To Know and to Care: A Review of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. Second Edition, Nancy McWilliams The Guildford Press, New York and London, 2011
Robert M. Gordon, Ph.D. ABPP
I know some people will reject this book because “Psychoanalytic” is in the title. Others will reject this book because “Diagnosis” is in the title. However, this essential text is highly useful to all practitioners of any theoretical orientation if they can get past the negative stereotyping. The term “Diagnosis” as used in this book is in line with the original definition of the word that is derived from Greek- meaning a distinguishing, to perceive, to know thoroughly. The second part of the book title explains that the point of diagnosing is to know how to help. McWilliams clarifies that, “The main object of this book is to enhance practice...” and that is what this book does extremely well.
Nancy McWilliams never looses the person to the diagnosis. “Once I have a good feel for the person, the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client...one can throw away the book and savor individual uniqueness.”
McWilliams writes, “I want to stress that analytic theories emphasize themes and dynamics, not traits; that is why the word "dynamic" continues to apply which is the appreciation of oscillating patterns...than the list of static attributes one finds ...in the compendia like the DSM.”
Psychoanalytic is in contrast to the behavioral assumption that personality is made up of additive behaviors and cognitions and that symptoms are functionally autonomous and may be diagnosed and treated independently of the rest of personality. I find it hard to imagine how any astute observer of human nature could accept such an insightless psychology. But a high level of mentalization is uncommon even among very intelligent individuals, and thus this simplicity is the dominant view. This is why this text is so needed and an important contribution.
Why A New Edition?
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) and the International Classification of Diseases- Mental and Behavioral Disorders, of the World Health Organization (ICD) are taxonomies that were developed to identifying and track the prevalence of medical diseases. They lack an implicit definition of mental health or emotional wellness and must politically be acceptable to practitioners of different theoretical orientations.
Nancy McWilliams originally wrote Psychoanalytic Diagnosis in 1994 because she wanted to expose students and practitioners to the inferential, dimensional, contextual concept of diagnoses that is also appreciative of the subjective experience of the patient, that was very different to the DSM III that became more symptom focused.
McWilliams has since the 1994 volume, asked practitioners to e-mail her with criticisms and suggestions based on their clinical experience. She integrated many of their suggestions into this current volume. She also incorporated the recent findings from psychodynamic theory, developmental, process and outcome research and findings from neuroscience. I also wonder how much her experience in working on the Psychodynamic Diagnostic Manual (PDM), which was published in 2006 contributed to her thinking about her 2011 diagnostic text. My guess is that this book allowed McWilliams to express her own thoughts more purely and fully. There are areas of disagreement between this book and the PDM that I will later discuss. But let me say here, that I agree with McWilliams in making level of personality organization a distinct and essential axis- which is not the case with the PDM.
I am often upset when I see the constant relabeling of constructs to be politically correct, to give the appearance of a new or more precise finding, or when some other theoretical orientation rediscovers the psychodynamic wheel- gives it a new term and calls it their discovery. McWilliams has none of that, and will often use in this text, the older terms if they are more explored and explanatory over the more recent terms.
One cannot compare the reading of encompassing taxonomies such as the DSM, ICD and even the PDM with a well-written book. I have read the various DSM and ICD editions many times with heroic effort and lots of coffee. Reading them makes me feel ADD. The DSM and ICD- necessarily lack humanity. They are compilations of all possible agreed upon disorders, and they are not about teaching insight into personality. And while the PDM also tries to cover all the bases, it is a much better read than the DSM and ICD, because of McWilliams’ writing.
Her writing style is much like she describes her therapy sessions. She points out the necessity at times, to judiciously self-disclose. Her personal sharing gives the text a soul and you feel you are with a warm and wise teacher. For example when discussing the value of psychoanalysis, McWilliams discloses, “I share this opinion, having benefited all my adult life from a good early classical analysis.”
Let me share with you an example of her eloquent style that pervades this text: “When any label obscures more than illuminates, practitioners are better off discarding it and relying on common sense and human decency, like the lost sailor who throws away the useless navigational chart and prefers to orient by a few familiar stars.” It is writing such as this, which makes this text enjoyable, as it is enlightening.
The Psychodynamic Paradigm Shift
There are at least two interacting major paradigm shifts in psychoanalytic theory and the non-dogmatic McWilliams has long been on top of them.
