1/ A case formulation is a working hypothesis for therapist & patient to consider & reflect on together. Therapist should share it with pt, in clear, experience-near language, as a possibility for mutual consideration. Pt can revise, edit, elaborate on, or correct it. It can then
2/ be reformulated based on pt's input, and process repeats until pt & therapist can home in on a formulation that 1) fits pt's experience & 2) fits therapist's psychological understanding of what is underlying pt's difficulties. Formulation is dynamic, not static—it may evolve
3/ as therapy unfolds & new understandings emerge. A simple formulation might be:
Tx: I notice when you describe experiences where you feel rejected or excluded, you dwell on it at length & criticize yourself harshly. But when you tell me about times someone appreciated and
4/ wanted you, you brush past it quickly, before the feelings even have a chance to register. This could help explain why you so often feel down & depressed.
Pt: What do you mean? What does it have to do with depression?
Tx: Well, if you amplify & dwell on painful experiences
5/ and brush aside & minimize experiences that might otherwise be pleasurable, then you'd be left with only painful feelings.
Pt: I see that. But the times people wanted me & included me aren't very important. It's just minor, everyday stuff that doesn't mean anything.
6/ Tx: Yes, that's exactly what I'm talking about. When you have an interaction & feel like the other person isn't that interested, that's a major event. You take it to heart & dwell on it. But when you have an interaction where the other person values & wants you, that's minor &
7/ irrelevant. It barely registers at all.
Pt: [perking up] Why do I do that?
Tx: I don't know yet. Just now, neither of us knows. But I think it could be helpful to understand it so you don't have to keep doing it this way, so the painful feelings don't have to be as painful,
8/ and there can be more room for pleasurable feelings to get in. That's one way therapy could help you. Is that what you want?
Pt: Yes, I do want that.
Here's example of how therapist & pt start to develop case formulation, treatment focus, & WORKING alliance.
9/ *And don't forget WORKING alliance is not an alliance based on just anything. It does not just mean therapist & patient get along well or feel connected. It's an alliance based on a shared purpose—a shared understanding of the work you are there to do together.
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Therapy influencers get millions of follows w 1 core message
😇You are a victim & you are a good
😡Someone else is to blame & they are evil
It feels good because it sides with our defenses, not insight & self-awareness
In the long run, it’s a self-destructive & self-defeating
/2 More specifically, the message bolsters the defenses of splitting and primitive projection—among the costliest defenses of all defenses
Splitting is a form of dissociation where we compartmentalize good and bad feelings, dividing ourselves and others into binary categories
3/ of good and bad. This impairs our ability to perceive reality accurately and function in reality—because people are not cartoonish, two-dimensional caricatures that come in black & white categories. We are talking about human beings. Humans are complex, contradictory, nuanced,
1/ I consider it malpractice for a psychotherapist to do paperwork in session. The patient has a right to our full presence and attention. That’s a bare minimum requirement for a psychotherapy relationship. Without that, psychotherapy is not happening
/2 What we’re really seeing is ever-greater encroachment & intrusion of administrative, bureaucratic, and financial agenda into the therapist-patient relationship & therapy “space,” with less and less space (if there is any space left at all) for the actual work of psychotherapy
3/ That’s bad enough, and profoundly destructive. But what’s worse is when therapists (and instructors & clinical supervisors) identify with these agenda and start conflating these agenda and intrusions with the practice of psychotherapy itself—and start teaching trainees it's
Psychiatrist told my patient she had generalized anxiety disorder & would need to take meds (SSRIs) for life. When she objected, he said the meds were like eyeglasses—she could live without them but would always be handicapped
Symptoms gone after 6 mos psychotherapy & no meds /1
She even asked the psychiatrist if psychotherapy could address her difficulties. That’s when he came up with the eyeglass nonsense. He seemed to operate from the assumption that “GAD” (generalized anxiety disorder) is a medical disease to treat with medication, and a chronic
/2
lifelong one at that
I’d bet my last penny the psychiatrist has no real understanding of what psychotherapy is, how it works, what it can accomplish. He’s supposed to know, but he doesn’t
I’d like to think this is an isolated incident and chalk it up to a bad, uninformed
/3
1️⃣Greater attachment security / sense of safety in relationships
2️⃣More integrated & coherent experience of self & others
3️⃣Increased sense of personal agency
4️⃣ More realistically-grounded & reliable self-esteem
(video at end)
2/ “vital signs” cont'd
5️⃣Greater emotional resilience & capacity for affect regulation
6️⃣Greater ability to reflect on & understand own and others' inner experience ("mentalization")
7️⃣Increased comfort functioning both independently & interdependently (communally)
3/ Ten “vital signs” cont'd
8️⃣ More robust sense of vitality and aliveness
9️⃣ Enhanced capacity for acceptance, forgiveness, gratitude
🔟Movement toward more mature and flexible defenses
*adapted from Nancy McWilliams, Psychoanalytic Supervision, chapt. 3
People misunderstand therapy because they have no template for what serious psychotherapy is. They’ve never encountered it. So they apply their existing templates (friend, teacher) and get it wrong. Many poorly-trained therapist also get it wrong—they’ve never seen the real deal
What people don’t get—and really cannot get unless they’ve been exposed to it—is that a psychotherapy relationship is NOT like other relationships. It’s not like a a friend, teacher, parent, coach, advisor, etc. It’s not like any other social or professional relationship. It’s /2
like a PSYCHOTHERAPY relationship and not comparable to anything else
Skilled therapists learn to create psychotherapy relationships through their own in-depth psychotherapy & through one-on-one clinical supervision/consultation with skilled supervisors. We’re talking years /3