An Interview with Nancy McWilliams, Ph.D.
Nancy McWilliams, PhD, has been an active teacher, supervisor, and therapist in New Jersey for many years, and is one of the founding members of this institute. In 1994, she began a series of wonderfully clear and comprehensive books: Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (1994), Psychoanalytic Case Formulation (1999), and Psychoanalytic Therapy: A Practitioner?s Guide (2004). In 2006, she co-edited The Psychodynamic Diagnostic Manual.
Dr. McWilliams recently sat down with CPPNJ candidate Andrew Roth, Ph.D. to discuss her career as a psychoanalyst and author, and to talk about psychoanalysis and psychoanalytic psychotherapy: what it means to patients, what it means to therapists, and the empirical research support for its efficacy.
Can you tell us something about your personal history, and why you became a psychoanalyst?
First of all, I fell in love with Freud at Oberlin College, where I majored in political science. My faculty advisor, who later became my husband, told me he felt I was pretty psychologically minded, and suggested I consider writing a paper on Freud's Civilization and its Discontents for my junior year thesis in political theory. That was my real introduction to psychoanalysis. I strongly suspect that my mother was pretty psychoanalytically oriented; she had a Masters Degree from Columbia Teachers College, and they were fairly analytic at the time. She died when I was nine, so I can't know, but a lot of the tone of my upbringing seems to me, in retrospect, to have been very psychoanalytically friendly. She would sort of explain people's probable motives if my feelings got hurt and she was very psychological.
After I graduated from college, I moved to New York and wrote to Theodore Reik to ask if I could talk to him about how somebody in my generation would go about learning how to be a therapist. He was kind enough to see me and tell me that I should be analyzed. And he was right: I needed an analysis, and I had a very good one. Reik was interested in being my analyst, but he was quite elderly. I had lost a mother young, and I was, even then at 22 years old, bright enough to know it wasn't a good idea for me to plunge into an analysis with someone who was likely to die during the treatment. So, I turned him down and he referred me to the Theodore Reik Consultation Center, which was the clinic of his analytic institute, the National Psychological Association for Psychoanalysis (NPAP). I had an intake interview and they just assigned me someone. I barely had enough money for the $15 per session fee. That's one of the reasons I was instrumental in founding CPPNJ's Psychotherapy Center, where anyone can get analytic psychotherapy or a full analysis on a sliding scale (800-870-5940).
I then did my analytic training at NPAP, which was the parent institute from which the New York Center for Psychoanalytic Training branched off, from which the Institute for Psychoanalysis and Psychotherapy of New Jersey (IPPNJ) later branched off. Then over the last few years, IPPNJ merged with the Contemporary Center for Advanced Psychoanalytic Study (CCAPS) to form CPPNJ. I got my PhD from Rutgers, where I specialized in Personality rather than Clinical Psychology because I wanted to study with Sylvan Tomkins, who taught in that department, and because my overall fascination with individual differences went beyond a strictly clinical interest.
In my personal life, I enjoy hiking, and I sing.with a couple of other women as a trio called Three Blonde Chicks, although I haven't done that for awhile. And I still sing with an amateur group. I have two daughters. My older daughter is a professor of Political Science at Pomona, and my younger daughter, who's thirty, is one of the creators of the video games, Guitar Hero and Rock Band. She is also lead singer, rhythm guitarist, and songwriter for an all-girls punk rock band in Boston.
What are your thoughts on psychotherapy and the current American culture?
I think psychoanalysis got a toehold in this culture only because it was new and sexy, not because American culture is particularly friendly to the kind of European attitude that appreciates paradox and tragedy and limitation and a certain kind of nuance. Americans have a very practical, problem-solving, optimistic kind of culture; they want a simple formula. But there's a yearning in people for something more than that; there always has been in this culture. People find it in religion, they find it in philosophy, and they find it in various kinds of mental disciplines. And that hunger is still there. The culture doesn't give it much support. We psychoanalysts have a sensibility that is somewhat at odds with the culture. I think we all feel it, and I think we all have to support each other for trying to offer a corrective for some of the worst aspects of the culture. Our culture is constantly giving messages that essentially appeal to our most primitive narcissism, such as: if you're beautiful/rich/famous enough, you'll be happy, or if you retire and play golf all day, you'll be happy. And therapists know that isn't true. We know that a lot of happiness has something to do with the capacity to accept limitation, and to grieve what isn't possible, and to be okay with what you have instead of constantly striving for more. I'm sort of fascinated by how many current commercials are organized around the theme of "You deserve it. You're worth it." It's playing to the most grandiose and infantile parts of ourselves that therapists know aren't particularly adaptive for people to keep acting out in their adulthood. We know that giving children the constant message that they are special and superior - all of them "above average," as Garrison Keillor notes - creates kids with an inflated, empty sense of self, who worry that they are frauds, that they are really ordinary, that they have to present a false self to be acceptable. We know that realistic and resilient self-esteem is about engagement with the truth of who one is, with all one's flaws and vulnerabilities and conflicts. So I think we have a different angle of vision and we have to keep expressing that.
