Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Type Schizoid Psychopathic Narcissistic

General Highly sensitive to interpersonal Organizing preoccupation – getting Arrogant/entitled – oblivious, thick-skinned, overt –
Core stimulation – fear of closeness but over on or consciously manipulating overt sense of entitlement, devalues most people, strikes
theme also longing for closeness others; preoccupied with power for observers as vain and manipulative or charismatic and
Range from high-functioning to deeply its own sake. commanding.
disturbed: From the creative genius to Mostly in the borderline-to-psychotic Depressed/ Depleted – hypervigilant, thin-skinned,
the catatonic patient. range covert, shy – ingratiatingly, seeks people to idealize,
There are two types: easily wounded, chronic envy of others seen as in a
1) aggressive- actively predatory, often superior position.
violent Disorder of the Self – a deficit state - core difficulty
2) Passive/parasitic – more dependent, with identity and self-esteem – inner sense of and /or
less aggressive, relatively non-violent terror of insufficiency, shame, weakness, and
manipulator, the “con-artist” inferiority.

Pathogenic hypotheses: Compensation for early

disappointments vs. fixation on normal infantile
grandiosity
Drive, Drive - Oral-level issues – fear of being Temperament Constitutionally more sensitive to unverbalized
affect, engulfed, taken over Lower reactivity of autonomic nervous emotional messages - infants that are preternaturally
Temper- Temperament - hyperreactive and system – higher-than-average attuned to unstated affects, attitudes, and expectations of
ament easily overstimulated threshold for pleasurable excitement others.
Affect - very much in touch with many More basic aggression than others – Either an innately strong aggressive drive or an innate
emotional reactions- perceive what biological substrate for the higher level lack of tolerance for anxiety about aggressive impulses
others disown effortlessly; of affective and predatory aggression (they may be scared of their own power).
General emotional pain when Affect Gifted children treated as narcissistic extensions.
overstimulated; affect are so powerful Emotional poverty Emotions
that they feel they need to suppress Rage and envy are dominant affects Shame (ugliness, helplessness, impotence) – sense of
them; are removed from the emotional Anxiety – they feel it but act out so fast being seen bad or wrong
contact with their own greed; to relieve themselves from such a toxic Envy (guilt) -if I feel deficient and I perceive you as
do not struggle with shame or guilt. feeling that the observer has no chance having it all, I may try to destroy what you have by
Withdrawal, seeking satisfaction in to see it deploring, scorning, or criticizing it.
fantasy, rejection of corporeal world; Associate ordinary emotions with Fear (anxiety) – afraid of falling apart, of precipitously
weakness and vulnerability; no losing their self esteem or self-coherence and abruptly
concept in using language to articulate feeling as nobody rather than somebody.
feelings; use words to manipulate. Deny remorse and gratitude
Feel humiliated to ask for help

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Defenses To interpersonal stimulation respond Omnipotent control – deliberate Idealization/devaluation – dominant defenses – other
with defensive withdrawal and syntonic attempt to use others (diff. realistic aspects are overridden by concerns about
fantasies about intimacy. from BPD who make others to feel comparative prestige.
manipulated w/o being aware of the Perfectionism – grandiose outcome/depressive outcome
Lack of defenses that blot out affective feeling elicited) – demands for perfection/chronic criticism in self or
and sensory information – repression, Projective identification – result of others; inability to find joy amid the ambiguities of
denial their inarticulateness human existence.
Or those that organize experience along Acting out – no experience of the
good-bad lines – compartmentalization, increase in self-esteem that results from Identification with prestige positions – preceded by
reaction formation, undoing, turning control of impulse idealization.
against the self Dissociation – different extents from
minor to total amnesia

Object The social world is dangerous and Failure of early attachment No capacity to discriminate between genuine feelings
relations engulfing. translated into a basic failure of and efforts to please or impress others.
Deep ambivalence about attachment human attachment Valued not for what they really were but because of the
“Come close for I am alone, but stay function they fulfilled – makes the child feel that if his or
away for I fear intrusion!” Never attached psychologically, her real feelings are found out rejection and humiliation
Sexually apathetic often despite being incorporate good objects, or identified will follow – fosters the development of a false self.
functional and orgasmic. with caregivers. Family atmosphere of constant evaluation.
Crave unattainable sexual objects while Identification with a stranger Stunted capacity to love - “Their need of others is deep
feeling vague indifference towards selfobject experienced as predatory. but their love of them is shallow!”
available ones. a) Weak, depressed, masochistic Goals – to love w/o idealizing; to express genuine
Parenting: mothers/sadistic fathers or feelings w/o shame.
1) Impinging, overinvested, b) Indulged materially and deprived
overinvolved emotionally or
2) Seductive or boundary- c) Repeated messages from the
transgressing mother or caregivers that no limits to the
impatient, critical father. prerogatives of a person so inherently
3) Double-binding, emotionally entitled to exert dominance should be
dishonest messages lead them posed.
to withdrawal and deep
hopelessness
Self Split between self and the world, and Polarized between the desired Needs external affirmation in order to feel internal
between the experienced self and condition of personal omnipotence (I validity.
desire. can make anything happen) and the Constant need of self-objects

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Self Their self stands at a safe distance from feared condition of desperate Self experiences: vague falseness, shame, envy,
the rest of the humanity - disregard for weakness. emptiness or incompleteness, ugliness and inferiority
conventional social expectations Aggressive and sadistic acts may Compensatory counterparts: self-righteousness, pride,
Detached, ironic, and faintly stabilize the sense of self by reducing contempt, defensive self- sufficiency, vanity and
contemptuous unpleasant arousal and restoring self- superiority.
Abandonment is a lesser evil than esteem. The sense of being “good-enough” is not a part of
engulfment. Grandiosity in a child results from their internal categories.
Self-esteem is often maintained by upbringing that lack consistency Fear (anxiety) – afraid of falling apart, of precipitously
individual creativity - have a high Primitive envy – the wish to destroy losing their self esteem or self-coherence and abruptly
standard for creative endeavors that which one most desires feeling as nobody rather than somebody.
The schizoid wants confirmation of Those in psychotic range – been known Sense that their identity is too tenuous to hold together
his/her genuine originality, sensitivity, to kill what attracts them. and weather some strain – fear of fragmentation –
and uniqueness. hypochondriac and morbid fear of death.
Avoidance of feelings and actions that express awareness
of either personal fallibility or realistic dependence on
others.

