Psychoanalytic Case Formulation / Edition 1

by Nancy McWilliams PhD

Overview

What kinds of questions do experienced therapists ask themselves when facing a new client? How can clinical expertise be taught? From the author of the landmark Psychoanalytic Diagnosis, this book takes clinicians step-by- step through developing an understanding of each client's unique psychology and using this information to guide and inform treatment decisions. McWilliams shows that while seasoned practitioners rely upon established diagnostic categories for record-keeping and insurance purposes, their actual clinical concepts and practices reflect more inferential, subjective, and intuitive processes. Interweaving illustrative case examples with theoretical insights and clinically significant research, chapters cover assessment of client temperament, developmental issues, defenses, affects, identifications, relational patterns, self-esteem needs, and pathogenic beliefs.

Winner—Gradiva Award, National Association for the Advancement of Psychoanalysis

Product Details

ISBN-13:	9781572304628
Publisher:	Guilford Publications, Inc.
Publication date:	03/26/1999
Edition description:	New Edition
Pages:	240
Product dimensions:	6.00(w) x 9.00(h) x (d)

About the Author

Nancy McWilliams, PhD, ABPP, is Visiting Professor Emerita in the Graduate School of Applied and Professional Psychology at Rutgers, The State University of New Jersey, and has a private practice in Lambertville, New Jersey. She is author of Psychoanalytic Diagnosis, Second Edition; Psychoanalytic Case Formulation; Psychoanalytic Psychotherapy; and Psychoanalytic Supervision; and is coeditor of Psychodynamic Diagnostic Manual, Second Edition. She is a past president of the Society for Psychoanalysis and Psychoanalytic Psychology, Division 39 of the American Psychological Association (APA), and is on the editorial board of Psychoanalytic Psychology. A graduate of the National Psychological Association for Psychoanalysis, Dr. McWilliams is also affiliated with the Center for Psychotherapy and Psychoanalysis of New Jersey, and serves on the Board of Trustees of the Austen Riggs Center in Stockbridge, Massachusetts. She is the recipient of honors including the Gradiva Award from the National Association for the Advancement of Psychoanalysis; the Goethe Scholarship Award from the Section on Psychoanalytic and Psychodynamic Psychology of the Canadian Psychological Association; the Rosalee Weiss Award from the Division of Independent Practitioners of the APA; the Laughlin Distinguished Teacher Award from the American Society of Psychoanalytic Physicians; the Hans H. Strupp Award from the Appalachian Psychoanalytic Society; and the International, Leadership, and Scholarship Awards from APA Division 39. Dr. McWilliams is an honorary member of the American Psychoanalytic Association, the Moscow Psychoanalytic Society, the Institute for Psychoanalytic Psychotherapy of Turin, Italy, and the Warsaw Scientific Association for Psychodynamic Psychotherapy. Her writings have been translated into 20 languages.

Read an Excerpt

CHAPTER 1

The Relationship between Case Formulation and Psychotherapy

This book represents an elaboration of my deeply held conviction that for therapy to be therapeutic, it is more important for the clinician to understand people than to master specific treatment techniques. I have nothing against technique, and in my own development as a psychotherapist, I have honed many useful technical skills. But I look with dismay on the current enthusiasm for generating "empirically validated treatments" ("EVTs") and teaching this collection of symptom-specific and manualized strategies as if it represents the essence of the psychotherapy process. The excitement over EVTs has created a growth industry in some sectors of the mental health economy — if you own the rights to a quick and empirically supported treatment for a problem that has attained a DSM label, you can probably retire tomorrow — but it threatens to do so at the cost of depriving beginning therapists of a vast and clinically invaluable literature on the treatment implications of any human being's individual psychology.

It seems to me self-evident that unless one understands someone's unique, personal subjectivity, one cannot infer the best treatment approach for that individual. What helps one person can damage another, even if the presenting problems of the two people seem comparable, and even if a particular strategy has reduced target symptoms in a statistically significant number of people in a well-defined pool of subjects with similar problems. As many clinically sophisticated observers have pointed out (e.g., Goldfried & Wolfe, 1996), the procedures and conditions that confer "empirical validation" on a technique are usually markedly different from the circumstances in which most practitioners work. And the current economic and political pressures to redefine psychotherapy as a set of short and symptom-targeted procedures are so patently incompatible with the intellectual and professional motivations of most practitioners as to be laughable.

