PSYCHODYNAMIC FORMULATION

PRESENTED BY-Dr. KAMRAN CHISTY

MODERATOR-Mrs. REETI
 INTRODUCTION
• Formulation-is explanation or hypothesis.

• Case formulation-it’s an hypothesis that help us

to answer the questions about the way a patient
feels ,think and behaves.

• Psychodynamic formulation-its an hypothesis,

about the way a person thinks, feels and behaves,
which considers the impacts and the
development of unconscious thought and
feelings.
History of Psychodynamic formulation
• Psychodynamic formulation is at junction where
therapy, theory and science meet, but past had
few auspicious findings.
• Sietz 1966 started consensus for making dynamic
approach which ended without agreement.
• MALAN 1983 developed formulation method.
• 1987 after advent of DSM-3 multi axial system
the perceived the need of psychodynamic
-Psychotherapeutic treatment and
-Descriptive diagnoses.
 Methods
• The Core Conflictual Relationship Theme (CCRT)-
CCRT focuses on relationship patterns as the
central feature of individual dynamics and
transference in or out of the treatment situation.
• The Plan Diagnosis(PD)-focuses on dynamic
features related to transference, resistance and
insight in therapy.
• The Idiographic Conflict Formulation (ICF)-focuses
on stress and internal conflict, and the
individual's adaptation to them in or out of
treatment .
 Importance/uses.
• Make treatment recommendations and set goals
• Understand what patients need developmentally
• Develop therapeutic strategies and predict the
way patients will react in treatment(transference)
• Construct meaningful interventions
• Help our patients to create cohesive life
narratives
 How do We Construct
a Psychodynamic Formulation
• DESCRIBE the patient’s primary problems and
patterns
• REVIEW his/her developmental history
• LINK the problems and patterns to the history
using organizing ideas about development
 DESCRIBE the primary patterns and
problems
• Self-Everything we do in life, from having
relationships with others to choosing what we
do for work and play, relates to how we think
about ourselves – that is, to our self-
experience.
• Self-1.self perception
2.self esteem regulation.
 1.Self perception
• When we think about people’s self-perception
in a psychodynamic formulation, we have to
consider not only their demographics but also
their conscious and unconscious thoughts and
feelings about themselves.
• This includes their sense of
1.Identity - is our sense of who we are.
2.Fantasies about themselves-
 Identity description
Mr Nishad was good at physics at 12th
because of his good rank in entrance he
entered in M.B.B.S .Now he wanted to
combine his interest of physics with
current course and wants to take M.D
Radiology. He says he enjoyed his ug life
and marrying his batch mate once he
gets in P.G.
Mr Chisty was good at 12th because of his
parents wish entered M.B.B.S .Now he
wants to get into medicine but parents
want surgery. He recently had breakup
with ug mate who he wanted to get
married as he thinks she's is not
supportive.
 Fantasies about the self
• Fantasies about the self provide us with
comfort, goals, and escapes . They also help us
to move forward, strive, and achieve.
• For example- Mr Prateek imagines being
praised by a teacher for an assignment well
done, going on date with girl he likes, buying a
hybrid car and buying the newly launched
gadgets.
 Example
• A 22 year old medical intern Mr Nishad
presented to opd with symptoms of
depression. He felt depressed after 1 week of
marriage of his batch mates who were his
close friends. He say “my dress was better
than grooms dress". He also says that bride is
his very good friend and he use to spend a lot
of time during college days.
 Self-esteem regulation
• Esteem is respect or admiration.
• Self esteem is the respect or admiration we have
for ourselves.
• Self-esteem regulation- The ability to pick oneself
up after disappointments or slights
• And is an important part of how people function
in the world.
• Anything that imperils a person’s good feelings
about himself/herself is a self esteem threat (also
called a narcissistic injury).
 Following variables to describe
individual patterns of self-esteem
regulation:

• Vulnerability to self-esteem threat.

