Notre Dame Psychoanalytic Character Diagnosis Case Seminar Reading Analysis Students are expected to summarize the key points of the readings and provide t

Notre Dame Psychoanalytic Character Diagnosis Case Seminar Reading Analysis Students are expected to summarize the key points of the readings and provide the class with an analysis of how you believe the readings contribute to the discussion of case seminar, including clinical examples where applicable. Offer your thoughts regarding the strengths of the readings and any limitations that you noted, as well as clinical insights you may have gained. Be prepared with notes and/or an outline of what you will present. Also be prepared to address questions from students on the topic/s covered in the readings, by speaking to how the readings addresses those issues, as well as providing your own thoughts. I will attach the reading. If you cannot see the attachments, please let me know. Ch 2- Psychoanalytic Character Diagnosis by Nancy McWilliams Psychoanalytic
Diagnosis
Understanding Personality Structure in the Clinical
Process
Nancy McWilliams
THE GUILFORD PRESS
New York London
Epub Edition ISBN: 9781609184988
© 2011 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
McWilliams, Nancy.
Psychoanalytic diagnosis : understanding personality structure in the clinical process / Nancy McWilliams. — 2nd ed.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-60918-494-0 (hardcover : alk. paper)
1. Typology (Psychology) 2. Personality assessment. 3. Personality development. I. Title.
[DNLM: 1. Personality Disorders—diagnosis. 2. Personality Assessment. 3. Personality Disorders—therapy. 4. Psychoanalytic
Therapy. WM 460.5.P3]
RC489.T95M38 2011
616.89?17—dc22
2011002833
In grateful memory
Howard Gordon Riley
Millicent Wood Riley
Jane Ayers Riley
About the Author
Nancy McWilliams, PhD, teaches in the Graduate School of Applied and Professional Psychology
at Rutgers, The State University of New Jersey, and has a private practice in Flemington, New
Jersey. She is a former president of the Division of Psychoanalysis (39) of the American
Psychological Association and is on the editorial board of Psychoanalytic Psychology. Dr.
McWilliams’s books have been translated into 14 languages, and she has lectured widely both
nationally and internationally. She is a recipient of honors including the Rosalee Weiss Award for
contributions to practice from the Division of Independent Practitioners of the American
Psychological Association; Honorary Membership in the American Psychoanalytic Association; and
the Robert S. Wallerstein Visiting Scholar Lectureship in Psychotherapy and Psychoanalysis at the
University of California, San Francisco. A graduate of the National Psychological Association for
Psychoanalysis, Dr. McWilliams is also affiliated with the Center for Psychoanalysis and
Psychotherapy of New Jersey and the National Training Program of the National Institute for the
Psychotherapies in New York City.
Preface
When I originally wrote Psychoanalytic Diagnosis, I knew from my experience as a
teacher that students and early-career psychotherapists needed exposure to the inferential,
dimensional, contextual, biopsychosocial kind of diagnosis that had preceded the era inaugurated
by the 1980 publication of the third edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III) of the American Psychiatric Association. In particular, I wanted to keep alive
the sensibility that represented decades of clinical experience and conversation, in which human
beings have been seen as complex wholes rather than as collections of comorbid symptoms. I also
saw how confusing it was, even to psychodynamically oriented students, to try to master the
bewildering diversity of language, metaphor, and theoretical emphasis that comprises the
psychoanalytic tradition. The need for a synthesis of the sprawling and contentious history of
analytic theory, as it pertains to understanding one’s individual patients, was evident.
In the early 1990s I was also nourishing a faint hope that the book would have some influence
on mental health policy and on our culturally shared conception of psychotherapy, which were
beginning to be transformed in disturbing ways. No such luck: The breadth and depth of change
since then have been stunning. For a host of interacting reasons, psychodynamic—and even
broadly humanistic (see Cain, 2010)—ways of understanding and treating people have become
devalued, and the likelihood that a patient with significant character pathology, the hallmark of
most psychodynamic treatment, will find genuine, lasting help in the mental health system has, in
my view, plummeted. As the cognitive-behavioral movement continues to develop, some of its
practitioners have become as upset with these developments as analytic therapists have been; my
CBT-oriented colleague Milton Spett recently complained (e-mail communication, May 28, 2010),
in reaction to this trend, “We treat patients, not disorders.”