One involves epistemological and relational assumptions about how observing affects the observed. McWilliams alludes to the Heisenberg uncertainty principle when trying to understand another in the context of a professional relationship. However, psychoanalysis takes this source of methodological error and turns it into a treatment whereby the act of mutual observation can change the patient for the better.
We see the second shift discussed back in her 1994 first edition where McWilliams had the vision that psychodynamic theory is a complex, non-linear, non- additive system. She continues to remind of us of this in the 2011 edition. I agree and further think psychoanalytic theory has evolved from the basic topographical/tripartite/interpersonal constructs to a theory of the bio-psycho- social mind as a “complex adaptive system (CAS).” A CAS is a multilayered series of systems and subsystems with many interacting constructs that are adapting to each other and contexts, with periodic emergences. In this sense, drives, defenses, affect tolerance and regulation, temperaments, fantasies, introjects, cognitions, self subsystems, moral reasoning, memories, mental capacities, self-other boundaries, contexts and conflicts are all interacting at mainly an unconscious level. Symptoms are viewed as emergences from this complex adaptive system. Certainly, Karl Popper’s criticism that psychoanalytic hypotheses are not falsifiable is irrelevant to a complex adaptive system. CAS helps us to better understand complex phenomena that cannot be view in a laboratory without invaliding the process. The preferred scientific methodology for CAS is replicatable observation, computer modeling and non-linear statistics. This fits well with McWilliams’ view of the diagnostic process as complex and on a dancing landscape.
PDM vs. Psychoanalytic Diagnosis
Nancy McWilliams not only contributed to the formulation of the PDM (along with a rare coming together with some of the finest minds of our field), but also did a beautiful job in the PDM’s readability. The PDM is divided into the Personality Patterns and Disorders- P Axis (which includes 14 main personality disorders), the Profile of Mental Functioning Axis- M Axis, and the
Symptom Patterns Axis- S
Axis. It also covers a section on the Classification of Child and Adolescent Mental Health Disorders and a section on the Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood.
Psychoanalytic Diagnosis focus only on adult personality, but goes beyond the few paragraphs of descriptions found in the PDM. It goes into fascinating detail about personality organization, defensive functioning and character styles and describe how they impact treatment. McWilliams does not cover the range of the PDM (which serves as a near complete taxonomy), but instead focuses on the most common issues found in practice and of which she is most personally familiar.
The Efficient Two Axis Model
McWilliams’ taxonomy is fundamentally based on just two Axes. The first dimension conceptualizes a person's degree of developmental grow or personality organization (neurotic-normal level, borderline level and psychotic level). McWilliams assesses the neurotic, borderline, and psychotic levels of personality structure in terms of favorite defenses, level of identity integration, adequacy of reality testing, the capacity to observe one's pathology, nature of one's primary conflict, and transference and countertransference.
She explains that “borderline” is not a distinct personality disorder as introduced by DSM III, but an over-all level of severity. It is a stable instability between the border of neurotic and psychotic ranges, characterized by a lack of identity integration and reliance on primitive defenses without the overall loss of reality testing that is seen with people at the psychotic level.
The second axis identifies the type of character or personality patterns (psychopathic, narcissistic, paranoid, depressive, schizoid, etc.). She explains that though this two-axis model is oversimplified, it is useful in synthesizing and streamlining diagnostics for newcomers.
She however does acknowledge other important diagnostic considerations. She wrote “...particularly in the early phases of therapeutic engagement, to consider the emotional implications of someone's age, race, ethnicity, class background, physical disability, political attitudes, or sexual orientation than it is to appreciate the clients’ personality type.”
Nancy McWilliams lists five main reasons for diagnosing: 1. Its usefulness for treatment planning. She writes, “Treatment planning is the traditional rationale for diagnosis.” Understanding character styles help the therapist be more careful
with boundaries with a histrionic patient, more pursuant of the flat affect with the obsessional person, and more tolerant of silence with a schizoid client.
2. Its implications for prognosis. “Realistic goals protect patients from the demoralization and therapist from burnout.”
3. Its contribution to protecting consumers of mental health services.
A careful diagnostic evaluation reduces the likelihood that someone will continue to waste time in a professional relationship for which he or she is deriving little benefit.