• Internal response to self-esteem threats.
• Use of others to help regulate self-esteem.
 Vulnerability to self-esteem threats
• Some people can maintain their positive self-
regard in the face of massive emotional
injuries, such as severe medical illness or job
loss, while others crumble if someone looks at
them the wrong way on the street.
• People who are very vulnerable to self-esteem
threats are sometimes said to have fragile
self-esteem
Mr Nishad 45 year old orthopedic Ms Nupur, a 25-year-old single obg-pg,
surgeon following accident was removed began to have some mild acne on her
of from a private nursing where he was face. As a result, she became distraught,
working as main consultant from 10 avoided social situations, and worried
years, he was almost 1 year on bed. constantly that she have to face difficulty
During recovery period he revised most in getting marry.
of his text books and applied for junior
resident job in a medical college .During
early days he felt bit sad about himself.
After promotion he says that now he
enjoys teaching and its satisfying to see
many new surgeons getting training
under him.
 Internal response to self-esteem
threats
• When people experience a threat to their sense of self,
they respond in a way that helps them to buoy their
self-esteem.
• This entire process may occur unconsciously.
• Two mechanisms-which develop in childhood an
coalesce fairly stable throuhout in adulthood.
1. Less adaptive patterns-are more brittle and often
jeopardize other functions and relationships.
2. More adaptive patterns-restore positive feelings
flexibly while maintaining other functions,such as
relationships with others
 Less adaptive patterns
A 25 year old Nupur is good looking lady
supported by parents wants to get into
movies. She believes people in movies
earn more money. although she has not
acted in any movie she says “she has
better dancer compare to other in film
industry” In addition, she says that she
has the name of a VIP in the TV industry
and she is sure it will ‘‘just take one
phone call.’’
A 25 year old Nishad whose is good
looking guy and his parents want him to
get in movies. He believes he wont be a
successful actor as he has no talents. He
downplays the fact that he has acted
only in school dramas. Now currently he
is taking acting classes recently he
submitted a video assignment to his
teacher, his teacher texted him that ,
‘‘video was Really good! Looking forward
to your next video,’’ which Mr Nishad
interpreted to message that the video
was terrible.
 More adaptive internal responses
Mr Pratheek is a star cricketer of his
college. Being a good player and good
human, people don’t like playing with
him as he score more and does not allow
other to take the strike even in casual
game.
Mr Chisty owns a catering company that
is doing very well. After becoming very
anxious while competing with colleagues
for ‘‘important events,’’ he now often
‘‘forgets’’ to get his bid in on time for big
jobs. He says, ‘‘I prefer to stay small,’’
although he sometimes tells his brother
that he wishes that he could make more
money.
 Use of others to help regulate self-
esteem
When Mr Nishad said to a patient ms Mr chisty always take suggestion from
Rani on follow-up that he will be not pratheek before taking any decision even
available for next 3 months. Ms Rani as simple as buying cloths
cried and said, ‘‘I can’t believe that
you’re going for three months.I am about
to face my board exam next month – it
will be the hardest time of the year for
me!’’