Political and economic forces account for much of this change (see Mayes & Horwitz, 2005, for
the political history of the paradigm shift in the area of mental illness “from broad, etiologically
defined entities that were continuous with normality to symptom-based, categorical diseases” [p.
249]). At least in the United States, corporate interests—most notably those of insurance companies
and the pharmaceutical industry—have sweepingly reshaped and thus redefined psychotherapy in
line with their aims: maximized profits. In the service of short-term cost control, there has been a
reversal of decades-long progress in helping individuals with complex personality problems—not
because we lack skill in helping them, but because insurers, having marketed their managed-care
plans to employers with the claim that they would provide “comprehensive” mental health
coverage, later declined arbitrarily to cover Axis II conditions.
Meanwhile, drug companies have a substantial stake in construing psychological problems as
discrete, reified illnesses so that they can market medications that treat each condition.
Consequently, the emphasis is no longer on the deep healing of pervasive personal struggles, but on
the circumscribed effort to change behaviors that interfere with smooth functioning in work or
school. When I wrote the first edition of this book, I did not realize how much graver the prognosis
for person-oriented (as opposed to symptom-oriented) therapy would become in the years after its
publication (see McWilliams, 2005a, for a more detailed lament).
The climate in which therapists in my country currently practice is much more inclement than
in 1994. Contemporary practitioners are besieged with suffering people who need intensive, longterm care (Can anyone convincingly argue that psychopathology is decreasing in the context of
contemporary social, political, economic, and technological changes?). They may be expected to see
patients every 2 weeks, or even less frequently, and to carry caseloads so large that genuine
connection with and concern for one’s individual clients is impossible. They are overwhelmed with
paperwork, with efforts to justify even the most unambitious treatment to anonymous employees of
insurance companies, with translating their efforts to help clients build agentic selves into slogans
such as “progress on target behaviors.” Official “diagnosis” under such pressures can often be
cynical in spirit and thus in function, as clinicians label patients in ways that will permit insurance
coverage and yet stigmatize them as little as possible.
Ironically, the current state of affairs makes it more rather than less important for
psychotherapists to have a heuristic but scientifically enlightened sense of the overall psychology of
each patient. If one wants to have a short-term impact, one had better have some expedited basis
for predicting whether a person will react to a sympathetic comment with relief, with devaluation of
the therapist, or with a devastating sense of not being understood. Hence, there is an even greater
need now than in 1994 to reassert the value of personality diagnosis that is inferential, contextual,
dimensional, and appreciative of the subjective experience of the patient. My role in developing the
Psychodynamic Diagnostic Manual (PDM Task Force, 2006) attests to this concern, but in that
document, what could be said about any type or level of personality organization was limited to a
few paragraphs, whereas here I can elaborate more fully.
An indirect source of the widespread contemporary devaluation of the psychoanalytic tradition
may be the expanding gulf between academics and therapists. Some degree of tension between
these two groups has always existed, largely because of the different sensibilities of the individuals
attracted to one role or the other. But the chasm has been greatly enlarged by increased pressures
on academics to pursue grants and quickly amass research publications. Even those professors who
would like to have a small practice would be foolish to do so in the current academic climate,
especially while seeking tenure. As a result, few academics know what it feels like to work
intensively with severely and/or complexly troubled individuals. The researcher–practitioner gulf
has also been inadvertently widened by the growth of professional schools of psychology, where
aspiring therapists have little opportunity for mutually enriching exchange with mentors involved in
research.
One result of this wider fissure is that psychodynamic formulations of personality and
psychopathology, which emerged more from clinical experience and naturalistic observation than
from the laboratories of academic psychologists, have too often been portrayed to university
students as archaic, irrelevant, and empirically discredited. Although decades of research on
analytic concepts are typically ignored when current critics idealize specific evidence-based
treatments—in their 1985 and 1996 books, Fisher and Greenberg reviewed over 2,500 such studies
—the paucity of randomized controlled trials of open-ended psychodynamic therapy has cost us
dearly. In addition, the arrogance of many analysts in the heyday of psychoanalysis, especially their
belief that what they experienced with each patient was too idiosyncratic to be researchable,
contributed to negative stereotypes held by nonclinical colleagues.
