Tracy D Eells (editor) - Handbook of Psychotherapy Case Formulation-The Guilford Press (2022)

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HANDBOOK OF PSYCHOTHERAPY CASE FORMULATION
Handbook of 
Psychotherapy 
Case 
Formulation
T H I R D E D I T I O N
edited by 
Tracy D. Eells
The Guilford Press
New York London
Copyright © 2022 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
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with the standards of practice that are accepted at the time of publication. 
However, in view of the possibility of human error or changes in behavioral, 
mental health, or medical sciences, neither the authors, nor the editors and 
publisher, nor any other party who has been involved in the preparation or 
publication of this work warrants that the information contained herein is 
in every respect accurate or complete, and they are not responsible for any 
errors or omissions or the results obtained from the use of such information. 
Readers are encouraged to confirm the information contained in this book 
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Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Names: Eells, Tracy D., editor. 
Title: Handbook of psychotherapy case formulation / edited by Tracy D. 
 Eells. 
Description: Third edition. | New York : The Guilford Press, [2022] 
 Includes bibliographical references and index. | 
Identifiers: LCCN 2021058319 | ISBN 9781462548996 (paperback) | ISBN 
 9781462549009 (hardcover) 
Subjects: LCSH: Psychiatry—Case formulation. | Psychiatry—Differential 
 therapeutics. | Psychotherapy—Methodology. | BISAC: PSYCHOLOGY / 
 Psychotherapy / General | PSYCHOLOGY / Clinical Psychology 
Classification: LCC RC473.C37 H46 2022 | DDC 616.89/14—dc23/
eng/20211216 
LC record available at https://lccn.loc.gov/2021058319
To my parents,
to Bernadette, Elias, Aidan, and Lillian,
and to all the contributors to this 
and to previous editions of this book 
vi
About the Editor
Tracy D. Eells, PhD, is Professor of Psychiatry and Behavioral Sciences at 
the University of Louisville. A licensed clinical psychologist, he maintains 
a psychotherapy practice, is active in research, and teaches psychotherapy 
to psychiatry residents and clinical psychology graduate students. Dr. Eells 
has published several papers on psychotherapy case formulation and has 
conducted workshops on the topic for professionals. He is on the editorial 
boards of multiple psychotherapy journals. 
 vii
Contributors
Ephi J. Betan, PhD, private practice, Atlanta, Georgia
Jeffrey L. Binder, PhD, ABPP, Department of Psychiatry and Behavioral Sciences, 
Vanderbilt University Medical School, Nashville, Tennessee
Fredric N. Busch, MD, Columbia University Center for Psychoanalytic Training 
and Research, Weill Cornell Medical College, New York, New York
Franz Caspar, PhD, Department of Clinical Psychology and Psychotherapy, 
University of Bern, Bern, Switzerland
Fredrick T. Chin, MS, Department of Psychology, University of Nevada, Reno, 
Reno, Nevada
Carrie U. Cole, MEd, The Gottman Institute, Seattle, Washington
Donald L. Cole, DMin, LPC, LMFT, The Gottman Institute, Seattle, Washington
John T. Curtis, PhD, Department of Psychiatry and Behavioral Sciences, 
Weill Institute for Neurosciences, University of California, San Francisco, 
San Francisco, California
Barnaby D. Dunn, PhD, Mood Disorders Centre, University of Exeter, 
Exeter, Devon, United Kingdom
Tracy D. Eells, PhD, Department of Psychiatry and Behavioral Sciences, 
University of Louisville, Louisville, Kentucky
Rhonda N. Goldman, PhD, The Chicago School of Professional Psychology, 
Chicago Campus, Chicago, Illinois
John M. Gottman, PhD, The Gottman Institute, Seattle, Washington
Julie S. Gottman, PhD, The Gottman Institute, Seattle, Washington
Leslie S. Greenberg, PhD, Department of Psychology, York University, Toronto, 
Ontario, Canada
viii Contributors
Brin F. S. Grenyer, PhD, School of Psychology and Illawarra Health and Medical 
Research Institute, University of Wollongong, Wollongong, New South 
Wales, Australia
Steven C. Hayes, PhD, Department of Psychology, University of Nevada, Reno, 
Reno, Nevada
Christina E. Jeffrey, PhD, Department of Psychology and Counseling, University 
of Central Arkansas, Conway, Arkansas
Willem Kuyken, PhD, Department of Psychiatry, University of Oxford, 
Oxford, United Kingdom
Ely M. Marceau, PhD, School of Psychology, University of Wollongong, 
Wollongong, New South Wales, Australia
John C. Markowitz, MD, Department of Psychiatry, Columbia University 
Vagelos College of Physicians and Surgeons, and New York State Psychiatric 
Institute, New York, New York
Barbara L. Milrod, MD, Department of Psychiatry, Albert Einstein College of 
Medicine, Bronx, New York; New York Psychoanalytic Institute, New York, 
New York; Columbia University Center for Psychoanalytic Training and 
Research, New York, New York
Jacqueline B. Persons, PhD, Oakland Cognitive Behavior Therapy Center, 
University of California, Berkeley, Berkeley, California
Charles R. Ridley, PhD, Department of Educational Psychology, Texas A&M 
University, College Station, Texas
Nicholas L. Salsman, PhD, ABPP, School of Psychology, Xavier University, 
Cincinnati, Ohio
Brandon T. Sanford, MS, Department of Psychology, University of Nevada, Reno, 
Reno, Nevada
George Silberschatz, PhD, Department of Psychiatry and Behavioral Sciences, 
Weill Institute for Neurosciences, University of California, San Francisco, 
San Francisco, California
Cory E. Stanton, MS, Department of Psychology, University of Nevada, Reno, 
Reno, Nevada
Peter Sturmey, PhD, Department of Psychology, Queens College of the City 
University of New York, Flushing, New York
Holly A. Swartz, MD, Department of Psychiatry, University of Pittsburgh School 
of Medicine, Pittsburgh, Pennsylvania
Michael A. Tompkins, PhD, San Francisco Bay Area Center for Cognitive 
Therapy, University of California, Berkeley, Berkeley, California
Hadas Wiseman, PhD, Department of Counseling and Human Development, 
University of Haifa, Haifa, Israel
 ix
Preface
The primary goal envisioned for the first two editions of the Handbook of 
Psychotherapy Case Formulation was to address the gap between the con-
sensus view that case formulation is a core psychotherapy skill and the lack 
of commensurate training in the skill. Previous editions of the Handbook 
also aimed to bring several evidence-based methods of case formulation to 
a wider clinical audience. Since the last edition, case formulation has con-
tinued to receive more attention, as evidenced by the publication of several 
texts and many journal articles on the topic, including special issues of 
journals. A revision is needed, therefore, to incorporate recent research and 
thinking about case formulation.
In this third edition, all chapters carried over from the previous edition 
have been thoroughly updated to incorporate developments in the method, 
new research, and improvements in training therapists to use the method. 
Some of these have been revised to focus on the application of case for-
mulation to specific populations or problems, specifically, individuals with 
personality disorders, depression, suicidality, and panic disorder. In addi-
tion, new chapters have been added, including chapters on case formulation 
from the perspective of mindfulness-based cognitive therapy, acceptance 
and commitment therapy, and couple therapy.
Because case formulation is fundamentally an applied skill, a further 
goal of this thirdedition is to increase the clinical utility of the book. As in 
previous editions, chapter authors demonstrate how the case formulation 
method described in the chapter is developed, and they produce a complete 
formulation based on an actual case. As an added feature for this edition, 
each chapter also describes an entire case of therapy on a session-by-session 
basis, showing how the formulation shaped the course of therapy.
A hallmark of previous editions was that each chapter describing a 
x Preface
method of case formulation followed the same organizational format. With 
minor changes, the third edition retains this format. The reasons for the 
standard format are to facilitate comparisons among the methods, to ensure 
that similar categories of information are provided for each method, and 
to increase the book’s ease of use. All contributors were asked to organize 
their chapters according to the following headings: historical background 
of their approach, conceptual framework, multicultural considerations, 
evidence base supporting the method, steps in case formulation construc-
tion, application to psychotherapy treatment planning and practice, a case 
example, and a section on learning the method. Specifically:
	• Historical Background of the Approach. In this section, authors 
describe the historical and theoretical origins of their case formulation 
approach.
	• Conceptual Framework. The goal of this section is to present what 
is formulated and why. Authors were asked to consider the following ques-
tions: What assumptions about psychopathology and healthy psychologi-
cal functioning underlie the approach? What causal or probabilistic model 
is assumed to underlie the method? What assumptions about personality 
structure, development, self-concept, affect regulation, and conflict (if any) 
are made? What are the components of the case formulation and what 
is the rationale for including each component? How are treatment goals 
incorporated into the model? Does the formulation predict the course and 
outcome of therapy, including obstacles to success? If so, how?
	• Multicultural Considerations. Authors were asked to address the 
following questions: How suitable is the approach for patients of diverse 
ethnic and cultural backgrounds? Should any special consideration be 
given in the formulation with regard to the patient’s gender, disability sta-
tus, age, religion, or veteran status? How are these varying sociocultural 
and identity contexts accounted for within the formulation? More gener-
ally, which patients are appropriate and inappropriate for formulation with 
the method? What type and range of problems is the method suitable for?
	• Evidence Base Supporting the Method. This section summarizes 
evidence supporting the use of the method in psychotherapy. In what ways 
is the method evidence-based? How is it informed by research?
	• Steps in Case Formulation Construction. The goal of this section is 
to provide a detailed, step-by-step description of how to construct a case 
formulation with the method under discussion. After reading this section, 
readers should be able to try constructing a case formulation using the 
method presented. Questions authors were asked to address included the 
following: How much time is required to formulate the case? What materi-
als are used (e.g., interviews, questionnaires, progress notes)? What role 
 Preface xi
does the patient play in constructing the formulation? What form does the 
final product take?
	• Treatment Planning and Practice. This section addresses how the 
therapist uses the formulation in therapy. For example, is the formulation 
shared directly with the patient, and if so, in what form?
	• Case Example. A detailed case example is presented to illustrate 
how the method is applied in the treatment of a specific individual. In addi-
tion to describing how the case formulation is developed and presenting 
a complete formulation, the chapter authors present an entire course of 
therapy showing how the formulation informed and guided treatment.
	• Learning the Method. This section addresses how therapists are 
best trained to use the case formulation method. It provides readers with 
concrete steps to take to learn the method described.
The contributors to this edition have made their own style decisions 
with respect to handling gendered and nongendered singular pronouns. It 
is my hope that this revised edition, including the standard chapter format, 
the additional case formulation methods described, and the grounding of 
each method in evidence, provides readers with multiple and varied tools to 
draw upon in therapy. 
 xiii
Contents
Chapter 1 History and Current Status of Psychotherapy Case Formulation 1
Tracy D. Eells
Chapter 2 The Core Conflictual Relationship Theme for Personality Disorders 36
Brin F. S. Grenyer, Ely M. Marceau, and Hadas Wiseman 
Chapter 3 Panic-Focused Psychodynamic Psychotherapy 61 
Fredric N. Busch and Barbara L. Milrod
Chapter 4 Plan Formulation Method 88
John T. Curtis and George Silberschatz 
Chapter 5 The Cyclical Maladaptive Pattern 113
Jeffrey L. Binder and Ephi J. Betan
Chapter 6 Case Formulation in Interpersonal Psychotherapy of Depression 144
John C. Markowitz and Holly A. Swartz
Chapter 7 Thematic Mapping: A Transtheoretical, Transdiagnostic 179 
 Method of Case Conceptualization
Charles R. Ridley and Christina E. Jeffrey
Chapter 8 Optimizing Psychotherapy with Plan Analysis 209
Franz Caspar
xiv Contents
Chapter 9 Cognitive-Behavioral Case Formulation 252
Jacqueline B. Persons and Michael A. Tompkins
Chapter 10 Dialectical Behavior Therapy Case Formulation of Individuals 287 
 Who Are Chronically Suicidal
Nicholas L. Salsman
Chapter 11 Behavioral Approaches to Psychotherapy Case Formulation 320
Peter Sturmey
Chapter 12 Case Conceptualization in Mindfulness-Based Cognitive Therapy 353
Willem Kuyken and Barnaby D. Dunn
Chapter 13 Case Conceptualization in Acceptance and Commitment Therapy 380
Fredrick T. Chin, Cory E. Stanton, Brandon T. Sanford, 
and Steven C. Hayes
Chapter 14 Case Formulation in Emotion-Focused Therapy 410
Rhonda N. Goldman and Leslie S. Greenberg
Chapter 15 Conceptualization in the Gottman Method of Couple Therapy 445
John M. Gottman, Julie S. Gottman, Donald L. Cole, 
and Carrie U. Cole
 Index 485
 1
1
History and Current Status 
of Psychotherapy Case Formulation
Tracy D. Eells
Recognition of the central role that case formulation plays in psychother-
apy planning and treatment has accelerated since the last edition of this 
handbook. Evidence for this claim includes the publication of several books 
that focus exclusively or primarily on case formulation (e.g., Bruch, 2015; 
Eells, 2015; Goldman & Greenberg, 2015; Haynes, O’Brien, & Kahol-
okula, 2011; Ingram, 2012; Kramer, 2019; Kuyken, Padesky, & Dudley, 
2009; Persons, 2008; Sperry & Sperry, 2020; Sturmey, 2009; Tarrier & 
Johnson, 2016; Zubernis & Snyder, 2016). Other books present methods 
of psychotherapy in which formulation is a key step (e.g., Benjamin, 2018; 
Levenson, 2017; McWilliams, 2011), and still others focus on case formu-
lation in the treatment of specific psychological conditions (e.g., Clark & 
Beck, 2011; Manber & Carney, 2015; Zayfert & Becker, 2007) or spe-
cific populations such as children and adolescents (Manassis, 2014), fami-
lies (Reiter, 2014) or forensic populations (Sturmey & McMurran, 2011). 
Psychotherapy case formulation has also been the topic of research and 
critical reviews (e.g., Easden & Kazantzis, 2018; Eells, 2009; Fishman, 
2010; Rainforth & Laurenson, 2014; Ridley, Jeffrey, & Roberson, 2017), 
including at least two special editions of journals (Godoy & Haynes, 2011; 
Ridley et al., 2017). Additionally, two peer-reviewed journals focusing on 
case presentations and review have continued to remain vibrant (Fishman, 
2002; Hersen, 2002). Both journals involve the presentation of cases in a 
standard format thatincludes a section on case formulation. A recent litera-
ture search revealed more than 2,700 publications on “case formulation” 
2 HanDbook of PsyCHoTHEraPy CasE formulaTion
or “case conceptualization” since 1980, with an accelerating curve; and 
more than 30 books on the topic have been published since the last edition 
of this volume.
With these developments in mind, my task in this chapter is to trace 
the history of the concept of formulation in psychotherapy and to provide 
an overview of its status. The primary goal is to provide a context in which 
to better understand the chapters on specific case formulation methods that 
follow. I begin with a working definition and then review major historical 
and contemporary influences on the form and content of a psychotherapy 
case formulation. Next, I survey trends in psychotherapy case formulation 
research. Finally, I propose five tensions that influence the psychotherapy 
case formulation process. A guiding theme throughout the chapter is that 
case formulation is a core psychotherapy skill that lies at an intersection of 
diagnosis and treatment, theory and practice, science and art, and etiology 
and description.
A WORKING DEFINITION
Psychotherapy case formulation is a process of developing a hypothesis 
about the causes, precipitants, and maintaining influences of a person’s 
psychological, interpersonal, and behavioral problems, as well as a plan 
to address these problems (Eells, 2015). A case formulation helps organize 
information about a person, particularly when that information contains 
contradictions or inconsistencies in behavior, emotion, and thought con-
tent. Ideally, it contains structures that permit the therapist to understand 
these contradictions and to categorize important classes of information 
within a sufficiently encompassing view of the patient. A case formulation 
also serves as a blueprint to guide treatment and as a marker for change. 
It should help the therapist experience greater empathy (Elliott, Bohart, 
Watson, & Murphy, 2018) for the patient and anticipate possible ruptures 
in the therapy alliance (Eubanks, Muran, & Safran, 2018). Importantly, it 
informs the therapist about what to do next in therapy, not only from ses-
sion to session but also as events unfold within sessions.
As a hypothesis, a case formulation may include inferences about 
predisposing or antecedent vulnerabilities based on a pathogenic learning 
history, early childhood traumas, biological or genetic influences, socio-
cultural influences, currently operating contingencies of reinforcement, or 
maladaptive schemas and beliefs about the self or others. The nature of 
this hypothesis can vary widely depending on which theory of psychother-
apy and psychopathology the clinician uses and what evidence the clini-
cian draws from. Psychodynamic approaches focus on unconscious men-
tal processes and conflicts (Messer & Wolitzky, 2007; Binder & Betan, 
Chapter 5, this volume; Busch & Milrod, Chapter 3, this volume; Perry, 
 History and Current status 3
Cooper, & Michels, 1987; Summers, 2003). A cognitive therapy formula-
tion might focus on maladaptive thoughts and beliefs about the self, others, 
the world, or the future (e.g., Beck, 2020; Persons & Tompkins, Chapter 
9, this volume). In contrast, a behavioral formulation traditionally may 
not emphasize intrapsychic events but, instead, focus on the individual’s 
learning history and a functional analysis related to environmental contin-
gencies of reinforcement and inferences about stimulus–response pairings 
(Sturmey, Chapter 11, this volume; Wolpe & Turkat, 1985). Contemporary 
behavioral formulations increasingly incorporate cognition and affect as 
components in the functional analysis (Nezu, Nezu, & Cos, 2007). Bio-
logical explanations might also be interwoven into a case formulation. 
Some experts advocate pursuing rigorous causal connections between a 
psychopathological condition and its determinants (Haynes, O’Brien, & 
Godoy, 2020; Mumma & Fluck, 2016), whereas others stress achieving an 
explanatory narrative that may not have a factual basis in “historical truth” 
but is nevertheless therapeutic in that it provides a conceptual account of 
the patient’s condition and a procedure for improving it (Binder & Betan, 
Chapter 5, this volume; Frank & Frank, 1991; Spence, 1982). Evidentiary 
sources may include the client’s self-report, psychometric findings, psycho-
therapy process and outcome research, epidemiological research, and evi-
dence from behavioral genetics (Eells, 2015). As a hypothesis, a case formu-
lation is also subject to revision as new information emerges, as tests of the 
working hypothesis indicate, and as a clinician views the patient through 
the lens of an alternate theoretical framework.
Case formulation involves both content and process aspects. Content 
aspects comprise several components that together paint a holistic picture 
of the individual, focusing on his or her problems. They may also include a 
prescriptive component that flows directly from the earlier descriptions and 
hypotheses and proposes a plan for treatment (Sperry, Gudeman, Black-
well, & Faulkner, 1992). The treatment plan may include details such as the 
type of therapy or interventions recommended, the frequency and duration 
of meetings, therapy goals, obstacles to achieving these goals, resources to 
address problems, a prognosis, and a referral for adjunctive interventions 
such as pharmacotherapy, group therapy, substance abuse treatment, or a 
medical evaluation. Alternatively, interventions other than psychotherapy, 
or no interventions at all, might be recommended.
The process aspects of case formulation refer to the clinician’s activi-
ties aimed at eliciting the information required to develop the formula-
tion content; typically, this process primarily involves conducting a clinical 
interview. Two general categories of information should be kept in mind 
during a formulation-eliciting interview. The first is descriptive informa-
tion, which includes demographics, the presenting problems, coping steps 
taken by the patient, any history of previous mental health problems or 
care, medical history, and developmental, social, educational, and work 
4 HanDbook of PsyCHoTHEraPy CasE formulaTion
history. Although the selection of descriptive information can never be free 
of the influence of theory or implicit bias, there is usually no attempt to 
interpret or infer meaning in this section; instead, the emphasis is on pro-
viding a reliable information base. The second category is personal mean-
ing information, which refers to how the patient experiences and inter-
prets the events described. To elicit this information, the therapist asks and 
observes how descriptive events affect the patient’s thoughts, feelings, and 
behavior. The therapist can also infer personal meaning information from 
narratives the patient tells.
HISTORICAL AND CONTEMPORARY INFLUENCES
In this section I review four influences on psychotherapy case formulation. 
These are the medical examination and case history, models of psychopa-
thology and its classification, models of psychotherapy, and psychometric 
assessment.
The Medical Examination and Case History
The major influences on the form and logic of the psychotherapy case for-
mulation are the medical examination and case study, which have their roots 
in Hippocratic and Galenic medicine.1 The rise of Hippocratic medicine in 
the 5th century b.c.e. marked a repudiation of polytheism and mythology 
as sources of illness or cure. It also signaled an embrace of reason, logic, 
and observation in understanding illness and the conviction that only natu-
ral forces are at play in disease. The Hippocratic physicians believed that 
diagnosis must rest on a firm footing of observation and employed prog-
nostication as a means of corroborating their diagnoses. They took a holis-
tic view of disease, viewing the patient as an active participantin his or her 
cure. Foreshadowing the contemporary wellness movement, holistic medi-
cine approaches, and psychotherapists’ advocating for a focus on patients’ 
“problems in living” (Sullivan, 1954), the Hippocratics viewed disease as 
an event occurring in the full context of the patient’s life. Their treatment 
efforts were aimed at restoring a balance of natural forces in the patient.
Working within erroneous theoretical assumptions involving humoral 
interaction, vitalism, and “innate heat,” the Hippocratic physician’s 
basic task was to determine the nature of a patient’s humor imbalance. 
Toward this end, a highly sophisticated physical examination developed 
in which the physician, using his five senses, sought objective evidence to 
determine the underlying cause of the observed symptoms. According to 
Nuland (1988), Hippocratic case reports included descriptions of changes 
in body temperature, color, facial expression, breathing pattern, body posi-
tion, skin, hair, nails, and abdominal contour. In addition, Hippocratic 
 History and Current status 5
physicians tasted blood and urine; they examined skin secretions, ear wax, 
nasal mucus, tears, sputum, and pus; they smelled stool; and they observed 
stickiness of the sweat. Once the physician had gathered and integrated this 
information, he used it to infer the source of humoral imbalance and how 
far the disease had progressed. Only then was an intervention prescribed. 
The main point to be appreciated is the empirical quality of this examina-
tion. Symptoms were not taken at face value, nor were they assumed to be 
the product of divine intervention; instead, objective evidence of the body’s 
ailment was sought.
The focus on observation and empiricism by Hippocrates and his stu-
dents laid the foundation for physical examinations performed today. It 
serves as a worthwhile credo for the modern psychotherapy case formu-
lation. Importantly, the Hippocratics also provide modern psychotherapy 
case formulators with the caveat that even concerted efforts at objectivity 
and empiricism can fall prey to an overbelief in a theoretical framework 
into which observations are organized.