Psychoanalysis is certainly not going to die: We help people, they know it, and they tell people. People will still be looking for what we have to offer. However, I don't think we'll survive as psychoanalysis in the health care system. We can learn how to play the game of the health care system and talk to managed care companies in terms of target symptoms and behavioral aims. But psychoanalysis is going to become a treatment for people who are either reasonably wealthy or who are lucky enough to live in communities where there are clinics that manage to give psychoanalytic therapy to people who are not so well-off.
What is the impact of insurance, research, and evidence-based-treatment on psychoanalysis?
We have seen a very subtle and sinister paradigm shift that's been orchestrated mostly by the insurance companies and the drug companies. It used to be understood that psychotherapy was a healing relationship, and it's been recast as a set of techniques that you apply to discrete disorder categories. And it's stunning what's happened. One of the things that's occurred sort of silently is that, while it's a completely reasonable argument to say that psychotherapy should be based on research in addition to clinical experience, we are being asked lately to conceive psychotherapy as, not based on research, but like research. To do a certain kind of research, you have to isolate a particular disorder, you have to take measures before and after a delimited amount of treatment, and you have to manualize what you're doing so you know that everybody is doing the same thing. And that's required for a certain kind of research. But people have made what I think the philosophers would call a category mistake by insisting that therapists then should be orienting their attention to delimited disorder categories, taking measures before and after short term interventions, and manualizing what they do. That makes no sense because the aims of psychotherapy are very different from the aims of a certain narrowly defined kind of outcome research.
What the insurance companies want to do is claim that the relief of the symptom is all you have to worry about, and yet no good physician would ever equate the relief of a fever or the relief of a skin rash with the cure of an illness. What we're seeing there is that that kind of effort is not so much a medical model as it is a research model. Researchers aren't trained clinically, and they have to go by observable signs. They have to have a measurable criterion for the success of therapy. So, observable symptoms and the relief of observable symptoms makes sense for researchers to look at.
Unfortunately, there has been more and more estrangement between researchers and practitioners for many reasons; academic researchers don't know much about psychotherapy or what therapy is really like, and they are all too willing to give insurance companies their lines about what they should measure because it's what researchers measure.
But what we're really suffering from is the effects of a shift in 1980, when they tried to make the DSM responsive to the needs of researchers. Researchers were complaining that different geographical areas and different mental health subcultures diagnosed things really differently. They wanted something that was universal, which is certainly legitimate, but they also were complaining that diagnostic criteria required clinical inference, and they wanted externally observable categories. When we would tell them something like, "We diagnose narcissistic personality disorder by seeing whether a self-object transference develops in treatment," they said, "Well that's useless for us." So they wanted signs that you could check off - present versus absent criteria sets. And that makes sense, again, for a certain kind of research. And I think the people who shifted the DSM in that direction, including Robert Spitzer, who was the main architect of that, now have significant regrets about it because they didn't anticipate what the insurance companies would do with that, and they didn't think that the practitioner community was as fragile as it turned out to be in the face of these corporate interests that want to take DSM categories, exclude Axis II, even though we have research showing that more than half of people who come for treatment have significant character issues interwoven with their Axis I stuff, and define things in these reified ways.
Is there significant empirical evidence for the efficacy of psychoanalytic psychotherapy?
There is huge empirical evidence basis for psychoanalytic therapy. I don't know if you've seen Jonathan Shedler's article, "The Efficacy of Psychodynamic Psychotherapy," that was published recently in The American Psychologist. It's extremely powerful. (Readers can find this and other articles by Jonathan Shedler at www.psychsystems.net/shedler.html. And the evidence is not only supportive for the procedures of psychoanalytic therapy, but also for the concepts. There is literature in attachment, in affect, in personality types, in defense, in neuroscience that very much supports traditional psychotherapy. And often, young people have bought into the idea that because a lot of psychoanalytic therapies are so client-specific and artful and not manualized, therefore they're not evidence-based, but that's just not true.
How can therapists stay psychologically supported and intellectually stimulated after graduation?
Well, of course, newly licensed people are facing all kinds of difficulties these days that they didn't in my era, financially, and in terms of their time, and they also tend to get licensed around the time they want to start families. But, I would urge them to get as much of their own psychotherapy as possible despite all that. It's critical support in the difficult work of dealing with one suffering human being after another. And I also think that one burns out in this profession rather easily without opportunities to keep learning, and learning at a deep level. I find that younger practitioners are very conscientious about getting CE credits, and yet they quickly feel that many of the programs are below their capacity. They feel a lot of them are not very in-depth. So I normally encourage them to go into analytic training, or if they can't afford full analytic training to take advantage of analytic institutes to join supervision groups, to go to programs sponsored by analytic institutes because they're not as insulting to their adulthood and their competence as some of the more ordinary, formulaic ones that are offered.
It's both keeping you supported and keeping you stimulated that you need to provide for in your career. I think these days young practitioners are being required to carry caseloads that would be unimaginable 20 or 30 years ago and to treat patients as if they're just a series of disorder categories that you apply a particular technique to. And that will burn out people really fast, unless they have a place where they can explore themselves and where they can safely keep learning with other people - peer consultation groups are particularly important.