Psychoanalytic Case Formulation (Book Review)

Author:  McWilliams, Nancy
Publisher: New York: Guilford Press, 1999
Reviewed By: Johanna Krout Tabin, Fall 2002, pp. 56-58

A Conversation with Nancy McWilliams

Knowing that we were meeting in order to share some thoughts in the newsletter, Nancy was very forthcoming. I do not take up space here by transcribing my own frequent murmurings, but I hope that Nancy’s voice will be heard in the reader’s inner ear as slow and thoughtful yet full of feeling.

Johanna: These notes are questions I wanted to ask you while reading your latest book, but anyone who reads the book might want to know what were you like as a little girl.

Nancy: (Laughter) They tell me that I was a very sensitive but cheerful child and very naturally empathic and easy. I was the middle child. So middle children often are sensitive to conflict and wanting to reduce conflict, I think. Does that make sense? They are also a little bit more unconventional, but probably the determining thing in my childhood was my mother’s death of cancer when I was nine, which was then repeated. My father remarried; I had a very loving stepmother, whom I called my second mother, who got cancer when I was eighteen and then died by the time I was twenty. So twice I went through these family losses of a mother and that gave me, first of all, a lot of identification with people who are suffering. Secondly, a tendency to idealize some of the things that the culture tends to devalue but that are considered maternal. When you lose your mother you tend to remember all the comforting, nurturing and emotionally empathic aspects of life that are hard to come by; and so I think it tended to make me idealize a certain kind of mothering. Both of my mothers were very good mothers.

My mother had been a teacher before she married and a teacher of the deaf. She was very interested in things psychological. When I was a little girl she would not allow me to have two friends over. She said you can either have one friend over or three. But when there are three girls together, two always gang up against one. I thought everyone had that rule because it was such a reasonable rule. It was a very psychological rule. That was only one of a number of things like that. When somebody hurt my feelings, and I think my feelings were probably hurt fairly easily because of my sensitivity as a kid, she wouldn’t minimize my feelings at all—but then she would talk to me about what might have been going on in the other person that they might have acted that way. Maybe they were jealous of me. That kind of thing. So I think I took it in with mother’s milk, this tendency to try to understand other people. She was college educated and I wonder how much she was exposed to psychoanalytic theory. She went to Barnard in the late ‘20s or early ‘30s.

Johanna: The Columbia atmosphere was psychoanalytic.

Nancy: She was at Teacher’s College, but I don’t know. There is a lot you don’t know about your mother when she dies when you are that young.

Johanna: Being psychological-minded must have been part of her as a person, too.

Nancy: My sisters both remember the same thing. With her emphasis upon kindness, she had certain rules. If you accept a date with a boy and then a boy you liked better asked you out, you were committed to the first boy. That’s just it. And at a Sadie Hawkins dance, “Why don’t you ask the less attractive guy to dance?”

Johanna: This was your second mother?

Nancy: This was my first mother.

Johanna: You were only nine?

Nancy: (Laughs) Oh, yes. Well, she knew she was going to die a couple of years before she did. And she made it her mission to make the children as self-reliant as possible. And very deliberately went about sort of preparing me for things I would face later, as a teenager.

Johanna: And obviously, you remember.

Nancy: I do. I learned later that when she was diagnosed, she went to the superintendent of schools and she said, “I am going to die. My husband is going to be pretty much a wreck.” She was right about that, too. “I want you to assign my daughters to the most nurturing, sensitive teachers that you’ve got.” (Tears in both our eyes, and her voice Which he did. I remember my fifth grade teacher with great affection. So I have a sense of her arranging for me to be watched over. The other thing that was very determinative for me was that my father, although a very loving parent, was a difficult man. He had… People have asked me why my sensitivity to the possibility that people may have some kind of brain damage or dysfunction. He had some dysfunction from an encephalitic illness when he was a child and it made him prone to outbursts of rage. And he never attacked anyone in the family, either verbally or physically. But he would go into rages about public issues, for example. And he was frightening to me. And he was a puzzle to me. How could he be so loving and warm but also sometimes so crazy? He had that need for order that Goldstein talks about in brain-damaged people. Eventually I figured out what the problem was. He was a very successful man and a very loving man. I think that‘s what oriented me toward diagnosis—trying to understand people. I loved my father and I wanted to figure him out.

So the combination of a very psychological mother that I idealized because I lost her too soon and identified with powerfully, and a father who also was very supportive but very different—was important. Also my father was very much a feminist. He wouldn’t have called himself that, I suppose. But he always did some of the housework. He always assumed that his daughters would get educations and could do whatever they wanted to pursue. I never ran into sexism in my family. So all those things I guess...

Johanna: It interests me that you are planning a book on doing psychoanalysis, making a natural trilogy after diagnosis and evaluation.

Nancy: That’s what my editor kept saying for a couple of years while I was resisting doing a third one. She said, “You need to write a book on technique, on treatment.” And I kept saying, “My whole shtick is that technique should flow from a deep understanding of the person.” Eventually that became the motive for me to write another book. I realized that I found myself thinking for my own students, “I wish somebody would write a book about psychoanalytic therapy that did not take a healthy neurotic person as the standard, because they don’t get patients like that.” A book that talks about what psychoanalysis as a theory has to offer for the treatment of everybody—addicted people, multidiagnosed people, borderline people, psychotic people.