Before it could be described as modern, the Hippocratic ethos required 
two additional ingredients: a focus on anatomical (and subanatomical) 
structure and function as the foundation of disease and the establishment 
of planned experimentation as a means of understanding anatomy and 
disease. These ingredients were supplied more than 500 years after Hip-
pocrates by another Greek physician, Galen of Pergamon. Before Galen, 
a detailed knowledge of the body’s anatomy and how disease disrupts it 
was considered ancillary information in medical training, at best. Galen’s 
emphasis on anatomy and structure can be seen as a physiological pre-
cursor to current psychological theories that posit central roles for mental 
structures. These include psychodynamic concepts of id, ego, and superego, 
as well as self-representations, or schemas, which both cognitive and some 
psychodynamic theorists and researchers emphasize (Segal & Blatt, 1993).
Galen was the first to prize experimentation as a method for under-
standing anatomy. In a series of simple and elegant experiments, he proved 
that arteries contain blood and that arterial pulsations originate in the 
heart. Consistent with this Galenian spirit, experimentation to test for-
mulations about the “psychological anatomy” of psychotherapy patients 
has been proposed by several psychotherapy researchers and methodolo-
gists (e.g., Barlow & Hersen, 1984; Fishman, Messer, Edwards, & Dat-
tilio, 2017; Haynes, O’Brien, & Godoy, 2020; McLeod, 2010; Morgan & 
Morgan, 2001; Stiles, 2003). Further, many of the authors of chapters in 
this volume explicitly link their case formulation methods to empirically 
supported psychotherapies and to a tradition of empiricism.
Another significant advance in medical science regarding diagnosis 
occurred many centuries after Galen. This was the publication, in 1769, 
of Giovanni Morgagni’s De Sedibus et Causis Morborum per Anatomen 
(The Seats and Causes of Disease Investigated by Anatomy). Morgagni’s 
6 HanDbook of PsyCHoTHEraPy CasE formulaTion
work is a compilation of over 700 well-indexed clinical case histories, each 
linking a patient’s symptom presentation to a report of pathology found at 
autopsy and any relevant experiments that had been conducted. De Sedibus 
was a remarkable achievement in that it firmly established Galen’s “ana-
tomical concept of disease.” Although we now understand that illness is 
not only the product of diseased organs but also of pathological processes 
occurring in tissues and cellular and subcellular structures, the reductionist 
concept of disease still predominates. An 18th-century physician using De 
Sedibus to treat a patient could use the index to look up his patient’s symp-
toms, which could be cross-referenced to a list of pathological processes 
that might be involved. Morgagni’s credo, that symptoms are the “cry of 
suffering organs,” parallels the guiding assumption of some psychotherapy 
case formulation approaches that symptoms represent the “cry” of underly-
ing psychopathological structures and processes.
A second accomplishment of Morgagni’s is his foundation of the clini-
copathological method of medical research, in which correspondences are 
examined between a patient’s symptoms and underlying pathology revealed 
at autopsy. Although there is no psychological equivalent of the conclusive 
autopsy, the advent of the clinicopathological method foreshadowed an 
emphasis on obtaining independent, corroborating evidence to substanti-
ate hypothesized relationships in psychology. Morgagni’s De Sedibus also 
demonstrated how advances in medical science can occur on a case-by-case 
basis and how the integration and organization of existing information can 
advance a science. The creation of online case study journals, such as Prag-
matic Case Studies in Psychotherapy (Fishman, 2000), provides a database 
of psychotherapy cases with standard, researchable categories of informa-
tion included. Such efforts may mark the beginning of a psychological De 
Sedibus.
By extending the reach of our five senses, the tools and technologies of 
medicine have also added immensely to diagnostic precision; in doing so, 
medicine has provided a model for psychotherapy case formulations. Exam-
ples of developments in medicine that aided diagnosis include Laennec’s 
invention of the stethoscope in the early 19th century, Roentgen’s discovery 
of X rays, and recent developments in brain imaging techniques. If parallels 
exist in psychology, one might cite Freud’s free association (Lothane, 2018), 
Skinner’s demonstration of the power of stimulus control over behavior 
(Skinner, 1953), the technology of behavior genetics (Waldman, 2007; Plo-
min, 2018), and the advent of psychometrics (Wood, Garb, & Nezworski, 
2007). Each of these “technologies” has added to our understanding of 
individual psychological and psychopathological functioning.
As this review of the medical examination and case study has shown, 
the structure and logic of a traditional psychotherapy case formulation 
are modeled closely after medicine. Specific aspects borrowed include an 
emphasis on observation, the assumption that symptoms reflect underlying 
 History and Current status 7
disease processes, experimentation as a means of discovery, an ideal of 
postmortem (or posttreatment) confirmation of the formulation, and an 
increasing reliance upon technology to aid in diagnosis. 
Models of Psychopathology and Its Classification
A clinician’s understanding and knowledge of psychopathology and of the 
ways in which psychopathological states develop, are maintained, and are 
organized will frame how that clinician formulates cases. Understanding 
and knowledge impose a set of constraints about what the clinician views 
as “wrong” with a person, what needs to change,how possible change is, 
and how change might be effected. Although an extended discussion of 
the nature and classification of psychopathology is beyond the scope of 
this chapter, three themes that underlie ongoing debates on this topic are 
particularly relevant to case formulation. (For an expanded discussion, see 
Achenbach, 2020; Blashfield, 1984; and Blashfield & Burgess, 2007.)
Etiology versus Description
Throughout its history, psychiatry has oscillated between descriptive and 
etiological models of psychopathology (Mack, Forman, Brown, & Fran-
ces, 1994; Surís, Holliday, & North, 2016). The tension between these 
approaches to nosology reflects both dissatisfaction with descriptive mod-
els and the scientific inadequacy of past etiological models. During the 20th 
century and into the 21st, this trend has been seen as Kraepelin’s descrip-
tive psychiatry gave way to a psychosocial focus inspired by Adolf Meyer 
and Karl Menninger, as well as a Freudian emphasis on unconscious deter-
minants of behavior. A focus on description to the virtual exclusion of eti-
ology was revived in 1980 with the publication of the third edition of the 
Diagnostic and Statistical Manual of Mental Disorders (DSM-III; Ameri-
can Psychiatric Association, 1980) and has continued into the present with 
DSM-5 (American Psychiatric Association, 2013), as well as the Inter-
national Classification of Diseases (ICD-10 and ICD-11; World Health 
Organization, 2018). Nevertheless, research on the causes of and con-
tributors to psychopathology continues vigorously, as the current National 
Institute of Mental Health Research Domain Criteria (RDoC) framework 
demonstrates (National Institute of Mental Health, 2020). However, the 
impact of the RDoC framework on a revised nosology remains uncertain 
(MacDonald & Krueger, 2013), and some researchers have expressed con-
cern that the framework overprivileges biomedical research as compared 
to psychosocial and sociocultural research (Berenbaum, 2013; Teachman 
et al., 2019). With etiology currently not represented in current psychiatric 
nosologies, a conceptual vacuum is created that psychotherapy case formu-
lation aims to fill for the individual patient.
8 HanDbook of PsyCHoTHEraPy CasE formulaTion
Categorical versus Dimensional Models
Just as psychopathologists have oscillated between etiological and descrip-
tive nosologies, so have they long debated the merits of categorical versus 
dimensional models of psychopathology (Kendell, 1975). The categorical 
or “syndromal” view is that mental disorders are qualitatively distinct from 
each other and from “normal” psychological functioning. The categori-
cal approach expresses the “medical model” of psychopathology, which, in 
addition to viewing diseases as discrete pathological entities, also adheres 
to the following precepts: (1) diseases have predictable causes, courses, and 
outcomes; (2) symptoms are expressions of underlying pathogenic struc-
tures and processes; (3) the primary but not exclusive province of medicine 
is disease, not health; and (4) disease is fundamentally an individual phe-
nomenon, not a social or cultural entity. The categorical approach to psy-
chopathology is traceable in recent history to Kraepelin’s “disease concept” 
and is embodied in the diagnostic and statistical manuals published by the 
American Psychiatric Association since 1980.
The categorical model has faced considerable criticism in recent years. 
Dissatisfaction stems from problems such as symptom heterogeneity within 
categorical diagnostic entities, poor reliability, high levels of comorbidity, 
limited predictive validity, and concern that categorical models do not cap-
ture individual differences in personality problems (Hopwood et al., 2018; 
Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Likening the cat-
egorical model of personality disorders to phrenology, the geocentric model 
of the cosmos, and pre-Hippocratic views of mental illness, Hopwood and 
other leading psychopathologists pointedly write, “The categorical model 
has become a hindrance to research and practice” (2018, p. 84).
Those advocating a dimensional approach claim that psychopathol-
ogy is better viewed as a set of continua from normal to abnormal. Hop-
wood and colleagues (2018) assert that dimensional models enhance reli-
ability, have stronger links to basic research on personality, and eliminate 
challenges associated with personality disorder comorbidity and symptom 
heterogeneity. Others assert that dimensions can be measured more eas-
ily, better capture subclinical phenomena, and are a more parsimonious 
way of understanding psychopathology (Blashfield & Burgess, 2007). The 
movement toward dimensional models of personality disorders has reached 
the point at which a dimensional model is presented in DSM-5 (Ameri-
can Psychiatric Association, 2013) for consideration and future research. 
Perhaps more significantly, the recently released 11th edition of the World 
Health Organization’s ICD (2018) replaces a categorical personality disor-
der approach with a five-domain dimensional trait model. The five ICD-11 
trait domains are negative affectivity, detachment, dissociality, disinhibi-
tion, and anankastia. Clinicians first rate a patient with respect to a level 
of personality disorder severity, followed by the option of rating the person 
 History and Current status 9
with respect to the five trait domains, along with a borderline pattern qual-
ifier (Bagby & Widiger, 2020).
Regarding case formulation, what difference does it make whether a 
nosology is dimensional or categorical? Three factors can be identified: 
potential for stigmatization, goodness-of-fit to a therapist’s conception of 
personality organization, and ease of use.
Compared with dimensional models, categorical approaches may be 
more prone to stigmatize patients due to a greater tendency to reify what is 
a theoretical construct. For example, being told that one “has” a person-
ality disorder can produce or exacerbate feelings of being defective, espe-
cially when proffered as an “explanation” of one’s condition. This “formu-
lation” can also have an unnecessarily demoralizing effect on the therapist. 
Dimensional approaches may be less prone toward stigmatization because 
dimensions vary from normal to abnormal ranges and are not assumed to 
represent discrete psychological conditions.
When expressed in experience-near, functional, and context-specific 
terms, a case formulation can serve as a therapeutic adjunct to either a 
categorical or dimensional system, thus reducing the potential for stigmati-
zation. For example, instead of labeling a person as “having” a personality 
disorder, the therapist might offer a formulation-based intervention such as 
“Could it be that when threatened by abandonment, you hurt yourself in an 
attempt to bring others close, but instead, you only drive them away?”; or 
“I wonder if you are letting others decide how you feel, instead of deciding 
for yourself.”
The dimensional–categorical debate also has implications for the case 
formulator’s frame of reference in understanding personality. If one views 
personality in an intraindividual context (Valsiner, 1986, 1987)—that is, 
as an internally organized system of interconnecting parts—then one’s 
preference for a categorical or dimensional approach will influence the 
“parts” one identifies and one’s view of how they interrelate. The categori-
cal approach assumes that signs, symptoms, and personality traits cluster 
together, forming a whole that constitutes an organization greater than the 
sum of its parts (see Allport, 1961). Thus, from the intraindividual stand-
point, if a patient exhibits an extreme fear of abandonment, suggesting 
borderline personality disorder, the case formulator might examine more 
closely for impulsivity, self-image problems, and risk of suicide. Reaching 
to the research literature, the case formulator might also assess for a sense 
ofperceived burdensomeness and suicide capability when assessing for sui-
cidality (Chu et al., 2017).
The dimensional approach is the better fit if one views individual per-
sonality in an interindividual frame of reference (Valsiner, 1986, 1987); 
that is, as an array of traits that do not necessarily interrelate and that are 
best understood according to how they compare with their expression in 
other individuals. Dimensional approaches such as the five-factor model 
10 HanDbook of PsyCHoTHEraPy CasE formulaTion
(Costa & Widiger, 1994) are built on the assumption that the dimensions 
are not correlated. Thus an individual’s score on the trait “Agreeableness” 
would not help one predict his or her degree of “Conscientiousness.” A 
clinician working from an interindividual frame might propose a set of 
cardinal traits as composing the core of a case formulation.
Ease of use is another consideration relevant to case formulation, as a 
case formulation must often be done quickly. Many find it more natural to 
think in categories than in dimensions, including in health care, as clinical 
decisions are often categorical in nature (e.g., treat or not, use intervention 
A or B). Categories may also have greater ease of use in helping a therapist 
and patient identify and label problems to address in therapy, as a kind 
of shorthand. For example, Ridley and Jeffrey (Chapter 7, this volume) 
note how useful the metaphor “Daddy’s Unwanted Girl” was in a case they 
describe.
Can the categorical and dimensional perspectives be reconciled? As 
stated elsewhere (Eells, 2015), a therapist need not choose between the cat-
egorical and dimensional lenses, and it is helpful to be familiar with both 
modes of thinking. Cognitive scientists have found that we think more eas-
ily in terms of categories; it feels natural and is quick. Yet dimensional 
approaches are parsimonious and address shortcomings of categorical sys-
tems. Each can serve a purpose, and one can learn to view clients alter-
nately using either approach.
Normality versus Abnormality
Related to the issue of dimensional versus categorical models of psychopa-
thology are decisions as to what is and what is not normal behavior and 
experience. These decisions are central to the task of psychotherapy case 
formulation. They guide not only the structure and content of the formula-
tion and the process by which the case formulation is identified but also 
the clinician’s intervention strategies and goals for treatment. First, it is 
important to recognize that all conceptions of psychopathology are social 
constructions, at least to some extent (Millon, 2011). They reflect cultur-
ally derived, consensually held views as to what is considered abnormal and 
what is not.
Several criteria can help in making decisions about what is normal 
or not. These include the following: statistical deviation from normative 
behavior, personal distress, causing distress in others, violation of social 
or cultural norms, deviation from an ideal of mental health, personality 
inflexibility, poor adaptation to stress, and irrationality (Millon, 2011; 
Ramsden, 2013). These criteria provide a baseline and a context against 
which the patient’s behavior and experiences can be compared. They enable 
the case formulator, first, to understand patients better by comparing their 
stress responses with normative stress responses and, second, to assess the 
 History and Current status 11
separate contributions of dispositional versus situational, cultural, social, 
and economic factors to a patient’s clinical presentation. The case formu-
lator does not act as judge of the patient’s experiences but uses normative 
views of normality and abnormality to help the patient adapt.
In sum, the content and structure of a psychotherapy case formulation 
is inextricably linked to the therapist’s implicit or explicit views regard-
ing the etiology of emotional problems, the dimensional versus categorical 
debate about mental disorders, and assumptions about what is normal and 
abnormal in psychological functioning.
Models of Psychotherapy
The therapist’s approach to psychotherapy will, of course, greatly influence 
the case formulation process and end product. In this section, I review four 
major models of psychotherapy with a focus on their contributions to case 
formulation. These approaches are psychoanalytic, humanistic, behavior, 
and cognitive therapies.
Psychoanalysis
Although its influence has declined in recent years (Paris, 2019), psycho-
analysis has had at least three major influences on the psychotherapy case 
formulation process. The principal contribution is the development by 
Freud and his successors of models of personality and psychopathology 
that have significantly shaped our understanding of normal and abnor-
mal human experience and behavior. Among the most significant psycho-
analytic concepts are psychic determinism and the notion of a dynamic 
unconscious, the overdetermination and symbolic meaning of symptoms, 
symptom production as a compromise formation, ego defense mechanisms 
as maintainers of psychic equilibrium, and the tripartite structural model 
of the mind. Beginning with the early formulation that “hysterics suffer 
mainly from reminiscences” (Breuer & Freud, 1893/1955, p. 7), psycho-
analysis has provided therapists with a general framework for understand-
ing experiences that patients report in psychotherapy. Subsequent formu-
lations by object relations theorists (e.g., Kernberg, 1975, 1984) and self 
psychologists (Kohut, 1971, 1977, 1984) added to psychoanalytic concep-
tions of individuals with personality disorders (see also McWilliams, 2011).
A second contribution of psychoanalysis to case formulation relates to 
an expanded view of the psychotherapy interview. Before Freud, the psy-
chiatric interview was viewed similarly to an interview in a medical exami-
nation. It was highly structured and focused on obtaining a history and 
mental status review, reaching a diagnosis, and planning treatment (Gill, 
Newman, & Redlich, 1954). Since Freud, therapists recognize that patients 
often enact their psychological problems, and especially interpersonal 
12 HanDbook of PsyCHoTHEraPy CasE formulaTion
problems, while describing them to the therapist (e.g., Binder & Betan, 
Chapter 5, this volume; Busch & Milrod, Chapter 3, this volume; Cur-
tis & Silberschatz, Chapter 4, this volume; Grenyer, Marceau, & Wise-
man, Chapter 2, this volume; Levenson, 2017). The interview process itself 
became an important source of information for the formulation. That is, 
the way patients organize their self-presentations and thoughts, approach 
or avoid certain topics, and behave nonverbally has become part of what 
the therapist formulates.
A third contribution of psychoanalysis to formulation is its empha-
sis on the case study. Although the value of the case history continues to 
be debated (e.g., Fishman et al., 2017; Flyvbjerg, 2006; McLeod, 2010; 
McLeod & Elliott, 2011), there is little question that Freud elevated the 
method’s scientific profile. The case study was the principal vehicle through 
which Freud presented and supported psychoanalytic concepts.
Interestingly, psychoanalysis has not traditionally incorporated the 
concept of a medical diagnosis into a formulation (Gill et al., 1954). Freud’s 
own lack of interest in diagnosis is revealed in the index of the Standard 
Edition of his complete works, which shows no entries for “diagnosis” or 
“formulation,” although a few under “anamnesis.” Pasnau (1987) and Wil-
son (1993) assert that psychoanalysts’ lack of emphasis on diagnosis con-
tributed to the “demedicalization” of psychiatry in the early 20th century. 
These writers claim the “disease concept” was not seen as compatible or 
relevant to psychoanalysts’ focus on unconscious psychological determi-
nants of symptoms as opposed to organic determinants, nor to an emphasis 
on motivational states, early life history, or interpersonalrelationship pat-
terns.
Alongside its contributions to case formulation, psychoanalysis has 
been criticized for applying general formulations to patients when they do 
not fit. One prominent example may be Freud’s case study of Dora (see 
Lakoff, 1990). Psychoanalytic formulations have also been criticized for 
being overly speculative (Masson, 1984), for exhibiting a male bias (Hor-
ney, 1967), and for lack of scientific rigor (Paris, 2019).
Humanistic Therapy
Proponents of humanistically oriented psychotherapies have tradition-
ally taken the view that case formulation, or “psychological diagnosis,” is 
unnecessary and even harmful. According to Carl Rogers (1951), “Psycho-
logical diagnosis . . . is unnecessary for [client-centered] psychotherapy, and 
may actually be detrimental to the therapeutic process” (p. 220). Rogers 
was concerned that formulation places the therapist in a “one up” position 
in relation to the client and may introduce an unhealthy dependency into 
the therapy relationship, thus impeding a client’s efforts to assume responsi-
bility for solving his or her own problems. In Rogers’s (1951) words, “There 
 History and Current status 13
is a degree of loss of personhood as the individual acquires the belief that 
only the expert can accurately evaluate him, and that therefore the measure 
of his personal worth lies in the hands of another” (p. 224). Rogers (1951) 
also expressed the social philosophical objection that diagnosis may in the 
long run place “social control of the many [in the hands of] the few” (p. 
224). Although Rogers’s criticisms serve as a caveat, they also seem based 
on the assumption that the practice of “psychological diagnosis” neces-
sarily places the therapist and patient in a noncollaborative relationship 
in which the formulation is imposed in a peremptory fashion rather than 
reached jointly and modified as necessary. It is also noteworthy that con-
temporary exponents of phenomenological therapies are less rejecting of 
formulation than was Rogers but tend to emphasize formulation of the 
moment-to-moment experiences of the client rather than proposing global 
patterns that describe a client (Goldman & Greenberg, Chapter 14, this 
volume).
Contributions of humanistic psychology to case formulation include its 
emphasis on the client as a person instead of a “disorder” that is “treated,” 
its focus on the here-and-now aspect of a human encounter rather than an 
intellectualized “formulation,” and its view of the therapist and client as 
equals in their relationship. Humanistic psychology also takes a holistic 
rather than a reductionist view of humankind. Humanistic psychology has 
contributed techniques that facilitate insight and a deepening of experience 
(Goldman & Greenberg, Chapter 14, this volume) and has emphasized 
an evidence-based approach to understanding psychotherapy processes 
and outcomes, even if these contributions remain largely unacknowledged 
today (Farber, 2007).
Behavior Therapy
Behavior therapists have historically downplayed traditional assessment 
and diagnosis (Follette, Naugle, & Linnerooth, 2000; Goldfried & Pomer-
anz, 1968). Reasons are many and include an emphasis of the former on 
unobservable mental entities or forces, on classification per se, on concerns 
about lack of utility in helping individuals, and on a mismatch between the 
goals of traditional assessment and those of behavioral analysis (Follette 
& Darrow, 2014; Follette et al., 2000; Hayes & Follette, 1992). Further, 
diagnostic categories are largely incompatible with behaviorists’ emphasis 
on problems rather than diagnoses and on evaluating problems through 
“functional analysis.” Functional analysis involves identifying target 
behaviors, the environmental variables and contingencies that control the 
behaviors, and the application of behavioral principles to facilitate change 
(Sturmey, Chapter 11, this volume). Some behaviorists have acknowledged 
limitations in the functional analysis approach to case formulation, primar-
ily due to difficulties in replicability and resulting problems in studying 
14 HanDbook of PsyCHoTHEraPy CasE formulaTion
patients scientifically (Hayes & Follette, 1992). More recently, behavior 
therapists, as well as some cognitive therapists (e.g., Persons & Tompkins, 
Chapter 9, this volume), have broadened the notion of functional analysis 
to include consideration of an individual’s thoughts and feelings, not only 
their behavior, and by incorporating functional analysis into a case formu-
lation format (Haynes et al., 2011; Nezu et al., 2007). The “third wave” of 
behavior therapy (Hayes, 2004) has added an emphasis on concepts such 
as nonjudgmental present focus, values, and the observing mind, using ter-
minology such as mindfulness and acceptance (Chin, Stanton, Sanford, & 
Hayes, Chapter 13, this volume; Kuyken & Dunn, Chapter 12, this vol-
ume.)
Behavior therapy has made major contributions to the case formula-
tion process. First is its emphasis on symptoms and problems. Behaviorists 
strive to understand the “topography” of symptomatology, including rel-
evant stimulus–response associations and contingencies of reinforcement. 
In contrast to psychodynamic thinkers who view symptoms as symbolic 
of a more fundamental problem, behaviorists traditionally focus on symp-
toms as the problem and aim directly at symptom relief. As noted above, 
however, the third wave of behavior therapy moves beyond the goal of alle-
viating symptoms to that of increasing self-awareness and learning flexible 
and adaptive behavioral repertoires. Second, more than other practitioners, 
behaviorists have emphasized environmental sources of distress and, more 
particularly, how an individual’s surroundings may function to reinforce 
both maladaptive and adaptive behavior. Consequently, greater attention 
has been placed on changing the environment rather than the individual. 
