Diagnosis in Psychoanalytic / Psychodynamic Psychotherapy

Psychoanalytic / psychodynamic therapists also make diagnostic assessments for their clients, but their understanding of diagnosis is quite different than mainstream psychiatric diagnosis (ICD or DSM).

Why diagnose?

• For treatment planning
• Prognostic implications
• Client protection
• The communication of empathy
• Forestalling flights from therapy
• Always provisional, never definitive
• Beware of possible abuse of diagnosis/labeling
• Useful in the beginning & in crisis

Diagnosis as a tentative / flexible guide

A skilled therapist is someone who can use their diagnostic insight into the client as a flexible, provisional, and adaptable guideline for therapeutic relationship. They should have the ability to establish and maintain a genuine connection with the client, all while preventing the diagnosis from casting an overwhelming shadow. As psychoanalytic/psychodynamic therapists, our approach does not center on treating a diagnosis (or a symptom cluster); instead, we prioritize engaging with the client as a multifaceted individual, addressing their diverse complexities without resorting to reductionism. Our shared goal is to nurture healing, facilitate self-discovery, promote autonomy and agency, and encourage liberated and fulfilling relationships.

A. Personality Syndromes
a. Developmental Level of Personality Organization

i. Healthy-Neurotic-Borderline-Psychotic spectrum

ii. Continuum with thresholds

iii. Healthy range: Optimal or very good functioning in all or most mental capacities, with modest, expectable variations in flexibility and adaptation across contexts.

iv. Neurotic range: Basically, a good sense of identity, good reality testing, mostly good intimacies; fair resiliency, fair affect tolerance and regulation; rigidity and limited range of defenses and coping mechanisms; favors defenses such as repression, reaction formation, intellectualization, displacement, and undoing.

v. Borderline range: recurrent relational problems; difficulty with affect tolerance and regulation; poor impulse control, poor sense of identity, poor resiliency; favors defenses such as splitting, projective identification, idealization/ devaluation, denial, omnipotent control, and acting out.

vi. Psychotic range: delusional thinking; poor reality testing and mood regulation; extreme difficulty functioning in work and relationships; favors defenses such as delusional projection, psychotic denial, and psychotic distortion.

b. Personality Type / Style (Character)

i. Personality Style vs. Personality Disorder

ii. Personality Style: Ways of thinking, perceiving, experiencing emotion, modes of subjective experience, & modes of activity

iii. Depressive, dependent, anxious-avoidant-phobic, obsessive-compulsive, hysterical-hysterionic, schizoid, somatizing, narcissistic, paranoid, psychopathic, sadistic character organizations (each one will be reviewed separately in the future).

iv. Everybody has a certain character style, usually a mixture of some of the above styles. In their mild to moderate forms, they are regarded as expectable human personality variations, with different strengths and weaknesses. In their extreme and rigid forms, they could be regarded as personality disorders.

B. Profile of Mental Functioning
a. Cognitive and affective processes

i. Capacity for regulation, attention, and learning

ii. Capacity for affective range, communication, and understanding

iii. Capacity for mentalization and reflective functioning

b. Identity and relationships

i. Capacity for differentiation and integration (identity)

ii. Capacity for relationships and intimacy

iii. Capacity for self-esteem regulation and quality of internal experience

c. Defense and coping

i. Capacity for impulse control and regulation

ii. Capacity for defensive functioning

iii. Capacity for adaptation, resiliency, and strength

d. Self-awareness and self-direction

i. Self-observing capacities (psychological mindedness)

ii. Capacity to construct and use internal standards and ideals

iii. Capacity for meaning and purpose

C. Symptom Patterns: Subjective Experience

Symptoms encompass the complaints that clients report and/or that therapists identify. These may include symptoms such as depressive mood, anxiety, sleep disturbances, relational conflicts, lack of motivation, and more. While psychoanalytic therapy does not primarily focus on symptoms, they still hold significance. However, the emphasis lies in understanding how these symptoms are personally experienced and exploring their underlying meanings and functions.

For instance, the experience and significance of a symptom like depressive mood can vary widely from person to person based on their individual personality traits and life experiences. As a result, psychoanalytic/psychodynamic therapy is fundamentally tailored to the unique needs of each individual. It should be distinguished sharply from manualized treatments, whether they are biological or psychological in nature.

Main differences between mainstream psychiatric (ICD/DSM) and psychoanalytic diagnostic approaches

. Descriptive/categorical vs. Subjective experience / dimensional

. Symptom clusters vs. underlying patterns / meaning / subjectivities

. Experience-distant vs. experience-near

. Cure of the symptom vs. underlying patterns/mechanisms

. Influence of drug companies vs. dislike of drug companies

. «I have social phobia» (reification of self-states) vs. «I am a painfully shy person» (Owning self-states)

Comparison of the Medical Model and the Psychoanalytic Model

The traditional medical model commences with the observation and examination of symptoms, culminating in a diagnosis that serves as the foundation for the treatment process.

Conversely, the psychoanalytic/psychodynamic model differs notably from the medical model. It initiates with the establishment of a relational connection and observation, followed by the development of a tentative diagnostic formulation. This formulation is treated as a flexible guide within the therapeutic relationship.