March 26, 2012

Introduction—Biography and Practice

Nancy McWilliams has a long-standing interest in presenting psychoanalysis in a way that is accessible to students from a range of backgrounds, and who are treating a wide variety of patients. Passionately interested in individual differences, she has cultivated a clinical practice with a patient population that is diverse in terms of race, ethnicity, sexual orientation, and diagnosis.

Perspective on Research and Practice

McWilliams feels that when it comes to research, our field has continued to suffer from some of the arrogance that typified it during its heyday—the sense that our ideas are self-evidently correct and don’t need to be tested through controlled empirical study. She sees other systemic factors contributing to the research/practice split:

• Analytic institutes are typically not university based, so there is an absence of dialogue with other intellectuals and researchers
• PsyD programs (which she otherwise supports) de-emphasize research in favor of clinical training
• The increased difficulty of the tenure and promotion process in academia requires an increased involvement in grant application processes and thus less likelihood that researchers’ extensive experience with practice will inform their research.

Nancy noted that contemporary researchers often lack empathy for the kinds of problems clinicians deal with and can be contemptuous of therapists for not taking the time to read research. On the other hand, therapists view research as not relevant to them, especially when it comes to randomized control studies with cherry-picked patients, delimited treatment time spans, and outcomes measures limited to the relief of observable symptoms. This kind of research in particular leaves McWilliams cold, as it does not address the kinds of complex growth and development that matter to therapists.

Nancy finds some areas of research particularly interesting and relevant to practice. Long-term outcome studies of therapy as it is actually practiced are very important, though they are expensive and difficult to do. She is interested in psychotherapy process studies like those done by Sampson and Weiss (e.g., Weiss, Sampson, & the Mount Zion Psychotherapy Research Group, 1986). She also notes the importance of therapist and patient personality and relationship variables in determining outcome. As an example of this, she gives Blatt and Zuroff ’s (2005) article on the therapeutic alliance and personality variables in both therapist and patient. She would like to see more research done on therapist personality variables; for example, the common positive factors of therapist warmth and authenticity and the negative impact of the therapist’s narcissism.

Looking a bit farther afield, Nancy suggested that she has found some nonclinical social science research to be relevant, such as attribution research. She also feels that some of the neuroscience research has been very important and relevant to clinical practice. Much of the interview focused on the neuroscience research.

Research Applied to Practice

Nancy discussed three major areas of neuroscience research and their applicability to clinical work.

1. Jaak Panksepp’s work on anxiety centers in the brain (e.g., Panksepp, 1998; Panksepp & Biven, 2012). Panksepp has differentiated between two major types of anxiety that are mediated by different brain regions and circuitry. The PANIC system is linked to separation and attachment, is mediated by serotonin, and is helped by SSRIs. The FEAR system is heir to our fear of predators and is experienced as annihilation, paranoid, or psychotic anxiety. This form of anxiety is relieved by benzodiazepines and alcohol, not by SSRIs, which is why patients with this type of anxiety often have substance abuse problems, especially with alcohol and other “downer” drugs.

Differentiating these types of anxiety, about which a long clinical literature preceded Panksepp’s research, informs the therapist’s approach. We need to speak to patients differently according to the type of anxiety they experience. Patients with anxiety based on the FEAR system will not respond well to intervention themes of attachment, feelings of loneliness, etc. They need a different presence from us, and interventions that focus on the fear of fragmentation.

2. LeDoux’s work on emotional memory (e.g., LeDoux, 1996, 2002). Joseph LeDoux did a series of experiments in the nineties that demonstrated that emotional memory is permanent, and that our belief as psychoanalysts that we could correct early emotional conditions was falsely sanguine. In fact, we can help patients deal with their emotions in certain more constructive ways, but we can’t undo those emotions. The fact is that traumatized patients can do better through therapy, but can’t expect to “recover” their pretraumatized self. They need to mourn the loss of their sense of innocent safety and learn to differentiate current stresses from the emotionally engraved traumatic ones.

These findings have helped shift Nancy’s therapeutic approach with some seriously disturbed patients. Looking back, she wonders if she didn’t “mis-ally” with some traumatized patients, expecting a degree of change that contributed to patients’ demoralization based on the knowledge that she hadn’t gone through the experiences they had gone through. Over time, she has come to better appreciate the limits of how much patients can change, shifting her focus from the possibility of transformation to the reality of accepting permanent emotional change and helping the patient cope with its effects.

Nancy discussed a patient with multiple personality disorder whom she was treating when she read LeDoux’s work. This patient seemed to assume that “enough goodness” in the transference would heal her and extinguish her experiences of being overwhelmed. When Nancy shifted the therapeutic approach to a more realistic appreciation that this patient would never be “untraumatized,” the patient responded with anxiety and disappointment on the one hand and relief on the other. Her ability to work through and integrate these (previously dissociated) affective states was therapeutic.

