Psychoanalytic Diagnosis: Understanding Personality

Needed for assessment part of treatment.

Thought provoking book on understanding how disorders present, how to differentiate them, and how treatment approaches changes for each one.This book assumes some psychology background. However, I have managed to find the book relatively easy to understand. I am an engineer who has never taken a single psychology course. But I am interested in the subject and read other psychology material on my free time.

This is an in depth introduction to the field of psychodynamic theory. The fact that the first half of "Psychoanalytic Diagnosis" goes under banner of "Conceptual Issues" is no accident - as a central text for a course on the philosophy of psychoanalysis it would serve well. To those skeptical of the value of psychoanalytic theory, I can think of no better refutation than this book. The second half of the book charts "Types of Character Organization" and, while reading the whole aids comprehension and reveals a remarkable coherence, it is possible to read, or refer back to, specific chapters profitably in isolation. Not only is this a wonderful introductory text, it can be pulled from the shelf for years to come, if only to have the benefit of such a lucid articulation of difficult concepts.McWilliams does write with exceptional clarity. However, the subject matter is, to state the obvious, exceptionally complicated. Necessarily then the book is very dense. Not a page is wasted. While a straight read through will provide a wealth of stimulating insights and an overall approach to fathoming character structure, to assimilate all the content requires dedicated study. The grace of McWilliams' style can beguile one into thinking that the book is "easier" than it is. What follows is an attempt at a summary of an already highly condensed work.Granting that people have relatively stable patterns of thought and behaviour, and that such stable patterns constitute what we call "character" or "personality", the book asks, "How is one to classify types of personality?". Psychoanalytic concepts are used to structure a classification. In terming the concepts "psychoanalytic" McWilliams is primarily distinguishing her sympathies from those informed by behaviourism; perhaps the key feature being that psychoanalytic theory proposes the existence of unconscious processes of thought and emotion, while behaviourism attempts to provide an explanatory psychology without recourse to the unconscious. More generally, she is aligning herself with a tradition stretching back to Sigmund Freud.Several distinct schools of thought are identified: drive psychology, ego psychology, object relations, and self psychology. McWilliams explicitly sees herself as a synthesizer. While acknowledging that some thinkers would see elements of the various schools as incompatible, she regards them as largely complementary. Furthermore, she sees a common underlying approach in these schools.Formally, McWilliams summarizes her insight thus: "The essential character structure of any human being cannot be understood without an appreciation of two distinct and interacting dimensions: developmental level of personality organization and defensive style within that level" (p.40, Chapter 3). The rest of the book is largely an elaboration of this dense statement.Informally, she illustrates her point via an anecdote - a friend, not familiar with psychology, says he has just two categories for people: "1) Nuts and 2) Not nuts"; she replies that psychoanalysts assume "that everyone is irrational to some degree", and then ask two questions: "1) How nuts?, and 2) Nuts in what particular way?" (p.40).These two questions correspond to the two dimensions in the formal statement: thus, "How nuts?" is answered by considering the developmental level of personality organization, and "Nuts in what particular way" is addressed by consideration of defensive style."Developmental level" refers to the idea that humans pass through a series of relatively discrete stages of psychological development. Psychological health equates to reaching a level of function appropriate for one's biological and social age."Defensive style" implies that there is something to be defended against. The human psyche is taken to be defending itself against the world. More specifically, the child's psyche is considered capable of withstanding only a certain amount of frustration and trauma, beyond which it must defend itself by retreating from reality in one or more of a number of ways. As an adult, too, defense against reality's hardships is necessary. But psychological health is seen as, firstly, the ability to accept as much reality as possible, that is to bear hardship (the notion of "ego strength"), and to be flexible in one's use of defenses, and, as an adult, relying principally on those methods which least distort reality. In contrast, pathology exists if one method of defense predominates, this constituting a "defensive style", especially if the defense is one more suited to very early, that is infantile, life, where reality is grossly distorted or denied.The question "Why diagnose?" is directly addressed - the answer, at its most general level, being that diagnosis, if held as provisional, articulates understanding and so assists treatment. McWilliams discussion is, of course, nuanced beyond this brief statement.The above are the foundations on which the book is built. The