Adam Blatner

This article is a complement to and/or extension of  another paper on this website: The Art of Case Presentation. Other relevant articles include: The Real Diagnostic Categories, Diagnosis in Psychiatry,
Factors in Human Development , and others.

What’s wrong with the patient? What really is the problem? A term like “depression” rarely explains much. Offering a diagnostic label is not an explanation. It’s like a doctor saying something like, “You have a problem with your heart.” It doesn’t explain the why, the how much, and the how of the problem.

Patient’s problems are rarely only in their own minds. Most of the time they are compounded by family reactions, other health care concerns, relationships with agencies and institutions, economics, social stigma, cultural and religious meanings of the problem, etc. Neurophysiological factors–the health of their brains–also are to be considered. Indeed, systems theorists would question the practice of locating the problem “in” the “identified patient.”

Therapists should be able to develop a coherent explanation for much (not necessarily all) of what is going on with most patients after several sessions. (There remain a small percentage that are diagnostic mysteries, and if things are at all unclear, please! ask for a consultation with an experienced colleague who seems to be astute in the realm of diagnosis! Don’t wait for ten sessions–you might be missing a subtle neurological or medical condition that could be remedied!)

The first group of sessions should be aimed in part at evaluating the problem, clarifying its nature, making a “diagnosis”– not just in the sense of finding a “name” for the problem according to the official psychiatric Diagnostic and Statistical Manual (the DSM-4); but rather in the original sense of the term, derived from the ancient Greek, “to know-through.”

So, case formulation is the psychodynamic equivalent of a physician understanding the pathophysiology of a patient’s medical problem. Formulating a case means constructing a meaningful story, that is, placing the patient’s present illness within the context of his or her life. Formulation is also the foundation for rational treatment planning and as such constitutes the key process in clinical practice! All diagnostic inquiries, examinations, and tests are oriented towards this end.

An approach to preparing a formulation is to imagine that you were consulting on a case with a colleague or supervisor, and they asked, “What do you think is going on with this patient?” Then exercise your imagination further by considering what you’d say as you attempted to explain your understanding to the patient and his or her family, or to communicate succinctly to the therapist who will be taking over the case.  (A good formulation should be a kind of story, weaving together many threads, and ideally should take at least twenty minutes to present. If you can encapsulate the person’s story in less than five minutes, the chances are that your understanding is still too sketchy and over-simplified, if not just partial or even mistaken!)

Because psychiatric patients suffer from as diverse a range of psychosocial problems as there are different kinds of medical problems, there is no single formula for describing the relevant dynamics in every case. For example, the organization of a formulation would depend on whether the patient is suffering from chronic or acute symptoms, or both. Similarly, is the patient involved in complex family interactions or do the symptoms seem to be confined primarily only to the individual? Are there significant associated medical conditions or dysfunctions at the level of cortical neurotransmitters? Are the stressors obvious and significant or minimal and elusive? Thus, you’ll need to tailor your formulation to fit the relevant themes in the case.

Don’t be lulled into complacency by your ability to categorize the patient’s symptoms and signs in according to the American Psychiatric Association’s DSM-4. Such “diagnoses,” in fact are little more than a exercises in nosology. Such a “diagnosis” only assigns a general category of phenomena and tells us relatively little about the “why,” the dynamics of the individual person behind the “label.” Each case of anxiety disorder or schizophrenia is unique.

Formulation is Not a Case Summary

Case formulation is the next step past case presentation (see the paper on this website about the art of preparing a case presentation.) Formulating a case involves making appropriate inferences about a person’s problem in light of an understanding of the nature of normal and pathological development. Drawing inferences and constructing a story goes beyond a mere summary of the relevant facts of a case and addresses a higher level of abstraction. This point should be emphasized, because many professionals jumble bits of summary in with formulation, and this habit results in muddled thinking.

A summary should include the distilled elements of the history, physical and mental status examination, relevant tests, etc. These should be distilled down into the key positives and negatives sufficient to make a descriptive diagnosis. A formulation then draws those facts into a meaningful pattern. Admittedly, there’s a knack to this skill, and it develops with practice and clinical experience.

Systems of Organizing a Formulation

There are a number of systems for addressing the many facets of a case.