But even putting aside the issue of whether contemporary trends in third- and fourth-party involvement are undermining good mental health care, there is an ongoing need for our training literature to explicate the bases on which most experienced therapists draw their treatment conclusions. I have felt for many years that psychotherapy is too frequently taught "backward," with a favored technique taught before a trainee fully appreciates the conditions that give rise to the need for that technique. Specifically, the student of therapy is told that a particular approach is the "best" or "true" way to reduce psychological suffering, with the explicit or implied codicil that patients who cannot conform to that way of working must receive "deviations" from the best technique or, worse, be rejected as untreatable. Psychoanalytic institutes have probably been more guilty of this than any other training organizations, with their common prejudice that psychoanalysis is the treatment of choice for anyone who is "analyzable," and that lesser candidates for treatment require rather unfortunate "parameters" — therapeutic "alloys" instead of Freud's "pure gold." But I have found comparable conceits in the trainers of family therapists, Gestalt therapists, rational–emotive therapists, humanistic therapists, and others.

Often such teachers are relatively distant from the clinical trenches and have some personal interest in promulgating a particular approach. In a reasonable world, however, technique would be derived from an understanding of personality and psychopathology, not from the technical preferences of the practitioner (cf. Hammer, 1990).

In what follows, I talk almost exclusively about the implications of a good case formulation for psychoanalytically oriented treatment. I hope readers of other orientations will nonetheless be able to make the necessary translations into their own favored concepts and find the material applicable to their work. I have written within a psychoanalytic framework because I have always had a temperamental affinity for psychoanalytic theory, because analytic concepts constitute the professional language in which I have learned to speak, and because I have seen analytic therapy work. I do not think psychoanalytic treatment is the only way to help people, and in fact, I think a good psychodynamic case formulation can be an excellent basis for designing a cognitive-behavioral treatment or family systems therapy or other intervention.

Although I am a psychoanalyst, I find myself recommending family therapy, or relaxation exercises, or psychoeducation, or eye movement desensitization and reprocessing, or sex therapy, or a medication consult, or numerous other nonpsychodynamic interventions, depending on my understanding of a person's particular psychology. I send patients to behaviorally trained colleagues when I lack the skills to address a particular area of their suffering, and they send clients to me when they feel there is some personality issue operating that can only be addressed in long-term, intensive, analytic therapy. Most practicing clinicians I know do the same. What conscientious therapists have in common, despite their differences in favored theories and language, is their effort to understand each patient as fully as possible, so that they can make the most informed treatment recommendation. Assuming my readers share this attitude, let me begin by articulating some central psychoanalytic ideas relevant to case formulation.

BASIC PREMISES

In creating a psychodynamic case formulation, the interviewer's aim is usually to increase the probability that psychotherapy for a particular person will be helpful. There are, of course, other reasons to formulate a case, including a clinician's effort to give appropriate advice to staff dealing with a patient, or figuring out what to say to a patient's family, or making a good referral. But they are all related to working out the best intervention for the person whose psychology is being conceptualized. By understanding the idiosyncratic way an individual organizes knowledge, emotion, sensation, and behavior, a therapist has more choice about how to influence him or her in all these areas and to contribute to the improvements in life for which he or she has sought professional help. When we construct a formulation that seems to make sense of the diverse pieces of information we get in an intake interview, we do so with a view to exerting therapeutic influence on the patient's subjective world.

Because the whole point of a dynamic formulation is the development of interventions that will achieve certain therapeutic goals, it may be helpful for me to say a few things about the goals of psychotherapy as they are understood by most psychoanalytic practitioners. The fact that several of these goals are attainable only in traditional, long-term therapy should not deter clinicians with more circumscribed treatment possibilities from making careful case formulations; in fact, the shorter the time and the more compromised the circumstances in which one can do therapeutic work, the more critically important are the therapist's working hypotheses. I am emphasizing traditional goals for three reasons: (1) to orient those who are still able to do standard, open-ended psychoanalytic therapy; (2) to encourage those in less favorable situations to distill from these objectives what is possible and applicable in their settings, and (3) to give voice to a set of deeply cherished values that contemporary economic and political pressures have been undermining.

