Table of Contents
Title Page
Copyright
Dedication
Acknowledgments
Introduction
Part One: Introduction to the Psychodynamic Formulation
Chapter 1: What is a Psychodynamic Formulation?
What is a formulation?
What makes a formulation psychodynamic?
A developmental process
Nature or nurture?
More than reporting
Different kinds of psychodynamic formulations
Not a static process
Formulating psychodynamically is ultimately a way of thinking
Chapter 2: How do We Use Psychodynamic Formulations?
Formulation is our map
Using a psychodynamic formulation in treatment
Do we share our formulations with our patients?
Chapter 3: How do We Construct a Psychodynamic Formulation?
The three basic steps to create a psychodynamic formulation
Part One References
Part Two: Describe
Chapter 4: Self
Defining the area: self
Variables for describing patterns related to the self
Learning about patterns related to the self
Describing self-experience
Chapter 5: Relationships
Defining the area: relationships
Variables for describing patterns related to relationships
Variability in relationship patterns
Learning about relationships
Describing relationships
Chapter 6: Adapting
Defining the area: adapting
Variables for describing patterns of adapting
Learning about how someone adapts
Describing adapting
Chapter 7: Cognition
Defining the area: cognition
Variables for describing cognition
Learning about cognition
Describing patterns related to cognition
Chapter 8: Work and Play
Defining the area: work and play
Variables for describing work and play
Learning about work and play
Describing work and play patterns
Putting it Together—A Description of Problems and Patterns
Presentation
Describe
Part Two References
Part Three: Review
Chapter 9: What We're Born with—Genetics and Prenatal Development
Genetics and heredity
Prenatal development
Prematurity and peripartum brain injury
Nature and nurture—a two-way street
Resilience
Adult problems and patterns that suggest a genetic or prenatal origin
Taking a developmental history of the prenatal phase
Taking a developmental history from adults who do not know their biological parents
Chapter 10: The Earliest Years
Connecting to the primary caregiver
“Good enough” parenting
What develops during the earliest years?
Adult problems and patterns that suggest origins in the earliest years
Taking a developmental history of the earliest years
Chapter 11: Middle Childhood
From two-person relationships to three-person relationships
Three-person relationships
What develops during middle childhood?
The role of temperament and psychiatric disorders during middle childhood
Negotiating middle childhood when there have been earlier problems
Adult problems and patterns that suggest origins in middle childhood
Taking a developmental history of the middle childhood years
Beyond the triad
Chapter 12: Later Childhood, Adolescence, and Adulthood
Development beyond the early years
Later childhood: 6–12 years
Adolescence: 13–18 years
Young adulthood: 18–23 years
Adulthood: 23 years and beyond
Taking a developmental history of these periods
Remembering the whole life cycle
Putting it Together—A Developmental History
Presentation
Developmental history
Part Three References
Part Four: Link
Chapter 13: Trauma
What is trauma?
Basic ideas about how trauma can affect development
Linking problems and patterns to the impact of trauma
A sample formulation—linking to trauma
Linking to trauma guides treatment
Chapter 14: Early Cognitive and Emotional Difficulties
Why talk about difficulties rather than disorders?
Basics related to the impact of cognitive and emotional difficulties on development
Parental response and early treatment can help mitigate the impact of cognitive and emotional difficulties on development
Linking problems and patterns to the impact of early cognitive and emotional difficulties
A sample formulation—linking to the impact of early cognitive and emotional difficulties
Linking to early cognitive and emotional difficulties guides treatment
Chapter 15: Conflict and Defense
Conflict and compromise
Basics of ego psychology
Linking problems and patterns to conflict and defense
A sample formulation—linking to conflict and defense
Linking to unconscious conflict and defense guides treatment
Chapter 16: Relationships with Others
Basics of object relations theory
Relationship patterns are multidimensional
Linking problems and patterns to relationships with others
A sample formulation—linking to relationships with others
Linking to relationships with others guides treatment
Chapter 17: The Development of the Self
Basics of self psychology
Linking problems and patterns to the development of the self
A sample formulation—linking to the development of the self
Linking to the development of the self guides treatment
Chapter 18: Attachment
Basics of attachment theory
Linking problems and patterns to attachment styles
A sample formulation—linking to attachment
Linking to attachment styles guides treatment
Putting it Together – A Psychodynamic Formulation
Presentation
Describe
Review
Link
Part Four References
Part Five: Psychodynamic Formulations in Clinical Practice
Chapter 19: Psychodynamic Formulations in Acute Care Settings
Psychodynamic formulations help in all settings
Challenges of psychodynamic formulation in the acute care setting
Chapter 20: Psychodynamic Formulation in Pharmacologic Treatment
A psychodynamic formulation helps guide pharmacologic treatment
Gathering information for a targeted formulation in pharmacologic treatment
Constructing a psychodynamic formulation in a psychopharmacologic treatment
Chapter 21: Psychodynamic Formulation in Long-Term Psychodynamic Psychotherapy: Revising Over Time
Formulations change over time
Initial presentation
Describe
Review the developmental history
Link
Use of the formulation
Chapter 22: Sharing Formulations with Our Patients
How do we decide how and when to share formulations?