Transf/ Most analysts enjoy treating people Transference – projection of internal Transference
Countertr with schizoid character structures and predator – manipulation/charm to Instead of projecting a discrete internal object (i.e.
they are grateful to have a place where promote personal agenda parent) the narcissist projects either the grandiose or
the expression of their feelings will not the devalued self.
arouse alarm, disdain or derision. Countertransference – temptation to try - devalue/idealize in powerful ways
Transference to prove helpful - lack of interest in transference explorations – they are
Approach therapy with sensitivity, Moralistic outrage so ego-syntonic so that they are inaccessible to
honesty and fear of engulfment Unempathic feelings – concordant ctr. exploration – they really believe that the therapist is
Commonly tongue-tied, empty, lost in Complementary countertr. – therapist second rate/wonderful
the early phases. feels under patient’s thumb - efforts to make these reaction Ego-alien will fail at the
Long silences have to be endured while beginning
patient internalizes the safety of the
setting. Countertr.
Patient test therapist’s ability to tolerate Sense of having been obliterated, being ignored as a real
their confusing messages and maintain person.
empathy. Boredom, irritability, sleepiness, and the vague sense that
Contertransference nothing is going on in the treatment.
Because schizoids withdraw into Occasionally, the sense of grandiose expansion.
detached and obscure styles of Tendency to confront non-empathically.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Transf/ communication it is easy to fall into Tendency to bemoan the patient for the bad deal he
Countertr counterdetachment – see them as got from others.
interesting specimens.
The subjective fragility of the schizoid
is frequently mirrored in the therapist’s
frequent sense of weakness and
helplessness. Images and fantasies of a
destructive and devouring external
world may also absorb both parties.
Counterimages of omnipotence and
shared superiority may also be present.
Fond perceptions of the patient as a
unique, exquisite, misunderstood genius
or unappreciated sage may dominate the
therapist’s inner responses perhaps in
parallel to the attitude of the
overinvolved parent who imagined
greatness for this special child.
Thera- More responsive therapeutic style is It is much better to err on the side of Patience is a primary requisite in treating narcissistic
peutic required. inflexibility that to show, in the hope patients – acceptance of human imperfections – the
implica- Working with schizoid patients requires that it will be seen as empathy, what therapist should embody a nonjudgmental, realistic
tions a degree of authenticity and a level of the patient will see as weakness. attitude towards his own frailty.
awareness of emotions and imagery that Not bending at all is the right response A narcissistic person actually needs the therapist
would be possible only after years of to the special needs of the psychopath. more than do people without significant self-esteem
work with patients of other character Since power is the only quality deficits.
types. antisocial people respect, power is the Kohut – sees narcissism developmentally – maturation
Since therapists are somewhat on the first thing the therapist must went along normally and ran into some difficulties in the
depressive side and fear abandonment demonstrate. resolution of normal needs to idealize and deidealize –
more than engulfment they try to move Uncompromising honesty: talking analogy – a plant whose grow was stunted by too little
closer. straight, keeping promises, making sun and water at critical points – need to give plenty of
Empathy with schizoid’s need for good on threats, and persistently sun and water as it will finally thrive – benign
emotional space may consequently be addressing reality. acceptance of idealization/devaluation and
hard to come by. It is useless to invite the expression of unwavering empathy – subtype of supportive therapy
Early in therapy, interpretations assumed feelings of badness since the (according to Kernberg) suitable for frail (depressed-
should be avoided on the basis of patient lacks a normal superego and depleted) narcissistic persons towards the psychotic end.
patient’s fears of being treated doubtless committed sins in order to - therapist’s acknowledgement of errors – lack of

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

intrusively. feel good (omnipotent) rather than bad empathy is devastating for a narcissist – apology
Phrase one’s remarks in the (weak). confirms the patient’s perception of mistreatment
words/images used by the patient in Never show the suspect that it is (validation) and sets an example of maintaining self-
order to reinforce the sense of reality important to you to get a confession. esteem while admitting to shortcomings.
and internal solidity. Rigourous tough-mindedness and rock- Kernberg – structurally – something went awry very
Normalizing – a way to communicate bottom respect seems to be the winning early – a plant that has mutated into a hybrid – aberrant
that the schizoid’s internal world is combination. parts should be pruned – tactful but insistent
comprehensible. confrontation of grandiosity and the systematic
interpretations of defenses against envy and greed.
Reframing of imaginal richness as talent
rather than pathology is deeply Constant mindfulness of the person’s latent self-state –
relieving. injury of patient’s self esteem may lead to termination.
Use of literary/artistic sources of
imagery.

It is important that therapists accept to

act like and to be seen as a “real person”
not just a transference object. The
schizoid has an abundance of “as if”
relations and needs the sense of the
therapist’s active participation as a
human being: supporting risks in the
direction of relationships, being playful
or humorous in ways that were absent in
the client’s history.
Transference reactions are not only not
obscured by a more responsive style,
they may even be more accessible to
interpretation.
Differen- Degree of pathology Psychopathic vs. Paranoid Narcissistic personality vs. narcissistic reaction
tial It is critical to evaluate how disturbed a Significant overlap – many have strong Circumstances that undermine the sense of self-esteem
diagnosis person in the schizoid range is. DSM IV tendencies in both directions may lead to a secondary narcissistic disturbance
gives two alternative schizoid Both are concerned with issues of characterized by use of narcissistic defenses
diagnoses. power but from different perspectives. (omnipotence, devaluing, idealization i.e., the medical
It is essential to distinguish psychotic Unlike psychopaths, people with student who sounds opinionated, hypercritical, and
processes. essential paranoid structure have idealizes a mentor).

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Differen- It is equally costly to misunderstand a profound guilt the analysis of which is Narcissistic vs. Psychopathic
tial psychotic as a nonpsychotic schizoid critical to their recovery from suffering. Both character types reflect a subjectively empty internal
diagnosis character or the other way around. One Psychopathic vs. Narcissistic world and a dependence on external events to provide
should not assume that a person is at Both character types reflect a self-esteem.
risk for decompensation simply because subjectively empty internal world and a Most sociopathic people do not idealize repetitively, and
he/she has a schizoid character. dependence on external events to most narcissistic ones do not depend on omnipotent
Schizoid vs. Obsessive Compulsive provide self-esteem. control.
Schizoids isolate themselves and spend Most sociopathic people do not idealize Many people have aspects of both character types, and
a great deal thinking even ruminating repetitively, and most narcissistic ones self-inflation can characterize either one.
about the major issues in her fantasy do not depend on omnipotent control. Kohutian approach to narcissistic personalities – based
life. Some have rituals or behaviors that Many people have aspects of both on empathy would not work for psychopathic as they see
appear compulsive. character types, and self-inflation can sympathetic demeanor as a mark for weakness. The
Obsessive individuals in contrast with characterize either one. approach advocated by Kernberg centering on the
schizoid people are usually quite social; The differential is very important confrontation of the grandiose self would be more
they are apt to be moralistic while because treatment considerations are respectfully assimilated by a psychopathically organized
schizoid people are not particularly quite different for the two groups person.
invested in questions of right or wrong. (sympathetic mirroring comforts most Narcissistic vs. Depressive
People with OC personalities deny or narcissistic people but antagonizes The more depressive narcissistic person can easily be
isolate feelings unlike schizoid antisocial ones). misunderstood as having a depressive personality. The
individuals who identify them internally Psychopathic vs. Dissociative narcissistically depressed people are subjectively empty,
and pull back from relations that invite Sometimes hard to differentiate the whereas characterologically depressive persons are
their expression. basically psychopathic person who uses subjectively full of critical and angry internalizations.
some dissociative defenses and a Narcissistic vs. Obsessive compulsive
multiple personality with one or more The attention to details may be part of the narcissistic
antisocial and persecutory alter quest for perfection. When narcissistic patients that are
personalities. hungry for empathic mirroring and affirmation of self are
treated as OC that struggles for control and guilt over
anger and fantasized aggression the outcome is usually
bad.
Narcissistic vs. Hysterical
The need for distinction comes more often for women.
Because hysterically organized people use narcissistic
defenses they are readily misinterpreted as narcissistic
characters. Women whose hysterical presentation
includes a considerable exhibitionistic behavior and a
pattern of relating with men in which idealization is

