PGH Psychodynamic Formulation

Dr. Cesar A.
Alfonso
Associate Professor of Psychiatry,
Columbia University Medical Center
Training & Supervising Analyst & Adjunct Faculty,
New York Medical College Psychoanalytic Institute
Fellow of American Academy of Psychodynamic
Psychiatry & Psychoanalysis
Chair of Psychotherapy Section, World Psychiatric
Association
Dr. Alma L. Jimenez
University of the Philippines College of Medicine
Member of Psychotherapy Section, World
Psychiatric Association
Dr. Anselmo T. Tronco
Chair, Department of Psychiatry & Behavioral
Medicine, Philippine General Hospital
Dr. Constantine D. Della
Member of Psychotherapy Section, World
Psychiatric Association
Dr. Michael P. Sionzon
Training Director, Department of Psychiatry &
Behavioral Medicine, Philippine General Hospital
DEPARTMENT OF PSYCHIATRY & BEHAVIORAL MEDICINE
COLLEGE OF MEDICINE & PHILIPPINE GENERAL HOSPITAL
UNIVERSITY OF THE PHILIPPINES - MANILA
14th POST-GRADUATE COURSE

and
2 BALATAZAR V. REYES, Jr. PSYCHIATRIC LECTURE SERIES
nd
UTILIZING the PSYCHODYNAMIC FORMULATION to

OPTIMIZE THERAPEUTIC OUTCOMES
OBJECTIVES of the COURSE
Discuss the process of making

1 a psychodynamic formulation
Explain how to apply the

psychodynamic formulation in the
2 management of mental health
conditions & mental illness
WHAT is a PSYCHODYNAMIC
FORMULATION & WHY is it
IMPORTANT?
Constantine D. Della, M.D.
DEFINITION of TERMS
CASE PSYCHODYNAMIC
FORMULATION FORMULATION FORMULATION
• Hypothesis about
Explanation Hypothesis the way a person
or that explains thinks, feels, &

behaves in relation
the way a
hypothesis to UNCONSCIOUS
thoughts & feelings
person thinks, • Impact of heredity
feels, & & environment on
• May change over
behaves time
Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

HOW DO WE USE THE
PSYCHODYNAMIC
FORMULATION?
• A map that guides the treatment process
• Make treatment recommendations & set goals
• Understand what patients need developmentally
• Develop strategies & predict transference
• Construct meaningful interventions
• Help patients create cohesive life narratives
• May or may not be shared with the patient

HOW DO WE CONSTRUCT the
PSYCHODYNAMIC
FORMULATION?
DESCRIBE the patient’s problems
& underlying issues
REVIEW the patient’s
developmental history
LINK the patient’s problems & issues
with the developmental history
TODAY’S ACTIVITIES
•Didactic lectures
•Video presentations
•Small group discussions
TODAY’S LECTURES
1 2 3 4
Des- Revie- Linking Psycho-
cribing wing the the dynamic
the person’s person’s formu-
problems lation in
person’s develop- & issues relation
problems mental with the to clinical
& under- history develop- care
lying mental
issues history
CHANGES in the SCHEDULE
TIME ACTIVITY
9:30 A.M. Video 1: Patty’s Problems & Patterns
9:50 A.M. Lecture 1: The Person’s Problems & Underlying Issues
10:20 A.M. Break
10:35 A.M. Video 2: Patty’s Past
10:55 A.M. Lecture 2: The Person’s Developmental History
11:35 A.M. Break
Presentation of Outputs: Describing Patty’s Problems & Patterns;
11:45 A.M.
Patty’s Developmental History
12:05 P.M. LUNCH BREAK
CHANGES in the SCHEDULE
TIME ACTIVITY
Lecture 3: Links Between the Person’s Problems & Issues with the
1:05 P.M.
Developmental History
1:45 P.M. Break
Presentation of Outputs: Focused Description of Patty’s Problems &
1:55 P.M. Patterns; Focused Review of Patty’s Developmental History; Linking
Patty’s Problems & Patterns with her Developmental History
2:15 P.M. Feedback from Faculty
2:35 P.M. Break
Lecture 4: Utilizing Patty’s Psychodynamic Formulation for her
2:50 P.M.
Clinical Care
3:15 P.M. Open Forum
3:40 P.M. Summary & Closing
THE VIDEO
• Dramatized scene adapted from a real case
• The role of the patient (Patty) is enacted by an
actor
• First consult
• Processed for the purpose of the course
• 2 parts
• Patient’s problem
• Developmental history
THE WORKBOOK
•Guide to create the psychodynamic
formulation of Patty
•Individually, fill in the blanks/tables
as each of the lecturers go through
their presentations
•Breaks will be used
•2 selected groups will present
group outputs in plenary
THE EVALUATION FORMS
•Please accomplish
•Submit to the secretariat at the end
of the course in order to obtain your
certificate of attendance
THE SURVEY FORM
• Part of a study on the practice of

psychodynamic psychotherapy in the
Philippines
• Voluntary
• Collected before the lectures begin
Enjoy the
workshop!
Case Summary
Patty is a twenty-one-
year-old Grade 1 English
teacher who came in with
a chief complaint of
“sobra akong
kinakabahan at naiisip
kong saktan ang aking
Patty says that this
anxiety—which started
after a brief affair with
her college professor that
she initiated to improve
her grades—worsened in
the last six months,
As she recounts, this
present episode was
triggered by a
confrontation at a parent-
teacher conference
regarding her
effectiveness at her job.
Video 1: Patty’s Problems and

Patterns
Psychodynamic Formulation
The Problem with Patty

“Who is Patty?”
Anselmo T. Tronco, MD, FPPA
Objectives
• To discuss the theory in describing the problem for
consult as applied to the case of Patty
• To discuss the theoretical framework that guides
the psychodynamically-informed psychiatrist in
understanding the person that comes for consult as
applied to the case of Patty
The Artist the Healer
Old paint on canvass, when they fade,

A shipwreck gives way to a ship with its
sails unfurled
a raging sea is painted over by a calm
bay,
And underneath a dark ominous sky
Is a clear blue horizon.
It is as if the painter changed his mind or,

Is it, as in life, what was in the mind and
heart of the painter
At that very moment shaped the image,
the experience?
The reason why the patient
comes
PROBLEM
Present concern that needs to
be addressed
Patty has uncontrollable

thought of hurting her mother;
scared that she will be crazy
because of this.
Describing the Problem and the Person
An Integrative Map
Describing the Person: The Self
• Self-perception
• Conscious and unconscious
feelings of self
• Identity: sense of who we are
• Fantasies about the self:
accurate attunement of talents
and limitations with fantasies
• Self-esteem regulation
• Vulnerability to self-esteem threats
• Internal response to self-esteem
threats
• Use of others to regulate self-esteem
• Self-esteem
• Respect or admiration we have of
ourselves
• Self-esteem threat
• Anything that imperils a person’s
good feelings about himself or
herself
Relationships: Variables that Describe
Relationship Patterns
• Trust
• Sense of self and others
• Security
• Intimacy
• Mutuality
Trust
• Essential for having
meaningful, mutually
satisfying relationships
• Lack of trust leads to
constant fear of aggression
from others, a sense of
being neglected, perennial
feelings of aloneness
Sense of Self and Others
• Capacity to see oneself and others in a three-
dimensional way, i.e., self and others have:
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
Security
• Feeling safe with another person, that the
relationship will persist even if there is
• Physical separation
• Disagreements
• Other negative feelings
• A secure attachment is characterized by
• Tolerance of ambivalent feelings about other people
• A variety of long-lasting relationships
• Form relationships more slowly
Intimacy
• Closeness, where there is sharing of things about
themselves such as feelings, experiences, wishes,
and disappointments
Mutuality
• Relationships are mutual when both people
involved are able to give and take
Adapting: Adjusting to Internal and External
Stimulation
• Ways of adapting to
1. Defense mechanisms –
adaptive, flexible,
connected to thoughts and
feelings
2. Impulse control
3. Managing emotions
4. Sensory regulation
Impulse Control
• Capacity to delay gratification
Cognition: General Clusters of Executive
Function
1. General cognitive abilities –
intelligence, memory,
attention, speech and
language
2. Decision-making and
problem-solving
3. Capacity for self-reflection
and reality-testing
4. Mentalization
5. Judgment
Mentalization
• Capacity to infer what the person is thinking and
feeling
Work & Play
• Work: physical or mental
effort exerted to do or
make something;
purposeful activity
• Play: people who know
how to play have healthier
emotional lives and age
more successfully
The artisan paints with uncertainty,

Unsteadfastly
With the teacher’s gentle presence, he still
paints and paints
Images spring from his mind and heart
With a teacher’s loving gaze,
The colors bring them to life
It is as if, the teacher connects and engages

Towards a sense of certainty of shapes and
colors
In art as in healing conversations,

The therapist loving respect helps the patient
Unfold his life story
Questions to ask to elicit
characteristics of areas of
function
Please refer to your workbook and fill them up as we proceed with the
questions
Questions to ask on Self
Self Perception Patty’s Case
Do you think that you have an accurate Patty does not know who
sense of your strengths and difficulties? she is. She says she is the
What do others say about that? Do they person whom her mother
tend to think that you can do more than you tells her to be.
think that you can?
Self Esteem Vulnerability Patty’s Case
Tell me about a time when you didn’t get Patty said that she feels
something you really wanted. How did it upset. She feels she
make you feel? deserves more because
she gives her best always
but people do not
recognize it.
Self Esteem Vulnerability Patty’s Case
All people have things that make them Patty feels bad when she is made to
feel less than good about themselves. feel that she is not good enough or not
What kind of things make you feel that validated and recognized
way?
Internal Responses to Self-esteem Patty’s Case
threats
Do you tend to feel that others around Patty said that she feels that she is
you are incompetent? better among other teachers.
Use of Others for Self-esteem Patty’s Case