Even now, when some exemplary empirical work has shown the effectiveness of analytic
treatments (e.g., Leichsenring & Rabung, 2008; Shedler, 2010), we are left with the self-defeating
political legacy of many analysts’ contempt for research on the analytic process. The increasing
shaping of clinical psychology into a positivist “science,” the cost-containment efforts by insurance
companies, the economic interests of the pharmaceutical industry, and the dismissive reaction of
some analysts to outcome research of any kind have generated the “perfect storm” leading to the
devaluation of psychodynamic psychology and psychotherapy.
Contemporary misfortunes aside, there are additional spurs to the revision of this book. Since
its original publication, cognitive and affective neuroscientists have begun to illuminate genetic,
physiological, and chemical bases of psychological states. Research on infancy, especially on
attachment, the conceptual baby of the psychoanalyst John Bowlby, has added new angles of vision
to our understanding of the development of personality. The relational movement has inspired a
significant paradigm shift within large sections of the psychoanalytic community. Cognitive and
behavioral therapists, as their movement has matured and their practitioners have worked with
more complex patients, are developing personality concepts that are remarkably similar to older
psychoanalytic ones. And my own learning continues. I know more now about Sullivanian, neoKleinian, and Lacanian theories than I knew in 1994. I have had the benefit of critiques from
teachers who have assigned Psychoanalytic Diagnosis, from the students they have taught, and
from fellow practitioners who have read it. And I have had 20 more years of clinical experience
since I first envisioned the book.
I was not entirely surprised by the success in North America of the first edition: I suspected as I
was writing it that I was far from the only person who felt the lack of such a text for students of
psychotherapy. But its international reception has astonished me, especially its warm welcome by
therapists in countries as diverse as Romania, Korea, Denmark, Iran, Panama, China, New
Zealand, and South Africa. Its popularity in my own country has brought me invitations to speak in
unexpected mental health subcultures (e.g., to Air Force psychiatrists, evangelical pastoral
counselors, prison psychologists, and addictions specialists), and its impact beyond North American
borders has introduced me to therapists throughout the world, who have taught me about the
personality dynamics they most commonly face. In Russia, it was suggested to me that the national
character is masochistic; in Sweden, schizoid; in Poland, posttraumatic; in Australia,
counterdependent; in Italy, hysterical. In Turkey, therapists working in traditional villages
described patients who sound remarkably like the sexually inhibited women treated by Freud, a
version of hysterical personality that has virtually disappeared from contemporary Western cultures.
This exposure to psychotherapy around the world has been a heady experience, one that I hope has
enriched this revision.
At the urging of colleagues working in more traditional and collectivist cultures where
emotional suffering is often expressed via the body (e.g., with Native American groups and in East
and South Asian communities), I have expanded the section on somatization and suggested the
utility of the concept of a personality type organized around that defense. I have revised my review
of defenses, including somatizing, acting out, and sexualization with the more primary mechanisms.
For reasons of length, and to avoid contributing to any tendency to pathologize people from
cultures where somatization is normative, I decided against devoting a full chapter to somatizing
personalities. Readers hoping to learn more about treating those who regularly and problematically
become physically ill, and about others whose personalities are not covered here (e.g., sadistic and
sadomasochistic, phobic and counterphobic, dependent and counterdependent, passive–aggressive,
and chronically anxious people), will find help in the PDM.
In some parts of this second edition, I have changed very little, beyond trying to tighten up the
writing, in observance of the principle “If it works, don’t fix it.” In others, there has been a more
ambitious overhaul in light of new empirical findings and new theoretical perspectives.
Psychoanalytic developmental observations have gone way beyond Mahler, and contemporary
neuroscience has begun identifying clinically relevant brain processes that previously we could
describe only metaphorically. Researchers in attachment have extended our understanding of
relationship and have minted terms (e.g., “mentalization,” “reflective functioning”) that capture
processes central to overall mental health. Neuroscientists have corrected some of our mistaken
beliefs (e.g., that thought precedes affect or that memory of extreme trauma is retrievable [Solms &
Turnbull, 2002]) and have greatly expanded our knowledge of temperament, drive, impulse, affect,
and cognition. Some randomized controlled trials have been done on psychoanalytically informed
treatments, and new meta-analyses have been conducted on existing studies.
