Nancy McWilliams on Psychoanalytic Psychotherapy and Psychoanalysis

Nancy McWilliams: I come from a whole family of teachers, and I have had a teaching component to my career since the early 1960s if you count my years as a camp counselor, and at the college level since about 1970 in one form or another. So for a very long time, if I wanted to get people interested in the stuff that fascinated me I had to make it accessible to them.

I taught an undergraduate course in theories in psychotherapy for several years with people who had really no background in psychoanalytic thinking, and I slowly developed a kind of skill, I guess, in making it relevant to people's ordinary lives, as opposed to talking to other scholars or theorists in the field.

NM: I learned that there are a lot of identity issues involved in people becoming therapists and they tend to get organized around one theory or sensibility when becoming being a therapist. But all of us are looking at the suffering human animal and trying to be helpful, and eventually we're all going to learn similar things and have different language for talking about it. I have tried to fight the tendencies in me that presume a position of knowing more than other people or making them the devalued other. It's a natural human thing to do, but a lot of grief comes from it.

I've learned enormous amounts from people of very different paradigms than my own. You not only find a lot of common ground, but you find the areas where your own particular point of view has blind spots.

NM: I came to psychoanalysis not through psychology but through political science. My first experience reading Freud was as a junior in college, when my political science professor suggested I had a kind of psychological sensibility, so perhaps for my honor's thesis in political theory I'd like to read Civilization and its Discontents and talk about Freud's political theory. That's what sort of started me down this path.

I really found in the psychoanalytic movement a very subversive kind of orientation toward the world, and there were only a couple of decades where, for various interacting reasons, psychoanalysis was highly prestigious in American culture. During those decades of roughly the 1950s and 1960s, it was a quick way to prestige in the medical establishment if you were a psychiatrist. The way to get moving ahead in your discipline was to get psychoanalytic training, and that pretty much guaranteed you eventually a leadership position in the department of psychiatry. But that was sort of a fluke of the times, and it's behind us now.

I'm actually kind of happy it's behind us, because during those years a lot of people were attracted to psychoanalysis not because they loved it or they were really curious about the unconscious. They were attracted to it for narcissistic reasons, and they didn't tend to make very good therapists because they liked being right. They didn't like being surprised. They took a superior position toward their patients and talked down to them.

Many of the current troubles in psychoanalysis come from an era where people spoke rather arrogantly. They felt they were in the chosen profession. I don't think psychoanalysis does very well when it's culturally at the center; it does much better from a point of view of marginality in describing things that the culture doesn't necessarily see so easily.

NM: I do think it's very hard on contemporary students who fall in love with psychoanalysis and want to work in depth with people. Corporate agendas tend to have an awful lot of power in this culture, and it's in the interest of both insurance companies and drug companies to describe human suffering in a fairly superficial way and to apply either a drug or a short-term treatment to it.

These are hard times economically. People who want to really get to know their patients in all their complexity have to fight against some of the pressures to oversimplify things and do some quick-fix intervention. I think we've seen a paradigm shift from a cultural understanding that psychotherapy is a healing relationship in which you might use several different kinds of techniques, but the healing relationship is the definitional part of it. It's been redefined as a set of techniques that are applied to discrete disorder categories. It's moved therapists from being healers to being technicians—and often technicians at the behest of the larger culture, which has an interest in putting people in the cogs that exist in the great commercial machine, and not necessarily increasing the meaningfulness of life or the satisfactions of life.

NM: Yes. I seem to be seeing more and more people lately that are coming to me for anxiety or depression or an eating disorder or something Axis I-ish, who, when I actually listen to their story, they aren't living a livable life. They're commuting one and a half hours to work. They're staying at work from 8:00 in the morning until 7:00 at night. They barely see their children.

They're trying to take care of a house, a summer house, a couple of kids, a boat—if they're people of reasonable means—elderly parents, a dog. And they're just driven. The culture seems to tell them that they should be happy this way. And of course, that's not a livable life. It's just crazy.

NM: Yes.

NM: I don't think that being a therapist is like being a parent in most respects. But in terms of the affects involved, it's not too different. You deeply love your kids, but you also have hopes that they'll be their best self—not be satisfied with living a kind of minimal existence. So I don't think that deeply loving people means that you have no hopes for their doing better.

I think all the empirical literature on what's effective in psychotherapy, not just psychoanalytic therapy, ends up emphasizing relationship and personality. And when you talk about relationship or about the working alliance, you're talking about the two parties making an attachment to each other, which is just a fancy word for love. It certainly includes hatred and all the other affects, but it's a commitment. There's a kind of devotion that characterizes a therapeutic relationship in which somebody can grow. And we haven't talked too much about that.

