Since 1981, psychotherapist Nancy McWilliams has been a visiting professor of psychology at Rutgers' Graduate School of Applied and Professional Psychology. An expert in psychotherapy, psychoanalysis, grief, trauma and dissociation, she is a principal author of the new Psychodynamic Diagnostic Manual. A collaborative effort of five major psychoanalytic organizations, the PDM is intended to be a companion to the Diagnostic and Statistical Manual, the official listing of all mental diseases recognized by the American Psychiatric Association. But unlike the DSM, which classifies mental problems according to symptoms, the 600-page PDM focuses on underlying personalities and emotional lives of patients. McWilliams, who has a master’s degree and a Ph.D. in psychology from Rutgers, lives and practices in Flemington, N.J. Her late husband, Wilson Carey McWilliams, was a political science professor at Rutgers from 1970 until his death in March of 2005.
Q. Why was the Psychodynamic Diagnostic Manual needed?
A. The DSM since 1980 has been valuable for researchers. If you’re doing research on Borderline Personality Disorder in California, you now use the same criteria to define it that researchers in Boston are using. Until then, there were so many different ways that people used diagnostic concepts, you could use the same name for rather different phenomena. So the DSM is useful to researchers, but not so useful to therapists, who deal with what is going on at the internal level of a person with a problem. Drug companies and insurance companies, for different reasons, have a stake in thinking of diagnostic categories as discrete disorders – if you’re a drug company, then you market a drug for a given disorder. If you’re an insurance company, then you can know from empirical research that 12 sessions make a difference for a specific condition, narrowly conceived. But that kind of research screens out people with complex problems – and most patients therapists see have complex problems. It’s a rare patient with a panic attack and no other disorder. We wanted a more holistic description of mental and emotional suffering, to counteract the pressures in the other direction.
Q. How does this new manual differ from the DSM?
A. It defines “mental health” in terms of certain capacities (resilience, reality-testing, self-esteem regulation, affect tolerance, moral sensibility, capacity for intimacy, and others) that exist on a continuum, and it construes psychological problems dimensionally, in terms of degree of severity. For example, a college student who never had bulimia before but has gained a little weight starts vomiting to control it, and knows it’s a problem – that person may be able to be helped in a couple of sessions. Another may have the same symptoms, but has been bingeing and purging since she was 6; her mother taught her that way of controlling her weight. That person may take as much as a year in therapy before she can even comprehend other ways to think about food. What I mean is that there’s a level of severity of different kinds of problems that is not addressed in the DSM. You can have an obsessive-compulsive personality and be a very high-functioning person, or you can be on the verge of psychosis, so obsessed that you never leave the house. The PDM takes these differences into account and emphasizes patients’ subjective experiences, not just their observable symptoms.
Q. Psychotherapy, compared with other methods, such as drug therapies and cognitive behavioral therapies, has come under attack in recent years as being too expensive and time-consuming. How do psychotherapists respond to that?
A. It would be nice if you could cure cancer in a couple of sessions, but some things do take time. The insurance companies say they offer comprehensive mental health coverage, but they come up with ways of discouraging psychotherapy to save money in the short run. You can make a good argument, though, that it [psychotherapy] reduces costs in the long run. There’s evidence that it reduces the number of sick days in workers, and it has numerous preventive functions. When insurance won’t pay for long-term out-patient treatment of people with significant mental problems, those people tend to become “revolving-door patients” who get hospitalized in crisis, discharged, and rehospitalized during the next crisis. Hospital care costs geometrically more than outpatient care, so now, by denying people care when they’re not in total disorder, we may be increasing the number of people bouncing in and out of the hospital.
One thing we’re trying to do in the PDM is represent a broader, more European, more philosophical sensibility than the narrow American sensibility that has informed psychological research. I’m worried that in recent years, we therapists are being redefined by the culture, which wants us to change from being healers to being technicians, wants us to fix people up and send them back into the trenches, as opposed to encouraging them to reflect on their lives. Psychotherapy is more in-depth than simple symptom relief. We’d like patients to feel more able to tolerate strong feelings, maintain self-esteem, and have a degree of autonomy. The contemporary vision of psychotherapists as people who fix your categorical disorder in a few sessions should be counter-balanced. I have nothing against helping people in as short a time as possible, but in the process, I would hope that they would try to know themselves better. I see this issue in a very broad intellectual context, quite interdisciplinary. And one of the things that makes Rutgers comfortable for me is its commitment to interdisciplinary, rigorous scholarship.
Q. What was your role in the collaborative effort that produced the PDM?
A. I wrote the adult personality section, in consultation with others, and I edited all the clinical sections. I was recruited for this task because of a book I wrote in 1994, "Psychoanalytic Diagnosis" (Guilford Press), one of three textbooks I’ve written. It has sold well – it’s in about 12 languages now. There is evidently a hunger people have had for thinking of diagnosis in a broader way that’s clinically useful.
Q. What does your visiting professorship at Rutgers entail?
A. I work one full day a week, teaching one lecture course and one supervision seminar each semester, and supervising some doctoral dissertations. I think it works out well for both me and GSAPP. It’s wonderful for me to be around colleagues who do serious research and scholarship in psychotherapy, and working with graduate students keeps me alive to the concerns of younger psychologists, not just those in my age cohort. The diagnosis book came out of teaching at Rutgers. My students got tired of my complaining that there should be a book that synthesizes clinical understandings of personality structure, and they urged me to write such a book. My department chair at that time, Stan Messer, joined them in putting me on this path that led to my eventual role in creating the PDM.