Never Mind!
Some Caveats Regarding Psychodynamic Formulations
During the pandemic, I collaborated with several colleagues from the Columbia Center for Psychoanalytic Training and Research in revising a book that teaches how to do a psychodynamic formulation (Psychodynamic Formulation Project, 2022). The book is highly recommended for training purposes of students and residents going into psychiatry and other mental health disciplines.1
What are Psychodynamic Formulations?
For clinicians, formulations serve a synthetic function. Ideally, they distill all information gathered during a patient interview into digestible bites. Doing so allows practitioners—whether presenting a case to a senior colleague, a consultant, a peer or the readers of an academic book or journal—to communicate with each other about the work being done with patients.
Psychodynamic formulations resemble case descriptions in other medical specialties. In a medical case formulation, one presents a history of the presenting illness, a past medical history, a review of the body’s different organ systems (cardiac, gastrointestinal, neurological, etc.), a physical examination and laboratory findings. All of this is then distilled into a diagnostic assessment followed by a treatment plan.
Nevertheless, there are some distinctions between medical diagnostic assessments and psychodynamic formulations.
Ideally, a medical assessment relies upon objective findings. These would include a physical examination that requires seeing, touching, auscultating (listening with a stethoscope), smelling and historically even tasting. Laboratory data, such as blood and urine tests, X-rays, CT scans, MRIs and tissue biopsies, are used to substantiate most medical assessments in the modern age.
Psychodynamic formulations, however, are more subjective. Although some objective findings are observable (a depressed patient is crying, a manic patient is speaking loudly and rapidly, an anxious patient is unable to sit still, etc.), the underlying causes of most psychiatric disorders are unknown. This means there are often no laboratory tests to confirm a case formulation.
Complicating matters further, even the history provided by a patient may be inaccurate, whether due to cognitive issues, selective memory, dissociation, outright lying or repression (Freud, 1915; Spence, 1982).
Finally, psychodynamic formulations are often characterized by theoretical biases that reflect the belief system of the formulator. These biases are most obvious when looking at some of the psychodynamic formulations from the past described below—but these biases can be seen in the present day as well.
The Case of Ulcers
In a 1938 case write-up, the formulator arrived at the conclusion that the patient had an Ulcer Personality. At that time, recurrent ulcers were thought to be a psychosomatic illness, the result of the mind creating physical symptoms in the body:
“This patient is a forty-one-year-old female attorney who came to analysis for recurrent duodenal ulcer, agoraphobia, handwriting difficulties and a feeling of social maladjustment. . . [She] exhibited certain personality trends described as frequent in ulcer personalities.
“Specifically, I refer to the intense incorporating tendencies which are repressed and lead to over-compensation through increased activity and ambitious effort in life. She was an aggressive, hard-working, efficient and successful attorney. She maintained a very independent attitude towards other members of the firm and refused to accept favours from anyone. The deeper oral receptive and aggressive tendencies were almost but not entirely denied” [Wilson, 1938, pp. 23-24].
The psychoanalytic literature abounds with case histories formulating psychodynamic causes for gastrointestinal ulcers. However, in 1983, gastroenterologists Barry Marshall and Robin Warren, who would later go on to win the 2005 Nobel Prize in medicine, first published their discovery of Helicobacter pylori, a bacterium found to cause gastric ulcers.
Consequently, antibiotics are now the contemporary treatment of what was once considered a psychosomatic illness thought to be brought on by intrapsychic conflicts making it amenable to psychoanalytic treatment.
To quote Emily Litella (aka Gilda Rader) regarding the the psychoanalytic theory of ulcers:
Formulating Homosexuality
Ulcers were not the only clinical issue subject to questionable psychodynamic formulations. Consider the field’s historic theorizing about homosexuality. In the following published case report from the 1950s, the patient’s homosexuality is formulated as a psychological and behavioral problem arising from his relationship with his mother:
“He was thirty-four years old, unmarried, when he came for treatment because of insomnia, indecision, periodic gastric distress, a tendency to withdraw from others, and an increasing impulse toward homosexual gratification. The homosexuality had been manifest in his late adolescent and early adult life. During the past three years he had been interested in women and in men but was active sexually only with men.
“The case demonstrates that the mother had long been unconsciously seductive with her son and that this parent’s specific permissive impulse, communicated to the patient as an adolescent, induced his overt homosexual behavior.” [Kolb & Johnson, 1955, p. 508]”
Yet, despite the claims formulated by these authors, the “causes” of homosexuality—or of heterosexuality for that matter—remain unknown and a question of ongoing scientific interest (Bailey et al., 2016).
Although historic formulations about the “causes” of homosexuality had little scientific basis, they dominated psychoanalytic thinking for much of the twentieth century. It was only in 1973, after being challenged to actually review the science, that the American Psychiatric Association (APA) removed the diagnosis of homosexuality from its diagnostic manual (DSM). The World Health Organization later followed suit in 1992 by removing the diagnosis from the ICD-10 (Bayer, 1981; Sbordone, 2003; Cochran et al., 2014; Drescher, 2015).
Nevertheless, it took several decades for psychoanalytic practitioners, deeply attached to their own formulations, to accept the growing consensus that homosexuality was a normal expression of human sexuality (Drescher, 2008; Isay, 1996; Roughton, 2002).
So what are we to make of the psychoanalytic theory of homosexuality?
The Negro Personality
A final historical example is this formulation regarding the “lower-class Negro Personality” in a 1951 study:
“The result of the continuous frustrations in childhood is to create a personality devoid of confidence in human in human relations, of an eternal vigilance and distrust of others. This is a purely defensive maneuver which purports to protect the individual against the repeatedly traumatic effects of disappointment and frustration. He must operate on the assumption that the world is hostile.