Mrs Rani displays a striking lack of empathy in thinking only of the way her therapist
Mr Nishad helps her to maintain her self-esteem.
Similarly, Mr Chisty sees his friend pratheek existing only to validate his own
experiences.
 Relationships
• Relationships are the interactions that we have with
people in our lives.
• Types-
• parent–child relationships of early childhood,
• The peer friendships of later childhood,
• The romantic and sexual
• Relationships of adulthood
• For most of us, relationships with family, friends,
significant others, and colleagues provide us with some
of the most rewarding experiences of our lives.
• Relationships can also be a source of frustration, pain,
and confusion.
 Variables for relationships
• Trust
• Sense of self and other
• Security
• Intimacy
• Mutuality
 Trust
• The ability to trust others is essential for having
meaningful, mutually satisfying relationships.
• Lack of trust leads to constant fear of aggression
from others, a sense of being neglected and
feeling of aloneness.
• Being overly trusting can be problematic, too –
the person who trusts everyone or who trusts
people he/she shouldn’t may also have
difficulties with trust.
• But having at least one or two people who you
really trust is vital for adaptive functioning.
 Case scenario
After working for 10 years mr Chisty was Mr Asish runs a small caterer business
thrown out of the company. although hes and want it to hand over his busness to
married he feels that “his wife spends his son.whom he belives he trained
most of the time with her family”. He no enough under him to maintain his
longer speaks to most of his friends and business and he believes that his son will
acquaintances because, ‘‘they all just look after him in the way he cared him. .’’
want money from you in the end.’’ When Asish has friend Ramesh a close friend
his therapist suggests that he is with whom he has shared his wishes.
depressed and could benefit from
medication and therapy, he says, ‘‘Yeah,
how much did the drug companies pay
you to say that?’’
s
 Sense of self and other
• Being able to think about oneself and others
in a three-dimensional way is critical to having
healthy relationships.
1 Both bad and good qualities
2 separate and unique feelings, beliefs, needs,
or motivations
3 Generally consistent feelings about self and
others from past to present
 Case scenarios
Mr Chisty says that his boss is a ‘‘selfish’’
who only cares about his own
promotion. He ‘‘loved’’ him when he was
recruited. Chisty’s boss did not trained
him properly and never guided him.
When Mr Chisty’s bonus was cut even
after achieving target, he tried calling
and demanding his bonus, despite the
fact that his boss supervises over 50
people. When boss explained that
everyone in the department had to take
a bonus cut for not achieving target, Mr
Chisty vilified his boss for being weak
and considered quitting.
Mr Nishad thinks that his boss is smart
and creative but a bit passive. When he
didn’t get the bonus he thought he
deserved, he made an appointment to
discuss this with boss. Nishads boss
explained that the department had not
done well . Mr Nishad was disappointed,
and even wondered if perhaps his boss
had not made ‘‘enough of a case’’ for him
with the ‘‘higher-ups,’’ but also
understood the pressure on him. He
generally works well with his boss and
likes his candor and collegiality but is
sometimes frustrated by his less
aggressive nature.
 Security
• security refers to the state of being safe;
security in a relationship refers feeling safe
with another person.
• This means being able to feel that the
relationship will persist even if there are-
- physical separations
- disagreements
- other negative feelings
 Case scenario
Mr Ramesh, a 28-year-old post graduate
student who cannot finish his thesis,
recently breakup with her girlfriend after
he thought she flirted with his best friend
at a party. SHe denies his charge and says
that he has often noticed flirting with
other girls. He’s is angry and refuses to
see either his girlfriend or his best friend.
he tells you that he met a new girl a
week ago and says, ‘‘I think I’m in love,
she’s perfect!’’ and planning to get
engaged after exams.
Mr Asish is a 28 year-old post graduate
student who is about to finish his thesis.
he lives with his girlfreind of 2 years;
they’ve talked about getting married
after he settles into his new job in a year
or so. Asishs girlfriends closest friend is a
male colleague. While Asish was mildly
anxious about this at first, he has now
formed a close friendship with that guy.
he occasionally jokes about how silly he
was to be worried.
 Intimacy
• Intimacy refers to closeness and familiarity.
• People are intimate with one another if they
share things about themselves, such as feelings,
experiences, wishes, and disappointments.
• example
• Mr Ramesh, a 30-year-old man, meets a woman
at a bar and tells her the story of his last three
relationships before the second drink.
• Mr suresh, a 34-year-old man, lived with his
girlfriend for 3 years before he shared with her
that he had a schizophrenic brother
 Mutuality
• Relationships are mutual when both people involved
are able to give and take.
• Consider these situations: Nishad and chisty are both
friends, Nishad is one person who constantly talks
about himself while the chisty always listens.
• This situation feels unfair, because it seems as if one
person is doing all the giving, while the other does all
the taking.
• The takers have a limited capacity for empathy and
thus do not consider the needs of others. Without this,
relationships are unbalanced and lack mutuality
Variability in relationship patterns
• people may have strengths in some aspects of
their relationships while having difficulty in
others.
• For example, a person may be able to be
emotionally intimate with friends but not with
romantic partners. Another person might have a
very secure relationship with his/her partner but
lack sexual intimacy.
• variability in relationship patterns is essential for
understanding this critical area of functioning.
 Adapting
• Adapting means adjusting.
• Internal stimulation includes
• thoughts and fantasies
• feelings and anxiety
• pain and other physical sensations
• External stimulation includes
• relationships with others
• economic and work-related pressures
• trauma and other environmental events
 Variables for describing patterns of
adapting

