Individuality and Psychotherapy Nancy McWilliams, PhD, ABPP Southwest Psychoanalytic Society Tucson, AZ December 1, 2018

“The limits of my language are the limits of my world” Ludwig Wittgenstein 1889 - 1951 “The limits of my language are the limits of my world”

Client outcomes vary according to: 1. Personality factors 2. Relationship factors www.apa.org/about/policy/resolution-psychotherapy.aspx Blatt, S. J., & Zuroff (2005). Empirical evaluation of the assumptions in identifying evidence based treatments in mental health. Clinical Psychology Review, 66, 423-428.

What Should Have Been

What Should Have Been

What Actually Occurred

What Actually Occurred

1. Temperament Thomas, A., Chess, S., & Birch, H. G. (1968). Temperament and behavior disorders in children. New York: International Universities Press. Escalona, S. K. (1968). The roots of individuality: Normal patterns of development in infancy. Chicago: Aldine. Kagan, J. (1994). Galen’s prophecy: Temperament in human nature. New York: Basic Books.

2. Attachment Style Bowlby, J. (1969). Attachment and loss: Vol 1: Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and loss: Vol 2: Separation: Anxiety and anger. New York: Basic Books. Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press. Holmes, J. (2001). The search for the secure base: Attachment theory and psychotherapy. Philadelphia: Taylor & Francis. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press. Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford Press.

3. Observed Clinical Patterns Freud, S. (1916). Some character types met with in psychoanalytic work. Standard Edition, 14, 311-333. Reich, W. (1933). Character analysis. New York: Farrar, Straus, & Giroux. Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York: Norton. Shapiro, D. (1965). Neurotic styles. New York: Basic Books. MacKinnon, R. A., & Michels, R. (1971). The psychiatric interview in clinical practice. Philadelphia: Saunders. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies: New Haven, CT: Yale University Press. McWilliams, N. (1994, rev. ed. 2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford.

4. Defensive Organization Freud, A. (1936). The ego and the mechanisms of defense. New York: International Universities Press. Laughlin, H. P. (1970). The ego and its defenses. New York: Jason Aronson. Vaillant, G. E. (1992). Ego mechanisms of defense: A guide for clinicians and researchers. Washington, DC: American Psychiatric Association. Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York: Guilford. Perry, J. C. (2014). Anomalies and specific functions in the clinical identification of defense mechanisms. Journal of Clinical Psychology, 70, 406‒418.

5. Implicit Cognitions Weiss, J., Sampson, H., & the Mt. Zion Psychotherapy Research Group (1986). The psychoanalytic process: Theory, clinical observations, and empirical research. New York: Guilford. Weiss, J. (1993). How psychotherapy works: Process and technique. New York: Guilford. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Silberschatz, G. (Ed.) (2005). Transformative relationships: The control-mastery theory of psychotherapy. New York: Routledge.

6. Affective Patterns Tomkins, S. S. (1995). Script theory: In E. V. Demos (Ed.), Exploring affect: The selected writings of Silvan Tomkins (pp. 312-388). New York: Cambridge University Press. Panksepp, J. (2004). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Anstadt, Th., Merten, J., Ullrich, B., & Krause, R. (1997). Affective dyadic behavior, core conflictual relationship themes and success of treatment. Psychotherapy Research, 7, 397-417.

7. Drive (motivational systems) Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. New York: Other Press. Fisher, H. (2005). Why we love: The nature and chemistry of romantic love. New York: Henry Holt & Co. Fisher, H. (2010). Why him? Why her? Finding real love by understanding your personality type. New York: Henry Holt & co. Panksepp, J., & Biven, L. (2012). The archeology of mind: Neuroevolutionary origins of human emotions: New York: Norton.

8. Individualistic versus Communal Orientation Jung, C. G., & Baynes, H. G. (1921). Psychological types or the psychology of individuation. London: Kegan Paul. Balint, M. (1945). Friendly expanses—Horrid empty spaces. International Journal of Psycho- Analysis, 36, 225-241. Roland, A. (1988). In search of self in India and Japan: Toward a cross-cultural psychology. Princeton, NJ: Princeton Univ. Press. McGoldrick, M., Giordano, J., & Garcia-Preto (Eds.) ( (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford. Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the therapeutic process. Washington, DC: American Psychological Association. Akhtar, S. (Ed.) (2010). Freud and the Far East: Psychoanalytic perspectives on the people and culture of China, Japan, and Korea. Northvale, NJ: Jason Aronson. Tummala-Narra, P. (2016). Psychoanalytic theory and cultural competence in psychotherapy. Washington, DC: American Psychological Association.

