Professional Documents
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11, 416–423
Abstract All psychiatrists should be able to construct a psychodynamic formulation of a case. A key advantage of
formulation over diagnosis is that it can be used to predict how an individual might respond in certain
situations and to various psychotherapies. This article looks in some depth at what psychiatric trainees
need to be taught about psychodynamic formulation. We introduce formulation in terms of four levels,
each level corresponding to a different degree of theoretical and clinical sophistication and therefore to
different trainees’ needs. We use a case vignette to illustrate how a clinical situation might be formulated
at each of these levels.
This is the first of two articles by Mace & Binyon on the teaching of alongside a series of systematic inferences drawn
psychodynamic formulation to senior house officers and specialist
registrars. The second article (Mace & Binyon, 2006) will concentrate
from this. As a clinical report, it must account for
on the process of teaching. symptoms and disabilities in the light of adverse
events and developmental patterns. As a psycho-
dynamic explanation, it will discuss interpersonal
We regard the capacity to formulate cases psycho- and intrapsychic mechanisms. It is therefore likely
dynamically as a key clinical skill that all psy- to refer to internal conflict, developmental difficulties
chiatrists should be ready to apply to any case or unconscious processes.
material. Its applications are potentially beneficial A psychodynamic formulation has a number of
in many ways. Formulation should not have to wait clinical uses. It helps any psychiatrist to see what a
until formal psychotherapy is being considered as a person is doing, thinking and feeling, and to explain
treatment option, and great theoretical sophistication why. It helps in anticipating how that person may
is usually not required. An appreciation of the behave in the future and how they may respond to
purpose of psychodynamic formulation is key not adverse events and to different treatments. This is
only to doing it effectively, but also to teaching it. particularly relevant in the assessment of new
patients for psychological therapies, where a prin-
cipal task of the assessor is to arrive at an adequate
The purpose of psychodynamic formulation in order to make recommendations for
formulation further work. Formulation can also guide the treating
psychotherapist by providing a map of treatment.
A psychodynamic formulation should summarise This can be used by both therapist and supervisor to
the dynamics of a clinical situation, allowing its keep a treatment ‘on track’ and also to evaluate the
apparent motivation to be grasped by someone who progress made as the treatment continues.
is otherwise unfamiliar with it. The formulation will The principal uses of formulation are summarised
explain the nature and timing of key developments in Box 1. Item 3 probably corresponds to the most
up to the present and will facilitate predictions of commonly recognised function of formulation – that
what is likely to happen in the future. It incorporates it tries to provide a psychological account of why
a summary of relevant background information, this patient is having this problem at this time. Items
Chris Mace is consultant psychotherapist and Director of Medical Education at South Warwickshire Primary Care Trust (The
Pines, St Michael’s Hospital, Warwick CV34 5QW, UK. E-mail: C.Mace@Warwick.ac.uk) and honorary senior lecturer in
psychotherapy at the University of Warwick. He is a training programme director in psychotherapy and has a research interest in
assessment for psychotherapy. Since this article was written, he has joined the UK OPD task force. Sharon Binyon is a consultant
in adult psychiatry with a special interest in psychotherapy, and Associate Medical Director to North Warwickshire Primary Care
Trust. She is clinical tutor and scheme organiser for the Coventry & Warwickshire SHO training scheme.
The disorder that a diagnosis names is presumed to distinction between diagnosis and formulation: the
have a typical history. Yet there are real differences term ‘case formulation’ is sometimes encountered
in the utility of this predictive function: most as inclusive of both diagnosis and psychoydnamic
diagnoses in psychiatry are indistinguishable on the formulation (Eells et al, 1998). Furthermore,
basis of their natural history, lacking the predict- psychodynamic formulations proper vary in the
ability of organic syndromes such as the dementias. thoroughness of the explanation that is sought, as
Formulation, however, strives to take sufficient well as the theoretical sophistication with which
factors into account to differentiate one individual’s it is expressed. While explanation is key to
expected prognosis from another’s. Its predictive proficiency at formulation, a survey (Eells et al,
validity can be checked only against subsequent 1998) has confirmed our own impression that
events. If things develop in unexpected directions, many ‘formulations’ remain essentially descriptive,
the formulation is likely to need modification even if without a full transition to explanation and
the patient’s diagnosis is unchanged. prediction.