3. Mark Solms’s studies indicating that traumatic memories are not repressed, but instead are never laid down and stored in the first place (Kaplan-Solms & Solms, 2000; Solms & Turnbull, 2002).

In early trauma, glucocorticoids can overwhelm the hippocampus, meaning that episodic memory (“I was there and it happened to me”) is never achieved, although other forms of memory (somatic and emotional) do register. Thus, in cases of early trauma, the psychoanalytic model of repressed memory is not applicable. Those few remaining analysts who use an old model of repressed memory and embark on a quest to uncover “what really happened” are not only using poor technique, but are also disregarding important scientific findings.

Nancy noted the implications of these findings for the analyst’s authority. The idea that you as the analyst know the truth and can make the relevant interpretations has been deconstructed by relational analysts, and further called into question by Solms’s studies on the effects of trauma on memory. As analysts we have to tolerate ambiguity and uncertainty, and help our patients do the same. We and the patient may know that something (traumatic) happened, but may never know exactly what it was. Regardless, we may need to help the patient deal with the consequences of trauma, in some cases looking outside the treatment for historical validation, and taking active measures to avoid retraumatization.

Drawing more personal conclusions from her own clinical experience as well as research findings, McWilliams feels that she has come to tolerate intense transferences better than she did in the past. She has come to differentiate her own experience in treatment, in which she was able to analyze the transference and link it to past experiences, from the transference experiences of traumatized patients, who may not be able to attach the intense transference experiences to events per se. What is therapeutic for these patients is to tolerate more than to analyze the intense transferences. Understanding the different “unconsciousnesses” of different patients (Fonagy’s [e.g., Fonagy, Gergely, Jurist, & Target, 2002] concept of mentalization is relevant here) is an integral part of how we can grow as therapists and people.

The Future of Research Toward the end of the conversation, Nancy came back to two visions of how clinicians can benefit from research. First, on the level of inquiry, interest, and curiosity, she hopes to learn more about the impact of temperament and personality differences on the therapeutic process. (For example, she noted that, according to recent research done in Australia [Hyde, 2009], most therapists have depressive temperaments, are self-critical, and move toward people. This might not be the right fit for some patients.) And second, she feels that research plays an important part in our need to advocate for the profession of psychoanalysis. Whether it be Shedler’s (2010) meta-analysis of therapy outcome or Susan Lazar’s (2010) comprehensive report on the preventive effects of long-term therapy, research is critical to the survival of our profession.

In closing, McWilliams made a plea to both researchers and clinicians for mutual respect. Clinicians have to respect how hard it is to do good research and researchers would do well to respect the difficulty and complexity of the clinical project. She feels that the small group of psychoanalytic researchers who do clinical work deserve our special support.

References

Blatt, S.J., & Zuroff, D.C. (2005). Empirical evaluation of the assumptions in identifying evidence based treatments in mental health. Clinical Psychology Review, 25, 459-486.

Fonagy, P., Gergely, G., Jurist, E.L., Target, M. (2002). Affect regulation, mentalization and the development of the self. New York; Other Press.

Hyde, J. (2009). Fragile narcissists or the guilty good: What drives the personality of the psychotherapist? Unpublished doctoral dissertation, Macquarie University, Sydney, Australia.

Kaplan-Solms, K. & Solms, M. (2000). Clinical Studies in Neuro-Psychoanalysis. London: Karnac Books. Lazar, S.G. (Editor) & Committee on Psychotherapy of the Group for the Advancement of Psychiatry (2010). Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Arlington, VA: American Psychiatric Publishing, Inc.

LeDoux, J. (1996). The Emotional Brain: The mysterious underpinnings of emotional life. New York: Simon & Schuster.

LeDoux, J. (2002). Synaptic self: How our brains become who we are. New York: Viking. Panksepp, J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford University Press.

Panksepp, J., & Biven, L. (2012). The archaeology of mind: Neuroevolutionary origins of human emotions. New York: Norton.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, 98-109.

Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. New York: Other Press.

Weiss, J., Sampson, H, & the Mount Zion Psychotherapy Research Group (1986) The Psychoanalytic Process: Theory, Clinical Observation, and Empirical Research. New York: Guilford Press

About the Author

Steve Axelrod, PhD, practices psychotherapy and psychoanalysis as well as organizational consultation in New York City. He is a graduate of the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis. Steve initiated the Practice Survey in 2008, has been active in a number of division-wide efforts to advance the profession, and is a Contributing Editor to DIVISION/Review.