We have some theories of it that are sentimentalized. You can't decide you're going to love somebody into health, but if you make a genuine authentic relationship with somebody and try to be honest with them, be honest with yourself, and help them increase their honesty with themselves, you're talking about a relationship characterized by love. You're accepting who they are, including all their darker parts. They're tolerating who you are, including all your mistakes and failures. And that sounds like love to me.

NM: Yes. On the subject of experiences where I felt like somehow I couldn't get a therapeutic relationship really going, that's happened many times to me, where I have failed with somebody. Sometimes I thought I failed, and many years later I find out that the patient really felt that they got something important. And other times I thought I've done a pretty good job, and I later find out that I missed something important. You can't be in this business for too many years without getting humbled about how little you really know.

NM: One person recently came back to me after 30 years, and I thought I had bombed with her. I was surprised that she came back to me, and, I reminded her that we kind of fizzled out. We both decided at a certain point that the therapy didn't seem to be moving. I asked her to just think out loud about what had happened.

What came out was a story about how, when she was little, her mother wanted her to be a musician, and she had no musical ear at all. Her mother's agenda was that she was going to be a great performer. She practiced and practiced, and went through excruciating performances, and tried to be good--and just didn't quite succeed.

I realized as she was talking about this that when I first worked with her, I was so excited that I had somebody that I thought was a good candidate to put on the couch and do real psychoanalysis with, that what I had enacted was, I was like her mother in wanting to fit her to a technique that I wanted to do, that really didn't suit her.

When we talked about that 30 years later, we decided that we would work face to face, and I would be more disclosing. I think we worked much better the second time around. You don't usually get the chance to undo your original mistakes.

In that case, I think that was a narcissistic thing. I wanted to see myself as an analyst, and here was a person that I thought I could put on the couch and ask to free associate. And I ended up replicating a childhood scene where the agenda of the authority didn't fit the particular inclinations of the kid—or the patient, in this case.

NM:

Teaching Psychoanalysis

I'm finding that students know a lot less about psychoanalytic ideas. Some of them have been very explicitly told that psychoanalysis has been empirically discredited, which is patently untrue. But there are a lot of academics that believe that.

Part of the reason for that is that there is an increased schism between academics and therapists at this point, for numerous sociological reasons. It used to be common that people who taught abnormal psychology might have a small private practice and know what it's like to be in the trenches trying to help suffering people. Now, it's so much harder to get promotion and tenure that they'd be crazy to do that. They have to chase grants. They have to turn out short-term studies and get a publications list.

So academics' image of therapists is often wildly off base from the therapeutic community as it actually exists. They tend to think that therapists apply their theory uncritically rather than try to adapt to every patient flexibly. So students are taught all that old psychoanalytic stuff, especially drive theory. I haven't heard an analyst talk in terms of drive theory for at least 30 years. But the academics tend to think that psychoanalysis stopped in 1923.

So students come in not knowing that there has been a whole scholarly evolution of psychoanalytic theory. One of the reasons they don't know this is that analysts pretty much pursue their interests in freestanding institutes and not in the academy, so there hasn't been cross-fertilization there. Analysts, I think, are to a great extent responsible for some of the estrangement with academic psychologists, because they wanted to develop in communities of their own.

So students now come to us with very little exposure to what's central to the psychoanalytic community. And we have to adapt to that. I've been asked in recent years, “What is the meaning of the term ‘transference’?” -- something that any graduate student would have known 10 years ago. One student not long ago asked me what the term “ambivalent” meant.

On the other hand, as they get taught various cognitive behavioral techniques and so forth, they are often learning stuff that's very parallel to psychoanalytic learning. Some of what Marcia Linehan does is not too different from what Peter Fonagy or Otto Kernberg does. She just speaks a very different language. Jeffrey Young’s schema therapy is not too different from psychoanalytic ideas about organizing motifs in people. But students tend not to know that.

NM: Yes. It's an interesting thing. It used to occur. Certainly, Erich Fromm spoke a lot at that level. Robert Lifton and Karen Horney certainly did. There were a lot of social commentaries from analysts a few decades back—not so much now. Eric Erikson would be another good example, or Robert Coles addressing the problems of the poor and the marginal. But I think that was part of that European sensibility.

We're a little bit more narrow in the United States. We're a little bit more pragmatic. We're more optimistic—"let's figure out what this is and fix it." A big part of the psychoanalytic sensibility is trying to help people accept what can't be changed. But that goes contrary to an American conceit that you can be anything you want to be, which, to me, is a pretty psychotic belief. I might want to be a giraffe; I'm not going to get there. But we actually raise our kids saying, "You can be anything you want to be."