Diagnosis is also expected to be a guide to
treatment. In other medical specialties, there is a
close link between this function and what the The four-level model
diagnosis conveys about aetiology and prognosis. We shall distinguish between different levels of
Although this function is relatively weak for most formulation in terms of what they demand from the
psychiatric diagnoses, the current rules of evidence- clinician (Box 2).
based practice are reinforcing expectations that an First comes an appreciation that factors specific to
accurate diagnosis carries clear implications for the patient are necessary in explaining what has
treatment. In the field of psychological treatments, happened to this person, even if their contribution
however, diagnosis by itself remains a poor way of cannot be clearly articulated. Second comes a
choosing a treatment that is likely to be effective. willingness to draw these and other known facts
There are real differences between individuals in together. This will yield a narrative account of the
their responsiveness to most treatment methods, but individual’s situation that conveys an under-
diagnosis remains a poorer guide to prognosis than standing of why things happened in the way they
other patient characteristics such as defensive style did. Third is an attempt to think about these
(Perry, 1993). An argument can therefore be made summarily. This combines systematic identification
that, in drawing on other kinds of clinical knowl- of past and present factors that explain the onset
edge, formulation provides a sounder basis than and maintenance of difficulties with some concep-
diagnosis on which to identify and choose tualisation of conflicts that underpin the patient’s
treatments. disclosures and actions. A summary of this kind
Formulation comes into its own in providing a should be sufficiently cogent to permit prediction
blueprint of the likely targets to be addressed during about future behaviour. At the final, fourth level,
a treatment in order for the presenting difficulties to explanation is assisted by sufficient psychodynamic
be resolved. It is a reference against which the actual theory for the formulation to be systematically
outcome of the treatment can be judged. Although articulated and refined. Theory is most useful as
its content may be unique to an individual patient, it a foundation for descriptions of individuals’
is possible for formulation to follow a systematic underlying strengths and vulnerabilities; in pro-
method that produces comparable results with viding a consistent framework for identification of
different formulators, facilitating its use in the routine conflicts with which their symptoms are associated;
assessment of clinical progress (for an example, see and in describing enduring aspects of their inter-
Malan & Orsimo,1990). personal style. The differences between these levels
will become clearer using the following case vignette
as illustration.
What is a formulation like?
One of the reasons why it is difficult to give (or
even to find) examples of psychodynamic formu- Box 2 Four levels of psychodynamic formu-
lations is that there is no generally agreed format lation
for them to follow. Some significant attempts have 1 Recognising the psychological dimension
been made (Perry et al, 1987; Aveline, 1999; Kassaw
& Gabbard, 2002), but these tend to confirm that 2 Constructing an illness narrative
‘psychodynamic formulation’ has been linked to a 3 Modelling a formulation
range of types of summary rather than a universal 4 Naming the elements
model. There can also be confusion over the
Case vignette: Arthur him. When he had shown his mother how unhappy
Arthur is a married man of 35 who works as an his father’s taunts made him, she became unwell and
accountant. He was referred after being taken by his went to stay with her sister, leaving Arthur to face
wife to his general practitioner (GP). He had been his father’s sarcasm alone. Although Arthur was too
lying in bed for days and then she found him searching afraid even to think of arguing with his father, he
in their attic in the dark. He refused to tell the GP what remembered feeling vengeful and becoming bullying
he was doing there, but on questioning admitted to towards his younger sister, whom his father adored.
very interrupted sleep, loss of appetite and feeling While at school, Arthur had tried to work hard.
