Robert M. Gordon,Ph.D. ABPP

I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients. They were naively trying to help and before they knew it, they were defending themselves in court, with their professional careers at risk. The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders. For example, a patient may have a dependent personality disorder that is organized at either the neurotic or borderline levels of severity.  If it is at the borderline level (no matter how sweetly the patient initially seems), the patient will most likely use splitting (splitting reality into extremes so that you suddenly go from a “great” therapist to an all bad, rejecting or abandoning therapist) and projective identification (project his own manipulateness and hostility on to you and then treats you accordingly). The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) makes these distinctions and so much more. You will less likely to be blind sided by a victimizing patient if you are familiar with the PDM formulation of personality.

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I have recently presented a workshop “Ethics and the Difficult Person: What the PDM can teach us all.”  Since ethics education is a requirement in Pennsylvania, I have had all sorts of psychologists in my ethics workshops.  Most were non or anti-psychodynamic. After I advertised this workshop, I had to find a much bigger room. I had the largest response to an ethics workshop in ten years; I had four times the usual number of attendees.

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A few months later I presented a workshop on advanced MMPI-2 interpretation with the aid of PDM formulation (Gordon, 2007c). It was the most well attended MMPI workshop I did in about 25 years, with about triple the usual number of attendees.  Many of the psychologists had little interest in the MMPI-2, but were there to hear about the PDM.

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Both the ethics workshop and the MMPI-2 workshop had few psychologists who identified themselves as being primarily “psychodynamic.” I am currently collecting data on how non-psychodynamic psychologists react to the Psychodynamic Diagnostic Manual. So far, the data suggests that 80% of the attendees found that the PDM was more helpful than the DSM in understanding both the surface and depth of personality.  Many of the non-psychodynamic psychologists were amazed at the usefulness and scientific basis of psychodynamic constructs. So, why did my workshops swell in size when the PDM was added to the learning experience? It seemed that non-psychodynamic psychologists needed a rationalization to learn about psychodynamic formulation. The rubric of ethics, risk management and better MMPI-2 interpretation allowed them to gain valuable knowledge without feeling disloyal to their learned anti- psychodynamic biases.

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Most psychologists have been deprived of the rich psychoanalytic literature and empirical findings due to the false statements from competing schools of psychology (Gordon, 2003a). The PDM addresses this issue by devoting approximately half the 857 page book to the section entitled, “Conceptual and Research Foundations for a Psychodynamically based Classification System for Mental Health Disorders.” The review of psychological research supports that perceptions, attitudes, motives, symptoms and interpersonal behaviors are largely influenced by a dynamic unconscious.

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The PDM begins with the P Axis, a classification of personality patterns and disorders, since research supports that symptoms typically come from personality functioning.  The PDM looks at each personality pattern or disorder in terms of Temperamental, Thematic, Affective, Cognitive, and Defense patterns. It then moves to the M Axis, a profile of mental functioning, and finally considers the S Axis, the symptom patterns and subjective experience. Anyone can find the PDM useful in case formulation regardless of what kind of therapy one does. The PDM is not doctrinaire, and the PDM Task Force made an effort to use language that is accessible to all the schools of psychology. For example, Cognitive-behavioral therapists could just focus on the cognitive aspects of a personality disorder and ignore the other factors and their dynamic interaction.

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By utilizing the PDM (as compared to just the ICD or DSM), clinicians will better understand the personalities of patients who often produce ethical dilemmas and risk management issues.  In addition, the PDM’s descriptions of the Moral Masochistic and Relational Masochistic patterns offers important insights into many psychotherapists who submerge their needs and safety to accommodate a victimizing patient. 
 

References

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Gordon, R. M. (2007c). The Powerful Combination of the MMPI-2 and the Psychodynamic Diagnostic Manual, Independent Practitioner, Spring Issue, 84-85.

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Gordon, R.M. (2003a) Towards a Theoretically Individuated and Integrated Family Therapist,  Psychotherapy, Vol. 1, Moscow,

Russia 8-4, January Issue. (This and other relevant articles are available at www.mmpi-info.com)

 

PDM, Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.