In Psychoanalytic Therapy, Dr. Nancy McWilliams demonstrates an integrative psychoanalytic approach characterized by the effort to create an egalitarian, here-and-now relationship in which therapist and client may work collaboratively on the client's problems. Her therapeutic process is organic: Instead of following a set method, she derives her style of working from psychoanalytic ideas applicable to the particular client and consistent with her own personality.
In this session, Dr. McWilliams interviews a woman in her mid-30s who is in an apparently abusive, longstanding relationship with a significantly older man. McWilliams listens to the client's experience and then helps her cope with her fear of separation.
Dr. McWilliams' fascination with individuality has been the engine behind her journey as a therapist. In the therapeutic role—whether she is appreciating individual differences in psychopathology, personality, ethnicity, sexual orientation, life experience, religious belief, or any other phenomena that shape a person's sense of self and create his or her psychological vulnerabilities—Dr. McWilliams tries to attune herself to what it is like for each unique person to engage with the world. Dr. McWilliams was trained as a psychoanalyst in the tradition of Theodor Reik and was also influenced by the personology of Henry Murray, the affect theory of Silvan Tomkins, the British object relations movement, the American interpersonal movement, and the humanistic, "third-force" psychologists.
In recent years, Dr. McWilliams has been attracted to the writings of relational psychoanalysts and control-mastery theorists. She is temperamentally integrative and resonates to the work of synthesizing theorists like Fred Pine and Martha Stark. Dr. McWilliams has appreciated the findings of researchers such as Sidney Blatt, whose studies have revealed a dimension of individual difference with significant implications for how to foster healing, especially from depressive conditions. She pays attention to the empirical literature in areas such as attachment, affect, development, defense, and brain function, as well as research on psychotherapy process and outcome.
What Dr. McWilliams values most about the psychoanalytic tradition is its emphasis on individual subjectivity. Despite the widespread belief that analysts treat all their clients with one inflexible technique, Dr. McWilliams has seen scant evidence for that stereotype. The proverbial fly on the wall watching her with various clients would see continuity in who Dr. McWilliams is, but considerable discontinuity in whether she talks a lot or a little, whether she asks the patient to talk about the past or not, whether she answers questions or explores the motives for asking them, whether she jokes with the client or wonders aloud why the person needs to keep her laughing. Analysts derive their style with any patient from their evolving knowledge of that person in the context of the relationship that develops in the therapy process.
Psychoanalytic therapy does not fit well into the paradigm of an expert applying a technique. It is more like a laboratory in relationship. In this peculiar and safe arrangement, one person is encouraged to say as much as possible about his or her thoughts, feelings, fantasies, wishes, hopes, conflicts, and impulses—especially as they arise within the treatment and are felt toward the therapist—while the other tries to make sense out of these expressions. Repetitive patterns are observed by both parties, and meanings are inferred that cast light on the patient's life outside the consulting room. Beyond those generalities, it is hard to characterize a "typical" psychoanalytic treatment.
When working with anyone, Dr. McWilliams attends constantly to transference phenomena (the ways in which a patient's past experiences shape their responses to the therapist and the therapy), but whether she brings transference issues into their conversation depends on her sense of the person's particular needs. Dr. McWilliams trusts her own subjectivity to register subtle and critical data; she keeps a close eye on her emotional reactions, imagery, and associations to understand what the person is communicating through tone, facial affect, body language, and other nonverbal modes. Whenever possible, she prefers that the client come up with the insights, while she simply facilitates the process of exploration. How one listens is ultimately more important than what one says.
Dr. McWilliams sees herself as in a long line of analysts who have stressed that patients need a new experience, not just new knowledge. At the same time, she is struck with the variability of what patients experience as helping. She does not think there is one therapeutic mechanism: What is helpful varies greatly from person to person. Some people benefit from insight into themselves, others from experiencing a new kind of relationship. Some feel helped by emotional catharsis, while others need to put a cognitive frame around unwieldy feelings. Some need sensitive reflection, and others need blunt confrontation. Clinical and empirical psychoanalytic studies of individual differences help clinicians to make informed choices about what to do with whom, and when.
Dr. McWilliams expects to make mistakes and to disappoint her patients frequently during their struggle together to grasp complicated and difficult issues, and she has learned that her patients profit from opportunities to confront and correct her when she has misunderstood them. These inevitable ruptures in the therapeutic relationship allow clients to learn how damaged relationships may be repaired and strengthened, something many people have not previously experienced. She hopes that her willingness to admit to, and explore the consequences of, her errors also models a capacity for self-acceptance despite imperfection. In her experience, realistic self-acceptance can be more valuable than behavior change per se, though behavior typically changes as self-acceptance increases.
While she is passionate about psychoanalytic therapy, a calling that suits her personality, she believes there are many ways to help people. The temperament of some individuals is not a good fit for the introspective, affectively dense nature of analytic work. Some people need medication, a twelve-step program, cognitive–behavioral treatment, or family systems work more than they need what Dr. McWilliams offers. Other people need different approaches as prerequisites or accompaniment to psychoanalytic collaboration. Like most people who become therapists out of a wish to help, Dr. McWilliams is grateful for anything that reduces a patient's suffering. But what she most enjoys doing—and what she sees as offering short-term, long-term, and preventive outcomes that go far beyond symptom relief—is intensive psychoanalytic therapy and analysis.
Nancy McWilliams, PhD, is the author of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (1994), Psychoanalytic Case Formulation (1999), and Psychoanalytic Psychotherapy: A Practitioner's Guide (2004), and is associate editor of the forthcoming Psychodynamic Diagnostic Manual. She teaches at the Graduate School of Applied and Professional Psychology at Rutgers, the State University of New Jersey. She is president-elect of the American Psychological Association's (APA's) Division 39 (Psychoanalysis), associate editor of the Psychoanalytic Review, and on the editorial board of the journals Psychoanalytic Psychology and Contemporary Psychoanalytic Studies.
Dr. McWilliams has written widely on personality structure and personality disorders, psychodiagnosis, sex and gender, trauma, intensive psychotherapy, and contemporary challenges to the humanistic tradition in psychotherapy. Her books have been translated into 12 languages, and she has lectured widely both nationally and internationally. Her book on case formulation was given the Gradiva Award for best psychoanalytic clinical book of 1999, and in 2004 she was given the Rosalee Weiss Award for contributions to practice by the APA's Division 42 (Psychologists in Independent Practice). A graduate of the National Psychological Association for Psychoanalysis, she is also affiliated with the Institute for Psychoanalysis and Psychotherapy of New Jersey and the National Training Program in Contemporary Psychotherapy. She has a private practice in Flemington, New Jersey.
- McWilliams, N. (2005). Preserving our humanity as therapists (with critique from and response to John Norcross). Psychotherapy: Theory, Research, Practice, Training, 42, 139–159.
- McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner's guide. New York: Guilford Press.
- McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford Press.
- McWilliams, N. (1998). Relationship, subjectivity, and inference in diagnosis. In J. W. Barron (Ed.), Making diagnosis meaningful: Enhancing evaluation and treatment of psychological disorders (pp. 197–226). Washington, DC: American Psychological Association.
- McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford Press.
- McWilliams, N., & Weinberger, J. (2003). Psychodynamic psychotherapy. In G. Stricker & T. A. Widiger (Eds.), Comprehensive Handbook of Psychology, Vol. 8: Clinical Psychology (pp. 253–277). New York: Wiley.
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