Robert M. Gordon,Ph.D. ABPP

Abstract

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The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) was introduced to 192 psychologists as part of either ethics/risk management or MMPI-2 workshops; 65 were psychodynamic, 76 CBT and 51 other non-psychodynamic psychologists (i.e. systems, humanistic/existential, eclectic with no primary preference, etc.). Over all the psychologists gave the PDM a 90% favorable rating. There were no differences between the psychodynamic and other non-psychodynamic psychologists in their ratings of the PDM. Only the CBT psychologists significantly rated two out of four questions less than the psychodynamic psychologists in the areas requiring more abstract reasoning or psychological mindedness. For these psychologists, a non-hermeneutic, concrete language may help in communicating a psychodynamic formulation. The appreciation of the PDM across theoretical orientations suggests the need for greater psychodynamic and PDM education in psychology programs.

Key words: Psychodynamic Diagnostic Manual (PDM), psychodynamic nosology, teaching psychodynamics, concrete thinking

Reactions to the Psychodynamic Diagnostic Manual (PDM) by Psychodynamic, CBT and Other Non- Psychodynamic Psychologists

The introduction of a new psychological diagnostic system is historic, and such events are often met with both excitement and suspicion.  Psychologists might particularly feel negative towards a nosology that appears antithetical to their own biases. This study looks at how psychologists from different theoretical orientations reacted to the new Psychodynamic Diagnostic Manual (PDM Task Force, 2006).

The PDM is a psychological diagnostic classification system for adults, adolescents and older children and infants. It considers the developing whole person. With adults, it starts at the level of personality organization (healthy, neurotic or borderline), then personality patterns or disorders (P axis), then mental capacities (M axis), and finally the often-resulting symptoms (S axis). The PDM is based on neuroscience, treatment outcome, personality assessment and developmental research.

The PDM uses language that is accessible to all the schools of psychology, and is useful in case formulation that could improve the effectiveness of any psychological intervention. 

Not surprisingly, the PDM has received very favorable reviews from the psychoanalytic community (Clemens, 2007; Ekstrom, 2007; Migone, 2006; and Silvio, 2007). It is not clear however how non-psychodynamic and anti-psychodynamic psychologists would react to the PDM. Behavioral and Cognitive behavior therapies partly evolved as a reaction against psychoanalysis and proponents still carry a strong bias against psychodynamic thinking (Lazarus, 2005; Trinidad, 2007).  This bias may be due to defensiveness about one’s dynamics or a lack of psychological mindedness or concreteness (Fenchel, 2005; Gordon, 2008). Theoretical prejudices present challenges to teaching, and the introduction of the PDM offers an opportunity to study the initial reactions of psychologists of different orientations.   
About a year after the PDM was published, I introduced it in three of my workshops; two were ethics/risk management workshops and one was an advanced MMPI-2 workshop. I focused on the P axis- Personality Patterns and Personality Disorders and the three levels of personality organization or level or severity.

“Borderline” is used by the PDM as a level of severity and not as a specific personality disorder as in the DSM. After determining the level of severity, the PDM asks us to then consider the personality pattern or personality disorder. 

In my ethics and risk management workshops I showed how the PDM’s concept of borderline as a level of personality organization is important to identifying difficult patients. I argued that the DSM’s narrow definition of borderline as a personality disorder allows for many therapists to become blindsided. For example a patient with dependent personality patterns may first seem compliant and sweet, but if his or her personality is organized at the borderline level, that patient is likely to later present ethical dilemmas and risk management problems (Gordon, 2007b).

In my MMPI-2 workshop I suggested that the integration of qualitative data (such as the PDM’s determination of healthy, neurotic and borderline personality organizations) and the MMPI-2’s quantitative scores creates a powerful combination to boost validity. For example, the same high Lie score for a person at the healthy level of personality organization can mean high morality; for a person at the neurotic level it could mean repression; or a person at the borderline level it could mean denial and splitting (Gordon, 2007a).  

Most of the psychologists at the workshops had rejected psychodynamic theory in favor of other theories.  If they were taught psychodynamic theory and practice at all, it was usually as an unscientific historical relic. Therefore, in my teaching I emphasized the PDM’s research basis and the PDM’s formulation of personality as useful regardless of one’s favored theoretical orientation.  

Hypotheses

Hypothesis 1: Overall, psychologist’s initial impressions of the PDM should be favorable since the PDM was taught as useful regardless of one’s theoretical orientation. 
Hypothesis 2: CBT psychologists should rate the concrete areas taught in the workshops (the categorizing of personality) no different than the psychodynamic psychologists. However, the CBT psychologists should rate the questions related to the overall psychodynamic conceptualization of personality, which requires more abstract reasoning or psychological mindedness lower than the psychodynamic psychologists.
Hypotheses 3:  Psychologists who are neither psychodynamic nor CBT should be in a middle position in their attitudes toward the PDM.

