Once we’ve assessed the patient, we can formulate the case in order to recommend treatment using the Problem->Person->Goals->Resources model:
-Problems: what is/are the problems? How do we prioritize them?
-Person: what is this person’s general level of functioning. What is his or her level of ego function? What are his or her characteristics defenses? Super-ego function? What are his or her strengths and weaknesses?
-Goals: What does the person want to help with? What do you think that he or she needs help with?
-Resources: What are the available resources that can be used to try to achieve the goals?
Once we take a history and do a thorough evaluation of the patient, we are ready to formulate the case in order to decide what type of treatment, if any, would be most helpful at this time. The initial formulation can be thought of as bringing together these four clients.
we call this method of formulation the problem->person->goals->resources model. In this chapter , you will learn how to use this model to make the best treatment recommendations for your patient.
So let’s begin with the problem. Defining the patient’s problem often sounds easier than it is. The patient might not be aware of what his or her problem is, or the most presenting problem might not be the patient’s chief complaint. During the assessment phase, one of our main jobs is to determine what we think the patient’s problem is-and if there are numerous problems, to prioritize them.
Ms C presents for psychotherapy saying that she is lonely and that she heard that psychotherapy could be helpful with commitment problems. In the course of the evaluation, you learn that Ms C has been drinking a bottle of wine per night.
In this example, Ms C says that she has a problem with relationships, but it becomes rapidly evident that she has a problem with alcohol. Thus, her chief complaint may not be her most pressing problem. The important thing is to prioritize the patient’s problems without dismissing the patient’s subjective experience of what he or she thinks is most important. Continuing with Ms C, let’s fast forward to the therapist’s formulation:
Therapist-Ms C, I’m so glad that you learned about this treatment and that you are interested in exploring it. You’ve really been unhappy about your relationships and I think that I can help you with that. It also sounds like you’re drinking more than you had been and that this might be exacerbating some of your difficulties. Let’s see if we can create a plan that addresses both of these issues.
We have to remember that just because we’re assessing the patient for psychotherapy doesn’t mean that some other form of treatment might not be indicated. Patients who present for psychotherapy may have many different types of problems, including mood disorders, anxiety disorders, eating disorders, and substance abuse disorders. The presence of a disorder requiring medication does not preclude the use of psychotherapy, including psychodynamic psychotherapy. Depending on the situation, the patient might need to be stabilized with medication before beginning psychotherapy. For example, a very depressed patient with psychomotor retardation might have difficulty speaking in sessions, but once her symptoms improve she might benefit from psychotherapy. On the other hand, a patient with dysthymia and relationship issues might begin medication and psychotherapy at the same time.
As we discussed in Chaper 4, people have characteristics ways of dealing with their environment that we call ego functions. These develop throughout the person’s life and form the basis of the person’s characteristic way of functioning. In formulating the case, we need to not only consider the symptoms that are bringing the person to treatment at this time, but also the person’s underlying ways of responding to stress, relationships, and all of the other internal and external stimuli that face every day. This is the part of the formulation that we call the person. Most importantly, this will include the assessment of ego functions, defense mechanisms, super-ego function, strengths, and weaknesses.
During the assessment, we need to talk to our patients about goals. Understanding the goals of the treatment is essential for making an informed treatment recommendation. Setting goals involves considering both the patient’s hopes and wishes for treatment as well as the therapist’s assessment about what is needed and realistically achievable. The goals of the patient and the therapist are not always the same. Sometimes patients are consciously aware of their goals and sometimes they are not. Sometimes they state them outright and sometimes you have to ask for them. As much as possible, always try to make goal setting a collaborative process.
Regardless, determining the patient’s goals is a critical factor in deciding whether psychodynamic therapy is indicated.
Sometimes psychodynamic psychotherapy is the treatment of choice but the resources are not available. Resources include both:
-factors related to the system, including availability of therapists, types of treatment, and treatment hours.
-Factos related to the patient;s resources, including financiial situation, health insurance, family support and time.
Consider the situations
Mr D is interested in undergoing psychodynamic therapists but there isn’t a therapist in her part of the state who is familiar with this type of treatment. Mr. E has an evaluation for psychotherapy
A sample formulation
Once you have all of these elements, you can construct your initial formulation. Here is an example:
Mr H is a 45 year old man who presents with the chief complaint; “I am not getting along with my wife”
Mr H says that for the past six months, he and his wife have been arguing more than they were before. This is in the context of Mr H’s mother in law coming to live with them during her recovery from a major illness. Mr H says that he loves his wife and that he would like to understand why he is so angry with her. There is no evidence of mood or anxiety disorder.
Throughout life, Mr H has exhibited excellent ego function. He has very good judgment, many close long-term relationships, and a generally good ability to tolerate anxiety and strong affects. This is part of why his recent anger stands out as a problem. His mother died when he was seven years old and he has a vague idea that this could be related to the current problem. (psychological mindedness).
Mr H has a nuanced view of others and can perceive then as having both good and bad qualities. He has many adaptive defenses that are generally repression-based. He sublimates anxiety and aggression by excelling in athletics and pursuing hobbies such as woodworking. He has many close personal relationships that he uses to cope with anxiety and stress. He habitually keeps strong feelings out of awareness, suggesting a prominent reliance on isolation of affect as a defense. He has been reading books about marriage in mid-life to learn more about this problem (intellectualization).
He has kept a job for many years and has many close long-term relationships. He is motivated for treatment and seems to love his wife very much. He derives a great deal of satisfaction from his work.
He occasionally has more than three drinks on a weekend night. Over 10 years ago, he was drinking on a more regular basis. He is somewhat disconnected from his feelings.
Mr H has a developed sense of right and wrong. His guilt regulation tends to be appropriate, as evidenced by his consultation for this problem.
Mr H would like to improve his relationship with his wife and to understand why this situation has made him so irritable. The therapist agrees with this short-term goal and adds the long-term goal of helping Mr H to understand more about the way in which his mother’s death continues to affect his relationships.
Mr H has insurance that will cover 50 percent of the clinic fees, and he is able to pay the rest out of pocket. He will be able to take time at lunch to come to sessions.
In this example, the “person” section tells us that Mr H has generally good ego function and is relatively psychologically minded. His interpersonal problem seems to stem from conflicting feelings about his mother that are coming to the fore in the context of his mother-in-law’s illness and presence in his household. These suggest that Mr X will be helped by a psychodynamic psychotherapy with a primarily uncovering stance designed to help him to learn more about feelings that are out of awareness. He agrees with these goals and has the resources to begin the therapy.
The formulation brings together what we have learned so that we can make a recommendation. In the next chapter, we will review the indications for psychodynamic psychotherapy so that you can use formulation to make the best treatment plan with your patient.