Regulation
Do you know when you’ve done a good Patty needs praise from others but what
job without needing to hear praise from matters most to her is the validation and
others? praise from her mother
Questions to ask on relationship
On Trust Patty’s Case
Is there someone in the world whom Patty said yes

you really trust?
Whom do you trust most in your Patty trusted her boyfriend
life?
Do you think that person would help Patty believes that her boyfriend
you in an emergency? Do you think is the one who really cares for
that person really cares about you? her
On Sense of self and others Patty’s Case
Tell me about someone who is important to you. No data

What is he/she like?
How do you think that others see you? No data
On Security Patty’s Case
Do you have close friends? How Patty said she has no friends
many, and for how long? Do you
tend to stay in touch with old
friends?
Do you date (men, women, or Patty has a boyfriend but no
both)? If so, how long do your enough data on this
relationships generally last? Do you
tend to start relationships slowly or
quickly?
Do you tend to worry that the No data
people you feel close to will leave
you? Can other people soothe you
when you are upset?
Question on Intimacy Patty’s Case
Is there someone whom you feel Patty said she confides most of
you can tell almost anything? the time with her boyfriend.
Do you have sex as often as you’d Patty has sexual activities with
like to? How often? Are you her boyfriend but she describes
able/willing to initiate sex/to it as something she needs to do
respond when your partner even if she does not find
initiates it? pleasure in it.
Question on Mutuality Patty’s Case
Do you feel your Patty said that she does not want
partner/friend/parent gives you what to lose her boyfriend because he
you need? is her only confidant
Do you think your Although not verbalized, Patty
partner/friend/parent gets what gives her boyfriend sex in
he/she needs from you? exchange. And her mother, the
academic awards
Questions to ask on adaptation
Question to ask on defenses Patty’s Case
Do you feel you always react in the Patty says that she usually do
same way, or do you feel you have ritual activities such as cleaning
different strategies depending on to divert her attention
the circumstances?
Question to Ask on Impulse Patty’s Case
Control
Do you think that people would Patty says she is not a risk-taker.
describe you as a risk-taker? Do She worries a lot on what her
you ever feel that you’re too mother will tell her. Thus, she
impulsive? always seeks her opinion first
Question to Ask on Managing Patty’s Case
Emotion
What happens when you get angry Patty feels that she needs to do
or anxious? Can you ‘‘sit’’ with the something always
feeling or do you feel driven to do
something? If so, what?
Would people describe you as calm No data
and even-tempered? As volatile?
Question to Ask on Sensory Patty’s Case

Regulation
Do you think that you’re particularly No data
sensitive to things like loud noises or
smells?
Do you ever experience the No data
environment in ways that you think
that others don’t?
Questions to ask on Cognition
Question to Ask on Decision- Patty’s Case

Making, Problem-Solving, and
Judgment
Do you find it easy/hard to make Patty has a hard time making
decisions? decision for herself. She needs to
Tell me about a recent decision that consider the opinion of her
you made. How did you reach it? mother.
Are you a person who tends to She needs to follow the rules and
follow rules? does not break them.
Have there been times when you
broke rules?
Questions to ask on work and
play
• work and play:
1. well-matched to the person’s developmental level,
talents, and limitations?
2. comfortable and satisfying?
3. adequate for care of self and dependence?
4. culturally-sanctioned?
New paint on canvass,

They can fade but the images that spring out
Of the artist’s mind and heart
Are expressions of hope and aspirations
It is as if, the artist repaints

With optimism and glee
Isn’t it that what we help our patients to become

Is to live their lives well.
Anselmo T. Tronco
July 23, 2018
3:30AM
Given this data from Patty’s
case how do you characterize
Patty’s different areas of
function?
Using the workbook, fill up this table
This process will be done during the break.
Instructions
• Groups to collate individual answers
• Present group output in the areas of functioning
after the second lecture
BREAK
Video 2: Patty’s Past
THE DEVELOPMENTAL
HISTORY
Constantine D. Della, M.D.
OBJECTIVES of the
PRESENTATION
1. Discuss the guiding principles in obtaining the
person’s developmental history
2. Describe the essential elements of the following
phases of development in developing a
psychodynamic formulation
a. Genetics & prenatal development
b. Earliest years (birth to 3 years)
c. Middle childhood (3 to 6 years)
d. Late childhood (6 to 12 years)
e. Adolescence (13 to 18 years)
f. Young adulthood (18 to 23 years)
g. Adulthood (23 years & beyond)
GUIDING PRINCIPLES
• Nature & nurture

• Relationships are key
• Trauma is critical
• Chronology is relevant
• Development is lifelong

GENETICS & PRENATAL
DEVELOPMENT
• Heredity
• Psychiatric disorders
• Temperament
• Prenatal development
• Maternal habits
• Maternal physical & emotional health
• Peripartum events

PROBLEMS & PATTERNS in
ADULTHOOD that may have
GENETIC & PRENATAL ORIGINS
• Psychiatric disorders
• Stable temperamental traits (e.g.,
inhibition, sensation seeking or
avoidance, impulsive aggression)
• Cognitive &/or behavioral problems

GENETICS & PRENATAL
DEVELOPMENT
SOME IMPORTANT QUESTIONS PATTY’S CASE
Anyone in the family with a history of
No data
mood, anxiety, or psychotic disorder?
Anyone in the family who was
No data
hospitalized for a psychiatric problem?
Anyone in the family who committed or
No data
attempted suicide?
Anyone in the family who uses
No data
substances?
Anyone in the family with particular
No data
temperamental traits?
Family members think that you remind
No data
them of another family member?
GENETICS & PRENATAL
DEVELOPMENT
Born prematurely? How many weeks? Incubated?
No data
How long?
Mother had any illnesses during pregnancy with
No data
you?
Mother not eating or sleeping well during
No data
pregnancy with you?
Mother was an adolescent during her
Mother was depressed or under a lot of stress
pregnancy; father abandoned her
during pregnancy with you?
mother; mother wanted her aborted
Surgeries immediately after birth? No data
Medical problems since birth? No data
Genetic disorders in the family? No data
Did mother smoke, drink alcohol, or use drugs
No data
when you were little? Now?
EARLIEST YEARS
(BIRTH to 3 YEARS)
• Trust other people
• Form secure attachments
• Develop & maintain a stable sense of
themselves & others
• Understand & regulate emotions
• Develop language & other cognitive
skills
ORIGINS in the EARLIEST YEARS
• Difficulties with self-esteem

management & maintaining a stable
sense of self
• Difficulties trusting others & maintaining
stable relationships
• Difficulties with self-regulation

EARLIEST YEARS
(BIRTH to 3 YEARS)
Where did you live after you were born? Cared for by adolescent biological
What type of dwelling? With whom? mother
Financial circumstances of people you lived
No data
with?
Adopted? What age? Circumstances? Adopted by grandaunt at age 3
Did your parents want to have a child when
you were born? Were they happy to have a Unwanted pregnancy
child?
Birth order? How did it affect your earliest
Only child to father
years?
Earliest memory? No data
Primary caregivers? What were they like? No data on biological mother
Were your primary caregivers happy with Biological mother abandoned by
their lives? Stressed out? her father
EARLIEST YEARS
(BIRTH to 3 YEARS)
Were primary caregivers emotionally or
No data
physically ill?
Were your primary caregivers drinking or
No data
using drugs?
Relationship of primary caregivers with their
No data
own parents?
Were you loved & care for? Held or kissed?
Called pet names? Scribbles tacked in the No data
ref?
Memories of being soothed when upset?
No data
Who usually calmed you down?
Pictures/videos of early family? No data
EARLIEST YEARS
(BIRTH to 3 YEARS)
Memories of difficult or upsetting
No data
experiences?
Physically ill &/or hospitalized?
No data
Who took care of you?
Primary caregiver absent or
No data
inconsistently present?
Memories of emotional trauma? No data
Physical or sexual experiences that
No data
made you uncomfortable?
MIDDLE CHILDHOOD
(3 to 6 YEARS)
•Self-perception & self-esteem

regulation
•Relationships with other
•Moral development

ORIGINS in MIDDLE CHILDHOOD
• Difficulty committing to a relationship
• Sexual inhibitions
• Fear of competition, particularly with
same-sex rivals
• Inhibited ambition & self-sabotage in
the face of success

MIDDLE CHILDHOOD
(3 to 6 YEARS)
Changes in relationships with primary
Given away for adoption
caregivers?
New closeness with a different caregiver?
New caregivers: grandaunt & her
husband; controlling, belittling,
intrusive, hypercritical, & punitive
Changes in primary caregiver? mother; inconsistent caregiving of
mother; received money from
adoptive father in exchange for
buying him alcohol & cigarettes
Change in environment? Socioeconomic
Moved to new home
status? Geographic move?
New siblings? Relationships with them? Now? No siblings
MIDDLE CHILDHOOD
(3 to 6 YEARS)
Other adults moving into the
None
household?
Any illnesses? None
Major separations from
None
caregivers?
Separation of caregivers? No
Physical & verbal hostility
Emotional, physical, or sexual
from mother; feelings of
abuse?
being unwanted
LATER CHILDHOOD
(6 to 12 YEARS)
•Cognitive development & building

ego function
•Relationship outside of the family
•Changes in the family
•The wider world