Despite the fact that psychodynamic therapists try not to moralize or to impose their personal views on patients, and despite the historical concern of analysts to avoid being enforcers of the conventions of particular cultures or subcultures, psychoanalytic therapy is not, and has never pretended to be, free of either basic assumptions or organizing values. When we talk about improvement in therapy (under which rubric I include both weekly, face-to-face treatment and more intensive forms such as classical psychoanalysis), we refer implicitly to a range of goals that go beyond relief of the specific problem for which a person has sought help. Some clients share the treater's broader vision of health and growth implicitly at the outset of treatment, and others come to it out of identification with the therapist during the course of their therapeutic work.

This vision of the objectives of therapy includes the disappearance or mitigation of symptoms of psychopathology, the development of insight, an increase in one's sense of agency, the securing or solidifying of a sense of identity, an increase in realistically based self-esteem, an improvement in the ability to recognize and handle feelings, the enhancement of ego strength and self-cohesion, an expansion of the capacity to love, to work, and to depend appropriately on others, and an increase in the one's experience of pleasure and serenity. In addition, there is empirical as well as anecdotal evidence that when these changes occur, other specific improvements happen as well, including better physical health and greater resistance to stress (Gabbard, Lazar, Hornberger, & Spiegel, 1997). A comment on each area follows.

GOALS OF TRADITIONAL PSYCHOANALYTIC THERAPY

Symptom Relief

It probably goes without saying that the primary objective of psychotherapy is relief of the problem(s) for which the client originally requested treatment. It is my impression that symptom relief for most conditions occurs about as fast in dynamically oriented therapy as it does in other kinds of treatment. A patient's "presenting problem" or "chief complaint," which has typically become unbearable at the time he or she decides to give up commonsense self-treatment and consult a professional, often ameliorates or diminishes in severity once a therapeutic relationship is secure. Given the opportunity, people tend to stay longer in analytic treatment not because they are not getting help but because they are. Analytically oriented therapy tends to go on longer than therapy conducted in accordance with other theoretical orientations, because both client and therapist are pursuing goals of general mental health that go beyond the swift removal of a particular disturbance.

It is also rare that someone comes to a therapist with a single, delimited difficulty. The young woman with "simple" anorexia turns out to be enmeshed in a perfectionistic family in which her eating disorder is only one expression of her entrapment; the man who comes for short-term couple therapy to "improve his communication" with his wife turns out to have a secret lover who is rearing his unacknowledged child; the little boy referred for "acting up" with authorities has a private habit of torturing small animals. People rarely put their ostensible presenting problems in a detailed, confessional package when they come to a stranger; they prefer to feel out the therapy relationship before prying open their personal Pandora's box. In fact, many patients keep important secrets from their therapists for years, until they have built up enough trust to tolerate the anxiety that goes with revealing any area of deep shame, or until they have been helped enough in other areas to have a basis for hope that they could change in the area of the secret. Studies that limit subjects to those with a circumscribed, admitted complaint (as most studies of psychotherapy efficacy must do in order to zero in on a particular phenomenon) can shed only the weakest light on symptom relief as it actually happens in the field.

Finally, people typically come to analytic therapy because they want to get at the attitudes and feelings that underlie their vulnerabilities to particular symptoms. Sometimes they know this at the outset of treatment, and sometimes it is clearer to them in retrospect. One can often get someone to stop behaving in a self-destructive way, but it takes considerable time and work to get that person to a place where there is no longer a vulnerability or temptation to do so. People come to analytic therapy not just to get control over a troublesome tendency but to outgrow or master the strivings that are causing such a battle over control. The man who is compulsively unfaithful to his partner wants not just to stop having affairs but to be relieved of his constant preoccupation with fantasies about them. The woman with an eating disorder wants not just to stop vomiting but to get to the point where food is merely food to her, not a repository of desperate temptation and wretched self-loathing. A man or woman who was sexually abused in childhood wants to change internally, subjectively, from feeling like a sexual abuse victim who happens to be a person to a person who happens to have been a sexual abuse victim (Frawley-O'Dea, 1996).