worthless. He had been expressing fears that he was When he was bullied for a period he had been afraid
incapable of doing his job well for several weeks to ask for any help, but had to see the headmaster
beforehand. He had stopped working, was staying because he lost his temper and savagely beat another
indoors and had begun to express a view that others boy after one attack too many. It was shortly after
would be better off without him. He told the GP he this reprimand he became so withdrawn that the
was very afraid his wife would leave him, although GP was called in and psychiatric assessment con-
he could not explain why. sidered. Arthur spoke of feeling humiliated by the
Arthur is reluctant to talk about his past and tells whole experience. After leaving school he had been
enquirers everything was ‘fine’. He has no formal mostly studious, but would become quite violent if
psychiatric history although his GP had recommended he drank too much. He was cautioned by the police
he see a psychiatrist when he had taken several weeks on one such occasion, and his girlfriend said she
off school at the age of 13. He had also been unable to would have nothing more to do with him. Arthur
work for several weeks when a girlfriend left him in recalls feeling abandoned and also being terrified his
his early 20s. His wife described him as a workaholic name would appear in the newspaper just before he
and a perfectionist who was devastated if he made a spent several weeks off work with what he refers to
small mistake. as ‘depression’.
Turning to recent events, Arthur admits to having
felt under pressure from his wife to ask his boss for
Level 1: Recognising the psychological some leave. The plan was for Arthur to look after
dimension their young disabled son while his wife went to a
family wedding abroad. His boss had refused, saying
A patient is seen not only as an example of someone the company was too busy to spare him at the time
with diagnosis X, but as someone whose difficulties he wanted to go. Arthur took this as a rebuke that he
need to be understood in relation to events and their had not worked hard enough to allow him time off.
He suppressed any wish to argue with his boss, but
own characteristic ways of reacting and relating.
felt inadequate afterwards. This feeling increased after
Arthur clearly has depressive symptoms that are
his wife upbraided him at home for letting her down
becoming sufficiently severe for him to earn a and for not being firm enough. Arthur found himself
diagnosis of a unipolar affective disorder. There is shouting at their son and felt very guilty at this. Just
little information to suggest why this is happening days later he was found in the attic.
to him at this time, although the onset is apparently
recent. However, there is information that he has The narrative that has built up now gives a more
withdrawn from others in a very similar way in the comprehensive picture of how Arthur experienced
past and clear precipitants for him doing so then particular events. It puts the appearance of his symp-
could also be relevant now. toms in the context of exposure to increasingly intense
and unwelcome feelings (of shame, resentment,
rejection and guilt) with him feeling increasingly
Level 2: Constructing an illness narrative useless before he withdraws from his family.
The intelligibility of the patient’s story increases as
an account is developed that links past and present. Level 3: Modelling a formulation
This indicates when major changes in the patient’s
subjective experience occurred and what may have The aim at this stage is to acquire a more structured
brought them about. and dynamic understanding of how different patho-
Let us continue with the vignette. genic factors operate and interrelate with each other.
The traditional framework of predisposing,
Further interviewing reveals more aspects to Arthur’s
precipitating and maintaining factors can be adopted
story. At first he has simply described his father as
in a selective reorganisation of information that has
‘old-fashioned’ and ‘strict’. Subsequently, he provides
illustrations of how his father used to berate him in been gathered during systematic enquiry. This allows
front of family and friends for being stupid, leading statement of one or more conflicts between conscious
Arthur to believe that his school reports were never or unconscious wishes that underpin the persistence
good enough. While he feared his father more than of the presenting problem and the (often under-
his mother, he was never sure that she would defend estimated) distress it brings. Whether or not the
Box 4 OPD dimensions of structure Box 6 Primary types of conflict in the OPD
system
• Self-perception
• Self-regulation 1 Dependence v. autonomy
• Maturity of defences 2 Submission v. control
• Object perception 3 Desire for care v. autarchy
• Communication 4 Valuing self v. valuing object
• Capacity for attachment 5 Guilt conflicts
6 Oedipal/sexual conflicts
7 Identity conflicts
associated with these); and conflicts that currently
underpin a patient’s preoccupations or distress. They
are summarised in Boxes 4–6 and discussed in their countertransference to the patient) are indis-
further detail below. The system is grounded in object pensable for this.