ORIGINS in LATER CHILDHOOD
• Cognitive difficulties
• Self-esteem problems

LATER CHILDHOOD
(6 to 12 YEARS)
Obligated to get scholastic awards in
Time in school? Any difficulties or troubles? Did
exchange for mother’s approval;
teachers inform your parents of any problems with
punished severely for mistakes or
you?
shortcomings regarding school work
Learning problems? None
Friends? No friends; difficulty trusting others
Household chores; no play; had to be
Activities?
independent
Mother had a miscarriage; felt guilty &
afraid because she wished the
pregnancy would not be successful;
Changes in the family?
mother became more irritable & harsh;
received money from father in exchange
for giving him a massage
Illnesses? Medications? None
LATER CHILDHOOD
(6 to 12 YEARS)
Serious troubles? None; obedient child & student
Fear & resentment towards
Disturbing or traumatic experiences? mother who became more
punitive
See a therapist, counselor, psychiatrist? No
Repetitive cleaning in response
Behavioral problems?
to obsession with contamination
Special school? No
Medications for a behavioral problem? No
Startled even at her mother’s
Sadness or nervousness? How long?
non-angry voice
ADOLESCENCE
(13 to 18 YEARS)
•Identity
•Body changes
•Cognitive & emotional difficulties

ORIGINS in ADOLESCENCE
• Poor sense of identity

ADOLESCENCE
(13 to 18 YEARS)
How do you remember your teenage years? Focused on studies to please her
Happy? Stormy? mother
Did not feel validated for her
Relationship with parents?
scholastic achievements
Physical development? same time as peers? No data
Anxiety or depression? No data
Use of substances? How often? How long? No data
Boyfriend or girlfriend? ?
Changes in family or living situations None
Illnesses? Traumatic situations? None
YOUNG ADULTHOOD
(18 to 23 YEARS)
•Intimate relationships & sexuality

•Responsibilities in the world

ORIGINS in YOUNG ADULTHOOD
• Dependency on other people

• Mood & anxiety symptoms

YOUNG ADULTHOOD
(18 to 23 YEARS)
Graduated with honors from
How far did you continue in school?
college
Living arrangements? Lives with parents
Wanted to be a flight attendant
Aspirations in life? How did you realize
but mother wanted her to be a
them?
teacher
How do you remember this time of your
life? Fulfilling? Disappointing? Frustrating?
Boyfriend is her only confidante;
Romantic or sexual relationships?
sex life not fulfilling
YOUNG ADULTHOOD
(18 to 23 YEARS)
Social life? Friends? How close? Socialize No friends; boyfriend is the only
one-on-one or in a group? social connection
Financial status?
Anxieties about not being a
Work? Fulfilling or not? perfect teacher affected her
occupational functioning
Leisure? Satisfying or not?
Anxiety? Depression? Substance use?
Traumatic situations?
ADULTHOOD
(23 YEARS & BEYOND)
•Finding meaning in work & love

•What is important to the person

ADULTHOOD
(23 YEARS & BEYOND)
SOME IMPORTANT QUESTIONS
Work history? Satisfying or not?
Financial status?
Family life?
Leisure time? Satisfying or not?
Medical or psychiatric problems?
Substance use?
Sexually active or not?
Loss of significant relationships?
Happy with the choices you made in life?
Given this data from Patty’s
case how do you characterize
DEVELOPMENTAL HISTORY
(problematic or not)
Instructions
• Present group output in the areas of functioning
after the second lecture
BREAK
Presentation of the groups
Describe and Review
Putting It Together: DESCRIBE
PROBLEM
• Patty has obsessional thoughts of hurting her mother.
She is scared that she will go crazy.
PATTERNS
1. SELF
• Self-Perception
• Patty’s identity is unclear, attachment is insecure, and
boundaries are porous. This lack of identity is a
consequence of Patty’s not reflecting on and thinking
through life choices.
PATTERNS
• SELF
• Self-Esteem Regulation
• Self-Esteem Vulnerability
• Her self-esteem regulation is inadequate. Her self-esteem vulnerability
is when she is made to feel “not good enough,” by women who behave
like her mother in a harsh, diminishing manner
• Internal Response to Self-Esteem Threats
• Grandiosity is Patty’s response when her competence as a teacher
was challenged. She expressed that she is far better than her co-
teachers.
• Performing well in academics was a well used response when her
sense of self-worth is diminished
Describing Patty’s Self-Perception and
Self-Esteem Regulation
• Her choices are mainly a reflection of her mother’s
desires of what she should be, specifically, her
career choice and choice of her boyfriend, dictated
upon by her mother. She does not have close
friends, and she is sensitive to people’s negative
reactions to her
PATTERNS
2. RELATIONSHIPS
Trust She has a problem with basic trust. Patty has a consistent sense
that her mother does not love her enough, that she needs to be what
she wants her to be. She also has to give in to what her boyfriend
wants (sex) because of fear of rejection.
Sense of Self and Patty devalues her mother but idealizes her boyfriend. She also has
Others poor boundaries with her mother
Security Patty hasn’t developed friends as she was growing up. She can’t
cope with ambivalent feelings about her mother in that her mother
makes her feel anxious. She believes that she can be rejected if she
does not agree with her boyfriend to having sex with her boyfriend
even if she doesn’t like it. Possibly because of anticipation of
rejection if she asserts what she likes.
Intimacy Patty’s lack of friendships indicates difficulty in intimacy. Her
relationship with her boyfriend needs to be further explored but it
seems to lack intimacy as well.
Mutuality In Patty’s relationship there seems to be mutuality but it is
transactional in nature. What Patty gives and takes differs from the
other person (ex. to her boyfriend and mother)
PATTERNS
2. RELATIONSHIPS
Synthesis:
• She has limited capacity for intimacy (no friends)
although she shows some mutuality in her relationship
(transactional). She probably gives more than she takes
in relating with others. She has difficulty in trusting
others.
PATTERNS
3. ADAPTING
• Patty’s defenses range from less adaptive such as
• splitting
• projection (anger that she feels is projected towards her
mom, but also internalized)
• pathological idealization and devaluation
• displacement (of anger towards a thought thus
obsession of hurting her mother)
• sexualization (flirtatiousness and seduction of professor
to get a high grade)
• turning against the self (blaming herself for the
miscarriage of her mother)
• projective identification (possibly, but not yet fully
explored)
Defenses
• However, sublimation, an adaptive defense, is also
shown, as evidenced by her consistent excellent
academic performance
• Rationalization is also used when she explained
why the mother of her student confronted her as
not a good teacher
Managing Emotions and Impulse
Control
• When the mother of her student judged her as “not
a good teacher,” she kept her anger to herself. This
connotes fair capacity to manage emotions and
impulse control
• However, her anger towards her mother makes her
unable to maintain a good enough relationship with
her mother
PATTERNS
3. ADAPTING
Synthesis:
• She utilizes splitting (idealization and devaluation),
projection, sexualization, turning against the self,
possibly projective identification—which are less
adaptive defenses. Rationalization, a more adaptive
defense, and sublimation, a most adaptive defense, are
also utilized.
• She is a fairly emotional person but the defenses are
less flexible. She has good impulse control but can be
self-deprecating.
PATTERNS
4. COGNITION
Decision-Making, Patty seduced her professor to manipulate him to give a high grade
Problem-Solving, in Physics so that she could maintain her scholarship showed limited
and Judgment problem-solving and decision-making skills.
Her response to Mrs. Franchie and the mother of her student which
was keeping her emotions to herself may show good impulse
control; however, this suggests at best fair problem-solving because
she bottled up these painful emotions
Judgement is poor, to at best, fair
Mentalization, Patty has not shown much capacity to reflect on her motivations,
Capacity for Self- thoughts, and feelings. Although she was adequately able to
Reflection and express her feelings, she was not able to reflect on her participation
Reality Testing in the social difficulties.
Reality testing is fairly good.
PATTERNS
4. COGNITION
Synthesis
• She is quite intelligent, able to organize her thoughts
and express them well. Her problem-solving skills and
judgement are only fair. Her capacity for self-reflection
and mentalization is only fair. Judgment is good.
PATTERNS
5. WORK & PLAY
• Patty showed discipline and persistence in work,
but she only derives partial satisfaction from being
a teacher. Even her seriousness in doing well in
school was wrought with fear of failure because of
her mother. The work she does is matched to her
developmental level, talents, and limitations
• Play is an unfamiliar experience in her childhood
and up to adulthood.
• Work is culturally sanctioned
PATTERNS
5. WORK & PLAY
Synthesis
• Her work life is her strength, although not fully satisfying.
It is also culturally sanctioned, and probably enough to
partially finance her needs. However, she hasn’t
“learned” to play.
Thank you!
REVIEW
GENETICS & PRENATAL
DEVELOPMENT
Patty was an only child. She does not have any
knowledge about the backgrounds of her biological
parents except that her mother was a young adolescent
girl & that her father abandoned them when he learned
that her mother was pregnant with her. Her mother
wanted her aborted but was prevailed upon by an aunt
who promised to adopt her. As a young teenage
pregnant girl who was abandoned by her partner, Patty’s
mother may not have been physically & emotionally
capable to cope with the stresses of pregnancy thus
compromising Patty’s prenatal development.
EARLIEST YEARS
(BIRTH to 3 YEARS)
Patty does not have any memories of this
part of her life. She was told that her mother
took her away from her adoptive mother after
she was born. Her adoptive mother is not privy
to Patty’s first 3 years of life. She was raised by
a single teenage mother who wanted her
aborted. Given these, Patty’s ability to establish
trust, secure attachment, a stable sense of self
& of others, & emotional regulation may have
been compromised.
MIDDLE CHILDHOOD
(3 to 6 YEARS)
Patty’s mother gave her back to her adoptive
mother when she turned 3 years of age for reasons
unknown to her. Patty’s adoptive mother was controlling,
belittling, intrusive, hypercritical, & punitive causing her
to feel unwanted. Although her adoptive father did not
take part in her upbringing, Patty enjoyed the money he
offered in exchange for running errands to buy his
alcohol & cigarettes. These experiences may have
contributed to poor self-perception & self-esteem
regulation. Furthermore, such developmental disruptions
may have impaired her capacity to establish healthy
relationships with others.
LATER CHILDHOOD
(6 to 12 YEARS)
In order to obtain her adoptive mother’s approval, Patty
was obedient & diligent both at home & in school. She did not
have time to play or develop friendships because all her
energies were channeled to doing household chores & attaining
scholastic awards. Any indication of failure or shortcoming was
met with severe physical & verbal punishment. Thus, she
constantly lived in fear & resentment towards her mother. After
her mother miscarried, Patty became guilty & more afraid of the
latter. Her father continued to reward her monetarily for her
“services,” this time including giving him a massage. These
disruptions in this stage of Patty’s developmental history may
have compromised her capability to build ego functions and
relationships with people outside of her family.
ADOLESCENCE
(13 to 18 YEARS)
Patty’s focus on school work &
household chores continued. Yet, despite
all her efforts to please her mother, she
did not feel that the latter appreciated
her. This lack of validation from her
mother may have adversely affected
Patty’s self-identity & contributed to
emotional difficulties.
YOUNG ADULTHOOD
(18 to 23 YEARS)
In spite of the fact that Patty’s college course
was imposed by her mother, she graduated with
honors. Her boyfriend is her only social connection
and confidante. In return, she complies with his
sexual demands even if she does not enjoy them.
She is generally competent at work but is easily
disturbed by the thought that she is not perfect.
Her aspirations for validation & perfection may
have compromised her capacity to build intimate
relationships & a healthy sexuality.
CONCLUSIONS
• Obtaining an accurate & adequate
DEVELOPMENTAL HISTORY of the
person is important because it helps
provide explanations to current
PROBLEMS & PATTERNS.
• In the absence of facts, however, we may
deduce from the developmental problems
that appear in later years of life.
• In Patty’s case, her earliest years were
problematic & laid the ground work for
problems in later developmental years.
Lunch
Psychodynamic Theories Linking