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

quickly followed by devaluation may appear to be

narcissistic but their concerns about self are gender
specific and fueled by anxiety more than shame. Outside
certain highly conflicted areas they are warm, loving and
far from empty.
Therapeutic requirements are contrasting: hysterical
patients thrive when the attention is focused on object
transference; narcissistic ones require appreciation of
self-object phenomena.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Type Paranoid Depressive/Hypomanic Masochistic

General The whole personality is organized Depression is the opposite of mourning - People The masochist is a depressive who still
around the theme of power, either the who grieve normally do not get depressed, even has hope
persecutory power of others or the though they are pervasively sad during the period that
megalomaniac powers of self. follows bereavement or loss. Core belief (magical thinking) that
Two subtypes: introjective and anaclitic through pain something important is
Core theme: attacking/being attacked by Introjective – concerned with self-definition, self- achieved (that otherwise is forbidden) or
humiliating others; worth, self-critical thoughts something even more painful is averted;-
Core defense: dealing with one’s felt Anaclitic – concerned with relatedness, trust, -suffering, complaining, self-damaging
negative qualities by projecting them; preservation of attachments and self-depreciating
the disowned attributes then feel like - an unconscious wish to torture others
external threats. Hypomanic personality – depressive organization with one’s pain
Mostly in the borderline range counteracted by denial; usually in the borderline - the anguish of feeling non-existent or
range alienated is profoundly worse than any
- mood inflation, lack of guilt, irrationally positive temporary physical discomfort
estimation of the self - does not connote a love of pain or
- incapable of being alone, defective in empathy, suffering
lacking a systematic approach in cognitive style
Subtypes:
Moral masochistic – self-esteem depends
on suffering; unconscious guilt disallows
experiences of satisfaction and success.
Relational masochistic – relationship is
unconsciously believed to be dependent
on one’s suffering victimization.

Affect, Temperament DEPRESSION Childhood trauma and maltreatment

Drive, High degree of innate aggression or Drive create contrasting dispositions in children
Temper irritability - oral fixation – eating, smoking, drinking, talking, of different sexes:
ament Active symptomatic style in infancy - kissing girls – masochistic; boys – sadistic (by
irregularity, nonadaptability, intensity or - sadism against self; anger turned inward identification with the aggressor)
reaction, negative mood Affect - conscious sadness and deep
Hyperexcitability - sadness – major affect unconscious guilt
Affect - conscious, ego-syntonic, pervasive sense of - anger, resentment, indignation – see
Combination of Fear and Shame culpability themselves as suffering but unfairly,

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Shame – use of denial/projection are Temperament victimized.

very powerful so that no sense of shame - premature loss – suffered early frustration that
is accessible to the Self; they foil the overwhelmed their capacity to adapt
efforts of those trying to humiliate them - emotionally astute – “hypersensitive”,
Differential – the shame of narcissist is “overreactive”
that they can be unmasked
Anger, vindictiveness, resentment HYPOMANIA
Envy – increased vulnerability; is dealt like the depressives they are organized along oral lines
with by projection; “the others are out to – may talk nonstop, drink recklessly, bite their nails,
get me because things about me that they chew gum, smoke, gnaw on the insides of their mouth.
envy.”
Unconscious yearning for closeness
with a person of the same sex.
Unbearable burden of unconscious guilt
– terrorized of being unmasked by the
therapist – transform this fear into
constant efforts to discern the “evil”
intent behind anyone’s else behavior
towards them.

Defenses Projection – can be at psychotic, Defenses in depression Reflect the effort to master an expected
borderline or neurotic level - Introjection – the most powerful and organizing painful situation by
Psychotic – e.g I am followed by defense provoking an expected punishment that
homosexual Romanian agents – wish for - identification with the lost love-object will relieve the anxiety and provide
same-sex closeness, power, - unconscious internalization of the more hateful reassurance about one’s power – at least
ethnocentrism qualities of an old love object the time and place of one’s suffering is
Borderline – projective identification – - positive attributes are remembered fondly while self-chosen – a process called passive-
they try to make the projection fit negative ones are felt as part of the self into-active transformation.
Neurotic – internal issues are projected - turning against the self – maintains a sense of
in a potentially ego-alien way – they power (if the badness inheres in me, I can change this Repetition compulsion
describe themselves as paranoid disturbing situation) – people favor suffering over beliefs such as: whenever things are calm,
helplessness a storm is about to break
Denial, reaction formation - - idealization – seek idealized objects to compensate Dimensions of masochistic acting out:
correlates of projection for diminution; difference from narcissistic people – 1) Provocation – use of guilty power over
Freud’s example of reaction formation idealization is organized around moral issues rather helpless impotence – provoke until the
and projection – “I don’t love you, I hate than status and power. Other’s behavior supports their conviction

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

you” (reaction formation); projection “I Defenses in mania 2) Appeasement ( message: “I am already

don’t hate you, You hate me!” Core defenses are denial and acting out. suffering, so please withhold any further
Other examples of Denial – tendency to ignore or to transform into punishment!”)
projection/displacement: I don’t love humor events that would distress/alarm most other 3) Exhibitionism (message: “Pay
him, she loves him; I don’t love him, I people. Anything that distracts is preferable to attention, I am in pain!”)
love her; emotional sufferance. 4) Deflection of guilt (message: “See
Acting out – run from situations that might threaten what you made me to do!”)
with loss; sexualization, intoxication, provocation.
Devaluation – a defense isomorphic with the Moralization – more interested in
depressive tendency to idealize, esp. when they winning a moral victory than in solving a
contemplate making loving attachments that they fear practical problem.
will disappoint. Denial – deny being abused and protect
Omnipotent control – those in temporarily psychotic the perpetrator
state: invulnerable, immortal, grandiose.

