Psychodynamic Formulation
Description
A leading text for psychodynamic clinicians and practitioners
Psychodynamic Formulation: An Expanded Approach delivers an exceptional exploration of psychodynamic explanations and hypotheses that seek to explain how a person's conscious and unconscious thoughts and feelings may have developed and may be causing or contributing to the challenges they face.
This latest edition of the leading reference includes a refreshed and reinvigorated emphasis on the impacts of culture and society, as well as the importance of diversity and inclusion, on psychodynamic formulation. It puts new focus on lived experience, including trauma, and on how clinical bias can contribute to the perpetuation of trauma.
In addition to newly included activities and exercises, readers will find:
* A practical, step-by-step guide to collaboratively creating psychodynamic formulations
* Comprehensive discussions about how what we're born with and environmental influences contribute to development
* Suggestions for using psychodynamic formulations in many clinical settings, including acute care and psychopharmacologic treatment
* An educator's guide to teaching psychodynamic formulation
Perfect for mental health practitioners with a professional or personal interest in psychodynamics/psychoanalysis, Psychodynamic Formulation: An Expanded Approach will earn a place in the libraries of trainees in all mental health fields.
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Persons
The Psychodynamic Formulation Collective is a group of psychiatrists and psychoanalysts who came together following George Floyd's murder and nationwide protests against police brutality to address the historical neglect of sociocultural context in psychodynamic formulation, in particular the effect of social oppression.
Shirin Ali, an assistant clinical professor of psychiatry at the Columbia University Vagelos College of Physicians and Surgeons. A graduate of the Columbia University Center for Psychoanalytic Training and Research, she enjoys teaching and supervising psychiatry residents in psychodynamic psychotherapy. In her clinical practice, she focuses on mood and anxiety disorders, psychosis, culture and identity, and emerging adulthood.
Deborah L. Cabaniss, a professor of clinical psychiatry at the Columbia University Vagelos College of Physicians and Surgeons, associate director of the Adult Psychiatry Residency Program in the Columbia University Department of Psychiatry, and a training and supervising analyst at the Columbia University Center for Psychoanalytic Training and Research. Her teaching and writing focus on psychotherapy education, and she practices psychiatry and psychoanalysis in New York City.
Sabrina Cherry, a clinical professor of psychiatry at Vagelos College of Physicians and Surgeons, Columbia University. She is also an associate director and training and supervising analyst at the Columbia Center for Psychoanalytic Training and Research where she teaches candidates and conducts research on psychoanalytic career development. She practices psychotherapy and psychoanalysis in New York City.
Angela Coombs, an associate medical director at Alameda County Behavioral Health, where she focuses on increasing access to county mental health services and supports clients in East Oakland, California. Her scholarly work focuses on mental health inequities facing Black American populations and other minoritized and/or marginalized groups.
Carolyn J. Douglas, an associate clinical professor of psychiatry at the Columbia University Vagelos College of Physicians and Surgeons and an adjunct associate professor of clinical psychiatry at Weill-Cornell Medical College. She has been closely involved in psychiatric residency training throughout her career, has published several articles about teaching psychodynamic psychotherapy, and has won teaching awards from residents in psychiatry both at Columbia and at Weill-Cornell for her didactic courses and supervision in supportive psychodynamic psychotherapy.
Jack Drescher, a distinguished life fellow of the American Psychiatric Association and a clinical professor of psychiatry at the Columbia University Vagelos College of Physicians and Surgeons. He is also an adjunct professor at New York University's Postdoctoral Program in Psychotherapy and Psychoanalysis and a training and supervising analyst at the William Alanson White Institute.
Ruth Graver, an assistant clinical professor of psychiatry at the Columbia University Vagelos College of Physicians and Surgeons. She teaches and supervises at the Columbia University Center for Psychoanalytic Teaching and Research where she is currently the co-chair of the Columbia Academy for Psychoanalytic Educators (CAPE), a new program designed to hone skills relevant to treating and supervising candidates. Her scholarly interests include clinical technique, attachment theory, and psychoanalytic writing. She conducts her clinical practice of psychotherapy and psychoanalysis in New York City.
Sandra Park, a training and supervising analyst at the Columbia University Center for Psychoanalytic Training and Research and an assistant professor of psychiatry at the Weill Cornell Medical Center. She has a private practice in Manhattan, and she teaches and supervises at Columbia and Cornell.