Insight

Early in the psychoanalytic movement, there was an idealization of understanding as the primary route to emotional health. Freud's idea that the key to healing was to make conscious what had been unconscious derived both from his experiences of patients' symptomatic improvements when they were able to remember and feel things they had consigned to the unthinkable and from a general scientific positivism that assumed that to understand something was to master it. The equation of truth with freedom, an association at least as old as the oracle at Delphi (whose motto was "Know thyself") still pervades most psychoanalytic thinking.

Although contemporary analysts consider understanding, especially the affectively charged "Aha!" kind of understanding that has usually been termed "emotional insight," to be of immense therapeutic significance, they also credit numerous "nonspecific" factors (e.g., the therapist's quiet modeling of realistic and self-respectful attitudes, the client's experience and internalization of the therapist's stance of acceptance, the fact that the therapist survives the patient's seemingly toxic states of pain and rage) with just as much power. In fact, over the past couple of decades, almost all psychoanalytic writing about what is curative in therapy stresses relationship aspects of the treatment experience over traditional notions of insight (e.g., Loewald, 1957; Meissner, 1991; Mitchell, 1993).

Even the meaning of "insight" has shifted over the years from a somewhat static concept to a process embedded in relationship. In the "modern" age of psychoanalytic evolution, the term implied the attainment in therapy, via help from a dispassionate, objective practitioner, of an accurate understanding of one's personal history and a realistic appreciation of one's motives and circumstances (e.g., Fenichel, 1945). In these postmodern times, the term implies that patient and therapist have created together, from their combined subjectivities and the quality of the relationship that evolves between them, a narrative that makes sense of the client's background and predicament — a narrative truth rather than a historical one (Levenson, 1972; Spence, 1982; Atwood & Stolorow, 1984; Schafer, 1992; Gill, 1994). It is emblematic of current sensibilities that Donna Orange suggested for her recent book on psychoanalytic epistemology (Orange, 1995) the title "Making Sense Together."

Despite the dethronement of insight from its position as the sine qua non of psychological change, for analytic therapists, and for most clients, understanding remains a central goal. Both parties in the therapy relationship try to articulate the "unthought known" (Bollas, 1987). The analytic emphasis on understanding is partly attributable to the fact that the two participants in the work need something interesting to talk about while the nonspecific relational factors are doing their quiet healing. It may also reflect the fact that the kinds of people who seek to practice or undergo psychoanalytic therapies appreciate insight as a value in itself. Knowledge is thus pursued for its own sake in dynamic therapy, as well as for the sake of specific treatment goals.

Agency

In the preceding paragraphs, I mentioned the ancient conviction that knowing the truth sets people free. An internal sense of freedom is probably one of the most precious aspects of anyone's personal psychology. Most clients come to therapists because something is compromising their subjective sense of agency. They are being controlled by their depression or their anxiety or their dissociation or their obsession or compulsion or phobia or paranoia and have lost the sense of being master of their own ship. Sometimes they come because they have never felt in charge of their life, and they are beginning to imagine that such a state of mind would be possible if they were to get some help.

(Continues…)

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Excerpted from "Psychoanalytic Case Formulation"
by .
Copyright © 1999 Nancy McWilliams.
Excerpted by permission of The Guilford Press.
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Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Introduction
1. The Relationship between Case Formulation and Psychotherapy
2. Orientation to Interviewing
3. Assessing What Cannot Be Changed
4. Assessing Developmental Issues
5. Assessing Defense
6. Assessing Affects
7. Assessing Identifications
8. Assessing Relational Patterns
9. Assessing Self-Esteem
10. Assessing Pathogenic Beliefs
Concluding Comments

Interviews

Mental health practitioners and students, regardless of primary theoretical orientation. Serves as a text for graduate-level students of clinical psychology and psychiatry and for trainees in psychoanalytic institutes.

