Psychoanalytic Case Formulation

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Preface
 

The first time a supervisor asked me to venture a “dynamic formulation” of the case material I had just heard, I became instantly incompetent. I knew vaguely what I was being asked to do—namely, to suggest how the person’s symptoms, mental status, personality type, personal history, and current circumstances all fit together and made sense—but I drew a blank as to where to begin. This was my introduction to the more interpretive, synthetic, artistic aspects of psychodiagnosis. Until I had been asked for that formulation, I had rarely in my training been encouraged to work inferentially, to open myself up to a creative process fueled by intuition, to feel my way into another human being’s intimate life and formulate that person’s suffering in a way that would express his or her unique categories of subjective experience rather than the preformatted, “objective” categories of received diagnostic wisdom. Like any well-socialized student, I had gotten good at memorizing factual data, telling teachers what I thought they wanted to hear, and looking for the requisite number of “signs” that would either confirm or rule out a well-known diagnostic entity, but this assignment asked for something different and was initially very intimidating.

Most of us learn psychodynamic case formulation, as I eventually did, by identification with mentors who are good at it and. who can demonstrate how better understanding produces better treatment. I am not entirely sure that this creative, affectively infused process can be captured in a book. But I was also uncertain initially whether psychoanalytic character diagnosis could be effectively taught via the printed page, and I have repeatedly heard from students and practitioners that my writing on that topic has been helpful. So when my editor pointed out that in Psychoanalytic Diagnosis (McWilliams, 1994), despite my 

harping on the importance of sensitively assessing personality structure, I devoted only a footnote to how one arrives at such an assessment, I began thinking about how to convey in writing the ways in which experienced psychodynamic therapists think about patients.

They certainly do not think of them simply in terms of the criteria for “disorders” that are codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. To their credit, the authors of the DSM-IV have been explicit about the limitations of “disorder” taxonomies, especially from the point of view of the practicing clinician rather than that of the empirical researcher (American Psychiatric Association, 1994, p. xxv). To be a good therapist, one must have an emotional appreciation of individual persons as complex wholes—not just their weaknesses but their strengths, not just their pathology but their health, not just their misperceptions but their surprising, unaccountable sanity under the worst of conditions.

My previous book concerned the implications of personality structure for treatment. An appreciation of a client’s character type is, however, only one of the factors that influences therapists in their decisions about how to work with someone. We want to know what stresses account for any person’s coming to us at this particular time, how he or she has unconsciously understood those stresses, and what aspects of his or her unique background have created a vulnerability to this kind of stress. We also want to know how the person’s age, gender, sexual orientation, rabe, ethnicity, nationality, educational background, medical history, pribr therapy experience, socioeconomic position, occupation, living arrangements, responsibilities, and religious beliefs are connected with the kituation about which we are being consulted. We ask about eating patterns, sleeping patterns, sexual life, substance use, recreations, interests, and personal convictions. We put all that together into a narrative that makes this human being and his or her psychopathology comprehensible to us, and we derive our recommendations and our way of relating to the client from that narrative (see Spence, 1982). Thus, in contrast to my previous book on diagnosis, this one concerns itself not just with those aspects of people’s psychologies that comprise Axis II of the DSM but with data appropriate to Axes I, III, IV, V, and other areas.