Jonathan Shedler’s workshop “Treating Personality Patterns and Disorders: Clinical Case Formulation as a Roadmap to Treatment” took place at the Tavistock and Portman Clinic this Friday 24th October 2014, following his lecture on the “Efficacy of Psychodynamic Therapy: The Talking Cure in The Era of Evidence Based Practice” the day before. He is internationally acclaimed for establishing psychodynamic therapy as an evidence-based treatment in his article titled “The Efficacy of Psychodynamic Psychoherapy”.
In the workshop Dr Shedler started out by outlining different personality types and stating that most patients do not come with personality disorders as presenting complaints (e. g. “Hello, Doctor, I have come to see you because I am suffering from Narcissistic Personality disorder!”) but rather with symptoms such as depression and anxiety. He described how from DSMIII through to DSMV there was a gradual movement away from personality and psychodynamic principles towards behavioural symptoms, which he finds decreasingly useful for clinical practice and diagnosing. He equated depression and anxiety to the medical symptom of fever, which I found quite helpful and insightful. He stated that depression and anxiety should not be seen like illnesses in themselves that should simply be treated with medication as the beginning and end of the treatment. Like a fever, depression and anxiety are symptoms of underlying conflicts and personality types which lead to relational issues and difficulties with engaging with the world in constructive ways. He illustrated that a medical doctor would not treat every fever in the same way, in fact they would be negligent if they did. Some fevers could just be a symptom of a cold and could be treated with paracetamol, whereas it could also be a symptom of something like Ebola, Malaria or other more serious issues. Depression and anxiety should be tackled in similar ways – it is important to start with the question “What is the underlying cause here?” In some cases medication might be called for and appropriate, but it should always just be seen only as a part of the treatment, and definitely not the end of it.
Dr Shedler explains how different personality disorders (or personality types as he prefers to call them – less pathologising) cause the symptoms of depression and anxiety:
- Narcissistic personality types always feel some sense of entitlement and that the world is exploiting them or not giving them the respect and special treatment they should get. A narcissistic person will experience a constant and increasing sense of disappointment with the world and will isolate more and more, therefore leading to depression.
- And avoidant person will put others’ needs before their own and therefore struggles to see their own needs and get them met – often mixed with a sense of resentment and passive-aggression. This leads to increasing self-limitation of what that type of person exposes themselves to. It also limits chances for exploration, meaningful relationships and fulfilling experiences and growth, eventually also leading to depression and anxiety.
- The paranoid personality type is driven, according to Dr Shedler, by cut off and unexpressed anger. This person cannot allow him or herself to experience all the anger that they carry, and therefore split it off and project it into the world. As a result the whole world seems hostile towards them, leading to high levels of anxiety and defensiveness. Likely passive-aggressive behaviour frequently causes aggressive or avoidant reactions in others, often putting the individual in the position of the victim, confirming his or her world-view.
- The psychopathic / antisocial personality type performs deviant and often harmful and violent acts, often for sadistic excitement and pleasure, but often, more disturbingly, ‘because they could, and got away with it.’ Both types show that empathy is impaired or non-existent. This type of person might develop anxiety and depression purely resulting from harsh interventions by society limiting them in they actions, for example imprisonment.
Dr Shedler stated that he has found DSMIV diagnosing via SCIDII not very helpful, because it is too focused on behaviours and also has limitations because it is based on answers by the patient. He illustrated this problem by stating that there is no point in asking a narcissistic patient if they think they have empathy. The SWAP assessment tool which he developed with a colleague is based on around 200 questions answered by the clinician, which he finds much more accurate and useful. It also incorporates psychodynamic elements into the assessment and diagnosing process which the DSM dropped over time.
He described how in his practice he uses the first session to make a clinical formulation of the patient’s personality type and way of relating / attachment style, as well as trying to find out if psychodynamic therapy can help, and if there is a good fit between the therapist and the patient. He doesn’t launch straight into the treatment but has a few consultations and then determines a formulation and treatment plan, and only then treatment begins. He also emphasised that the formulation is a collaborative effort between therapist and patient, not something that the therapist ‘does’ to the patient. He also explained that with narcissistic and antisocial patients it is important to be realistic and clear that treatment outcomes can be very limited and should be adjusted and kept in mind. This might be controversial in light of trends towards inclusion – a philosophy that everyone has the right for treatment.
Dr Shedler, who clearly seems very mentalization / MBT and attachment oriented, focuses his formulation and treatment plans around a patient’s representation of self and of other, as well as relational patterns that show themselves in the transference already in the first few sessions. He described the difficulty of knowing what to focus on when designing a treatment plan, when there a several ways to go. According to Dr Shedler it is a good idea to focus the work on what seems to be the aspect in the personality patterns that is at the core of what causes difficulties.
During live supervision and role-play Dr Shedler gave the audience an experiential insight into his way of working. He emphasised how powerful it is to use one’s countertransference in producing a case formulation and a treatment plan. Watching him asked the ‘patient’ in role-play questions I started to think that he actually wasn’t doing very much. But then he interrupted and shared his countertransference and how it informed his thinking. True MBT style he had stepped back from the dynamics of transference and countertransference that had developed, and stated that the feeling of not getting to the patient was not a failure but instead valuable information for him as a clinician. This, together with biographical information, led him to his clinical formulation of this person as an avoidant and narcissistic patient who felt dead inside and could not let another person in, and that it is this that keeps playing itself out for the patient in his life and relationships. Interestingly, the SWAP assessment did not diagnose a personality disorder in this patient (neither did the DSMIV), but it nevertheless indicated the characteristic personality patterns of this patient, pinpointing guides for the roadmap in a useful way.
What was interesting in the end were the responses when Dr Shedler asked the audience for their own countertransference to the played patient. Most responses, which seemed to come from the psychoanalytic spectrum of this mixed audience, felt like speculative, intrusive interpretations rather than a sharing of countertransference, which Dr Shedler commented on. It was also refreshing to see him shrug his shoulders at some of the interpretations (which were meant to be questions), saying that he doesn’t know and one could only speculate. He delivers this healthy and clinically useful awareness of his limitations with the confidence of a Karate black belt (which he is). He has truly embraced the ‘not knowing stance’ central to Mentalization Based Therapy and similarly the ‘sitting with uncertainty’ equivalent in attachment-based psychotherapy. My own initial reaction of “he’s not really doing anything” and “he doesn’t really know what he’s doing”, which were subsequently replaced by respect resulting from his sharing of insightful thinking, for me were another sign of how easily these approaches can be dismissed, especially when confronted with the ‘confident delivery’ of seemingly impenetrable psychoanalytic perspectives.
It all seems to come back to Winnicott’s “good enough mother” – Dr Shedler’s workshop was a powerful and experiential reminder of the importance of staying curious about our patients and our relationships with them, rather than getting carried away by, and imposing, our own imagination and speculation.
Seeing rather than impinging.
Find information on Jonathan Shedler PhD and his publications here: