https://youtu.be/NNvTjWKa5VQ?si=7E7hV6BHgiwyChBN

This is a transcript ** of Nancy McWilliams’ lecture. I find this invaluable and worthy of repeated hearing.

The Psychodynamic Diagnostic Manual is an attempt to describe personality in a dimensional, complex way. I prefer not to talk about “disorders,” because everyone has a personality. We all express traits—schizoid, paranoid, narcissistic, psychopathic, hysterical, obsessional, dissociative, dependent, masochistic, hypomanic, counterdependent, sadistic, somatizing, phobic, and more.

Personality doesn’t arrive suddenly. It usually develops gradually, as a complex interplay of several factors: your temperament, the emotions emphasized in your early environment, the defenses you learned, the people you identified and counter-identified with, how you were taught to support your self-esteem, and how you learned to cope with disappointment. Did you learn to grieve and move on, or to blame? Did you feel good when you sacrificed for the greater good, or when you triumphed over others?

Babies differ widely in temperament—some are easy, others are more difficult—and the family’s response matters enormously. If your temperament fits the family’s expectations, you feel understood; if not, you may feel defective. On top of temperament, there are developmental challenges: neglect, trauma, overcontrol, or other forms of family response that you learn to adapt to. The brain, as a prediction machine, assumes that what repeatedly happened in childhood is how the world will always be.

Trauma at any age can disrupt personality. Substance use also complicates things. There isn’t an “alcoholic personality”—when someone sobers up, their underlying personality emerges.

Beyond Diagnosis: The Importance of Individual and Cultural Context

I have always been fascinated not only with diagnostic categories but with individual differences—how therapy is influenced when someone is an adoptee, a twin, of a different race, class, or religion than you. These differences go far beyond diagnosis. Therapy is about adapting to another person and striving to build an egalitarian, supportive, and helpful relationship.

When I travel, people often tell me the “dominant” personality type in their country: Swedes say schizoid; Italians, hysterical; Poles, post-traumatic; Russians, masochistic; Norwegians, avoidant; Australians, counterdependent; Singaporeans, obsessive-compulsive; Japanese, somatizing. And when I ask about Americans, people usually hesitate, then say: narcissistic.

We live in a culture that fuels narcissism—anxious about status, constantly changing, obsessed with individual rights to the point of justifying destructive acts.

Common Personality Styles

The most common personality type, and one with considerable research support, is depressive. Interestingly, it is also common among therapists. Depressive individuals are drawn toward others, self-critical, sensitive to separation and to criticism. When criticized, they tend to assume something is wrong with them, unlike paranoid individuals who immediately assume something is wrong with the critic. Depressive people use introjection—turning against themselves—while paranoid people use projection—blaming others.

Masochistic personalities are organized around suffering. This does not mean they love pain, but that they learned survival strategies in situations where suffering secured attention. Some remain in abusive relationships because loneliness feels worse than abuse. Often, they had parents who neglected them—except when they were injured or sick.

Paranoid personalities are preoccupied with trust and distrust. They may distrust almost everyone, but idealize figures like cult leaders or tyrants. Similarly, schizoid personalities struggle with closeness and distance: withdrawing from intimacy yet yearning for it, sometimes allowing moments of exquisite closeness before retreating. Therapy must respect their sensitivity to overstimulation.

Obsessive-compulsive personalities are organized around control and its loss. Conscientiousness, neatness, timeliness—these are central. Yet often, they maintain at least one area of hidden disorganization, the “dirty drawer.”

Histrionic personalities are preoccupied with gender, power, and sexuality. In therapy, it is important not to replicate dynamics of male dominance or patronizing advice. Instead, the therapist must support the patient in finding her own solutions.

Narcissistic personalities defend against shame with grandiosity. Some present with overt arrogance, others as “closet narcissists” or hypersensitive to criticism. Both extremes reflect the same underlying structure.

Dependent personalities define themselves through others: “I am Tom’s wife, Jane’s mother, Sonia’s teacher.” This can be adaptive, but becomes problematic during life transitions—retirement, divorce, or bereavement—when attachments are lost and identity feels empty.

Counterdependent personalities take the opposite stance: “I need no one. I’m fine.” This is not always narcissism, but often the survival strategy of those who learned not to rely on anyone.

Psychopathic personalities—what the DSM calls antisocial—are organized around omnipotent control. Their worth depends on their ability to dominate. They crave power more than admiration. Often they reach positions of leadership because of this drive.

Levels of Personality Organization

It is critical to distinguish levels of organization—healthy/neurotic, borderline, and psychotic—because the same symptoms look and behave differently depending on level.

• Healthy/Neurotic level:

People have secure attachment, can use mature defenses (humor, sublimation), and can grieve painful realities. They assume the therapist is well-intentioned, even when hurt. Alliance ruptures are repairable. Almost all therapies are effective.

• Borderline level:

Defined by intensity of affect, disorganized attachment, and primitive defenses (splitting, denial, projective identification, omnipotent control). Alliance ruptures are frequent and constitute the central work of therapy. Therapists must:

• Monitor the relationship closely

• Be emotionally expressive

• Set explicit boundaries and contracts

• Expect painful ruptures and repair them

• Seek supervision and consultation

• Psychotic level:

Patients here are terrified, struggling with confusion between self and other. They may misinterpret benign cues as dangerous, or hold delusional beliefs. Therapy requires:

• Emphasis on safety

• An egalitarian but authoritative stance

• Respect, humility, and “anti-humiliation”

• Normalization of thoughts and feelings

• Active, conversational style, not neutrality

Delusions can be understood as creative theories to make sense of overwhelming experience. Respecting the intelligence behind them, while gently offering alternative perspectives, preserves dignity.

Clinical Lessons and First Sessions

Effective treatment depends on fitting the therapy to the patient’s level of organization. Evidence-based methods (e.g., exposure therapy) may work with higher-functioning OCD patients but fail with more fragile ones. Misapplication demoralizes therapists and harms patients.

In first sessions, my priority is building a relationship. I ask: “What brought you here?” “How do you understand your suffering?” I explore their own theories and look for triggers—anniversaries, losses, transitions. I ask about temperament, earliest memories, substance use, eating disorders, sexual history. I want to know whether they can describe themselves and others in nuanced, three-dimensional ways, or only in rigid categories.

I allow some self-disclosure to establish trust. Patients want to meet a real human being, not someone hiding behind a script.

Treatment Goals

Therapy cannot erase a personality type; it helps people become healthier versions of themselves.

• “You can change the economics but not the dynamics.”

• An obsessive person will not become hysterical, but can become less rigid, more flexible.

• A trauma survivor cannot be “un-traumatized,” but can live without being defined by trauma.

Advice for Students

Read widely, then set theory aside in the room.

• Care about people.

• Be humble.

• Be interested.

• Let patients correct you when you stumble.

• Consult when you feel stuck—maybe it’s a misdiagnosis, maybe it’s fit, maybe it just takes time.

The essence of the work is presence, respect, and humanity.

END

** The transcript is to preserve the lecture in case the video disappears.

REFERENCE

American Psychoanalytic Association. (2021, September 24). Nancy McWilliams on the psychodynamic diagnostic process [Video]. YouTube. https://youtu.be/NNvTjWKa5VQ