“The self-referential aspect of this is contained in the formula, “I am not a lovable creature.” This, together with the same idea drawn from the caste situation, leads to a reinforcement of the basic destruction of self-esteem” [Kardiner & Ovesey, 1951, p. 308].
While reading such formulations may seem jarring to a modern reader’s sensibility, they are consistent with a time when professional white men found it perfectly reasonable to explain what they “knew” about the psychology of Black people. The most dramatic, historic example of such hubris was the 19th century diagnosis of drapetomania, a medical rationalization describing “the disease that caused slaves to run away.”
As for the psychoanalytic theory of the Negro personality . . .
Theory’s Impact on Formulations: Pick Your Own Secret Sauce
Finally, most psychodynamic formulations are further complicated by the theories to which a case’s formulator adheres. Kardiner & Ovesey, referenced above, frequently refer to “adaptation” in their study of Black men, a reference to “adaptational psychodynamics,” a theory proffered by the founder of their psychoanalytic school, Sandor Rado (1969).
Yet, as noted in a previous post, there are multiple “schools” of psychoanalysis, with differing groups ascribing their own meanings and importance to differing developmental milestones (Greenberg & Mitchell, 1983; Stepansky, 2009).
For example, when doing a psychodynamic formulation, one might theorize that the patient’s problems stem from the first year of [preoedipal] development (Klein, 1935). Perhaps difficulties arise from factors in ages three to five (Freud, 1924). Maybe the problems stem from issues arising in pre-adolescence (Sullivan, 1956). It is even possible to formulate a case based upon psychological vulnerabilities during any stage in the life cycle (Erikson, 1950).
Yes, Do Formulate, But Hold Your Theory Lightly
The purpose in demonstrating some problems embedded in psychodynamic formulations is not to discourage anyone from formulating. After all, it would be difficult to do any clinical work with a patient without having some kind of formulation to guide the treatment.
However, it is important to be aware of the limitations of one’s formulations. One should be prepared to hold one’s formulations lightly, meaning they should be subject to change and reformulation when new information arises.
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1. Disclosure: All royalties from Psychodynamic Formulation: An Expanded Approach are being donated to the Margaret Morgan Lawrence Scholarship Fund at the Columbia Center which offsets the cost of training people from groups underrepresented in psychoanalysis. Dr. Lawrence was a Columbia Center graduate and America’s first Black psychoanalyst.
REFERENCES
Bailey, M.J., Vasey, P.L., Diamond, L.M., Breedlove, S.M., Vilain, E. & Epprecht, M. (2016). Sexual orientation, controversy and science. Psychological Science in the Public Interest, 17(2):45-101.
Bayer, R. (1981). Homosexuality and American Psychiatry: The Politics of Diagnosis. New York: Basic Books.
Cochran, S.D., Drescher, J., Kismodi, E., Giami, A., García-Moreno, C. & Reed, G.M. (2014). Proposed declassification of disease categories related to sexual orientation in ICD-11: Rationale and evidence from the Working Group on Sexual Disorders and Sexual Health. Bulletin of the World Health Organization, 92:672–679.
Drescher, J. (2008). A history of homosexuality and organized psychoanalysis. J. American Academy of Psychoanalysis & Dynamic Psychiatry, 36(3):443-460.
Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5:565-575.
Erikson, E.H. (1951). Childhood and Society. New York: W. W. Norton.
Freud, S. (1915). Repression. Standard Edition, 14:141-158. London: Hogarth Press, 1957.
Freud, S. (1924). The dissolution of the Oedipus complex. Standard Edition, 19:73-79. London: Hogarth Press, 1961.
Greenberg, J. & Mitchell, S.A. (1983). Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press.
Isay, R.A. (1996). Becoming Gay: The Journey to Self-Acceptance. New York: Pantheon.
Kardiner, A. & Ovesey, L. (2014/1951). The Mark of Oppression: Explorations in the Personality of the American Negro. Mansfield Centre, CT: Martino Publishing.
Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. International J. Psycho-analysis, 16:145-174.
Kolb, L.C. & Johnson, A.M. (1955). Etiology and therapy of overt homosexuality. Psychoanalytic Quarterly, 24:506-515.
Pincock, S. (2005). Nobel Prize winners Robin Warren and Barry Marshall. The Lancet, 366(9495):1429.
Psychodynamic Formulation Project (2022). Psychodynamic Formulation, 2nd Edition. Hoboken, NJ: Wiley-Blackwell.
Rado, S. (1969). Adaptational Psychodynamics: Motivation and Control. New York: Science House.
Roughton, R. (2002). Rethinking homosexuality: What it teaches us about psychoanalysis. Plenary Address. J. American Psychoanalytic Association, 50:733-763.
Sbordone, A.J. (2003). An interview with Charles Silverstein, PhD. J. Gay & Lesbian Psychotherapy, 7(4):49-61.
Spence, D. (1982). Narrative Truth and Historical Truth: Meaning and Interpretation in Psychoanalysis. New York: Norton.
Stepansky, P.E. (2009). Psychoanalysis at the Margins. New York: Other Press.
Sullivan, H.S. (1956). Clinical Studies in Psychiatry. New York: Norton.
Warren, J.R. & Marshall, B. (1983). Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet, Jun 4;1(8336):1273-1275.
Wilson, G.W. (1938). The transition from organ neurosis to conversion hysteria. International J. Psycho-Analysis, 19:23-40.