Interview with Dr. Nancy McWilliams: Publication of German translation of Psychoanalytic Diagnosis by Natalia Braun

July 10, 2025 marks publication of the first book by the renowned psychoanalyst, psychologist, author, and teacher, Dr. Nancy McWilliams, in German language. One of Dr. McWilliams seminal works, Psychoanalytic Diagnosis, was translated by Natalia Braun and published by Kohlhammer, German publishing house. It makes accessible the teachings of Dr. McWilliams for German speaking audience, which has not yet been familiar with her work. This closes a gap not only in psychoanalytic literature in German language but also in the literature on psychotherapy in general. Dr. Nancy McWilliams has made an important contribution to the development of meaningful psychotherapy, supervision, and inferential, contextual, and dimensional diagnostics versus descriptive. In her teachings, Dr. McWilliams puts great emphasis on personality differences both in patients and clinicians, which has enriched the way psychotherapy is being practiced. Her books on diagnosis, case formulation, psychotherapy, and supervision have been translated into 20 languages, and she has taught in 30 countries. Now one of her books will be available in German for the first time.

Dr. Nancy McWilliams is Visiting Professor Emerita at Rutgers University's Graduate School of Applied & Professional Psychology and has a private practice in Lambertville, NJ. She is a former president of the Division of Psychoanalysis (39) of the American Psychological Association, is on the editorial board of Psychoanalytic Psychology, and is co-editor of all editions of the Psychodynamic Diagnostic Manual. She is the recipient of honors including the Rosalee Weiss Award from the Division of Independent Practitioners of the American Psychological Association, Honorary Membership in the American Psychoanalytic Association, and the Robert S. Wallerstein Visiting Scholar Lectureship in Psychotherapy and Psychoanalysis at the University of California, San Francisco. A graduate of the National Psychological Association for Psychoanalysis, Dr. McWilliams is also affiliated with the Center for Psychotherapy and Psychoanalysis of New Jersey and the National Training Program of the National Institute for the Psychotherapies in New York City. She is on the Board of Trustees of the Austen Riggs Center, a renowned psychiatric treatment and teaching facility.

Natalia Braun: Dr. McWilliams, welcome to the German speaking professional circle! I am delighted to present your work here and to have this conversation with you. I have always found your work to be indispensable in clinical practice, among many other things, because you pay close attention to personality and you do so in a highly accessible way. Could you please tell us more about why personality differences are so important in clinical practice?

Dr. Nancy McWilliams: I suspect that an interest in personality differences is a central reason that many of us became therapists. We find ourselves wondering why one person reacted warmly to a friendly “Hello,” while another person became irritated, as if interrupted, and another became suspicious that our affability betrayed an ulterior motive. In clinical work, irrespective of one’s theoretical orientation, one cannot help noticing that a comment that is welcomed as empathic by one patient leaves a different patient cold or is even taken as an offense.

Basing our interventions solely on symptomatic criteria misses the reality that identical symptoms can reflect profoundly different underlying subjective experiences. I have been interested in individual differences all my life – not just in personality patterns but in differences that result from factors such as whether one was born a twin, or was adopted as a child, or had a physical disability, or has a minority sexual identity or orientation, or is from a culture, ethnicity, or faith tradition different from my own. I enjoy trying to mentalize the inner mental worlds of others.

On a much less lofty level, perhaps because my undergraduate background was in Political Science, I was not initially accepted into a doctoral program in Clinical Psychology. But my application was strong enough that I was invited to study in the Personality Psychology department of a good university, where I had many fine teachers and became immersed in the scholarly literature on personality.

Natalia Braun: What would be an example of what could happen during treatment if personality is not taken into account?

Dr. Nancy McWilliams: The therapist would be at risk of misunderstanding the problem and approaching it in an unhelpful way. In current mental health practice, we tend to develop treatments for DSM or ICD disorder categories, which are defined by externally observable features and not by the meanings and subjective experiences of those symptoms. So, for example, there are treatments for depressive disorders that have been developed without consideration of whether the depression is more anaclytic or more introjective (I am using Sidney Blatt’s terms here). We know from extensive research that it matters greatly to treatment whether the subjective experience of depression is of existential loneliness and emptiness (the anaclytic version) or of internal badness and unworthiness (the introjective version). What is helpful to those respective kinds of patients is different. For example, if you offer realistic compliments to a man in an anaclytic depression, he may feel comforted. But if you do that with a man who is internally self-hating, he is likely to get more depressed because of feeling that he has fooled you, that you don’t see what he is really like.

We know from Jaak Panksepp’s neuroscientific work that there are two different anxiety centers in the brain, mediated by different neurotransmitters. His PANIC/GRIEF system is basically the attachment system; anxiety from that system is what we have long called “separation anxiety.” Because it is mediated partly by serotonin, the serotonin reuptake inhibitors may relieve this kind of anxiety. But Panksepp’s FEAR system is the legacy of terror about being destroyed by a predator. It represents what psychoanalysts have called “annihilation anxiety” or “paranoid anxiety” or “psychotic anxiety” and is not mediated by serotonin. Even pharmacologically this is vital information. Therapeutically, to convey empathy, it matters greatly to appreciate the difference between fear to be alone and fear to be annihilated. But the DSM and ICD tend to define anxiety sheerly by what is externally observable, such as sweaty palms and rapid heartbeat, and not to differentiate one internal experience from another.