I have retained, however, many references to older literature, both clinical and empirical.
Personality by its nature is a fairly stable phenomenon, and there is a wealth of disciplined and
useful observations about it from decades ago that I would rather honor than ignore. I have never
shared the typically American assumption that the “newest” thing is self-evidently better than
everything that came before it; in fact, given realistic pressures on current intellectuals, and given
the narrowness of much professional training, it seems unlikely that current work can always be as
thoughtful and far-reaching as that of writers who inhabited a less frantic, less driven era.
Acknowledgments
In the first edition of Psychoanalytic Diagnosis, I thanked my clients and virtually my
entire community of colleagues. It is even truer now that this book is a product of a whole “climate
of opinion” (to steal W. H. Auden’s moving image of Freud). I emphasized in that volume that my
organization of personality levels and types was not “my” taxonomy but my best effort at
representing mainstream psychoanalytic ideas. At this point, given current controversies among
analysts about whether diagnosis itself is valuable (the topic of a 2009 online colloquium of the
International Association for Relational Psychoanalysis and Psychotherapy), I cannot presume to
represent the diagnostic center of gravity of the psychoanalytic movement. And yet this book
encompasses far more than my own thinking. For several years I have been asking practitioner
audiences to e-mail me with criticisms of any statements in the first edition that do not fit their
clinical experience. A great number of therapists, including many who practice in other countries
and in settings very different from mine, have written to say that this conceptualization supports
their own clinical experience. Some have taken me up on the invitation to criticize, and I have
integrated many of their suggestions when rewriting various chapters.
Beyond those I named in 1994, there are too many people to enumerate here who have
contributed to this revision. But I should single out Richard Chefetz, who spent many hours
critiquing the chapter on dissociation and educating me about contemporary findings in
traumatology. I am also grateful to Daniel Gaztembide (and to Brenna Bry, my department chair—
a radical Skinnerian who appreciates psychoanalysis—who astutely assigned him to me as a “work–
study” student). Daniel sent me regular briefs about relevant research and theory. For his
psychoanalytic wisdom and his fine ear for tone, I have depended, as always, on my friend Kerry
Gordon. For his eagle eye in spotting typos, I thank Tim Paterson. Finally, for their friendship and
candor, I want to acknowledge some colleagues who have influenced me in the years since the first
edition: Neil Altman, Sandra Bem, Louis Berger, Ghislaine Boulanger, the late Stanley Greenspan,
Judith Hyde, Deborah Luepnitz, William MacGillivray, David Pincus, Jan Resnick, Henry Seiden,
Jonathan Shedler, Mark Siegert, Joyce Slochower, Robert Wallerstein, Bryant Welch, and Drew
Westen. And thanks to the many unacknowledged others whose ideas have found their way into
this book. My mistakes and misunderstandings are my own.
Contents
Cover
Title
Copyright
Dedication
About the Author
Preface
Acknowledgments
Introduction
A Comment on Terminology
A Comment on Tone
PART I. CONCEPTUAL ISSUES
1 Why Diagnose?
Psychoanalytic Diagnosis versus Descriptive Psychiatric Diagnosis
Treatment Planning
Prognostic Implications
Consumer Protection
The Communication of Empathy
Forestalling Flights from Treatment
Fringe Benefits
Limits to the Utility of Diagnosis
Suggestions for Further Reading
2 Psychoanalytic Character Diagnosis
Classical Freudian Drive Theory and Its Developmental Tilt
Ego Psychology
The Object Relations Tradition
Self Psychology
The Contemporary Relational Movement
Other Psychoanalytic Contributions to Personality Assessment
Summary
Suggestions for Further Reading
3 Developmental Levels of Personality Organization
Historical Context: Diagnosing Level of Character Pathology
Overview of the Neurotic–Borderline–Psychotic Spectrum
Summary
Suggestions for Further Reading
4 Implications of Developmental Levels of Organization
Therapy with Neurotic-Level Patients
Therapy with Patients in the Psychotic Range
Therapy with Borderline Patients
Interaction of Maturational and Typological Dimensions of Character
Summary
Suggestions for Further Reading
5 Primary Defensive Processes
Extreme Withdrawal
Denial
Omnipotent Control
Extreme Idealization and Devaluation
Projection, Intr…
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