In Praise of Nancy McWilliams: On Psychodynamic Therapy

I forget when I first stumbled upon Nancy McWilliams, but it was some time ago. I had started with W.R.D. Fairbairn's pioneering work on the schizoid personality, and then read Melanie Klein and Harry Guntrip on the same phenomenon.

It was, however, only when I came to McWilliams that I found an essay on the topic that is the clearest and most compelling treatment of them all. Not unrelated to this post, McWilliams in that essay quotes Harold Davis to the effect that “'psychoanalysis is a profession by schizoids for schizoids'.”

On the strength of that essay, and also very much respecting Jonathan Shedler, who regularly extolls McWilliams work on Twitter, I put her Psychoanalytic Psychotherapy: A Practitioner's Guide on my reading list, and have now had a chance to go through it very carefully. It is excellent, especially for those with little background in psychoanalysis. 

I appreciate her openness in the preface where she recognizes that there is a legitimate diversity of treatments, but that psychodynamic approaches are often neglected when it comes to studies of their efficacy. From here she notes that her approach in writing this book will be to emphasize what may be applied "to all clients," and not just those who have signed up for psychodynamic therapy. I take her to mean that psychodynamic theory is applicable and useful in understanding patients even if a given therapist operates predominantly from a tradition of CBT or DBT (etc.). 

In this she puts me in mind of the great philosopher Alasdair MacIntyre whose early work in the philosophy of science and the development of theoretical traditions--and the clashes between them--rightly reminds us that one mark of a stronger tradition is its capacity to more fully and helpfully account in a better way for the gaps in, or problems raised by, its rivals. 

The other welcome note in the preface is that McWilliams is not going to be a zealous crusader insisting that everyone must slavishly imitate her methods, or those of psychoanalysis more generally. Instead she speaks of the "need for therapists to honour their own individuality in the arrangements they make" (xiii). The preface ends by McWilliams recognizing her own debts to various figures, including Theodor Reik (he of the "third ear") and especially Frieda Fromm-Reichmann, whom I wrote about appreciatively and at length here. 

Later on she returns to this theme, insisting in several places that one should "integrate one's individuality into the role of therapist" (p.52) and that therapists are most successful when they "relax and let their unique personalities become their therapeutic instrument" (53). As she notes later, "when it goes well, psychoanalytic therapy feels to both parties like a conversation from the heart, not the head" (66).

The patient seeing you being genuine and open, and speaking from the heart, can find all this therapeutic. But we must, of course, do more than that--if a bit of warm listening and sincere opening up were all that a patient needed, then they would simply turn to a good friend or family member, not a psychotherapist. The uniqueness of the role is that we must also challenge patients to grow. 

Throughout the book one has the sense of serenity in McWilliams: she is not someone who defensively feels she must be a fierce advocate for or against any particular approach, or to challenge patients in an obnoxious fashion. In this, as I have remarked elsewhere, she stands firmly in Freud's line who, pace the myths talked about him, emerges in his correspondence and in Paul Roazen's original and invaluable scholarship, as very "liberal" in encouraging all sorts of methods of healing, not just psychoanalysis. 

In her discussion on the "American Medicalization of Psychoanalysis," McWilliams, in fact, emerges as a critic of the tradition she is defending and its "cult-like atmosphere," its often ideological and hidebound ways that have, perhaps more than anything else, contributed to the vastly diminished standing psychoanalysis has in this country. 

By contrast, she notes that contemporary psychoanalysis in this country, to the extent it remains viable and healthy, tends, rightly, to eschew tendencies towards "purity" of both theory and method, being comfortably eclectic in some ways ("I remain skeptical of orthodoxies, especially technical ones" [p.23]). 

In her first chapter she draws close to something I am working on in my next book: the increased openness towards spirituality in psychoanalysis today, and psychology generally. Here she references the work of Bion in particular, whom I discussed a bit here. 

What, if anything, distinguishes a psychoanalytic approach from any other? McWilliams begins by noting that there must be a "curiosity and awe" for the unconscious, and an awareness that most of our behavior, thoughts, and feelings are not in fact consciously determined. This requires of the therapist a willingness regularly to have what one thought one knew about the patient disconfirmed and disturbed. If, she suggests, one is attempting to practice some version of Freud's "evenly hovering attention," then this might not be so difficult for in that state one has not fixated on any one thing, least of all some notion of causation which might blind us to other factors in play. 