A formulation that is more balanced in attributing maladaptive behavior 
to the individual and his or her environment is less stigmatizing. Third, 
behaviorists have emphasized empirical demonstrations to support the 
effectiveness of their approaches. This includes measuring symptomatol-
ogy, isolating potential causal variables, and systematically varying them 
and examining the effects on behavior. This tradition dates to Watson’s 
demonstration with Little Albert that specific phobias can be produced and 
extinguished according to principles of classical conditioning.
Cognitive Therapy
In a series of influential volumes, Beck and his colleagues have set forth 
general formulations about the causes, precipitants, and maintaining influ-
ences in depression (Beck, Freeman, Davis, & Associates, 2004), anxiety 
disorders (Beck, Emery, & Greenberg, 1985; Clark & Beck, 2011), person-
ality disorders (Beck, Rush, Shaw, & Emery, 1979; Beck, Davis & Free-
man, 2015), and substance abuse (Beck, Wright, Newman, & Liese, 1993). 
Within the cognitive framework, specific mechanisms have been theorized 
for specific disorders, such as panic disorder (Clark, 1986; Craske & 
 History and Current status 15
Barlow, 2014), social phobia (Clark & Wells, 1995), and posttraumatic 
stress disorder (Ehlers & Clark, 2000). These formulations emphasize a set 
of cognitive patterns, schemas, and faulty information processes, each spe-
cific to the type of disorder. Individuals with depression, for example, tend 
to view themselves as defective and inadequate, the world as excessively 
demanding and presenting insuperable obstacles to reaching goals, and the 
future as hopeless. The thought processes of individuals with depression 
are described as revealing characteristic errors, including making arbitrary 
inferences, selectively abstracting from the specific to the general, over-
generalizing, and dichotomizing. In contrast, formulations of individuals 
with anxiety tend to center around the theme of vulnerability, and those of 
substance-abusing individualsmay focus on automatic thoughts regarding 
the anticipation of gratification and increased efficacy when using drugs or 
symptom relief that will follow drug intake. Until relatively recently, cogni-
tive psychologists tended to focus on general formulations for these disor-
ders rather than tailor-made variations constructed for a specific patient 
(Persons, 1989, 2008; Persons & Tompkins, Chapter 9, this volume; Tar-
rier & Calam, 2002; Tarrier & Johnson, 2016). As Persons and Tompkins 
(Chapter 9, this volume) note, the jury is still out on whether individual-
ized formulations have a differential impact on the outcome of cognitive-
behavioral therapy than when generalized formulations alone are used.
Psychometric Assessment
Among clinical psychology’s contributions to understanding psychopathol-
ogy are the development of reliable and valid personality tests, standards 
for constructing and administering these tests, and the application of prob-
ability theory to assessment (Wood et al., 2007). The influence of these 
developments on psychotherapy case formulation has been indirect, how-
ever, and not what it potentially might be. One reason may be a tendency 
among clinical psychologists to see psychotherapy and psychometric assess-
ment as separate, and perhaps incompatible, enterprises. Second, questions 
have regularly arisen about the practical value of psychological assess-
ment for psychotherapy (e.g., Hayes, Nelson, & Jarrett, 1987; Korchin & 
Schuldberg, 1981; Nelson-Gray, 2003; Wood et al., 2007). In fact, little 
research has examined the incremental benefit of psychological assessment 
on treatment planning, implementation, and outcome, despite the avail-
ability of research strategies for addressing this issue (Hayes et al., 1987; 
Hunsley & Meyer, 2003).
What are the potential contributions of psychometrics and psychomet-
ric thinking to psychotherapy case formulation? First is the use of validated 
personality and symptom measures themselves in the case formulation pro-
cess (Koerner, Hood, & Antony, 2011). As the reader of this volume will 
see, some authors routinely use symptom measures and empirical progress 
16 HanDbook of PsyCHoTHEraPy CasE formulaTion
monitoring as part of their case formulation process. Some of these tools 
have been demonstrated to provide incremental validity in predicting treat-
ment outcome and to signal when treatment failure may be at risk (Lam-
bert, 2007, 2013). Other authors have discussed psychotherapy applications 
of frequently used psychometric instruments, for example, the Minnesota 
Multiphasic Personality Inventory (MMPI; Finn & Kamphuis, 2006) and 
the Personality Assessment Inventory (Morey, 2003). In addition, semistruc-
tured interview protocols such as the Mini-International Neuropsychiatric 
Interview (M.I.N.I.; Sheehan et al., 1998) or tools such as the Shedler–
Westen Assessment Procedure (SWAP-200; Shedler & Westen, 2004) could 
be used to aid in the diagnostic component of case formulation.
A second potential contribution to case formulation relates to the way 
of thinking that is associated with psychometric assessment. An aware-
ness of concepts such as reliability, validity, and standardization of admin-
istration of a measure may increase the fit of a case formulation to the 
individual in question. For example, just as standardized administration 
of psychological tests is important for a reliable and valid interpretation of 
the results, so might it be important for the therapist to adopt a standard 
approach in an assessment interview to understand the client more accu-
rately and empathically. In accomplishing this goal, the therapist should 
not be rigid or wooden but, instead, should strive to be close enough to the 
patient’s thoughts and feelings while also sufficiently distant as to remain a 
reliable instrument for assessing the patient’s problems, including the pos-
sible expression of those problems in the therapy relationship. Maintaining 
such a stance is particularly important during the psychotherapy interview 
because it is the most frequently used tool for assessing psychotherapy 
patients and is also subject to problems with reliability (Koerner et al., 
2011).
In this section, I have traced historical and contemporary influences 
that have shaped the process and content of the psychotherapy case formu-
lation to what it is today. As reviewed, its form and structure originated 
in Hellenic days and are deeply embedded in medicine but have also been 
altered in significant ways by psychoanalytic, humanistic, behavioral, and 
cognitive psychology. Psychotherapy case formulation has also been influ-
enced by how psychopathology is understood and by the advent of psycho-
metric assessment.
CASE FORMULATION RESEARCH
Case formulation has been subject to a considerable amount of research, 
although more is needed. In this section I highlight major focus areas and 
related findings. Several excellent reviews and critiques of aspects of case 
 History and Current status 17
formulation research have been published in recent years, and these provide 
many details beyond the scope of this chapter (Bucci, French, & Berry, 
2016; Easden & Kazantzis, 2018; Persons & Hong, 2016; Rainforth & 
Laurenson, 2014; Ridley, Jeffrey, & Roberson, 2017). Each chapter in this 
Handbook provides a section discussing research on the specific method 
presented. In this summary, I discuss case formulation reliability and valid-
ity studies, research investigating the contribution of case formulation to 
treatment processes and outcomes, and work on case formulation compe-
tence, expertise, and training.
Case Formulation Reliability
The value of a case formulation is relative to its reliability, as well as its 
validity, which is discussed in the following section. Reliability here refers 
to how well clinicians can independently construct similar formulations 
based on the same clinical material. Reliability can also refer to how well 
the formulations of clinicians match a formulation constructed by an 
expert or a team of experts or, alternatively, the extent to which clinicians 
agree that an already constructed formulation or its components fit a set of 
clinical material.
In 1966, a Chicago psychoanalyst, Philip Seitz (1966), published 
an article detailing the efforts of a small research group to study what 
he termed “the consensus problem in psychoanalytic research” (p. 209). 
For 3 years, the group of six psychoanalysts independently reviewed either 
detailed interview notes from a single case of psychotherapy or dreams 
taken from several psychotherapy cases. Each formulator wrote an essay-
style narrative addressing the precipitating situation, focal conflict, and 
defense mechanisms at play in the clinical material. The participants also 
reported their interpretive reasoning and evidence both supporting and 
opposing their formulation. After the formulations were written, they were 
distributed to each member of the group, who then had the opportunity 
to revise the original formulation in light of clues provided in the formula-
tions of others. The group met weekly to review their findings. Despite the 
group’s initial enthusiasm, the results were disappointing, even if predict-
able. Seitz reported that satisfactory consensus was achieved on very few of 
the formulations.
The primary value of Seitz’s paper is that it alerted the community of 
psychotherapy researchers and practitioners to the “consensus problem.” 
If psychotherapy research aspired to be a scientific enterprise, progress had 
to be made in the consistency with which clinicians describe a patient’s 
problems and ways of managing them. Seitz’s (1966) paper is also valuable 
for its presentation of why the clinicians had difficulty obtaining agree-
ment. A general reason was the “inadequacy of our interpretive methods” 
(p. 214). One of these inadequacies was the tendency of group members to 
18 HanDbook of PsyCHoTHEraPy CasE formulaTionmake inferences at an overly deep level, for example, making references 
to “phallic–Oedipal rivalry” and “castration fears.” Seitz (1966) also rec-
ognized that the group placed “excessive reliance upon intuitive impres-
sions and insufficient attention to the systematic and critical checking of 
our interpretations” (p. 216). These remarks foreshadowed those of later 
researchers who have identified limitations and biases in human informa-
tion-processing capacities and the conditions required to make best use of 
intuition (Kahneman, 2011; Kahneman & Klein, 2009).
In the years following the publication of Seitz’s paper, multiple research-
ers focused on improving the reliability of psychotherapy case formulations. 
The first to successfully achieve this was Luborsky (Grenyer et al., Chapter 
2, this volume; Luborsky, 1977; Luborsky & Barrett, 2007) with his core 
conflictual relationship theme (CCRT) method. Within a few years, more 
than 15 structured case formulation methods had been proposed (Luborsky 
et al., 1993). Although most of these methods were developed within a psy-
chodynamic framework, methods from behavioral, cognitive-behavioral, 
cognitive-analytic, and eclectic/integrative schools were also developed. A 
sampling of these methods includes the CCRT (Grenyer et al., Chapter 2, 
this volume; Luborsky & Crits-Christoph, 1990, 1998; Tallberg, Ulberg, 
Johnsen-Dahl, & Høglend, 2020), the plan formulation method (Curtis & 
Silberschatz, Chapter 4, this volume; Curtis, Silberschatz, Sampson, Weiss, 
& Rosenberg, 1988), the role relationship model configuration method 
(Horowitz, 1989, 1991; Horowitz & Eells, 2007), the cyclic maladaptive 
pattern (Binder & Betan, Chapter 5, this volume; Johnson, Popp, Schacht, 
Mellon, & Strupp, 1989; Schacht & Henry, 1994), the idiographic conflict 
formulation method (Perry, 1994; Perry, Augusto, & Cooper, 1989), the 
consensual response formulation method (Horowitz, Rosenberg, Ureño, 
Kalehzan, & O’Halloran, 1989), cognitive-behavioral case formulation 
(Persons, 1989, 2008), and plan analysis (Caspar, 1995; Chapter 8, this 
volume).
The reliability of several have been tested (Barber & Crits-Christoph, 
1993; Critchfield, Benjamin, & Levenick, 2015; Flinn, Braham, & das 
Nair, 2015; Kuyken, Fothergill, Musa, & Chadwick, 2005; Sørbye et al., 
2019). A recent review of 18 studies (Flinn et al., 2015) found that inter-
rater reliability estimates ranged from slight (.1–.4) to substantial (.81–1.0). 
These authors further found that “psychodynamic formulations appeared 
to generate somewhat increased levels of reliability than cognitive or behav-
ioral formulations; however, these studies also included methods that may 
have served to inflate reliability, for example, pooling the scores of judges” 
(p. 266). Evidence from reliability studies of cognitive-behavioral case for-
mulation methods found high levels of agreement (i.e., intraclass correla-
tion [ICC] >  .83) on case conceptualization content, but lower levels of 
agreement on underlying cognitive mechanisms (mean ICC of .46, range 
was .07–.70; Easden & Kazantzis, 2018).
 History and Current status 19
Case Formulation Validity and Contribution to Treatment Process 
and Outcome
There has been less research on case formulation validity than on case for-
mulation reliability, and, as with reliability studies, researchers have used a 
variety of methods to assess validity and have assessed validity from many 
perspectives. Easden and Kazantzis’s (2018) systematic review of cognitive-
behavioral case formulation validity found 16 studies that sought to evalu-
ate validity in relation to symptom change. Seven of these included some 
measure of effect size concerning the relationship between aspects of case 
conceptualizations and patient symptoms, but three of these involved very 
small samples. No overall conclusions were reported due to the disparate-
ness of the studies.
Outside of the cognitive-behavioral perspective, a study by Horowitz, 
Luborsky, and Popp (1991) examined the convergent validity of the role 
relationship model configuration (RRMC) method (Horowitz, 1989, 1991; 
Horowitz & Eells, 2007) by qualitatively comparing it with the CCRT 
method of case formulation (Luborsky & Crits-Christoph, 1990; Grenyer 
et al., Chapter 2, this volume). The results were that the methods iden-
tified similar core emotional and interpersonal conflicts, that the CCRT 
was easier to perform, but that the RRMC yielded more information about 
defense processes. Several other studies have followed a similar methodol-
ogy (e.g., Collins & Messer, 1991; Perry, Luborsky, Silberschatz, & Popp, 
1989; Persons, Curtis, & Silberschatz, 1991). They tend to find convergent 
and divergent validity depending on the case formulation method and the 
respective underlying theory.
One way to construe case formulation validity is to examine the extent 
to which a case formulation predicts events or themes that emerge later in 
therapy, a form of predictive validity. For example, Horowitz, Eells, Singer, 
and Salovey (1995) compared RRMCs constructed early in a long-term 
therapy with psychotherapy transcripts in the second and final thirds of 
the psychotherapy. Findings were that key interpersonal, emotional, and 
defensive themes identified early in therapy were still the focus of attention 
at later points in the therapy. In another series of intensive case studies, 
Silberschatz (2005) found that therapist interventions that were consistent 
with a formulation predicted both process events—particularly a deepen-
ing of experiencing on the part of the patient—and outcome of the therapy 
(see also Messer, Tishby, & Spillman, 1992). Luborsky (1996) conducted 
similar studies involving the CCRT.
Experimental studies have examined the incremental validity of case 
formulations by comparing patients randomly assigned either to standard 
manualized therapy or to tailored therapy based on a case formulation 
(e.g., Schulte, Kunzel, Pepping, & Schulte-Bahrenberg, 1992; Ghaderi, 
2011) or on intervention modules selected according to an individualized 
20 HanDbook of PsyCHoTHEraPy CasE formulaTion
assessment of the needs of the patient (Chorpita et al., 2013). Overall, these 
studies have not found differences in outcome between groups. One way to 
understand these results is to recognize that some degree of individualiza-
tion occurs even in manualized therapy, creating a lack of heterogeneity 
between levels of independent variables. Easden and Kazantzis (2018) also 
note that most studies of this type are underpowered. They conclude that 
research has yet to establish whether case conceptualization can enhance 
therapy outcomes and offer suggestions for further research.
Mumma and colleagues (Mumma, 2011; Mumma & Fluck, 2016; 
Mumma, Marshall, & Mauer, 2018) have offered a variety of interest-
ing perspectives on assessing case formulation validity. They center on a 
person-specific, hypothesis-testing approach involving repeated assess-
ments using measures that have both idiographic and nomothetic compo-
nents and that can be evaluated with simple statistical tests. The approach 
Mumma and colleagues offer recognizes the critical distinction between 
the intraindividual and interindividual frames of reference—more partic-
ularly, that a pattern of results derived from an interindividual frame of 
reference may not extend to the intraindividual frame of reference (Eells, 
2007; Hilliard, 1993; Kim & Rosenberg, 1980; Kraemer, 1978; Lewin, 
1931; Morgan & Morgan, 2001; Sidman, 1952; Thorngate, 1986; Tukey 
& Borgida, 1983). Put more simply, “[t]he basis and justification for the 
person-specific approach derives from the notion that patterns of correla-
tions between items on a questionnaire may be different, depending on 
whether data are collected from many persons or from one person across 
many times” (Mumma, 2011, p. 30).
Case Formulation Competence, Expertise, and Training
A body of case formulationresearch has also focused on issues related to 
case formulation competence, expertise, and training. Questions considered 
include whether more experienced or expert therapists are better at case for-
mulation than novices, and, if so, what distinguishes the process followed 
by experts; how best to train therapists in case formulation; and how to 
measure case formulation competence. We explore these questions in turn.
There is evidence that experts not only produce higher quality case for-
mulations but also that they follow a different process than do novices and 
experienced therapists who lack case formulation expertise (Eells, Lombart, 
Kendjelic, Turner, & Lucas, 2005). Eells and colleagues found that expert 
cognitive-behavioral and psychodynamic therapists produced case formu-
lations that were more comprehensive, elaborated, complex, and systematic 
in terms of following a consistent process from case to case; in addition, the 
treatment plans of experts were more elaborated and more tightly linked 
to the inferred mechanisms and the problem list. In terms of content, the 
formulations of the experts contained more information, specifically more 
 History and Current status 21
descriptive, diagnostic, inferential, and treatment-planning information. 
They also exhibited more inferential and deductive reasoning as compared 
with the nonexperts (Eells et al., 2011). A qualitative analysis indicated 
that high-quality formulations developed by both cognitive-behavioral and 
psychodynamic therapists used low-level inferences and a pattern of alter-
nating between descriptive information and inference making as the formu-
lation was being developed (Eells, 2010). Interestingly, in these studies by 
Eells and colleagues, novices performed better than experienced therapists, 
a finding that has been replicated (Vollmer, Spada, Caspar, & Burri, 2013) 
and that has implications for professional development.
In another study, Kuyken and colleagues (2005) assessed the quality 
of cognitive-behavioral formulations and found high variability, with 44% 
rated as being at least good enough. These researchers also found that the 
quality of case formulations was associated with clinical experience and 
accreditation status. Similarly, Baer (2005) found a small but positive rela-
tionship between case formulation quality ratings and treatment response. 
Interestingly, the relationship between case formulation quality ratings and 
treatment response was stronger for individuals with complex diagnoses. 
In a similar study, Easden and Fletcher (2018) investigated the relationship 
between therapist competence in case conceptualization and outcome in 
psychotherapy. They found that therapist competence explained 40% of 
within-patient variance and 19% of between-patient variance associated 
with significant and positive change on the Beck Depression Inventory–II 
(BDI-II; Beck, Steer, & Brown, 1996).
A few studies have been conducted on training therapists to learn and 
apply case formulations. Caspar, Berger, and Hautle (2004) developed a 
computer-supported approach that was well accepted and led to improve-
ment in the ability of trainees to cover the relevant aspects of a case con-
ceptualization. In another study, Kendjelic and Eells (2007) found that a 
2-hour “generic” training in psychotherapy case formulation led to sta-
tistically significant improvements in case formulation quality. Mumma 
(2011) suggests that the complexities of formulation-based treatment make 
these treatments more vulnerable to judgmental and inferential bias than 
are standardized treatments. Consequently, he proposes the development 
of specific manuals on how to test and validate formulations. He further 
recommends that formulations be assessed during training to provide the 
trainee with feedback on accuracy and validity, with the goal of improving 
clinical decision-making judgments and improving outcomes.
Related to Mumma’s recommendations, researchers are increasingly 
developing tools to measure psychotherapy case formulation competence 
(Bennett & Parry, 2004; McMurran & Bruford, 2016; Kuyken et al., 2016; 
Müller, 2011) and are including them in case formulation manuals (e.g., 
Eells, 2015; Kuyken et al., 2009). For a review of case formulation compe-
tency measures, see Bucci et al. (2016).
22 HanDbook of PsyCHoTHEraPy CasE formulaTion
In sum, considerable research has taken place related to case formula-
tion, and it appears to be increasing. Findings suggest that reliable formu-
lations can be developed, depending on the format and primarily when 
inference levels are low. Research also suggests that therapists differ in case 
formulation competence and that formulation competence may be related 
to outcome. Finally, more research is needed to establish whether case for-
mulations provide added benefit to psychotherapy outcome as compared 
with treatment that does not explicitly adhere to a formulation.
TENSIONS INHERENT IN THE CASE FORMULATION PROCESS
I now examine five tensions that are at play when developing an effec-
tive and useful case formulation. Each tension represents competing and 
incompatible goals faced by the clinician in attempting to understand a 
patient and the patient’s problems. The clinician must reconcile each of 
these tensions if the case formulation is to serve as an effective tool for 
psychotherapy.
Immediacy versus Comprehensiveness
The task of case formulation is foremost a pragmatic one. A formulation 
helps the clinician choose what to do next in therapy, both within and 
across sessions. From the first hour of therapy, the clinician aims to under-
stand the patient’s symptoms, core problems, goals, obstacles and strengths, 
coping or defense processes, interpersonal style, maladaptive behavior pat-
terns, life situation, and so on, all toward the goal of developing and imple-
menting a treatment plan. For this reason, a case formulation is needed 
relatively early in treatment. At the same time, the more comprehensive and 
therefore informed a case formulation is, the better it will serve the clini-
cian and patient. The priority given to practicality necessarily exacts a cost 
in comprehensiveness.
Some writers have advised that a case formulation should be completed 
during the initial interview with a patient (Kaplan & Sadock, 1998; Mor-
rison, 2014), whereas others assert the formulation is not complete until 
therapy is complete (Binder & Betan, Chapter 5, this volume). Although it 
may be unrealistic to produce a sufficiently comprehensive case formulation 
based on a single hour, research shows that experienced physicians begin 
to entertain and rule out diagnostic possibilities from the earliest minutes 
of medical interviewing (Elstein, Shulman, & Sprafka, 1978). The same 
may be the case for expert psychotherapists, as we reviewed earlier (Eells et 
al., 2005; Eells, 2010). Another aspect of the tension between immediacy 
and comprehensiveness is that the clinician observes a restricted behavior 
sample in a relatively controlled interview context. This restricted sample 
 History and Current status 23
may obscure a patient’s capabilities or limitations that would be apparent 
in other settings, with additional time to observe, or with information from 
multiple sources.
In sum, therapists seeking to balance the goals of immediacy and com-
prehensiveness must efficiently identify what information is needed to help 
the patient and avoid areas that may be intriguing or interesting but have 
little to do directly with helping the patient.
Complexity versus Simplicity
One can construe the case formulation task in relatively simple or com-
plex terms. If an overly simple construction is offered, important dimen-
sions of the person’s problems may go unrecognized or misunderstood. If 
overly complex, the formulation may be unwieldy, too time-consuming, 
and impractical. In addition, the more complex a case formulation method, 
the more difficultit may be to demonstrate its reliability and validity. Thus, 
a balance between complexity and simplicity is an important aim in case 
formulation construction. Parsimony is an important guiding principle.
Of course, even the most complex of formulations falls far short of the 
complexity of the actual person one interviews. As the writer Robertson 
Davies (1994) asks, then answers: “How many interviewers, I wonder, have 
any conception of the complexity of the creature they are interrogating? Do 
they really believe that what they can evoke from their subject is the whole 
of their ‘story’? Not the best interviewers, surely” (p. 20).
