notes on: psychodynamic diagnosis
a newfound respect for therapists (part 2)
More often than not, mainstream discussions of mental illness are simplistic, formulaic, and deterministic. Psychobabble and therapy-speak dominate all kinds of discourse—whether or not they explicitly have to do with mental health—creating a society that is obsessed more with the appearance of mental well-being than the achievement of it.
This has, unsurprisingly, left me frustrated with and skeptical of the current state of therapy, which seems to have normalized much of the nonsensical discourse around mental health. But several months ago, I watched a two-part interview with psychotherapist Nancy McWilliams that had a tremendous effect on me. For the first time, I was able to watch what exceptional therapy looks like, and I developed an appreciation for its practitioners, rare as they may be.
In my last post, defining mental health, I shared the main takeaways from the first part of McWilliams’ interview, which covered the 10 qualities of mental health. To recap, these are safety and attachment security; self-continuation; self-efficacy; self-esteem; resilience; self-reflection and mentalization; self vs. community advocacy; vitality (my favorite one); acceptance; and love, work, and play.
In this post, I want to share information from the second part of her interview, which covers the psychodynamic diagnostic process, a more nuanced approach to therapy and mental health than the system laid out by the DSM. She talks about the common personality types seen in therapy, how they manifest on a spectrum from high- to low-functioning, how each level on the spectrum should be treated according to research, and specific examples of therapist-patient interactions at each level.
Whether you decide just to watch the interview, read this post, or do both, I believe this information will be helpful to all, regardless of their experiences with mental illness. I strongly recommend watching the interview at some point, as I had to leave out a lot of details and fascinating examples for the sake of length.
McWilliams speaks about this topic in a precise and nuanced way, choosing each word with care and intention—I hope this is evident in my post.
Enjoy.
Early on in the interview, Nancy McWilliams touches on one of the reasons behind the modern simplification of mental illness:
Some of the things that have made clinical thinking less popular are: one, the pressures of drug companies, who love categorical diagnosis—because if you have an illness, they can market a drug for it; they don’t want to hear about complexity and context and dimensionality. And two, if you’re an insurance company, you think, OK, all you have to do is get rid of the symptoms. They don’t do that with other illnesses, but they do with psychiatric illnesses.
You miss a lot when you diagnose that way. For example, you can’t tell by the DSM description of depressive disorders whether it’s an introjective depression—where the subjective experience is I’m bad, I’m evil, I’m a terrible person, and there’s a lot of guilt—versus an anaclitic depression, where the person feels I’m empty, I’m hungry, I need an attachment, life is meaningless without an attachment. Those two kinds of subjective experiences of depression have exactly the same vegetative signs and meet the same DSM criteria, but they have different implications for treatment.
The rest of the interview demonstrates exactly why such nuance is so important. McWilliams begins by describing some of the common personalities seen in therapy and how a skilled therapist might approach treatment based on each type. But there’s an added level of complexity to providing the best treatment: what matters is how each personality manifests depending on its level of dysfunction, with healthy and neurotic at the high-functioning end of the spectrum, followed by borderline, and then psychotic at the most severe end.
Let’s start with the personality types before moving to the levels of (dys)function.
some common personality types in therapy
Depressive personality is characterized by “a pattern of pervasive, chronic sense of loss; inadequacy; a deep-seated fear of rejection or disappointing others; chronic self-criticism.”
Depressive personalities are sensitive to criticism and tend to use introjection, or “the unconscious adoption of ideas and attitudes from others.” When criticized, they tend to assume that there is, in fact, something wrong with them. This differs from, say, paranoid people, who might respond to criticism by using projection, or turning the criticism back at the person criticizing: “What’s wrong with YOU?”
Self-defeating people with depressive problems might approach their issues as perpetual victims. Like those who lack vitality, the self-defeating might see therapy as an opportunity to complain about other people and assign therapists the impossible task of fixing their lives.
One thing to note is that someone with a depressive personality might never experience a depressive episode, but they have the dynamics that go into one.