Situations in which sharing formulations is particularly helpful
Generating a life narrative
Part Five References
Epilogue
A new set of clinical skills
A new way to understand your patients
From formulation to treatment
An invitation to curiosity
Appendix—How to Use Psychodynamic Formulation: A Guide for Educators
Describe
Review
Organizing ideas about development
Link
Using formulations to guide treatment
Recommended Reading
Recommended Reading: Part One
Recommended Reading: Part Two
Recommended Reading: Part Three
Recommended Reading: Part Four
Recommended Reading: Part Five
Index
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Library of Congress Cataloging-in-Publication Data
Psychodynamic formulation / by Deborah L. Cabaniss ... [et al].
p. ; cm.
Includes bibliographical references.
ISBN 978-1-119-96234-2 (cloth)
I. Cabaniss, Deborah L.
[DNLM: 1. Mental Disorders–diagnosis. 2. Mental Disorders–therapy. 3. Patient Care Planning. 4. Psychoanalytic Therapy–methods. WM 141]
616.89–dc23
2012047255
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Cover image: Nicki Averill Design & Illustration
Cover design by Nicki Averill Design & Illustration
For our families:
Thomas, William and Daniel
Marc, Rebecca and Ruth
Jon, William and Ben
Michael, Sam and Jacob
Eric, Lena and Maia
This book may be seen as a companion to Psychodynamic Psychotherapy: A clinical manual. For details, see www.wiley.com or scan this QR code:
Constructing a psychodynamic formulation is one thing, but trying to teach someone else to construct one is something else entirely. It's like trying to teach someone to tie a shoe. You know how to do it, but what are the steps? How do you put things together? What do you have to know in order to do it? This is what my coauthors and I tried to figure out. The result is our DESCRIBE/REVIEW/LINK method and a curriculum that helps students learn why psychodynamic formulations are important and how to construct them from the bottom up. Along the way, Sabrina Cherry and I wrote formulations and discussed our thought process over countless phone calls; Carolyn Douglas helped to keep us balanced between nature and nurture; Ruth Graver helped to devise a wonderful, dimensional way to describe function; and Anna Schwartz reminded us of the centrality of trauma and the utility of formulations in multiple settings. Both Psychodynamic Psychotherapy: A Clinical Manual and Psychodynamic Formulation would not be what they are if not for this incredible team of women who are outstanding clinicians, educators, and writers. I am, as ever, grateful for their time, effort, creativity, and friendship.
The beta version of this book was road-tested by our terrific Columbia residents, and I thank them for putting up with early drafts riddled with typos. Having the opportunity to teach them day in and day out, year after year, keeps us asking the important questions about education. I owe many thanks to Justin Richardson, who helped me to conceptualize new ways of teaching formulation and with whom I taught for 5 years. David Goldberg, Deborah Katz, and Volney Gay are world-class psychodynamics educators whom I have come to rely on for their wisdom and guidance—each of them carefully read the entire manuscript and gave us invaluable comments that helped us to shape the final product. Sarah Paul offered insightful comments as well. Steven Roose kept me on track to think about function rather than disorders, and Roger MacKinnon made sure that psychodynamic formulation would always be a central part of psychiatric training at Columbia. Joan Marsh, our editor at Wiley, has become a friend and I am grateful for her enthusiasm about our work. Maria Oquendo and Melissa Arbuckle continue to support our teaching at Columbia, without which none of this would be possible.
