psychodynamic formulation american journal of psychiatry 144 (1987) 543-555

8/12/2019 Psychodynamic Formulation American Journal of Psychiatry 144 (1987) 543-555

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Spring 2006, Vol. IV, No. 2 297F O C U S

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In the course of supervising mental health profes-sionals, we have noted that a comprehensive psycho-dynamic formulation is seldom offered and almostnever incorporated into the written record. Ourexperience is reflected in the psychiatric and psycho-analytic literature, where psychodynamics are oftendiscussed but psychodynamic formulations are

rarely presented. In this paper we discuss the pur-pose and structure of the psychodynamic formula-tion, provide three illustrations, and indicate howthese formulations can help guide all treatments.

PURPOSE OF THE FORMULATION

In many respects a dynamic formulation and aclinical diagnosis share a common purpose.

Although both hold intellectual, didactic, andresearch interests, their primary function is to pro-vide a succinct conceptualization of the case andthereby guide a treatment plan. Like a psychiatricdiagnosis, a psychodynamic formulation is specific,brief, focused, and therefore limited in its intent,scope, and wisdom. It concisely and incisively clar-ifies the central issues and conflicts, differentiating

what the therapist sees as essential from what is sec-ondary. Also like the diagnosis, additional informa-tion and changes over time may lead tomodifications of the patients dynamics and howthey are formulated, with corresponding alterationsin treatment. Again, like the diagnosis, the psycho-dynamic understanding of a patient serves as a sta-

bilizing force in conducting any form of therapy;its general effect is conservative, discouraging achange in tack with every slight shift of the wind.

One common misconception is that a psycho-dynamic formulation is indicated only for thosepatients in a long-term, expressive psychotherapy.This belief ignores the fact that the success of any

treatment may involve supporting, managing, oreven modifying aspects of the patients personality.Therapeutic effectiveness or failure often hingeson how well or poorly the therapist understandsthe patients dynamics, predicts what resistancesthe patient will present, and designs an approachthat will circumvent, undermine, or surmountthese obstacles.

A second common misconception is that the con-struction of a psychodynamic formulation is prima-rily a training experience. For example, MacKinnonand Yudofsky (1), while agreeing with the impor-tance of understanding a patients psychodynamics,state: A written case formulation is principally forthe education of the clinician or for clinical caseconferences. The thought and preparation involvedin this exercise constitute an important learningexperience for the beginning student of psychiatry.These authors then later suggest, Even an experi-enced therapist can benefit from this task in a con-fusing or difficult case. Although MacKinnon and

Yudofsky are here referring to a complete case for-mulation (which includes the present illness, psy-chopathology, developmental data, diagnostic

The PsychodynamicFormulation:Its Purpose, Structure, and ClinicalApplication

Samuel Perry, M.D.Arnold M. Cooper, M.D.

Robert Michels, M.D.

Abstract: 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 patients life and identifying nondynamic determinants of the psychopathology, the formulation

explains the development of central conflicts and their repetitive effect on the patients behavior. It concludes by

describing how these conflicts will be manifested in treatment. Three sample formulations and their application arepresented to illustrate the value of this clinical tool.

(Reprinted with permission from the American Journal of Psychiatry 1987; 144:543550)


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classification, and prognosis), one may erroneouslyconclude that a written psychodynamic formula-tion is a task reserved for special situations ratherthan a fundamental component of all treatments.

A third common misconception, related to thesecond, is that the construction of a psychodynamicformulation must be elaborate and time-consuming.

This view derives in part from various reviews in thepsychiatric literature that, in an attempt to be inclu-sive, describe in detail all the requirements of a thor-ough evaluation (14) or the multiple dynamicconflicts that may influence any aspect of humanbehavior (5, 6). The trainee may get the impressionthat anything short of an exhaustive dynamic expla-nation of each symptom or character trait is too sim-plified to be of value. This impression is ofteninadvertently reinforced when the supervisor pointsout some less essential aspects of the case that havebeen omitted in the condensed overview. A morehelpful didactic approach accepts that the initial for-mulation is by necessity partial and tentative, but bydescribing the patients leading unconscious needsand incipient defenses, the formulation may be suf-ficient to predict initial transferences and guide sup-portive or directive interventions. In time, as theclinical impression deepens, the linkage of currentbehavior to formative experiences and intrapsychicconflicts will become more clear and substantiated.

