Psychoanalytic Psychotherapy: A Practitioner’s Guide (Book Review)

Author:  McWilliams, Nancy
Publisher: New York: NY: Guilford Press, 2004
Reviewed By: Aaron L. Pincus, Spring 2005, pp. 25-27

I will admit from the start that I am biased. Having consistently used both Nancy McWilliams’ (1994, 1999) previous books for the psychotherapy practicum I supervise in our doctoral program, I was already confident I would like this book both personally and professionally. The bias is self-fulfilling and I do, in fact, like the book very much. However, I must also say that despite my bias, the third installment of McWilliams series on psychoanalytic practice differs from the first two. The book is more loosely organized and less specific than its predecessors, and this appears inherent to the gray area between being and doing that is traversed throughout the book’s 12 chapters. McWilliams’s book is as much or more about being a psychoanalytic psychotherapist than it is about doing psychoanalytic psychotherapy. This stands in contrast to recent books on psychodynamic psychotherapies that strive for effective manualization of therapeutic practice (e.g., Clarkin, Yeomans, & Kernberg, 1999). McWilliams makes it clear that her intent is not to present a treatment manual, but rather to provide young professionals and those in training with an overarching, integrative primer focusing on the essential features of psychodynamic treatment across populations, pathologies, and psychoanalytic paradigms. She has achieved and surpassed her goals. In articulating these essentials and warning against slavish reification of technique, the book is a survival guide for trainees and young professionals, a highly relevant reminder for supervisors and training programs of often overlooked professional issues and challenges, and a tome of experiential wisdom that practitioners of any orientation at any level of experience can easily identify with.

Chapters 1 and 2 orient the reader to McWilliams’ philosophy regarding therapeutic practice. These are presented as “articles of faith” and “psychoanalytic sensibilities” that underlie psychoanalytic psychotherapies. Perhaps most fundamental of all is the commitment to honesty (i.e., low defensiveness, expression of the true self, authenticity). This commitment pervades the entire book. McWilliams is honest about the good and the bad of psychoanalytic training and practice, the unglamorous realities of psychotherapy as a career, and when specific about doing therapy, she is honest about its process and limits. This is embodied in a section discussing accidental meetings with patients outside of therapy that destroy alliance and end treatment. For such instances McWilliams admits, “I do not know of any way to deal with these severe, therapy-destroying reactions other than with a philosophical attitude: Shit happens” (p. 168). I smiled when I turned the last page over and found the final section of the book returns to the topic honesty, given it is implicit in almost every page.

Beyond honesty, the articles of faith include the belief that knowing oneself deeply will have complex positive effects on the individual and the best preparation to conduct psychoanalytic psychotherapy is to also be a patient in such treatment. Psychoanalytic sensibilities are “habits of thought” that underlie the psychodynamic viewpoint. Curiosity and awe support a receptive, open approach to discovery of, and with, the patient. An appreciation of the etiological complexity of psychological phenomena highlights therapeutic understanding of conflict, multiplicity of attitudes, overdetermination, and multiple function. Identification and empathy promote use of the self in treatment. Sensitivity and attunement to affect broaden how we come to know the patient beyond verbal report via attention to nonverbal behavior and countertransference. This reminded me of Rollo May’s (1983) distinction between “knowing about a patient” and “knowing a patient.” The importance of attachment (and introjection) compels practitioners to fundamentally link relationship with etiology, therapeutic process, and clinical change. Finally, faith in the therapeutic process encourages working beyond symptom relief and toward personal growth and becoming. Rather than presenting a model for doing psychotherapy, McWilliams encourages therapists to approach their work with these attitudes guiding conceptualization and flexible intervention. These are certainly the attitudes I want to instill in my supervisees.

The remainder of the book covers elemental topics in clinical training and practice that are often overlooked when a specific paradigm and technique is emphasized and provides two case presentations that synthetically portray these attitudes in treatment. Chapter 3 discusses clinical training. McWilliams normalizes mistakes as inevitable and encourages using them as opportunities to heal clinical ruptures. She reminds us that clinical trainees are often high achievers and perfectionistic and contrasts this with the reality that psychotherapy is an endeavor that consistently forces us to face our imperfection. She encourages trainees to incorporate their individuality into their therapeutic identity, optimize supervision, engage in a personal therapy, and pursue a broad, diverse education.

Chapter 4 discusses the task of preparing the client for psychotherapy. While coverage of these topics is fairly nonspecific, the fact that the task of socializing the client to the therapy process is mentioned at all is unique and admirable. This includes establishing physical and emotional safety and educating the client about the process. Notably, McWilliams reminds us to tolerate negative transference, appreciate the inevitability of relational enactments, stay uncompromisingly honest, and provide understandable rationales to clients who present with common obstacles to using treatment effectively.

Chapters 5 and 7 focus on boundaries in therapeutic practice. I didn’t see the necessity of separating the two chapters with a chapter on basic therapeutic processes (chapter 6) and this reflects the somewhat loose organization of the text. Chapter 5 focuses on the therapeutic frame and covers basic issues in the practical arrangements of therapy (e.g., time, fees, confidentiality, between-session availability, limit setting, and patient tests of the frame). Chapter 7 presents various quandaries, or “things they didn’t tell me in my graduate program.” With regard to handling unexpected encounters with patients outside of therapy and innocent invitations to personal events from patients, McWilliams reminds us that to our patients, we are never really out of role. Despite this, she promotes a flexible approach to decisions regarding what to do. Another set of issues involves management of enactments such as attacks of one’s professionalism, loaded invitations, gifts, requests for other treatments, and requests for special treatment. Finally, issues around therapist disclosure, the role of touch, and sex are discussed. In all cases, McWilliams suggests a conservative but flexible approach to managing these types of therapeutic issues. She promotes an honest look at things. For example, it is best to see requests for touch as indicating feelings that need to be processed rather than discharged, but there are always honest exceptions. As for sexuality in clinical practice, she reaffirms our ethical commitment not to act but reminds us to honestly acknowledge its presence and place.