I'd also like to thank the many students and educators who are using and enjoying Psychodynamic Psychotherapy: A Clinical Manual. The overwhelmingly positive response we got to the Manual energized us write this companion volume. We are delighted that it has helped to make psychodynamic technique more understandable, and we hope that this book does the same for psychodynamic formulation.
Older and wiser than they were when we wrote the first book, my children William and Daniel are now resigned to the idea that their mom likes writing on nights and weekends. I know that they are proud of me and of the work I'm doing. They will be ready to edit the next book. And, once again, Thomas read every word—sometimes twice—and kept the faith even when I didn't. I couldn't do any of it without him.
Deborah L. Cabaniss
New York
September 2012
When we look up at the Rocky Mountains, we see some of the most beautiful scenery on Earth. If asked to describe it, we could wax poetic about the snow capped peaks, alpine meadows, and craggy ravines. That's what they are now—that's what we see. But how did the Rockies get to be the Rockies? How did they form? To figure that out, geologists have used information gathered from the rocks themselves, as well as theories about plate tectonics, to hypothesize that the Rockies arose when two continental plates collided. No one on Earth saw this happen—in fact, no one has ever seen a tectonic plate. However, the evidence is good that forces moving beneath the Earth's surface millions of years ago led to the formation of one of the most beautiful places on the globe. These subterranean forces, in addition to millions of years of rain, snow, ice, and wind, made the Rockies what they are today. This hypothesis helps us understand the history of our planet and predict the way the Earth will continue to change in response to forces working below and above the surface.
When we meet adult patients, we see what they are like now. We hear their speech, observe their behaviors, and listen to their ideas. But how did they come to be the way they are? What forces shaped them? Like geologists, psychodynamic psychotherapists look beyond the surface for answers to these questions. They hypothesize that people are shaped by forces working both beneath and above the surface over time, and they believe that thinking about how that happened is important for understanding a person's past, present, and future. Their hypotheses are their psychodynamic formulations, and these formulations are essential to every aspect of the way they treat their patients.
Students and clinicians are often needlessly daunted by the prospect of creating psychodynamic formulations, wondering how they can learn about subterranean forces that even their patients cannot easily access. While it takes time and thought, every clinician can learn to construct psychodynamic formulations using three steps:
This book will teach you each of these three steps using clear language and illustrative examples. Part One will introduce you to the psychodynamic formulation and the DESCRIBE/REVIEW/LINK method; Part Two will teach you to DESCRIBE problems and patterns; Part Three will teach you to REVIEW the developmental history; and Part Four will teach you the various ways of LINKING the problems and patterns to the history using different organizing ideas about development. Part Five will offer ways to use psychodynamic formulations in various clinical situations and settings. Finally, Parts Two–Four are followed by Putting it Together sections that offer full, clinical illustrations of the part of the formulation you've just learned about. Note that all of the clinical examples in the book feature fictional people.
A psychodynamic approach to case formulation is unique in that it considers the way the unconscious mind affects our thoughts, feelings, and behavior. However, as psychodynamic psychotherapists, we are interested in everything that has affected and will affect our patients. This includes both nature and nurture. For this reason, we have intentionally included a considerable amount of information about genetics, temperament, and trauma and the way in which they impact development. It is our firm belief that we should not construct psychodynamic formulations in silos – we cannot hypothesize about the development of our unconscious thoughts and feelings without considering the impact of our endowment and early cognitive and emotional problems on that development. Our hope is that this will encourage you to think broadly about the myriad factors that have affected the way your patients think, feel, and behave.
This book is appropriate for medical students, social work students, psychology students, psychiatry residents, and practicing clinicians. It can be used by individuals who are interested in learning about psychodynamic formulation on their own, as well as by students and teachers in educational settings. Our students learn to DESCRIBE in their earliest years of training, to REVIEW developmental histories slightly later, and to LINK once they have a substantial amount of clinical experience (see Appendix for more specifics). Whether you are an individual learner or an educator, we suggest that using Psychodynamic Formulation in this stepwise fashion will help you and/or your students to learn to construct psychodynamic formulations without feeling overwhelmed by the task.