Patient’s Problems and Patterns to
History
Alma L. Jimenez, MD, FPPA
Associate Professor
Department of psychiatry and Behavioral Medicine
Describe Review ?
1. We described Patty’s problems and patterns.
2. We reviewed her personal history to appreciate
their development.
3. Now, we will offer an hypothesis of why things
happened – psychodynamic formulation:
• a narrative that will try to explain how and why Patty
thinks, feels, and behave the ways she does, based on
her developmental history.
Describe Review ?
• Why is Patty behaving this way?
• Why does she think or feel this way about herself?
• Why is her reaction to stress this way?
• Why is she having difficulty handling criticisms?
Describe Review Link
• We will explain the why Patty has her problems

and patterns by linking them with her
developmental history through organizing ideas:
Objectives
• To apply psychodynamic theories in
psychodynamic formulation as organizing ideas to
link the patient’s patterns with developmental
history to her problems.
Main Message
• Psychodynamic theories organize the patient’s
problems and patterns and developmental history
and link them to each other into a narrative that
gives reasons for the patient’s thoughts, feelings
and behavior.
Outline
1. Psychodynamic theories
a. Basics
1) Trauma
2) Cognitive and emotional difficulties
3) Conflict and defense/ ego psychology
4) Object relations theory
5) Development of the elf
6) Attachment theory
b. Clinical situations where the theories are relevant
2. Putting it together
a. Focus describe
b. Focus review
c. Link
d. Treatment based on the formulation
PrincipleBasics of the psychodynamic
Principles of the psychodynamic theories

• Unconscious
• Development
• Psychic determinism
• Dreams and fantasies
• Therapist
• Change
Basics of trauma - stressful and disturbing events
that overwhelm the individual can affect the
development of all aspects of functioning
• DSM-V - exposure to actual or threatened death, serious injury or sexual

violence in one or four ways:
(a) directly experiencing the event;
(b) witnessing, in person, the event occurring to others;
(c) learning that such an event happened to a close family member or
friend; and
(d) experiencing repeated or extreme exposure to aversive details of
such events, such as with first responders.
• Behavioral symptoms re-experiencing, avoidance, negative cognitions and mood,
and arousal
Determinants of extent of impact of trauma
general family stress

and the child’s social peer relationships
environment
early relationship
with primary
parental
caregivers, including
socioeconomic status
the caregivers’
-
responsiveness to
the difficulty
the nature, timing,

adequate early
and chronicity of the
treatment
difficulty
the way the difficulty

is conceptualized by
resilience Development the caregivers and,
by the child
Link these clinical problems to the impact of trauma:
• Self- experience • Interpersonal relationships
• Low self-esteem • Difficulty in trusting
• Early (childhood) , • Paranoia
protracted abuse
• Victim takes blame rather
• Difficulty in intimacy
than blame abuser
• Two experiences of oneself
and the world: before
trauma and after trauma
• Later in life
• Adapting
• Regulation of affect and impulses • Abnormal set of responses to
• Intense emotional and physical external stimuli
hyperarousal or from emotional • Misread magnitude of event
blunting or numbing • Hyperreact
• Difficulty in self-soothing eg self- • Avoidant
harm
Trauma treatment: safety
• Essentially, problem of trust
• Solution: learn to develop sense of safety
• Allow patient…
• Acknowledge affects
• Demonstrate acceptance and nonjudgment
• Demonstrate trustworthiness, promote security
• Form secure attachment
• Integrated sense of self
• Promote understanding of trauma
Basics of cognitive and emotional difficulties
• Mental health conditions that primarily affect cognitive abilities including
learning, memory, perception, and problem-solving; as well as problems with
depression or anxiety
• Childhood
• autism spectrum disorders
• academic/learning difficulties (including learning disorders)
• attentional difficulties (including ADHD)
• anxiety (including OCD, phobias, and separation anxiety disorder)
• enuresis/encopresis
• motor/verbal tics
• mood difficulties (including depression)
• Adolescence
• anxiety (including panic disorder, generalized anxiety disorder, and PTSD)
• eating (including anorexia nervosa and bulimia)
• conduct (including conduct and oppositional defiant disorders)
• emotional regulation and impulse control
• mood (including major depression and bipolar disorder)
• psychosis (including schizophrenia)
• substance abuse
• Adulthood
• Postpartum depression
• Midlife transition
Impact of difficulties on development
• Childhood
• Predict lifetime of problems
• Development of self-esteem
• Relationship with others
• Rchool performance
• Adolescence
• High risk since brain systems appear to be most vulnerable
• Affect regulation
• Control impulses
• Self-restraint
• Consolidate identity
• Adulthood
• Sense of self
Link these clinical situations to the impact of early
cognitive and emotional difficulties
• ‘‘Mismatch’’ between what we describe and what

we review
• History in childhood of unexpected interruption of
previously normal development
• Personal or family history of cognitive and/or
emotional difficulties
Early cognitive and emotional difficulties treatment: recognize and
support
• further testing (e.g., neuropsychological testing)

• taking a family history
• recognition and acknowledgment
• appropriate interventions… (cognitive remediation,
pharmacotherapy, etc
• treatment of underlying difficulties, such as anxiety
and depression
Basics of Ego Psychology
id
More
adaptive
ego
Anxiety Less
superego
adaptive
Conflict Defense
Adult problems can be linked

to unconscious conflicts and defenses.
Defense
Mechanisms Definition
Denial Refusal to appreciate information about oneself or others
Projection Attribution to others of one’s own unacceptable thoughts or feelings
Projective Attribution of unacceptable personality characteristics to another followed by an
identification attempt to develop a relationship based on those characteristics
Regression A partial return to earlier levels of adaptation to avoid conflict
Splitting Experiencing of others as being all good or all bad
Conversion Transformation of unacceptable wishes or thoughts into body sensations
Reaction Transformation of an unwanted thought or feeling into its opposite
formation
Isolation Divorcing a feeling from its unpleasant idea
Rationalization Using seemingly logical explanations to make untenable feelings or thoughts more
acceptable
Displacement Redirection of unpleasant feelings or thoughts onto another object
Dissociation Splitting off of thought or feeling from its original source
Sublimation A mature mechanism whereby unacceptable thoughts and feelings are channeled
into socially acceptable ones
Link these clinical situations to
the impact of conflict and defense
• Circumscribed problems: able to trust, to have a
good sense of self and other, and to form secure
relationships, but manifest
• Competitive anxiety and inhibitions
• struggle with fantasies of besting their parents and fears about
consequently losing their love
• Difficulties with commitment and sexual intimacy
• early fantasies of closeness with a desired caregiver while
earing punishment for this wish from a rival caregiver may
persist into adulthood, leading to conflicts that can impede
intimacy
Unconscious conflict and defense
treatment: adaptive ways of reconciling
conflict and tolerating anxiety
• Uncovering – making the unconscious conscious

