Psychoanalytic Diagnosis

How do we understand someone's mental health difficulties? In her book, Psychoanalytic Diagnosis, Nancy McWilliams sets out how it can be done by looking at a client's personality. In this article, I will summarise what we can learn from this.

Systems of diagnosis

Diagnosing mental health issues is often done using the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, these manuals typically only look at observable symptoms and often produce unscientific results. I wrote about the problems with these labels recently.

Several new systems are emerging that focus more on a narrative approach, such as the Power Treat Meaning Framework or trauma-informed approaches.

The psychodynamic community also have their own approach to diagnosing. The Psychodynamic Diagnostic Manual (PDM) could be compared to the DSM, but measures people on three axes: the personal (P) axis, the mental functioning (M) axis, and the symptoms (S) axis.

The S axis is comparable to what the DSM and ICD discuss. But in addition to that it includes the M and P axes. The M axis, which looks at an individual's ability to function in critical areas such as self-regulating, or establishing and maintaining relationships. The P axis attempts to describe how an individual's personality is organised, which is to say how they view the world and what defences they typically use.

It is this P axis that the book Psychoanalytic Diagnosis is concerned with and that I shall be discussing here.

A note on language

In the book and this article, the language used is that of the psychoanalytic movement. For example, we will use words like psychotic, borderline, schizoid and masochistic.

Throughout the article, I will attempt to translate concepts into their CBT and humanistic counterparts to make it more accessible.

It is important to note that these words may have a different meaning in psychoanalysis than in general parlance. Again, I will try to translate these concepts to a non-psychoanalytic audience, but I also encourage you to keep these differences in mind as you read.

Developmental levels

The first dimension to consider is the developmental level. In Freudian terms, we might be asking, "At what stage did the individual's development get stuck?" In more general terms, we are asking where someone falls in terms of being neurotic, psychotic and borderline.

Neurotic clients are in touch with reality. They know their problems are in their head. For example, social anxiety. They know social situations are safe, but cannot stop themselves from panicking when they enter one.

They struggle because their defences are too rigid and too automatic. In CBT terms, we might talk about automatic thoughts, and in EFT terms, we might talk about patterns of emotional avoidance. They can accept reality and want to learn how to loosen these defences.

Neurotic clients respond rapidly to therapy because they agree on what the problem is and are eager to tackle it. They respond well to a range of therapies: for example, CBT has proven to be highly effective with phobias. This makes sense because it challenges a client's automatic responses and encourages them to develop greater psychological flexibility.

Psychotic clients are on the other end of the spectrum. They are out of touch with reality. They see the problem as outside of their head. This may seem obvious with clients experiencing psychosis, but psychotic organisation is not the same as psychotic symptoms. Consider the following examples:

• An obsessive-compulsive client who insists that one should unplug every electrical device in the house before going out in case there is a fire.
• An anorexic client who insists that being thin is a good thing and that their BMI of 14 is not dangerous to their health.
• An angry client who insists they have every right to shout, scream and bully their employees because they are the boss.

These clients are likely to require much more extensive therapy because the therapist must undertake the daunting task of building a shared understanding of the problem.

The task of building this shared understanding is difficult because such clients are not ready to accept reality. In Freudian terms, they lack ego strength and have fragile boundaries. In very simple terms, we might say they do not have enough self-esteem to accept that the problem might be them.

If such issues are not attended to, any behavioural interventions are likely to fail. As such, these clients often benefit from non-CBT approaches such as intensive analysis (in McWilliams's opinion) and person-centred, compassion-focused, or schema therapy (in my opinion), which focus on building self-esteem and self-efficacy.

It is important to note that while it is a spectrum, it is not necessarily a spectrum of functioning. Some psychotic individuals can function very well, whereas a neurotic client with agoraphobia may find it incredibly life-limiting.

To describe borderline clients as being in the middle would be an oversimplification. Borderline clients typically struggle with interpersonal functioning as a result of trauma. They typically lack a strong and consistent sense of identity and struggle with reality testing. They often engage in black-and-white thinking, or splitting in psychoanalytic language.

Therefore, while they may be more in touch with reality than psychotic clients, therapy is likely to proceed equally slowly because building a therapeutic alliance will take much longer. Such clients have been abused by many of the people they are close to and the systems that are supposed to protect them, and are therefore understandably hesitant in trusting their therapist.

Personality types

Now that we have explored different levels of development, we begin to look at the typical patterns we can see in the way that the self is organised. That is to say, "how does someone see, understand and make sense of the world?". In Freudian terms, the question might be "what defences does this person typically use, and what are they defending against?"