1. What are the relevant factors at the different levels of psychosocial organization–i.e., somatic, intrapsychic, family, social network, culture, etc.?
2. What are the current roles and role strains, conflicts,
3. imbalances, or deficiencies?
4. What are the stressors and precipitants in a case?
5. What are the psychodynamic issues?
6. What is the status of the relevant prognostic variables?
7. How can the case formulation be further summarized,
8. considering the different types of causation?

Some of these will be considered in the following section, and some aspects will be elaborated in appendices to this article.

Levels of Organization of Psycho-social Pathology

To begin with, a formulation must be comprehensive, meaning that it should address the person in his or her life space as a holistic system. This means that all levels of organization need to be considered.

In medicine, physiological events occur on many levels: • atomic • molecular • sub-cellular • cellular • tissue • organ • organ system • organism-as-a-whole

In psychiatry, psychosocial events occur also at the following levels: • psycho-somatic • intra-psychic • interpersonal • family • small group • organizational • cultural • species and ecosystem

An adequate formulation should describe the dynamics at least three of these levels. A better formulation addresses even more.These levels are considered in greater detail in Appendix A.

Current Roles & Role Strains

There are two useful strategies for a practical, quick assessment: (1) clarify the client’s relevant social network; and (2) elucidate the client’s major life roles. These latter in general can be classified as:

• romantic (dating, marital)
• vocational
• economic
• nuclear family
• extended family
• avocational (social-recreational)
• religious (philosophical-spiritual)

The social network can actually be diagrammed, with the client at the center, and figures for others placed around according to how close is the relationship. Each person is noted, along with how the client feels about that person, and in turn how the client perceives or believes the other person feels toward the client.

Inquiry into the client’s relationships and life roles is often experienced by clients as far more reasonable and understandable than many of the often seemingly irrelevant questions posed by therapists in formal mental status interviews– or as asked on such off-putting tests as the MMPI. Thus, this approach leads to a strengthened rather than weakened treatment alliance.

Another variable that needs to be considered early on is the client’s history of experiences with previous helpers, especially those in the medical or psychotherapeutic professions. Have these experiences been felt to be helpful, time-wasting, or outright harmful? (Unfortunately, the latter is not infrequently so.) It helps near the outset of working with clients to clarify objections to previous treatment efforts and renegotiating the helping relationship so that these criticisms are explicitly addressed.

We clinicians should also weave this survey into our formulations. The present state of social integration or alienation; the present state of morale related to primary life role categories; these are often more crucial in both really understanding the client than any elaborate understanding of the early life dynamics.

Regarding the issue of current vs past stresses: One aspect of both the behaviorist and psychoanalytic traditions is a tendency to analyze a problem primarily in terms of the past. However, it’s my impression that most (more than half) of our clients are affected as much if not more by relatively realistic present stresses and future concerns! And treatment plans which underestimates these and overemphasizes the past not infrequently cause patients to become disoriented, confused, mystified, disempowered, and/or resentful that obvious issues are being ignored in the pursuit of “causes” in early childhood.

Of course, the main issues in some patients and situations are obviously to be found in the past; and in most cases some of the relevant contributing factors are similarly located. However, before pursuing such a developmental approach, it is best to assess the present situation.

Stressors and Precipitants

A story of a problem has two parts: Events leading up to the crisis–the “stressors,” and events that finally “push it over the edge”–the “precipitants.”

The stressors may arise from many sources– all the aforementioned levels of organization may be involved. For example, a man may have been losing sleep (psycho-somatic), having family and job problems, becoming more isolated at work and in the community, and then becomes caught up in some political ideology and cultish subgroup. All these events may have played off of each other, and the precipitating event could then occur also at any level, perhaps an opportunity to join in a terrorist act or an episode of family or work-related violence.

Add to these more current stressors the predispositions which carry over from the more distant past. Here is where the more psychoanalytically-oriented theories have more relevance.

What misunderstandings, distortions, residual currents of fear, shame, anger, excitement, and other emotions contaminate present  perceptions, cognitions, and behavioral reaction patterns? What deficiencies in modeling, support, or opportunities for corrective re-balancing have left the patient lacking in having the flexibility to react in more adaptive ways?