Chapter 6 addresses basic therapy processes. Here, basic means basic: listening, talking, influences on therapeutic style, power, and love. These topics are often missing from therapy manuals focusing on a specific technique. For example, McWilliams suggests the basic goals of therapeutic listening are to create a holding environment and potential space, as well as to promote the patient’s self-acceptance and reduce shame. She also wisely reminds us that much of our talking in therapy serves to communicate to patients that we have been listening. Other basics regarding talking include use of ordinary language, promoting first person expression, using metaphors, and developing a rhythm. Consistent with her entire approach, she encourages acknowledging and using power and love honestly in psychotherapy.

Chapters 8 and 9 provide two case presentations. The first case describes work with a neurotically organized patient who presented as traumatized, masochistic, obsessive-compulsive, and rigid. The second case describes a 10-year treatment of a patient with borderline personality organization who presented as impulsive, paranoid-masochistic, self-harming, and aggressive. Both these cases successfully illuminate the psychoanalytic sensibilities McWilliams outlines, though neither provides a formal application of a treatment model. Nonetheless, McWilliams is honest and candid, providing both the successes and the mistakes of these long-term treatments and vividly communicates the realities of being a psychoanalytic psychotherapist.

In chapter 10, McWilliams switches focus back to the patient and discusses basic lessons patients learn in psychoanalytic psychotherapies. In covering these lessons, she again wisely reminds us that what is commonsense to the psychotherapist may be news to the patient. I found this chapter among the strongest in the book. With regard to emotion, psychoanalytic treatments help them learn to integrate emotion into their organization of experience, to understand that there are universal emotional experiences, to recognize that thoughts and feelings do not equal acts, to become comfortable and adaptively in control of emotions, and to tolerate mixed feelings. Psychoanalytic psychotherapy helps patients create a maturational context for their problems and a developmental framework for understanding self and the world. Such therapies also help patients reduce stress levels and recover a sense of control after traumatization. Put simply, the patient learns that every situation is not a risk for retraumatization and also learns how to avoid real retraumatization. Finally, many patients learn to accept sexuality without shame and to grasp the complexities of desire and fear of intimacy. This is all phrased in straightforward language that avoids theoretical hegemony or technical rigidity.

The final two chapters return centrally to being a psychoanalytic psychotherapist, illuminating occupational hazards and gratifications, and discussing the importance of therapist self-care. I think McWilliams is at her best when honestly addressing some of the challenges therapists encounter. These include liability and insurance issues, the financial costs and responsibilities of private practice, physical problems associated with a rather sedentary occupation (my spine certainly empathizes with her spine), emotional exhaustion, indirect traumatization, guilt arising from our wish to help more and faster while always encountering our limitations or worse, from a patient’s suicide. Other topics discussed that are not found in treatment manuals include problematic aspects of psychotherapists’ relationships such as encountering suspicion or self-consciousness in others when they learn one is a psychotherapist, managing nonpatient requests for help, and always having to consider our out-of-role behavior. I also appreciated discussion of psychotherapists’ tendency to adopt a therapeutic role when they need not to. It reminded me of the difficulty some trainees have in simply having a casual conversation. McWilliams also reminds us that there are hostile or insensitive professionals who view psychoanalytic practice with incredulity, often due to archaic and caricatured understandings of psychoanalytic approaches.

The book succeeds at many levels. McWilliams does provide highly useful discussions of many topics not typically found therapy texts, especially those emphasizing a particular technique. Those of us who supervise trainees commonly encounter these topics and the text will go a long way in providing an articulate source for trainees to refer to when faced with such issues. In fact, the book is most helpful when covering these uncommon but essential topics. The book does have some drawbacks. First, when the text turns to doing psychotherapy (rather than being a psychotherapist), it is rather nonspecific and it will not serve as a stand-alone therapy training text. The “no model as model” for psychotherapy will likely be disappointing to trainees who are anxious to begin learning what to do and how to do it. It would be most appropriate to assign it as a supplementary text. Second, despite having trainees as its main target audience, I found the text required some specialized knowledge such as familiarity with Kernberg’s neurotic-borderline-psychotic object relations continuum. Finally, appreciation of the psychoanalytic sensibilities is enhanced by clinical experience. The downside of this is that beginning trainees will inevitably grasp the sensibilities’ scope and implications in ways limited by their experience. The upside is that practitioners at all levels of experience can take in the benefits of the book.

Clarkin, J., Yeomans, F., & Kernberg, O. (1999). Psychotherapy for borderline personality. New York: Wiley.
May, R. (1983). The discovery of being. New York: Norton.
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding structure in the clinical process. New York: Guilford.
McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford.

Aaron L. Pincus is associate professor of psychology at Pennsylvania State University. He teaches graduate seminars in personality theory and personality assessment, and supervises a clinical training practicum emphasizing contemporary psychodynamic psychotherapy for personality disorders.

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