• Free association
• Defense analysis
• Supporting
• Promote more adaptive defenses
Basics of object relations theory
Internalized experiences Adult

templates
wiwth caregiveers relationships
• Problems arise from unconscious repetition of early

relationships with others
Templates
• Need fulfilling
Child who is loved and Caregiver who is adequately loving

cared for satisfaction and providing
• Need-frustrating
Child who is needy and Caregiver who is inadequately loving
whose needsare unfulfilled frustration and providing
Templates Adult relationships
• Need fulfilling trust
Child who is loved and Caregiver who is adequately loving

cared for satisfaction and providing
• Need-frustrating unsafe; unreliable

Child who is needy and Caregiver who is inadequately loving
whose needs are unfulfilled frustration and providing
Link these clinical situations to the
impact of relationships with others
• Global relationship problems involving lack of trust
• More circumscribed relationship problems involving
unrealistic expectations of others
Relationships with others treatment: understand their
problematic templates and to develop
new, healthier ones
• Develop insight
• Interpret and understand transference (reactivated early
relationship templates)
• Patient becomes more aware of negative relationship
templates, then improve ability to tolerate more
ambivalent connections to people
• Develop more complex, nuanced images of important
early caregivers
• need for splitting decreases and object constancy improves
• Create new templates
• Relationship with the therapist provides the basis for
new, healthier relationship templates.
Basics of self psychology
Mirroring
Empathic Coherent
parenting/ idealizability sense of
selfobjects self
Allows
grandiosity
the development of the self
• Low self-esteem
• Overly inflated, but fragile, self-esteem
• Problems with empathy and envy
Self treatment: use therapeutic
relationship to develop healthier
sense of self
• Allow idealization to flourish
• Use empathic failures to help patient see therapist as
separate , flawed, but nevertheless good and caring
person
• Guide patients to affirm themselves
Attachment creates sense of
safety that develops
stress emotional
adaptation regulation
responses to
sense of
anxiety and
security
affects
Attachment patterns
Adult attachment
styles
Parent Child
Secure Insecure
Secure → Secure
Insecure: dismissive/avoidant→ Insecure: avoidant
Avoidant
Insecure: preoccupied/anxious→ Insecure:
ambivalent
Insecure: disorganized → Insecure:
Ambivalent disorganized
Disorganized
the impact of attachment styles
Problems
Interpers with self-
onal regulation
problem and
managing
s affect
Difficulty
Poor sense
with
of self
empathy
Attachment treatment: make people
aware of their attachment patterns
and help them to attach in new
ways
• Becomeaware of attachment styles
• Improve affect management
• Develop a more secure attachment style
Putting it together – A
1. Presentation
2. Describe the problems and patterns after asking
questions about the patient’s general functioning
3. Review the developmental history
4. Link the problem and patterns to history
• Focus description
• Focus review
• Ask a focus question
• Choose organizing idea (theory)
5. Write chronological narrative
6. Base treatment on formulation
1. Presentation
• Focus review
1. Presentation
• Focus review
Check out this table
focus DESCRIBE
1. Get sense of the person’s overall function
2. Focus on the aspects that are giving the person
the greatest difficulty.
focus REVIEW
1. Get a sense of the person’s overall history
2. Focus on the points in development that were
most likely to have disrupted or supported
healthy development.
3. Summarize the highlights
Ask a focus question
• How might early trauma lead to
problems with affect regulation/
unmanageable anxiety?
• How might depression in childhood
lead to problems with self-esteem
management?
• How might an abusive foster mother
lead to interpersonal problems in
adulthood?
• How might a critical, invalidating,
abusive foster mother lead to a drive
to achieve?
• How might having a misattuned
mother hinder someone to develop
intimacy in a relationship?
• How might the overly close
relationship with her father lead to
sexual pragmatism?
Choose an organizing idea
• Consider:
• the way the patient tells his/her story
• the needs of the clinical situation
• Lead with the information from the
description and the history
• Focused DESCRIPTION:
• Focused REVIEW:
Theories Basics Problematic Clinical Situations
Trauma Extraordinarily stressful and disturbing events Problems with self-experience

overwhelm the individual, leading to Problems with regulation of affect and impulses
unconscious failure to trust Problems with interpersonal relationships
Problems with adapting
Cognitive and Cognitive and emotional difficulties interrupt ‘‘Mismatch’’ between what we describe and what we review
Emotional developmental tasks and unrecognized deficits History in childhood of unexpected interruption of previously normal
Difficulties development
Personal or family history of cognitive and/or emotional difficulties
Ego Conflicts occur constantly and underlie the way Circumscribed problems
Psychology we think, feel and behave, moldinh our Competitive anxiety and inhibitions
personality styles Difficulties with commitment and sexual intimacy
Object Early interactions with important caregivers Global relationship problems involving lack of trust
Relations help shape the way we come to think, feel, and More circumscribed relationship problems involving unrealistic
behave in relationships expectations of others
Self Empathic caregiving affects the development of Low self-esteem

Psychology the self Overly inflated, but fragile, self-esteem
Problems with empathy and envy
Attachment Early attachment styles affect how people Problems with self-regulation and managing affect
develop their sense of self, relationship Difficulty with empathy
with others, ways of adapting to stress,
and patterns of self-regulation
1. Presentation
• Focus review
Writing a psychodynamic
formulation
• Focus question
• Start with a summary that outlines focal points.
• Then try to comment on the way the person
developed during each phase of life.
• Links between history and adult patterns are
hypotheses
• ‘‘perhaps’’
• ‘‘maybe’’
• ‘‘it could be’’
• ‘‘it is likely that’’
Theories Treatment
Trauma Develop sense of safety
Cognitive and Recognize and support
emotional
difficulties
Ego Find more adaptive ways of reconciling conflict and tolerating anxiety
psychology
Object Develop insights about negative templates and form new template
relations
Self Allow idealization to flourish
psychology Use empathic failures can help patient see therapist as separate
separate, flawed, but nevertheless good and caring person.
Guide patients to affirm themselves
Attachment Develop awareness of attachment styles
psychology Improve affect management
Develop a more secure attachment style
Given these theoretical
considerations, how do you LINK
Patty’s problems and patterns
with her developmental history to
explain her current problem?
Instructions
• Present group output in the psychodynamic
formulation after the break
BREAK
Group Presentation
Using the workbook, fill up this
table
Closure
Patty’s case: Presentation
• Patty is a twenty-one year old,
grade one English teacher who
came in with a chief complaint of :
“I am so nervous and I keep
thinking of hurting my mother).”
• Patty says that this anxiety, which Patty certainly reacts strongly to
started during her college years, criticism.
following a brief self-initiated affair
with a professor, for purposes of I wonder how she functions in
improving her grade, worsened in other aspects of her life?
the last six months, accompanied
by unwanted thoughts of having
sex with men and of hurting her
mother.
• This present episode was
triggered by a confrontation during
a parent – teacher conference
regarding her effectiveness as a
teacher.
Problem
• Patty’s Problem and Patterns
Patty’s reaction to criticisms about her effectiveness as a teacher has precipitated panic attacks and unwanted, intrusive thoughts. While the anxiety has been
• Patty decided to seek consult because of her fear that she may be going crazy.
Self Relationship Adapting Cognition Work and Play

• Incoherent self- • Insecure personal relationships - • Uses a range of defenses from • Iintelligent and • works hard
perception- marked by a general lack of trust, adaptive to less adaptive ones in • displays reasonably • admits having
• Poor self-esteem inability to tolerate ambivalent different situations good executive
difficulty
regulation feelings towards others, and fear of • Uses sublimation, rationalization, functions.
relaxing
• Grandiose response to abandonment lack of empathy , reaction formation and isolation of • However, she
self-esteem threats shallow affect to defend against her negative shows poor • has no friends
• Demands much feelings towards her punitive judgment, difficulty other than her
attention from others, mother.. with decision- boyfriend.
sustain good feelings • However, in her relationship with co- making and
towards herself workers, she tends to understate problem-solving.
emotions and to be inflexible as she • In herrelationships,
is driven to behave compulsively. she has difficulty
• In her very close relationships, she mentalizing
tends to employ splitting as a • Lacks y self-
defense. reflectiion
Focused Description
Patty’s difficulties seem to be global, particularly affecting the areas of self, relationships, affect regulation.
vague recall of Atmosphere of fear of disciplinary Obsessions with
Later childhood, adolescence and adulthood

Earliest years (0-3 years)
Middle childhood (3-6 years)

Genetics and prenatal development
born to a 14-
year-old memories during her actions from her strict, grade- contamination, causing
mother who early years. conscious mother. her to manifest repetitive
initially cared for by her developed non-dysfunctional cleaning behavior
reportedly,
initially mother for three compulsions to avoid At age of seven, she
wanted to months, then punishments. experienced getting
abort the abandoned startled even at the
pregnancy Cared for and adopted slightest sound of her
by a midwife mother’s voice, intrusive,
distressing memories of
Punitive, bitter and being yelled at, avoiding
harsh mother and being alone with her
passive, distant mother, and difficulty
adoptive father concentrating while
studying.
tried to fit the image of a
perfect child,
accommodating to the
wants of her mother
strove for the highest
FOCUSED REVIEW academic honors and was
never able to assert
The most problematic parts of Patty’s history occurred during the earliest childhood years. They involved traumatic neglectful,
herself and enjoy play or
abusive, invalidating relationships with her caregivers- biological mother and adoptive parents
leisure
Ask a focus question
• How might early trauma lead to
problems with affect regulation/
unmanageable anxiety?
• How might depression in childhood
lead to problems with self-esteem • How might adverse early
management?
• How might an abusive foster mother
experiences within the
lead to interpersonal problems in
adulthood?
context of an adoptive
• How might a critical, invalidating, relationship cause
abusive foster mother lead to a drive
to achieve? difficulty in many areas
• How might having a misattuned of difficulty in life?
mother hinder someone to develop
intimacy in a relationship?
• How might the overly close
relationship with her father lead to
sexual pragmatism?
Theories Basics Problematic Clinical Situations
Trauma Extraordinarily stressful and disturbing events Problems with self-experience

overwhelm the individual, leading to Problems with regulation of affect and impulses
unconscious failure to trust Problems with interpersonal relationships
Problems with adapting
Cognitive and Cognitive and emotional difficulties interrupt ‘‘Mismatch’’ between what we describe and what we review
Emotional developmental tasks and unrecognized deficits History in childhood of unexpected interruption of previously normal
Difficulties development
Personal or family history of cognitive and/or emotional difficulties
Ego Conflicts occur constantly and underlie the way Circumscribed problems
Psychology we think, feel and behave, moldinh our Competitive anxiety and inhibitions
personality styles Difficulties with commitment and sexual intimacy
Object Early interactions with important caregivers Global relationship problems involving lack of trust
Relations help shape the way we come to think, feel, and More circumscribed relationship problems involving unrealistic
behave in relationships expectations of others
Self Empathic caregiving affects the development of Low self-esteem