Johanna: That’s another one of your valuable statements. Your clarity in some ways reminds me of one of my favorite books, Haim Ginott’s Between Parent and Child. He is also witty, but the similarity that I wanted to ask you about is a seeming patness in the examples that sometimes seems more dazzling than instructive. Do you know the book?

Nancy: Yes, you know, a Girl Scout camp was very important to me in my formative years, also. That’s where I got some continuity with all those losses. My family moved a lot, too. The administrators of that camp used to have the counselors read that book in order to train them to be sensitive to the campers.

Johanna: Good for him because I can think of none better as basic to handling situations.

Nancy: It was a “her,” by the way; a lesbian couple ran the camp.

Johanna: Interesting.

Nancy: And they were kind of surrogate mothers to me. Which also has given me a very strong feeling of connection with homosexual subcultures and groups.

Johanna: I have a note from your book to ask you more about your ideas on homosexuality, if there is time. The reason I mentioned the Ginott book, however, is that often people respond to his examples as seeming almost too facile You make it clear that you are reacting to what you feel needs to be supplied with a particular patient. If someone does not see things as deeply as you do, might your accounts seem a bit magical, interesting to read but not easily applied?

Nancy: Yes, well, I don’t know the answer to that. It is in appreciation of that that I spent most of one chapter in the book I am now writing on defending the traditional idea that the more analysis the analyst gets the better. People haven’t made a systematic argument about that since Frieda Fromm-Reichmann. And yet, paradoxically, I think that sometimes the most well educated, most theoretically well-analyzed people have been guilty of the most elemental crimes of insensitivity toward patients; and some of the most ordinary aides on psychotic wards are much better therapists. I have a friend who has had several psychotic breaks. And I have had him speak to my classes about what helped him and what didn’t. The thing he put the most stress on—he didn’t mind when people made mistakes with him, he knew he was very hard to understand. If they were mistakes of the head it was fine. But if they were mistakes of the heart, they were unforgivable. When people made a mistake of the kind to try to manipulate him into behaving in ways that suited the purposes of the hospital that created mistrust. But if someone made a mistake that was simply getting something wrong, although they were trying very hard, that was all right. And that has stayed with me, too.

Johanna: Somehow that reminds me of a topic in your book, managed care. I happen to share with you the policy of not having anything to do with it.

Nancy: It’s disturbing on so many levels. One is that it’s exerting a subtly corrupting influence where people are getting used to what they have to tell managed care companies in order for treatment to continue. It is such a distortion of what treatment is about. And that gets into the record as what treatment is about. And it involves people in a kind of psychopathy. It’s a very demoralizing pressure on students. It’s terrible.

Johanna: Plus, a colleague who was using managed care calculated how much she actually earned, after filling all the forms and making all of the tedious phone calls that could take hours even to initiate. It came to $10 an hour. As a paid companion, she could make more money.

Nancy: Yes, I’m very concerned about it. And I don’t see the public getting educated about what some of the alternatives are. I think APA has made a mistake to go after prescription privileges at this point. It makes enemies of the psychiatrists right at the time when we needed to find common cause with them. Someone said it’s like fighting for deck chairs on the Titanic to take on this issue at this time. I know that for training, it will mean instead of time to learn about psychotherapy, we’ll be taking time to teach students to prescribe. And what will happen to psychology is what is happening to psychiatry. People who want to be psychotherapists are having a terrible time with it. All the forces are on the side of being medicaters.

Johanna: It is especially egregious because of the poor quality of science behind prescription.

Nancy: I haven’t read the much literature on that myself, but friends of mine like George Atwood have made the same point. Still, I’ve got to make sense out of certain clinical experiences I’ve had.

Johanna: The only question is what is helping.

Nancy: That may be. That may be. With the genetic argument, that’s always seemed problematic to me. I suspect that there are genetic dispositions toward everything. And it’s sort of like a genetic disposition toward heart trouble. That doesn’t mean you’re going to get heart trouble. It means that you probably are more sensitive to certain stresses than other people. There is research that shows this: genetics are not determinative.

Johanna: I do want us to touch upon what you clarify about diagnosis, the DSM type and the psychoanalytic type. But first I want to take up the matter of disclosure. I liked so much what you said to differentiate between honesty and intimacy, personal intimacy.

Nancy: Yes. I do think that patients have the right to know certain things about their therapist. Especially when they’re trying to decide whether they want to work with you.

Johanna: You consider the patient’s right to know at the beginning.

Nancy: Later, when people ask me a question that is full of transferential meaning and they’re annoyed that I don’t answer it right away, I like to be able to say, “Do you remember at the beginning I asked you if there were any questions you wanted to ask as a precondition before deciding to work with me? This didn’t seem to be such an important issue then. So there’s something very special about it now. Why would that be?”

Johanna: I think you said you drew the line at talking about your sex life before someone’s deciding whether to work with you.

Nancy: (Laughs) Sure. Or sometimes religious questions. Sometimes—not often—but sometimes people ask you very intimate questions. It’s an honest answer to say, “I’m just not comfortable talking about an area that private to me. But I am very interested in why it’s an important area for you to ask me about.” I think that it is good modeling, too, to exemplify a person who is not going to be exploited.

Johanna: Time limitations make me take this as the moment to thank you very much for your generous responses today.

Johanna Krout Tabin has written on a wide variety of psychoanalytic subjects. She is a founding member and member of the faculty and administrative board of the Chicago Center for Psychoanalysis. Johanna feels the work of the Division is important enough for her to belong to several Sections. Her own most special interest is in how lingering developmental issues affect treatment.

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