Method

Psychologists seeking continuing education credits were in one of three of my workshops: 1) a workshop using the PDM to help with MMPI-2 interpretations, 2) a spring workshop “Ethics and the Difficult Person: What the PDM can teach us all,” and 3) the same Ethics workshop in the fall. All the workshops were in Pennsylvania where continuing education credits and ethics continuing educations credits are mandatory. At the time of ethics workshops, it was the end of the two-year, 2005-2007, cycle for completing our continuing education requirements. This gave me a rare sample of psychologists from a broad range of theoretical orientations, including many who would otherwise not go to a workshop with a psychodynamic theme. 

There were a total of 192 psychologists who turned in their surveys; 65 identified themselves as primarily psychodynamic, 76 as primarily CBT, and 51 as other (i.e. systems, humanistic/existential, eclectic with no primary preference, etc.). This sample is consistent with the distribution of theoretical orientations by psychologists in other surveys (Gilroy, Carroll,  & Murra, 2002, Hollanders & McLeod, 1999). 

At the end of the workshop, I asked the psychologists to fill out a survey stating their primary theoretical identification and rate their reactions to the PDM to four questions:

1. I learned how the PDM could help me better understand the personalities of    clients/patients.

2. I found the levels of personality severity (healthy, neurotic, borderline) helpful.

3. I better understand the value of the concept of borderline as a level of personality organization as compared to a personality disorder.

4. I believe that the PDM can help me understand a person’s full range of mental health.

Questions 2 and 3 relate to the concrete concept of personality categories. Questions 1 and 4 relate to the more abstract concept of the psychodynamic understanding of personality. They rated the questions on a scale from “1= Low” to “7= High.”  

Results

Results from each survey question:

Question 1 (abstract): “I learned how the PDM could help me better understand the personalities of clients/patients.” 

The ratings were for Psychodynamic (M = 6.15, SD = .91), Other (M = 5.84, SD = .97), and CBT (M = 5.61, SD = 1.17). The ANOVA results indicate that a significant mean difference exists on Question 1 by Group F (2, 190) = 4.86, p < .01, (all tests are two-tailed), Partial η2 = .05, Power = .80. Scheffe post hoc tests revealed that Psychodynamic had a significantly higher mean on Question 1 compared to CBT (mean difference = .54, standard error = .17, p = .009 ).  

Question 2 (concrete):  “I found the levels of personality severity (healthy, neurotic, borderline) helpful.”
The ratings were for Psychodynamic  (M = 6.06, SD = 1.07), Other (M = 6.00, SD = .92 ), and CBT (M = 5.77, SD = 1.35 ). The results indicate that no significant mean difference exists on question 2 by Group F (2, 190) = 1.29, p = .278, Partial η2 = .01, Power = .28.  
Question 3 (concrete):“I better understand the value of the concept of borderline as a level of personality organization as compared to a personality disorder.”

The ratings were for Psychodynamic (M = 5.77, SD = 1.23), Other (M = 5.84, SD = 1.05), and CBT (M = 5.81, SD = 1.13). The results indicate that no significant mean difference exists on question 3 by Group F (2, 190) = 0.06, p = .941, Partial η2 = .00, Power = .06. 
Question 4 (abstract):“I believe that the PDM can help me understand a person’s full range of mental health.”
The ratings were for Psychodynamic  (M = 6.18, SD = .90), Other (M = 5.76, SD = 1.07), and CBT (M = 5.66, SD = 1.20). The results indicate that a significant mean difference exists on question 4 by Group F (2, 190) = 4.58, p < .05, Partial η2 = .05, Power = .77. 

Scheffe post hoc tests revealed that Psychodynamic had a significantly higher mean on question 4 compared to CBT (mean difference = .53, standard error = .18, p = .015). 

Hypothesis 1: Overall, psychologist’s initial impressions of the PDM should be favorable since the PDM was taught as useful regardless of one’s theoretical orientation. 

For all four questions combined, 90% of the 192 psychologists surveyed from the workshops rated the PDM favorably (ratings in the 5-7 range). Hypothesis 1 is supported by the data. 

Hypothesis 2: CBT psychologists should rate the concrete areas taught in the workshops (the categorizing of personality) no different than the psychodynamic psychologists. However, the CBT psychologists should rate the questions related to the overall psychodynamic conceptualization of personality, which requires more abstract reasoning or psychological mindedness lower than the psychodynamic psychologists.

The CBT psychologists had significantly lower mean ratings on question 1 and 4 (questions requiring more psychological mindedness) compared to the psychodynamic psychologists. However, the CBT psychologists were no different in their rating of the PDM in more concrete questions 2 and 3. Hypothesis 2 is supported by the data. 

Hypotheses 3:  Psychologists who are neither psychodynamic nor CBT should be in a middle position in their attitudes toward the PDM. 