Constructing formulations is not just an interesting exercise—it's an essential part of how we treat our patients. Although this book will teach you to write a psychodynamic formulation, our true goal is for you to use what you learn here to constantly think about psychodynamic formulations for every patient you see. Without psychodynamic formulations, we can only see the surface—we cannot understand the extraordinary forces that work together to shape the way people think, feel, and behave. It is this understanding that helps us to know what our patients need to learn about themselves, and what they need to develop, in order to live more satisfying, freer lives. So, let's move on to begin learning about Psychodynamic 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.
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.
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
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.
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.
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.
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.
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 psychodynamic formulation. Over time, both patient and therapist learn about new patterns and new history. With this, new ways of thinking about development may become useful, and these can help generate new hypotheses. The process of describing patterns, reviewing history, and linking the two using organizing ideas about development is repeated again and again during the course of the treatment, shaping and honing both the therapist's and patient's understanding.
We think that the best way to learn to formulate psychodynamically is to actually write a psychodynamic formulation. Taking the time to do this, as well as forcing yourself to commit your ideas to paper (or screens!), will help you to consolidate your ideas about a patient and to practice the skills that you will learn in this book. But not all formulations are written. In fact, most are not. We formulate psychodynamically all the time—when we listen to patients, when we think about patients, and when we decide what to say to patients. Ultimately, formulating psychodynamically is a way of thinking that happens constantly in a clinician's mind. Our hope is that you will use the skills that you learn in this book to formulate psychodynamically all the time with all your patients.
Now that we have introduced some basic concepts, let's move on to Chapter 2 to further explore the way we use psychodynamic formulations.
Sometimes we share our psychodynamic formulations with our patients, and sometimes we use them privately to help shape our therapeutic strategies and interventions.
Having a working psychodynamic formulation means having a continuously evolving idea about the unconscious thoughts and feelings that affect our patients' ways of thinking, feeling, and behaving. But how do we learn about a part of the mind that is out of awareness? We listen carefully to what our patients say so that we can pick up clues that might guide us toward unconscious material, we reflect on what our patients say, and we intervene in ways that help them to learn more about their minds [7]. As we listen, we do not necessarily know where we're going—in psychodynamic psychotherapy, we follow the patient's lead. But the fact that we follow the patient's lead does not mean that we work without a map. That map is our psychodynamic formulation. When we have a sense of our patients' primary problems and patterns, their developmental histories, and how and why they developed as they did, we listen to them with this in mind.
To further explore this, let's consider the example of Ms A. She is a 43-year-old woman who has come for treatment with Dr Z because she is worried that her husband will leave her. She explains that her husband is a “genius” and that she cannot understand why he wants to remain married to someone who just stays home and takes care of the children. She says,
I've become one of those boring housewives. The only thing I can talk about is the soccer schedule.
As Dr Z conducts the evaluation, she learns that Ms A is unable to say anything good about herself. Dr Z also recognizes that Ms A's self-effacement seems incongruous given her apparent abilities—she was a gifted painter who gave up her career when she married. Dr Z begins to wonder about why Ms A has this view of herself. As Dr Z takes the developmental history, she learns that Ms A's mother was a world-famous scientist who was critical of her daughter's complete lack of interest in science, preferring Ms A's brother who became a physicist. Dr Z constructs an early psychodynamic formulation (hypothesis) that Ms A has unconscious, maladaptive ways of perceiving herself and regulating her self-esteem and that these unconscious self-perceptions and conflicts might have developed as a result of Ms A's problematic relationship with her mother. Although Dr Z knows that she has much more to learn about Ms A, she uses her preliminary formulation to make a treatment recommendation and to work with Ms A to set early goals, saying:
It is clear to me that you are worried about your relationship with your husband. However, it also seems that you are overly tough on yourself and that you do not allow yourself to do things that interest you. These difficulties could be related to longstanding feelings you have about yourself that may date back to your early relationship with your mother. Exploring these feelings in a psychodynamic psychotherapy may help us to understand why you are so unhappy in your current situation and help you to improve both your relationship and your feelings about yourself.
Ms A agrees and she and Dr Z begin a twice-a-week psychodynamic psychotherapy. Dr Z uses her hypothesis that Ms A was not able to develop an adequate sense of self to understand that M has a developmental need to improve her self-perception and her capacity for self-esteem regulation. This forms the basis for Dr Z's therapeutic strategy; she will listen to everything that Ms A says, paying close attention to material that might relate to Ms A's difficulties with her sense of self.
For example, one year into the treatment, Ms A says to Dr Z,
You must be tired of me just talking about my problems day after day. You probably have other patients who need your help more than I do.