Object Repeatedly felt Object relations in depression Self-defeating behavior is always very
relations/ overpowered/humiliated through - early or repeat loss- separation from a love object object related – is meant to engage others
interperson criticism, capricious punishment by - a major loss in separation-individuation phase in the masochistic process
al adults who cannot be pleased, utter virtually guarantees some depressive dynamics Unconscious belief: “If I suffer enough
mortification. - unless they are hurried, children wean themselves as it will turn out good for me!” (people
Psychotic, borderline – ridicule, separation is naturally sought by youngsters who are will pay attention and take care of me).
scapegoats confident of the availability of the parent if they need to Theme – people were there for the
Neurotic – teasing, sarcasm combined regress and refuel; it is ordinarily the mother, not the baby, patient when he/she was in deep enough
who feels keenly the loss of a gratifying instinctual
with warmth trouble.
satisfaction at weaning – and by analogy at other times of
separation.
Unresolved dependency – “Please, don’t
Unmanageable anxiety in a primary - circumstances that made it difficult for the child to leave me! I’ll hurt myself in your
caregiver who is incapable of understand realistically what happened when a loss absence!”
comforting – inducing the idea that pt’s took place. Fear abandonment more than pain - the
private feelings have a dangerous power. - family atmosphere in which mourning is discouraged only time when a parent was emotionally
Modeling of a paranoid parent. i.e., beliefs that grief is dangerous and needs for invested in them was when they were
Steps comfort are destructive – guilt inducers (“you are just being punished.
First – both feelings and reality were feeling sorry for yourself!”) Teasing – combination of affection and
disavowed by primary care giver - mother who clings “I’ll be so lonely without you!” – cruelty can also breed masochism –
instilling fear, shame rather than the or pushes the child away counterphobically “Why suffering the price of relationship
feeling of being understood. can’t you play by yourself?!”; in former situation – Attach to friends of the “misery-love-
Second – denial, projection – modeled. being autonomous is hurting; in the latter – they come company” type

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Third – Primitive omnipotent fantasies to hate the dependent strivings. Either way, a part of Tend to recreate abusive relationships.
reinforced leading to guilt the self is experienced as bad. May swing from masochistic to
Final – interaction with external world – - significant depression in a parent paranoid orientation.
anger. 1) paranoid –“I’ll attack you before you
“I will hit you before you get a chance to Object relations in mania attack me!”
hit me!” A pattern of repeated traumatic separations with no 2) masochistic – “I’ll attack me first so
opportunity for the child to process them emotionally. you don’t have to do it!”
Criticism and abuse are also common. The paranoid sacrifice love for power
May have remarkable energy, wit and charm but their The masochist sacrifice power for love.
relations with others are superficial because of their
unconscious fear of becoming attached.

Self Belief that hatred, aggression and The depressive self Comparable with that of the depressive –
dependency are dangerous. Believe that they are bad unworthy, rejectable, guilty, deserving
- worry that they are inherently destructive of punishment
Polarity – - unconscious convictions that they deserved rejection Plus – sense of being needy and
impotent/humiliated/despised self- - criticism may devastate them incomplete - permanent state of dread,
image vs. - therapist with a depressive personality (very often almost always unconscious, that an
omnipotent/vindicated/triumphant encountered in therapists) may use their position as a observer will discern their shortcomings
one reaction formation (undoing as well) to their sense of and reject them for their sins
First – engenders terror and shame destructiveness. - feeling that one is doomed to be
Second – engenders guilt misunderstood, unappreciated and
The manic self mistreated
Combination of sexual identity The manic continuum loads more heavily in the Grandiose and scornful – exalted in their
confusion, longings for the same sex borderline and psychotic areas because of the suffering and scornful of those lesser
closeness, preoccupations with primitivity of the processes involved. mortals who could not endure equivalent
homosexuality. Self-disintegration/fragmentation tribulation with as much grace
Homosexuality – longing for a peer, Self-esteem is maintained by a combination of success Self-esteem is enhanced by bearing
safe way to get away from solitude and at avoiding pain and elation at captivating others. misfortune courageously - Sly smile
isolation Masterful at attaching other people to themselves when mistreated - feel sadistic pleasure in
emotionally without reciprocating an investment of defaming their tormenters so soundly
comparable depth. Fight back by not fighting back
Suicide/psychosis can suddenly invade a manic exposing their abusers as morally
fortress if some loss becomes too painful to deny. inferior for showing their aggression

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Projection – project badness into others

and then behave in a way that elicits
evidence that the badness is outside rather
than inside (similarities with the paranoid)
– but they need others as the repository of
their sadistic inclinations
Transference Transference Depressive Transference
/ In most cases is swift, negative and Transference Masochistic patients tend to reenact with
Contratr. intense. Project on the therapist their introjects – harsh, the therapist the drama of the child who
Therapist seen as potentially sadistic, primitive superego – and are afraid that the need care but can only get it if she is
disconfirming and humiliating (rarely as respect of the therapist would vanish if he/she really demonstrably suffering.
a savior). knew them. The subjective task of the masochist is to
They may fix their eyes on the therapist As the patients progress in therapy, they project less persuade the therapist that
– “paranoid stare”. and experience the feelings as anger/criticism toward - needs to be rescued
Countertransference the therapist. - deserves to be rescued
Either anxious or hostile. Negativity – they do not expect to be helped and but they dread that the therapist is
Because of powerful defenses of nothing the therapist does is making a difference. This - uncaring, distracted, selfish, critical,
denial/projection – therapist may feel the is usually a transitory phase abusive
emotional reaction that the patient has Medicated patients tend to experience less the ruthless - will expose, blame and abandon
exiled from the consciousness. E.g. – self-loath of the borderline and psychotic states – it is May be more or less conscious – ego-
patient may feel full of hostility while as if the depressive dynamics have been made syntonic/ego-alien according to the level
therapist feel fear or patient may feel chemically ego-dystonic. Then the pathological of personality organization
vulnerable/helpless while therapist feels introjects can be analyzed as with the neurotic
sadistic/powerful. patients. Countertransference
Countertransference Countermasochism and sadism
Easy to love as patients – even borderline and Supportive/empathic strategies that work
psychotic depressives are palpably seeking love and with a depressive person are
connection and ordinarily induce a natural caring counterproductive with a masochistic one
response. in that they invite regression.
Ranges from benign affection to omnipotent rescue The more pronounced the suffering, the
fantasies (complementary) – response to the patient’s more giving the response; the harder
unconscious belief that the cure for depressive therapist tries, the worst things gets. “Just
dynamics is unconditional love and total try to help me – I’ll get only worse!”
understanding.
Depression is contagious – concordant ctrf; feeling of
demoralization, incompetence or “life is a bitch and

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

then you die!”

Mania/hypomania
Countertransference
Patients might be fascinating, insightful, confusing
and exhausting.
Nagging feeling –that with such a turbulent history,
the patient should be showing more emotionality in
recounting it.
The most dangerous countertransference –
underestimation of the degree of suffering and
potential disorganization that lie beneath their
engaging presentation (Rorschach test often picks a
level of psychopathology that no one suspected).