The other non-psychodynamic psychologists for all four questions were not significantly different than the psychodynamic or CBT psychologists. Since they were not distinctively between the psychodynamic and CBT psychologists, hypothesis 4 was not significantly supported by the data. Surprisingly, the other non-psychodynamic psychologists reacted to the PDM better than expected. 

Discussion

The sample of 192 psychologists was not randomized, however, it is a sample of psychologists from the full range of theoretical orientations. The results, as predicted, showed excellent support for the PDM (90% favorable rating).

CBT and psychodynamic psychology represent the opposite poles of epistemological assumptions (Gordon, 2008) and therapeutic interventions (Hilsenroth, Blagys, Ackerman, Bonge, & Blais, 2005). However, the CBT psychologists had a favorable reaction to the PDM in the areas that were concrete and required little psychological mindedness. 

Surprisingly, the other non-psychodynamic psychologists did not rate the PDM significantly different than the psychodynamic psychologists for all four questions.  The CBT psychologists represent a distinct group in their reaction to psychodynamic concepts. 
Several psychologists wrote on their survey that they had not been exposed to the scientific basis and usefulness of psychodynamic formulation. Many stated that throughout their university education they only heard an anti-psychodynamic bias. Psychodynamic research and treatment are rarely or poorly taught in universities . Westen recently commented that, "Virtually no psychodynamic faculty are ever hired anymore. I can name maybe two in the last 10 years" (from a New York Times article, Spiegel, 2006).  

Since there is good empirical support for psychodynamic theory and treatment (as reviewed in the PDM), and that most CBT psychologists prefer to see psychodynamic therapists (Dattilio, 2003; Gilroy, Carroll & Murra, 2002), it seems that the university psychology departments should provide quality education in psychodynamic psychology and the PDM. When the PDM and psychodynamic thinking was presented in a non-doctrinaire manner, emphasizing its research basis and usefulness in case formulation, there was appreciation regardless of the psychologists' favored orientation. Psychologists who have difficulty with hermeneutic thinking might still gain a respect for psychodynamic formulation if the instruction is concrete and empirically based. 

 

References

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Clemens, N. A. (2007). The psychodynamic diagnostic manual: A review. Journal of Psychiatric Practice, 13(4), 258-260.

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Ekstrom, S. (2007). Review of Psychodynamic Diagnostic Manual. The Journal of Analytical Psychology, 52(1), 111-114.

 

Fenchel, G.H. (2005). Concreteness In Difficult Patients. Issues in Psychoanalytic Psychology, 27(1) 17-26,

 

Gilroy, P. J., Carroll, L., & Murra, J. (2002). A preliminary survey of counseling psychologists' personal experiences with depression and treatment. Professional Psychology: Research and Practice, 33(4), 402-407.

 

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

 

Gordon, R. M. (2007b). PDM valuable in identifying high-risk Patients, National Psychologist, 16(6), November/December, page 4.

 

Gordon, R.M. (2008). “Integrating Theories,” chapter 9 in, An Expert Look at Love, Intimacy and Personal Growth, pp. 86-100, Allentown, Pa.: IAPT Press.

 

Hollanders, H., & McLeod, J. (1999). Theoretical orientation and reported practice: A survey of eclecticism among counsellors in Britain. British Journal of Guidance & Counselling, 27(3), 405-414. 

 

Hilsenroth, M. J., Blagys, M. D., Ackerman, S. J., Bonge, D. R., & Blais, M. A. (2005). Measuring Psychodynamic-Interpersonal and Cognitive-Behavioral Techniques: Development of the Comparative Psychotherapy Process Scale. Psychotherapy: Theory, Research, Practice, Training, 42(3), 340-356.

 

Lazarus, A. A. (2005). Is there still a need for psychotherapy integration? Current Psychology: Developmental, Learning, Personality, Social, 24(3), 149-152.

 

Migone, P. (2006). La diagnosi in psicoanalisi: Present azione del PDM (Psychodynamic Diagnostic Manual). [The psychoanalytic diagnosis: Presentation of the Psychodynamic Diagnostic Manual (PDM).]. Psicoterapia e scienze umane, 40(4), 765-774.

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

Silvio, J. R. (2007). Review of Psychodynamic diagnostic manual. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(4), 681-685.

Spiegel, A. (2006). More and More, Favored Psychotherapy Lets Bygones Be Bygones. New York Times, February 14, found on Internet. 

Trinidad, A. (2007). How not to learn cognitive-behavorial therapy (CBT). 
          American Journal of Psychotherapy, 61(4), 395-403.

 

Author’s note:

Robert M. Gordon, Ph.D. Allentown, Pa. 
You can contact the author at rmgordonph@rcn.com

The reference for a preliminary report on one question from this research is: Gordon, R.M. (2008) Early reactions to the PDM by Psychodynamic, CBT and Other psychologists. Psychologist-Psychoanalyst, XXVI, 1, Winter, p.13.