Clinician Bias versus Objectivity
A third tension in the case formulation process is between a therapist’s 
efforts at a sound understanding of a patient and inherent limitations in 
every therapist’s ability to do so. There is a long research tradition dem-
onstrating the limits of clinical judgment, inference, and reasoning (Garb, 
1998; Kahneman, 2011; Meehl, 1954; Stanovich, 2009). Common errors 
include overconfidence, hindsight bias, the representativeness and avail-
ability heuristics, confirmation bias, illusory correlation, neglecting base 
rates, and “halo” and recency effects. (See Eells, 2015, pp. 31–52, for a 
fuller discussion of cognitive heuristics that could affect case formulation.) 
Meehl (1973) identified multiple examples of logical and statistical errors 
that can undermine clinical judgment. These include either overpatholo-
gizing patients based on their “differentness” from the clinician or under-
pathologizing based on their “sameness”; presuming, merely based on the 
coexistence of symptoms and intrapsychic conflict, that the latter are caus-
ing the former; conflating “softheartedness” with “softheadedness”; and 
treating all clinical evidence as equally good. Psychoanalysts have also long 
been aware of how distortions in a therapist’s understanding of a patient 
24 HanDbook of PsyCHoTHEraPy CasE formulaTion
can affect the therapy. This awareness is reflected in terms such as counter-
transference, projection, and suggestion (see also Meehl, 1983).
Observation versus Inference
Fourth, all case formulations are built on both observation and infer-
ence about psychological processes that organize and maintain an indi-
vidual’s symptoms and problematic behavioral patterns. If a clinician relies 
too heavily on observable behavior, he or she may overlook meaningful 
patterns organizing a patient’s symptoms and problems in living. If the 
clinician weights the formulation excessively on inference, the risk of los-
ing its empirical basis increases. Thus, a clinician must achieve a balance 
between observation and inference. The clinician should be able to provide 
an empirical link between psychological processes that are inferred and 
patient phenomena that are observed. It may aid the clinician to label infer-
ences according to how close to or distant from observable phenomena they 
lie. As noted earlier, research suggests that expert cognitive-behavioral and 
psychodynamically oriented therapists alternate systematically between 
observation and inference as they formulate cases (Eells, 2010).
Individual versus General Formulations
A case formulation is fundamentally a statement about an individual and 
is thus tailored to that specific individual’s life circumstances, problems, 
needs, wishes, goals, fears, thought patterns, and so on. Nevertheless, in 
arriving at a conceptualization of a patient, the therapist must rely on his or 
her knowledge about psychology, knowledge of the psychotherapy and psy-
chopathology research literature, and other sources of evidence, as well as 
past experiences working with other individuals, especially those who seem 
similar to the person in question. The goodness-of-fit from the general or 
theoretical to the specific or individual is never perfect.
When attempting to balance the individual and the general in con-
structing case formulations, two general kinds of errors are possible. First 
is the Procrustean-bed error of attempting to make a patient fit a general-
ized formulation that really does not fit. As mentioned earlier, Freud’s anal-
ysis of Dora has been criticized on this point. Examples are not restricted 
to psychoanalysis. In the cognitive-behavioral realm, for example, attribut-
ing a patient’s panic symptoms entirely to catastrophic interpretations of 
bodily sensations may neglect significant life history events or relationship 
patterns that also contribute to the onset and maintenance of the symp-
toms, as well as to the meaning they have for the patient (see Busch & Mil-
rod, Chapter 3, this volume). Overgeneralizing can also result from stereo-
typing patients based on ethnicity, age, gender, appearance, socioeconomic 
background, or education.
 History and Current status 25
A second kind of error is to overindividualize a formulation, neglect-
ing the vast array of evidence that has accumulated from psychotherapy 
and psychological research, as well as prior expert experience. If each 
patient is taken as a tabula rasa with experiences so unique that the thera-
pist disregards previous knowledge, then the therapist is doing the patient 
a disservice.
Thus a balance must be reached between an individual and a general 
formulation. Humility is an asset in this respect. The match between any 
model and any individual is inherently imperfect, and the formulation is 
never more than an approximation of the individual in distress.
CONCLUSIONS
At the outset of this chapter, I described psychotherapy case formulation 
as lying at an intersection of diagnosis and treatment, theory and practice, 
science and art, and etiology and description. To conclude the chapter, I 
return to this point. With respect to diagnosis and treatment, a case for-
mulation provides a pragmatic tool to supplement and apply a diagnosis to 
the specifics of an individual’s life. It also serves as a vehicle for converting 
a diagnosis into a plan for treatment, in terms of both general treatment 
strategies and “tactics” with respect to one’s choice of specific interven-
tions. A psychotherapy case formulation provides a link between theories of 
psychotherapy and psychopathology, on the one hand, and the application 
of these theories to a specific individual, on the other. The case formulation 
transposes theory into practice. As both science and art, a case formulation 
should embody scientific principles and findings but also an appreciation of 
the singularity and humanity of the person in therapy. Finally, case formu-
lation fills a gap between description and etiology. In sum, a psychotherapy 
case formulation is an integrative tool. In the hands of a therapist who 
knows how to construct and use it, a case formulation is indispensable.
NOTE
1. Much of the material in this section is based on Nuland (1988).
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36
2
The Core Conflictual Relationship 
Theme for Personality Disorders
brin f. s. Grenyer
Ely m. marceau
Hadas Wiseman
HISTORICAL BACKGROUND OF THE APPROACH
Case formulation for people with personality disorders is made easy using 
the core conflictual relationship theme (CCRT) method. The reason is 
the tight overlap in our contemporary understanding of what personality 
disorders are and how the CCRT method brings this to life. Personality 
disorders involve two main difficulties—understanding the self and under-
standing others. Indeed, the World Health Organization’s (WHO; 2018) 
International Classification of Diseases, 11th Revision, states: “Personal-
ity disorder is characterized by problems in functioning of aspects of the 
self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or 
interpersonal dysfunction (e.g., ability to develop and maintain close and 
mutually satisfying relationships, ability to understandothers’ perspec-
tives and to manage conflict in relationships).” Importantly, it is not just 
conflict in understanding the self and others but also how this manifests 
in multiple contexts as a pervasive set of difficulties in people with per-
sonality dysfunction. For ICD-11, these problems “are maladaptive (e.g., 
inflexible or poorly regulated) and manifest across a range of personal and 
social situations (i.e., is not limited to specific relationships or social roles).” 
The CCRT provides a method of describing these pervasive, maladaptive 
 The Core Conflictual relationship Theme 37
relationship themes and thus provides an effective tool for understanding 
and formulating the core problems in personality disorder casework.
Thus personality assessment often begins with the basic question: 
What are the central relationship patterns of the individual in terms of how 
they understand themselves and how they see themselves in the world with 
others? One early approach to this question used projective measures—
asking people to respond to ambiguous images to understand how they 
see the world. Morgan and Murray (1935) studied people’s verbalizations 
to Thematic Apperception Test (TAT) pictures and found that there were 
three main aspects: (1) a driving force, (2) expressed toward or away from 
an object, with (3) a resulting subjective response of satisfaction or dis-
satisfaction (p. 293). For example, a picture of a couple in silhouette might 
stimulate in a person with personality disorder a response of (1) desire for 
closeness that is (2) feared to lead to disappointment from the other and 
hence (3) withdrawal from the relationship.
Following these early ideas, the CCRT method developed further from 
Lester Luborsky’s (1976) formative work to operationalize the therapeutic 
alliance as an essential component of psychotherapy. To better understand 
the therapeutic alliance, Luborsky applied his attention to the dialogue 
between clinician and patient during his study of verbatim transcripts of 
psychotherapy sessions. In this way, he noticed a pattern emerging in the 
conversations (Luborsky, 1977). People in therapy tell narratives that detail 
relationship interactions, with friends, partners, work colleagues, and even 
the therapist. Relationship narratives are often identified by an index such 
as “I remember when . . . ”, or “Like, for example, when . . . .” Narratives 
of relationships often illustrate a problem or emphasize an observation, 
and they contain within them the same tripartite structure as found in the 
projective method of Morgan and Murray (1935).
According to Luborsky, a person’s CCRT consists of three elements: 
(1) the wishes (W) of the speaker, which correspond to various needs (e.g., 
attachment needs to obtain love and nurturing); (2) the perceived reac-
tions or response of others (RO; e.g., hostility or aggression); and (3) the 
response of the self (RS; e.g., withdrawing and becoming depressed). The 
three elements (W, RO, RS) of the CCRT therefore code the dynamics of 
the relationship interaction and document patients’ basic attempts to get 
their needs met and how these needs are met or frustrated by the other, 
resulting in the patient’s reaction.
Historically, the CCRT approach to assessing core conflictual relational 
themes has shown considerable concordance with Freud’s original observa-
tions about transference (Luborsky, 1998). Freud noticed how people com-
ing for treatment for mental health conditions expressed attitudes, beliefs, 
and wishes toward the therapist that closely resembled the same patterns as 
the relationships described outside of the therapy room. This became under-
stood as a “stereotype plate” or “transference template” (i.e., a relationship 
38 HanDbook of PsyCHoTHEraPy CasE formulaTion
schema—how a person sees themselves and others in the world shapes their 
expectations for future relationships). These attitudes are thought to derive 
from early attachment experiences, for example with parents, and general-
ize to other relationships over time, including with the therapist. They are 
thought to derive from “a combined operation of his [or her] innate disposi-
tion with the influences brought to bear on him [or her] during his [or her] 
early years” (Freud, 1912/1958a, p. 99). The importance here is that these 
“transfer” from relationship to relationship as CCRT patterns.
CONCEPTUAL FRAMEWORK
Although the CCRT can be conceptually related to concepts and approaches 
such as object relations theory, attachment theory, biosocial theory, sup-
portive–expressive dynamic therapy, schema therapy, mentalization, and 
transference-focused therapy, it is at its heart an atheoretical method that 
does not require psychodynamic or cognitive-behavioral knowledge. How-
ever, as a clinical research tool, it can significantly enhance and deepen our 
understanding of these different models of psychopathology and personal-
ity functioning.
Indeed, the CCRT method of describing relationship patterns by a 
wish-response of other-response of self-sequence provides a helpful tool to 
understand contemporary theories and methods to treat personality disor-
der. For example, object relations theory lies behind one evidence-based 
therapy for personality disorder, transference-focused psychotherapy 
(TFP; Yeomans, Clarkin, & Kernberg, 2015). Object relations are essen-
tially CCRT patterns: internalized representations of others in relation to 
the self as derived from early attachment figures. Therapy works with these 
internalized object relations, or transference-related CCRT patterns, to 
understand their origins but also to work through and modify them in the 
direct interactions with the therapist. The therapist attends to the CCRT 
patterns told and also enacted in the patient–therapist relationship to both 
understand and modify the ubiquity of a patient’s negative transference 
attitudes and, over time, integrate and internalize more healthy patterns.
Similarly, Linehan’s biosocial theory, the basis for the evidence-based 
dialectical behavior therapy (DBT; Linehan, 2015) describes “invalida-
tion,” a central, repetitive “response of other” from caregivers often found 
in patients with borderline personality disorder (BPD). In this description, 
a child may have a wish (W) to be heard and taken seriously, but this (RO) 
is responded to by the caregiver by ignoring, invalidating, or dismissing the 
child, leading (RS) the child to feel hurt, self-critical, angry, and destruc-
tive. DBT works to reduce the negative effects of emotional sensitivity 
through mindfulness, emotion regulation, and distress tolerance strategies 
and to strengthen relationship patterns through training in interpersonal 
effectiveness to better achieve positive CCRT patterns.
 The Core Conflictual relationship Theme 39
Additionally, the CCRT can bring to life attachment theory as origi-
nally described by Bowlby (1969/1982, 1988) and as integrated into another 
evidence-based therapy for personality disorder, mentalization-based 
therapy (MBT; Bateman & Fonagy, 2016). MBT focuses on strengthening 
one’s sense of self and the other through attending to the interactions and 
discussions between therapist and patient. Using elaboration on CCRTs, 
the aim is for patients to better mentalize others’ reactions and their own. 
Bartholomew and Horowitz (1991) helpfully organize such attachment 
themes on self–other dimensions and the degree to which they are positive 
or negative. Secure attachment involves a positive view of self and others, 
leading to healthy interdependence; or, in CCRT terms, a (W) wish to be 
close is (RO) satisfied by others, leading to (RS) relationship satisfaction. 
Preoccupied attachment involves a negative view of self and a positive view 
of others, leading to anxious overdependence on others; fearful attachment 
involves a negative view of self and negative view of others, leading to a 
more helpless avoidance; and a dismissingattachment pattern involves a 
positive view of self but a negative view of others, leading the person to 
prioritize autonomy. Building on early evidence showing parallels between 
CCRTs from waking narratives and CCRTs from dreams (Popp et al., 
1996), Mikulincer, Shaver, and Avihou-Kanza (2011) examined individual 
differences in attachment insecurities (anxiety and avoidance) in relation 
to CCRT themes extracted from the dream diaries of young adults. In line 
with attachment theory, attachment-related avoidance predicted avoidant 
wishes and negative RO’s in the dreams, and attachment anxiety predicted 
wishes for closeness (especially in dreams following stressful days) and 
negative RS and both positive and negative RO’s, with negative RO’s being 
more common in dreams following stressful days.
The CCRT can also be used to describe the personality disorder schema 
as described by Kellogg and Young (2006) in schema-focused therapy (SFT; 
Arntz & Genderen, 2009), another evidence-based therapy for personal-
ity disorder. For example, the abandoned/abused child mode essentially 
describes a “response of other” CCRT pattern such as W: to be taken care 
of; RO: abandoned and abused; RS: unloved, helpless, and alone. The 
angry and impulsive child mode may reflect a “response of self” CCRT 
pattern such as W: to be protected; RO: mistreated and rejected; RS: angry 
and impulsive. The detached protector mode may describe a “response of 
self” CCRT as W: to be safe; RO: invalidated and abused; RS: withdrawal, 
isolation, avoidance. The punitive parent mode describes a “response of 
other” CCRT such as W: love; RO: punitive; RS: self-critical, self-harming. 
In each of these cases, the therapist brings the mode or CCRT pattern to 
the patient’s awareness to encourage insight but also to work through to 
the healthy parent mode—W: nurtured; RO: protects and affirms; RS: self-
control and emotional security. The child–parent–adult metaphor reflects 
the influence of the psychoanalytic theory of transactional analysis (Berne, 
1964) on schema therapy, but it can also helpfully be understood as the 
40 HanDbook of PsyCHoTHEraPy CasE formulaTion
enactment of core CCRT patterns experienced in the patient’s early years 
that continue to shape the patient’s current emotional life.
MULTICULTURAL CONSIDERATIONS
Although the CCRT began its initial development in the United States, 
it was quickly studied across many nations, languages, and cultures and 
has been translated into Italian, Swedish, Spanish, French, Czech, Slo-
vak, Albanian, Hebrew, Japanese, and Chinese (contact Brin Grenyer for 
details). The essential learning from these different translations and studies 
is that the same structure of CCRT patterns can be applied across cultures, 
making it a universal language or approach to studying narratives (Atzil-
Slonim, Wiseman, & Tishby, 2016; Popp & Taketomo, 1993; Weinryb, 
Barber, Foltz, Göransson, & Gustavsson, 2000). This is achieved through 
the flexibility of the CCRT method as a tool for clinical formulation, which 
is maximized through using content and narratives exactly as they natu-
rally occur in the subjective accounts of individuals. This allows the cul-
tural context of the individual to be embedded in CCRT formulation and 
promotes culturally sensitive clinical practice.
Though there are few published studies of the CCRT approach across 
cultures, a number of studies have focused on the role of CCRT analysis 
to understand the effects of intergenerational trauma in particular groups, 
with a focus on accounts provided by adult children of Holocaust survi-
vors (“second generation to the Holocaust”) illuminating the effects on 
current relationship experiences (Wiseman & Barber, 2004, 2008; Wise-
man, Metzl, & Barber, 2006). Another way in which this tool has been 
applied is in the analysis of narratives, or stories, in historical documents. 
In one example of this work, multiple studies of the CCRT method were 
conducted to characterize relationships between God and people in the 
Bible in an analysis of the first five books of the Bible (Popp, Luborsky, 
Andrusyna, Cotsonis, & Seligman, 2002) and the New Testament (Popp 
et al., 2003) and in relation to intergroup attitudes (Popp et al., 2004). In 
another example of the CCRT method applied to the analysis of literary 
works, two novels written by authors experiencing anorexia nervosa were 
analyzed, with findings suggesting that CCRT patterns can be obtained 
through sources broader than psychotherapy session content (Stirn, Over-
beck, & Pokorny, 2005).
EVIDENCE BASE SUPPORTING THE METHOD
As a method for case formulation, the CCRT has strong links with the 
scientist/practitioner model. This is emphasized in the body of literature 
 The Core Conflictual relationship Theme 41
documenting use of the method as an empirical tool to operationalize rela-
tionship patterns so they can be quantified and utilized in psychotherapy 
process–outcome research. The following will provide an overview of some 
of the most recent CCRT research studies—a body of work that serves 
to illuminate psychotherapy process–outcome links and lead to refinement 
and innovation in using the CCRT as a method of formulation, with each 
informing the other in a reciprocal way. Early CCRT research studies are 
comprehensively reviewed in the second edition of Understanding Transfer-
ence (Luborsky & Crits-Christoph, 1998), and the reader is referred there 
for foundational studies.
Most recently, the CCRT method was used to distinguish patients 
with comorbid depression and personality disorder who showed an early 
response to psychotherapy versus those who did not (Hegarty, Marceau, 
Gusset, & Grenyer, 2020). The Leipzig–Ulm CCRT method (Albani et al., 
2002) was used to categorize scorable components in transcripts of therapy 
Session 3. Both groups endorsed similar relationship wishes, but wish satis-
faction was lower for the non-early responders, who also endorsed distinct 
RO and RS categories. Others (RO) were perceived as less reliable and sup-
portive and more aggressive, and patients (RS) experienced less feelings of 
being loved and self-determined. These negative relationship patterns were 
hypothesized to interfere with patients’ benefiting from the therapeutic 
relationship, contributing to a slower treatment response.
The CCRT method has been used to investigate the therapist–patient 
relationship in a number of studies. One particular area of focus is the role 
of countertransference, broadly defined as therapists’ reactions to patients 
in psychotherapy (Hayes, Gelso, Goldberg, & Kivlighan, 2018; Hayes, 
Gelso, & Hummel, 2011). Specifically, the CCRT method has been used 
to investigate patterns of countertransference in therapists treating adoles-
cents (Tishby & Vered, 2011), identifying different types of countertrans-
ference in the context of early, mid-, and late stages of therapy (Tishby & 
Wiseman, 2014), examining disclosures during clinical supervision (Mes-
sina et al., 2018), and comparing therapists’ countertransference responses 
to patients with BPD versus major depressive disorder (MDD; Bourke & 
Grenyer, 2010). CCRT methodology has also been used to investigate 
intersubjective processes in therapy, including the therapist–client interac-
tion, through exploring relational CCRT interplay within dyads and asso-
ciations with the therapeutic alliance (Wiseman & Tishby, 2017). Relat-
ing therapist countertransference identified through the CCRT themes of 
therapists with their parents and with their clients (Tishby & Wiseman, 
2014) to therapist-reported alliance rupture and repair showed that when 
therapists repeated their RS with their parents of feeling “helpful” with 
their clients, it was associated with rupture resolution. However, when 
therapists attempted to “repair” their parent RO “opposing and rejecting” 
by making an effort to be helpful (RS opposite of the negative parent RO), 
42 HanDbook ofPsyCHoTHEraPy CasE formulaTion
it was associated with high rupture intensity and less resolution (Tishby & 
Wiseman, 2020).
One recent innovative study combined the CCRT method with a 
neuroimaging paradigm by using functional magnetic resonance imaging 
(fMRI) to identify patterns of brain activation associated with the recall 
of personal CCRT versus control narratives in healthy control participants 
(Loughead et al., 2010). Narratives higher in CCRT content were associ-
ated with increased brain activity in regions related to episodic memory 
and understanding self and other. There are now a number of studies inves-
tigating the relationship between neurobiology and psychotherapy (e.g., 
Marceau, Meuldijk, Townsend, Solowij, & Grenyer, 2018), and adapta-
tions to the CCRT method provide a novel methodology to illuminate the 
neural underpinnings of interpersonal processes in psychotherapy within 
the context of fMRI (Grandjean et al., 2020).
A small body of work has examined the use of the CCRT method 
and unique CCRTs that may emerge in particular clinical populations and 
groups—for example, adult offenders with intellectual and developmen-
tal disabilities (Hackett, Porter, & Taylor, 2013), chronic fatigue (Van-
denbergen, Vanheule, Rosseel, Desmet, & Verhaeghe, 2009; Vanheule, 
Vandenbergen, Desmet, Rosseel, & Insleghers, 2007), BPD (Chance, Bake-
man, Kaslow, Farber, & Burge-Callaway, 2000; Drapeau & Perry, 2009; 
Drapeau, Perry, & Korner, 2010), or alexithymia (Vanheule, Desmet, Ros-
seel, Verhaeghe, & Meganck, 2007)—and as a function of secure versus 
insecure attachment style (Waldinger et al., 2003). In each of these studies, 
the relationship between interpersonal conflicts (CCRT patterns) relates 
sensibly to the emergence and severity of psychopathology, reinforcing the 
value of CCRT-informed clinical interventions (see the case study later in 
the chapter as an illustration of these processes).
An influential early study sought to investigate differences in CCRTs 
endorsed according to personality using Kernberg’s (1984) structural model 
of personality organization (Diguer et al., 2001). Psychotic, borderline, and 
neurotic groups did not show clearly distinguishable differences in CCRT 
content but rather showed overlap in terms of W’s, RO’s, and RS’s. This 
study demonstrated how individual differences, when combined across 
participants and diagnoses, tend to disappear into common CCRT pat-
terns. So, although at an individual level people can show unique CCRTs, 
there are also broad similarities in how people with different types of psy-
chopathology attempt to understand themselves and others. To be clear, 
these maladaptive patterns of relating demonstrated by the CCRT all show 
a similar pattern of the nonsatisfaction of wishes associated with the nega-
tive responses of others and attendant negative responses of self. Attending 
to other structural features, such as narrative complexity and pervasiveness 
of CCRTs, may also help to distinguish CCRT profiles according to psy-
chopathology.
 The Core Conflictual relationship Theme 43
STEPS IN CASE FORMULATION CONSTRUCTION
The focus here is on steps to identifying and using the CCRT in psycho-
therapy. That is, we describe how to find the CCRT within therapy and 
then how to use the CCRT to assist case formulation and hence treatment. 
We thus approach the CCRT as a clinical tool to help therapists organize 
their case formulations and to communicate their hypotheses and findings 
to patients and also professional colleagues, such as supervisors and mem-
bers of a therapy team.