Therapeutic Interpretation from ‘surface to depth” is Depression - face-to-face relationship (lying on

implications usually impossible because of multiple Acceptance and compassionate effort to understand couch can be perceived as dominating and
defense operations – denial, projection, are fundamental attitudes but are not enough; work humiliating and reenacting a
displacement (a man who longs for the towards control-mastery is also essential. sadomasochistic dynamic).
support of someone of his gender, 1) To their ego-syntonic feelings of unlovability and - emphasis of the real relationship as
misreads it as sexual desire, denies it, terrors of rejection the therapist should respond with well as on the transference – needs an
projects it into someone else and unconditional acceptance. exemplar of healthy self-assertion – “do
displaces it becomes overwhelmed with 2) It is imperative to explore patient’s reactions to not model masochism”, no use of
fears that his wife is having an affair separation (from short silences to vacation) – they are therapeutic self-sacrifice
with his friend). very sensitive to abandonment and may experience - avoidance of all traces of omnipotence
Analysis of denial and projection brings such loss as evidence of their badness (unconscious in the analyst’s tone
more defenses of the same kin. for neurotics but many times conscious for psychotics - avoid of buying into guilt and self-
Exploration and pointing out i.e., “you are taking off to punish my sinfulness!”). doubt (powerful pressure from
unconscious manifestations boomerang. What depressive patients really need is not masochistic clients to embrace their self-
1) use of humor/attitude of self- uninterrupted care but the experience that the indicting psychology). Show that you
mockery, amusement at world’s therapist returns after separation – that their hunger respect yourself and enjoy good things.
irrationalities and other nonbelittling did not permanently alienate the therapist; that the lost - no expression of sympathy; no “you
forms of wit – jokes are a time-honored object returns. poor thing!” but “How did you get
way to discharge aggression safely. They 3) Encourage patients to get in touch with their yourself into that situation?” The Ego-
also tell that the therapist is “real” and anger. Their fear to express anger comes from the building approach runs contrary to the
not playing a role or pursuing a secret unquestioned assumption that anger drives people patient’s belief that only helplessness

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

game plan. apart. It often comes as a revelation to the depressive elicits warmth.
2) Avoid the content, engage with the patients that the freedom to admit negative feelings - no rescue; treat them as grown-ups
disowned, projected feeling increases intimacy, while being false or out of touch - do all the above when the alliance in
3) Identify what was the recent trigger produces isolation. established; don’t go too strong, too
of upset 4) Don’t support the ego, attack the superego! fast!
4) Avoid direct confrontation of the Supportive comments may increase depression as the - consistently exposing irrational beliefs
content of a paranoid idea; do not offer patient usually thinks “I might have duped this makes the difference between a
alternative explanations but only when therapist into thinking I am okay. I’m bad for “transference cure” – the temporary
the paranoid client asks outright if the misleading such a nice person” Saying that envy is reduction of masochistic behaviors based
clinician agrees with their normal will be received with skepticism but teasing on the idealization of and identification
understanding. the patient for being purer than God or statements with the therapist’s self-respecting attitude
5) Avoid interventions that invite them to such as ‘Join the human race!” might be taken in. and a deeper and lasting movement away
explicitly accept or reject therapist’s When interpretations are put in a critical tone they are from self-abnegation.
ideas. From their perspective acceptance more easily tolerated by depressive people.
equals a humiliating submission and 5) Encourage rebellion (as triumph over the fear of
rejection invites retribution. retaliation from the therapist) – depressive patients
6) Make repeated distinctions between work so hard to be good so that their compliant
thoughts and acts. Go beyond behavior may be legitimately considered part of their
interpretation of feelings and fantasies to pathology. Anger and criticism stand for a new stance
the recommendation that one enjoys of self-valuation.
them. “Bad thoughts are a lot of fun 6) It is more important with depressive patients than
especially when one could do good with others to leave decisions about termination up to
deeds in spite of them”. them and it is also advisable to leave a door open for
7) One must be hyperattentive to further treatment. The cause of dysthymia frequently
boundaries – consistency is critical to a include an irreversible separation.
paranoid’s sense of security;
8) Therapist should convey both Mania/hypomania
personal strength and unequivocal Prevention of flight – unless the therapist discusses
frankness – sometimes what matters this in the first session, interpreting the person’s need
more than what is said is how to escape from meaningful attachments and
confidently, fortrightly and fearlessly the contracting with the client to remain for a certain
therapist delivers the message. period after feeling the impulse to bolt, there will be
Respect, integrity, tact, patience no therapy because there will be no patient.
Without psychotherapy they fail to work through their
experiences of ungrieved loss and to learn how to love
with less fear. They also stop taking medicine.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Frequently one must “go under” a defense; i.e.,

aggressively confronting denial and naming what is
denied rather than inviting the patient to explore this
rigid defense.
The therapist should interpret upward, educating
the hypomanic patient about normal negative affect
and its lack of catastrophic effects.
Therapy should move slowly because of manic
terrors of grief and self-fragmentation. The clinician
who demonstrates deliberateness offers a spinning
client a different model of how to live in the world of
feelings.
Forthright tone – they need a therapist who is active
and incisive and who lacks cant, hypocrisy, and self
deception because emotional authenticity is a struggle
for them and because in their efforts to avoid psychic
pain most manic people have learned to say whatever
works. The therapist should inquire periodically
whether they are telling the truth, as opposed to
explaining away, entertaining and temporizing.
Differential Paranoid vs. Psychopathic Depressive vs. Narcissistic Masochistic vs. Depressive
Diagnosis Significant overlap – many have strong Often a depressed-depleted narcissistic is construed as Both coexist in many persons but usually
tendencies in both directions depressive. They differ in their inner experience. The one dominates. Treatment should be
Both are concerned with issues of power narcissist feels shame, emptiness, meaninglessness, directed towards the dominant dynamic.
but from different perspectives. boredom, and existential despair; the “melancholic” – If one treats a depressive person as
Projective processes are common in guilt, sinfulness, destructiveness, hunger, and self- masochistic, one may provoke increased
antisocial people, but where psychopaths hatred. The narcissistic person lacks a sense of self; depression and even suicide.
are fundamentally unempathic, paranoid the depressive has a painfully negative one. If one treats a masochistic person as
people are deeply object related. Countertransference with the narcissist is vague, depressive one may reinforce self-
Unlike psychopaths, people with irritated, affectively shallow; with the depressive is destructiveness.
essential paranoid structure have much clearer and more powerful, usually involving The predominant depressive person needs
profound guilt the analysis of which is rescue fantasies. to learn that the therapist will not judge,
critical to their recovery from suffering. Explicitly sympathetic, encouraging reactions can be reject, abandon and will be available
The main threat to long term attachment comforting to a narcissistically organized person, but when he/she suffers (unlike the
in paranoid people is not lack of feeling they may further demoralize a depressive. Attacking internalized object).
for others but rather experience of the superego in a narcissist is not helpful because self- The predominant masochistic person

