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Book Reviews |
Key Words: Books Reviewed
To formulate, according to the dictionaries, is to apply concepts in a systematic way. Psychoanalytic case formulation, in its customary sense, is the use of psychoanalytic theory to understand all, or nearly all, of the data gathered in the initial contacts with a potential patient in order to understand the patient's problem and how best to help him or her. Such a formulation should be comprehensive, including not only observations and inferences about the presenting problems, but also about how natural endowments and past experiences have shaped the person having the problems. It should take into account the realities of the patient's present circumstances in planning appropriate treatment choices. The data should not be limited to the patient's words in the "official" part of the sessions, but should include his or her behavior both inside and outside the interviews, as well as the therapist's responses to the encounter.
Formulation in this sense can be a difficult task for an unseasoned psychotherapist. Asked by a supervisor or conference leader to organize clinical material in a meaningful way and to make a recommendation for the next step, the inexperienced therapist frequently deals with only a few aspects of the material while ignoring other data that might be crucial for interventions. The interplay of affect between patient and therapist, for example, is often suppressed in clinical discussions, to the detriment of diagnostic accuracy and treatment planning. But perhaps a more important problem is that the new therapist is expected to apply concepts about which he or she as yet has little knowledge. It is not always easy for students to get help in learning this part of being a therapist, and one suspects that their teachers may be sending mixed messages about formulation. A recent study1 of psychiatrists and training directors found that whereas 80% of those surveyed considered conducting individual psychodynamic psychotherapy to be an important skill for a psychiatrist, only 50% thought that it was important to be familiar with psychoanalytic theory to be able to do so!
Psychoanalytic Case Formulation, by Nancy McWilliams, Ph.D., addresses this problem in an engaging, sophisticated, balanced, and accessible way. McWilliams, who teaches psychoanalytic theory and therapy at the Graduate School of Applied and Professional Psychology at Rutgers and is a senior analyst with the Institute for Psychoanalysis and Psychotherapy of New Jersey and the National Psychological Association for Psychoanalysis, is clearly no fan of DSMs (they increase reliability but not validity) or HMOs (they unscientifically devalue good psychotherapy). But DSMs and HMOs are a part of the contemporary psychotherapeutic scene, and their presence makes it doubly important to "get it right" in one's initial diagnostic understanding. "If a client is restricted to a short-term therapy relationship," she writes, "it is more important, not less, to operate from a sound diagnostic basis. If the job the patient wants done cannot be done under the conditions that a paying third party insists on, it is up to the therapist to be honest about that and to know how to convey to the client an understanding of that person's particular psychology and its therapeutic requirements." Her book has a slight "polemical edge," as she puts it, which understandably derives from the plight of psychotherapy in today's health care delivery system.
McWilliams discusses the initial encounters with a prospective patient and gives useful suggestions for conducting intake interviews. Although she is guided by her knowledge of analytic concepts, the intake interview is free-form, not the rigid filling out of a checklist. Diagnosis and treatment according to a manual are not for McWilliams.
She presents basic analytic concepts in a series of excellent chapters: assessing what cannot be changed, developmental issues, defense, affects, identifications, relational patterns, self-esteem, and pathogenic beliefs. She thinks "it is hard for new therapists to understand the evolutions and transformations of classical psychoanalytic theory without having some sense of Freud's original hypotheses." She follows classical concepts of analytic psychology with other, more contemporary analytic ideas about the subject, then shows how these concepts apply to the therapist's choice of interventions. Clinical vignettes bring the material to life.
McWilliams' orientation is "classical," but it is integrated into a subjective/empathic tradition. In each of the areas she covers, she discusses the use and misuse of the subjective reactions of the interviewer and their diagnostic importance. To illustrate: a therapist's awareness of feeling duped or contemptuously bested might be the key to recognizing that the therapist is dealing with a psychopathic person. But the therapist should strive to be as objective as possible about his or her subjectivity, because subjectivity, if undisciplined, can go awry. McWilliams warns, for example, against automatically assuming that a therapist's affect has been "put into" the therapist by the patient. This is a common enough formulation about some countertransferences, but it can become a "malignant kind of projection" instead of a useful empathic counterresponse. McWilliams hopes that the therapist's own therapy or analysis will be helpful in refining the use of empathy and subjectivity. Supervision and consultation with colleagues also help.
Psychoanalytic Case Formulation should be of great value to seasoned therapists as well as to beginning therapists trying to find their way in a complicated discipline. Psychoanalytic concepts are presented clearly and in sufficient detail to be understandable and useful, with abundant references for those who want further information. It should also be very useful for psychoanalytic candidates, who today often bring less clinical experience to their training than was formerly the case. And it should also be helpful to the teachers and supervisors of therapists of whatever ilk. It's a good book.
FOOTNOTES
Robert L. Stewart, M.D., is Training and Supervising Analyst, Cincinnati Psychoanalytic Institute, and Emeritus Professor of Psychiatry, University of Cincinnati, Cincinnati, OH.
REFERENCES
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