relations theory, but its terminology is eclectic. A To return to our case example, consider now what
complete OPD formulation also includes two other happened once Arthur was referred for further inter-
dimensions – one for the patient’s experience of view with a (male) psychiatrist experienced in
illness and prerequisites for treatment, the other for psychotherapy.
a standard (ICD) diagnosis. We confine description
here to aspects of the three psychodynamic Arthur rang up on the day of his appointment to try
dimensions that recommend it as a device for to cancel the interview, but an experienced secretary
teaching sophisticated formulation; a full account persuaded him to attend. He presented as a rather
may be found in the literature (OPD Task Force, 2001). worn man, older than his years, who looked anxious
By requiring the dimensions of structure, relation- and haunted as well as downcast. Explaining his
ships and conflict to be thought about independently attempt to cancel the appointment, he said that he
for each patient, and by providing nomenclature and had felt someone else was bound to make better use
of the appointment than himself and he had not
a system for noting the conclusions that are reached,
wanted to waste anybody’s time. He admitted to
the OPD system helps clinicians to produce a
feeling anxious in a way that had become much worse
consistently structured formulation covering intra- that morning. When the assessor suggested he may
psychic and interpersonal dynamics. As well as also have been worried about being judged if he came,
increasing the explanatory value of a formulation, he agreed that was so. He talked about how he was
the system enables clinical teams conversant with often worried about this and how he was frequently
the underlying theoretical model to communicate judged very unfairly by others, citing his boss’s
effectively about patients’ needs, vulnerabilities and disapproval of him. The psychiatrist encouraged him
likely responses. to say why he felt his boss was disapproving of him
In clinical practice, production of a psycho- and Arthur started to recount how his leave was
dynamically articulate formulation needs to draw refused. When the interviewer commented that the
boss may have behaved as he did because he valued
both on observations available only during active
Arthur’s work, Arthur checked himself, becoming less
interaction with a patient and on reported
willing to talk about his boss and looking at the assessor
information. This is evident from the requirement to with more reserve. Arthur commented rather sharply
base formulation of a patient’s characteristic inter- that his wife had felt the interview would not get
personal behaviours on observations of others’ anywhere either. The psychiatrist asked him carefully
experiences of the patient and of how the patient what it was that his wife had said about him coming
repeatedly makes them feel. Interviewers’ own to the assessment. After a very significant pause,
observations of how a patient makes them feel (i.e. Arthur replied that she had said it wouldn’t do any
good if he tried to hide things and because he was
bound to do so it would be ‘another offer wasted’. His
interviewer suggested Arthur must be feeling very
Box 5 Dimensions of interpersonal relations trapped between other people’s demands on him.
in the OPD system Arthur clenched his fists, staring at the psychiatrist,
then looked away, before starting to sob quietly.
• Patient’s (repeated) experience of others
• Patient’s (repeated) experience of him/herself The psychiatrist was moved by this encounter and
• Others’ (repeated) experience of the patient took care to record his feelings. These ranged from
• Others’ (repeated) experience of themselves irritation at Arthur’s attempts to back off to a wish to
in interaction with the patient protect him from others’ unreasonable demands.
