Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process

by Nancy McWilliams

They may come for treatment complaining of a specific Axis I disorder, but their problems may go far beyond those symptoms.

hypomanic personalities, for example, because early experiences of depending on others came out disastrously, tend to bolt from relationships as soon as the therapist’s warmth stimulates their dependent longings.

Counterdependent people, whose self-esteem requires denial of their need for care, may also rationalize running from treatment when an attachment forms, because they feel humiliated when implicitly acknowledging the emotional importance of another person.

note how hard it may be for them to find the courage to stay in therapy.

The patient will feel the anxiety and will wonder about the practitioner’s competence. This self-replicating cycle can lead to all sorts of basically iatrogenic problems.

formulation is always tentative and should be acknowledged as such. Patients are often grateful for the clinician’s avoidance of pretension and demonstration of care in considering different possibilities.

Therapists, whose personalities are often rather depressive (Hyde, 2009), are quick to turn any apparent setback into self-censure.

times of crisis or stalemate, when a rethinking of the kind of dynamics I face may hold the key to effective changes in focus.

defending against being fully present with the patient’s pain. Diagnosis can, like anything else, be used as a defense against anxiety about the unknown.

emotional implications of someone’s age, race, ethnicity, class background, physical disability, political attitudes, or sexual orientation than it is to appreciate that client’s personality type.