Psychodynamic Formulation

Deborah L. Cabaniss, Sabrina Cherry, Carolyn J. Douglas, Ruth Graver, Anna R. Schwartz, Ruth L. Graver

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9781119962342
• eBook ISBN: 9781118557297
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

How do our patients come to be the way they are?

What forces shape their conscious and unconscious thoughts and feelings?

How can we use this information to best help them?  

Constructing psychodynamic formulations is one of the best ways for mental health professionals to answer questions like these. It can help clinicians in all mental health setting understand their patients, set treatment goals, choose therapeutic strategies, construct meaningful interventions and conduct treatment.

Despite the centrality of psychodynamic formulation to our work with patients,  few students are taught how to construct them in a clear systematic way.  This book offers students and practitioners from all fields of mental health a clear, practical, operationalized method for constructing psychodynamic formulations, with an emphasis on the following steps: 

• DESCRIBING problems and patterns
• REVIEWING the developmental history
• LINKING problems and patterns to history using organizing ideas about development.

 The unique, up-to-date perspective of this book integrates psychodynamic theories with ideas about the role of genetics, trauma, and early cognitive and emotional difficulties on development to help clinicians develop effective formulations.

Psychodynamic Formulation is written in the same clear, concise style of Psychodynamic Psychotherapy: A Clinical Manual  (Wiley 2011). It is reader friendly, full of useful examples, eminently practical, suitable for either classroom or individual use, and applicable for all mental health professionals. It can stand alone or be used as a companion volume to the Clinical Manual.

 

Part One: Introduction to the Psychodynamic Formulation

Chapter 1

What is a Psychodynamic Formulation?

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Key concepts

A formulation is an explanation or hypothesis.

A case formulation is an hypothesis that helps us to answer questions about the way a patient thinks, feels, and behaves.

A psychodynamic formulation is an hypothesis about the way a person thinks, feels, and behaves, which considers the impact and development of unconscious thoughts and feelings.

A person's development is affected by both hereditary and environmental influences, and thus, both should be included in a psychodynamic formulation.

Psychodynamic formulations do not offer definitive explanations; rather, they are hypotheses that we can change over time.

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What is a formulation?

Very nice history. Now can you formulate the case?

All mental health trainees have heard this, but what does it mean? How does one formulate a case? Why is it important?

Formulating means explaining—or better still, hypothesizing. All health care professionals construct formulations all the time to understand their patients' problems. In mental health fields, the kinds of problems that we are trying to understand involve the way our patients think, feel, and behave. We often call this kind of formulation a case formulation. When we formulate cases, we are not only thinking about what people think, feel, and behave but also why they do. For example,

Why is she behaving this way?

Why does he think that about himself?

Why is she responding to me like this?

Why is that his way of dealing with stress?

Why is she having difficulty working and enjoying herself?

What is preventing him from living the life he wants to lead?

Different etiologies suggest different treatments; thus, having hypotheses about these questions is vital for recommending and conducting the treatment.

What makes a formulation psychodynamic?

There are many different kinds of case formulations [1-3]. There are cognitive behavioral therapy (CBT) formulations, psychopharmacologic formulations, and family systems formulations—just to name a few. Each type of formulation is based on a different idea about what causes the kinds of problems that bring people to mental health treatment.

One way of thinking about this postulates that these problems are often caused by thoughts and feelings that are out of awareness—that is, that are unconscious. This is called a psychodynamic frame of reference. Thus, a psychodynamic formulation is an hypothesis about the way a person's unconscious thoughts and feelings may be causing the difficulties that have led him/her to treatment. This is important to understand, as helping people to become aware of their unconscious thoughts and feelings is an important psychodynamic technique.

A developmental process

It's well known that psychodynamically oriented mental health professionals are interested in their patients' childhoods. But why? Well, using psychodynamic technique is about more than just helping people to become aware of their unconscious thoughts and feelings—it's also about understanding how and why those unconscious thoughts and feelings developed. We can use that understanding in many different ways when we treat our patients. Sometimes we share this understanding with our patients to help them see that they are behaving as if earlier conditions still persist:

Example

Mr A's mother, while loving, was extremely undependable. For example, she frequently forgot to pick him up from school. As an adult, Mr A has difficulty believing that his friends and lovers will be consistent in their relationships with him. His therapist is able to help him see that this difficulty may have stemmed from his out-of-awareness fear that people in his adult life will behave as his mother did.

At other times, we use this understanding to help patients develop capacities that were not fully formed during their earlier years:

Example

Ms B, a brilliant student, is unable to think highly of her accomplishments. Raised in foster care, she never received praise for her talents. Understanding this, her therapist is able to help her to believe that her perception of herself is not consonant with her abilities. Over time, she is able to develop new ways of managing her self-esteem.