A fourth misconception is the notion that the for-mulation need not be written, as though somehowa patients psychodynamics go without saying.Our concern here is that if the formulation is never

actually constructed and recorded, the patients psy-chodynamics will remain mysterious, ambiguous,and all encompassing. E.M. Forster allegedly said,I never know what I think until I read what I

write. His pointand oursis that the process ofwriting helps one achieve a clearer point of view.The written psychodynamic formulation is there-fore valuable, even if seen only by the therapist who

wrote it. The therapist who has a clear formulationof the patients central conflicts is more capable ofcommunicating that understanding to the patientin a consistent way. In addition, the dynamicallyprepared therapist is more likely to anticipate andrecognize patterns of resistance or acting out thanlag one step behind, using ad hoc (or even post hoc)formulations to respond to specific events.

A fifth and final misconception is that therapistswill become so invested in their dynamic formula-tions that they will not be able to hear or acceptmaterial that does not fit a preconceived mold. Onthe contrary, constructing a dynamic formulationhelps one to recognize its incompleteness, to inquireabout pieces of the puzzle that are missing, to appre-ciate that not every piece fits neatly into place, and

to accept the inevitable complexities and limitedknowledge of every clinical situation. Furthermore,the formulation not only helps therapists accepttheir own limitations, it helps them accept thepatients pathology as well. The patients behaviors intreatmentdependent, angry, avoidant, defiant,passive-aggressive, seductive, suspicious, noncompli-

ant, and so onare seen as manifestations of thepatients dynamics, as characteristic problems thatcan be predicted and understood and for which ther-apeutic interventions have been planned. As a result,the patient is not put in the paradoxical and unten-able position of having to overcome his or her psy-chopathology as a prerequisite for treatment.

STRUCTURE OF THE FORMULATION

As we conceive it, the psychodynamic formula-tion is relatively brief (500750 words) and hasfour parts: 1) a summary of the case that describesthe patients current problems and places them inthe context of the patients current life situationand developmental history; 2) a description ofnondynamic factors that may have contributed tothe psychiatric disorder; 3) a psychodynamic expla-nation of the central conflicts, describing their rolein the current situation and their genetic origins inthe developmental history; and 4) a prediction ofhow these conflicts are likely to affect treatmentand the therapeutic relationship.

PART1: SUMMARIZING STATEMENT

The opening paragraph outlines why this particu-lar patient presents with this diagnosis and these par-ticular problems at this particular time. Byeliminating extraneous information, it succinctlyidentifies the patient, the precipitating events, theextent and quality of interpersonal relationships, themost salient predisposing features of the past history,and those prominent behaviors which the formula-tion will attempt to explain psychodynamically. Thisoutline is not intended to summarize the entire casebut rather to highlight the clinical situation that thepsychodynamic formulation will address. By anal-ogy, these first sentences are similar to the condensedadmission note placed in the medical chart by the

ward attending physician in contrast to the detailedhistory presented by the third-year medical student.

PART2: DESCRIPTION OF NONDYNAMIC FACTORS

After the essential features of the case have beenthoughtfully distilled, this second paragraph men-tions the nondynamic factors that may have con-tributed to the psychiatric disorder, such as genetic


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meaning, to express her sexual wishes more adap-tively than by her intermittent noncompliance

with medication, and over time to feel less guiltyabout her forbidden desires.