Masochistic personality, a type of depressive psychology, is characterized by “self-sacrifice, enduring suffering, a tendency to seek punishment, and a struggle with assertiveness.”
Those with a masochistic personality are compelled to demonstrate their suffering to others either to show they are a good person or to maintain a relationship. The masochistic type (e.g., someone who stays with an abusive partner because the alternative, being alone, seems worse for them) does not necessarily enjoy pain. Rather, his pain tolerance might have developed as a survival strategy (e.g., his parents only paid attention to him when he was in pain; he had to rely on his abusive parents for food and shelter as a child).
Paranoid personality can be characterized by a “pervasive distrust of others, coupled with a tendency to interpret others’ actions as malevolent.”
While they are often (rightly) described as suspicious and distrusting, paranoid people might also over-trust the people they idealize. For that reason, their psychology is best thought of in terms of their preoccupation with trust and distrust; they do not have normal levels of either.
Schizoid personality is traditionally characterized by “emotional detachment, social disinterest, and a preference for introspective solitary activities.”
While paranoids are preoccupied with trust vs. distrust, schizoids are preoccupied with closeness vs. distance; they feel lonely and want to be close to others but often retreat when closeness occurs.
Obsessive-compulsive personality is characterized by “perfectionism, rigidity, a fear of losing control, preoccupation of order, difficulty delegating tasks; they are organized around what’s right to do, timely, conscientious, neat, fastidious.”
At the same time, and in line with the theme of control vs. discontrol, obsessive-compulsives might have a part of their life that is out of control, like a dirty drawer.
Throughout the interview, McWilliams illustrates the implications of each personality type for treatment. For example:
If you’re a patient with a schizoid psychology, and I [the therapist] don’t get that about you, I may—because I have a depressive psychology—be moving toward you, trying to comfort you, trying to offer you stuff.
But your experience of that is going to be, you’re impinging on me, you’re in my space, I’m not comfortable. So, with a schizoid person, I’ve learned to sit back and check in on how over-stimulated they may be feeling in this particular point.
Meanwhile, the paranoid patient will likely be concerned with trust and the possibility of betrayal; the obsessive-compulsive with control vs. discontrol, neatness vs. messiness, promptness vs. lateness.
Histrionic personality types are interested in gender, power, and sexuality, and are characterized by “attention-seeking behavior, emotional shallowness, a strong desire for external validation, and intense emotional expressions.”
Here’s another example of how personality type influences treatment:
If you are a powerful, heterosexual male treating a female who has somewhat hysterical tendencies, you don’t want to mansplain to her, because her psychology is that she feels like the inferior or weaker gender. So, you want to help her find her own solutions to things rather than come in like, you know what you should do? Because that’s a replication of the sense that men have the power and women don’t. And if you don’t have the power, all you can do is try to use your sexuality to even up the power disparity—and that usually goes badly.
But there are other kinds of personality which, if you simply keep asking the patient, how have you thought about that? what would your solution be? how do you feel about that and what implications does that have for your life? they feel like you’re being evasive. With a paranoid patient, they want to know what you think.
Narcissistic personality is characterized by “grandiosity or covert grandiose fantasies, a need for admiration, and avoidance of feelings of inadequacy; this is accompanied by a lack of empathy and a sense of entitlement.”
McWilliams reminds us of closet narcissists: those who seek help from therapists to gain popularity, fame, or riches, and believe such status will solve all their problems. This is not much different from the narcissists who already believe they are popular or wonderful—both are concerned with the same preoccupations. Their grandiosity is used to defend against shame.
According to McWilliams: “If you have an arrogant narcissistic person, the kind that the DSM describes, and they have a terrible injury—they aren’t promoted or they lose their job, beauty, wealth, or whatever it is they’re constructing their grandiosity on—then you see the shamed, anxious, humiliated version: the closet narcissist.”
Dependent personality is characterized by “excessive reliance on others, a fear of abandonment, passivity, and constant seeking of reassurance to mitigate fears of abandonment.”