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

betrayal. They connect with others on attack is not part of the narcissistic dynamism. needs to find out that self-assertion not
the basis of similar moral sensibilities Interpretations that redefine emotional experience in helpless suffering can elicit warmth and
Differential and hence they and their love objects are terms of anger will also fail with narcissists as their acceptance and that the therapist unlike
Diagnosis united on the basis of what is good and main state of feeling is shame not self-directed the parent who could be brought to
right, any perceived moral failing by the hostility. Turning the anger-in into anger-out will reluctant attention only if a disaster was in
person with whom they are identified relieve and energize the depressive characters. With a progress, is not particularly interested in
feels like a flaw in the self that must be narcissistic person, attempts to work “in the the details of the patient’s current misery.
eradicated by banishing the offending transference” may be belittled or absorbed into an
object. overall idealization, but a depressive patient will
Paranoid vs. Obsessive appreciate this approach and make good use of it.
They share a sensitivity to issues of Depressive vs. Masochistic
justice and rules, a rigidity and denial Very closely connected in the self-defeating patterns
around “softer” emotions, a Hypomanic vs. Hysterical
preoccupation with issues of control, a Warm, engaging, apparently insightful hypomanic
vulnerability to shame, and a penchant patients (esp. women) can be misunderstood as
for righteous indignation. hysterical. Maintaining a more detached attitude that
They also scrutinize details and may invites autonomy makes the hypomanic to feel only
misunderstood the big picture because of superficially understood and not held. The
their fixation on minutia. unconscious conviction that anyone who seems to like
Furthermore, obsessional people in the them has been duped exists in hypomanics just as in
process of decompensation into the depressives. It will issue in devaluation of and
psychosis may slide from irrational flight from the therapist unless addressed directly.
obsessions into paranoid delusions. Doing this with a hysterically organized person is
They differ in the role of humiliation in contraindicated. Evidence of abruptly ended relation
their histories and sensitivities; the with people of both sexes, a history of traumatic and
obsessive person is afraid of being unmourned losses, and absence of the hysterical
controlled but lacks the paranoid person’s concern with gender and power are areas of
person’s fear of physical harm and differentiation.
emotional mortification. Hypomanic vs. Narcissistic
Obsessional people are much more Grandiosity being a central feature of manic
likely to cooperate with the interviewer functioning it is easily to misconstrue a hypomanic as
despite their oppositional qualities; a grandiose narcissist. Narcissistic people lack the
therapists working with them do not turbulent, driven, fragmented backgrounds of most
suffer from the same degree of anxiety hypomanic patients. Even though an arrogant
that paranoid patients induce. narcissist is difficult to treat and resists attachment in
Rage reactions to conventional many ways, the danger of immediate flight is

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

clarifications and interpretations in a minimal.

patient one has believed to be
Differential obsessional may be the first sign that his Hypomanic vs. Compulsive
Diagnosis or her paranoid qualities predominate. Are both “driven” but similarities are superficial.
Unlike the hypomanic, the compulsive individual is
capable of deep object relations, mature love, concern,
genuine guilt, mourning and sadness, lasting intimacy
but is modest and socially hesitant. The hypomanic is
pompous, loves company, and rapidly develops
rapport with others only to lose interest in them soon
afterward. The compulsive loves details which the
hypomanic casually disregards. The compulsive is tied
down by morality and follows all rules, while the
hypomanic cuts corners, defies prohibitions, and
mocks conventional authority.
Mania vs. Schizophrenia
A manic in a psychotic condition can look very much
as a schizophrenic during an acute episode. Good
history to assess underlying flatness of affect and
capacity to abstract is necessary. The “schizoaffective”
conditions comprise psychotic-level reactions that
have both manic and schizophrenic features.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Type Obsessive Compulsive Hysterical Dissociative

General Organized around thinking and doing Preoccupied with issues of gender, sexuality and Identical with the diagnosis of
dominance of thinking (obsessional character); power Dissociative Identity Disorder
dominance of doing (compulsive character) Two types: inhibited and flamboyant Dissociative problems range from mild
used in a defensive mode Inhibited – more common in highly structured, depersonalization to polyfragmented
the two classes of symptoms can be separated moralistic (sub)cultures; emotional reserve, multiple personality disorder.
obsessions and compulsions are normally sexual naivete, inexperience and inhibition, Constitutional capacity for self-
present in persons who are not obsessional or conversion symptoms and somatization. hypnosis; early, severe, and repeated
compulsive as character Flamboyant (demonstrative) – more common physical and/or sexual trauma
in liberal (sub)cultures; tendency toward
repeated crises and dramatizations,
seductiveness and sexual impulsiveness;
problems with achieving full sexual response
are common.
“Hysteric” is the term used for neurotically
organized individuals and “histrionic” for those
in borderline range.
Affect, Rectal hypersensitivity - Anal fixation Anxiety – the major affect; lability of affect; Constitutional capacity for self-
Drive, aggressive urges. OC attitude may originate in may look superficial, artificial, and hypnosis.
Temperament early dyadic struggles over toilet training exaggerated Overwhelming affect that could not be
scenario resulting in issues about cleanliness, Temperament – intense, hypersensitive, and processed: primordial terror and horror.
stubbornness, concerns with punctuality, sociophilic - high anxiety, high intensity, high The more numerous and conflicting the
tendencies towards withholding but possibly reactivity – esp. interpersonally emotional states activated the harder is
also around eating, sexuality and general to assimilate an experience without
obedience. The kind of baby that kicks and screams when dissociation.
The experience of being controlled, judged, and frustrated and shrieks with glee when
required to perform on schedule creates angry entertained
feelings and aggressive fantasies, often about
defecation, that the child eventually feels as a seek stimulation but get overwhelmed by too
bad, sadistic, dirty, and shameful part of self. much of it
Harsh all-or-nothing superego – sphincter more dependent on right hemisphere
morality functioning

Affective conflict
rage (at being controlled) vs. fear (of being

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

condemned or punished)
Affect is muted, suppressed, unavailable or
rationalized; words are used to conceal feelings
not to express them
anger is the acceptable feeling if it is based on
righteous indignation
shame