Aaron Reliford, vice chair for diversity, equity and inclusion and an associate clinical professor of child and adolescent psychiatry at New York University. He is also the training director of NYU's Child and Adolescent Psychiatry Fellowship, and both the director of child and adolescent psychiatry and the associate medical director of Behavioral Health Sunset Terrace Family Health Center of NYU Langone Brooklyn. Dr. Reliford's clinical research interests include telepsychiatry, racial health disparities in pediatric mental health, cultural psychiatry, pediatric psychopharmacology, effects of early trauma on development of psychopathology, child parent psychotherapy, psychoanalysis, and dynamic/insight oriented psychotherapy.
Anna Schwartz, a clinical assistant professor of psychiatry at the Columbia University Vagelos College of Physicians & Surgeons. She is also a faculty member of the Columbia University Center for Psychoanalytic Training and Research, where she has taught and supervised psychotherapy trainees for many years. She is in private practice in New York City.
Susan C. Vaughan, the Aaron R. Stern Professor of Psychodynamic Psychiatry at Cornell University. She also served as the Director of the Columbia University Center for Psychoanalytic Training and Research from 2017 to 2022. She has special interest in LGBTQ issues and teaches about sexuality, gender, and the intersections between psychotherapy and neuroscience.
Content
Preface x
Acknowledgments xiv
PART ONE Introduction to the Psychodynamic Formulation 1
1 What Is a Psychodynamic Formulation? 3
2 How Do We Create a Psychodynamic Formulation? 10
3 How Do We Use Psychodynamic Formulations? 14
4 Psychodynamic Formulation and Bias 18
5 Who We Are Affects Our Formulations 23
PART TWO DESCRIBE 29
6 Self 35
7 Relationships 44
8 Adapting 53
9 Cognition 62
10 Values 76
11 Work and Play 84
Putting It Together--DESCRIBE Problems And Patterns 93
PART THREE REVIEW 97
12 What We're Born With 105
13 The Earliest Years 121
14 Middle Childhood 135
15 Later Childhood 143
16 Adolescence 149
17 Adulthood 155
Putting It Together--REVIEW a Life Story 161
PART FOUR LINK 165
18 Trauma 169
19 Early Cognitive and Emotional Difficulties 181
20 The Effects of Culture and Society 193
21 Conflict and Defense 205
22 Relationships with Others 214
23 The Development of the Self 225
24 Attachment 235
Putting It Together--LINK to Collaboratively
Create Psychodynamic Formulations 247
PART FIVE Psychodynamic Formulations in Clinical Practice 261
25 Psychodynamic Formulations in Acute Care Settings 263
26 Psychodynamic Formulations in Pharmacologic Treatment 273
27 Psychodynamic Formulations in Long-Term Psychodynamic Psychotherapy 282
28 Collaborative Formulations in Clinical Practice 291
End Note 298
Appendix A - An Educator's Guide to Using Psychodynamic Formulation: An Expanded Approach 299
Appendix B - DESCRIBE, REVIEW, LINK--An Outline 305
Recommended Reading 307
Index 316
1 What Is a Psychodynamic Formulation?
Key concepts
A formulation is an explanation or hypothesis.
A psychodynamic formulation is a hypothesis about the way a person's conscious and unconscious thoughts and feelings
- may have developed
- may be causing or contributing to the difficulties that have led the person to treatment
Throughout our lives, biological, psychological, and social/cultural factors affect the development of our conscious and unconscious ways of thinking about ourselves, our relationships with others, and our world; thus, all should be included in a psychodynamic formulation.
Psychodynamic formulations do not offer definitive explanations; rather, they are hypotheses that can change over time.
Psychodynamic formulations can aid our work with all patients, not just those in psychodynamic psychotherapy.
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? What is a formulation? Why is it important?
Formulating means explaining (Eells, 2022), or better still, hypothesizing. All healthcare professionals create formulations all the time to understand their patients' problems. In mental health fields, the kinds of problems we try to understand involve the way our patients think, feel, and behave. When we formulate, we think not only about how people think, feel, behave, but also why they do. For example,
Why is she behaving this way?
Why does he think that about himself?
Why are they responding to me like this?
Why is that his way of dealing with stress?
Why is she having difficulty working and enjoying time off?
What is preventing them from living the life they want to lead?
Different etiologies suggest different treatments; thus, having hypotheses about these questions is vital for recommending and conducting treatment.
What makes a formulation psychodynamic?
Many different kinds of formulations exist (Campbell & Rohrbaugh, 2006/2013; Eells, 2010; Wright et al., 2017). There are cognitive behavioral therapy 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.
