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The author reflects on contemporary diagnostic conventions in mental health and their impact on clinical practice, framing the “neo-Kraepelinian” (descriptive and categorical) diagnostic shift that began with DSM-III as unintentionally destructive to effective psychotherapy. She describes the international project of creating and improving the Psychodynamic Diagnostic Manual, an effort to restore a clinically useful diagnostic sensibility that values inference, dimensionality, context, and meaning.