Table Of ContentPSYCHOANALYTIC CASE FORMULATION
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Psychoanalytic
Case Formulation
Nancy McWilliams, PhD
THE GUILFORD PRESS
New York London
© 1999 Nancy McWilliams
Published by The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
http://www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a
retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or
otherwise, without written permission from the Publisher.
This book is printed on acid-free paper.
Last digit is print number: 19 18 17 16 15 14 13 12 11 10
Library of Congress Cataloging-in-Publication Data
McWilliams, Nancy.
Psychoanalytic case formulation / Nancy McWilliams.
p. cm.
Includes bibliographical references and index.
ISBN 1-57230-462-6
1. Psychiatry—Case formulation. 2. Personality assessment.
3. Behavioral assessment. 4. Interviewing in psychiatry.
5. Psychotherapist and patient. I. Title.
RC473.C37M38 1999
616.89—dc21 98-56044
CIP
For my husband,
Wilson Carey McWilliams
About the Author
Nancy McWilliams, PhD, teaches psychoanalytic theory and therapy at
the Graduate School of Applied and Professional Psychology at Rut-
gers—The State University of New Jersey. A senior analyst with the
Institute for Psychoanalysis and Psychotherapy of New Jersey and the
National Psychological Association for Psychoanalysis, she has a pri-
vate practice in psychodynamic therapy and supervision in Flemington,
New Jersey. Her previous book, Psychoanalytic Diagnosis: Under-
standing Personality Structure in the Clinical Process (Guilford Press,
1994), has become a standard text in many training programs for psy-
chotherapists, both in the United States and abroad. She has also
authored articles and book chapters on personality, psychotherapy,
psychodiagnosis, sexuality, feminism, and contemporary psychopath-
ologies.
vi
Preface
T>
HE first time a supervisor asked me to venture a "dynamic formula-
tion" of the case material I had just heard, I became instantly incompe-
tent. I knew vaguely what I was being asked to do—namely, to suggest
how the person's symptoms, mental status, personality type, personal
history, and current circumstances all fit together and made sense—but
I drew a blank as to where to begin. This was my introduction to the
more interpretive, synthetic, artistic aspects of psychodiagnosis. Until I
had been asked for that formulation, I had rarely in my training been
encouraged to work inferentially, to open myself up to a creative pro-
cess fueled by intuition, to feel my way into another human being's inti-
mate life and formulate that person's suffering in a way that would
express his or her unique categories of subjective experience rather than
the preformatted, "objective" categories of received diagnostic wisdom.
Like any well-socialized student, I had gotten good at memorizing fac-
tual data, telling teachers what I thought they wanted to hear, and look-
ing for the requisite number of "signs" that would either confirm or
rule out a well-known diagnostic entity, but this assignment asked for
something different and was initially very intimidating.
Most of us learn psychodynamic case formulation, as I eventually
did, by identification with mentors who are good at it and who can
demonstrate how better understanding produces better treatment. I am
not entirely sure that this creative, affectively infused process can be
captured in a book. But I was also uncertain initially whether psychoan-
alytic character diagnosis could be effectively taught via the printed
page, and I have repeatedly heard from students and practitioners that
my writing on that topic has been helpful. So when my editor pointed
out that in Psychoanalytic Diagnosis (McWilliams, 1994), despite my
vii
viii Preface
harping on the importance of sensitively assessing personality structure,
I devoted only a footnote to how one arrives at such an assessment, I
began thinking about how to convey in writing the ways in which expe-
rienced psychodynamic therapists think about patients.
They certainly do not think of them simply in terms of the criteria
for "disorders" that are codified in the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM) of the American Psychiatric Associa-
tion. To their credit, the authors of the DSM-IV have been explicit
about the limitations of "disorder" taxonomies, especially from the
point of view of the practicing clinician rather than that of the empirical
researcher (American Psychiatric Association, 1994, p. xxv). To be a
good therapist, one must have an emotional appreciation of individual
persons as complex wholes—not just their weaknesses but their strengths,
not just their pathology but their health, not just their misperceptions
but their surprising, unaccountable sanity under the worst of condi-
tions.
My previous book concerned the implications of personality struc-
ture for treatment. An appreciation of a client's character type is, how-
ever, only one of the factors that influences therapists in their decisions
about how to work with someone. We want to know what stresses ac-
count for any person's coming to us at this particular time, how he or
she has unconsciously understood those stresses, and what aspects of
his or her unique background have created a vulnerability to this kind
of stress. We also want to know how the person's age, gender, sexual
orientation, rate, ethnicity, nationality, educational background, medi-
cal history, prior therapy experience, socioeconomic position, occupa-
tion, living arrangements, responsibilities, and religious beliefs are con-
nected with the situation about which we are being consulted. We ask
about eating patterns, sleeping patterns, sexual life, substance use, rec-
reations, interests, and personal convictions. We put all that together
into a narrative that makes this human being and his or her psycho-
pathology comprehensible to us, and we derive our recommendations
and our way of relating to the client from that narrative (see Spence,
1982). Thus, in contrast to my previous book on diagnosis, this one
concerns itself not just with those aspects of people's psychologies that
comprise Axis II of the DSM but with data appropriate to Axes I, III,
IV, V, and other areas.
This book is more about the process than the outcome of diagnosis.
Even though there are numerous good sources on how to conduct an
initial interview (e.g., MacKinnon & Michels, 1971; Othmer & Oth~
mer, 1989), and several recent publications explicating different person-
Preface ix
ality diagnoses or disorders (Akhtar, 1992; Millon, 1981; Kernberg,
1984; Josephs, 1992; Benjamin, 1993; Johnson, 1994), I am not aware
of many primers on how therapists reflect on the deluge of information
they obtain in a diagnostic interview—how they put it into not only a
diagnostic formulation but also a general psychodynamic one. One no-
table exception is a guide by Paul Pruyser, who in 1979 not only de-
scribed the process of psychodynamically influenced interviewing but
also championed its importance with eloquence. Twenty years later,
much has changed, both in psychoanalysis and in the culture at large.
Currently, given pressures for quick, atheoretical diagnosis, it may be
even more important than previously for those of us in the mental
health business to remind ourselves of the complexities and subtleties
involved in trying to understand people and their psychological prob-
lems.
I am hoping to reach the same audience I have addressed previ-
ously, namely, people committed to becoming therapists, whether their
field is psychiatry, psychology, social work, counseling, education, pas-
toral work, nursing, psychoanalysis, relationship counseling, or the ex-
pressive therapies that involve the visual arts, music, and dance. Beyond
the narrow goal of teaching practitioners how to develop and refine a
dynamic formulation, I hope also to illustrate the value of the kinds of
knowledge that constitute mainstream psychoanalytic expertise, and to
provide support to my colleagues and students, so many of whom are
suffering from the current, market-driven climate of cynicism about in-
tensive and sustained mental health care. The public deserves therapists
who maintain the integrity of psychological services and who resist let-
ting economic pressures compromise either their commitment to a deep
understanding of individuals or the compassion that naturally derives
from that commitment.