• Defenses-1.more adaptive
2.less adaptive
• Managing emotion
• Impulse control
• Stimulus regulation
 Cognition
• Cogito ergo sum – Descartes famously
asserted that the fact that we think is
evidence of our existence.
• The way we think is reflected in almost
everything that we do, including problem
solving, organizing our thoughts,remembering
things, and focusing our attention.
 Variables for describing cognition
• General cognitive abilities- individuals will affect
their functioning in every other area – the way
they think about themselves, their relationships
with others, how they adapt to stress, and their
work and play.
• Decision making and problem solving -People
make decisions and solve problems in very
different ways.
• Ability to organize thinking, plan ahead, and think
creatively.
• Self-reflection and reality testing-is the capacity
to examine one’s own thoughts and behaviors.
• Reality testing-ability to differentiate reality from
fantasy.
• Mentalization- is the capacity to understand that
other people have thoughts and feelings that are
different from one’s own. The ability to
• mentalization is central to the ability to
empathize with others. This describes its
importance for understanding cognitive function.
• Judgment-it’s the capacity to consider the
consequences of behavior.
• superego function- In psychodynamic terms,
the capacity to know right from wrong is part .
 Work and Play Key
• Work- work as ‘‘physical or mental effort
exerted to do or make something; purposeful
activity.
• Play-everyone has a different way of Relaxing
on a beach, watching TV, reading fiction,
socializing, throwing a football, traveling,
cooking.
 Variables Work and Play Key
• Well matched to developmental
level/talents/limitations
• Comfortable/satisfying/pleasurable
• Adequate for care of self and dependents
• Culturally sanctioned
 Case scenario
• A 42 years old male patient who’s single ,currently not
working presented to OPD with complaints of RTA following
alcohol intake and sad mood with death wishes. He started
alcohol consumption 27 years back following his mothers
separation from his father. He left studies at that time and
started working , he shifted to many places and changed
many jobs as he could not bear any one criticizing him and
most of the times his employer cheated him especially in the
last ashram where they said they will get him marry. He has
disturbed interpersonal relationship with younger brother
following some business partnership in past and attempted
suicide for the same reason by jumping in front of truck. He
says“’he has worked hard for many years early in frpm early
in morning to late in night still he could not save any money
and has no home , feel ashamed of his alcohol habit”.
 Describe patient problems
• Problem- alcohol intake, sadness, loss of interest in
work, disturb interpersonal relation ship.
• Self-
• Identity- not fully established as he don’t know what
kind of job he likes. He wants to earn money. Not sure
what kind of job he wants.
• Fantasies about himself- he wants to build home and
wants to get marry.
• Vulnerable to self esteem- threats he thinks he may
get cheated in future to.
• Internal response to self-esteem threats- less adaptive
he could not bear criticism and changes jobs.
• Relationships-difficulty in establishing and
maintaining.
• Trust is lacking as he was constantly got
cheated from his mother to his employers.
• Sense of self and other- he hardly has any
friends and has no one as bystander.
Intimacy and mutuality is lacking as there are
no visitors in ward and no bystander.
• Adaptability- when ever he sad he just take
alcohol he could not manage stress. when
someone criticizes at job he changes it less
flexible and has poor impulse control .
• Cognition-as he worked as waiter for almost
27 years defines he has strong general
cognitive functions.He again want to rejoin s
waiter which says he has good sense of self
relflection as he knows his talent and
limitations.Now he want to quit alchol as
people are not respect if he drink alcohol
shows he has sense of mutuality.
• Work and leisure-His work is consonant with
his talents and training and gives him
satisfaction. He is able to support himself. His
worry about
• His idea of rejoining as waiter suggest he is
not able to enjoy activities outside of work .
• But taking alcohol for drinking for relaxing in
leisure time is not culturally acceptable.