9. Internalized Object Relations (Inner Working Models/Schemas) Fairbairn, W. R. D. (1952). An object-relations theory of the personality. New York: Basic Books. “internalized object relations” French, T. (1958). The integration of behavior, vol. 3. The reintegrative process in a psychoanalytic treatment. Chicago: University of Chicago Press. “repetitive structures” Bowlby, J. (1969. Attachment and loss: Vol. 1: Attachment. London: Hogarth. “inner working models” Malan, D. H. (1976). The frontier of brief psychotherapy. New York: Plenum. “nuclear conflicts” Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. “representations of internalizations that have been generalized (RIGs)” Dahl, H. (1988). Frames of mind. In H. Dahl, H. Kachele, & H. Thomae (Eds.). Psychoanalytic process research strategies (pp. 51-66). New York: Springer-Verlag. “fundamental and repetitive emotional structures (FRAMES)”

More internalized object relational concepts Aron, L. (1991). Working through the past—working toward the future. Contemporary Psychoanalysis, 27, 81-108. “internal relational models” Tomkins, S. S. (1995). Script theory In E. V. Demos (Ed.), Exploring affect: The selected writings of Silvan Tomkins (pp. 312-388). New York: Cambridge University Press. “nuclear scenes” Bucci, W. (1997). Psychoanalysis and cognitive science. New York: Guilford. “emotion schemas” Luborsky, L., & Crits-Cristoph, P. (1996). Understanding transference (2nd ed.). Washington, DC: American Psychological Association: “core conflictual relationship theme” Lyons-Ruth, K. (1999). The two-person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. Psychoanalytic Inquiry, 19, 576-617. “implicit relational knowing” Horowitz, M. (1998). Cognitive psychodynamics. New York: Wiley. “personal schemas” Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner’s guide. New York: Guilford. “individual schemas”

10. Organizing Developmental Issue (“Severity Dimension”) Freud, S. (1905). Three essays on the theory of sexuality. Standard Edition, 7, 135-243. Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. In Love, guilt and reparation and other works 1921-1945 (pp. 262-289). New York: Free Press. Erikson, E. H. (1950). Childhood and society. New York: Norton. Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Mahler, M. S., Pine, F., & Bergmann, A. (1985). The psychological birth of the human infant. New York: Basic Books. Steiner, J. (1993). Psychic retreats: Pathological organization in psychotic, neurotic, and borderline conditions. London: Routledge. Bateman, A., & Fonagy, P. (2004). Mentalization-based treatment for borderline personality disorder. New York: Oxford University Press.

Psychodynamic Diagnostic Manual-2 Guilford Press 2016 Steering Committee Vittorio Lingiardi Nancy McWIlliams Sponsoring Organizations International Psychoanalytical Association American Psychoanalytic Association  International Association for Relational Psychoanalysis and Psychotherapy Division of Psychoanalysis (39), American Psychological Association American Academy of Psychoanalysis and Dynamic Psychiatry  American Association for Psychoanalysis in Clinical Social Work  Italian Group for the Advancement in Psychodynamic Diagnosis Assn. Europeenne de Psychopathologie de l’Enfant et de l’Adolescent Confederation of Independent Psychoanalytic Societies International Society for Adolescent Psychiatry and Psychology 21 21

PDM diagnosis approach Importance of idiographic dimension and case formulation Personality structure as a context for psychopathology Considering subjectivity of both patient and therapist Making diagnosis clinically meaningful Clinician’s relational experience as a key element for the assessment process Put the diagnosis in the life cycle Considering individual’s strengths and resources

Guiding Principles for PDM-2 Transparency Inclusiveness Flexibility Empirical rigor Clinical utility

Diagnosis for clinical purposes Dimensional rather than categorical Inferential rather than reified Contextual rather than isolated Integrated rather than artificially “co-morbid”

Changes/Improvements in PDM-2 Publication by Guilford Press. Implications: Better marketing, better copy-editing, better accessibility. Separation of Child and Adolescent sections. Addition of Elderly section. Addition of clinician-friendly tools. Omission of separate section summarizing research. Additional comparison/critique re: ICD, DSM. Heterotypical and homotypical developmental foci. (Rejected change: “Practitioner Diagnostic Manual” or “Psychological Diagnostic Manual”)

Organization of PDM-2 Adult section Personality Patterns and Disorders Levels of personality organization Styles of personality Mental Functioning Axis Symptom Axis Illustrative cases

Subsequent sections Infancy/preschool years Childhood Adolescence Later life (the elderly) Tools

A psychotic level of personality organization Gordon, R. M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by psychodynamic, CBT, and other non- psychodynamic psychologists. Issues in Psychoanalytic Psychiatry, 31, 55-62.

Dimensional conceptualizations: Hysteria, masochism, narcissism, and psychopathy Zetzel, E. (1968). The so-called good hysteric. International Journal of Psycho-Analysis, 49, 256-260. Kernberg, O. F. (1988). Clinical dimensions of masochism. Journal of the American Psychoanalytic Association, 36, 1005-1029. Kernberg, O. F. (1984). Aggressivity, narcissism and self- destructiveness in the psychotherapeutic relationship: New developments in the psychology and psychotherapy of the severe personality disorders. New Haven, CT: Yale University Press. Meloy, J. R. (Ed.). (2001). The mark of Cain: Psychoanalytic insight and the psychopath. Hillsdale, NJ: Analytic Press.

The dimensionality of psychosis Kelleher, I., & Cannon, M. (2016). Putting psychosis in its place. American Journal of Psychiatry, 173, 951-952. “The classic nosologic divide in psychiatry has been between neurosis and psychosis. The two were originally conceptualized as distinct categories of mental illness, and it was only the odd (irrelevant!) case that “tipped over” from the former to the latter. Extensive research over the past decade and a half has upended this notion, blurring previously sharp diagnostic boundaries, reframing psychosis as a continuum and casting the relationship between neurosis and psychosis in a very different light.”