A psychodynamic frame of reference suggests that these problems may be caused or contributed to by thoughts and feelings that are out of awareness-that is, that are unconscious. These unconscious thoughts and feelings affect the way we think about ourselves, other people, and our relationship to the world Thus, a psychodynamic formulation is a hypothesis about the way a person's conscious and unconscious thoughts and feelings
- may have developed
- may be causing or contributing to the difficulties that have brought the person to treatment
This is important to understand, as helping people become aware of their unconscious thoughts and feelings is an important psychodynamic technique.
Unconscious vs. implicit
According to social scientists, implicit mental processes are those that "occur outside conscious awareness" (Devos & Banaji, 2003). People may not be aware that they exist, or they may simply operate outside of conscious control (Devos & Banaji, 2003). When implicit processes influence our judgments-for example, about people on the basis of race or gender-we call this implicit bias (FitzGerald & Hurst, 2017). We can have these biases about ourselves, others, or society at large. In this book, we use the terms unconscious and implicit interchangeably to mean mental processes that operate out of awareness and that, once formed, automatically influence our thoughts, feelings, and behaviors.
A developmental process throughout life
It's well known that psychodynamically oriented mental health professionals are interested in their patients' childhoods. But why? One reason is that using psychodynamic technique is about more than just helping people become aware of their unconscious thoughts and feelings-it's also about trying to make sense of how and why those unconscious thoughts and feelings developed.
Although there are significant temporal windows early in life during which massive amounts of development occurs, conscious and unconscious thoughts and feelings change throughout life. Erikson's "Eight Ages of Man" (Erikson, 1968), which conceptualizes development as occurring throughout the life span, is a good place to begin, but today we must take this even further. Traumatic events that occured to parents before conception; maternal stress during pregnancy; discrimination, inequity, and systemic oppression during adulthood; and late-life loss may all contribute to the individual's mental life in the here and now. Thus, we aim to address the entirety of a person's lived experience in a psychodynamic formulation.
While that's all well and good, how can we learn about and try to make sense of developmental processes that have already occurred? Even with videos and scrapbooks, we can't go back in time to watch early development unfold. In this way, creating a psychodynamic formulation is a lot like being a detective trying to solve a mystery. Like the detective, we work retrospectively, first looking at our patients' problems and patterns and then scrolling back through their life stories to try to understand their development.
Biological, psychological, and social
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 (Locke, 1689/1975). E. O. Wilson argued that social behavior is shaped almost entirely by genetics (Wilson, 1975/2000). Nature-nurture: it isn't one or the other but both, with the relative contributions of each varying from person to person. Freud (1937/1964) called the nature part "constitutional" and the nurture part "accidental." However, you think about it, people come into the world with their inherited genetics 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; complex interactions between the two result in our characteristic views of ourselves, the way we relate to other people, and our patterns of adapting to stress. In thinking about how to understand and describe how we develop, we must consider genetics, intrauterine exposures, temperament-the biological factors-as well as the environmental factors. They are all part of psychodynamic formulation.
Traditionally, psychoanalysts thought about the environmental part of the equation as related mostly to the effects of children's early interactions with the people in their immediate environment (e.g., primary caregivers and other family members). This immediate environment is sometimes called the person's microsystem (Bronfenbrenner, 1977). We often think of these early interactions as the psychological factors contributing to a person's development. But culture and society also affect the development of the conscious and unconscious ways we think about ourselves, other people, and our world (Fanon, 1952/2019). This includes both the person's communities (e.g., schools, religious groups, local organizations)-sometimes called the mesosystem-as well as society at large (e.g., laws, public policies, cultural values)-sometimes called the macrosystem (Bronfenbrenner, 1977). This is particularly pronounced when we are disadvantaged by what has been described as hierarchical systems of oppression, including racism, sexism, heterosexism, cisgenderism, ableism, classism, ageism, and religious or ethnic discrimination (Crenshaw, 2017; Hays, 2016). These systems affect us throughout our lives, and may powerfully and adversely affect our implicit mental processes even when our early experiences with caregivers were generally positive. In this edition, we expand the psychodynamic formulation to include the way that culture and society affect the development of conscious and unconscious ways of thinking about the self, others, and the world throughout life (see Chapter 20).
More than reporting
A news story gives a report of what happened; a psychodynamic formulation offers a hypothesis about why things happened. The following examples illustrate the difference.
Reporting
Nick, who is 32 years old and has been married for 10 years, presents because he needs to go on a business trip and is unable to be away from his wife for more than one night. He was born to a single teenage mother who had little support and who likely had postpartum depression. As a child, Nick had severe separation anxiety and spent long periods of time at home "sick."
Formulating
Nick, who is 32 years old and has been married for 10 years, presents because he needs to go on a business trip and is unable to be away from his wife for more...