In her second chapter, McWilliams quotes Christopher Bollas from his first (and to my mind still his best) book, The Shadow of the Object: Psychoanalysis of the Unthought Known: "in order to find the patient, we must look for him within ourselves." 

She rounds out this chapter with a brief discussion on the role of faith--in the process, in ourselves, and in our patients--though there is no mention here of the extensive writings on the topic by Nina Coltart, who, to my mind, has covered this topic perhaps more forcefully than anyone else I know of. 

Chapter 3, "The Therapist's Preparation," begins by noting that we are going to make mistakes, and need to be okay with that. What happens after the mistake is often more crucial than the mistake itself. Will this lead to an enactment, or rupture, and if so, how is that handled? 

In her fourth chapter, McWilliams discusses the well-known findings about the centrality of the therapeutic or working alliance to the success (or failure) of all therapies. The patient cannot be expected early on to know to check in about this, so the therapist needs to make a regular point of asking  "How are you feeling about working with me?" or "Are you finding yourself comfortable talking with me?" (p.82). 

I have, so far, only once been scared by a patient, but I managed to wrestle control over my fear by, as it were, "channeling" the spirit of D.W. Winnicott (whom I last wrote about here), about whom it was often said that he refused to be afraid of his patients. I thought fear would be something you'd just have to get used to, if it came to that, but McWilliams addresses fear and threats of various sorts in several places in the book, and she helpfully reminds us that "the therapist's sense of safety is as important as the patient's" (80). 

Later on in a related vein she will note that protecting therapist and patient alike is also part of the reason for the frame, and one should never deviate from it lightly. If, she says, you ever feel uneasy about any request that seems to veer towards a boundary violation, trust your gut and err on the side of being conservative. Boundaries and frames, moreover, are crucial in managing the huge power differential that exists in therapy, of which we must ever be mindful. 

If a sense of safety on the part of the patient exists, and boundaries are in good working order, then the patient may begin to experience his capacity to express hostility and contempt toward the therapist without fear of retaliation. Handling this requires a deft touch so that you do not masochistically collude in diminishing yourself on the one hand, nor in reacting defensively and perhaps vindictively on the other. 

The topic of hate returns late in the book, when she notes that a therapist might well need to encourage a patient not merely to express that feeling, but even feel encouraged to enjoy it. 

Handling other requests also requires a deft touch. A bit earlier, in her section "The Art of Saying No" (p.126), she has some very useful advice which I had no sooner read then within a day or two had occasion to put it into practice, finding success on both occasions (to my considerable relief!). She refers to those sometimes awkward conversations one must have with patients, often over fees, or no-show policies, or other limits. Rather than give them a lecture on how such limits or policies are really in the patient's best interest, she finds it much easier to elicit co-operation if she presents those as helping to fulfill her needs. 

I did this with a patient who had sustained a serious injury and then not showed up to two appointments in a row. I could legitimately tell this person that I was worried they might have been hospitalized with worsening injuries and I was worried about them. This prompted a phone call the following week when another (different but serious) reason kept my patient from making the appointment. I think both of us felt relief that this was handled now openly and simply via this expedient manner. 

Chapter six ends with some welcome reflections on the nature of psychoanalytic love. Here, as earlier, she has returned to Freud's famous observation in a letter to Jung that psychoanalytic cures are, in the end, ones of love. This, she insists rightly, is not an infantilizing form of love but one of serious respect that takes account of all qualities, positive and negative, in the patient. It is not cheap sentimentality, and certainly never exploitative. 

Chapter 10 offers some brief comments on sexuality, noting "how sexually diverse people are," and learning this can often be a very freeing part of good psychoanalytic therapy: "the appreciation of sexual diversity and the capacity to own one's unique sexuality without apology are frequent 'nonspecific' outcomes" (pp.254-55). 

The final chapters of the book offer an array of more practical tips to therapeutic practice, with welcome comments on malpractice hearings and ethical violations, and how to handle them. The very last chapter is focused entirely on self-care, one form of which she advocates that I also greatly love doing: writing. Here she quotes Michael Eigen that "psychoanalysis is a writing cure, not only a talking cure. Writing helps organize experience of sessions, but it also helps discover and create this experience." 

In the end, McWilliams has a lovely answer as to why many of us might be, at least in part, motivated to do this work: "our patients heal us as we heal them" (p.281).