What are the patient’s significant stressors and why do they cause the patient to react in a dysfunctional fashion? Equally important, what other weaknesses and strengths in the patient’s life must be taken into account in order to design a comprehensive and appropriate treatment plan?

The key to formulation is to aim at what isn’t obvious, to address the more subtle implications. For example, in a patient suffering from an “Adjustment Disorder” in the face of the obvious stress of the death of a significant other, the question to be raised is why the patient isn’t coping. Certainly such an individual would be symptomatic, but only with the symptoms of normal grief. The elaboration of such symptoms into depression or some maladaptive behavior requires complicating factors. This is the equivalent to asking in the case of a simple wound why it isn’t healing normally. In the case of a wound, there are usually three factors: infection due to foreign bodies in the wound, a lack of apposition of the edges of the wound, or poor blood supply or nutrition. In the same sense, what is lacking in a psychopathological disorder? Does the person isolate himself? Is there a lack of certain basic coping skills? Are there “contaminating” tendencies towards irrational guilt or shame due to past experiences or artificial cultural norms?

In some cases, the major stresses and perpetuating factors are fairly obvious, often even to the patient himself. In other cases, patients don’t know why they are experiencing psychiatric symptoms, and often the reasons aren’t that apparent to their therapists. Then there are those who don’t even think they have a problem but are so identified by their family or others in their social network. Even when the stresses are obvious, though, there remains the more subtle questions, why this patient and not another? Why now? Under what circumstances would this not have happened?

Psychodynamic Issues

Psychodynamics may be simply defined as the interactions among the various parts of the mind/body. These are often problematic due to conflict, ambiguity, distortion, and habits of suppression, compartmentalization, and illusion. Here are some psychodynamic themes to consider in constructing a formulation:
1. What are the patient’s goals? These may be known to the
patient or unconscious. There are usually a number of them:
a. How is the patient believing they can escape or avoid
certain awarenesses or life challenges?
(1) Which “defense mechanisms,” modes of self-
deception, or adaptive strategies are they using?

(Note: Learn the defense mechanisms! Learn them well! Be able to imagine examples of how they are used. Noting several of the predominant defenses used by the patient is often the core of the formulation.)

b. What illusions are secretly maintained in order to
support a sense of self as adequate, integrated,
consistent, strong, etc.?
(e.g., revenge, self as martyr, etc.)

c. What conflicts are going on between…
(1) different incompatible goals
(2) different parts of the self, different roles
(3) oneself and others in the social situation

2. What key skills or experiences are lacking?
a. Is there any information needed? Never underestimate the impact of sheer ignorance. Many people don’t know that
certain strategies or life-affirming activities even exist or are accessible to them.

b. As a corollary of the above, what ordinarily expectable learning or socializing experiences have been missed in the
course of the patient’s development? Targeting these can serve as important elements in the treatment planning.

c. What previous experiences of coping are available for a transfer of learning? Often patients have areas of
competence which may be utilized in developing new skills

d. Are there interferences from previous unhappy “helping” experiences, from previous therapists or other caretakers
which lead to resistances to therapy?

Important Prognostic Variables

Whatever the diagnosis, I’ve found that the most important variables involve four areas:

1. How “voluntary” is the patient, to the setting, to the therapist, to the procedures?
2. What degree of psychological mindedness does the patient posess–can s/he at all reflect on the workings of his or her own mind and the impact of behavior on others?
3. What is the patient’s ego strength?
4. What social and economic resources are available for supporting the patient’s rehabilitation?

These are discussed more fully on another paper on this website, “The Real Diagnostic Variables”

Types of Causation

Another way to think about the various sources of your patient’s problem, the different etiologies, might be in terms of categories first noted by the ancient Greek philosopher, Aristotle, who described four kinds of causation: Material, Efficient, Formal, and Final (Ettin, 1992). Applied to psychiatric case formulation, this categorization asks the following questions:

• Material: Identify all components, in terms of the various levels mentioned above. Is the patient’s body a factor? If there are intrapsychic elements, what are they?
• Efficient: What is the “energy” (motivational) source? Pressure from others? A desire to do well? A desire to avoid feelings and challenges?
• Formal: What is the “blueprint,” the strategy? Which cognitions, beliefs, and more, the linkages, the “if…then…” ideas drive the patterns?
• Final: What is the goal? Whose goals are being considered? What are some of the more subtle pay-offs? People are teleological in their functioning, as Alfred Adler pointed out. They think in terms of the future, in terms of anticipated rewards or feared consequences, even if these are largely illusory or merely fantasy.