Example 4. A fireman hospitalized for a severeburn develops a posttraumatic stress disorder. Thepsychodynamic formulation acknowledges the sit-

uational precipitants but also elucidates that forthis man the intrusive thoughts and nightmaresrepresent a conscious fear of going crazy and anunconscious fear of being a helpless dependentboy, a fear he has reacted against over the years byassuming a machismo style. In consideration ofthese dynamics, the psychiatric consultantaddresses not only the conscious fear by reassur-ingly educating the patient about his acute post-traumatic stress disorder and its favorableprognosis, but also addresses the unconscious fearof passivity by supporting the patients manlinessand the heroic nature of his injury. This permitsthe development of a transference relationship in

which the terror of the trauma can be reworked.Example 5. An elderly retired executive with a

mild dementia has become so rigid and demandingthat his wife has lost her freedom and patience. Thepsychodynamic formulation accepts the organicdeterminants of his change in behavior, but alsonotes that the patients inflexibility is partly due toa long-standing conscious need to be in charge, arecent preconscious recognition of his cognitivedecline, unconscious feelings of anxiety and shamerelated to loss of adult capacities, and reparative

attempts to maintain a sense of security and con-trol by regulating his own life and the lives of thosearound him. By explaining these dynamics to the

wife the therapist increases her tolerance, and bysuggesting more adaptive ways for the patient tofeel secure (clocks in every room, limited demandsand expectations, consistent environment, titratedstimuli, written schedule, and so forth) the thera-pist is able to channel his or her dynamic under-standing into simple, practical interventions.

These highly condensed examples are notintended to illustrate all the subtleties, complexities,and applications of a psychodynamic formulationbut merely to indicate that the presence of nondy-namic factorsgenetic, traumatic, organic, and soforthdoes not preclude the clinical value ofunderstanding a patients psychodynamics and,conversely, that a psychodynamic formulation doesnot ignore the effect of nondynamic factors on thepatients mood, thoughts, and behavior. Thedynamic formulation is consistent with the biopsy-chosocial model (7), is relevant to all forms of psy-chiatric treatment, and is not reserved only for thosepsychiatric conditions in which biological features

are less well defined (e.g., personality disorders) andonly for those treatments that are insight oriented(e.g., exploratory psychotherapy). Even for disor-ders that are more clearly nondynamic in their eti-ology (e.g., schizophrenia, dementia) and fortreatments that are more biomedical in theirapproach (e.g., psychopharmacotherapy), the thera-

pist who formulates not only the cause but also thespecific meaning of the illness will be better pre-pared, when appropriate, to communicate thisunderstanding empathically (8) and to interveneeffectively rather than with stereotyped responses. Apseudohumanitarian approach, a form of verbalhandholding that does not consider the characterstyle of a particular patient, may be experienced byparanoid patients as intrusive, by histrionic patientsas seductive, by obsessive patients as demeaning, bydepressed patients as undeserved and therefore guiltprovoking, and by dependent or phobic patients asa sanction for further regression or avoidance. To beeffective, the therapist must recognize those capaci-ties of the patient which are temporarily or perma-nently deficient and for which an auxiliary ego isindicated, the unconscious meanings of thesedefects to the patient, and the available strengths ofthe patient that will be encouraged and enhanced.

As described later the psychodynamic formulationfacilitates this task by helping the therapist to con-ceptualize the issues systematically rather than rely-ing only on intuition.

PART3: PSYCHODYNAMIC EXPLANATION OFCENTRAL CONFLICTS

If the first part of a psychodynamic formulationis similar to a clarification (a synthetic integrationof the available data), this third part is more like aninterpretation (an integrative inference based onpsychoanalytic principles that considers uncon-scious fantasies and motives). As in the clinical sit-uation, this interpretation is of necessityspeculative, a hypothesis that will be tested andmodified by additional data. Unlike the clinical sit-uation, though, this interpretation is primarily aguide for the therapist; in most instances it doesnot directly represent what the patient will be told.

This section of the formulation is most usefulclinically if it does not attempt to explain too muchin too many ways but instead focuses on the cen-tral conflicts and then uses prototypic psychody-namic models to explain how these conflicts arebeing resolved. The danger of not focusing on thecentral conflicts and of not using standard psycho-dynamic models is that the formulation (and con-sequently perhaps the treatment itself) will lack anintegrative coherence.