 Reviewing of developmental history
• Genetics and heredity-
• Psychiatric disorders-father ,mother and
brother has history suggestive of ads.
Maternal habits-mother alcoholic.
• Maternal physical and emotional health-as
she eloped with another person history
suggestive of marital discord, depression and
domestic violence.
Taking a developmental history of the
earliest years
Taking a developmental history of the earliest
years involves learning about the
• Environment into which the child was born
• Characteristics of the primary caregivers
• Quality of early relationships with primary
caregivers
• History of separations and trauma
 Developmental history
• Genetics and prenatal development-he is born
to married couple belonging to low socio
economical status. History suggestive of Alcohol
dependence in parents and domestic violence in
mother.
• Early environment-very poor family stayed in hut.
Quality of the early relationships with the
primary caregivers-poor as he father was not so
caring and mother as young kids
 Earliest years (birth to age 3)
• Patient shared warmth relationship with his
mother, how ever his relationship father is not
clear. He has good relationship with elder
sister. He could describe some good old
memories of his grandmother.
 Middle Childhood(3-6 years)
• He joined school around four years,he was
afraid of teachers and he reports he
remembers he use to get afraid of his father
when he use to see him beating his mother
during evening times.he has seen his mother
crying and screaming.
 Later Childhood
(6-12years)
• He had many friends, he was poor in studies
and use play a lot. He use to bunk school and
use to go to get tamarind or any other berries
by bunking class.he grown his hairs very long
by watching movies even after getting
punishment he and his friends refused to cut
his hairs.
 Adolescence (age 13–18)
patient saw is mother leaving him and his
siblings and eloping with a man of other
community.his father fought many with his
mother and her partner to get her back afeter
som days they left mangalore.patient and his
elder sister was adopted by relative and took
them to chennai where he worked as
carpenter and his sister worked as housemaid.
.
 Later adulthood (age 23 to present)
• At the age of 26 years he came back to
Mangalore he joined ashram as ther was a
deal they will get him marry which dint
happened till 7 years of working in ashram he
lost his interest in work and later he joined his
brother caterer business there also he had
problem with his bother following which he
attempted suicide.
 Linking
• Trauma
• Early cognitive and emotional difficulties
• Conflict and defense
• Relationships with others
• The development of the self
• Early attachment patterns
• Trauma-seperation of mother sadness
• alcohol intake.
• early cognitive and emotional difficulties-
He has good cognition-continued doing work-
poor impulse control-anxiety-drinking.
• conflict and defense- Less adaptive patterns-
he left jobs frequently and lack trust-chronic
mood disorer.
• Relationships with others-poor interpersonal
relationship-poor trust-no intimacy-no
mutuality-chronic mood disorder.
• The development of the self-poor.
• Early attachment patterns- poor.
 Linking guides treatment
• If we link adult problems to early trauma, we need to help our
patients understand their traumatic experiences and repair
disrupted development.
• If we link problems to unconscious conflicts and defenses, we need
to help our patients develop more adaptive ways of dealing with
them.
• If we link problems to relationships with others, we need to help
our patients develop new relationship templates.
Our formulations guide our goals for treatment, the way we listen
to our patients, and the way we choose our interventions .
• We can help our patients by
• (1) making them aware of a problematic aspect of their
development or function and
(2) helping them to develop new, healthier function.
 New elements to be incorporated
• Temperament-helps to find out determinants
of behaviour and experience.
• Importance of Hereditable components-
genetics studies identified hereditable factors
for personality.
• Better classification and identification of
childhood pathology.
• The impact of subsyndromal illness has not
well studied.
• Inculsions of other models out of
psychoanalytic tradition.
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