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...