Learning the Art of Case Formulation

For those who are building the skill, here are some suggestions which you might find helpful. As you begin to practice, let your goal be just a partial formulation, addressing only a few themes–enough, say, to fill about two or three paragraphs. Discuss these with supervisors or colleagues and take notes as you ask them to draw you out regarding other aspects of the case.

As you become a bit more adept at this skill, after doing about ten brief formulations, push yourself to write out at least two pages of formulation. Let this also serve as a complement to a case summary as you transfer off of a service or refer a patient on to another care provider. Imagine that you’re writing for a person who really needs to know what’s been happening; and further, imagine what you would like to know if you were receiving the case as a referral. Keep in mind that what you are describing should lead to treatment strategies.

Another approach is to work backward from what you have discovered has been most helpful, or what your intuition suggests what probably would be most useful. Then work backwards to check if those intuitions have any basis in the patient’s realistic situation. Making these dynamics explicit becomes part of the formulation.

A variation of this is to consider, as you take or review the history, how the story might be different. What if, say, a father had been present? Or a therapist earlier in life? What experiences might have made a difference? How is it that some people come through what this patient lived through, yet they have adapted? By making explicit those countervailing experiences, you can more clearly define the kinds of deficiencies that make all the difference.

The best way to learn the art of case formulation is to practice it as a skill, like playing a musical instrument. You need to push yourself to do it repeatedly, get feedback, and then use the feedback to refine your performance. It’s too easy to do a half-hearted job.

A socio-political digression. I’m sad to say that it’s possible to work within many psychiatric contexts and there’s no real requirement for much more than a general summary and a simple DSM-4 diagnosis. Although this may be the minimum requirement of the administrative system, it is really insufficient for delivering high quality care. I think the ideal of being a professional rather than a mere technician is that the professional goes beyond the ordinary requirements of a job to advance their own skills, the state of the art, and the needs of the patient or client. True health care requires this kind of commitment.

A professional also cultivates humility, knows that there are skills that need to be developed and refined. Thus, give yourself permission to be a beginner in the skill of case formulation, to be imperfect. Begin with small formulations and occasionally push yourself for a more comprehensive review, perhaps for a case conference. Most psychotherapists cannot do this, but you can learn with a little practice. It’s not really harder than learning to do a trick of moderate difficulty on a skateboard, or to improve some other athletic or musical skill.

Again, keep your formulation free of details from the case summary. There should be no re-statement of the case in the formulation, only a shift to a more abstract level. Here is where you should draw inferences, nowhere else.

In summary, use these guidelines as an aid to constructing viable formulations. It’s a skill which requires practice and can only be learned through doing. Constructing a succinct and plausible case formulation is the one activity I know of which will impress your supervisors, patients, and colleagues more than a clear and organized case presentation (see my article regarding this), and that is making a clear formulation. Use these guidelines and practice, practice, practice.

References

Blatner, A. (1993). The art of case presentation. Resident & Staff Physician.

Ells, T. (1993). Integrative psychodynamic/cognitive case formulation. (Presentation, University of Louisville.)

Ettin, M. (1992). Foundations and applications of group psychotherapy. Boston: Allyn & Bacon. pp 316-339.

MacKinnon, R.A. & Yudofsky, S.C. (1986). DSM-III diagnosis and the psychodynamic case formulation. In The Psychiatric Evaluation in Clinical Practice. Philadelphia: Lippincott.

Perry, S., Cooper, A.M. & Michels, R. (May, 1987). The psychodynamic formulation: Its purpose, structure, and clinical application. Am. J. Psychiatry, 144(5), 543-550.

Schwab, J.J. (? date). Case Formulation. Unpublished paper. University of Louisville.

Weisman, A.D. (1959). Psychodynamic formulation of conflict. Archives of General Psychiatry, 1: 288.