Dependent people define who they are in relation to others—e.g., someone’s wife, someone’s mother, someone’s teacher—and don’t know who they are absent those relationships. Meanwhile, counter-dependent personalities “avoid dependencies, intimacy, and are concerned with maintaining autonomy and self-reliance.” They believe that they can’t depend on anyone but themselves.
Psychopathic personality, or what the DSM calls anti-social personality, is characterized by “manipulative behavior, impulsivity, deceitful conduct, shallow emotions, and a disregard for the rights and feelings of others without ethical constraints.”
The internal experience of the psychopathic personality, which the DSM glosses over, is the need for omnipotent control. My worth is dependent only on what I can make happen. I’m understimulated, so I’m going to attack the world manipulatively, and I don’t care about other people. These people tend to be in or seek very powerful positions because power organizes everything. McWilliams explains that they love power more than the narcissistic gratification of being seen as powerful.
levels of personality organization
McWilliams reminds us that it’s almost always the case that people have some combination of different personalities—but understanding the levels of personality organization is what allows for truly personalized and effective treatments. People’s psychologies are organized on a spectrum from high-functioning (i.e., healthy and neurotic) to dysfunctional (i.e., borderline and psychotic).
Healthy organization is characterized by “adaptive coping, positive relationships, realistic self-perception, resilience, effective problem-solving, and fulfillment.”
Neurotic organization is characterized by “moderate psychological distress, anxiety-driven behaviors, and unresolved conflicts.”1
Some typical characteristics of those at the high-functioning level:
Almost every therapy will be useful
They have healthy attachment security and assume their therapists are well-intentioned, even when providing difficult feedback or advice
They can observe complexity within themselves and others, building three-dimensional pictures of people (i.e., not all good vs. all bad)
They respect boundaries with their therapists and can easily resolve ruptures in therapist-patient relationships
They can develop realistic goals in therapy
They can acknowledge painful realities and talk about them with nuance as opposed to being in denial or relying on blame; they feel catharsis and relief at the end of sessions after describing their feelings, which allows them to move quickly toward grieving
They are more likely to use adaptive, rather than primitive, defenses; these include sublimation (transforming socially unacceptable impulses to socially acceptable or productive activities, like redirecting sadistic urges by becoming a surgeon) or having a sense of humor about themselves
Borderline organization is characterized by “intense emotional instability, identity issues, fear of abandonment, turbulent relationships, impulsive behavior, self-image challenges.” The psychodynamic process uses the term borderline for people who are too troubled to be considered just neurotic, but not troubled enough to be considered psychotic; hence, they are on the borderline between neurosis and psychosis.
This original definition is distinct from the way borderline is commonly used today. As McWilliams describes: “When DSM-III decided they had to include something about borderline in 1980, but they didn’t want to talk about anything dimensional, they took a type of borderline—namely a histrionic, self-dramatizing, affect dysregulated kind of borderline—and made it the definition.”
Some typical characteristics of those at the borderline level:
It’s hard to put themselves back together after talking about their feelings in a session
They tend to have insecure, anxious, and disoriented/distressed attachment
They are not able to modulate their affect and often experience intense affects
They rely on primitive, rather than adaptive, defenses such as:
Denial, withdrawal, dissociation
Splitting: seeing oneself or others as either all good or all bad; the inability to integrate conflicting feelings
Projection: the unconscious attribution of one’s unconscious (and usually disavowed) thoughts and feelings onto others; this includes doing it in a way that makes that projection true or induces the projected feelings in the other
Omnipotent control: a belief that one can “make anything happen”; an enjoyment of exerting power over others, though this is more evident in the psychopathic level of organization
Several clinicians are working on therapies specifically for those at the borderline level. McWilliams highlights some commonalities between their discoveries:
The top priority for therapists at this level is to monitor the therapist-patient relationship because stability cannot be taken for granted the way it is at the healthy or neurotic levels. This means consistently asking patients how they feel about the topics of conversation and the pace of the therapy. This approach is important for maintaining an alliance with a borderline patient, whereas it might come off infantilizing to someone on the high-functioning end of the spectrum.
