Nancy McWilliams is one of the world’s leading psychoanalytic psychologists, renowned for her contributions to personality theory, psychotherapy, and psychoanalytic diagnosis. As a distinguished clinician, author, and teacher, she has influenced generations of mental health professionals through books such as Psychoanalytic Diagnosis, now considered a modern classic.
On May 23 she visited Gothenburg to give a lecture on diagnosis at the invitation of Psykoanalysens Akademi (the Psychoanalytic Academy) with SAPU (Scandinavian Academy for Psychotherapy Development) as co-organizer. During her visit, I had the privilege of sitting down with her for an interview at Hotel Draken, where she and her husband, Michael Garrett, were staying during their time in Gothenburg.
Nancy McWilliams begins our meeting not by talking about theory, but by telling me a little about her own story. She recalls growing up with a mother who was deeply interested in psychology and whose death, when Nancy was only nine years old, awakened a lasting curiosity about suffering, loss, and the emotional lives of others. Although she was always fascinated by people, she initially sought a broad education rather than a professional identity. Entering college, she considered becoming a classicist, drawn to Greek, Latin, and philosophy. She deliberately avoided majoring in psychology because, at the time, the discipline seemed dominated by laboratory research on rats rather than the study of human experience. Instead, she chose political science, where questions of human motivation and behavior were central. Those early intellectual interests and personal experiences would eventually converge, leading her toward the psychoanalytic perspective that has made her one of the field’s most respected contemporary voices.
Daniel: What led you to choose to become a clinical psychologist and psychoanalyst? Can you tell us a little about the journey that brought you there?
Nancy McWilliams: In my junior year in the politics department, my faculty advisor said to me, “For your thesis on political theory, you’re a very psychologically oriented person. You might want to consider doing a thesis on Sigmund Freud’s implicit political theory.” And he handed me a copy of Civilization and Its Discontents. I fell in love with Freud’s mind and began reading all kinds of things in psychoanalysis. There were a lot of popular books on analysis at that time. This would’ve been 1965. So Erik Erikson, Karen Horney, Rollo May, Herbert Marcuse, Norman O. Brown – there were a lot of people who brought together political and psychological ideas. And I was particularly taken with the work of Theodor Reik, the first psychoanalytic psychologist and a protégé of Freud. I realized that he was still alive and living in New York, where I was living right after I graduated from college. So I wrote him a letter and asked if I could meet with him. I wanted to meet someone who had been close to Freud. He was very gracious and responded right away.
I asked him what advice he would give someone who was interested in this area, and he said, “Well, you must be analyzed.” So I thought, “I’m in New York City. They still do that here – the old thing with the couch – so I should do that while I have a chance.” He sent me to the institute he founded, which was the first psychoanalytic institute for non-medical practitioners, because the medical psychoanalytic institutes would not let him teach for them.
I graduated from my institute in 1978. That was the same year I got my license to practice as a clinical psychologist. I went through my institute at the same time I was pursuing my doctorate in psychology. And I was lucky enough to attend Rutgers University, because my first husband got a really good job there. He was the faculty advisor who handed me Civilization and Its Discontents. It was before we thought of it as a patriarchal abuse of power for a faculty member to have a romance with a student. But we were married until he died in 2005.
Daniel: You have worked for many years, nearly half a century – in what ways has the psychoanalytical understanding of psychological difficulties and their treatment changed during that time?
Nancy McWilliams: In some ways it’s changed very much. But in other ways, in terms of its core, its emphasis on trying to be honest with yourself, it hasn’t changed very much. But I think psychoanalysis began with an effort to understand people that we would now mostly see as trauma victims, people with what were then called hysterical disorders, which we would now mostly define as functional neurological disorders and conversion-dissociative disorders.
So psychoanalysis started with a great interest in trauma, and Freud’s first theory of hysteria involved the idea that there was much more sexual abuse of young girls than was ever admitted. But then he kind of fell in love with his own theory of development and realized the universality of certain fantasies about sexual relations with parents.
He put a lot of emphasis on that, and so psychoanalysis forgot about trauma. By the 1950s or ’60s, there was very little psychoanalytic focus on traumatic experience and much more of an emphasis on whether you were organized around an Oedipal idea or a pre-Oedipal idea.
I had a few colleagues back then who had patients with dissociative disorder, and they thought they were the only people treating someone with multiple personality disorder. They thought it was so rare. And then, by the ’80s, we were seeing dissociation everywhere.
