Introduction

Most of what follows is accumulated psychoanalytic wisdom. It is my own synthesis of that wisdom, however, and reflects my idiosyncratic conclusions, interpretations, and extrapolations. The organization of character possibilities along two axes, for example, which seems to me so clearly inferable from psychoanalytic theories and metaphors, may seem contrived to analysts who visualize the varieties of human personality in other images, along other spectra. I can only respond that this graphic depiction has been of value in my experiences acquainting relatively unprepared students with the welter of analytic concepts that have developed over more than a century.

The main object of this book is to enhance practice, not to resolve any of the conceptual and philosophical problems with which the psychoanalytic literature is replete. I am more interested in being pedagogically useful than in being indisputably “right.” A recurrent emphasis in the chapters that follow concerns the relationship between psychodynamic formulations and the art of psychotherapy. Beyond conveying certain basic therapeutic attitudes, including curiosity, respect, compassion, devotion, integrity, and the willingness to admit mistakes and limitations (see McWilliams, 2004), I do not believe in teaching a particular “technique” in the absence of trying to understand the psychology of the person to whom one is applying the technique.

Readers may have encountered the argument that psychoanalytic ideas are irrelevant to the deeply distressed, to people with crushing reality challenges, to minorities, addicts, the poor, and others. If this book succeeds in conveying the richness and particularity of analytically informed therapies, it will correct that misconception, even though the two axes on which I organize diagnostic information comprise only some of what it is helpful to know about any client.

A COMMENT ON TERMINOLOGY

A strikingly cyclical effort to sanitize speech has contributed to widespread misunderstanding of the psychoanalytic tradition. Over time, whatever the original intentions of those people who coined any specific psychological term, labels for certain conditions ineluctably come to have a negative connotation. Language that was invented to be simply descriptive—in fact, invented to replace previous value-laden words—develops an evaluative cast and is applied, especially by lay people, in ways that pathologize. Certain topics seem inherently unsettling to human beings, and however carefully we try to talk about them in nonjudgmental language, the words we use to do so attain a pejorative tone over the years.

Today’s “antisocial personality disorder,” as a case in point, was in 1835 termed “moral insanity.” Later it became “psychopathy,” then “sociopathy.” Each change was intended to give a descriptive, noncensorious label to a disturbing phenomenon. Yet the power of that phenomenon to disturb eventually contaminated each word that was invented to keep the concept out of the realm of moralization. Something similar occurred in the successive transformations of “inversion” to “deviation” to “homosexuality” to being “gay” to being “queer,” and yet people who are bothered by same-sex erotics still use the terms “gay” and “queer” to devalue. It will probably happen with the shift from “retarded” to “developmentally challenged.” Any phenomenon that tends to trouble people, for whatever reason, seems to instigate this futile chasing after nonstigmatizing language. It occurs with nonpsychological terms also; for example, it is endemic in controversies about political correctness. One outcome of this doomed project to sanitize language is that the older a psychological tradition is, the more negative, judgmental, and quaint its terminology sounds. The swift consumption, distortion, and prejudicial application of psychoanalytic terms, within the mental health professions and outside them, have been a bane of the psychodynamic tradition.

Paradoxically, another burden to the reputation of psychoanalysis has been its appeal. As concepts get popularized, they acquire not only judgmental meanings but also simplistic ones. I assume it would be hard for a reader who is new to psychoanalysis to come upon the adjective “masochistic,” for instance, without reacting to the label as a judgment that the person so depicted loves pain and suffering. Such a reaction is understandable but ignorant; the history of the psychoanalytic concept of masochism abounds with humane, insightful, useful, nonreductionistic observations about why some people repeatedly involve themselves in activities painful to them despite often heroic conscious efforts to do otherwise. The same can be said for many other terms that have been grabbed up by both nonanalytic clinicians and the literate public, and then bruited about with glib or condescending conviction about their meaning.

Concepts also get watered down as they come into common use. The term “trauma,” as popularly used, has lost its catastrophic overtones and can frequently be heard meaning “discomfort” or “injury.” “Depression” has come to be indistinguishable from brief periods of the blues (Horowitz & Wakefield, 2007). The term “panic disorder” had to be invented in order to restore to our ear the connotations of the older, perfectly useful phrases “anxiety neurosis” and “anxiety attack” once the word “anxiety” had been applied to everything from how one feels at a business lunch to how one would feel in front of a firing squad.

Given all this, I have struggled over how to present some of the material in this book. On a personal level, I try to observe the current preferences of groups as to how they should be identified and to respect the sensibilities of patients who object to certain diagnostic labels. Where current DSM terminology has become the norm for discussing a particular phenomenon, I use it unless it obscures older, richer concepts. But at a scholarly level, it seems an exercise in futility to continue to rename things rather than to use their existing names. Substituting “self-defeating” for “masochistic” or “histrionic” for “hysterical” may be preferred by those who want to avoid terms that contain psychodynamic assumptions, but such changes make less sense for those of us who think analytically and assume the operation of unconscious processes in character formation.

My somewhat ambivalent conclusion about the language to be used in this book has been to employ mostly traditional psychoanalytic nomenclature, alternating occasionally, in the hope of reducing the clanking weight of professional jargon, with more recent, roughly equivalent terms. Since I am trying to raise the consciousness of my audience about the rationale for each label that has come to denote a character attribute, I will generally rely on familiar psychoanalytic language and try to make it user-friendly. To the reader without a psychodynamic background, this may lend an anachronistic or even inferred judgmental tone to the text, but I can only ask such a person to try to suspend criticism temporarily and give the analytic tradition the benefit of the doubt while trying to consider the possible utility of the concepts covered.

A COMMENT ON TONE

Nearly everything one can say about individual character patterns and meanings, even in the context of accepting a general psychoanalytic approach, is disputable. Many concepts central to analytic thinking have not only not been systematically researched and validated, they are inherently so resistant to being operationalized and manipulated that it is difficult to imagine how they even could be empirically tested (see Fisher & Greenberg, 1985). Many scholars prefer to place psychoanalysis within the hermeneutic rather than the scientific tradition, partly because of this resistance of much of the subject matter to investigation by the scientific method as it has come to be defined by many contemporary academic psychologists.

I have erred in the direction of oversimplifying rather than obfuscating, of stating some ideas in a more sweeping way than many thoughtful professionals would consider warranted. This text is aimed at beginning practitioners, and I have no wish to increase the anxiety that inevitably suffuses the process of becoming a therapist by introducing endless complexity. In this second edition, however, in light of recent concern in the field about essentialism and absolutistic pronouncement, I have tried to tame any tendencies toward universalizing. All of us learn soon enough, from the unpredictable nuances of each therapy relationship into which we extend ourselves, how pale are even our most elegant and satisfying formulations next to the mystery that is human nature. Hence, I trust and encourage my readers to outgrow my constructions.