21st Century Aging

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Not Your Parent's Psychotherapy: Psychodynamic Therapy Today

An interview with Nancy McWilliams

Over the years, many students have told me they can credit one person for their interest in psychodynamic therapy and psychoanalysis.  That person is Nancy McWilliams, Ph.D.  Dr. McWilliams is the author of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (The Guilford Press, 1994), which is currently undergoing revision for release in 2011.  She is the author of many other publications and is the Associate Editor of the Psychodynamic Diagnostic Manual. She teaches and speaks internationally on psychodynamic psychotherapy, sex and gender, trauma, and personality structure. Dr. McWilliams is in private practice in New Jersey.  

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The contents of Psychoanalytic Diagnosis still inspire me, even though it has been many years since my initial reading.  It helps me to understand even the most complicated patients and is written so sensitively; I never feel that I am overly pathologizing those I am trying to help.

I recently had a chance to interview Dr. McWilliams and hope you will find her insights as useful as I did: 

As the main author of psychoanalytic textbooks used most widely in the training of students who are being introduced to the field, can you tell me one thing you hope students understand about psychoanalytic theory?

Dr. McWilliams:  I hope they understand that contemporary psychoanalytic theories, although they started with Freud, have benefited from over one hundred years of clinical experience, research, and scholarship. Students are often taught Freud's early theory, but since most academics are unfamiliar with the evolution of psychoanalytic ideas, they are given the impression that the field of psychoanalysis ossified around 1923 and has since been empirically discredited, neither of which is true.

Can you explain the difference between psychoanalytic therapy and psychoanalysis?

Dr. McWilliams: Psychoanalytic therapy is the application of psychoanalytic ideas to any kind of mental health treatment: short- or long-term, intensive or only once a week, with patients who suffer from diverse kinds of mental suffering. The term "psychoanalysis" can refer to psychoanalytic theory or to the psychoanalytically oriented community, or to a particular kind of mental health treatment. When the word is used to denote treatment, it refers to a particular type of psychoanalytic therapy aimed at in-depth personality exploration and change. The patient is seen multiple times a week and asked to free associate. Often the patient lies on a couch and the analyst sits outside the patient's line of vision, to promote the patient's access to fantasy, including fantasy about what the analyst is thinking and feeling. This arrangement tends to foster an intense relationship in which the patient's main psychological issues appear in the here-and-now of the sessions, and become the subject of a collaborative effort to understand and work out ways to change unsatisfying life patterns.

What do you think about the criticisms of psychoanalysis and psychoanalytic therapy? Are some of the critiques justified?

Dr. McWilliams: There have been so many different criticisms of psychoanalysis that this is a hard question to answer! Criticisms of Freud himself have sometimes been levied on the entire field, which is something like throwing out contemporary evolutionary theory because Darwin got some things wrong. The critiques of Freud the man - many of which have merit - are not necessarily relevant to the vast field that his early work inspired. I think psychoanalysis can be justly criticized for having developed mostly outside university settings, thus making it less likely that current psychoanalytic ideas are understood by scholars in other fields, and also making it less likely that analysts get the benefit of cross-pollination from other disciplines. In addition, I think many analysts - especially back in the days when being an analyst conferred instant status - became smug, behaved arrogantly toward their critics instead of engaging productively with them, and sometimes expressed an indifference to research that would have held their ideas up to scientific scrutiny. They are paying for these sins now. Although it is wrong to say that there is no empirical evidence for psychoanalytic ideas (in fact, there is a lot) , there is far less than there should have been. Critics who fault psychoanalysis for not subjecting itself to more empirical research seem to me to have an indisputable complaint. On the other hand, insufficiency of research is not the same thing as the notion that research has shown psychoanalytic ideas to be fallacious. Critics who assume that psychoanalytic ideas have been empirically disproven are wrong.

How do people know if psychoanalytic treatment is right for them?

Dr. McWilliams: The empirical literature on therapy outcome continually demonstrates that the relationship between patient and therapist is much more important than the "brand" of therapy, that the personal qualities of the therapist are far more relevant to the success of the treatment than his or her theoretical orientation. Having said that, I do think that there are temperamental differences among patients that suit them more toward one kind of treatment than another. Analytic therapies tend to be a good fit with people who are curious, who like to figure things out for themselves, who have some tolerance for ambiguity, who are comfortable with emotion, and who have some intuitive sense of the mystery of unconscious processes.

Since the notion of the unconscious is confusing for many people, can you explain how we might understand this concept?

Dr. McWilliams: I'm not sure we should talk about "the" unconscious, though it is common for analysts to do so, as they confront the magnitude and power of unconscious thoughts, feelings, and impulses every hour. I think most people intuitively grasp that we all often find ourselves behaving in ways we don't fully understand, and that our dreams and fantasies are full of images that feel alien from our more rational conscious functioning. Contemporary neuroscientists have demonstrated, whether they construe their discoveries this way or not, that analysts have been right about how much mental life is unconscious. Cognitive and behavioral therapists also acknowledge this, by the way, in their concept of "implicit" mental functions.

And what about transference? Is this concept useful in today's treatments?

Dr. McWilliams: I think that the concept of transference is valuable no matter what kind of treatment is being conducted. The fact that we understand the present based on experiences in our past, that our perceptions of people we loved early in life become transferred on to the therapist, was probably Freud's most important observation. Any therapist dealing with a patient who was abused by a parent can expect to encounter distrust, and to be the object of whatever strategies the patient employed as a child to remain as safe as possible under the circumstances. Any therapist facing a patient who was neglected by a parent can expect that the patient will find it hard to imagine that the therapist is really invested in helping. If one doesn't understand the effect of the past on the present, one can take things personally when people behave transferentially - blaming the patient for being "uncooperative," for example, rather than figuring out what is being replicated and talking about it so that the patient can take in the fact that life doesn't need to reiterate childhood miseries.

How did you become interested in psychoanalysis?

Dr. McWilliams: In my junior year in college I read a book by Freud, Civilization and Its Discontents, that I found fascinating. Eventually I decided to go into analysis myself, and somewhat to my surprise (because I was thinking I was doing this for mainly intellectual reasons), I found that it had a radically transformative effect on my life. I don't think my marriage would have succeeded without it, and I suspect I would not have had children or have enjoyed my profession as much as I have. It helped me profoundly, and it continues to help me, especially in extending my empathy into the diverse struggles of my patients. By inviting you into an honest, in-depth engagement with all the different parts of yourself, analysis allows you to find the part that resonates with whatever a patient is experiencing.

If you could change one thing about perceptions of modern day psychoanalytic treatment, what would that be?

Dr. McWilliams: I would challenge the stereotype that analysts are cold, withholding and arrogant. Effective analysts approach their work in a spirit of humility, expecting to learn from each patient, expecting to be surprised, expecting to make mistakes and be corrected by the patient. And in the context of the deep feelings that get processed by both parties in psychoanalytic therapies, the analyst comes to care deeply about the patient.

For more information about Dr. McWilliams, please see her website.

Tamara McClintock Greenberg, Psy.D., M.S., is an Associate Clinical Professor of Psychiatry at the University of California, San Francisco.

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