---

APPENDIX A:LEVELS OF PSYCHOSOCIAL ORGANIZATION

1. Somatopsychic:

a. What “constitutional” elements are relevant? Does the patient have an unusual sensitivity or, on the other hand, a relative lack of sensitivity (a kind of interpersonal or intra-psychic “denseness”)? Ther may be tendencies towards Tourette’s Syndrome, depression, mania, obsessive-compulsive disorder, schizophrenia, and many other disorders are now recognized as genetically influenced, and the presence of relevant family history or clues to tendencies from birth are appropriate.

b. It is becoming apparent that traumatic early experiences shift the actual neurophysiological functioning of an individual, and levels of arousal, irritability, and such may be also determined in part by altered somatic “thresholds.”

c. Temperament deserves to be noted as a significant determinant of behavior, of choice of symptom. There are many ways of describing temperament, and the question should be posed how the patient’s unique blend of temperamental inclinations have influenced his symptoms or dynamics.

d. There is an aspect of “learned” behavior operating on the somatopsychic level:

(1) Chronic bodily tension patterns are acquired in response to perceived threats. These fixate and perpetuate certain defensive attitudes. Fears, a readiness to shrink or attack, to evade or placate, resentments or sulks, tension-relieving slouching or life-avoiding neurasthenia, these and many other tendencies should be noted.

(2) Culturally acquired patterns of eating, excreting, bathing, and other psycho-somatic interactions are sometimes relevant in the etiology of certain complaints. I’ve seen a book on different sleep positions. The fear of using a toilet with others around is not uncommon.

This somatopsychic level not only includes basic neurophysiology, but also some other more subtle qualities:

(3) Ability: What talents or weaknesses are “constitutional”? In which general areas does the patient have the greatest intelligence? Are there any learning disabilities in a broader sense of the idea, such as gross or fine motor clumsiness or an impaired capacity for language or social sensitivity, etc. (Sometimes these are subtle, and regarding the social dimension, an individual may suffer from being oversensitive as much as from not being sensitive enough.)

(4) Temperament: Are there any basic inclinations which help to determine the choice of symptom? Some people are more uncertain of their position, more “autoplastic” (“I’m not ok”); others tend towards complacency or arrogance, they are more “alloplastic” (“You’re not ok.”) The former tend to develop more anxiety-based problems while the latter tend to develop more narcissistic and disruptive disorders.

2. Intrapsychic: This is the most commonly addressed level of psychodynamic functioning. The issues of what goals, defenses, conflicts, and deficiencies mentioned in the earlier section are all relevant here. Note especially:

a. Conflicts: What “parts of the self” can be identified that may be in conflict with other “parts of the self.” Name the different roles and the reasons for the conflict.

b. “Defense mechanisms” are only the most obvious forms of self-deception which are part of a broader range of phenomena. What are some of the main ways that the person supports his or her position?

c. Deficiencies: What types of experience were missed? (See p.3) A good deal of psychopathology occurs in part because the individual has not built an “infrastructure” of other healthier skills, and the problem behavior is to some degree a way to fill in the “vacuum.”

d. Overlearned behavior: Addictions, fixations, and a variety of other behavior patterns have become excessively reinforced. Premature sexual overstimulation, food as love or stimulation, and the various sources of mild or major addictions have their own power to alter the ecology of the mind.

3. Interpersonal: What are the patient’s issues at this level?

a. Access to Others: Are there sufficient numbers of people in the patient’s social network to provide support? How available are they in terms of geography and time? Which social needs are not being met?

b.  Opportunities to interact in the area of one’s competence? (Some patients only seem to be able to interact in areas of mediocrity or even inadequacy in their school or work situations, and their areas of talent are unrecognized or not available for participation.) Has encouragement been available, or the chance to show one’s competence and get recognition?

c. Habitual patterns of relating to others are important to note: Tendencies towards being deferential, competitive, uncaring, indifferent, narcissitic, etc., all should be noted, and in addition, how successful the person has been at their strategy to engage or avoid others.
(1) Note the person’s role repertoire and levels of functioning in each role. Behavioral complexes at home may differ from those at school or work. Whole patterns of behavior may be quite different when the patient is with those with whom he feels safe, comfortable, valued. For example, some youngsters come alive with peers while others are stifled by classmates but relax around the grown-ups. Some people have a varied role repertoire and others seem to be the same in most situations.

