Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed

by Nancy McWilliams, PhD, Guilford Press, 2011, New York, NY, 426 pages, $60.00.

The second edition of this landmark book introduces its readers to basic concepts of psychoanalytic diagnosis, personality organization, and “defensive processes” and then applies those concepts to specific clinical entities. It is remarkable both for what it retains of value from the first edition and for what it introduces as useful “updates” in this second edition. As would be expected in a single-author textbook, a value of the book is consistency. Dr McWilliams conveys a coherent, well-communicated appreciation of psychoanalytic concepts both as a professional educator and as a seasoned (obviously rather skilled) clinician.

Even a clinician educator who has had the privilege of spending significant amounts of time with some of the leading figures in American psychoanalysis, this volume adds useful nuances to both my clinical and educational activities on nearly a daily basis. In the conceptual issues part of the book, Dr McWilliams provides an excellent rationale for both the value of psychoanalytic diagnosis and the important clinical effort of obtaining a developmental history of our patients in order to produce a clinical formulation. The fundamental differences in developmental levels of personality organization have implications for therapeutic action and anticipating the clinical consequences of different interventions. Dr McWilliams presents useful examples of how very similar words in the treatment relationship would result in very different internal experiences and emotional and behavioral responses in patients with neurotic, psychotic, and borderline levels of personality organization. The examples she uses easily translate into didactic teaching, clinical supervision, and clinical care.

The chapters on primary and secondary defensive processes are also thoughtful, articulate, and rich with clinical examples that help translate intellectual concepts into diverse situations.

From a trainee’s perspective, the Psychoanalytic Diagnosis manual is an essential tool for navigating the basics of psychodynamic-psychoanalytic therapy. In giving the young therapist a framework for conceptualizing any particular patient, Dr McWilliams graciously translates into a practical approach a multidimensional view of the personality structure. The book provides enough information to help one grasp an analytic stance without overwhelming one with details. Anticipating the beginner’s confusion when exposed to new material, she reviews at the end of each chapter the major concepts discussed. With humor, warmth, and enthusiasm, Dr McWilliams instills confidence while making the book a delectable read. There is no doubt that the goal of “enhancing practice” has been achieved. This book is highly recommended to any clinician-in-training as a foundation for psychoanalytic thinking and also to any practicing therapist as a well-structured and comprehensive resource.

Dr McWilliams concludes with a “Suggested Diagnostic Interview Format” as an appendix. This is perhaps the only disappointing part of an otherwise excellent introductory textbook. The brevity of this appendix probably reflects space limitation.

We believe this book will be a rich addition to learning about psychoanalytic diagnosis (and psychoanalytic concepts) for any younger mental health professional who is seriously interested in depth psychology. It will also be a valuable tool for more experienced clinicians and educators who would like assistance in translating fairly complex concepts into language in a framework that can be appreciated by learners of a variety of different levels of sophistication and disciplinary backgrounds.

James W. Lomax, MD

jlomax@bcm.edu

Mihaela Cristina Ivan, MD

Author affiliations: Baylor College of Medicine, Houston, Texas.

Potential conflicts of interest: None reported.