And that's the kind of language of a young country that has enormous resources and not too many limits. I don't think it's the best language for us anymore, but we're kind of stuck with it. The sensibility of people who've lived with more limitation than Americans have is, I think, good for us to take in.

But I have to say that an awful lot of what psychoanalysis contributed to the United States had to do with people coming over before or during the Holocaust and having a kind of broad European learning that's not that common in the United States. And that whole generation has pretty much died off now. But they enriched not just psychology—they enriched the social sciences, the natural sciences, mathematics. We had an awful lot of very, very bright people who had a more wide-ranging set of interests than is typical for the pragmatic American sensibility.

NM: I'm not sure. I have my optimistic days and my pessimistic days. I think psychoanalysis will endure because we help people. They know it. They tell their friends. I see many people who've tried many other things, and they eventually come for analytic therapy and they get a lot out of it. But I don't think we're going to survive in the mainstream healthcare system.

I don't see any sign of that—at least not the more intensive, long-term, open-ended work that most of us like to do in the psychoanalytic community. I think it's hard to imagine, under the current circumstances, that the culture at large is going to support that being available for anybody but people who can afford it out-of-pocket. In the Scandinavian countries it's a little different, but they have a single-payer system.

Sweden, a few years ago, decided not to offer psychoanalysis—meaning several-times-a-week psychoanalytic work—on the national health plan, and there was a kind of grassroots objection to it and they put it back in. But I can't imagine that happening in this country. And in a few years, I think it's going to be unlikely in Sweden, because although it used to be a wealthy country, it's been stressed a little bit more in recent years. And as countries struggle, they try to cut down what they offer. So I just can't imagine that intensive long-term work is going to be supported in general.

Susan Lazar's recent book, Psychotherapy Is Worth It, really documents how cost-saving it is to get a lot of psychotherapy, even intensive psychotherapy. It saves on jail time, on sick days from work, on addictions. But most of the ways we measure the cost of healthcare is very long-term.

Insurance companies ask their benefits' managers, "How much money did you save us this year?" And people change their jobs, so they change their insurance. So they don't really have a 50-year view, or even a 10-year view, of putting out money now to do prevention in the long run.

I'm quite convinced—and there's plenty of empirical data to support this—that psychotherapy and intensive psychotherapy and psychoanalysis are very cost effective for the culture, but I don't see politically that we can make that argument effectively. So I think we'll become a kind of therapy that people will get privately.

NM: I don't know that I can honestly say that I have had to go through a lot of personal struggle and pain. I have loved my work. As soon as I discovered you could actually make a living by listening to people and getting close to them and trying to help them, I was thrilled. I feel very fortunate to have been able to have the kind of career that I've had. And I don't feel it's been Sturm und Drang at all. I've had very good teachers myself. I had a very good analyst. As I'm older, I realize more than I did when I was younger how lucky I was about that, because if I had a person who was a bad match—it's a powerful kind of relationship, and it can do harm as well as good. But I had good supervisors, good teachers, good colleagues, a good analyst, and I've been just constantly fascinated by the work. I guess I would tell students to follow their passion: if this is what they want to do, they can make a living doing it.

NM:

Take to the Streets

The sermon I've been giving to psychoanalytic audiences lately is get out of your offices and talk to people outside the psychoanalytic community.

We have something very precious and valuable, and we can talk to each other about it until the cows come home, but I think we have some responsibility to be socially useful and apply some of the knowledge to social problems and to making people's lives better—not just in the consultation room, but in the culture as a whole.

We should be talking about things like why the teenage suicide rate has gone up so high, and what our ideas are about the obesity epidemic, and what are the strains of contemporary life. When you were asked before about people who have commented more on the social level, and I was naming people like Erich Fromm, there are a few people now.

Christopher Lasch is dead, but he was trying to talk about that in recent decades. Jonathan Lear tries to talk about it. There are people that are trying to talk to the larger public about some of the knowledge that we've accrued over 100 years of listening carefully to people and their struggles, and I'd like to see us take to the streets more than we typically do.

NM: Part of it, I think, is that it involves being quite visible, including to our patients, and some of our patients are terribly upset when they see us out of role. I think analysts get very conservative about what they do because we've all had experiences of a patient being devastated when they find out when we have a different political belief from them, or that they disagree with something, or they're ashamed of us. I think it's very inhibiting being a therapist.

NM: Thank you. I loved your questions and it was fun to have this conversation.