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Identifying the central conflicts requires bothinductive and deductive reasoning. The aim is tofind a small number of pervasive issues that runthrough the course of the patients illness and canbe traced back through his or her personal history,and then to explain how the patients attempts toresolve these central conflicts have been both mal-

adaptive (producing symptoms and characterpathology) and adaptive (characterizing his or hergeneral style of pleasure, productivity, and personalrelationships). Conflicts are opposing motives and

wishes, both conscious and unconscious; centralconflicts are repetitive, link and explain a numberof important behaviors, and usually contain ele-ments that are hidden from the patients awareness.For example, a man may consciously wish to be lessdepressed but unconsciously fear that recovery willboth lead to an uncontrolled expression of his ownrage and free others to express their resentmentagainst him if he is not protected by illness.

Once the central conflicts and themes have beenidentified, they are formulated psychodynamically.

At present, at least three models of mental func-tioning are being used by dynamic psychiatrists.These models are overlapping and differ in theemphasis they give to one or another aspect ofdevelopment and psychopathology. In practice,most psychiatrists prefer one model, on the basis ofprior training and personal predilection, but useother models as the clinical situation may require.If the original model does not seem to be concep-tually useful, the therapist sees if the formulation of

a given patient will be more fruitful when cast interms of an alternative model. As with many othersciences, the absence of a meta-model to explain alldata makes this trial and error unavoidable.

Even though an admixture of different models isoften clinically necessary, it is useful theoreticallyand conceptually to understand the basic concepts,virtues, and limitations of prototypic psychody-namic models. Recognizing the oversimplificationinvolved, we will describe the three most common:1) ego-psychological (9); 2) self-psychological (10);and 3) object relations (11, 12). They all share thecore concept of dynamic unconscious mental activ-ity; that is, they assume that human behavior is con-stantly influenced by unconscious thoughts, wishes,and mental representations. These three models alsoassume that complex psychological functions passthrough a regular sequence of epigenetic stages andphases (each of which carries its own particular vul-nerabilities and opportunities and involves an inter-action between nature and nurture) and that thedistortions, fixations, and regressions occurring atdifferent stages will leave their mark on later devel-opment. In short, these models assert that all indi-

viduals have an inner life that is important inunderstanding their outer life and that they are eachthe product of their personal history.

The ego-psychological model emphasizes thecentral role of the adaptive efforts of the ego bothduring development and in therapy. Behavior,mediated by the ego, is viewed as a defensive com-

promise among 1) wishes and impulses; 2) innerconscience, self-observation, and criticism; and 3)the potentialities and demands of reality. Effectiveego functions allow an appropriate delay betweenperemptory wishes and actions and protect theindividual from excessive anxiety or depression

while providing for security, pleasure, and effec-tiveness. A dynamic formulation that uses thismodel will describe the nature of unconscious

wishes, unconscious fears, characteristic defenses,and the resulting patterns of inhibition, symptoms,and character, tracing each of these through theindividuals life. The ego-psychological model givesspecial focus to derivatives of forbidden sexual andaggressive strivings, their resolution during theoedipal phase, and the ongoing residual intrapsy-chic conflicts and defensive compromises thatdetermine character and symptoms. This modelgives less attention to interpersonal issues and tovery early, pre-oedipal influences on development.