Dr Z uses her formulation to help Ms A notice her problematic self-perception, saying,
I think that you presume that I, like your mother, will be disappointed in you and will be more interested in others.
Over time, Ms A begins to believe that Dr Z is, in fact, truly interested in her. Through her conversations with Dr Z, she realizes that she had a distorted expectation that Dr Z, like her mother, would find her dull and lacking. Together, they use this formulation to create a life narrative for Ms A, which helps her to make sense of how she developed this maladaptive unconscious fantasy. In Ms A's words,
I never realized how hurt I was that my mother wasn't as interested in me as she was in my brother. I also never understood the toll that this took on the way I thought about myself. I'm now seeing that my husband isn't uninterested in me—I just presume that everyone is.
As the treatment unfolds, Dr Z deepens and alters her formulation, but she continues to use it to help her to set goals, develop her therapeutic strategy, listen to the patient, construct interventions, and foster Ms A's understanding of her life. It will remain key to every part of the treatment, from beginning to end.
Sometimes we share our psychodynamic formulations with our patients, and sometimes we use them privately to shape our therapeutic strategies and interventions. As we'll discuss further in Chapter 22, we make decisions about this based on what we think is most clinically helpful for the patient in that moment. When patients are self-reflective and able to think about the impact and development of their unconscious thoughts and feelings, it can be helpful to share our formulations:
Example
Ms B is a 30-year-old woman who comes to therapy with Mr Y because she is unsure about her upcoming wedding. She says that although she loves her fiancé, she is worried that she will end up being as unhappy a wife as her mother was. In therapy, Ms B and her therapist evolve the hypothesis that Ms B has an unconscious conflict—although she loves her fiancé and wants to spend her life with him, she feels guilty about having the kind of marriage her mother never had. Understanding this allows her to go ahead with her wedding and to feel better about her relationship.
When patients are less self-reflective, it may be more useful to use our formulations privately:
Example
Ms C is a 58-year-old woman whose husband of 25 years died 6 months ago. She comes to the clinic for help with disorganization, explaining to Dr X that she is having trouble doing things like paying bills and balancing her checkbook. After determining that Ms C does not have symptoms of anxiety, depression, or cognitive impairment, Dr X asks Ms C whether her husband had taken care of the household finances. Ms C acknowledges that he had, but says that she doesn't think that her current problems have anything to do with her husband's death: “I've always been independent, so I'll be fine alone.” Dr X hypothesizes that Ms C's inability to take over her husband's tasks is related to feelings about having lost her husband, but thinks that Ms C is not ready to talk about this and that she is highly invested in feeling independent. Therefore, Dr X uses her formulation privately to help Ms C develop strategies for doing one task at a time. This helps Ms C to feel more able to approach these tasks and to feel more independent, although she remains unable to discuss how much she misses her husband.
While both Mr Y and Dr X developed psychodynamic formulations about their patients, Mr Y shared his formulation with Ms B, while Dr X used her formulation without explicitly sharing it. But how did these therapists construct their formulations? We will begin to explore that in Chapter 3.
How do we develop hypotheses to explain things we observe? It could be anything—a cultural trend, the relationship between two people, or a natural phenomenon. For example, let's say that people have a sense that there was less snowfall than usual in their town, and they want to know whether this will be a trend. First, they need to define the phenomenon by using careful observation and measurement. Then, they have to research the history of snowfall in the area. Once they've done this, they can use meteorological theories—for example, theories about global warming—to help them link their observations and the history to form an hypothesis about what's happening and what might happen in the future. They can then explain their hypotheses to others in a cogent way.
We follow the same steps when we construct psychodynamic formulations to help us understand how and why people develop their characteristic patterns of thinking, feeling, and behaving. This process involves three basic steps. We
Taken together, these three steps comprise the formulation. Each step is crucial to the process and is discussed at length in Parts Two–Four; we briefly outline them here by way of introduction.
Before we think about why people developed their primary problems and patterns, we have to be able to describe what they are. Here, we're not just talking about the chief complaint, but about the issues that underlie the person's predominant ways of thinking, feeling, and behaving. We can divide these into five basic areas of function:
It is important to describe each of these areas in order to understand the way a person functions. To do this, we learn from what the patient tells us as well as from what the patient shows us. For example, a patient may say that he/she gets along well with others but then argue with the therapist throughout the evaluation. We have to use both sources of information when we describe his/her relationships with others. It's also essential to have more than just a surface description of each of these functions in order to really understand our patients. We will address all these areas and how to describe them in Part Two.