Finally, we can help support patients' functioning that is impaired by acute or chronic problems:

Example

Mr C presents for therapy because he is having difficulty handling his children during his long divorce. He describes feeling that his parents' divorce, which happened early in his life, had catastrophic effects on his development. His therapist helps him to acknowledge his fear that his divorce will permanently damage his children and to understand the way in which this fear is affecting his parenting. This helps him to relax with his children and to develop alternate strategies for engaging them.

Although their techniques are different, each of these therapists uses an understanding of the patient's development to guide the treatment. Thus, our psychodynamic formulations need to include

1. ideas about how unconscious thoughts and feelings might affect our patients' problems

2. ideas about how those unconscious thoughts and feelings might have developed

That's all well and good, but how can we understand a developmental process that has already occurred? Even with camcorders and scrapbooks, we can't go back in time with people to watch their development unfold. In this way, constructing a psychodynamic formulation is a lot like being a detective trying to solve a mystery—the deed is done and we have to look backward and retrace our steps in order to crack the case. Like the detective, we work retrospectively when we construct a psychodynamic formulation—that is, we first look at our patients' problems and patterns and then scroll back through their personal histories to try to understand their development.

Nature or nurture?

So how do our characteristic patterns of thinking, feeling, and behaving develop? John Locke said that each person is born as a blank slate—a tabula rasa [4]. E. O. Wilson argued that social behavior is shaped almost entirely by genetics [5]. Nature—nurture—we have to believe that it isn't one OR the other but BOTH. Freud called the nature part “constitutional factors” and the nurture part “accidental factors” [6]. However you think about it, people come into the world with a certain genetic loading and then continue to develop as they interact with their environment. The more we learn about the interrelationship between genes and environment, the clearer it is that our genetics shape our experience and vice versa, so some complex interaction between the two results in our characteristic views of ourselves, the way we relate to other people, and our methods for adapting to stress. Thus, in thinking about how to understand and describe how our patients develop, we have to consider genetic, temperamental, and environmental factors.

More than reporting

A news story gives a report of what happened; a psychodynamic formulation offers an hypothesis of why things happened. Here are two examples to illustrate the difference:

Reporting

Mr D was born prematurely to a teenage mother who had a postpartum depression. He had severe separation anxiety as a child and spent long periods of time home “sick.” As an adult, he is unable to be away from his wife for more than one night.

Formulating

Mr D was born prematurely to a teenage mother who had a postpartum depression. He had severe separation anxiety as a child and spent long periods of time home “sick.” It is possible that his mother's depression affected Mr D's ability to develop a secure attachment and that this made it hard for him to think of himself as a separate person. This may have impeded his capacity to separate successfully from his mother. Now, it may be making it difficult for him to be apart from his wife for more than one night.

Although both vignettes tell a “story,” only the second attempts to link the history and the problem to make an etiological hypothesis. A psychodynamic formulation is more than a story; it is a narrative that tries to explain how and why people think, feel, and behave the way they do based on their development. In the above example, the sentences “It is possible…” and “This may have impeded…” suggest causative links between Mr A's problem with separation and his history—links of which he is not aware of and are thus unconscious. These causative links make this a formulation and not just a history.

Different kinds of psychodynamic formulations

Psychodynamic formulations can explain one or many aspects of the way a person thinks, feels, or behaves. They can be based on a small amount of information (e.g., the history a clinician obtains during a single encounter in an emergency room) or an enormous amount of information (e.g., everything that a psychoanalyst learns about a patient during the course of an analysis). They can try to explain how someone behaves in a moment of therapy, during a discrete crisis, or over a lifetime. They can be used in any treatment setting, for brief or long-term treatments. If they are responses to questions about how people think, feel, and behave that consider the impact and development of unconscious thoughts and feelings, they are psychodynamic formulations.

Not a static process

It's important to remember that a psychodynamic formulation is just an hypothesis. As above, we can never really know what happened, but, in order to understand our patients better, we try to get an idea of what shaped the way they developed. Earlier in the history of psychoanalysis, the psychodynamic formulation was thought to be a definitive explanation of a person's development. Now we understand that it is better conceptualized as a tool to improve our treatment methods and understanding of our patients.

Hypotheses are generated to be tested and revised. The same is true of psychodynamic formulations. The process of creating a psychodynamic formulation does not end when the clinician generates an hypothesis; rather, it continues for as long as the clinician and patient work together. The formulation represents an ever-changing, ever-growing understanding of the patient and his/her development. We can call this a working p...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Acknowledgments
• Introduction
• Part One: Introduction to the Psychodynamic Formulation
• Part Two: Describe
• Part Three: Review
• Part Four: Link
• Part Five: Psychodynamic Formulations in Clinical Practice
• Epilogue
• Appendix—How to Use Psychodynamic Formulation: A Guide for Educators
• Recommended Reading
• Index