The self-psychological model postulates a psy-chological structure, the self, that develops towardthe realization of goals that are both innate andlearned. Two broad classes of these goals can beidentified: one consists of the individuals ambi-

tions, the other of his or her ideals. Normal devel-opment involves the childs grandiose idealizationof self and others, the exhibitionistic expression ofstrivings and ambitions, and the empathic respon-siveness of parents and others to these needs.Under these conditions, the childs unfolding skills,talents, and internalization of empathic objects willlead to the development of a sturdy self and capac-ities for creativity, joy, and continuing empathicrelationships. In this model, genetic formulations

will trace character problems to specific empathicfailures in the childs environment that distortedand inhibited the development of the self and thecapacity to maintain object ties. The formulation

will also describe how the individual has defen-sively compensated for these failures of self-devel-opment and will suggest the therapeutic strategyneeded to support the resumption of self-develop-ment that had been arrested in the past, emphasiz-ing the special transference needs of the patient.The self-psychological model is especially useful forformulating the narcissistic difficulties that arepresent in many types of patients (not just narcis-sistic personality disorder); however, the model


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lacks a clear conception of intrapsychic structure,and it is less useful for formulating fixed repetitivesymptoms that arise from conflicts between onesconscience and sexual-aggressive wishes.

The object relations model conceives of psychicstructures as developing through the childs con-struction of internal representations of self and oth-

ers. These representations range from the primitiveand fantastic to the relatively realistic; they are asso-ciated with widely varying affects (e.g., anger, sad-ness, feelings of safety, fear, pleasure) as well as withvarious wishes and fantasies (e.g., of sex, of control,or of devouring and being devoured). The growingchild struggles with contradictory representationsand feelings of self and others, tending to split thegood and bad images into different representations.

At this early level of development, one may feelthat one has two different mothers, for examplea good, gratifying one and a bad, frustrating one.In the more mature individual, these images areintegrated into coherent representations of a selfand others with multiple complex qualities,selected and formed in part to help to maintain anoptimal measure of self-esteem, tolerable affects,and satisfaction of wishes.

Using this model, the psychodynamic formula-tion focuses on the nature of the self and object rep-resentations and the prominent conflicts amongthem. A special emphasis is given to developmentalfailures in integrating the various partial and contra-dictory representations of self and others and to thedisplacement and defensive misattribution of aspects

of self or others. The object relations model is espe-cially useful for formulating the fragmented inner

world of psychotic and borderline patients whoexperience themselves and others as unintegratedparts; however, the model may be less useful for rel-atively healthier patients in whom conflict may moreeasily be described in terms of ego psychology.

PART4: PREDICTING RESPONSES TO THE

THERAPEUTIC SITUATION

This final section of the formulation is related tothe prognosis, but rather than predicting the overallcourse of the patients disorder, it focuses on themeaning and use that the patient will make of treat-ment. Particular emphasis is placed on understand-ing the probable manifestations of transference (bothpositive and negative) and the forms and modes ofresistance. The phrasing of this prediction will belinked to the psychodynamic model used in the pre-ceding section. For example, the ego-psychologicalmodel may emphasize what specific ego strengthsand deficits the patient brings to the therapeutic sit-uation and what defense mechanisms are likely to

predominate as the patient deals with central con-flicts. The self-psychological model will emphasizethe role of the therapists empathic responsivenessand the analysis of empathic failures in the process offorming new internal structures of the selfforexample, the patients needs to idealize either them-selves or the therapist or, at other times, to ignore the

therapist except as a source of admiration for exhibi-tionistic strivings. Finally, the object relations model

will emphasize which inner representations of selfand of others are likely to be activated and potentiallyenacted in the therapeutic situation. All three modelssuggest possible patterns of transference and resist-ance, offering valuable guides for the therapist.

SAMPLE PSYCHODYNAMIC

FORMULATIONS

Although the following psychodynamic formula-tions lack the authenticity, specificity, and richnessof a formulation that is accompanied by a fullerknowledge of the individual history, they areintended to convey something of the format ofprototypic dynamic formulations. The samepatient is used to illustrate each of the psychody-namic models described previously. These illustra-tions are admittedly somewhat artificial because, as

we have indicated, in clinical practice therapiststend to use one primary model, introducing sec-ondary models to explain features of the patientthat do not easily fit the primary model. However,by presenting each of the models in its pure form,

we hope to demonstrate the common utility of allthe models as well as highlight the potential andunavoidable impact of theory on treatment.