Or consider perfectionism: When treating someone for that tendency, it helps to know why the individual is perfectionistic. People with obsessional psychologies may be perfectionistic because they are strongly internally motivated to be morally as good as possible; people with narcissistic psychologies may be perfectionistic because they want to be admired by others and avoid shame; people with hysterical psychologies may be perfectionistic because they fear that if they are not perfect in the eyes of an important other, they will be rejected.

Natalia Braun: How did you initially come up with the idea to write Psychoanalytic Diagnosis?

Dr. Nancy McWilliams: It was my students in the Graduate School of Applied & Professional Psychology at Rutgers University who urged me to write that book. They got tired of hearing me complain that there should be a book like this – I was waiting for MacKinnon and Michels to update their 1976 book. My students told me, essentially, “You’ve got it organized - write it down!” During the late 1980s, when I began thinking about the project in response to that pressure, and at the urging of my department chair, Stanley Messer, I was starting to see that the 1980 revisions to the DSM, while quite useful to demographers and some researchers, were not representing accumulated clinical knowledge about personality. I was afraid that knowledge would be lost. The DSM section on personality “disorders” doesn’t go near covering the territory that clinicians need to understand about personality differences in both type and severity.

Natalia Braun: Who is this book intended for?

Dr. Nancy McWilliams: Because I was teaching graduate students in a Clinical Psychology training program, they were the original audience I had in mind. But I knew from many sources that there was a similar need among students of psychiatry, social work, psychoanalysis, psychiatric nursing, pastoral counseling, and other kinds of counseling. I was imagining a broad audience of beginning psychotherapists. What did not occur to me as I was writing the book was the possibility of its being useful beyond North America. Its popularity across clinical cultures has been a welcome surprise. And once the book was published, experienced clinicians told me it had also been helpful to them.

Natalia Braun: Not all diagnoses are the same. Some make sense, but others could cause harm. What would you consider a meaningful diagnosis and why is it important to diagnose properly?

Dr. Nancy McWilliams: Any diagnosis can be flat-out wrong. Even if more or less accurate, diagnosis can be used to objectify, and treat as “other,” any individual with whom it is hard to identify. For many years our diagnostic systems pathologized people of minority sexual orientation, and sometimes, our terminology reflects Western norms that pathologize people who live in traditional collectivist and tribal cultures. But the original Greek word “diagnosis” translates as “thorough understanding,” not dismissive labeling.

Clinical training and personal therapy should help us find in ourselves the elements we see in others, even in those who initially seem incomprehensible to us, such as individuals with psychotic hallucinations. Empathy, respect, and subjective attunement are crucial for clinical connection and for diagnosis. The DSM and ICD represent efforts to be objective, descriptive (non-inferential), and categorical (non-dimensional), a decision that was welcomed by many researchers. But good clinicians approach diagnosis empathically, seeing personality and clinical phenomena more dimensionally (from highly adaptative to severely problematic); they know that in psychological matters, it is not possible to cut nature at the joints. They also know that people’s suffering is contextual: any of us in settings where we are evaluated negatively and capriciously will develop paranoid “symptoms” that are neither a pathological syndrome nor a personality disorder; they result from a situation that inherently creates paranoia. Clinicians must infer the meaning of a symptom.

To be clinically useful, a diagnostic formulation should be provisional and subject to ongoing revision. Whenever possible, it should be decided upon jointly by therapist and patient. And when that is not possible, a clinician should be able to share the tentative diagnostic formulation in ordinary language and get correction or elaboration from the patient.

Natalia Braun: Could you please tell us more about how understanding the patient's personality affects their treatment in the early stages? Do you have any examples?

Dr. Nancy McWilliams: The implications can be profound. Knowing the difference between a person with an impulsive, explosive personality and a person with a temporal lobe brain tumor might make a life-and-death difference. More prosaically, misunderstanding someone as obsessional when the person’s ruminations involve more paranoid dynamics could lead well-intentioned efforts at exposure therapy when the main thing the patient needs is an appreciation of an underlying terror of humiliation. Being able to see that the charm of an apparently cooperative patient distracts from an underlying psychopathy might save immense clinical time that would otherwise be spent assuming that the person is capable of empathy. Most of us in this situation would refer such a person to someone with experience with antisocial patients, given that most clinicians are not skilled with that group.

Natalia Braun: Your book contains numerous vivid clinical case vignettes that illustrate different personality styles, and you have selected certain types of personality organization. Can you say something about your selection and give some examples that come to mind?