The therapist should expect ruptures in the therapist-patient relationship; these will be painful and often happen early on, and most of the therapeutic work will be spent on repairing those ruptures. People at the borderline level know they are difficult and that they have a strong impact on people, so one implication of this is that therapists cannot be too neutral like they would with neurotic patients; acknowledgment of a borderline patient’s strong impact on people is more productive for treatment. For example, if Sally, who is at the borderline level, tells her therapist Mike that she started cutting herself again and asks him if he’s mad at her, it’s more productive for Mike to respond with: “Look, it’s my job to help you be less self-destructive and right now you’re being more self-destructive. That doesn’t make me happy. What’s it like for you to see the anger on my face?” instead of “Let’s investigate why you think I’m angry with you.”
Therapists need to be very explicit about their limits and boundaries. For example, they might implement contracts about the consequences for various acts of self-harm or boundaries around communication (e.g., when to text or call, if at all). Therapists should also expect patients at this level to test these boundaries—but they must uphold them nonetheless, no matter how hard it is (e.g., ending a session on time, even if the patient is in a fetal position crying over the topics discussed). This is because people at this level tend to have experienced boundary violations (e.g., sexual assault), so it’s important to have a therapist who models what boundary setting and adherence look like in order to build that trust. Patients will likely express anger at the boundaries when they are enforced, but what’s likely happening subconsciously when patients test boundaries is that they are assessing whether rules will be rationalized and changed (which happens, for example, in cases of molestation).
Therapists have to be more emotionally expressive, especially when they are presented with binary dilemmas by the patient. McWilliams approaches this by explicitly asking for supervision from her patients. For example, when one of her patients at the borderline level falls silent, McWilliams will say something like, “As your therapist, I’m not sure what’s helpful to you when you fall silent like this. Part of me says I should be drawing you out, but then I’ll be seen as someone with an agenda. Another part of me is saying to wait until you’re comfortable talking to me, but I’m afraid you’ll see that as abandonment. What do you want me to do when you’re silent like this?” Sometimes patients might respond with fuck you, you’re the doctor, you figure it out, but other times they have solutions in mind. Either way, they get the message that the therapist is trying to help. One of her patients offered the solution to just wait for him to feel comfortable, and he tested her by not saying anything for three full sessions. Again, here is a boundary being set (by the patient this time), and it’s important to adhere to it.
Therapists should expect intense countertransferences, defined as “a therapist's emotional response to a client that is influenced by their past experiences, unresolved issues, and personal biases.” These emotional responses can be positive or negative, but they must be managed either way.
Therapists need consultation and supervision when they are treating patients at the borderline level. The best way to do this is by presenting their patient cases to a team of other clinicians who treat at this level.
Borderline patients who are successfully treated will become much more adaptable and self-soothing versions of themselves, but their intense psychology will remain.
Psychotic organization is characterized by “severe reality distortion, hallucinations, and delusions; impaired thought processes, disrupted emotions, and significant functional impairment.”
Some typical characteristics of those at the psychotic level:
They get confused between the boundary of self vs. other. McWilliams once had a patient who would rapidly change the topic when he started speaking about traumatic experiences. She shared this observation with him and expected him to say he just wasn’t ready to discuss those topics (as perhaps someone at the neurotic level might say). Instead, he said he was doing that to avoid hurting her. “He saw sympathetic sadness on my face when he started to get sad and felt he was damaging me. He couldn’t imagine that I was a separate person able to feel compassionately for his suffering. That is a [subtle] psychotic level of confusion between his mind and my mind,” she says.
There are also many at this level who are not diagnosable as schizophrenic or as psychotically manic or depressive, but who are very confused about what’s inside vs. outside and are invested in peculiar beliefs. The primitive defenses they rely on are not working for them and they are fragile and often in a state of terror.