THE EGO-PSYCHOLOGICAL MODEL

Part 1: Mr. A, a 52-year-old married business-man, presents on his own initiative with a depres-sive syndrome after being once again passed overfor promotion. He himself does not understandthis rejection, but it is probably related to his life-long tendencies to procrastinate and to annoy hissuperiors either by being obsequious or by chal-lenging their authority. He has a history of twountreated depressive syndromes, one in his 30s thatalso followed a professional failure and one in his40s that followed his sons defiant marriage to a

woman of another religion. Mr. As father was asickly, professionally frustrated type A personality

who died of a heart attack when Mr. A was in histeens. His mother has always been a martyr withsmoldering despair characterized by chronicinsomnia, self-doubt, obsessive ruminations, andsocial withdrawal. She never sought treatment.


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Part 2: Mr. A has essential hypertension, forwhich he takes methyldopa, 250 mg t.i.d.; hismothers history suggests a genetic predispositionto unipolar depression.

Part 3: Mr. As central conflict is between anunconscious wish to kill off his competitors and anunconscious fear that he will be killed if he acts on

that wish. Whenever he expresses derivatives of hiscompetitive wish directly, he becomes frightened ofretaliation; he therefore resorts to expressing the

wish indirectly by passive-aggressive maneuvers(e.g., procrastination). Conversely, whenever heresponds to this fear of retaliation by being solici-tous and obedient, he inwardly feels resentful anddiminished. To contain this struggle, Mr. A hasdeveloped intellectual mechanisms that, althoughadaptive for certain aspects of his work, are mal-adaptive interpersonally in that they isolate himemotionally from others.

Mr. As tendency to view every situation as acompetitive struggle can be traced to unresolvedanal and oedipal conflicts. During early child-hood, Mr. As depressed mother could not tolerateher sons assertiveness and declarations of inde-pendence; instead she imposed her will on Mr. Aand insisted that he eat, sleep, be toilet trained,and behave exactly the way she wanted so that herson would not be any trouble and add to her woes.

As a result, Mr. A entered the oedipal period witha view that any endeavor was a power struggle, inessence asking himself, Do I give in and bury therage over being controlled, or do I assert myself

and risk being punished either directly by mymother or internally by the guilt I feel by makingher more depressed?

This view of the world was then enhanced bycompetition from Mr. As perfectionistic and con-trolling father, who, frustrated by his own limita-tions and illness, would harshly reprimand Mr. Afor any assertion within the family or failure outsideof it. Fearing retaliation and struggling against hisfeelings of passivity, Mr. A identified with theaggressorfather and developed an even morepunitive superego. Mr. As need to repress his com-petitive rage and envy was reinforced by his fatherschronic heart disease; Mr. A feared that if he were toact assertively, he would kill off his rival. When thefather did die during Mr. As adolescence, the guiltover this unconscious oedipal victory made Mr. Aeven more wary of directly asserting himself in thefuture. All three of Mr. As depressive episodes wereprecipitated by failing to beat out competitors (col-leagues or his son), unconsciously reminiscent ofearlier defeats with his mother and father, but Mr.

A is unaware that he is equally afraid to win andface the resultant retaliation and guilt.

Part 4: Unconsciously Mr. A is likely to viewtreatment as another competition. Fearful anddependent at first, when his depression begins toimprove and he feels more like a winner, he mayrespond with guilty fear for a triumph so unde-served in one who unconsciously is consumed withmurderous wishes. In response to this guilt, he may

sabotage his improvement by prematurely stoppingtreatment or, less destructively, by focusing onresidual depressive symptoms, the side effects ofantidepressant medication, or his hypertension (anaffliction that unconsciously has become his pun-ishment for killing his father). This behavior willalternate with Mr. As viewing the therapist as the

winner (i.e., the authority figure to whom he isbeholden). Frightened of challenging the victordirectly, Mr. A may indirectly defy this authorityby appearing compliant, apologetic, and gratefulbut passive-aggressively forgetting appointmentsor his medication and devaluing the treatment.