4. Its value in enabling the therapist to convey empathy. Once one knows that a depressed patient also has a borderline rather neurotic level personality structure, the therapist will not be surprised if during the second year of treatment she makes a suicide gesture. Or once a borderline client starts to have hope of real change, that the borderline client often panics and flirts with suicide in an effort to protect himself from traumatic disappointment.
5. Its role in reducing the probability that certain easily frighten people will flee from treatment. McWilliams points out that it is helpful for the therapist to communicate to hypomanic or counter-dependent patients an understanding of how hard it may be for them to stay in therapy.
I add to this list: 6. Its value in risk management. I do expert witness defense work. I often see cases where a therapist (usually without psychodynamic training) is being sued by a former patient for abandonment or mistreatment. These therapists mistakenly used a presenting symptom as the only diagnosis and missed the borderline level of personality or psychopathic personality and got into trouble.
7. It’s value in process and outcome research. I am tired of the typical allegiance biased, symptom focused, short-term, manualized treatment, with straw-man comparison groups, outcome research set up to justify superficial therapies. Both the PDM and McWilliams “Psychoanalytic Diagnosis” offer diagnostic constructs such as defensive style, level of personality organization and character organization that does not respond well to superficial treatments and do respond to psychodynamic treatments.
8. It’s value in court. I have used the PDM’s distinction between the parasitic vs. aggressive type psychopaths in court. When the opposing attorney protested that this was not in the DSM, “the bible of psychiatric diagnoses,” I retorted that it was not my bible and that it was a just the product of the psychiatric guild and that we were not required to use it. I argued that since the PDM was a product of five of the major psychoanalytic organizations and was supported by a great deal of research, it is therefore well within both Frye and Daubert rules of evidence regarding the admissibility of expert testimony. The Judge ruled that my testimony based on the PDM’s descriptions of two different types of psychopaths was admissible.
Examples How Diagnosis Helps with Treatment
McWilliams first looks at how the levels of personality organization are important in the therapeutic process. She states that the neurotically organized person is like the boiling pot with the lid on too tight making it the therapist’s job to let some steam escape (uncovering-expressive work). However, the psychotically vulnerable individual’s pot is boiling over, and it is the therapist’s job to turn down the heat and get the lid back on (supportive work).
She explained that since the psychotically vulnerable patient has problems with reality, it is important for the therapist to be very open and clarifying with demonstrations of trustworthiness. They require a "supportive therapy" that emphasizes active support of the patient's dignity, self-esteem, ego strength, and need for information and guidance.
With a neurotic level person in a paranoid state, the therapist lets the patient develop and explore his or her fantasies about the therapist and to interpret the transference. But an interpretation of transference is often not helpful with severely disturbed people.
McWilliams points out that for many neurotic level people, the best time to make interpretations is when the patient is a state of emotional arousal, so that the patient is less likely to intellectualize the affect. With borderline clients, who also require a supportive approach, the opposite consideration applies, because when they are very upset, it is hard for them to take anything in.
In addition to the therapeutic consideration of the personality organization axis, McWilliams offers many therapeutic strategies that are specific to each of the characterological types.
Will the PDM2 Resolve Some of the Conflicts with Psychoanalytic Diagnoses?
Robert Bornstein and I felt that the PDM needed to be operationalized. So we developed a clinician-friendly Psychodiagnostic Chart (PDC). We also had the idea of integrating the PDM’s diagnostic dimensions with ICD or DSM symptoms and having personality organization or structure as a separate dimension (as per Nancy McWilliams’ text).
I contacted Vittorio Lingiardi from Rome and asked him about his PDM2 project. Much to my delight, he and his team quite independently, were also considering having a separate personality organization axis and were also working on a streamlined PDM and operationaling it with user-friendly tools.
Recently, Bob Bornstein and I conducted an online survey asking practitioners to use our PDC with their patients. We asked how useful it was compared to the DSM or ICD symptom categorization. The results (2012 in Division Review, vol.6) showed that practitioners of all the major theoretical orientations felt that the
PDM’s taxonomy was much more helpful in working with clients than the DSM or ICD’s symptom focused diagnoses. This showed support for both the PDM and Nancy McWilliams formulations in her 2011 edition of Psychoanalytic Diagnoses.
I strongly recommend this recent edition of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process as a required text for doctoral and post-doctoral students to help them understand and treat patients. I recommend the PDM as an over-all taxonomy.