Early writings on the CCRT and those in scientific publications were 
often more focused on the CCRT method as a scientific research instru-
ment than as a clinical tool. These specific uses of the CCRT follow a 
procedure whereby interviews or therapy sessions are transcribed verba-
tim. The transcripts are then organized by (1) identifying the narratives 
(the parts of the session that describe relationships), (2) identifying scorable 
clauses (i.e., W, RO, RS phrases) within the narratives, and (3) matching 
these W, RO, RS components as individually described by the patient with 
dictionaries of typical W, RO, RS components in order to create standard 
categories of CCRTs that can then be compared within the patient over 
time and across different patients. These methods are well described else-
where (Luborsky & Barrett, 2007; Luborsky & Crits-Christoph, 1998) and 
are not repeated here, but it is worth noting that the CCRT can also be used 
as a clinical-quantitative tool with specific research applications (Parker & 
Grenyer, 2007) that include rating the intensity of CCRT themes (Grenyer 
& Luborsky, 1998). These methods are not so relevant for the clinician.
The CCRT is found in the narratives that patients tell in therapy. The 
specific narratives of importance are called relationship episodes (or RE’s). 
Patients who come to therapy spontaneously tell narratives to illustrate their 
difficulties. In the early sessions of treatment, patients typically tell around 
four to six narratives per 50-minute hour. An RE follows a basic structure 
of the beginning of the story, the middle section, and then the end. These 
are known because the patient will cue that they are going to tell a story 
with a phrase such as “The other day I . . . ” or “for example. . . . ” The 
role of the therapist is to listen to the story and cue the patient to ensure all 
the components are told. For example, the therapist might ask, “What were 
you hoping for?” to cue the W, or “How did he [or she] react?” for the RO, 
or “How did that make you feel?” for the RS. It is important to recognize 
that in typical narratives told in therapy, the whole story can evolve in its 
telling. Sometimes a patient will give some of the story, then digress, then 
come back and finish the story. The CCRT components can be told in any 
order. In some cases, it is easier for the patient to begin with their RS—that 
is, how they are feeling—before they tell about what it was that actually 
made them feel that way. Similarly, often the W component is not told; it is 
assumed that the therapist will be able to infer the W. However, although 
44 HanDbook of PsyCHoTHEraPy CasE formulaTion
it is usually possible to infer the wish, it can be very useful to inquire more 
directly to check understanding.
To illustrate a typical CCRT, we provide an example from the therapy 
with Ms. Cater, a 31-year-old female who presented with high anxiety that 
was interfering with her personal and work life. Early in therapy, Ms. Cater 
told this story, from which the main CCRT components can be identified:
“It was like, the other day Gerry, my boss, came over to me to ask if 
I’d help with a new project. I tried to smile and look confident because 
it was a great opportunity for me (W), but I’m sure he could tell how 
uncomfortable I was (RO). The person next to me jumped in and joined 
the conversation, and before I knew it, she was doing the project he’d 
come to talk to me about. I felt really embarrassed (RS) and let down by 
him (RO) and felt so sick in my stomach I couldn’t concentrate (RS).”
The only other task for the therapist in collecting narratives is to note 
who they are told about—the “object” of the narrative. Typically, these 
fall into a number of broad groups: narratives about romantic partners, 
parents, children, family members or relatives; friends, work colleagues, 
including bosses; acquaintances (e.g., in clubs, groups); and strangers (e.g., 
bus passengers, service providers). Two additional specific objects receive 
special attention—narratives told about the self and narratives told about 
the therapist. An example of the CCRT about the self is Ms. Cater, who 
said, “I was hoping to go to the party (W), but my fears took over imagining 
how embarrassed I’d feel (RO), so I stayed home and felt sick in the stomach 
(RS).” CCRTs about the therapist can be in twoforms, told or enacted. In 
an example of a told narrative, Ms. Cater said to the therapist, “I’m feeling 
like you are just sitting there doing nothing (RO), I talk and I talk and you 
don’t say anything (RO), I just wish you’d tell me what to do (W) so that I 
wouldn’t feel so alone and anxious (RS).” In contrast, an enactment occurs 
when there is an actual interaction that demonstrates the CCRT in the 
here-and-now therapist–patient communication. For example, Ms. Cater 
came into the therapy room and refused to talk (RS), but sat there, staring 
aggressively at the therapist. The therapist said, “So it’s hard for you to talk 
today,” to which she replied, “I’m feeling like I shouldn’t bother talking, 
because you don’t say anything anyway (RO).” Here, the patient enacted 
her expected RO (that others don’t help) by being defiant in refusing to talk 
(RS), even though she had come to therapy wanting to share (W) with the 
therapist how she was feeling.
TREATMENT PLANNING AND PRACTICE
Once a CCRT has been identified, the therapist may want to share that 
with the patient. More typically, therapists choose to wait until they hear 
 The Core Conflictual relationship Theme 45
a number of other narratives, to see whether similar or different CCRT 
patterns are told. The therapist listens for similarities as well as differences 
in CCRT patterns. Patients in the early stages of their recovery, who are 
very symptomatic, are often found to tell stories with similar themes that 
demonstrate a more stereotypical, pervasive single or main CCRT pattern. 
As treatment continues and patients begin to improve, stories are told that 
are longer, more flexible, and demonstrate variations in CCRT patterns, 
showing that the patient has greater mastery of their CCRT by being less 
rigid and more able to respond in different ways depending on the situation 
(Grenyer & Luborsky, 1996; Grenyer, 2002).
Once a therapist has developed a sense of the main CCRT pattern, 
they may choose to communicate this to the patient. This is done following 
a structure, as shown in Figure 2.1, outlining the three components along 
the lines “You want X, but the other person responds with Y, and you feel 
Z.” For example, in response to Ms. Cater (above), the therapist might say, 
“I understand how much you really (W) want to ‘jump into’ life and be 
involved in projects at work and get on with the important things we need 
to discuss here, but I’m also struck how you really struggle with the feeling 
that others (RO) will not help you, even judge you and let you down, and 
this leaves you (RS) feeling anxious, sick in the stomach, and angry with 
yourself.”
It is important to note that once the therapist has delivered a CCRT 
to the patient, the work is not done. In his famous paper on psycho-
therapy process, Freud (1914/1958b) discussed how the themes need to 
be “worked through.” Thus, over time, the therapist needs to listen for 
more CCRTs and continue to show how these patterns are active in the 
person’s life in order to bring them to awareness to assist in helping them 
be modified.
Working through is a core mechanism of change in psychotherapy. 
Freud stated, “This working-through .  .  . is a part of the work which 
effects the greatest changes in the patient and which distinguishes analytic 
treatment from any kind of treatment by suggestion” (Freud, 1914/1958b, 
p. 155). The process “may in practice turn out to be an arduous task for 
the subject of the analysis” (Freud, 1914/1958b, p. 155) and requires a 
“period of strenuous effort” (Freud, 1926/1959, p. 159). In general, the 
first goal of the therapist is to facilitate greater awareness of the CCRT pat-
terns in the patient’s life by using the CCRT formulation discussed earlier 
to bring these patterns to awareness. The second goal is to then work with 
the patient on modifying their CCRT patterns. Therapists can choose to 
work on one particular component (e.g., the RO) or set of components (e.g., 
RO–RS sequences). For example, with Ms. Cater, a considerable repetition 
in her CCRT pattern occurred due to her appraisal of others (RO) as not 
helping or even seeing her as being incapable. The therapist might choose, 
for example, to bring this pattern into the room and show how it might be 
operating in the here-and-now interactions with the therapist. When Ms. 
46 HanDbook of PsyCHoTHEraPy CasE formulaTion
Cater strongly experienced the therapist as not helping, the therapist was 
able to point out that, although the therapist may have had minor lapses 
of attention, the patient magnified these lapses while minimizing the other 
times when the therapist was attentive. Similarly, the therapist was able to 
remind the patient how often they had accurately been able to point out 
problems in other relationships. These helped the patient to broaden her 
understanding of what might be going on “in the mind” of others, helping 
her to relax a little more and not immediately think others were think-
ing the worst. This gave her a window of opportunity to develop enough 
confidence to ask more clearly for what she wanted from others without 
expecting rejection. Slowly, the pervasive CCRT patterns began to be mod-
ified, allowing her to experience more fulfillment of her wishes and greater 
enjoyment in her work and personal interactions.
Patient name: Date: Session number:
Narrative number: Main other person in the narrative:
Summary of incident/story/interaction:
W: Main wishes, needs, intentions expressed in this narrative:
RO: Responses of the other person:
RS: Responses of the self:
Possible CCRT formulation:
You want:
but/and the other person:
and you feel:
FIGURE 2.1. A simple way to record CCRT narratives told in therapy sessions.
 The Core Conflictual relationship Theme 47
CASE EXAMPLE
Description of Patient and Presenting Problems
Paige was a 17-year-old who was referred by the local hospital to a uni-
versity clinic specializing in the treatment of personality disorders. During 
her orientation to the clinic, Paige underwent clinical assessment and was 
deemed to meet criteria for a diagnosis of borderline personality disorder 
(BPD). In her initial presentation, she described struggling with abrupt and 
extreme fluctuations of her emotions, periods in which she would feel “hol-
low” and “like an empty shell,” difficulties maintaining friendships, expe-
riencing intense romantic relationships that quickly deteriorated and ended, 
weekend binge drinking leading to impulsive and risky sexual behavior, and 
a history of self-harm by cutting, which had increased in severity over the 
preceding 6 months. Her treatment was with Lyndsay, a female therapist 
who was a PhD-level early-career clinical psychologist practicing psycho-
therapy at the university health clinic. The clinician applied the principles 
for using the CCRT in psychotherapy as described here and in the manual 
by Book (1998).
When Paige first presented to the clinic, she was experiencing sig-
nificant emotion dysregulation, problems in her relationships, feelings of 
emptiness that were disturbing to her, and engaging in impulsive behaviors 
and self-harm. In relating her history of difficulties, she noticed that the 
transition to high school at age 13 was difficult and when she first noticed 
these problems. She reported that things became much worse following the 
breakup of a romantic relationship with Nick approximately 1 year ago at 
age 16, and this is when she first tried cutting herself to relieve the pain. 
At the beginning of therapy, Paige was attending high school and in an 
“on-and-off” relationship with Josh, a 20-year-old male. She entered ther-
apy after being discharged from a brief hospital admission for an overdose 
triggered by an argument with Josh. She was initially ambivalent about 
being in therapy, and she seemed to fluctuate between feeling as though it 
had something to offer and saying that she was only comingto please her 
mother.
As Lyndsay listened in the sessions, she slowly began to piece together 
the relevant history, although Paige’s autobiographical descriptions were 
fragmentary and lacking in detail, as is typical of people with severe BPD 
(Carter & Grenyer, 2012). Her biological father left the family when she 
was 18 months old. Her mother married a new partner when Paige was 
3 years old and had two more children by that partner. Her mother and 
Paige’s stepfather divorced when Paige was 14 years old. During therapy, 
Paige was living with her mother and two younger half-brothers, Dylan 
(15 years old) and Tom (12 years old). Paige described her stepfather as an 
alcoholic who would frequently drink and become verbally abusive toward 
48 HanDbook of PsyCHoTHEraPy CasE formulaTion
her mother, and on occasion this would escalate to physical violence. She 
also described times when she felt she had a good relationship with him. 
There was evidence from her descriptions that her mother had not coped 
well following their separation and was at times depressed, used alcohol to 
cope, and was occasionally suicidal.
Presentation of Formulation and Treatment Plan
By Session 8, Lyndsay had a clear sense of Paige’s major CCRTs and thus 
how to use these as a guide to focus treatment. Lyndsay did not explicitly 
tell Paige, “Here is your CCRT,” but rather used language that was as 
close to the client’s experience as possible to demonstrate these conflictual 
relationship themes to Paige in a way that was as meaningful to her experi-
ence and helpful to her understanding. In the early stages of therapy, Paige 
expressed a strong wish (W) to be looked after and helped, but she told a 
number of relationship narratives of her perception of others (RO) as being 
unavailable, not caring about her, and not helping her. Initially, it seemed 
she had difficulty in using words to express her feelings about these rela-
tionship narratives. She often spoke about the (RS) need to self-harm, and 
she reported increased cutting and binge drinking outside of therapy at this 
time.
As therapy progressed, Paige’s behavior settled, and she became more 
engaged in the therapeutic relationship and better able to express and reflect 
on relationship patterns in her life. The therapist’s CCRT formulation of 
Paige was developed and refined as therapy progressed over time. The ther-
apist used her developing knowledge of three key CCRT elements in the 
narratives to notice how these characteristic ways of relating and respond-
ing would become activated in relationships—first in relationships outside 
of the therapy and later within the therapeutic relationship. Paige formed 
a strong connection with Lyndsay, and her wish (W) to be looked after 
was activated. Lyndsay found this challenging because it had a regressed, 
childlike quality and there was a pull to take a parental controlling role 
in Paige’s life. Yet at the same time, Paige’s recurring experience of others 
(RO) was of not being helped and feeling rejected. Lyndsay had to balance 
being supportive while seeking ways to activate greater agency in Paige to 
counter her passive wish to be looked after by others.
About midway through the therapy, Lyndsay was exposed to the ubiq-
uity of Paige’s key relationship pattern through an enactment in the thera-
peutic relationship, a pattern that had previously only been evident in the 
relationship narratives Paige told in therapy. The earlier phases of ther-
apy thus corresponded to the first key goal of treatment using the CCRT 
method: facilitating greater awareness of CCRT patterns in the patient’s 
life. Over time, Paige’s CCRTs became more consciously recognized, acti-
vated, and able to be modified in the context of her experiencing a different 
 The Core Conflictual relationship Theme 49
kind of relationship with Lyndsay. The later phases of therapy included 
the “working through” of Paige’s CCRT patterns, the second key objec-
tive of the CCRT method; that is, helping patients reflect on the origins of 
these patterns and strengthen their capacity for new choices and behaviors 
that promote more satisfying interpersonal interactions and relationships. 
These changes are reflected in altered CCRT narratives during sessions, as 
well as within the therapeutic relationship, and were evident during Paige’s 
treatment.
Course of Therapy and Progress in Addressing Problems
The approach was brief time-limited therapy, with weekly sessions sched-
uled at the clinic, and took place over approximately 6 months, in addition 
to a pretherapy phase. Paige attended all 20 contracted sessions.
Pretherapy Phase: Evaluation and Socialization Interview
The first two sessions provided an opportunity to discuss Paige’s cur-
rent difficulties and for the therapist to complete a diagnostic and clinical 
assessment to consider treatment options. Key objectives of this pretherapy 
phase were building therapeutic engagement and alliance, making a diag-
nostic assessment, conducting a risk assessment to establish an acute versus 
chronic risk profile, completing a collaborative care plan, and collecting 
further information, with particular emphasis on noting and exploring 
relationship episodes (RE’s) as the therapist began to notice relationship 
themes conveyed in the interpersonal narratives that Paige told in therapy.
Using DSM-5, Paige endorsed eight of the nine criteria for BPD, and 
her problems were of sufficient duration, frequency, and severity to warrant 
a diagnosis. This diagnosis was provided and discussed with Paige. The 
therapist provided psychoeducation regarding development, symptoms, and 
effective treatment for BPD. The therapist also set the “frame” of treatment 
by recommending that Paige and the therapist agree to work together in 
treatment over the next 6 months of weekly appointments, with an oppor-
tunity to jointly discuss therapy progress and consider the need for further 
sessions toward the end of this time. Weekly sessions were scheduled at the 
same time and place, and all practical matters of the therapy arrangement 
(e.g., cost, duration of sessions, therapist and patient responsibilities) were 
discussed in preparation for commencing the psychotherapy contract.
Sessions 1–3: Ruptures, “Acting Out,” and a Core CCRT Emerges
During this first phase of therapy, the therapist was acutely challenged 
to maintain boundaries and, in the words of Winnicott’s (1953) famous 
maxim describing the importance of a satisfactory infant–caregiver bond, 
50 HanDbook of PsyCHoTHEraPy CasE formulaTion
a “good enough” relationship with Paige. There were frequent ruptures in 
the therapeutic alliance (Safran & Muran, 2000) marked by Paige’s with-
drawing into silence or becoming angry and hostile and a reported increase 
in her self-harming and binge drinking outside of session. It appeared that 
Paige was primarily expressing her needs through “acting out,” as opposed 
to consciously bearing the feelings related to these impulses to engage in 
destructive behavior (Freud, 1968). Through these behaviors, she invited 
the therapist to become more activated and vigilant and to take a protect-
ing, caring role.
The following excerpt from the beginning of Session 2 illustrates 
Paige’s high levels of anger and reactivity and her tendency toward acting 
out and testing the boundaries of psychotherapy, following the perception 
that her romantic partner, Josh, had abandoned her. It is possible to see the 
pervasiveness of a core conflictual relationship theme emerge even early in 
the therapy, illustrated with commentary below:
Paige: I feel like it’s over. He knows how much I need to come here, he’s 
just not helping. I wake up this morning and he’s not there! He was 
supposed to bring me here.
[CCRT Josh. Wish: to be helped (bring me to my therapy session); 
Response of Other: not there, absent, not helping; Response of Self: 
abandoned (feel relationship is over)]
Therapist: Is this aboutJosh?
Paige: I feel so sick. I wanted to vomit up everything but there was nothing 
in my stomach to vomit. I’ve been texting him all this morning. Even-
tually, at, like, 9:30 he replies with a single-liner “Had to go, later.”
Therapist: Sounds like a really bad morning.
Paige: I can’t believe how sick other people are. I’m sitting on the bus and 
people are just so rude and they stink and I just wanted to end it all. I 
wanted to run off the bus and into the path of a huge truck.
[CCRT bus passengers. Wish: to feel helped; Response of Other: rude, 
unpleasant; Response of Self: feel impulsive, suicidal]
Therapist: Has this happened before?
Paige: I could kill him. I expect to be looked after and he just abandons me 
like that. I might as well not be here.
[CCRT Josh. Wish: to be looked after; Response of Other: abandon-
ment; Response of Self: rage (want to “kill him”), helpless (“not be 
here,” give up, suicidal)]
Therapist: You really do need to be looked after.
Paige: I’m really trying, Lyndsay, and I want to do well for you. You’re the 
only one who can help me.
 The Core Conflictual relationship Theme 51
Therapist: And we can work through this together.
Paige: Ever since I walked in here it just clicked for me, like “Yep, that’s 
it.” You’re the one.
[CCRT therapist. Wish: to be helped; Response of Other: you can help 
me; Response of Self: belief in other person, hope]
Therapist: Do you experience this sickness feeling all the time or just 
sometimes?
Paige: You see, you can read me like a book. I know you’re here on Mon-
day and Wednesday because the receptionist told me. So I’m thinking 
“I could just call you up to check in.” That would be so nice.
Therapist: I think it’s important for us to talk about this stuff, but we 
need to talk about it in our sessions here together, not over the phone.
Paige: I get it, always the professional. I feel so sick again, I can’t stand 
it. I really feel like the urge to cut. I shouldn’t have come here today, I 
should have stayed in bed.
[CCRT therapist. Wish: to be helped; Response of Other: perceived 
rejection (only help in session, not outside); Response of Self: sickness, 
helplessness]
In this passage, Paige tells a number of CCRT narratives—about her 
boyfriend Josh, about the people on the bus, and about the therapist. In 
each CCRT, the wish expressed has the same theme: to be helped by others. 
Her expected response is to be abandoned, rejected, and let down, leading 
her to feel unwell, helpless, impulsive, enraged, and suicidal. One positive 
narrative is more a wish: that the therapist will not be like her expectations 
and will be there to meet her needs. The therapist states her boundaries 
about availability, which leads to a restatement of her core theme: that even 
the therapist will let her down like Josh, people on the bus, and others in 
her life.
The therapist made use of regular supervision in this time to manage 
what she experienced as turbulent sessions (including Paige’s threat to cut 
herself) in which it was difficult to stay present and therapeutically focused, 
due in part to her heightened emotional responses (or countertransference).
Sessions 4–8: Identifying Major CCRT Narratives
During this phase of the therapy, the therapist’s focus was on continuing 
to gather relationship narratives to gain an understanding of how Paige’s 
CCRT was active in her life. Over these sessions, Paige’s acting-out behavior 
reduced, and the therapist experienced improvements in the quality of the 
therapeutic alliance, with Paige also at times showing idealization toward 
the therapist and a belief that she was “different from all the others” and 
52 HanDbook of PsyCHoTHEraPy CasE formulaTion
“the only one that can help me.” In our experience, one of the features of 
BPD for some are wishes for an idealized strong person who can take over 
and satisfy the needs of the patient—akin to a primitive unmet need to be 
parented. Closely following these unrealistic idealized wishes, however, are 
anger and disappointment at others, leading to devaluation and rejection 
of those who had previously been idealized. Holding these tendencies in 
mind were important for Lyndsay to remain neutral, not to be pulled into 
enactments, and to be empathic and attuned without falling into either an 
idealized or a devalued position.
Three distinct themes began to emerge in the relationship narratives 
that Paige told in session:
1. Interactions in which she would become angry and hostile (response 
of self: RS) when perceiving others as attacking her (response of 
other: RO)
2. Feeling vulnerable and in need of reassurance that others would not 
leave her (RS) when they are perceived as abandoning her (RO)
3. Appearing competent but dismissing and withdrawn (RS) when 
others are seen to reject or exclude her (RO)
In all of these cases, Paige expressed similar relationship wishes: to be 
helped by others. This highlights another key issue that emerged during 
Paige’s treatment: Her relationships with others and sense of herself were 
defined by beliefs oriented around an external locus of control (Rotter, 
1966). She expressed low-agency narratives in which she viewed herself as 
helpless and frequently told narratives to the effect of “I need others to help 
and fix me.”
In the interpersonal content related in session over this time, Paige 
expressed relationship narratives from more recent events with peers at 
school, interactions with friends, and her relationship with Josh. She also 
related narratives about her mother, father, and stepfather, with their ori-
gins much earlier in her life.
Sessions 9–10: Enactments Become Activated in the Therapy Relationship
Enactments are special examples of the CCRT in which the pattern plays 
out between the patient and therapist in the here and now. A situation arose 
in Session 9 in which one of Paige’s CCRTs became highly activated in the 
relationship with her therapist and thus led to an enactment. When the 
therapist came to greet Paige in the waiting room at the beginning of Ses-
sion 9, another patient was mistakenly waiting for her session (which had 
in fact been scheduled for the next day). The therapist had a brief conversa-
tion with this patient in a lowered voice to clarify the mistake, momentarily 
disappeared to check, and returned to confirm the correct appointment 
 The Core Conflictual relationship Theme 53
time. The therapist then invited Paige inside to commence the session. Paige 
appeared withdrawn, was staring at the floor, and initially was silent. As 
the session progressed, she was only minimally responsive to the therapist’s 
questions about how her past week had been. Paige went on to become 
increasingly distressed in the session, saying to Lyndsay, “you care more 
about other patients” and “you filled my appointment with someone else 
because you don’t want to see me and I’m just too much trouble for you.” 