THE SELF-PSYCHOLOGICAL MODEL

Parts 1 and 2 are as in the previous material.Part 3: Mr. As central problem consists of his low

self-esteem and consequent need for continualrecognition and approval from others, along withhis inability to accept any limitations either in him-self (which lead to disapproval from others) or inothers (which reduce the value of their approval

when it occurs). Presumably, during childhood hisdepressed mother and sickly father were so self-

absorbed with their problems that they were unableto respond empathically to his age-appropriate aspi-rations; at the same time, both parents narcissisti-cally invested in their son the hopes that hisachievements would make up for their failures.Throughout his life Mr. A has strived to earn theaccolades he never received as a child, and althoughthis pursuit has lead to some professional success,his self-doubt and instability of self-objects taketheir toll, leading to a lack of confidence, to inap-propriate solicitous behavior, and to procrastinationof challenging tasks. In addition, having internal-ized his parents grand expectations (in order torepair his sense of deficit as well as to compensatefor theirs), he is unable to accept the limitations ofothers (e.g., his bosses or his sons) or himself (e.g.,physical illness, aging, his professional plateau).Being passed over for promotion was an injury to asense of self that was already enfeebled; the rejectionreawakened early empathic failures and unrealizedambitions. The resultant loss of self-esteem thencontributed to the current depression.

Part 4: In treatment, Mr. A will attempt to elicitthe therapists admiration and will have grand


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(though unconscious) expectations about what canbe accomplished, idealizing both himself and thetherapist. However, when the therapist fails torespond with just the right empathic quality, Mr. A

will be hurt and secretly enraged, and when the reallimitations of Mr. A or the therapist are exposed,Mr. A is likely to devalue the entire enterprise and

become more discouraged. Potential countertrans-ference problems may arise if the therapist prema-turely limits Mr. As need to be admired and toidealize the therapist.

THE OBJECT RELATIONS MODEL

Parts 1 and 2 are as in the earlier material.Part 3: Mr. As central problem is his failure to

integrate the good and bad representations of him-self and others. During childhood, his depressedmother could not respond to her sons need anddemands. Mr. A, unconsciously frightened that hisresultant rage would destroy the very one on whomhe depended, repressed his bad angry self and actedlike the good obedient son. This splitting was rein-forced by interactions with the controlling father

who punitively viewed any of Mr. As independentassertions as acts of defiance. Mr. A, frightened thathis competitive rage would either kill off the sicklyfather or lead to retaliation, again repressed his badangry self. During adolescence, when the surgetoward a more autonomous identity was mostintense, Mr. As father died. Responding to uncon-scious guilt for a forbidden wish that had come

true (i.e., killing off the father), Mr. A was evenmore compelled to keep the bad (assertive) selfrepressed and to maintain a tie to the lost object,both by an identification with the fathers perfec-tionism, and to punish himself for any success.

Although this splitting has enabled Mr. A to be rel-atively successful and to seem basically well inten-tioned, the facade is fragile. The efforts with hissuperiors to appear the good son are exaggerated,leading to obsequious and subservient behavior.Furthermore, when the bad angry self breaksthrough the repression, procrastination and obsti-nacy are the result. These signals of the bad self leadto increased self-punitive and restrictive reactionsin order to keep his rage contained.

Mr. As repression and splitting are compoundedby his use of projection; that is, he projects ontoothers his unconscious bad self. This process onlyreinforces his experience of others as either unnur-turing mothers or unsupportive, controllingfathers. This projection of the bad self contributedto Mr. As viewing his sons marriage as an act ofdefiance. Similarly, when passed over for promo-tion, Mr. A not only experienced this rejection as

reminiscent of enraging childhood rejections,devaluations, and abandonment but also viewed itas a retaliation for projected hostile wishes from hisbad self. His depression is therefore in part theresult of his punitive conscience condemning himfor projected hostile wishes and for failing to meetthe perfectionistic ideals of the good self.

