The psychodynamic formulation in child and adolescent psychiatry

DSM-III and DSM-III-R aid diagnostic clarity but do not help clinicians plan for common therapies available. A psychodynamic formulation has been described for adults to complement diagnosis and guide management. Child and adolescent psychiatrists would benefit if such a scheme were available for their use. Psychodynamic formulations based on current models are offered and their elements are described. Case vignettes and therapeutic plans are presented to show the practical value of a formal psychodynamic formulation, regardless of the treatment employed.     

The psychodynamic formulation updated

The goal of this article is to update the conceptualization and format of the traditional psychodynamic formulation to include new areas of knowledge and thereby increase its usefulness. Following a historical review of the concept of psychodynamic formulation, new elements are proposed as essential to update this clinical and educational tool. The traditional formulation format is described along with the modifications necessary to incorporate the new elements. A case example of an updated formulation is offered, including the traditional and new elements, and the potential value and limitations of this new approach are discussed.     

The psychodynamic formulation. How and why

Medical students and psychiatric residents are often required to write psychodynamic formulations. Guidelines are given to accomplish this task, which include consideration of the precipitating event and the needs that are stimulated by it. Next, the regulating and mediating functions of the mind are discussed along with predisposing factors. Two clinical cases are presented and sample formulations are given. Finally, the author relates the psychodynamic understanding to the overall treatment of the patient.     

The current status of psychodynamic formulation

In this paper, we examine the current status of psychodynamic formulation in psychiatric training and clinical practice. A survey of residency training directors confirms the presence of a general belief in the central importance of formulation but the absence of a clear definition or systematic guidelines. We review the literature and propose a definition of psychodynamic formulation, distinguishing it from isolated hypothesis or focus, diagnosis, case history and interpretation. We then present a systematic but flexible format for formulation and illustrate it with two case formulations.     

A method of teaching psychodynamic case formulation

In light of the paucity of literature discussing the systematic instruction of trainee psychologists in psychodynamic case formulation, the author introduces an eight-step method for teaching the theory and application of psychodynamic case formulation. The method involves clarifying the nature of psychodynamic formulations, outlining the characteristics of competent formulations, presenting a conceptually simple structure for organizing case material, exposing trainees to carefully selected written and video-recorded cases, and getting trainees to use their subjective responses to video-recorded initial clinical interviews as a source of useful hypotheses. A case study from the literature is used to demonstrate this formulation methodology. The paper concludes with a discussion of both the prerequisites for, and characteristics of, competent case formulation. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

The place of psychodynamic psychiatry in consultation-liaison psychiatry with special emphasis on countertransference

Psychodynamic theory can be applied to all aspects of consultation-liaison work. There are various psychodynamic treatment approaches that can have a powerful meaning to the patient. This can include understanding the patient's life trajectory through the elicitation of a life narrative, understanding defense mechanisms, and utilizing the patient's fantasies about illness. Patients who are physically ill regress and want to be understood. When this is achieved through a psychodynamic approach, the patient will be more likely to accept a referral for psychiatric follow-up when it is indicated. The consultation-liaison psychiatrist will also encounter transference and countertransference manifestations. Of particular usefulness can be derivatives of classical countertransference, which can be seen as reactions and identifications by the treating psychiatrist or the medical team to the patient that may interfere with effective care. "Countertransference Rounds" is a technique for examining such manifestations during the C-L team's discussion of patients.     

The case formulation in child and adolescent psychiatry

This article reviews the various definitions of case formulation, differences between diagnosis and case formulation, how case formulation for the child patient differs from the adult patient, and case formulation in the context of residency training, including challenges for residents transitioning from adult psychiatry. It presents a suggested structure for constructing a biopsychosocial formulation that can be applied in a training setting. Several specialized types of psychotherapy formulation are reviewed in more detail. The article concludes with a case example of a child psychiatry resident's case formulation before and after discussion in supervision.     

The psychodynamic formulation: its purpose, structure, and clinical application

The authors present a brief written psychodynamic formulation that focuses on central conflicts, anticipates transferences and resistances, and helps guide all psychiatric treatments. After placing the presenting problem in the context of the patient's life and identifying nondynamic determinants of the psychopathology, the formulation explains the development of central conflicts and their repetitive effect on the patient's behavior. It concludes by describing how these conflicts will be manifested in treatment. Three sample formulations and their application are presented to illustrate the value of this clinical tool.     

Assessing psychodynamic conflicts: I. Reliability of the idiographic conflict formulation method

Recent years have seen increasing interest in devising methods of studying psychodynamic phenomena. These efforts have had confront difficulties, first, in specifying the data, the observation language, and rules of inference for psychodynamic propositions, and second, in determining the reliability and validity of the measures used. Given how "fuzzy" traditional psychodynamic concepts are, it is no wonder that psychodynamic clinicians from Freud onward have achieved more success in generating new hypotheses than in testing their validity. As Reichenbach (1938) has observed, science requires that discovery be followed by systematic validation of all new propositions, regardless of their degree of popular acceptance. At the core of efforts to study psychodynamics have been methods to study ego functioning (Bellak and Goldsmith 1984), defense mechanisms (Perry and Copper 1988), and psychodynamic conflicts. This paper reports on the reliability of the Idiographic Conflict Formulation (ICF), a guided method for formulating an individual's psychodynamic conflicts.     

Adapting the cultural formulation for clinical assessments in forensic psychiatry

Even as forensic psychiatrists have increasingly contemplated the role of culture in forensic psychiatry, practical cultural evaluations remain an under-theorized area with scant research. Older conceptions of cultural competence may risk stereotyping the evaluee on the basis of perceived group characteristics. This article offers a revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) Outline for Cultural Formulation for use in forensic psychiatry by adjusting its formal guidelines with recommendations from the forensic mental health literature. As a person-centered method of conducting the interview, the Cultural Formulation probes cultural explanations of identity, illness, social support, functioning, and interaction with the medical and legal systems. In line with other psychiatric subspecialties, future research in forensic psychiatry can examine the extent to which the Cultural Formulation helps trainees with cultural competence, reconfigures diagnosis and treatment, and alters legal outcomes such as length of sentence.