Psychopathic (antisocial) personalities are driven by shame and see emotion as a weakness. They might brag about the bad things they have done while at the same time being embarrassed about minor transgressions that point to their vulnerabilities. Thy display little guilt and have feelings of omnipotent control. In therapy, they will try to figure out what the therapist's "angle" is and are best served by the therapist role modelling integrity.

Narcissistic personalities are organised around maintaining their self-esteem by getting affirmation from others. They are driven by shame and envy, and often idealise or devalue themselves and others. They are best served by the therapist role modelling acceptance of their imperfect selves. For example, owning up to our mistakes without being embarrassed.

Schizoid personalities withdraw into fantasy. Although this can lead to hospitalisation in the severe end, many schizoid individuals are highly successful. They are often hyperreactive, easily overstimulated, and often seen as soft, gentle people. They highly value their individuality, which can lead to difficulties compromising with others and a high level of self-criticism.

Schizoid individuals may be the most in touch with reality, failing to block out the harsh reality of life that most of us ignore. They are best served by the therapist helping them to transform their creative energy into something positive. Therapy works best when it is highly collaborative and based on the client's agenda.

Paranoid personalities deal with their negative qualities by disowning and projecting them. These qualities may serve them well if they choose to become serial killers or politicians. Such clients may display hostility in therapy, and are best served by responding with acceptance, letting them know their disowned qualities are normal human behaviour. Therapists should avoid challenging them and focus on demonstrating their attempts to understand.

Depressive and manic personalities are overwhelmed by sadness. Depression is different from grief in that grief diminishes the world, whereas depression diminishes ourselves. Grief also comes in waves, whereas depression is more constant. It can be introjective ("I'm worthless") or anaclitic ("I feel empty"). The sadness is often driven by anger turned in on the self, and clients may be prone to guilt.

Believing the worst in themselves, they are often thin-skinned. They may believe that if their therapist knew the real them, they would hate them. They are best served by offering them the core conditions, without getting into an argument about whether they are bad or not. They are often highly likeable and altruistic. Many therapists would fall into this category.

Mania is conceptualised as a depressive individual in denial. They display the opposite qualities, being full of energy and enthusiasm. What we would call bipolar is a client alternating between using denial as a defence successfully (manic phase) and the defence temporarily breaking down (depressive phase).

Masochistic (self-defeating) personalities often make decisions that are antithetical to their own wellbeing. Where depressives feel they deserve to suffer, masochists will experience anger and resentment at their suffering, while feeling they have no option.

This behaviour may be functional. For example, the child who can only get attention by getting into trouble, or the domestic violence victim who concludes that losing their relationship is worse than the abuse.

They are best served by focusing on self-efficacy and the control they have over their lives. Avoid modelling masochism (despite the frustration such clients might invoke) and instead model healthy self-regard. Treat them like adults and hold them to their decisions, consistently challenging them on how they make choices that affect their lives.

Obsessive and compulsive personalities are driven by thinking (obsessive), or doing (compulsive), or both. Whatever combination of these, what they are not doing is feeling, daydreaming, intuiting, listening, or playing. In short, they seem to think and act like robots, rather than humans.

Such clients are often overly conscientious, dependable, and reliable, but are also rigid, inflexible and hold impossible standards. Workaholics are often in this category. Obsessives are often paralysed by decision-making and always wait to make the "perfect" decision. Compulsives are the opposite, jumping into action without considering the alternatives.

These clients often use words to conceal feelings rather than express them. They are best served by reconnecting with their emotions and discouraged from intellectualising. But this should be done with care: when we ask a client, "But how does it feel?" and they respond with "I think...", they're not being obstinate, but rather are so disconnected from their feelings that they do not know how else to respond. Using imagery, symbolism, and poetry can be useful here.

Hysterical (histrionic) personalities often have high levels of anxiety, intensity and reactivity. They are "people people" who seem to thrive on drama; they are fun and playful. They may act in counter-phobic ways. For example, someone who is ashamed of their body making themselves the centre of attention.

Although these individuals may come across as manipulative, they differ from psychopaths in that they are not out to hurt others but simply seeking safety and acceptance, and are driven to achieve this in any way they can. They are often well served by non-directive therapy that explores their defences.

Conclusion

In this article, I have summarised how McWilliams suggests we understand an individual's difficulties through the lens of personality, as informed by psychoanalysis. There are perhaps two key messages for therapists to take home.

The first is that the level of development will have a large impact on therapy. Neurotic clients may make rapid progress, borderline and psychotic clients will take much more time. This is important for setting expectations and to protect the self-esteem of the therapist, who may wonder why they are making what they feel is relatively little progress.

The second is that personality types differ widely and that this has important therapeutic implications. Giving every client the same therapy is unlikely to be successful because obsessive clients need something very different from schizoid clients.

Understanding on what level of development a client is operating, and how their personality is organised, allows therapists to deliver a more personalised and more effective therapy.