Editorial Reviews

"Books by Nancy McWilliams used in unison make the best psychodynamic resources I have yet encountered in more than 60 years in the field."—Robert C. Lane, PhD, Department of Psychology, Nova Southeastern University

"This beautifully written, uniquely accessible guide to the psychoanalytic understanding of clinical cases will be of immense value to students and practitioners of all theoretical persuasions. I predict it will be among the most important and widely used books in this field for years to come." —George E. Atwood, PhD, Professor of Psychology, Rutgers University, New Brunswick, New Jersey

"Psychoanalytic Case Formulation is a worthy successor to Psychoanalytic Diagnosis. Nancy McWilliams has a pellucid writing style that brings complex concepts within the easy grasp of the reader. She has produced a book that is intelligently psychoanalytic without being restricted to any single vision of psychoanalysis. The critical concepts are developed well and the issues important to assessment—a concept that goes well beyond diagnosis—are explicated clearly and helpfully. This is a rare book that can serve as a text for beginning students and still has much to offer to accomplished professionals." —George Stricker, PhD, The Derner Institute, Adelphi University, Garden City, NY

From the Publisher

Reviewer: Daniel M. Haycraft, MD (Rush University Medical Center)
Description: The author's latest contribution to the field of psychotherapy is an artful and detailed development of the thought processes and subjective, empathic components of the therapeutic experience that ultimately guide development of case formulation in psychotherapeutic treatment.
Purpose: She set out to develop a written model of the thoughts, processes, and subjective aspects used by experienced analysts for developing treatment plans. This is a worthy, albeit ambitious goal, since learning the psychotherapeutic process has traditionally occurred through a mentorship model. She meets her objective well, producing an invaluable resource for those wanting to develop skill in the art of psychotherapy.
Audience: The book is primarily targeted toward those in the process of learning to become psychotherapists. It may, however, be equally beneficial for experienced therapists as well as for practitioners insisting on an "empirically based" approach to patient care. The author has excellent credibility, both from her academic and professional standing as well as from her landmark book Psychoanalytic Diagnosis.
Features: She presents a contemplative presentation of the thought processes and empathic experiences of an experienced psychotherapist, beautifully illustrated through case presentations. These thoughts and subjective experiences develop into an understanding of the dynamics of the patient's personality, which allow the case formulation to flow effortlessly from the understanding of the person.
Assessment: This is an excellent book. It is pleasurable reading, from a gifted author who simplifies one of the most arduous tasks of psychotherapeutic treatment.

Doody's Review Service

3 Stars from Doody

The author's latest contribution to the field of psychotherapy is an artful and detailed development of the thought processes and subjective, empathic components of the therapeutic experience that ultimately guide development of case formulation in psychotherapeutic treatment. She set out to develop a written model of the thoughts, processes, and subjective aspects used by experienced analysts for developing treatment plans. This is a worthy, albeit ambitious goal, since learning the psychotherapeutic process has traditionally occurred through a mentorship model. She meets her objective well, producing an invaluable resource for those wanting to develop skill in the art of psychotherapy. The book is primarily targeted toward those in the process of learning to become psychotherapists. It may, however, be equally beneficial for experienced therapists as well as for practitioners insisting on an "empirically based" approach to patient care. The author has excellent credibility, both from her academic and professional standing as well as from her landmark book Psychoanalytic Diagnosis. She presents a contemplative presentation of the thought processes and empathic experiences of an experienced psychotherapist, beautifully illustrated through case presentations. These thoughts and subjective experiences develop into an understanding of the dynamics of the patient's personality, which allow the case formulation to flow effortlessly from the understanding of the person. This is an excellent book. It is pleasurable reading, from a gifted author who simplifies one of the most arduous tasks of psychotherapeutic treatment.

Daniel M. Haycraft

Shows clinicians how to develop a dynamic case formulation and use this information to guide and inform treatment decisions, synthesizing clinical literature, diverse psychoanalytic viewpoints, and empirical research in psychology and psychiatry. First describes effective intake procedures and rationales, then looks closely at different aspects of the dynamic formulation. Guidelines are presented for assessing client temperament, developmental issues, defenses, self- esteem needs, and pathogenic beliefs. Case formulation is clearly and explicitly connected to treatment. Annotation c. Book News, Inc., Portland, OR (booknews.com)

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