Nancy McWilliams

PRESERVING OUR HUMANITY AS THERAPISTS

Psychotherapists have traditionally em-braced core values and beliefs that dif-fer significantly from many values andbeliefs that pervade contemporary,commercially oriented Western cul-tures. With their clients, therapists oftenquestion or challenge the culture’s ma-terialism, consumerism, appeals to van-ity and greed, disdain of dependencyand vulnerability, and abetment of nar-cissistic entitlement. Currently, how-ever, psychotherapy is being reshapedby descriptive psychiatric diagnosis,pressures from powerful corporate in-terests, and antagonism from influentialacademic psychologists and is threat-ened with becoming the servant of thesurrounding culture rather than itsparticipant/observer and critic. Theauthor notes symptoms of this trendand offers ideas about reversing it.

The Psychodynamic Diagnostic Manual: An Effort to Compensate for the Limitations of Descriptive Psychiatric Diagnosis

This article describes, from the perspective of a participant in the process, the background of and rationale for the development of the Psychodynamic Diagnostic Manual (PDM), a classification system based on both long-standing clinical observation and recent empirical research. It was hoped that the PDM would compensate for some of the unintended negative consequences to practitioners and their clients of uncritical reliance on descriptive psychiatric taxonomies such as the Diagnostic and Statistical Manual of the American Psychiatric Association. A shared and motivating experience of the contributors to the PDM was dismay at how the dominance of a narrow, descriptive-psychiatry model has promoted the decline of the empirically sound and clinically valuable idiographic tradition, in which clients’ difficulties are conceptualized in the context of their unique personalities, developmental challenges, and life contexts. Strengths and limitations of the new manual are discussed, as are ideas about its clinical utility.

The Psychodynamic Diagnostic Manual (PDM) and the PDM-2: Opportunities to Significantly Affect the Profession

In this article, we discuss the development of the Psychodynamic Diagnostic Manual (PDM) and its upcoming revision, the PDM-2. We describe the processes by which the PDM-2 is being developed and highlight important differences across both editions. At the same time, we emphasize the value of assessing internalized experience and how that can be of use toward the diagnostic assessment process.

On teaching psychoanalysis in antianalytic times: a polemic.

The author argues that in the current attitudinal climate, characterized by significant denigration of psychoanalysis coming from biologically oriented psychiatrists, academic psychologists, pharmaceutical firms, insurance companies, managed care organizations, anxious taxpayers, and revisionist critics of Freud, psychoanalysts need to adapt their training and supervisory practices to take into account the preconceptions of many of those seeking training as psychotherapists. Specifically, we need to appreciate the nature of the transferences toward analysts and analysis that exist in the wider mental health community and in the general public. These include assumptions that analysts are cold, arrogant, rigid, and worshipful toward Freud (who is himself seen as cold, arrogant, rigid, and narcissistic), and the prevalent misconception that psychoanalysis has been empirically discredited. Analysts need to find creative and honest ways, some of which are suggested by the author, to challenge the distortions in these stereotypes and to respond nondefensively and generatively to the grains of truth they contain. The essay concludes with some reminders of the legitimate strengths of the psychoanalytic tradition that suggest that its future is not as bleak as its disparagers have assumed.

Beyond traits: personality as intersubjective themes.

The author argues that research in the idiographic tradition is more conducive to effective clinical work than the uncritical adoption of specific “evidence-based therapies” for discrete symptomatic disorders. She views pressures on therapists to adopt evidence-based therapies without consideration of individual differences and personal subjectivity as the misapplication of a research paradigm to the clinical situation. Reviewing some recent empirical work on individuality and therapeutic process, she critiques efforts to formulate personality diagnosis on the basis of externally observable traits without attention to internal experience, and she contends that intrapsychic themes account for personality differences more powerfully than traits, even when traits are construed dimensionally.

More simply human: on the Universality of Madness

A dimensional conceptualization of psychosis that evolved from clinical experience has been replaced in recent decades by a categorical model useful for certain kinds of research. Although both dimensional and categorical paradigms have been valuable ways of viewing “madness,” the loss of a dimensional sensibility is arguably retarding our progress in developing therapies for psychotic suffering.

The contribution of Sidney Blatt's two-polarities model to the Psychodynamic Diagnostic Manual

This article reviews the theoretical and empirical contributions of Blatt’s two-polarities model of personality development and psychopathology to the second edition of the Psychodynamic Diagnostic Manual (PDM-2). First, we briefly provide an overview of the manual’s main features and describe the guiding principles of the revision process. We then discuss in more detail how Blatt’s model, which is focused on the dialectic interaction between anaclitic-introjective and relatedness vs self-definition dimensions in both normal and disrupted personality development, increases the PDM-2’s theoretical and empirical comprehensiveness and clinical utility, especially concerning the classification and assessment of personality and overall mental functioning in adult populations. Finally, we address the implications for the therapeutic process, showing how anaclitic and introjective patients may be differentially responsive to different psychodynamic techniques (e.g., supportive or expressive interventions). Taken together, these considerations demonstrate the importance of a more theory-driven and empirically informed diagnostic system that embraces, in accordance with Sidney Blatt’s empirically supported and psychoanalytically-oriented ideas, the complexities of human experience (both normal and pathological) and captures the subjective and underlying dynamics of psychological symptoms and syndromes.

Psychoanalytic Sensibility and Honoring Individual Differences: A Conversation with Nancy McWilliams

Nancy McWilliams, who is greatly influenced by the work of George Atwood and Robert Stolorow on intersubjectivity, wonders if, as clinicians, we are able to view the patient through larger frameworks beyond the symptomology described in the Diagnostic and Statistical Manual for Mental Health Disorders (5th ed.; DSM-5; American Psychiatric Association (APA), 2013). She asks in her interview, “Is the person’s life improving in the areas of love, in work, and play? Or increasing in self-esteem and affect tolerance and regulation or security of attachment?” And, “Do they have a sense of vitality?” Most importantly, she views these questions in the context of the intersubjective attunement she shares with each person she works with.