An Appreciation and Critique of PDM-2’s Focus on Minority Stress Through the Case of Frank

Abstract

In this article, Dr. Drescher presents a case of a sexual-minority patient treated by a sexual-minority therapist. The discussant, clinical psychologist and psychoanalyst Malin Fors, uses the case to reflect on the benefits and limits of the new section of the Psychodynamic Diagnostic Manual, 2nd Edition , called “Nonpathological Conditions That Could Need Clinical Attention” (minority stress).

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An Appreciation and Critique of PDM-2’s Focus on Minority Stress
Through the Case of Frank
Jack Drescher, MD
Columbia University
and New York University
Malin Fors, MSc
Finnmark Hospital Trust, Hammerfest, Norway
In this article, Dr. Drescher presents a case of a sexual-minority patient treated by a sexual-minority
therapist. The discussant, clinical psychologist and psychoanalyst Malin Fors, uses the case to reflect on
the benefits and limits of the new section of the Psychodynamic Diagnostic Manual, 2nd Edition, called
“Nonpathological Conditions That Could Need Clinical Attention” (minority stress).
Keywords: minority stress, PDM-2, psychoanalysis, homosexuality
In June of 2017, coinciding with the publication of the Psychody-
namic Diagnostic Manual, 2nd Edition (Lingiardi & McWilliams,
2017), this paper’s authors presented at the PDM-2 Conference in
New York City. On a panel entitled “PDM-2 and Non-Pathological
Experiences That May Require Clinical Attention,” Dr. Drescher
presented a case of his psychoanalytic treatment of an older gay man
followed by a discussion of the case by Dr. Fors.
Frank
Frank is a 50-something American-born gay White Jewish man
who was in a three-times-a-week, 9-year psychoanalysis following
a year of once-a-week psychotherapy.
1
Frank contacted me at the
recommendation of Dr. A., a psychiatrist who had been seeing him
and his life-partner, George, in weekly couples treatment. Frank
and George had been together 18 years. Dr. A. had been seeing
George individually for several years, treating him for a disabling
depression of more than 10 years’ duration. Frank described the
couples treatment as “helping me cope with George’s illness” and
helping with communication. At the initial visit, Frank’s stated
reason for entering individual treatment centered around com-
plaints of what he called “free-floating anxiety,” which had started
a year earlier. “I am negative about a lot of things—the glass of
water is half-empty. I’m very critical.” However, the most salient
feature of Frank’s presentation was his being entirely caught up in
trying to take care of George. He described himself as “following
George’s moods,” by which he meant that if George was de-
pressed, Frank felt depressed. If George felt better, Frank thought
that he felt better as well. Frank also reported a great deal of
anxiety about the demands of running his consulting firm; his
primary source of income came from consulting to one major
client. “I’m never able to relax and enjoy the business.” Nomi-
nally, he and George were equal partners in the business, which
they had started together. However, because of George’s disability,
Frank essentially did all the work.
Concerns About Money
The business did provide them with enough of an income to live
“moderately”— but not a great deal of savings. Because of the
nature of their business, they often got first-class service or “spe-
cial treatment” at a discounted price. Frank would repeatedly, and
proudly, report an occasion when a chef would send out a special
dessert after a meal or a hotel would upgrade his hotel room. The
close relationship between special treatment and whether one had
to pay for services was a recurring theme in Frank’s analysis. For
example, Frank immediately expressed concerns, in the initial
consultation, about the cost of treatment. He was already paying
for George’s two weekly visits with Dr. A. Furthermore, as he
would elaborate in our second meeting, his individual treatment
with a previous therapist had ostensibly floundered over financial
issues.
A year before our initial consultation, Frank had been seeing
another analyst, Dr. B., “on and off” over a 1.5-year period. He
described Dr. B. as “unresponsive” and unwilling to answer direct
questions; he would instead respond by asking, “Why do you want
to know that?” Frank also intensely resented Dr. B.’s policy of
charging for missed sessions, particularly if the absence was “not
my fault.” He cited the example of being stuck in a subway for 40
minutes as inciting a major disagreement over where the financial
responsibility rested between the two of them. Dr. B. charged
Frank for the missed session, saying, “This is my policy.” Frank
told himself he would leave treatment with Dr. B. if “something
1
A more extended presentation of work with this patient has been
previously published (Drescher, 2009). The clinical material here is re-
printed with permission of Taylor & Francis (http://www.tandfonline
.com).
Jack Drescher, MD, Department of Psychiatry, Columbia University;
and Department of Psychotherapy and Psychoanalysis, New York Univer-
sity; Malin Fors, MSc, Finnmark Hospital Trust, Hammerfest, Norway.
Correspondence concerning this article should be addressed to Malin
Fors, MSc, Finnmark Hospital Trust, Mian 4 F, 9601 Hammerfest, Nor-
way. E-mail: malin.fors@mac.com
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Psychoanalytic Psychology
© 2018 American Psychological Association 2018, Vol. 35, No. 3, 357–362
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