Psychology the self Overly inflated, but fragile, self-esteem
Problems with empathy and envy
Attachment Early attachment styles affect how people Problems with self-regulation and managing affect
develop their sense of self, relationship Difficulty with empathy
with others, ways of adapting to stress,
and patterns of self-regulation
Choose an organizing idea
• Consider:
• the way the patient tells his/her story
• Patty’s chief complaint is anxiety over the perception of people at work – parents of her
students and co-teachers – of her and yet, thoughts about hurting her mother surface. Her
relationship with her mother seems to be crucial for her.
• the needs of the clinical situation
• Difficulties in self-regulation, emotional regulation
• Lead with the information from the description and the history
• Focused DESCRIPTION:
• Patty’s difficulties seem to be global, affecting the areas of self, relationships, affect
regulation, more than cognition and work and play. Thus, the focus question for the
formulation is:
• Why does Patty have so many areas of difficulty in her life?
• Focused REVIEW:
• The most problematic parts of Patty’s history occurred during the earliest years. They
involved traumatic neglectful, abusive, invalidating relationships with her caregivers-
biological mother and adoptive parents.
Link: Self-regulation and affect management can be difficult in

people with insecure attachment. Global functional difficulties
likely point to adverse experiences in early childhood years.
Thus, Patty’s self dysregulation and impaired affect
management likely stem from early insecure attachment.
Patty’s difficulties seem to be global, The most problematic parts of Patty’s history
occurred during the earliest childhood years. They
particularly affecting the areas of self, involved traumatic neglectful, abusive, invalidating
relationships, affect regulation. relationships with her caregivers- biological mother
and adoptive parents
Patty’s early insecure attachment may have affected her patterns of self-regulation and affect
management
Writing a psychodynamic
formulation
• Focus question:
• How did insecure early attachment affect self regulation and affect
management throughout Patty’s life?
• How might Patty’s good cognitive ability mitigate the impact of early
insecure attachment?
• Start with a summary that outlines focal points.
• Then try to comment on the way the person developed
during each phase of life.
• Links between history and adult patterns are hypotheses
• ‘‘perhaps’’
• ‘‘maybe’’
• ‘‘it could be’’
• ‘‘it is likely that’’
Patty’s case: Psychodynamic Formulation
• Summary of focal points:
• difficulties seem to be global, more marked in self-regulation and affect management
• stems from the insecure attachment style that she developed in her early years
• inconsistent parenting from an incapable, unstable, possibly neglectful biological mother and an anxious,
preoccupied adoptive mother and a passive father
• ambivalent, clinging, and anxious about separation and exploration from infancy.
• Earliest childhood
• first three years of her life; teen-age mother ; wanted her pregnancy aborted
• left in the care of a childless midwife and her husband
• Middle childhood
• Experienced adoptive mother as anxious and preoccupied about others’ perception of her
• mother’s open threats to give her away at the slightest displeasure towards her
• difficulty establishing a solid dyadic relationship
• never developed basic trust or the capacity for a secure attachment
• Mother not attuned, which may have led to his difficulty developing a sense of his own affect states, or those of
others.
• difficulties with affect management, empathy, mentalization and self-regulation.
• Middle childhood…
• remained locked in a two-person relationship which her mother
• overwhelmed with sole relationship with mother and exacerbated fears of losing this all-important
relationship
• fear of abandonment further fueled by the hard-driving achievement –oriented mother’s shifting to
a non-caring, even abusive attitude, whenever she failed to meet expectations
• resorted to controlling her environment through compulsive cleaning behaviors to promote her
sense of security
• hyperactivating strategies to draw her mother’s engagement
• vigilant and effortful in her attempts to get caregivers attention
• Adolescence and younf adulthood
• conformed to her mother’s preference for her college course and choice of boyfriend
• transferred the fear of authority figures that she associates with her mother to the people at work
• Present episode
• associated failure to meet co-workers’ expectations with possible abandonment by her mother.
• overdependence on her boyfriend is strategically keeping him nearby
• manner of describing her experiences:, exaggerated appraisal of threats from her mother and
people at work; and catastrophic beliefs about transactions with her mother, her professor and co-
teachers; ready access to negative painful memories
It is theory that decides what can
be observed. Albert Einstein
Psychodynamic Formulation of
Patty’s Problem
Michael P. Sionzon, MD, FPPA
14th Post-graduate Course and 2nd BVR Psychiatric Education Lectures

July 23 - 24, 2018
Objectives
• Summarize the process of developing a
psychodynamic formulation
• Discuss points to consider when sharing the
psychodynamic formulation with patients
• Discuss how the psychodynamic formulation
directs treatment
The thing about psychodynamic
formulation …
• It is a hypothesis
• Needs to be tested and may be revised
• May evolve over the course of the therapy
• Tool to improve our treatment methods by
understanding our patients
formulation …
• May evolve over the course of the therapy
DESCRIBE – Problem and Patterns
(Strengths and Difficulties)
ADAPTING
RELATIONSHIPS COGNITION
• Defense mechanisms
• Trust • Impulse control • General cognitive abilities
• Sense of self and other • Managing emotions • Decision making and problem
• Security solving
• Sensory regulation
• Intimacy • Self-reflection and reality testing
• Mutuality • Mentalization
• Judgment
SELF WORK AND PLAY

• Self-perception
Problem • Well-matched to their developmental
• Identity “What brings level / talents / limitations
• Fantasies about the self the patient to • Comfortable / satisfying to them
• Self-esteem treatment • Adequate for care of self and
• Vulnerability and internal response to now?” dependents
self-esteem threats • Culturally sanctioned
• Use of others to regulate self-esteem
PROBLEM
Patty’s reaction to criticisms about her effectiveness as a teacher has precipitated panic attacks and unwanted, intrusive
thoughts.
SELF RELATIONSHIP ADAPTING COGNITION WORK AND PLAY
• Incoherent self- • Insecure personal • Uses a range of defenses from adaptive • Intelligent and • Works hard
perception- relationships - to less adaptive ones in different displays reasonably • Admits having
• Poor self-esteem marked by a situations good executive difficulty
regulation general lack of • Uses sublimation, rationalization, functions. relaxing
• Grandiose trust, inability to reaction formation and isolation of • However, she shows • Has no friends
response to self- tolerate affect to defend against her negative poor judgment, other than her
esteem threats ambivalent feelings towards her punitive mother.. difficulty with boyfriend.
• Demands much feelings towards • However, in her relationship with co- decision-making and
attention from others, and fear of workers, she tends to understate problem-solving.
others, sustain abandonment emotions and to be inflexible as she is • In her relationships,
good feelings lack of empathy , driven to behave compulsively. she has difficulty
towards herself shallow • In her very close relationships, she mentalizing
tends to employ splitting as a defense • Lacks self-reflection
FOCUSED DESCRIPTION
Patty’s difficulties seem to be global, affecting the areas of self, relationships, affect regulation, more than cognition and work
and play. Thus, the focus question for the formulation is: Why does Patty have so many areas of difficulty in her life?
PROBLEM
Patty’s reaction to criticisms about her effectiveness as a teacher has precipitated panic attacks and unwanted, intrusive
thoughts.
SELF RELATIONSHIP ADAPTING COGNITION WORK AND PLAY
• Incoherent self- • Insecure personal • Uses a range of defenses from adaptive • Intelligent and • Works hard
perception- relationships - to less adaptive ones in different displays reasonably • Admits having
• Poor self-esteem marked by a situations good executive difficulty
regulation general lack of • Uses sublimation, rationalization, functions. relaxing
• Grandiose trust, inability to reaction formation and isolation of • However, she shows • Has no friends
response to self- tolerate affect to defend against her negative poor judgment, other than her
esteem threats ambivalent feelings towards her punitive mother.. difficulty with boyfriend.
• Demands much feelings towards • However, in her relationship with co- decision-making and
attention from others, and fear of workers, she tends to understate problem-solving.
others, sustain abandonment emotions and to be inflexible as she is • In her relationships,
good feelings lack of empathy , driven to behave compulsively. she has difficulty
towards herself shallow • In her very close relationships, she mentalizing
tends to employ splitting as a defense • Lacks self-reflection
FOCUSED DESCRIPTION
Patty’s difficulties seem to be global, affecting the areas of self, relationships, affect regulation, more than cognition and work
and play. Thus, the focus question for the formulation is: Why does Patty have so many areas of difficulty in her life?
REVIEW – Developmental History
Genetics and Pre-natal Development
Earliest Years
•Heredity (0-3 years) Middle Childhood
•Prenatal (3-6 years) Later childhood, adolescence and
•Development Trusting others Adulthood
•Peripartum Forming secure attachments Sense of self (related to
•events Developing and maintaining body and sexuality) Ability to form relationships
stable sense of self and others Relationship with others outside of family (late childhood)
Understanding and regulating (capacity to tolerate Solidify identity (adolescence)
emotions competition and jealousy)
Building intimate relationships
Developing language and other Sense of morality and assuming responsibility
cognitive skills (young adulthood)
Building meaningful lives in work
and family and sustaining
inevitable losses of ageing (later
adulthood)
Later childhood, adolescence and

Born to a 14- Vague recall of Atmosphere of fear of Tried to fit the image of a perfect
adulthood

year-old memories during disciplinary actions child, accommodating to the
mother who her early years. from her strict, grade- wants of her mother
reportedly, Initially cared for by conscious mother. Strove for the highest academic
initially her mother for Gets startled even at honors and was never able to
wanted to three years, then the slightest sound of assert herself nor enjoy play or
abort the abandoned her mother’s voice, leisure
pregnancy intrusive, distressing
Cared for and At mother’s behest, took an
adopted by a memories of being educational course despite other
midwife yelled at, avoiding dreams
being alone with her
Punitive, bitter and mother Entered into a relationship with a
harsh adoptive man that she did not love upon
mother and passive, Developed non- mother’s suggestion
distant adoptive dysfunctional
compulsions to avoid Acquiesced to his sexual requests
father despite her reluctance.
punishments
FOCUSED REVIEW
The most problematic parts of Patty’s history occurred during the earliest childhood years. They involved traumatic
neglectful, abusive, invalidating relationships with her caregivers- biological mother and adoptive parents
Later childhood, adolescence and