Taking what was already known together with these
observations of how Arthur had behaved, it was system also provides a way of systematically record-
possible to sketch an outline of positions Arthur ing a patient’s attitudes to illness and treatment.)
adopted in relation to others that appeared relatively Operationalised psychodynamic diagnostics is not
fixed and repetitive. For instance, Arthur’s experi- the only way of achieving this, and it is continuing
ence of others as blaming and demanding leads him to develop through field tests. Among other objectives,
to react with an (unfulfilled) wish to attack them and these are identifying when items on the different axes
by isolating himself. This causes others to experience are most likely to be associated, so that the clinical
him as subtly attacking and as withdrawing from significance of particular patterns becomes clearer.
them, and they are left feeling he does not want them As it stands, OPD can be applied by experienced
but that they should protect him. Arthur, however, raters with relatively good reliability and it therefore
experiences these attempts to protect him as recommends itself for teaching (reliability has been
controlling and he further withdraws. Once others found to be highest for the structural items (Box 4)
react instead to their irritation by wanting to get rid when experienced raters formulate video sequences
of him, he is very sensitive to this and feels aban- (M. Cierpka, personal communication, 2005)).
doned. Recurrent cycles of interaction based on the
identified core experiences are set out in just this
way within a formulation of interpersonal relations. Making a formulation in practice
In describing conflict, the principal types listed in
Box 6 need to be considered. Although more than As we hope our model makes clear, what needs to go
one type is often present, precedence is given to those into a formulation will depend on the type of
deemed most significant in their impact, whatever formulation it is. An active process of gathering
their position in the list. From what is known about information before formulating will be necessary –
Arthur (and we still have relatively little information what Harry Stack Sullivan (1953) referred to as
about his relationships with his current family), two ‘reconnaisance’ before ‘summarising’. Quite detailed
types of conflict are particularly prominent. information is likely to be necessary about early life
Submission v. control seems to organise his (passive) and previous crises as well as the onset of recent
orientation to his boss and wife, and his difficulties difficulties, to allow likely predisposing and
in establishing a comfortable position in relation to precipitating factors to be identified.
his own control induce much resistant behaviour In the course of an interview, questions need to
before and during the interview. A second prominent focus on eliciting the patient’s subjective feelings and
conflict, the desire for care v. autarchy (being self- meanings behind possibly significant events. In
sufficient), intersects with this in Arthur’s life: his judging the significance of these, interviewers should
usual passive willingness to enjoy being cared for in be guided by the way in which patients express
a way that emphasises his sense of need and others’ themselves.
autonomy relative to his own leaves him particularly In addition to this form of history-taking, the
exposed at the moments the interviewer refused to interviewer should also be making observations
go along with these expectations. based on the interview itself. This becomes especially
Systematic consideration of the character traits in important in level 4 formulation, which can help
the dimension of structure (Box 4) reveals the degree aspects of interpersonal dynamics and conflict to be
of integration Arthur shows with each one. They are defined that were not readily apparent at level 3.
each compromised to a moderate degree: com- From the first moments of the encounter, observations
promised self-perception is evident in the dominance should be made concerning how the patient reacts
of negative feelings and his response to stress; in towards the interviewer. Are they unduly timid,
self-regulation he overregulates aggressive impulses assertive, seductive, aloof and so on – and what might
and esteem; impaired maturity of defenses in the this signify in terms of characteristic dynamic
rigidity of his obsessionality; his perception of others patterns? How do they behave when talking (or
and of their feelings is inconsistent and rigidly avoiding talking) about their feelings? Interviewers
limited (as in the earlier formulation of interpersonal need also to monitor their own feelings, noting when
relations). This also compromises his capacity to these appear to be a response to the patient that was
communicate with others (as seen in the interview) not previously present, rather than a response to
and the attachments he forms in his relationships unrelated events or thoughts.
(as in his presenting account).
This kind of formulation therefore provides a Conclusions
detailed psychodynamic footprint across the inter-
connected aspects of relations, conflict and internal Psychodynamic formulation needs to be under-
structure, but names these in a way that facilitates stood and valued as a process distinct from
reference to psychodynamic theory. (The full OPD psychiatric diagnosis. To produce a formulation, it
MCQ answers
1 2 3 4 5
a F a F a T a T a F
b T b T b T b F b F
c F c T c T c T c F
d T d F d T d F d T
e F e F e F e T e F
References This article cites 4 articles, 0 of which you can access for free at:
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