Defenses Obsessives – isolation of affect Repression – cardinal mental process in Dissociation – is often an invisible
Compulsives – undoing – unconscious meaning hysteria (Freud) – repressed memory and defense. When al alter/system of alters
of atonement and magical protection associated affect; it is accompanied by the is running things smoothly, no one
Deleterious compulsions such as – overdrinking, return of the repressed. outside the patient can see the
overeating, taking drugs, gambling, shoplifting, Symptoms effect a primary gain – resolution of dissociative process.
sexualizing – more characteristic of people at a conflict between a wish and a prohibition and BASK model (behavior, affect,
borderline level of organization a secondary gain – concern/interest from the sensation, knowledge) of dissociation
For higher functioning people isolation is used others. The loss of sexual attention is subsumes under the phenomenon of
as separation of affect from cognition i.e., compensated by nonerotic attention to her body dissociation a number of related
rationalization, moralization, and disability. processes. One can dissociate behavior
compartmentalization, intellectualization. Sexualization – may be highly seductive but (e.g. a paralysis or trance-driven self-
Displacement unaware of the implied sexual invitation mutilation), affect (as in la belle-
Reaction formation - Regression –to fend off trouble by disarming indifference or the memory of trauma
a defense against tolerating ambivalence potential rejecters and abusers. without feeling), sensations as in
Against wishes to be irresponsible, messy, Acting out – counterphobic – e.g behaving conversion anesthesias and “body
profligate, and rebellious. seductively when they dread sex; inclined to memories” of abuse, or knowledge as
Incessant rationality – reaction formation exhibit themselves when they are unconsciously in fugue states and amnesia.
against a superstitious magical kind of thinking. ashamed of their bodies, to make them selves
the center of attention when they are
subjectively feeling inferior to others, provoke
when are afraid of aggression etc.
Dissociation – response to being overwhelmed
– reduces the affectively charged information
they must deal with at once – la belle
indifference; fausse reconnaissance;
pseudologia fantastica.
Object Caregivers set high standards and expect 1) sense of gender assigned powerlessness in the Outstanding feature – abuse, usually
relations/ early conformity with them. upbringing including but not limited to sexual

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

interpersonal Problems occur when the parents are 2) special relation with father – i.e. abuse; parents of people with multiple
unreasonably exacting, prematurely demanding, frightening/seductive personality disorder are frequently
or condemnatory not only of unacceptable 3) combination of maternal inadequacy and themselves dissociative. Because they
behavior but also of accompanying feelings, father narcissism often have amnesia for what they do
thoughts and fantasies. 4) in males raised in matriarchies where they both traumatize their children and
Centrality of the issues of control in their masculinity is denigrated fail to help them understanding what
family – guilt and shame-inducing upbringings 5) gays with histrionic personality has happened to them.
Induction of guilt -“I expected more...from a.. they may evoke the more tender side of a male Object-seeking, hungry for relationship,
like you!” partner and then unconsciously devalue him for and appreciative of care.
Induction of shame – “what would people being less of a man (soft, feminine, weak)
think if you’re..?”
Idealization of self-control and deferral of
gratification

The opposite of the overcontrolling moralistic

family milieu – lack of standards – children do
not model their parents but take their standards
from cultural/social sources imposing on
themselves tasks that are unbuffered by a
humane sense of proportion. The family acts as
a countermodel.
the paradox of the harshest superego in those
who were laxly parented.

Self Both obsessive and compulsive people are so Sense of a small, fearful, and defective child Fractured into numerous split-off
saturated with irrational guilt and shame that coping as well as can be expected in a world partial selves, each of which perform
they cannot absorb any more of these feelings. dominated by powerful and alien others. certain functions that include host
Deep concern with control and moral rectitude They manipulate in order to achieve security, personality (usually the seeker of
equate right behavior with keeping away to stabilize self-esteem, to master frightening treatment who tends to be anxious,
aggressive, lustful, and needy parts of self possibilities by initiating them, to express
dysthymic, and overwhelmed) infant
fear they own hostile feelings – they regard not unconscious hostility.
only behaviors but also feelings as reprehensible and child components, internal
may nurture a kind of private vanity about the Attachment to an idealized object creates a persecutors, victims, protectors and
stringency of their demands on themselves. sense of derived self-esteem. helpers, and special-purpose alters.
self esteem comes form meeting the demands of Rescue operations are another way to promote The self is not only fragmented but
an internalized parent self-esteem – set out to change or to heal a also permeated by paralyzing fears

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Obsessives - worry a lot esp. when they have to present day substitute for a frightening-exciting and self-blaming cognitions.
make a choice that might turn badly – childhood object i.e., the sweet, warm, loving Everyone is the patient.
“doubting mania” – the effort to keep all the females falling in love with predatory,
options open – postpone the decision until it will destructive males in the hope of saving them.
be clear what the perfect decision would be. They equate their power with feminine
Compulsives – jump into action before attractiveness so that they experience a greater
considering alternatives – instrumental thinking than average dread of aging.
and expressive feeling are circumvented. The histrionic behavior differs form that of
When circumstances make it hard for the o/c narcissistic persons. They are not internally
individuals to feel good about themselves on the empty and indifferent. They charm people
basis of what they are figuring out or because they fear intrusion, exploitation and
accomplishing they become depressed. rejection.
Avoid affect-laden wholes in favor of separably They feel internally castrated. Exhibitionism –
considered minutia – they cannot see forest for they turn the physical inferiority into a feeling
the trees. of power in physicality. Exhibitionism is
counterdepressive.

Transference/ Transference Transference Transference

Countertransf “good patient” but difficult was originally discovered with clients in the Very intense because of the intensity of
. they experience the therapist as a demanding hysterical realm the abuse. Especially when child alter
and judgmental parent – become consciously the present is misunderstood as containing the personalities are in ascendance, the
compliant but unconsciously oppositional. perceived dangers and insults of the past; they present can feel so much like the past
there is something very object related about have difficulty processing new and that hallucinatory convictions (e.g., the
their unconscious devaluation/ contradictory information due to the high therapist is about to rape me etc.) are
dutiful cooperation plus undertone of irritability anxiety level not uncommon.
and criticism the combination of a hysterical female and a Countertransference
when the therapist comments on such feelings male therapist will immediately evoke the Dissociative patients induce intense
they are usually denied client’s central conflicts responses of love, care, and wishes to
with male therapists female clients tend to be rescue. Their suffering is so profound
excited, intimidated and defensively seductive and undeserved, their responsiveness to
Countertransference with female – subtly hostile and competitive simple consideration so touching, that
the combination of excessive conscious with both – child-like one yearns to put them on one’s lap and
submission and powerful unconscious defiance most cooperative and appreciative take them home (especially the child
can be maddening alters). However, they are also petrified
annoyed impatience, wish to shake them to be in borderline/psychotic range subjects tend to by any violation of normal boundaries
open about ordinary feelings, to give them a act out destructively, difficult to manage between therapists and clients.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