So psychoanalysis, at least in the United States, has moved away from thinking so much about repression and now thinks more in terms of dissociative post-traumatic phenomena, and also normal dissociation – normal different self-states.
Daniel: How has this affected the way you work?
Nancy McWilliams: To some extent, neuroscience and the work of Mark Solms and Jaak Panksepp have changed the way I work. My first patient, who’d had such severe trauma that she met the criteria for dissociative identity disorder, I approached working with the hope that we would work through her repression of what had happened to her. But I know now that very often, when you’re traumatized, the glucocorticoids that your brain secretes shut down the hippocampus. And it’s not a matter of your having episodic memory and repressing it. The memories were never formed as episodic memories. Instead, you have body memories and affective memories.
So now there is much more interest in integrating psychoanalytic ideas with the understanding of the body and how the body registers trauma. Bessel van der Kolk’s work has been important in that. So I think most contemporary psychoanalysts are integrative in terms of being very interested in neuroscience and trauma theory.
Daniel: When did you get interested in this topic?
Nancy McWilliams: Well, I started looking at this early because, in my graduate program, Silvan Tomkins was teaching. And he was just doing his original work on the face as the organ of affective expression and arguing with psychoanalysts that the drive was not the primary motivational system – certainly not libido and aggression in the way that Freud tried to be dualistic about the drives – but that affects were the primary drivers of psychological experience.
Daniel: If we look specifically at the place that psychoanalysis occupies in psychiatry – has it changed during your working life?
Nancy McWilliams: Oh, very much so. My second husband is a psychoanalyst and a psychiatrist. And he has also seen it up close. Back in the ’60s, ’70s, even ’80s, if you wanted to be the head of a psychiatry department, you really had to be an analyst because that was where the prestige was. But, like everything that we idealize, eventually that falls off the pedestal.
Now, psychiatry is mostly biologically oriented, and in most departments of psychology and psychiatry, psychoanalysis is very much devalued compared to biological explanations.
Part of this was our own fault. We – we meaning psychoanalysts – often behaved arrogantly, without the humility that there were many other angles of vision on things, including biological and cognitive behavioral systems theory.
When you’re trying to argue that, if you’re an analyst, you know everything that’s really important to know, you’re going to make people very angry at you.
Some of the change was due to the immense expansion in what we could know about the brain in the 1990s compared to the 1970s. So part of what happened in psychiatry was, for example, the effect of the antipsychotic medications.
Suddenly you didn’t have to sit down with psychotic phenomena and really try to understand the person. You just could calm the patient down with neuroleptic drugs. And that spawned a certain kind of, I don’t know, master narrative, and I was there when that was being created.
Daniel: What kind of master narrative?
Nancy McWilliams: That psychosis – and many other mental disorders – is caused by biological factors, and that there is no meaning in trying to understand the psychotic person and his symptoms. This has become the narrative that dominates psychiatry.
Daniel: Do you think that economic factors have played a part in this change?
Nancy McWilliams: A huge effect. Well, it’s in the interests of private companies, like drug companies and insurance companies, to spend as little as possible on mental health problems. So they want to believe that drugs can cure it, or that short-term, symptom-focused therapies can.
Daniel: How do you think contemporary social conditions affect psychological suffering and psychotherapy today?
Nancy McWilliams: I think there’s something about contemporary consumerism that pushes people into all kinds of psychopathology, especially narcissistic problems. That is much more problematic now than I think it once was. You can see this in advertisements. It’s interesting how Freud gets implicated in this because his nephew, Edward Bernays, began the movement toward advertising. And he used Freudian ideas to sell things, including that you’ll get better sex if you buy a certain product. But what contemporary advertisers have discovered is that you will get more purchasers for your product if you market it to the consumer’s narcissism. That the product will somehow enhance the person’s ego.
And look at social media, where you can be shamed on a scale you never could before. I mean, the world is so huge, and human beings have evolved to live in small tribal cultures where everyone knew you – they knew your strengths and weaknesses. But in this new kind of culture, you can reinvent yourself. And you can be massively shamed. You are always confronted with the difference between how you look and how a celebrity who’s had all kinds of cosmetic surgery looks. I think this affects people a lot.
Daniel: And what about economic inequality? Even in Sweden, the gap between the richest and the poorest has increased considerably over the past decades.
Nancy McWilliams: Yes. It’s actually dangerous to have a huge gap. I remember my first husband telling me, when we started to see this happening in the US in the ’80s and ’90s: “This is going to be very damaging to democracy. Because people will be left behind. They’ll see the difference.” You know, in the ’50s and ’60s, there was a huge middle class in the United States, and now there are gazillionaires and then there are ordinary working-class people, and they’re terrifically far apart.