When patients come to see us, we “take a history” to understand the events that led up to the presenting problem. But to construct a psychodynamic formulation, we need to do much more than that. Our goal is to learn everything we can about our patients in order to begin to make links between their histories and the development of their primary problems and patterns. To do this, we have to take a developmental history. This kind of history begins before birth, with the patient's family of origin, prenatal development, and genetic endowment; it includes every aspect of the first years of life, including attachment, early relationships with caregivers, and trauma, and it continues through later childhood, adolescence, and adulthood, until the present moment. Since we don't know why people develop their typical patterns, we have to consider everything—we're interested in heredity and environmental factors and the relationship between the two. We want to understand periods of development that went well, as well as periods that were problematic—we need all the information we can get to try to hypothesize causative links between the history and the development of the patient's primary characteristics. Reviewing the developmental history is the subject of Part Three.
The final step in constructing a psychodynamic formulation is linking the problems and patterns to the developmental history to form a longitudinal narrative that offers hypotheses about how and why the patient developed his/her ways of thinking, feeling, and behaving. In doing this, we can be helped by organizing ideas about development. These organizing ideas offer us different ways of conceptualizing and understanding our patients' developmental experiences. They help us to take the information that we have learned from the history and think about how it could have led to the problems and patterns we see in our patients. Different ideas may be more helpful in understanding different problems and patterns. The organizing ideas that we discuss in Part Four address the impact of the following on development:
So let's begin constructing psychodynamic formulations with Part Two—DESCRIBING function.
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Psychodynamic formulations help us to explain how and why people function the way they do.
Before we try to explain someone's function, we have to be able to DESCRIBE it.
We can do this by describing
We can divide these into patterns related to
We need to describe aspects of function about which the person is aware (conscious) as well as those about which the person is not aware (unconscious).
For each pattern, it is important to think about areas of strength as well as areas of difficulty.
When we think about how something functions, we consider whether it does what it was designed to do. A refrigerator is designed to keep food at a low temperature, so if the milk is cold, it is functioning well and if the milk is warm, it is functioning poorly. A car is designed to transport people from place to place, so if it reliably allows us to get around, it is functioning well and if it is always in the shop, it is functioning poorly. Things that are designed to have multiple functions can sometimes work well in one area but not in another. For example, if a desk chair that is meant to be both comfortable and stylish creates a sleek look in an office but leaves workers with backaches, it is fulfilling one function but not the other.
While it's easy to know the intended function of a refrigerator or a car, it's much harder to know what a person is supposed to be able to do. For example, should all people work? Get married? Have children? Belong to a religious organization? Be altruistic? Although some people might believe that all people should be able to do one or all of these things, as mental health professionals it is not our job to make those kinds of judgments. On the contrary, we know that there are as many ways to live as there are people on Earth. However, when people suffer, we know that their functioning is faltering in some way.
People function by thinking, feeling, and behaving. We construct formulations to try to explain how and why they function the way they do. But we have to be able to describe their function before we can explain it. We can do this by describing both the Problem and the Person.
The Problem is what is giving the person the most difficulty right now. It is generally, but not always, the reason that he/she gives for consulting a mental health professional. Sometimes we agree with patients about the primary problem and sometimes we don't, but either way we have to acknowledge and address their concerns. Here are a few examples of problems that bring people to psychotherapy:
Mr A presented to the clinic for help with understanding his teenage daughter.
Ms B consulted a therapist because she is unsure about whether she wants a divorce.
Ms C made an appointment because she feels increasingly anxious at work.
Mr D was sent for a consultation by his internist because he can't get back on his feet after being fired.
Ms E sought therapy because she can't figure out why she's not in a relationship.
Of course, many patients do not have only one problem. They might have depression and ongoing difficulty with a spouse, or they might drink too much alcohol or have an ailing parent. Nevertheless, it is important to develop the skill to identify and describe what is troubling the person the most right now so that we can try to explain the development of this problem in the psychodynamic formulation. Challenge yourself to answer the question, “Why did this person come to see me now?” and you are likely to identify the primary problem.