Part 4: In treatment Mr. A will at first be quiteingratiating, the good son depressively condemninghimself for past and present failures and wary thathe will not meet the therapists expectations (Mr. Asown projections). However, as Mr. A projects hisresentful and defiant self, the therapist may be per-ceived as being both emotionally uncaring and ascontrolling, projections that will reinforce in thetransference those early experiences with themother and father, respectively. The therapistshould be prepared for the likelihood that Mr. Asrise in self-esteem will initially be accompanied bydenigration of the therapist. The therapist must alsoanticipate that whenever Mr. A does express theresentful affects associated with the bad self, Mr. Asconscience will clamp down punitively and causeMr. A to become temporarily more depressed.

CLINICAL APPLICATION OF THE

FORMULATION

Although there are differences among the threeformulations, it is important to point out the simi-larities in their clinical conclusions and applica-tions. All three formulations alert the therapist that

after an initial honeymoon period, difficulties arelikely to develop in the therapeutic relationship.The ego-psychological model conceives of thisfalling out in terms of passive-aggressive defensivemechanisms, the self-psychological model predicts adevaluation of the therapist in response to inevitableempathic failures and limitations, and the objectrelations model anticipates that the patients angryand defiant self will be projected onto the therapist.

All three formulations also alert the therapist tosimilar countertransference problems: the ego-psy-chological model places these problems in terms ofcompetitive struggles with the patient over issues ofcontrol, the self-psychological model considersproblems of the therapists being initially idealizedand then devalued, and the object relations modelsuggests that the therapist may at times feel com-pelled to identify with the patients projections andthen assume the role of the uncaring and punitivefigure the patient most fears and expects.

All three formulations indicate that the patientsdynamics may directly affect his depressive symp-toms and compliance with whatever treatment isprescribed. The ego-psychological model views this


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resistance in terms of guilty fear accompanying hisimprovement and a need to indirectly defy author-ity. The self-psychological model predicts a phaseof discouragement and unwillingness to accept thedisappointing therapy. The object relations modelforesees that depressive feelings may recur if thispatient retreats from the emergence of his angry

bad self during recovery and that poor compliancewill accompany the view of the therapist as puni-tive and uncaring.

Finally, all three formulations share many simi-larities in indicating what therapeutic interventions

will be required to manage the anticipated transfer-ences, countertransferences, and resistances. Theyall see that this patient in particular will need anonjudgmental atmosphere where anger andresentment can be expressed spontaneously, he willneed appropriate recognition and reinforcement ofhis strengths (such as his intellectual capacities),and he will need a modicum of control in his treat-ment (such as deciding within reason the time ofday he takes his medication).

Despite these basic similarities, the different con-ceptual models will no doubt have some influenceon the treatments emphasis and language. We sus-pect that these differences would be most apparentin the nature of interpretations used in anexploratory psychotherapy and less apparent indirective, behavioral, supportive, or psychophar-macological treatment. Using the ego-psychologi-cal model, the therapist is likely to focus on therelationship between the patients current difficul-

ties and earlier competitive struggles with his par-ents. Using the self-psychological model, thetherapist will direct interpretations toward helpingthe patient appreciate the doubts and yearningsthat underlie his fragile grandiosity and will traceperceived empathic failures in the therapist to thosefailures that occurred in the patients childhood.

Finally, using the object relations model, the thera-pist will attempt to intercept a destructive negativetransference and acting out both by interpretingthe patients misperceptions of the therapist assomeone (like the father) wanting to control thepatient and by encouraging the patient to expressthrough fantasies, memories, and dreams those

angry feelings associated with the bad self, therebyindicating a capacity (unlike the mother) to toler-ate unpleasant affects.

However, in closing, it must be emphasized thatthe differences that may occur in an insight-ori-ented psychotherapy are relatively subtle com-pared to the more important value of thepsychodynamic formulation in conceptualizingcentral conflicts and anticipating the transferences,countertransferences, and resistances that occur inall treatments.

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