Lyndsay was surprised to hear these accusations and witnessed Paige 
become increasingly hostile and verbally aggressive toward her in the ses-
sion, saying things like “You’re not even helping me, you’re actually trying 
to make me worse!” During the session, Lyndsay found it hard to address 
this rupture, as she had not experienced Paige’s anger so clearly directed 
toward her until this point in the therapy.
Lyndsay took this session to supervision and was able to reflect on the 
enactment of material from some of Paige’s core CCRTs (i.e., perceiving 
others as abandoning her and becoming angry and hostile when others are 
perceived as attacking her). The supervisor helped formulate the hypothesis 
that Paige had experienced jealousy that the therapist cared more about 
other patients, that there was a rivalry, and that the therapist would reject 
Paige in favor of other, preferred patients and her special time slot would 
be taken away and filled by somebody else. This provided an important 
opportunity for the therapist to directly addressPaige’s RO’s—that oth-
ers didn’t like her and would abandon her and that others were attacking 
her. Lyndsay demonstrated to Paige how, in their work together, she had 
not rejected her or intended to attack her, and that indeed in this most 
recent case she had acted to protect their allocated time by sending the 
other patient away. Paige was able to experience in that moment a feeling 
of being held in mind, cherished, and liked, and this was a powerful experi-
ence in helping her open herself to the idea that she was “lovable and worth 
it”—challenging her pervasively held RO’s and opening her to one that 
could be more positive.
Sessions 10–15: New Relationship Narratives Show Improvements in Relationships
During the second half of the therapy, Paige began to show some changes 
in her life outside of therapy that were also evident in the relationship nar-
ratives she told in session. She was developing a wider circle of friends and 
an increased sense of agency and the CCRT patterns that would commonly 
show up in her narratives began to shift.
Lyndsay had worked to cultivate a therapeutic approach that empha-
sized a “curious stance” as an invitation for Paige to better help herself 
and develop more of an internal locus of control. Careful attention was 
required for Lyndsay to balance supportive (validation) and expressive 
(change-based) techniques in this time. Paige took greater ownership of 
54 HanDbook of PsyCHoTHEraPy CasE formulaTion
her therapy and started to more actively work on noticing her emotional 
responses and trying alternative CCRTs regarding her strong wish for help 
from others (e.g., “I want to help myself”; “Others will help me if I com-
municate my needs better”; “When I feel let down, I can look after myself 
better rather than becoming impulsive and suicidal”).
Overall, it seemed that Paige’s CCRTs were less conflictual, meaning 
there was less discrepancy between her wishes in interpersonal interac-
tions and how she and significant others responded to these wishes. Paige’s 
CCRTs were also less pervasive in the sense that each person in her life 
began to have their own unique CCRT. In this way, it was evident that 
Paige had begun to better differentiate between people rather than expect-
ing the same negative RO (i.e., rejection, abandonment, or attack) from 
all. She thus could begin to hold on to a positive CCRT with her therapist, 
experiencing Lyndsay as someone who was available and cared for her, 
and to internalize this as a new template for future relationship expecta-
tions. She was also able to reappraise some other older relationships in her 
developmental history (i.e., mother, father, stepfather) and see that they 
were less black and white and more layered in complexity and shades of 
gray.
The therapist regarded these changes as markers of termination, sug-
gesting that Paige had made progress and was ready to prepare for termi-
nation. Other markers of termination were also evident, including Paige’s 
initially reducing and then eliminating her use of self-harm as a coping 
strategy and reductions in her use of alcohol.
Sessions 16–20: Preparing for Termination: Old Patterns and Final Integration
The final five sessions provided opportunity for consolidation of Paige’s 
more adaptive emerging CCRTs and opportunities to continually work on 
greater awareness of earlier pervasive CCRTs. Paige noted feelings of sad-
ness, grief, and loss in working toward termination, and also at times felt 
a strong sense of abandonment, desiring reassurance from the therapist 
but also feeling betrayed and becoming angry and hostile. The therapist 
used her CCRT formulation to understand the reoccurrence and heighten-
ing of CCRT patterns that is often brought about through the sense of 
loss that termination invariably evokes. In all cases, the therapist helped 
Paige to challenge her pervasive perceptions of others’ negative responses 
(RO), continually work on building skills for more adaptive behaviors and 
attitudes in times of distress (RS), and reconsidering her wishes (W) in 
relationships to be more realistic and developmentally appropriate (i.e., 
tempering a desire for others to completely solve her problems and allevi-
ate all of her negative feelings to a greater wish for being close and sharing 
with others).
 The Core Conflictual relationship Theme 55
Analysis of the Case and Role of Formulation
Paige’s good treatment outcomes and her progression through psychother-
apy highlight the CCRT as a simple method to help the therapist identify, 
hold in mind, and bring awareness to ineffective patterns of relating that 
run counter to a patient’s needs and wishes in relationships. Initially, Paige 
had little awareness of her characteristic interpersonal patterns, and in the 
first phase of therapy (Sessions 1–3) she tended to respond to any experi-
ence of distress or frustration by engaging in destructive behaviors aimed 
at eliminating these feelings.
Paige’s key CCRTs were initially assessed (Sessions 1–3) and then fur-
ther formulated by the therapist during Sessions 4–8, leading to an enact-
ment of these patterns (Sessions 9–10) in which the therapist was able to 
provide a powerful new relational experience during the playing out of 
ingrained CCRT patterns in the therapeutic relationship. Paige made good 
use of therapy and displayed an increased focus on working hard each day 
and making better choices to take responsibility for her feelings and behav-
iors during this time. What was clear was that she became less externally 
focused and developed more agency and capacity to help herself over the 
course of therapy. This was captured in new narratives (Sessions 10–15), 
and the therapist’s CCRT formulation provided a simple method to moni-
tor and guide changes that helped Paige cultivate interpersonal interactions 
that better met her needs and wishes. Termination provided a chance to 
continually work on greater awareness of her earlier pervasive CCRTs (e.g., 
sense of abandonment), yet reflect on and integrate these changes and also 
plan for the future (Sessions 16–20). Therapy provided a chance for Paige 
to reconsider her relationship wishes and intense need of others to “help 
and fix” her and to understand the active role that she could play in also 
helping herself.
LEARNING THE METHOD
To use the CCRT in therapy, psychotherapists just need to learn the basics 
of the CCRT method as outlined in this chapter. With some practice, iden-
tifying the CCRT components can happen during the session, and these can 
be written down as file notes for later compilation by the therapist as the 
work progresses. Bringing these CCRTs to supervision helps the therapist 
test them with the supervisor, especially if tapes are available to examine 
and assess both the spoken components and also possible CCRT enact-
ments happening in the room. Considering enactments while taking into 
account the impact of the meeting of patient’s and therapist’s relational 
patterns enhance countertransference management (Schattner & Tishby, 
56 HanDbook of PsyCHoTHEraPy CasE formulaTion
2018). In contrast, using the CCRT in a research context requires more 
training, as reliability with other trained raters is important to establish. At 
present, seeking out experienced trainers and referring to the classic volume 
on the CCRT (Luborsky & Crits-Christoph, 1998) is the best place to start 
for those wanting to use the method in research.
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 61
3
Panic-Focused 
Psychodynamic Psychotherapy
fredric n. busch
barbara l. milrod
HISTORICAL BACKGROUND OF THE APPROACH
Psychoanalysis and the related psychodynamic psychotherapies have a his-
tory that extends well over a century. Breuer and Freud (1893–1895/1955) 
described some of what later became core psychoanalytic theories and 
approaches in their early clinical work, Studies on Hysteria. Some of these 
approaches and core concepts are important in contemporary symptom-
focused psychodynamic psychotherapies, including panic-focused psycho-
dynamic psychotherapy (PFPP; Busch, Milrod, Singer, & Aronson, 2012), 
particularly for patients with anxiety disorders. Freud and Breuer described 
and treated patients with “hysteria,” which roughly translates to patients 
suffering from what is currently described by the Diagnostic and Statistical 
Manual of Mental Disorders (DSM–5; American Psychiatric Association, 
2013) as conversion disorder. One case from Studies on Hysteria, Kath-
erina, presents with symptoms of what is described in DSM-5 as panic 
disorder.
Breuer and Freud (1893–1895/1955) described how seemingly inex-
plicable biophysiological symptoms appeared to carry symbolic emotion-
ally relevant meanings and that these symptoms often came to symbol-
ize central traumatic experiences that the patient suffered in the past. 
Memories of traumatic events and their connection to symptoms were 
not conscious or accessible and appeared to be “unconscious.” Although 
62 HanDbook of PsyCHoTHEraPy CasE formulaTion
known and stored in memory, they were not necessarily immediately avail-
able as regular memories. The “talking cure” involved verbal exploration 
of these symptoms. It was a method that enabled traumatic experiences 
and the unconscious meanings of these symptoms to be brought to the 
patient’s awareness. Access to these traumatic memories and understand-
ing of underlying, connected symbolic meanings were found to aid in relief 
of symptoms. Although the theory and range of interventions in psycho-
analysis has greatly expanded since these first psychoanalytic writings, the 
tenets described in Studies on Hysteria are still considered central to treat-
ing symptoms psychodynamically. In PFPP, helping the patient to uncover 
the emotional meanings of panic symptoms (also in part biophysiological 
symptoms) forms a core component of the treatment.
Based on these observationsin hysteria, Freud (1900/1953b) developed 
his initial theory of the model of the mind, the “topographical theory,” in 
which mental life was described as existing on two levels: either conscious 
or unconscious. In this framework, conflicted feelings and wishes in the 
unconscious that are unacceptable on some level to the person are kept 
from conscious awareness and emerge as symptoms. Freud (1926/1950) 
subsequently developed the “structural,” or tripartite, model of the mind. 
From this perspective, the mind is conceptualized as being divided into 
the id, which includes the drives and wishes; the superego, or conscience 
function, containing internalized prohibitions surrounding drive expres-
sion, as well as an internal reward function in which the person experiences 
a sense of gratification; and the ego, which encompasses perception, psy-
chological defense mechanisms, cognition, and self-representations. The 
ego modulates between the id and superego in part by triggering defense 
mechanisms, through which individuals unconsciously prevent their own 
awareness of impulses and conflicts they find to be disorganizing, frighten-
ing, or painful.
Using the topographical and tripartite models, patients were deter-
mined to be struggling with fantasies and urges deriving from the id, which 
were at the same time unacceptable to the ego and superego. Symptoms, 
such as panic attacks for example, often represent a compromise between 
disguised wishes and prohibitions, or so-called “compromise formations.” 
Having patients “associate freely,” or talk about what occurs to them about 
their symptoms, in the presence of the therapist’s nonjudgmental stance, 
aids in identifying underlying unconscious fantasies and bringing them into 
awareness. In our PFPP studies, we have demonstrated that this process 
provides relief of symptoms.
Using the tripartite model of the mind, Freud (1926/1950) described the 
function of anxiety as a response to psychologically meaningful dangers. 
One type of anxiety acts as a signal to alert the ego to the danger of emerg-
ing forbidden wishes by mobilizing defense mechanisms. Psychodynamic 
therapists utilize “signal anxiety” to help patients identify unconscious 
 Panic-focused Psychodynamic Psychotherapy 63
frightening feelings, fantasies, and conflicts. Another type of anxiety, 
“traumatic anxiety” (which is akin to panic attacks—disorganizing levels 
of often physically symptomatic anxiety), occurs when the ego’s defense 
mechanisms are overwhelmed by a sense of danger. This type of anxiety is 
often related to traumatic or adverse developmental events, which can be 
difficult to access due to intolerable emotions or a lack of the ego capacity to 
symbolize internal experience into language (for these patients, experiences 
often feel disparate or inchoate). In these instances, the therapist works with 
patients to give language and meaning to their anxieties by determining the 
links of these anxiety states to emotionally salient or traumatic events or 
fantasies. Using these psychoanalytic models, panic attacks can be viewed 
as a failure of the ego’s signal anxiety function in the face of dangers that 
evoke overwhelming disorganization (unconscious conflicts that are so raw 
and primitive they cannot be symbolized into language) or as the experience 
of traumatic anxiety. The therapist’s tasks include identifying the relevant 
unconscious fears (e.g., fears of anger disrupting or destroying a needed 
relationship) and to identify the link between the symptoms and contribu-
tory traumatic experiences.
Freud (1926/1950) also described core fears that emerge over the 
course of development. These include (1) fear of loss of a core attachment 
figure, also described as separation anxiety; (2) fear of the loss of a primary 
attachment figure’s love; (3) fear of disempowerment (referred to as castra-
tion fears); and (4) superego fear, or fear of being punished by a guilty con-
science. In clinical situations, the therapist works to define which of these 
fears are contributing to the patient’s anxiety (overlapping fears are com-
mon). Our research group developed a manualized psychotherapy based 
on these central psychoanalytic theories of anxiety that incorporates our 
clinical work, research studies, and the psychological literature, including 
studies of patients with panic disorder, to develop an organizing formula-
tion to understand and treat panic disorder (Busch et al., 2012).
Post-Freudian psychoanalytic and psychodynamic models for under-
standing origins of symptoms include object relations theory. Individuals 
form internalized representations of themselves and others, including sig-
nificant attachment relationships, over the course of development (Freud, 
1905/1953a; Bowlby, 1969). From a psychoanalytic perspective, problems 
in these representations, such as a sense that relationships with others are 
easily disrupted, can contribute to the development of symptoms such as 
anxiety. Current relationships with others are affected by perceptions of 
developmentally formative relationships that continue to exert compelling 
unconscious influence. These formative relationship patterns reemerge in 
current relationships, as well as in the transference, intensely held feelings 
and fantasies that patients maintain about their therapist.
Psychoanalysts have explored the impact of insecure and disrupted 
attachment on cognition and emotion. Fonagy and colleagues (Fonagy & 
64 HanDbook of PsyCHoTHEraPy CasE formulaTion
Target, 1997; Busch, 2008) have focused on the adverse impact of insecure 
attachment on the development of mentalization, the ability to conceive of 
behavior and motives in oneself and others in terms of mental states. A dis-
ruption or distortion in this capacity, in the context of insecure attachment, 
can lead to fears of loss, failure, and rejection, increasing the risk of anxiety 
and depressive disorders. Patients may also lack a capacity for symboliza-
tion of certain internal experiences. For instance, patients with panic dis-
order may be unable to recognize somatic sensations as being components 
of emotions, heightening the risk of catastrophic misinterpretation. PFPP 
therapists work with patients to aid in the development of their capacities 
for mentalization and symbolization.
The Development of Manualized, Symptom-Focused 
Psychodynamic Psychotherapies
In the 1970s, psychoanalysts and psychodynamic psychotherapists began 
to explore in greater depth the value of brief focused psychodynamic psy-
chotherapies. Malan (1979) described a brief focused psychotherapy that 
was designed to address defined core dynamics of patients. He reported 
anecdotally that these treatments could be clinically effective, although 
they were never systematically studied. Subsequently, as the need for sys-
tematic research of psychodynamic treatments became apparent, Luborsky 
(1984) published the first manual of psychodynamic psychotherapy. Sup-
portive–expressive therapy (SET) was not designed to address a specific 
presenting problem.
Beginning in the 1990s, psychoanalysts began to publish the first 
symptom-focused psychodynamic treatment manuals, including our 
group’s manual of PFPP (Milrod, Busch, Cooper, & Shapiro, 1997; Busch 
et al., 2012). These manuals (Bateman & Fonagy, 2016; Busch et al., 2012; 
Yeomans, Clarkin, & Kernberg, 2015) all contain psychodynamic formula-
tions focused on the specific disorders being treated, including descriptions 
of characteristic conflicts and defenses, modification of psychodynamic 
techniques in approaching these disorders, and sections addressing early, 
midphase, and termination phases of treatment. It was only when these 
essential building blocks were accomplished that scientifically credible, 
reliably reproducible outcome studies of psychodynamic treatment efficacy 
began in earnest. In the last 20 years, increasing evidence of the efficacy of 
psychodynamic treatments has emerged(Steinert, Munder, Rabung, Hoyer, 
& Leichsenring, 2017) , including for PFPP, the first psychodynamic treat-
ment to demonstrate efficacy for a DSM-IV (American Psychiatric Asso-
ciation, 1994) Axis I anxiety disorder (Milrod et al., 2007) and the only 
psychodynamic psychotherapy to date with replicated efficacy for any Axis 
I disorder (Beutel et al., 2013; Milrod et al., 2016; Svensson et al., 2021).
As these manuals and treatments were developed, the psychodynamic 
 Panic-focused Psychodynamic Psychotherapy 65
formulation (Perry, Cooper, & Michels, 1987) has increasingly been recog-
nized to be a core component of treatment. The formulation identifies how 
the patient’s symptoms relate to self- and other-representations, developmen-
tal and traumatic events, intrapsychic conflicts, and defenses. The formula-
tion provides a framework for how the therapist approaches and focuses 
on symptoms to identify and address contributory factors. Psychodynamic 
psychotherapists have increasingly recognized the value of sharing elements 
of the formulation with the patient early on in treatment, particularly when 
conducting a time-limited, symptom-focused psychotherapy. Therapist and 
patient work to develop and extend the formulation (this is a dynamic pro-
cess, in the sense of active modification of assessments and interventions) 
over the course of treatment to further relieve the patient’s symptoms and 
other associated relationships and life problems. This chapter elaborates in 
detail the elements and use of this core formulation for PFPP.
CONCEPTUAL FRAMEWORK
Psychoanalytic approaches, although powerful tools, have been mired in 
overly complex terminology and vagueness that can interfere with train-
ing and communicating ideas during therapy. We have found that focus-
ing on a specific disorder or set of clearly identifiable symptoms clarifies 
the specific nature of the formulation in a way that aids in education of 
clinicians regarding the treatment and in patients’ understanding of their 
symptoms. Indeed, our studies demonstrate that many patients are able to 
quickly comprehend these approaches and apply them to their own mental 
states and lives without any preexisting capacity for “insight,” heretofore 
viewed, albeit unsupported by research findings, as important.
Psychodynamic approaches focus on the development of psychopathol-
ogy in early life experiences, with a goal of understanding the origins of 
the patient’s symptoms to aid in their relief. According to psychoanalytic 
theory, temperamental factors, adverse developmental events, and trau-
matic experiences lead to problematic self- and other-representations (per-
sistent views of oneself and other people), common intrapsychic conflicts 
and defenses, as well as interpersonal difficulties, that result in symptoms 
and difficulty functioning. A core achievement of development is the capac-
ity to tolerate separation, gain autonomy, and manage ambivalent feelings 
toward caregivers. We examine how problems in these various areas con-
tribute to the development of panic disorder. In this process, we examine 
core elements of the psychodynamic formulation—self- and other-represen-
tations, intrapsychic conflicts, defenses, and mentalization skills—in the 
context of symptoms.
Anxieties and conflicts surrounding separation are core vulnerabili-
ties and symptoms of patients who suffer from panic disorder. This link 
66 HanDbook of PsyCHoTHEraPy CasE formulaTion
has been suggested by many clinicians over time, including Klein (1964), 
who found that half of his patients were “fearful and dependent children, 
with marked  separation anxiety, and difficulty in adjusting to school” 
(p. 405). He stated that this group “seems to have suffered from a chroni-
cally high separation anxiety level throughout life and to have developed 
panic attacks under conditions where they were peculiarly vulnerable” 
(pp. 405–406). There is now abundant epidemiological evidence that sup-
ports the link between panic disorder and a history of separation anxiety 
(Kossowsky et al., 2013; Milrod et al., 2014; Silove et al., 2015). The anxi-
ety arising from separation has been posited to derive from temperamen-
tal factors (behavioral inhibition as described and studied by Kagan and 
Rosenbaum; Rosenbaum et al., 1998; Rosenbaum et al., 1991), adverse 
developmental experiences, or often both. In each of these developmental 
pathways, patients never develop secure attachment relationships to other 
people. This problem, described as insecure attachment or fearful depen-
dency on others, highlights the individual’s feelings that others cannot 
be depended upon to be emotionally responsive or even present (Bowlby, 
1973; Main & Goldwyn, 1994; Milrod et al., 2014).
The Context of Symptoms
Acute stressors, described in the literature as “life events,” frequently occur 
just prior to panic onset (Busch et al., 2012; Faravelli, 1985; Klass et al., 
2009; Roy-Byrne, Geraci, & Uhde, 1986). Despite the DSM-5 (American 
Psychiatric Association, 2013) description of panic attacks as coming “out 
of the blue” (p. 209), from a psychodynamic perspective, the meaning of 
these events to the individual (including the unconscious significance they 
carry) and the affects triggered in response to these events play a central 
role in the development of panic attacks. In addition, the therapist explores 
the emotions and circumstances surrounding specific panic episodes. 
These provide additional clues as to the meanings, conflicts, and defenses 
that contribute to panic symptoms. The contexts, emotional states, and 
thoughts surrounding panic onset and subsequent attacks are considered 
core components of the case formulation.
Core Conflicts
Fears surrounding separation have a broad impact on the individual’s psy-
chology, including a persistent anxiety that relationships with close attach-
ment figures are evanescent and can be easily disrupted. These fears lead 
to difficulty identifying and tolerating (and sometimes modulating) angry 
and vengeful feelings and fantasies (Busch, Cooper, Klerman, Shapiro, & 
Shear, 1991; Shear, Cooper, Klerman, Busch, & Shapiro, 1993; Busch et 
al., 2012); the patient believes, often unconsciously, that the experience of 
 Panic-focused Psychodynamic Psychotherapy 67
anger will lead to rejection or damage to core attachment figures. For indi-
viduals prone to panic attacks, angry feelings and fantasies often remain 
unconscious; their potential emergence into consciousness can create 
intense anxiety or panic attacks due to fears of disrupting core relation-
ships. Both the dangers of disruption and the severity of conflict over angry 
feelings can lead to psychopathology. Individuals who better tolerate their 
emotions surrounding anger and attachment are less likely to develop anxi-
ety disorders. Psychodynamic treatments help patients to become aware of 
these affects and fantasies, articulate them, and render them less threaten-
ing once they can be better understood, leading to symptomatic change.
Defenses
According to Freud (1911/1958), defenses are triggered by unconscious 
conflicts in an also unconscious attempt to manage emotional threats aris-
ing from destabilizing angry feelings and fantasies or other intolerable con-
tents (e.g., guilt, unacceptable dependent wishes, or unacceptable sexual 
urges). Common defense mechanisms that can be identified in patients with 
panic disorder include reaction formation, undoing, denial, and somatiza-
tion (Busch, Shear, Cooper, Shapiro, & Leon, 1995; Busch et al., 2012). 
When reaction formation is operative, the patient consciously experiences 
positive feelings toward someone with whom they are unconsciously angry 
(or vice versa). In the use of undoing, individuals verbally or symbolically 
make amends for angry feelings and fantasies. A common statement of 
such patients using this defense is “I hate my husband/wife, but I really love 
him/her,” or “I love himto death.” By unconsciously attempting to convert 
anger to more affiliative feelings, patients reduce the unconscious threat 
they perceive—in effect, unconsciously undoing it—due to their rage at 
an attachment figure. In the use of denial, patients may disavow the pres-
ence of any angry feelings. “I don’t do anger,” announced one profoundly 
agoraphobic patient. Somatization represents another important defense in 
many anxiety disorders, enabling avoidance of specific fantasies and feel-
ings through focus on the body. Thus the somatic symptoms of patients 
with panic disorder represent a means of avoiding intolerable feelings and 
fantasies. In a psychodynamic treatment, the therapist focuses on meanings 
of defense mechanisms and uses them in therapy with the patient to identify 
emotions and fantasies that trigger symptoms.