Therapies for patients at the psychotic level will differ from therapies for those at the healthy or borderline level. For instance:
Therapists should be aware that patients may be making profound misinterpretations throughout therapy.
The top priority for therapists at this level is ensuring an environment that feels safe for the patient. This might require, for example, conducting sessions with an open door or letting patients examine the office before beginning sessions.
Therapists need to achieve a (tricky) balance between egalitarian and authoritative tones in therapy. They need to demonstrate that they are just another human being trying to help the patient, but that they also are competent and skilled in this area. The former prevents patients from feeling like they’re being condescended to, while the latter helps them feel like they are with someone who knows what to do.
It’s important to maintain a tone of respect. For example, a therapist might respond to a delusional patient’s theory by saying it’s brilliant—but when asked by the patient if the therapist agrees with the theory, the therapist would gently say something like, “No, I disagree for XYZ reasons, but if you want to hear what I think, I’d be happy to share.” Here, the therapist is looking up at the patient—not in an idealizing or admiring way, but in an “I can learn something from you” way. This is crucial with this group because they have histories of humiliation, which is a cause and effect of psychotic personality. Therapists should be anti-humiliators.
Oftentimes, patients at this level will have severe emotional reactions about simple thoughts, or they will fuse meaning with certain perceptions or emotions, so therapists will likely need to spend a lot of time teaching them to differentiate between inside and outside, thoughts and behaviors, etc. McWilliams provides a good example of this from her own practice:
There’s a certain amount of educating that goes on with people at this level, and you can do it not necessarily by heavy-handed didactic stuff.
For example, I had a woman in this range who came to me really upset at herself and felt she was a horrible person—she used the phrase the spawn of Satan—because she found herself having the fantasy of strangling her teenage daughter. So I was just about to go into this lecture about how most parents have fantasies of strangling their oppositional teenage kids now and then—but I realized she was so sensitive to humiliation that if I took that stance, it would sound like I was talking down to her.
So I said, “Ugh, tell me about it, when my daughters were that age I wanted to strangle them three times a day!” That made us equals. That imparted the lesson without my being a heavy-handed educator.Therapists should recognize and validate that patients are attempting to solve their personal problems, even if their solutions are delusional. By acknowledging this effort, therapists can help patients see the maladaptiveness of their solutions.
Therapists will need to be conversational with patients at this level, even more so than with those at the borderline level. Neutrality is counterproductive.
Counterintuitively, successfully treating someone at the psychotic level does not mean that person becomes borderline. Rather, it means they become a well-compensated person who is still dealing with a lot of annihilation anxiety but does not need to rely on delusions to manage the anxiety.
Applying this dynamic lens to mental health is crucial because it allows therapists to provide tailored treatments with higher success. Someone with OCD symptoms in the healthy to neurotic range could be a great candidate for exposure therapy, whereas someone else with identical OCD symptoms in the borderline or psychotic range will require much more work before she could ever benefit from exposure therapy. This is despite the fact that exposure therapy tends to be blanketly regarded as the evidence-based treatment of choice for OCD.
McWilliams reminds us that the goal of therapy is not necessarily to change who someone is but to help that person become more functional:
In terms of the levels, you want to help people become a better version of somebody at that level. But in terms of the types . . . you can change the economics, not the dynamics. You can help an obsessive-compulsive person find much better ways to deal with anger than rituals or intrusive thinking. But you’re not going to turn that person into a hysterical person or a depressive person. They’re still going to be obsessively organized, but they’ll be much more flexible, have more range, be able to use a much wider group of defenses, and not feel quite so rigid.
I’ve been thinking about this interview with McWilliams for months now. I revisit it often; it helps remind me that both socially and psychologically, humans are incredibly complex. I have immense gratitude for those who understand and work with these complexities, rather than exploit or dismiss them. More than anything, I was finally able to witness the level of skill (and patience, compassion, self-reflection) required for a therapist to be exceptional. Hence, my newfound respect for therapists.
The traditional psychoanalytic technique was test-driven on patients at the healthy level.