contents are then laid out as follows.A summary is given of the history and the key features of the four schools of theory mentioned previously (drive, ego, object relations, and self psychology) (p19-39). The sequence of developmental stages is outlined, using the suggestions of the four schools to frame the discussion (p40-66). Clinical implications of the developmental level at which a character is predominantly organized are discussed - here McWilliams suggests how therapy might be tailored to more severely disturbed patients (psychotic and borderline), along with a discussion of the more traditional, better-functioning, psychotherapy patient, the neurotic(p67-95). The defenses are grouped into two broad categories: primary (or primitive) defensive processes, and secondary (or higher-order) defensive processes. The primitive defenses are taken to be what the infant and very young child has at its disposal, while the higher-order defenses develop as we develop into adulthood. McWilliams is aware that various theorists suggest the existence of more or less extensive lists of the types of defense - she uses Anna Freud's proposal as a starting point. Space does not permit even a brief elaboration of these here, but perhaps simply listing the nosology of defenses will be of some value.Primitive Defenses (p96-116) - primitive withdrawal; denial; omnipotent control; primitive idealization (and devaluation); projection, introjection, and projective identification; splitting of the ego; dissociation.Higher-Order Defenses (p117-144) - repression; regression; isolation; intellectualization; rationalization; moralization; compartmentalization; undoing; turning against the self; displacement; reaction formation; reversal; identification; acting out; sexualization (instinctualisation); sublimation.The last half of the book is a chapter by chapter discussion of specific personality types. McWilliams wishes to "depathologize" the assigning of a character type - as she says, "Everyone has character". What is more, she allows, "We all have features of several personality styles", and a previously reticent style can come to the fore under external pressures. So while her taxonomy shares categories with DSM IV, she wishes to emphasize that its application is broader and less rigid. Thus considering a personality "disordered" or pathological is warranted only when the person's "defenses are so stereotypical that they prevent psychological growth and adaptation".Each chapter is structured into seven sections. There is a discussion of the particular personality style as viewed from the perspective of drive theory, ego psychology, object relations, and self psychology; a section is devoted to transference and countertransference with such patients; the therapeutic implications of making the diagnosis of the particular personality style; and finally a section considering differential diagnoses, including once again how this might affect treatment. A brief summary and a selection of further reading concludes each chapter.Again space precludes an expansive survey of the chapters. The taxonomy of personalities is listed below. McWilliams is conscious that a more comprehensive text would add further styles. In her apology for not so doing she does state her belief that her choices map the main divisions.Styles of Personality - Psychopathic (Antisocial) (p151-167); Narcissistic (p168-188); Schizoid (p189-204); Paranoid (p205-226); Depressive and Manic (p227-256); Masochistic (Self-Defeating) (p257-278); Obsessive and Compulsive (p279-300); Hysterical (Histrionic) (p301-322); Dissociative (p323-348).The book ends with a two page "Suggestive Diagnostic Interview Format". In a way this is neat segue into McWilliams two subsequent books, "Psychoanaltyic Case Formulation" and "Psychoanalytic Psychotherapy: A Practitioner's Guide" which show how the conceptual apparatus can be applied clinically. Unsurprisingly, both of these books are beautifully written, eschew dogma, and provide a wealth of wisdom.

In a time where the DSM, version whatever, has become the diagnostic equivalent of scripture, Nancy McWilliams offers a book that bases diagnoses on understanding the individual rather than a collection of odds-and-ends symptoms. Mental health practioners may always be bound by the DSM in working with insurance companies, but the ideas presented in this book will provide a much deeper understanding of what guides many of the surface-level symptoms. McWilliam's writing is clear and concise, simple enough for the beginner but addressing issues of the complexity of diagnoses appropriate for the practiced clinician. This is not a one-time read -- if you have read it once, you will find yourself returning to it many times again.

This is a great book for a beginning clinician or those unfamiliar with psychodynamics. It is clear and concise, she explains each idea clearly, while providing a basic history and different points of view on it. It is structured beautifully, very very accessible. I like the summaries and reading suggestions she provides. In all, one will get an excellent idea into diagnosis, regardless of their theoretical orientation. Also, this book helps one understand basic terms such as 'ego states' etc which we encounter in other psychotherapeutic literature but do not get. It is simply an excellent text and I think every clinician should read it. its really improved my understanding and aided my work.