Phobic symptoms can also be viewed as a defense, in which individuals 
displace their angry or other unacceptable feelings and fantasies on to spe-
cific areas in space or objects. Thus patients view these areas or objects as 
the source of danger to be avoided, rather than recognizing their own fright-
ening feelings and fantasies. Patients unconsciously feel they are exerting a 
measure of control over dangerous fantasies by externalizing and concret-
izing them. The therapist’s efforts are directed at the ways that the phobias 
68 HanDbook of PsyCHoTHEraPy CasE formulaTion
symbolize the patient’s unconscious fears, enabling an understanding of 
how these situations are misperceived as dangerous. Particularly in agora-
phobia, the most disruptive and global of phobias and a common accom-
paniment to panic disorder, each magical “danger space” is accompanied 
by an unstated but equally important fantasized “safe space” (Busch et al., 
2012). The “safe spaces” labeled by agoraphobics are often more dangerous 
places for these people in the real world (e.g., home environments in which 
severe abuse or neglect are perpetrated, relationships pursued in which the 
patient is physically threatened). These magical, inchoate ideas are incor-
porated into the understanding that the PFPP therapist imparts to patients 
to help them make sense of their anxiety symptoms.
Unconscious angry and ambivalent aspects of intense love attachments 
can result in the perceived need for a phobic companion (Deutsch, 1929). 
Partly in an unconscious attempt to prevent destruction of the love object 
by their hostile, compelling, destructive fantasies, patients feel the need 
to have this close person present at all times to demonstrate to themselves 
that their fantasies have not come true. Need for a phobic companion also 
commonly emerges from an unconscious rageful yet passive wish to control 
this person.
Panic attacks can represent a compromise formation between rage-
ful fantasies, which are viewed as dangerous, and self-punishment for the 
fantasies, experienced by the patient as disabling terror and disability. The 
sense of vulnerability triggered by panic attacks can reduce the perceived 
threat of aggressive fantasies: If the person is this sick and needy, they 
could not harm anyone else. Thus patients present themselves to others 
as harmless and in need of help. Although they are usually unconscious, 
aggressive impulses can be expressed by coercive efforts to control ambiva-
lently held others. The distress of panic symptoms can act as a form of 
self-punishment, unconsciously atoning for fantasies and feelings that trig-
ger guilt.
Representation of Self and Others/Transference
Patients with panic disorder typically view themselves as unsafe or inca-
pable, requiring others for protection, while perceiving others as tem-
peramental, frightening, controlling, or rejecting, aggravating their sense 
of insecurity (Busch et al., 2012). Their perceptions add to their sense of 
fearful dependency on attachment figures. Identification of these self- and 
other-representations aids in developing a psychodynamic formulation to 
understand and address the emotional/attachment sources of anxiety and 
panic.
Patterns of perceptions of significant others typically emerge in the 
relationship with the therapist; this universal psychological phenomenon, 
transference (Freud, 1905/1953a), is a cornerstone of psychoanalytic theory 
 Panic-focused Psychodynamic Psychotherapy 69
and practice. Focus on the transference can prove helpful to patients in 
recognizing underlying organizing fantasies that surround the therapeutic 
relationship and contribute to symptoms; this is a tool utilized in PFPP. 
Patients’ anxiety symptoms commonly intensify at times of separation 
(Busch et al., 2012; Milrod et al., 2014) from the significant people in their 
lives, including their therapists. Symptoms can worsen when treatment, 
regardless of modality, is temporarily or permanently discontinued. These 
separations and/or termination can provide important opportunities for 
patients better to articulate, understand, and learn to manage their mixed 
feelings about autonomy in the context of the transference. Thus the thera-
pist includes the state of the transference in the psychodynamic formula-
tion.
Mentalization Skills
Temperamental factors, adverse events, and trauma can interfere with the 
development of mentalization, the capacity to understand the minds of 
oneself and others (Fonagy & Target, 1997; Busch, 2008). Limitations in 
the ability to mentalize can interfere with identifying internal factors that 
contribute to anxiety and can also interfere with understanding relation-
ships with others, adding to perceived threats of abandonment and intru-
sion. Associated with mentalizing difficulties, patients prone to panic can 
lack the capacity to symbolically represent bodily states that contribute to 
emotions and cognitions. This difficulty can lead the patient to misinter-
pret bodily sensations as catastrophic (Craske, DeCola, Sachs, & Pontillo, 
2003). As part of this tendency, patients have difficulty differentiating sen-
sations surrounding anger from those of anxiety. Thus therapists work to 
help patients put these inchoate experiences into words and identify their 
meanings.
Anticipating Problems in Therapy
Psychodynamic psychotherapy is well suited to addressing hurdles to the 
progress of treatment. In PFPP, the therapist recognizes that as much as 
they are terrified by panic attacks, patients are more frightened by the 
unconscious conflicts that give rise to the symptoms. The exploration of 
contexts, feelings, and fantasies surrounding panic episodes, alongside the 
interpretation of defenses, provides a way of empathically helping patients 
recognize the origins of their symptoms and their underlying ongoing pres-
ent meanings. In addition, patients’ fears and fantasies will often emerge in 
the transference, providing a powerful opportunity to identify and under-
stand their conflicts in the context of the therapeutic relationship. Thus the 
core psychodynamic formulation provides a road map both for the treat-
ment of symptoms and addressing obstacles to the treatment.
70 HanDbook of PsyCHoTHEraPy CasE formulaTion
MULTICULTURAL CONSIDERATIONS
Throughout much of the history of psychoanalysis, given the relative cul-
tural and racial blindness of the past century within mainstream psychiatry, 
little attention was paid to the impact of culture, as the factors influencing 
the development of symptoms were felt to be universal. However, in the last 
20 years, cultural factors have been increasingly recognized and now are 
considered to be part of the core psychodynamic formulation (Stoute, 2017; 
Stoute & Slevin, 2016a, 2016b, 2017). For example, it is important to con-
sider that certain patients are from disadvantaged backgrounds or cultures 
that have suffered from institutionalized, structural racism and may have 
experienced an inordinate degree of trauma as a result. Negative cultural 
stereotypes can be internalized unconsciously, contributing to patients’sense of inadequacy. This not only has an influence on understanding the 
meaning of the patient’s experiences and symptoms but can also affect the 
transference to the therapist (Stoute, 2017; Stoute & Slevin, 2016a, 2016b, 
2017). In addition, cultures vary regarding the types of thoughts, feelings, 
and circumstances that are considered to be a threat. For example, in cer-
tain cultures it may be less acceptable to express uncomfortable emotions 
to close family members, leading to a greater focus on somatic symptoms, 
which are more acceptable.
In the past, psychoanalysts have averred that patients required a pre-
existing capacity for insight to be able to participate effectively in a psycho-
analytic treatment. However, in the psychodynamic approaches developed 
by our research group, we have found that most patients are quickly able to 
gain self-observational capacities. Exploring the context and emotions sur-
rounding symptoms begins to build the capacity to look inward. Demon-
strating how these efforts enable an understanding of the origins of symp-
toms further contributes to patients’ motivations for self-examination. 
Given the attention to cultural factors and an approach that aids patients 
in the development of insight, focused psychoanalytic approaches are well 
suited for a diverse range of ethnic and cultural backgrounds.
EVIDENCE BASE SUPPORTING THE METHOD
Milrod et al. (2007) conducted a randomized clinical trial (RCT) of 49 
patients with a primary DSM-IV (American Psychiatric Association, 1994) 
diagnosis of panic disorder with or without agoraphobia, comparing PFPP 
with a less active but efficacious psychotherapy for panic disorder, applied 
relaxation therapy (ART; Öst & Westling, 1995). PFPP had a significantly 
better response rate than ART (73% vs. 39%; p = 0.016), using the standard 
definition of “response”: a 40% pretreatment to posttreatment decrease in 
total Panic Disorder Severity Scale (PDSS) scores (Barlow, Gorman, Shear, 
 Panic-focused Psychodynamic Psychotherapy 71
& Woods, 2000). Participants in the PFPP condition experienced signifi-
cantly greater improvement in panic disorder symptoms as measured by 
the PDSS (p = .002) and in psychosocial functioning as measured by the 
Sheehan Disability Scale (Sheehan, 1983; p = .014). Gains were maintained 
at 6-month follow-up without intervening treatment. A study of reflec-
tive function (Rudden, Milrod, Aronson, & Target, 2008), conducted in 
conjunction with this first PFPP RCT, indicated that an operationalized 
measure of awareness of the link between emotional experience and panic 
symptoms—symptom-specific reflective functioning—improved signifi-
cantly from baseline to posttreatment in patients treated with PFPP, but 
not in those treated with ART.
Milrod et al. (2016) conducted a second RCT of 201 patients with 
primary DSM-IV (American Psychiatric Association, 1994) diagnoses of 
panic disorder with or without agoraphobia, comparing PFPP, cognitive-
behavioral therapy (CBT), and ART in a study conducted at two sites: Weill 
Cornell Medical College (Cornell) in New York City and the University 
of Pennsylvania (Penn). Attrition was significantly higher in ART, and 
patients who were more symptomatic dropped out of ART significantly 
more (69% in ART, 26% in PFPP, 24% in CBT, p =.013), indicating that 
ART is less tolerable, particularly for the sickest tercile of patients with 
panic disorder. There were significant site-by-treatment differences in out-
come: Patients treated at Cornell Medical College improved at the same 
rate in all three treatments, whereas patients treated at the University of 
Pennsylvania improved faster in ART and CBT than PFPP. At termination, 
Cornell patients responded better to PFPP and CBT compared to ART, 
whereas Penn patients did not show a significant differential response 
across treatments. Overall response rates across both sites were ART, 46%; 
CBT, 63%; and PFPP, 59% on the PDSS, but these differences in response 
rates did not reach statistical significance between treatments. There were 
notable between-site differences, including in numbers of patients main-
tained on psychotropic medications during the study (there was a sevenfold 
higher rate of psychotropic use at Penn than at Cornell), although these dif-
ferences did not fully account for between-site differences at termination. 
Although the three treatment conditions were not significantly different in 
response at treatment termination, at 12-month follow-up, PFPP and CBT 
outperformed ART. PFPP and CBT demonstrated equivalent 12-month 
follow-up outcomes, and the majority of patients treated in either of these 
interventions maintained remission from panic disorder at 12-month fol-
low-up (McCarthy, Chambless, Solomonov, Milrod, & Barber, 2018).
A process–outcome study (Keefe et al., 2019) involving this study 
found that the degree to which panic-focused interpretations were used 
in PFPP at midtreatment specifically correlated with level of subsequent 
improvement in panic symptoms. Patients with more severe personality 
disorders, particularly cluster B personality disorders (including histrionic, 
72 HanDbook of PsyCHoTHEraPy CasE formulaTion
borderline, narcissistic, and antisocial personality disorders), experienced 
more improvement in their personality disorder cluster symptoms in PFPP 
than in CBT (Keefe, Milrod, Gallop, Chambless, & Barber, 2018). PFPP 
has replicated efficacy in findings from two additional research groups 
(Beutel et al., 2013; Svensson et al., 2021).
STEPS IN CASE FORMULATION CONSTRUCTION
In PFPP the therapist works with the patient to determine how symptoms 
make sense as psychological phenomena and thus to help patients recognize 
their own feelings and thoughts in a more coherent way than they were 
able to before. A key understanding about panic and other anxiety symp-
toms is that specific, uncomfortable, and (what are experienced as) dan-
gerous ideas and impulses are represented in the panic experience, includ-
ing somatically. A core goal of treatment with PFPP is for the patient to 
become consciously aware of underlying emotional conflicts and, with this 
awareness, to begin to handle these feelings differently. The initial focus 
in PFPP is to gain the information necessary to delineate specific fantasies, 
conflicts, and feelings underlying the symptoms and begin to develop the 
psychodynamic formulation. The formulation then provides a road map for 
elucidating contributors to problems, enabling patients to grasp the mean-
ing of their symptoms.
In evaluating the patient with panic disorder, the therapist obtains a 
detailed symptom history, focusing on circumstances, timing, meanings, 
and feelings associated with episodes of intense anxiety or panic. The 
therapist begins by focusing on the context and emotions surrounding 
panic attacks, which patients often have not recognized or have avoided, 
often due to emotional conflicts arising from accompanying feelings and 
fantasies. The period of initial onset of panic attacks is explored with a 
goal of obtaining information about triggers, including life stresses. In our 
experience (Klass et al., 2009), these triggers often include recent losses 
or changes in circumstances that the patient experiences as threatening to 
their attachment to significant others. Other patients do not experience 
an actual loss but perceive an otherwise commonplace event as a threat to 
an attachment relationship based on their own psychological vulnerability. 
The therapist explores in depth how patients have reacted to these stresses 
and gains a sense of their ongoing impact.
In examining emotions surrounding panic, although anxiety would be 
thought to be the most common feeling that occurs during panic attacks, 
patients may experience a range of emotions. These can include feeling 
humiliated or shameful about feelings of lack of control or needing help 
from others. Not uncommonly, this exploration revealsanger that pre-
ceded the onset of panic attacks that patients have not attended to, in part 
 Panic-focused Psychodynamic Psychotherapy 73
because it has been overshadowed by their anxiety. The therapist not only 
obtains this information but is also alert to how patients may struggle with 
acknowledging events, feelings, and fantasies. These reactions are used to 
begin to identify defenses patients may employ and particular feelings and 
fantasies that are distressing for the patient.
The therapist develops with the patient an increasingly clear sense of 
precipitants and emotions surrounding panic onset. The patient can begin 
to collaborate in observing these factors and internal reactions as new 
attacks occur, gaining a sense of recognition, control, and a capacity to 
“step back” from these overwhelming states of mind.
Developmental History
As they obtain an improved understanding of the contexts and emotions 
surrounding panic, the therapist and patient explore the patient’s history to 
understand sources that have contributed to their panic. According to psy-
choanalytic theory, symptoms emerge based on vulnerabilities developed 
over the course of the patient’s history, beginning in early life. For example, 
the therapist examines how separation and anger, common contributors to 
panic, were managed within the family. Panic patients typically describe 
caregivers who struggled with tolerance of separation or anger, includ-
ing temperamental outbursts. Patients may also have experienced trau-
matic events that contributed to a heightened sense of threat in response to 
attachment, such as early losses or illness in caregivers. Thus therapists help 
patients develop models for understanding how they came to be vulnerable 
to anxiety and panic attacks. Additionally, this information provides an 
improved understanding of the current contexts of panic symptoms. For 
example, if the patient has panic attacks when experiencing separation or 
interpersonal conflict, understanding how their history contributes to these 
concerns helps clarify the sources of their symptoms.
Self- and Other-Representations
Identifying current precipitants and feelings surrounding panic episodes in 
the context of the patient’s developmental history allows improved clarifi-
cation of the patient’s internalized representations of themselves and others. 
Patients with panic disorder often view themselves as unsafe and requiring 
others for protection, while perceiving others as temperamental, frighten-
ing, controlling, or rejecting, aggravating their sense of insecurity (Busch et 
al., 2012). They tend to view others as potentially rejecting or abandoning 
them in response to expression of their needs. Or they may see others as 
overly fragile or easily damaged by their anger. These perceptions heighten 
the dangers they experience surrounding separation and anger, adding to 
the threat of disrupted attachments (Busch et al., 1991; Shear et al., 1993; 
74 HanDbook of PsyCHoTHEraPy CasE formulaTion
Busch et al., 2012). The therapist can examine how patients’ expectations, 
in part based on past experiences, can lead them to overestimate the threats 
from their feelings, fantasies, and current interpersonal interactions.
Intrapsychic Conflicts
As the therapist and patient gain a greater sense of the precipitants of panic 
and self- and other-representations, they can begin to identify core conflicts 
the patient struggles with. In our clinical experience from research studies, 
these conflicts commonly include fear of dependency wishes, with a belief 
that these wishes are shameful or humiliating, and hence make the patient 
feel inadequate, less-than, or incapacitated; or that others will not tolerate 
and will reject these wishes. Additionally, conflicts typically include fear 
of angry feelings and fantasies that could potentially disrupt relationships 
with significant attachment figures. When these dependent and aggressive 
wishes begin to emerge into consciousness, triggering attachment threats, 
patients experience intense anxiety in the form of panic and sometimes 
intense guilt. Guilt about dependent and angry wishes leads to another core 
dynamic, in which panic attacks are experienced as a form of punishment. 
The therapist communicates these conflicts as part of the formulation and 
elaborates with patients the broad range of feelings, fantasies, and circum-
stances in which these conflicts lead to symptoms.
Defenses
The therapist works to identify defenses associated with panic episodes. 
Defenses typically function to protect patients from awareness of their 
dependent and angry feelings and wishes and fears of disruption of rela-
tionships. In pointing out these defenses, the therapist not only illustrates 
how these defenses contribute to panic but also highlights to patients how 
they avoid awareness of their conflicts; the identification of defenses can 
then help patients gain conscious access to conflicts. For instance, using 
the defense mechanism of denial, patients may report an absence of angry 
feelings and fantasies, even in circumstances in which these feelings would 
be highly appropriate. The therapist can interpret that patients are uncon-
sciously avoiding the experience of being angry, likely because this emotion 
is frightening. Other defenses include somatization, reaction formation, 
and undoing (Busch et al., 2012). In exploring somatization, the therapist 
identifies how intolerable feelings and fantasies are displaced to the body. 
The therapist explores the meaning of the particular somatic symptoms to 
that patient. For example, bodily experiences of lack of control, such as 
vertigo, can represent a fear of lack of control of certain feelings and fanta-
sies, or they can serve as specific reminders of events, relationships, or fan-
tasies; alternatively, they may refer to specific memories. Undoing can be 
 Panic-focused Psychodynamic Psychotherapy 75
noted when patients “take back” comments they fear are overly aggressive. 
In reaction formation, patients express positive feelings toward those with 
whom they have reason to be angry. The therapist interprets how patients 
suppress anger in an attempt to reduce the threat they feel to attachment 
relationships. The treatment helps patients gain conscious access to their 
discomfort with negative feelings, which detoxifies the danger associated 
with these feelings and fantasies.
Mentalization
Constructing the formulation includes determining and addressing deficits 
in mentalization and symbolization capacities. The absence of these capaci-
ties interferes with patients’ understanding the meaning of their symptoms 
and heightens the tendency toward a catastrophic focus on the body. These 
deficits are indicated by a lack of awareness of mental states in the patient 
and others, such as ascribing panic attacks to something the patient ate 
or failing to recognize a pattern of separations preceding panic episodes 
(Rudden et al., 2008). The work of PFPP involves aiding patients in the 
development of mentalization and symbolization skills through examina-
tion of context, stressors, and meanings of symptoms, identifying relevant 
conflicts and defenses, and reevaluating the anticipated responses of others.
Cultural Factors
The development of the formulation includes the ongoing assessment of 
the impact of patients’ backgrounds, cultural context, and cultural fac-
tors that may play a role in the development or persistence of the patients’ 
symptoms. This includes identification of how patients’ cultural milieus 
have influenced the ways they think about their bodies, their sexuality, 
anxiety, psychiatric and medical illness, and mental states. In addition, 
the therapist assesses patients’ cultural backgrounds in relationship to 
their experiences of poverty, racism, disenfranchisement, and violence to 
understand their impact on patients’ symptoms and the meanings of the 
illness.
TREATMENT PLANNINGAND PRACTICE
Communicating with the patient about aspects of the formulation is a key 
part of the treatment process in PFPP, enabling an improved understand-
ing and verbalization of factors that contribute to panic symptoms. The 
therapist shares a preliminary formulation with the patient by the fourth 
session of treatment at the latest, which typically involves the contexts and 
emotions surrounding panic, preliminary notions about the meaning of 
76 HanDbook of PsyCHoTHEraPy CasE formulaTion
the patient’s symptoms, and relevant developmental history. More com-
plex formulations regarding conflicts and defenses are elaborated in sub-
sequent sessions as this information emerges and is processed by patients. 
Formulations are modified according to the responses of patients, with the 
therapist working to make the formulation more comprehensible and to fit 
more closely to patients’ experiences. That is, these formulations are also 
“dynamic” in the sense of changing with further information. The formu-
lation is developed over the course of treatment to enable an increasingly 
comprehensive understanding of contributors to the patient’s panic attacks 
and to identify interventions aimed at providing relief from panic and con-
tributing psychodynamic vulnerabilities.
In providing the formulation, recognition of context and emotions sur-
rounding panic helps patients to gain a greater sense of control over their 
symptoms and an opportunity to proactively observe and consider these 
central triggers. Identification of relevant self- and other-representations 
enables the therapist to address anxieties about separation, shame, and 
worries about criticism or rejection. The therapist and patient work to iden-
tify core defenses to address how patients avoid awareness of frightening 
feelings and fantasies. Articulation and elaboration of conflicts that lead 
to panic attacks and phobic avoidance allows patients to address fears of 
anger and abandonment involving attachment figures. These central con-
cerns invariably emerge in the relationship that patients develop with the 
therapist. Building mentalization capacities helps patients to gain a better 
capacity for symbolization of somatic and other inchoate catastrophic fears 
and explore what is occurring in their own minds, as well as in the minds 
of others.
The determination of the accuracy of the formulation is based on 
patients’ responses, the development of concepts that further understand-
ing of panic episodes, and relief of patients’ symptoms.
CASE EXAMPLE
Mr. A was a 35-year-old Black male computer programmer, in his second 
marriage, with a 5-year-old son from his first marriage, working as the 
head of a division at a technology company. Two days before his 35th birth-
day, while at work, he developed intense anxiety, numbness in his arms and 
legs, paresthesias, and “twitching” throughout his body. He thought he 
was having a stroke and went to the emergency room. His medical evalu-
ation was negative, and the doctor suggested that perhaps his symptoms 
were from stress. After the initial episode, he continued to experience fre-
quent panic attacks with similar symptoms and presented for treatment at 
our clinic 6 weeks later. He was diagnosed with panic disorder and enrolled 
in a study protocol to be treated with PFPP twice weekly over 12 weeks, for 
 Panic-focused Psychodynamic Psychotherapy 77
a total of 24 sessions. His therapist was a White male psychiatrist who was 
trained as a psychoanalyst (Fredric N. Busch).
The formulation developed in the case determined that Mr. A’s panic 
attacks were triggered in the context of pressures both at work and in his 
home life. At work, they occurred when he had to reprimand or fire an 
employee. Outside of work, they were triggered by tensions with his ex-wife 
surrounding the care of their child. These experiences were at odds with his 
need to be the “perfect boss and parent,” and he struggled with guilt and 
anxiety about disappointing others. At work it emerged that he was angry 
at the company’s directors for their mismanagement of his division, but he 
found this anger to be frightening and difficult to acknowledge.