Dr. Nancy McWilliams: Guilford Publications would not have been willing to publish a huge tome that covered all possible personality patterns. I had two criteria for those that I included. First, to maximize the book’s usefulness, I wanted to represent the most common psychologies that one sees in clinical practice; that is why sadistic personalities, for example, are not included. Second, I didn’t want to go beyond my own clinical knowledge. By the time I was writing the first edition of Psychoanalytic Diagnosis, I had had 20 years of clinical experience, much of it doing in-depth psychoanalysis. But I had not treated someone I would have diagnosed as having a dependent personality, or someone with a phobic personality, and so I omitted those. I hoped that after reading chapters on some common clinical presentations, readers would get a general orientation to personality and go from there.

Natalia Braun: As clinicians, we also have our personality differences. How do you think our own personalities affect our patients and their treatment?

Dr. Nancy McWilliams: I think we all naturally generalize from what is true for us. When that goes well, the patient experiences it as empathic. But when we project onto someone different from us, it can create injury and stalemate. What is true for me may not be true for a particular patient. For example, my own personality has elements of hysterical and depressive psychology. When I am distressed, I tend to move closer to a person I see as a potential source of comfort. But my schizoid patients, when distressed, need a lot of space. If I were to lean forward and express warm concern to someone with schizoid tendencies, the patient would likely feel impinged upon, distracted, and irritated. I had to learn that with these sensitive introverted individuals I need to lean back, give them time to collect themselves, and not overwhelm them with my wish to console them.

The relational movement in psychoanalysis has called attention to how our patients adapt to and influence us as well as vice versa. Some combinations are good, some not so good. For example, a therapist with narcissistic dynamics might have trouble finding empathy for someone with a dependent personality; a therapist with depressive dynamics might have trouble with a psychopathic patient; a person with obsessional dynamics would feel at sea with a more hysterical patient. The “fit” is as important in treatment as it is in family connections and friendships.

Natalia Braun: You have taught all over the world. Have you noticed any cultural influences on personality and perhaps a particular treatment trend that has developed as a result?

Dr. Nancy McWilliams: Anything I say in this area should be understood as a combination of my own and others’ impressionistic thinking, not speculations with an empirical base. Frequently, a therapist in a country I am visiting offers a comment about the most common personality type in their culture. A Russian therapist volunteered that Russians lean toward masochistic dynamics, an Italian colleague opined that Italians have a hysterical style, a Swedish clinician suggested that Swedes are often schizoid, a Chinese therapist said that dependent dynamics are common in China, a South African therapist talked about her country as a post-traumatic culture, a counselor in Singapore characterized his people as obsessive-compulsive, a Japanese therapist noted the frequency of somatization among the Japanese, an Australian psychologist told me he sees Australians as counter-dependent. When I ask people outside north America what they think is the national character in the United States, first they get obviously uncomfortable, and then they tentatively suggest: “Narcissistic?” I think they are right. The “individual rights” orientation of Americans, their frequent denial of realistic limits, and the fact that the US came into being as a rebellion against, and devaluation of, a “mother country” all imply narcissistic preoccupations.

It’s interesting to me that therapists all over the world recognize the different personality configurations covered in my book, but they may feel that the relative frequency of each differs in their country. Therapists tend to be highly intuitive, sensitive people, and I trust my international colleagues to find ways of applying my ideas clinically that are both personally authentic and culturally appropriate.

Natalia Braun: You address the challenges of the current economic and social climate and the current Wild West in the field of mental health, such as the overemphasis on interventions, the urge to perform the treatment quickly, and what lies behind the shiny label of so-called evidence-based therapies. Could you explain this in more detail for the German-speaking audience?

Dr. Nancy McWilliams: In the United States – and I hope that European cultures are somewhat insulated against these trends, but I fear that America is infecting the rest of the developed world – we have seen a perfect storm of influences that undermine thoughtful and devoted psychotherapy. These pressures come from drug companies, insurance corporations, and a small group of academic psychologists who resent what they see as psychoanalytic devaluation of their work. Pharmaceutical corporations like to think in simple diagnostic terms so that they can market medications for various “disorders,” insurance companies and government cost-cutters have short-term incentives to believe that quick fixes are possible, and academics need to test easily manualized short-term treatments so that they can get numerous publications that will ensure their tenure and promotion. These interests are not really consistent with improving our capacity to alleviate mental suffering at a deep level and prevent future psychopathology.

Natalia Braun: In your book, you wrote about the historical development of psychoanalysis and psychotherapy. How do you see the future in this field?

Dr. Nancy McWilliams: I suspect that the therapy of the future will be integrative. Although much of my career has been devoted to making sure we do not lose existing psychoanalytic knowledge, I think it is equally important that psychoanalytic practitioners become more open to contributions from beyond the psychoanalytic world. We need to respect relevant knowledge across theoretical orientations within and outside the mental health professions, and across disciplines. We are learning so much about trauma, neuroscience, attachment, addiction, and other areas – we need to think together about their implications for our work. I don’t think those implications will include developing more and more quick fixes that reify symptoms and remove the complex human being from the equation.

Natalia Braun: Thank you very much, Dr. McWilliams, for sharing your wisdom, and a very warm welcome!

Read the book by Dr. Nancy McWilliams in German:

Psychoanalytische Diagnostik (Kohlhammer).

Here is the link to the original book Psychoanalytic Diagnosis, second edition, in English.