Born to a 14- Vague recall of Atmosphere of fear of Tried to fit the image of a perfect
adulthood

year-old memories during disciplinary actions child, accommodating to the
mother who her early years. from her strict, grade- wants of her mother
reportedly, Initially cared for by conscious mother. Strove for the highest academic
initially her mother for Gets startled even at honors and was never able to
wanted to three years, then the slightest sound of assert herself nor enjoy play or
abort the abandoned her mother’s voice, leisure
pregnancy intrusive, distressing
Cared for and At mother’s behest, took an
adopted by a memories of being educational course despite other
midwife yelled at, avoiding dreams
being alone with her
Punitive, bitter and mother Entered into a relationship with a
harsh adoptive man that she did not love upon
mother and passive, Developed non- mother’s suggestion
distant adoptive dysfunctional
compulsions to avoid Acquiesced to his sexual requests
father despite her reluctance.
punishments
FOCUSED REVIEW
The most problematic parts of Patty’s history occurred during the earliest childhood years. They involved traumatic
neglectful, abusive, invalidating relationships with her caregivers- biological mother and adoptive parents
LINK – Problems and patterns to history to form hypotheses
about a person’s development
Early
cognitive and Conflict and Relationships Dev’t of the
Trauma Attachment
emotional defense with others self
difficulties
• Self-experience • Mismatch • Competitive • Global • Self-esteem • Self-regulation

• Affect between what anxiety and problems regulation including self-
regulation and is described inhibitions involving trust • Empathy and control and
self-control and reviewed • Difficulties with • Circumscribed envy affect
• Adaptation to • History of delay commitment problems regulation
stress or interruption and sexual involving • Empathy and
• Forming and in development intimacy unrealistic mentalization
maintaining • Personal or • More adaptive expectations
secure family history defenses from others
attachments of cognitive
and emotional
difficulties
Problem: Patty’s reaction to criticisms about her effectiveness as a teacher has precipitated panic attacks and unwanted, intrusive thoughts
of harming her mother.
Focused problem and pattern Focused review
• Global, affecting the areas of self, relationships, affect • Traumatic neglectful, abusive, invalidating relationships with her caregivers-
regulation, more than cognition and work and play biological mother and adoptive parents during her earliest years
Linking problems and patterns with developmental history to form hypothesis about development
Organizing idea: ATTACHMENT - Self-regulation – self-control and affect; Empathy and mentalization
Formulation:
• Stems from the insecure attachment style developed in her early years à inconsistent parenting from an incapable
biological mother, anxious, preoccupied adoptive mother and a passive father
• Caused her to become ambivalent with them, clinging, and anxious about separation and exploration
• Never developed basic trust or the capacity for a secure attachment
• Mother’s anxiety and preoccupation suggests that she was not particularly attuned to Patty àdifficulty developing a sense
of his own affect states, or those of others àcontributed to her adult difficulties with affect management, empathy,
mentalization and self-regulation
• Experienced her father as passive and ineffectual, thus remaining locked in a two-person relationship which her mother
• Hyperactivating strategies to draw her mother’s engagement à achieving academic honors, helping in household chores,
and staying at home àattempts to attain proximity, support and love
• Persisted in her adolescence and young adulthood àConformed to mother’s preference for her college course and choice of
boyfriend
• Questions of her effectiveness as a teacher àassociated this failure to meet expectations with possible abandonment by
her mother
Problem: Patty’s reaction to criticisms about her effectiveness as a teacher has precipitated panic attacks and unwanted, intrusive thoughts
of harming her mother.
• Global, affecting the areas of self, relationships, affect • Traumatic neglectful, abusive, invalidating relationships with her caregivers-
regulation, more than cognition and work and play biological mother and adoptive parents during her earliest years
Organizing idea: ATTACHMENT - Self-regulation – self-control and affect; Empathy and mentalization
Formulation:
• Stems from the insecure attachment style developed in her early years à inconsistent parenting from an incapable
biological mother, anxious, preoccupied adoptive mother and a passive father
• Caused her to become ambivalent with them, clinging, and anxious about separation and exploration
• Never developed basic trust or the capacity for a secure attachment
• Mother’s anxiety and preoccupation suggests that she was not particularly attuned to Patty àdifficulty developing a sense
of his own affect states, or those of others àcontributed to her adult difficulties with affect management, empathy,
mentalization and self-regulation
• Experienced her father as passive and ineffectual, thus remaining locked in a two-person relationship which her mother
• Hyperactivating strategies to draw her mother’s engagement à achieving academic honors, helping in household chores,
and staying at home àattempts to attain proximity, support and love
• Persisted in her adolescence and young adulthood àConformed to mother’s preference for her college course and choice of
boyfriend
• Questions of her effectiveness as a teacher àassociated this failure to meet expectations with possible abandonment by
her mother
How do we know we are on the
right track? (1)
• Sharing our formulations with our patients
• Share parts of the formulation relevant to current
discussion
• Important to consider how and when to share
• Translate formulation into a more
comprehensible language for our patient
• Deepen the psychotherapeutic process and
treatment
• Avoid overwhelming the patient
• Do not invite intellectualization
How do we know we are on the
right track? (2)
• When the patient rejects your formulation:
• Is the formulation wrong or is the patient not yet
ready to accept it?
• How to share
1. Focus on the material closest to the surface
2. Follow the affect
3. Listen to your countertransference
When to Share Formulations
1. Making treatment recommendations
• When recommending psychotherapy, it is
important to tell the patient :
• How we understand the problem
• What treatments are available
• Why we chose the treatment
2. Generating a life narrative
• Can be very therapeutic
• Help them to gain perspective of a difficult
moment in their lives
When to Share Formulations
3. Fostering insight during treatment
• Offering a developmental perspective helps patient
face difficulty insights about themselves
4. Preparing the patient for termination
• Remind patients what they have learned about
themselves
• Gives confidence about confronting new situations in
the future
formulation …
• May evolved over the course of the therapy
Treatment using Attachment
• Patients repeat their attachment styles with their
therapist
• Focusing the work on current, rather than past,
experience
• Patient and therapist can then observe and identify the
attachment style
1. Making people aware of their attachment patterns
2. Helping them form new attachment patterns
Treatment Goals
• Becoming aware of attachment styles
• Helping people be aware of how they evolved
enables patients to create new narratives about
themselves
• Improving affect management
• Help the patient to manage his/her feelings by
describing what is happening à minds of
both the patient and the therapist
Treatment Goals
• Developing a more secure attachment style
• Occur as therapists repeatedly experience,
observe, and describe the way their patients
handle feelings
• Patients internalize this, gradually learning to have a
clearer and more flexible idea of what goes on in
their minds and in the minds of their therapists
• Patients can develop functions that they were not
able to develop as children àIncreased ability to
self-regulate and to modulate affects
In Patty… (1)
• Because of her insecure attachment, we expect her to
have some ambivalence towards the therapist
• Need to gain her trust by demonstrating empathy with
her current subjective state à attunement
• Help in affect regulation
• Must not presume but take a “not-knowing stance”
• Patty’s submissive nature will make her prone to
accept our interpretations
• Invite exploration of her and other people’s mental
state
Bateman A, Fonagy P. Psychoanalytic Inquiry, 33:595–613, 2013

In Patty… (2)
• Arriving at alternative perspectives
• “side-by-side looking at each other’s thoughts and
feelings” à “imagine sitting next to the patient not
opposite”
Bateman A, Fonagy P. Psychoanalytic Inquiry, 33:595–613, 2013

Formulation in Acute Setting
• Special challenges to psychodynamic formulation
• The clinician’s time with patients is usually
limited
• History provided may be incomplete
• The formulation needs to target the acute
problem
Formulation with Pharmacotherapy
• Help clinicians to understand attitudes about …
• Illnesses
• Prescribing and taking of medication
• Treating clinicians
Important to remember…
“We formulate psychodynamically all the time –