And with, for example, AI, everybody’s worried they’ll be out of a job. They won’t know who they are. And young people are seeing that the world is being destroyed; the ecology on which we depend is being undermined by certain kinds of economic forces.
We wouldn’t have seen the rise of Donald Trump except for that difference. I think, psychoanalytically speaking, that impels people toward early fantasies of a powerful father who’s going to fix things. And we see this all over the world.
Daniel: Do you think psychoanalysis has something to contribute today, clinically or in other ways?
Nancy McWilliams: Well, not necessarily as a particular technique of psychotherapy. A lot of people assume that psychoanalysis is all about inviting the patient to use the couch and seeing them several times a week and so forth. That can be a very valuable form of therapy for people who are motivated enough to do that.
But, to me, the more important aspect of psychoanalysis is not a particular technique of therapy. It’s a knowledge base that has been built up over 100 years of clinical experience with people’s deepest secrets, longings and frustrations.
And so, for example, if you want to understand something like racism, psychoanalysis offers you more capacity to understand why that would persist than simply cognitive explanations or behavioral explanations. Kleinian ideas of needing to stay in the paranoid-schizoid position when you’re threatened, for example, are very valuable in understanding what happens to a culture or a person when they’re under a lot of stress or feel threatened.
I think that the future of psychotherapy is to be more integrative. Because we’re all looking at the same suffering. Different schools develop different languages, and we have different strengths and weaknesses in how we pursue it.
My husband, Michael Garrett, has done a very interesting integration of psychoanalysis and cognitive behavioral approaches to psychosis. Some CBT people in Great Britain, who are working in the public hospital systems, are trying to understand how to help people with diagnosed psychosis. And they are now interested in his psychoanalytic understanding. I think this is very hopeful – that clinicians from different schools listen to each other.
I think it’s always dangerous when any movement reverts into fundamentalism, and there’s only our way of thinking about something, and it’s superior to everyone else. Because the truth is that we’re all struggling to understand, and we have to learn from each other.
My most recent book, a co-authored book, is for CBT-trained people who are finding that they’re running into the limits of their training. They haven’t been taught anything about personality structure, defense mechanisms, resistance or countertransference. Increasingly, people have been coming to me over time saying: “I have all these evidence-based techniques for DSM disorders, but there’s something I know that I’m missing about the whole person that I think you might know more about from a psychoanalytic background.”
Nancy McWilliams: I have some curiosity about psychoanalysis in Sweden. When I first came here, there were a lot of psychoanalytic subgroups that were very alive and vital. But I found out that, more recently, Sweden has experimented with going completely into non-psychoanalytic efforts to help people. So I’m curious: what has happened to your country in the evolution of all this?
Daniel: I think you are right in your description. Psychodynamic and psychoanalytic treatment has to a large degree been replaced by CBT and medication in public healthcare. And some clinicians who work with psychodynamic therapy have to hide what they in reality are doing. For example, some clinicians register their sessions as CBT even if they’re not. I think that’s very corrupting.
Nancy McWilliams: Yes. I think that would be very corrupting to the soul somehow.
Daniel: So we’re reaching the end of our talk. This is a question from one of our readers. If you could give just one piece of advice to a young psychotherapist today, what would that be?
Nancy McWilliams: My advice would be to get your own psychotherapy with someone whom you feel comfortable with. And get in the habit of looking at your own history and your own feelings and how they affect what you do. For one thing, it will help you understand what it feels like to be in the patient role, talking to a stranger about intimate things. And it almost doesn’t matter what kind of psychotherapy it is. It should be a kind that makes sense to you, with a therapist with whom you feel comfortable. That’s the best preparation for working as a psychotherapist.
Daniel: Do you think it should be mandatory for professionals who work with psychotherapy to have their own therapy?
Nancy McWilliams: No, I don’t think it should be mandatory. Because that’s such a different experience from choosing it yourself. People need to find the psychotherapeutic experience by themselves so that they can fully take it in. That’s how you learn that therapy works.
I think it helps to know what it feels like to be the patient and to feel the effectiveness of the therapeutic relationship. I draw on that myself every day, on the fact that my own analysis helped me in a deep, radical way. And so I have confidence that therapy works. Young people starting out can’t have that confidence just from intellectual knowledge of various techniques. They have to have some other basis for feeling, “I have something to offer here.” And what they have to offer is their own care, their own curiosity, their own genuineness. The best way to find this is by going to therapy yourself.