In considering the interpersonal level of activity, the ideas of Harry Stack Sullivan or Eric Berne are more relevant. What kinds of manipulations, interactional “games” and learned behavioral patterns are part of the patient’s repertoire. Are there any people in the present (especially) or major figures in the past who entrained the patient with certain behaviors? Those who have been dominating, submissive, spoiling, critical, absent, volatile, confusing, or in other ways problematical often set up patterns of response which to some extent explain the patient’s present behavior. Describe these patterns.

4. Family and Small Group Dynamics: Interpersonal behaviors are complexified when there are two or more others involved. Triangulation, alliances, feeling “left out,” and patterns of getting attention or avoidance become more intricate.
a. What is the degree of cohesion in the person’s most personal social network? Do the people like each other? How much do they talk? Share? Recognize or react to each other?
b. Does the patient have certain roles in the family or group?
c. How did the person’s learning arise out of the various alliances in the nuclear family, and/or extended family? (Sometimes three or more generations of interactions are relevant.) Also, what present family dynamics are relevant.

5. Large Group or Organizational Dynamics: If the individual’s status in the class, tribe, neighborhood, workplace, peer group, extended family is disturbed, it can serve as a significant source of stress. In medicine, some “diseases” are caused by the sheer size and weight of a mass, whether it be a tumor pressing on an organ or a gross trauma from the outside. In the same sense, we must recognize the power of social forces in the etiology of psychiatric disorders.

At this level of the intermediate social network, the patient’s major group affiliations are assessed. Note the presence or absence of friends. What’s happening at school (for kids) or work (for adults)? We want more than merely a “history,” but rather an assessment of the adequacy of the opportunities for:
* self-expression–does the patient have a recognizable and rewarding role?
* learning new skills, even if only interpersonal
* learning wholesome skills with some possibilities for recognition, awards, elected position, etc.
* engaging in “role relief,” behaviors which balance the personality, so that if they’re in a negative, criticized, quarrelsome, or rebellious mode in some situations, do they have opportunities to feel like “winners” in other contexts? On the other hand, well-behaved, responsible people sometimes need to express their less responsible, silly, raucous, or outrageous feelings. And, most importantly:
* receiving recognition, positive “strokes,” feeling liked. Being in a congenial context is as important for psychic functioning as adequate nutrition is for physical functioning.

6. Subcultural Factors: The norms of people’s subculture, their beliefs, their values, their conflicts, and other general influences can become etiologic factors if:
a. The individual’s temperament, abilities, or inclinations cause frictions: Homosexuality, a woman wanting to do a “man’s” work, dyslexia, etc.
b. Changing values over time: What used to be an acceptable norm now becomes “old fashioned.”
c. Changing values as one moves from one cultural milieu to another. The kid from a middle-class neighborhood whose wage-earning parent becomes unemployed and as a result moves to a “rough” neighborhood may become “school phobic.”

Related to this, perhaps at a subcultural level, is a larger group dynamic. Who is this patient’s reference group? From who does s/he desire status recognition? All the kids at school, or at least those in the same grade? All the “cool” kids (“my friends”)? Others at the office or in the general profession? This larger group level represents the organizational dynamics of the school or workplace. Often there are problems of “fit.” Is the person well fitted for his or her role? Are the job/school requirements realistic? Are there particular people at one of these extended settings who are significant stressors?

7. More General Factors: Cultural, Historical, Political, Economic, and Ecological issues are occasionally but vividly relevant in the formulation of a case. Socio-economic class shifts and pressures, the impact of the mass media, the availability of drugs, worries about species survival, etc., have become significant factors, and not infrequently subconscious influences and stresses which need to be explicated in order to understand an individual’s overall sense of dysphoria or pattern of life-avoidance.

At this level of larger cultural factors we consider what this patient has been learning about life from the mass media and in the general neighborhood or region in which s/he lives. Even here there are levels of culture and subculture: Some people live in a world where education is devalued; others in a world where physical fights are the norm. There are subcultures in which drug use is common, and others where spiritual committment is a generally accepted value. There are generational and regional issues here. For example, we cannot assume that there is the kind of inhibition regarding teenage sexuality that there was a generation ago.

Nor should general economic and political realities be overlooked. Societal issues related to women, minorities, homosexuals, the disabled, those on welfare, and many other groups can serve as significant sources of stress.