choose to place the interests and wishes of others above their own.
However, I have observed in my practice and in my personal life that ex-
treme selflessness is a character trait that can be "used" to mask a variety of
psychological and emotional problems. The case histories of eale and John,
for example, reveal a tendency to create a selfless persona in order to dis-
engage from memories and affects associated with childhood trauma.
It is not uncommon for therapists to encounter patients who are preoc-
cupied with the lives of others. They have unintentionally created a con-
trived character that has been interpersonally rewarding and has helped
them cope with profound internal stress. Are they motivated by the need
for attention or approval, or is their extreme behavior pattern based on
some other unconscious self-serving motivation? In many cases, their self-
lessness is addictive-they give, accommodate, sacrifice, and defer until
they are exhausted and depressed from too many self-imposed responsibil-
ities with a minimum of personal satisfaction in return. By the time we have
engaged them in treatment, their caretaker identity has begun to deterio-
rate. The capacity of individuals to survive psychological crises and trauma
by creating a persona or mask-the genesis of the mask of kindness in par-
ticular and the causes and impact of its destruction-is among the subjects
explored in the pages that follow.
We will continue to admire those individuals whose selflessness, magna-
nimity, and philanthropic nature are healthy, authentic, and without com-
plex motivations. They are not the subjects of our clinical attention. How-
ever, those victims of trauma who overinvest in others to the relative
exclusion of their own need states may be at risk. Patients with caretaker
disorder are at a loss as to how to be noticed emotionally by others without
behaving in a false, compliant manner. They desperately require the re-
sponsiveness and nurturance they did not receive from their primary care-
givers. As therapists, they warrant our attention and determination to help
them become more self-focused while maintaining their natural inclination
to be good to others.

NOTES

1. E. Fromm, Escape from Freedom (New York: Avon, 1941), 61.

2. G. Bach and H. Goldberg, Creative Aggression: The Art of Assertive Living
(Beverly Hills, Calif.: Wellness Institute, 1974).
 ACKNOWLEDGMENTS

Many thanks to Jason Aronson, M.D., for his enthusiastic reception of my

proposal; Art Pomponio, Ph.D., for his editorial suggestions and the edito-
rial staff of Rowman & Littlefield; Neil Wilson, Ph.D., for his expertise in
psychoanalysis; James Fosshage, Ph.D., for his input from a self-psychology
perspective; Arnold Rachman, Ph.D., for introducing me to relational psy-
choanalysis; Norman Polansky, Ph.D., Frank Parone, LCSW, and Dan
Kalas, Esq., for their contributions; and the influence of the Menninger
Clinic in Houston, Texas, and their program for professionals in crisis.

xv
 THE INBORN ABILITY TO
PROTECT THE SELF

Since the turn of the twentieth century, researchers and clinicians have
speculated about the impact of psychological stressors on the human in-
fant. Their hypotheses have led to the proposal that newborns are
equipped with an innate protective shield that is in place to help absorb
invading negative stimuli. The evolution of this response capability be-
comes increasingly complex throughout the life cycle, culminating in an
elaborate psychological immune system that is essential for emotional and
psychological survival. One component of this system is the reflexive abil-
ity to invent a kaleidoscope of personas, or "masks," that camouflage emo-
tional pain and the overwhelming impact of childhood trauma. The mask
of kindness is a specific coping strategy that is effective as a protection for
many individuals because selflessness and fOCUSing on others diverts at-
tention away from the effects associated with the early psychological
trauma.
Individuals donning this mask and the beneficiaries in their surroundings
are not aware that functioning on an all-good level can be patholOgical and
that the consistent avoidance of receiving is symptomatic of a character dis-
order. As the effectiveness of this mask diminishes through attrition or ad-
verse life events, the contrived identity is shattered, and the effects of the
trauma erupt into consciousness, immobilizing the individual with anxiety,
panic, and depreSSion.
2 PART I

This part identifies the theoretical basis of our psychological protective

system, the components of that system, its benign and pathological func-
tions, the factors that contribute to an individual choice of a particular cop-
ing strategy within the system, and the impact of trauma that leads to the
breakdown of the system and the destruction of self-organization.
 o
PSYCHOLOGICAL AND
EMOTIONAL SURVIVAL

The innocence and "magic" of childhood and the developmentally essen-

tial grandiosity of adolescence inevitably yield to the realities of life's un-
certainties and adversities. The first time we become physically ill, our par-
ents are aware that our body is protected from diseases, and with proper
care and rest our health is restored. In the primary grades, we learn in bi-
ology what our parents already knew: that we are endowed with an immune
system that facilitates the healing process when we are phYSically ill. By
contrast with regard to our mental health, the high school curriculum in the
American educational system rarely makes reference to any "natural" way
we are protected from emotional conflict, crises, or trauma. Schools that of-
fer courses in general psychology do cite "mechanisms of defense" that to
some extent help us endure daily stress and adverse life events. However, if
and when we survive childhood psychological trauma, it is reasonable to
suspect that our inborn protective abilities are much more elaborate than
Simply the capacity to repress, sublimate, and project, for example. The
proposal that we are born with a complex psycholOgical protective system is
suggested, albeit tangentially, by research in child development and by a
sparsity of theories that are related to research.
Research fOCUSing on the multisensory field of infants indicates that new-
borns are equipped with cognitive and perceptual capacities that enable
them to develop an awareness of the presence of others around them. l At-
tachment theorY states that the infant--caregiver connection is based not