verbal enema or insist that they “shit or get off even high-functioning clients can have very
the pot” intense transference
sensation of the rectal sphincter tightening in the transference is a means through which
identification with the constricted emotional healing is achieved
world of the patient (concordant) or in a sometimes the patients cannot tolerate the
physiological effort to contain one’s retaliatory intensity of their transference
wish to “dump” on such an exasperating person. change to therapists that seem less like the
feeling of boredom for the client’s unremitting original overstimulating/devalued object may
intellectualization work out well
less feelings of insignificance, boredom and
obliteration that common during the treatment Countertransference
of narcissistic patients defensive distancing and infantilization
doubts about whether anything is being the most vulnerable relation – narcissistic male
accomplished in therapy are typical for both the therapist and female client
client and the therapist, esp. before the client is the pseudoaffect – self-dramatizing quality –
able to voice these feelings out. invites ridicule
an attitude of patronizing amusement will be
injurious to them
tendency to accept patient’s invitation to act out
omnipotence (as the patients would usually
regress) – the appeal of playing Big Daddy to a
helpless and grateful young thing
giving advice. Praising, reassuring, consoling
are all messages pointing that the patient is
weak and foster regression
fear and genuine helplessness are not the same
thing
Therapeutic First rule of practice – ordinary kindness – What hysterical clients need in contrast with Treatment feels a lot like doing family
implications they are used to being exasperating to others for what they may feel they need is the therapy with one person, and as in
reasons they do not fully comprehend, and they experience of having powerful desires that well-conducted family work, the
are grateful for nonretaliatory responses to their are not exploited by the object on whom they system, not a particular favored
irritating qualities. rely. member is the client.
Refusal to advise them, hurry them, and Slow pace is important especially when
criticize them for the effects of their isolation, therapist keeps relatively quiet dealing with trauma.
undoing, and reaction formation will foster more interprets process rather than content Hypnosis may put these patients at ease
movement in therapy than more confronting deals with defenses rather to what is defended when exploring traumatic emotions.

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

measures. against
An exception to the rule of refusing to advise – limits interpretation to addressing resistances Because transference inundates
compulsions that are outright dangerous (self- rush to interpret will remind the superior power dissociative patients it is valuable for
destructive). Options – either tolerate anxiety and insight of others the therapist to be somewhat more
about what the patient is doing until the slow fostering patient’s autonomy is therapeutic “real” than he or she customarily
integration of the therapy work reduces the integration of feelings and thinking is deficient behaves.
compulsion to act (preferable if the compulsion Transferences usually become
is not life threatening), or, at the outset, make analyzable because the client discovers
the therapy contingent on client’s stopping the a tendency to make attributions in the
compulsive behavior may contribute to the absence of the evidence, and he or she
fantasy of the patient that therapy will operate discovers that the sources of such
magically without their having at some point to assumptions are historical. In contrast,
exert self-control. dissociative people tend to assume that
By accepting compulsively self-harming people current reality is only a distraction from
into analytic treatment unconditionally the a more ominous reality: exploitation,
therapist may contribute to their fantasies that abandonment, torment. To explore a
therapy will operate magically. dissociative person’s transference, the
Emotional disengagement to be avoided. therapist must first establish that he or
Asking the patient’s direction about how much she is someone different from the
the therapist should speak, may support patient’s expected abuser – someone respectful,
autonomy and sense of self support. devoted, modest, and scrupulously
Power struggles may produce temporary professional.
affective movement but in the long run they
only replicate early and detrimental object
relations.
For obsessive persons – interpretations that
address the cognitive level of understanding
before affective responses have been
disinhibited will be counterproductive. The
difference between intellectual and emotional
insight is striking in these cases.
One was to bring more affective dimension to
the work is through imagery, symbolism, and
artistic communication – more poetic style of
speech rich in analogy and metaphor.
Help them express their anger and criticism

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

about therapy and the therapist – lay the ground

of it.
Go beyond identification of affect to
encouragement to enjoy it.
It is useful to comment on their difficulty
tolerating just being rather than doing.
If this patient ca be convinced that
expressiveness is something other than pathetic
self-indulgence.
Differential Obsessive vs. Narcissistic Hysterical vs. Psychopathic Most people with dissociative
diagnosis It is more harmful to treat a narcissistic as a Anecdotal evidence of affinity between the two psychologies do not come to the
compulsive than the other way around. categories i.e., between histrionic women esp. in therapist stating that their problem
Nevertheless, an old-fashioned, moralistic o/c borderline range and psychopathic men. dissociation.
will be distressed by being seen as needy rather Qualities such as sensational, flirtatious, Data that should raise the suspicion: known
than conflicted. excitable are often construed as hysterical in hx/o trauma, family background of severe
Obsessive vs. organic conditions women and psychopathic in men. However, alcoholism/drug abuse; personal hx/o
Perseverative thinking and repetitive actions of there are psychopathic women and histrionic unexplained serious accidents; amnesia for
the elementary school-years; pattern of self-
organic brain syndromes. men.
destructive behavior w/o rationale;
In the borderline to psychotic ranges many complaints of “lost time”, blank spells;
people have aspects of both pathologies. referral to self in the third person or the first
Hysterical individuals are intensely object person plural; voices or noises in the head.
related, conflicted, and frightened, and a Dissociative conditions vs. Psychoses
therapeutic relation with them depends on the Dissociative switching might be
clinician’s appreciation of their fear. construed as schizoaffective and bipolar
Psychopathic people equate fear with weakness condition due to the lability of mood.
and they disdain therapists who mirror their Premorbid personalities and object
trepidation. The defensive theatricality of the relatedness make the difference.
histrionic person is absent in sociopathy. Dissociatives are very attaching while
Demonstrating one’s power as a therapist will genuinely schizophrenic are flat and do
engage a psychopathic person positively yet will not draw the therapist into intense
intimidate or infantilize a hysterical client. attachment. However, dissociative
Hysterical vs. Narcissistic symptoms can coexist with
Both hysterical and narcissistic individuals have schizophrenia and with affective
basic self-esteem defects, deep shame and psychoses. To assess if dissociation is
compensatory needs for attention and part of a psychotic picture when voices
reassurance, both idealize and devalue. are reported, one should ask to speak

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Personality types apud Nancy McWilliams - “Psychoanalytic diagnosis” (1994)

Hysterically organized are basically warm and with “the part of you that are saying
caring, their exploitative qualities arise only these things”.
when their core dilemmas and fears are Dissociative vs. Borderline conditions
activated; their idealization often has its origins Are not mutually exclusive.
in counterphobia (This wonderful man would Dissociation resembles splitting and
not hurt me!) and their devaluation has a switches to alter personalities can be
reactive, aggressive quality. easily mistaken for changes in ego-
states. Amnesia makes a difference.
Dissociative vs. Hysterical conditions
Considerable overlap. Conversion
symptoms are common in people with
multiple personality disorder; hysterical
people dissociate in many ways. In
anyone with pronounced hysterical
symptoms one should ask about
dissociation. Hx/o trauma might be
absent in hysterical people while it
always severe in the dissociative ones.
Dissociative vs. Psychopathic conditions
Many antisocial people have
dissociative defenses. Hard to make the
difference between a sociopathic person
with a dissociative streak and a
dissociative person with a psychopathic
alter. Clinicians can resolve dissociation
easier than they can alter antisocial
patterns. Since dissociative people have
a good prognosis, there would be
significant crime preventive value in
giving intensive therapy to perpetrators
discovered to have DP.

25