when we listen to patients, when we think about
patients, and when we decide what to say to
patients. Ultimately, formulating psychodynamically
is a way of thinking that happens constantly in a
clinician’s mind.”
Summary
• The psychodynamic formulation links the patient’s
problem and patterns with the developmental
history using an organizing idea that centers
around theory
• In one way or another, we share our formulations
with our patients with careful consideration about
when and how
• Formulation is a tool to guide our therapy
• Also applicable in acute settings and when
combining with pharmacotherapy
THANK YOU FOR YOUR
ATTENTION.
Patty’s Problem and Patterns
Problem
•Distressing anxiety due to thoughts of hurting her mother after the PTC meeting and the conversation with her grade-
level coordinator
• Has conflicted • Has difficulty trusting • Has difficulty managing • Intelligent • Limited
sense of self others strong emotions, especially • Dependent on opportunities
• Feels eternally • Views relationships as anger and anxiety mother for for play
indebted to her transactions - assumes • Uses externalizing major decisions • Choice of
mother, thus needs people are using her and strategies to cope with (work and career was
to be completely allows herself to be used, strong emotions choice of forced upon
subservient and also tends to use (compulsive cleaning) partner) her
• Sees herself as people • Uses splitting- based • Poor judgment
better than her • Seeks validation from defenses (e.g. how she (i.e. flirted with
peers people to maintain self- regards her mother, BF, and professor)
esteem grade-level coordinator)
Focused Description
•Main difficulties center on regulating strong negative emotions that stem from difficulties in negotiating ambivalent
relationships. In these situations, her conflicted sense of self is brought to fore.
•Focused question: Why does she have limited, ambivalent relationships?
Patty’s Problem and Patterns
Problem
•Distressing anxiety due to thoughts of hurting her mother after the PTC meeting and the conversation with her grade-
level coordinator
• Has conflicted • Has difficulty trusting • Has difficulty managing • Intelligent • Limited
sense of self others strong emotions, especially • Dependent on opportunities
• Feels eternally • Views relationships as anger and anxiety mother for for play
indebted to her transactions - assumes • Uses externalizing major decisions • Choice of
mother, thus needs people are using her and strategies to cope with (work and career was
to be completely allows herself to be used, strong emotions choice of forced upon
subservient and also tends to use (compulsive cleaning) partner) her
• Sees herself as people • Uses splitting- based • Poor judgment
better than her • Seeks validation from defenses (e.g. how she (i.e. flirted with
peers people to maintain self- regards her mother, BF, and professor)
esteem grade-level coordinator)
Focused Description
•Main difficulties center on regulating strong negative emotions that stem from difficulties in negotiating ambivalent
relationships. In these situations, her conflicted sense of self is brought to fore.
•Focused question: Why does she have limited, ambivalent relationships?
Treatment (1)
• GOAL
• Helping people to understand their problematic
templates and to develop new, healthier ones
• For Patty – develop new template of relating to others
using the relationship with the therapist as a possible
new template
• PROCESS
• Object relations theory suggests that people will
reactivate their early relationship templates with the
therapist in the transference
• Transference needs to be understood and interpreted
Treatment (2)
• PROCESS (cont’d)
• For Patty – expect several possible transferences
to play out
1. Being used by the therapist for his own needs
2. Using the therapist for her own needs, possibly
in fantasies of rescue (could be subtly seductive)
3. Frustration when her needs are not met by the
therapist
4. Submissive attitude towards the therapist out of
fear of being rebuked
Treatment (3)
• Mechanism of change
• Becoming more aware of their negative
relationship templates in therapy, improves
ability to tolerate more ambivalent
connections to people
• Over time, they can develop more complex,
nuanced images of important early
caregivers. As this occurs, the need for
splitting decreases and object constancy
improves
Treatment (4)
• Mechanism of change for Patty
• Therapist can anticipate the possible
transference reactions of Patty towards him/her
• He/she can modulate his/her reactions so
they do not conform to Patty’s expected
reactions based on her relational template
• It can be pointed out that she is reacting as if
she were interacting with her mother
• Differences of the current situation and
relationships with the relationships where she
based her template on can be pointed out
Treatment (5)
• Process of change for Patty (cont’d)
• Repeated interactions will eventually be
internalized through implicit relational
knowing leading to change

§Unwanted §Biological mother Views self as eternally indebted Beginning consolidation

pregnancy, took her away for 3 to her mother for adopting her. of identity as someone
biological years. Sees absolute obedience as moral intelligent but still
mother §May have experienced imperative in exchange for basic continues to be rebuffed
wanted her inconsistent care since needs. by mother.
aborted mother was very young Strives to do well in school to win Tries to assert her own
§Views that and brought her back her mother's validation but is separate identity but
mother has §Negative impact may constantly rebuffed and her forced to bend to her
ulterior have been mitigated achievements are minimized. mother's will.
motives for by more consistent Relationship with father is Responds by accepting
adopting her care by adoptive transactional with no emotional her authority in major
mother connection areas of her life
§Changes in Undeveloped relationship with Continues transactional
environment and peers because of curtailment of relationships with men in
caregiver not freedom to play a sexualized way.
conducive in building Received physical abuse for small Develops maladaptive
trust and sense of mistakes and represses anger out and risky ways of solving
security of fear of abandonment. problem, relying on other
people to rescue her.
FOCUSED REVIEW
Patty’s difficulties may be traced to her earliest years when she was taken away by her biological mother. The inconsistent
mothering during this period may have predisposed her to have difficulty in forming relationships because of her inability to
trust and feel secure.

§Unwanted §Biological mother Views self as eternally indebted Beginning consolidation

pregnancy, took her away for 3 to her mother for adopting her. of identity as someone
biological years. Sees absolute obedience as moral intelligent but still
mother §May have experienced imperative in exchange for basic continues to be rebuffed
wanted her inconsistent care since needs. by mother.
aborted mother was very young Strives to do well in school to win Tries to assert her own
§Views that and brought her back her mother's validation but is separate identity but
mother has §Negative impact may constantly rebuffed and her forced to bend to her
ulterior have been mitigated achievements are minimized. mother's will.
motives for by more consistent Relationship with father is Responds by accepting
adopting her care by adoptive transactional with no emotional her authority in major
mother connection areas of her life
§Changes in Undeveloped relationship with Continues transactional
environment and peers because of curtailment of relationships with men in
caregiver not freedom to play a sexualized way.
conducive in building Received physical abuse for small Develops maladaptive
trust and sense of mistakes and represses anger out and risky ways of solving
security of fear of abandonment. problem, relying on other
people to rescue her.
FOCUSED REVIEW
Patty’s difficulties may be traced to her earliest years when she was taken away by her biological mother. The inconsistent
mothering during this period may have predisposed her to have difficulty in forming relationships because of her inability to
trust and feel secure.
Putting it all Together
Problem: Anxiety due to thoughts of hurting her mother
• Difficulties in regulating strong negative emotions • Difficulties traced to her earliest years
• Ambivalent relationships. • Inconsistent mothering
• Conflicted sense of self • inability to trust and feel secure.
Organizing idea: RELATIONSHIPS - Trust and unrealistic expectations
Formulation:
Patty’s anxiety after having thoughts of hurting her mother may be related to guilt and fear of retaliation after having such
malevolent thoughts. These thoughts may have been triggered by unexpressed anger towards the mother of her student and
her grade-level coordinator for unrealistic expectations of validation and protection. This experience brought to mind her
early experiences with her own mother. Those experiences serve as templates of how she manages her current relationships.
As a child, she received punishment for every mistake and sign of defiance. The anxiety may be an anticipation of
punishment for her thoughts which makes her feel like an ungrateful child. Patty finds it difficult to trust others. The
experience of being adopted, taken away and returned may have made her feel abandoned and unwanted. This was further
aggravated by thoughts of being used by her adoptive mother for her own personal needs. This makes her see herself only as
an instrument to fulfill other people’s needs. Patty responded by learning how to use people as well to gain what she needs
in exchange for favors. This was evident in how she related to her father, her professor and her boyfriend.
Patty’s innate intelligence and strong academic performance are her strengths and helps buttress her flagging self-esteem.
She thus goes to inordinate extremes to preserve it and feels attacked when it is questioned.
Putting it all Together
Problem: Anxiety due to thoughts of hurting her mother
• Difficulties in regulating strong negative emotions • Difficulties traced to her earliest years
• Ambivalent relationships. • Inconsistent mothering
• Conflicted sense of self • inability to trust and feel secure.
Organizing idea: RELATIONSHIPS - Trust and unrealistic expectations
Formulation:
Patty’s anxiety after having thoughts of hurting her mother may be related to guilt and fear of retaliation after having such
malevolent thoughts. These thoughts may have been triggered by unexpressed anger towards the mother of her student and
her grade-level coordinator for unrealistic expectations of validation and protection. This experience brought to mind her
early experiences with her own mother. Those experiences serve as templates of how she manages her current relationships.
As a child, she received punishment for every mistake and sign of defiance. The anxiety may be an anticipation of
punishment for her thoughts which makes her feel like an ungrateful child. Patty finds it difficult to trust others. The
experience of being adopted, taken away and returned may have made her feel abandoned and unwanted. This was further
aggravated by thoughts of being used by her adoptive mother for her own personal needs. This makes her see herself only as
an instrument to fulfill other people’s needs. Patty responded by learning how to use people as well to gain what she needs
in exchange for favors. This was evident in how she related to her father, her professor and her boyfriend.
Patty’s innate intelligence and strong academic performance are her strengths and helps buttress her flagging self-esteem.
She thus goes to inordinate extremes to preserve it and feels attacked when it is questioned.
Open Forum
Summary and Closure

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Dr. Cesar A.

14th POST-GRADUATE COURSE

UTILIZING the PSYCHODYNAMIC FORMULATION to

Discuss the process of making

Explain how to apply the

or that explains thinks, feels, &

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

• Part of a study on the practice of

Video 1: Patty’s Problems and

The Problem with Patty

Old paint on canvass, when they fade,

It is as if the painter changed his mind or,

Patty has uncontrollable

The artisan paints with uncertainty,

It is as if, the teacher connects and engages

In art as in healing conversations,

Use of Others for Self-esteem Patty’s Case

Is there someone in the world whom Patty said yes

Tell me about someone who is important to you. No data

Question to Ask on Sensory Patty’s Case

Question to Ask on Decision- Patty’s Case

New paint on canvass,

It is as if, the artist repaints

Isn’t it that what we help our patients to become

• Nature & nurture

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

• Difficulties with self-esteem

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

•Self-perception & self-esteem

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

•Cognitive development & building

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

• Poor sense of identity

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

•Intimate relationships & sexuality

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

• Dependency on other people

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

•Finding meaning in work & love

Cabaniss DL et al. (2013). Psychodynamic Formulation. USA: Wiley-Blackwell.

Psychodynamic Theories Linking

• We will explain the why Patty has her problems

Principles of the psychodynamic theories

• DSM-V - exposure to actual or threatened death, serious injury or sexual

general family stress

the nature, timing,

the way the difficulty

• ‘‘Mismatch’’ between what we describe and what

• further testing (e.g., neuropsychological testing)

Adult problems can be linked

• Uncovering – making the unconscious conscious

Internalized experiences Adult

• Problems arise from unconscious repetition of early

Child who is loved and Caregiver who is adequately loving

Child who is loved and Caregiver who is adequately loving

• Need-frustrating unsafe; unreliable

Trauma Extraordinarily stressful and disturbing events Problems with self-experience