His developmental history shed light on the origins of these conflicts. 
Mr. A described a relationship with his mother in which he felt he had to 
be submissive and take care of her. His father was distant and critical of 
him, and Mr. A felt he could not meet his father’s expectations. Given their 
attitudes, he did not feel safe experiencing or expressing his frustrations 
toward his parents. In addition, he was sent to live away from home on 
three occasions across the course of his childhood, each occurring suddenly 
and without warning. He interpreted these separations as punishment for 
behaving badly. He developed a compensatory effort to behave like the per-
fect child in an effort to avert the risk of abandonment. His panic attacks 
occurred in circumstances in which he felt increasing rage and fear of dis-
ruption in relationships in the face of excessive expectations, in the model 
of his relationship with his parents.
The treatment plan using this formulation involved helping Mr. A 
identify the interpersonal contexts of his panic attacks (criticism or dis-
missal of his employees, conflicts with his ex-wife) to help him feel more in 
control of his symptoms, engage his curiosity about why these things were 
so disruptive for him, and to develop an understanding of the meanings 
of triggers. The elucidation of his developmental history enabled a better 
understanding of the origins of the pressures he felt in the work setting, 
including the unattainable goal of being the “perfect boss.” In the course 
of psychotherapy, for the first time, Mr. A gained an understanding of the 
threat of abandonment that he experienced in relation to extended child-
hood separations from his parents. The therapist identified the conflicts 
surrounding his angry feelings, which he feared would disrupt relationships 
and lead to abandonment now. The emergence of his angry feelings and 
abandonment fears allowed them to be considered, understood, detoxified, 
and made less threatening and more consciously available, diminishing the 
intrapsychic threats they created, and made it possible for Mr. A to stop 
having panic attacks.
In Session 1, the therapist began by exploring the circumstances and 
feelings surrounding panic onset. Mr. A reported that he found his work 
extremely stressful, especially after his recent promotion to lead a division 
78 HanDbook of PsyCHoTHEraPy CasE formulaTion
at his tech company that was struggling to meet its goals. He was initially 
optimistic about turning things around, but this task did not go as he 
expected. As his division lost revenue, he found it necessary to pressure his 
employees to increase their productivity. He had wanted to be the “perfect 
boss,” highly supportive of his staff, but instead felt extremely uncomfort-
able about reprimanding and on occasion firing members of his team. He 
viewed his behavior as disappointing them and felt guilty and responsible 
for the persistent problems in his division. On the day of his first panic 
attack, which he described as his most stressful ever, he had to fire someone 
and worried about the damage it might cause her and her family.
In Sessions 2–4, the therapist and Mr. A explored the circumstances and 
feelings surrounding panic in greater detail. They determined that his panic 
attacks typically occurred when he needed to address problems with some-
one in his division about their work, pressing them to improve their produc-
tivity or giving them a warning about their employment. The therapist and 
patient learned that Mr. A also experienced panic attacks during meetings 
with the directors of the company about his division’s progress. In identifying 
the circumstances of his panic episodes, Mr. A began to recognize that the 
panic attacks arose in the contextof tense interchanges with his employees 
and bosses, not as coming out of the blue as he had initially thought.
The therapist explored in greater depth the emotions he was experienc-
ing surrounding his panic attacks. Mr. A readily acknowledged the guilt 
and fear he felt in communicating additional expectations to his employees 
that preceded his panic episodes. He became uncomfortable when he began 
to describe his meetings with his bosses, as he acknowledged frustration 
with the company’s leaders and the pressures they were putting on him. He 
minimized these feelings, averring, “I’m not angry, but I am frustrated,” 
using the defense of undoing (taking back) his anger. His discomfort related 
in part to his belief that he should be the “perfect” employee; that he should 
just “do his job” and not complain. As he began to feel safer acknowledging 
his anger, he admitted irritation with certain business decisions the leaders 
made and believed that management was significantly responsible for the 
stress he experienced in his new role.
Therapist and patient also discussed the panic attacks that occurred 
after conflicts with his ex-wife, Stacy, surrounding the care of their 5-year-
old son. Stacy frequently demanded to keep their son on weeknights or 
weekends when Mr. A was due to take him; she also often insisted that 
he pick up their son when the plan had been for Stacy to care for him. As 
with work, he felt pressured to respond to these demands, and the stress 
surrounding these decisions intensified since he had become busier at work. 
He argued with Stacy, but felt guilty and anxious afterward, and typically 
yielded to her demands.
The therapist also proceeded in these early sessions to explore Mr. A’s 
developmental history, with a goal of further identifying factors relevant 
 Panic-focused Psychodynamic Psychotherapy 79
to the onset of his panic attacks. Mr. A had a disrupted childhood in that 
on several occasions he was separated from his parents for long periods 
of time. His parents did not feel that his childhood home in his metro-
politan area was in a safe area, so he was sent to the Caribbean to be with 
his grandparents from ages 4–7. He returned to the metropolitan area to 
attend second grade but felt lost in the new school. He seemed to have 
learning difficulties, which were identified at that time. It was never clear 
what these “difficulties” had to do with separation from what had been a 
safe and comfortable environment and family in the Caribbean or to what 
degree this diagnosis was indeed accurate. He was separated again from his 
parents between ages 10 and 12, this time to live with an aunt and uncle in 
another northeastern city in the United States. He found them to be judg-
mental and controlling, but his schoolwork improved. He described feeling 
deeply wounded about being “sent away” and presumed that it must have 
been related to his parents’ viewing him as acting badly. In each of these 
instances, he described the pain and anxiety of missing his parents, worry-
ing about what he might need to do to reunite with them.
His home environment was further shaken after his parents divorced, 
when he was 14, after several years of conflict, which he found frightening 
due to the intense yelling and verbal threats they expressed to one another. 
Following the divorce, he went to military school in another state from 
8th to 11th grade. Although he was sad and scared much of the time at the 
school, he found ways to compensate for his learning problems. In college 
he was able to get technical training and become a computer programmer. 
He hoped his efforts would make his father proud of him, but their rela-
tionship remained strained, in part because his father hoped he would have 
pursued a career in the humanities.
Mr. A reported a highly problematic relationship with his mother, 
although prior to therapy he had not connected these experiences to his cur-
rent stress and panic attacks. An only child, he felt pressured to take care 
of his mother, who remained embittered about the divorce, which occurred 
in part because his father had an affair. He reported that he became her 
“counselor” and needed to be the man of the family. He felt a need to inter-
nalize his own thoughts and feelings to protect her. He reported that his 
mother was self-centered and developed a “victim stance.” She had had an 
accident when he was 18 when she tripped on an icy sidewalk and injured 
her leg, after which she successfully pursued a legal case. After that, Mr. A 
believed his mother made little effort to improve her situation, remaining 
nearly homebound and complaining about her fate.
Similar problems occurred when his mother, a domestic worker, 
became an aide for an older White man who was verbally abusive to her. 
As a young teen, Mr. A had to come to work with her on occasion. There he 
was exposed to the verbal abuse but was not allowed to respond, fearing his 
mother would be fired. These experiences were seen as additional instances 
80 HanDbook of PsyCHoTHEraPy CasE formulaTion
when he had to be submissive and hide his hurt and anger, this time based 
on an implied threat of racism.
He described his father as demanding and said contact with him was 
limited. His father, an English professor, was frustrated with Mr. A’s early 
academic struggles. Mr. A recalled a terrifying incident in which his father 
chased him around a table when he was 8 because he did not know what 
certain words meant. His father grabbed him, opened the door, and was 
poised to throw him out before his mother intervened. Father and son 
remained distant over many years. He had a rapprochement with his father 
in his early 20s after his father attended a therapy course that Mr. A rec-
ommended. Mr. A reported that in his culture, people are taught to respect 
parents and that children are not supposed to complain. In general, he 
blamed himself for the problems he experienced growing up and attempted 
to compensate by being the “perfect son.”
Mr. A described his ex-wife as “feisty” and frustrated that he would 
not make more effort to defend himself. Ultimately, she had an affair and 
subsequently married that man. Additional marital stresses were created by 
control struggles with his mother, who demanded his time and attention. 
Stacy was angry that he did not set better limits with his mother, while 
his mother attacked Stacy’s behavior. Things were much better with his 
second wife, whom he had married 2 years previously. His second wife was 
estranged from her own family, contributing to her greater tolerance of the 
behavior of Mr. A’s mother.
In Session 4 the therapist provided a preliminary formulation, noting 
Mr. A’s effort to be “perfect,” including as a son and boss, always nice to 
others, with the idea that they would like him in response. In this context, 
his need to discipline people at work and to set boundaries with Stacy and 
his mother was extremely difficult for him. He felt pressured to respond to 
the demands of his bosses, ex-wife, and mother, but was also angry about 
them. He found anger to be frightening, with compelling fears and a sense 
of foreboding, which he had not recognized, about being “sent away” and 
rejected. Thus his self- and other-representations included a view of him-
self as needing to yield to others who would readily reject him. He made a 
compensatory effort to be “perfect” and was constantly disappointed and 
angry at himself for his limitations.
With this formulation in mind, the therapist continued in Sessions 6–8 
to explore Mr. A’s ongoing struggles at work to further elucidate his con-
flicts and defenses. The individual who had promoted him to be director 
of his division had left the company, and Mr. A believed the new boss com-
mitted ethical lapses. He felt pressured to do things that were inappropri-
ate. When he expressed concern, he was told he needed a “dog-eat-dog” 
attitude. Therapist and patient explored howhe blamed himself for the 
problems of his division at the same time that he recognized he was placed 
in a very difficult position.
 Panic-focused Psychodynamic Psychotherapy 81
He was told by the company leaders to put additional pressure on his 
employees to increase output. Confrontation with his employees was the 
most painful for him. He felt he was hurting others rather than supporting 
them and felt guilty. When he met with them, his stomach was tight, as if 
he were waiting for someone to punch him. The therapist identified that 
Mr. A actually felt like he was punching others. The therapist noted that 
he was likely angry that others were making unreasonable demands and 
disappointing him, but Mr. A stated he was slow to get angry. The therapist 
interpreted that he feared his anger would lead to his being rejected, as he 
felt when he was sent away as a child. Mr. A responded that he had never 
made that connection but perhaps that could be the case, as he did believe 
he had done something “bad” that led to the separations.
In Sessions 8–10, the therapist explored further the tensions with his 
mother and ex-wife. Mr. A described how he had decided not to tell his 
mother he was marrying his current wife because he believed she would 
attempt to control the wedding. When he did tell her after the marriage, she 
would not speak to him for several weeks. He described how guilty he felt 
about disappointing his mother but believed it was necessary to maintain 
adequate boundaries.
Mr. A believed his mother recurrently attempted to punish him for 
any limit setting by being withholding, triggering intense guilt and anxiety 
on the part of Mr. A. For instance, on Mother’s Day she adopted an “Oh, 
don’t bother with me . . . ” attitude that he experienced as guilt inducing, 
passive–aggressive, and manipulative. He felt he was disappointing her, 
and she would withdraw from him as a punishment, their typical struggle. 
Her withdrawal felt reminiscent to him of being sent away as a child, which 
he felt was an abandonment. He believed that somehow if he were a better 
child he would have been permitted to stay in his home. He increasingly 
recognized that he presumed that he was being punished for his angry feel-
ings. With these interpretations and recognitions, Mr. A began to feel safer 
with his anger. As he became more comfortable, he backed away from fur-
ther contact with his mother.
The link between abandonment and not doing what was expected of 
him was explored in Session 12 in another memory. At age 7, his mother 
left him a bowl of cereal and told him to eat it. When he refused, she left 
the house, locking him inside. He panicked, took a chair and smashed a 
window, and then tried to climb out, cutting himself on the broken glass. 
His mother, who was waiting just outside, had to extract him with help 
from a neighbor. Therapist and patient identified this experience as likely 
his first panic attack.
Mr. A’s panic rapidly diminished as he increasingly understood that 
his symptoms represented his anger and the associated feelings of guilt and 
fears of abandonment that he could not tolerate and made him feel like 
a frantic, silenced child, as he had when he smashed the window. Mr. A 
82 HanDbook of PsyCHoTHEraPy CasE formulaTion
could now recognize that his anger not only triggered guilt and anxiety but 
had to be repressed to be perfect and pleasing. He realized that one place 
he learned to repress anger was toward the elderly White man his mother 
cared for when he was in high school. He was angry at his abusive behavior 
but did not express it, as he sensed it would put her job at risk. In exam-
ining cultural factors relevant to the formulation, he felt in part that his 
stance was an internalized racist issue, because he and his mother needed 
to be submissive to a White man to stay safe. He also felt guilty because he 
believed that his mother was tolerating this behavior so she could afford to 
send him to college.
Defenses that he used to combat his angry feelings included denial of 
anger, as at first he had difficulty even acknowledging these feelings. In 
addition, he demonstrated the unconscious use of reaction formation, as 
he went out of his way to take care of others toward whom he should have 
been justifiably angry. Recognizing his use of these mechanisms helped to 
further his understanding of his underlying anger and abandonment fears.
In Session 14 Mr. A reported that he had become enraged at Stacy 
when he came to pick up their son. Stacy was 2 hours late, causing Mr. A 
to miss a meeting. He yelled at her, feeling provoked, and Stacy called 
the police, who arrested him. Mr. A felt guilty and complained that his 
anger was now unleashed and difficult to control. At the same time, he 
was furious at Stacy for creating potential legal problems for him. The con-
flict diminished shortly afterward, and Stacy agreed not to press charges. 
Rather than leading to an escalation of conflict, after Mr. A expressed his 
displeasure with her manipulations about visitation times, Stacy reduced 
her requests for time changes and was more on time for their handoffs.
Mr. A’s improved mentalization skills aided in modulating his anger 
and anxiety. He recognized that at work, management was desperate to 
keep the company afloat, intensifying their pressure on him. Furthermore, 
he considered Stacy’s conflicts with him as a way of maintaining a relation-
ship with him, troubled as it was. He began to be more alert to her provoca-
tions and was able to more easily avoid being drawn into conflicts.
Over Sessions 14–18, Mr. A increasingly acknowledged and tolerated 
his frustration with management, his employees, and his mother. Over 
time, his increasing recognition, comfort, and productive expression of 
angry feelings in a more modulated way helped to improve his various rela-
tionships and, at his job, further improve his panic symptoms. He told the 
leadership at his company that his group could not function properly with 
the pressure they were putting them under. To his surprise, they backed 
off these efforts to some degree, although the stress within his division 
continued.
In Session 16, as Mr. A had not brought up feelings about termination, 
the therapist asked what thoughts and feelings he had about it. Indeed, 
the end of treatment had been on Mr. A’s mind, but he had not yet said 
anything about it due to fears about having tensions with the therapist. 
 Panic-focused Psychodynamic Psychotherapy 83
Particularly, he was concerned about the time limitation of the treatment, 
worried that he would not be able to address what he needed to within the 
remaining time. These concerns were addressed over the next several ses-
sions. The therapist explored Mr. A’s worries about bringing up these feel-
ings and how they represented his being the “good patient,” believing he 
was not supposed to raise his concerns with a White man. Furthermore, he 
was worried about how the therapist would react to his fears, and to some 
extent saw the end of treatment as another episode of being “sent away.”
These concerns presented an opportunity to bring his conflicts directly 
into the transference. Mr. A responded positively to the therapist’s empa-
thy with his frustration, as the therapist identified the patient’s submissive, 
fearful reactions as part of the broader pattern of his struggles. In this 
context, Mr. A was both able to see how these dynamics operated in the 
relationship with the therapist and to feel safer with his angry feelings, 
being able to express them toward the therapist.
In Sessions 23 and 24, Mr. A expressed sadness about the end of ther-
apy, describing how he would miss these opportunities to talk about his 
feelings, but he was heartened by the progress he had made. This progress 
included his being able to assert himself more at work, with his ex-wife, 
and with his mother. He was better able to tolerate the work pressure,in 
part due to his recognition that he could not be a perfect boss or employee, 
nor was it necessary that he do so. His panic remitted and he remained 
panic free at 6-month follow-up.
The formulation was developed, modified with more information, and 
used throughout this treatment to identify contributors to and meanings 
of Mr. A’s panic. The exploration of current circumstances (work stresses, 
problems with his ex-wife) and the associated emotions he felt (guilt and 
anxiety) provided an early recognition that the attacks were not “out of the 
blue.” The developmental history indicated how fear of abandonment, the 
pressures to respond to others, and the need to be perfect generated self- 
and other-representations that led him to be vulnerable to panic in his cur-
rent circumstances. The therapist identified the intense conflicts that Mr. A 
experienced around angry feelings as potentially leading to abandonment 
and his efforts to defend against these fears by denial and reaction forma-
tion. The elaboration of his previously unconscious conflicts and defenses, 
including in the transference, enabled his fears to ease and his panic attacks 
to resolve. This work also allowed a shift in Mr. A’s experience of his inter-
personal relationships, enabling a more assertive rather than submissive 
stance at his work and with his ex-wife and mother.
LEARNING THE METHOD
Therapists of all schools can implement the treatment interventions 
described in this chapter. Therapists with training and experience in 
84 HanDbook of PsyCHoTHEraPy CasE formulaTion
non-exposure-based psychotherapies may be able to learn PFPP more eas-
ily, as it is an affect-focused psychotherapy that does not utilize exposure-
based interventions. A crucial skill in any affect-focused therapy is devel-
oping the ability to respond to a patient’s negative affect in an empathic 
but nondirective manner (Markowitz & Milrod, 2011). Of the suggested 
approaches using the formulation, interventions identifying the context 
and feelings surrounding panic attacks are readily accessible to clini-
cians not familiar with psychodynamic psychotherapy. Therapists embark 
on this therapy recognizing that they will be able to make sense of the 
patient’s inchoate experiences. Explorations identifying the relevance of 
the patient’s developmental history to their current symptom picture rep-
resent an extension of typical clinical evaluation approaches. For a more 
in-depth understanding of psychodynamic approaches and the psycho-
dynamic formulation in general, specialized training at a psychoanalytic 
institute and/or psychodynamic psychotherapy training program is valu-
able. This general background training will aid therapists in elaborating 
self- and other-representations, conflicts and defenses, mentalization skills, 
and implementing techniques such as clarification and interpretation. This 
being said, many of our effective PFPP therapists thus far in our studies, 
and in those of others, have not had any formal psychodynamic training, 
although all of them identify as primarily affect-focused therapists.
Additionally, clinicians readily familiar with and trained in psychody-
namic psychotherapeutic approaches need to adapt these more open-ended 
methods to focus on specific symptoms, rather than using more traditional, 
open-ended, generalized approaches. A specialized 2-day therapist training 
program that we developed is implemented for learning how to use psycho-
dynamic psychotherapy in a focused manner in PFPP. Supervision of cases 
is necessary to master how to develop the formulations and treatment most 
effectively.
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88
4
Plan Formulation Method
John T. Curtis
George silberschatz
HISTORICAL BACKGROUND OF THE APPROACH
For more than 40 years, the San Francisco Psychotherapy Research Group 
(SFPRG; formerly known as the Mount Zion Psychotherapy Research 
Group) has conducted studies of psychoanalysis, psychodynamic psycho-
therapy, and time-limited psychotherapies (for an overview of this research, 
see Silberschatz, 2005b, 2017b). One primary focus of this enterprise has 
been to study the role of the analyst or therapist in the process of treat-
ment. Specifically, the group has tried to identify what it is that a therapist 
does that leads to patient improvement, stagnation, or deterioration in the 
course of treatment. In a variety of studies, the SFPRG has tested the broad 
hypothesis that when a therapist responds in accordance with a patient’s 
goals for therapy, the patient will show immediate improvement in the 
process of the treatment, and that this improvement will translate into an 
overall positive therapy outcome. Of course, this hypothesis is deceptively 
simple, for how does one identify, operationalize, and respond appropri-
ately to a patient’s goals for therapy? In clinical practice, a case formulation 
is usually implicitly or explicitly developed by the therapist to understand 
the meaning of an individual patient’s problems, to evaluate the appro-
priateness of therapeutic interventions, and to measure response to treat-
ment (see Perry, Cooper, & Michels, 1987). Formulations not only identify 
a patient’s manifest and latent problems but also the patient’s stated and 
unstated goals for therapy, possible obstacles and resistances to achiev-
ing these goals, and how the patient is likely to work in therapy to solve 
 Plan formulation method 89
the problems. To keep their research as clinically relevant as possible, the 
SFPRG decided to employ individual case formulations in studies of the 
process and outcome of psychotherapy. However, in order to employ clini-
cal formulations, the research group had to address the problem of getting 
therapists to agree among themselves, an issue that had bedeviled research-
ers for years (DeWitt, Kaltreider, Weiss, & Horowitz, 1983; Seitz, 1966).
Joe Caston, a member of the research group, did the groundbreaking 
work in this area, developing the plan diagnosis method (PDM; Caston, 
1977, 1986), the precursor to the plan formulation method (PFM). The 
PDM has been employed in studies of psychoanalyses and of time-limited 
psychodynamic psychotherapies to develop formulations. Although the 
PDM has proven to be very reliable (Caston, 1986; Curtis, Silberschatz, 
Sampson, Weiss, & Rosenberg, 1988; Rosenberg, Silberschatz, Curtis,Sampson, & Weiss, 1986), it needed to be modified to ensure the indepen-
dence of judges and to tighten the procedures for developing the items upon 
which the final formulation is developed (see Curtis et al., 1988, for a more 
complete description of the PDM and Curtis & Silberschatz, 1997, for a 
discussion of the problems with this method). A new procedure, the PFM 
(Curtis & Silberschatz, 1997; Curtis, Silberschatz, Sampson, & Weiss, 
1994) was thus developed. Recently, the PFM has been modified to include 
an “integration rubric” that ties the different components of a formulation 
together in a narrative format (see Figure 4.1 later in the chapter).
The PFM does not constitute a new method for formulating a case. 
Indeed, the components of a plan formulation and the processes involved in 
developing it are common to many approaches to psychotherapy case formu-
lation. Although originally developed to study the control-mastery theory 
of psychotherapy (Weiss, 1986, 1993), it is transtheoretical and has been 
employed in studies of other theories of therapy (e.g., Collins & Messer, 
1988, 1991; Persons, Curtis, & Silberschatz, 1991). The PFM requires that 
therapists review and evaluate clinical material to determine what is relevant 
and necessary for understanding a particular case and developing a treatment 
plan. The PFM is unique because it allows therapists who share a common 
theoretical orientation to develop a reliable comprehensive case formulation.
The PFM identifies a patient’s conscious and unconscious goals, the 
conflicts and inhibitions that inhibit or prevent the patient from pursuing 
or attaining these goals, the source(s) of these conflicts and inhibitions, 
information that might be helpful to the patient in understanding and over-
coming his/her conflicts, and behaviors or interventions on the part of the 
therapist that will be helpful. The PFM may differ from other approaches in 
one basic assumption: that an accurate formulation of an individual patient 
can often be developed quite early in the therapy. Indeed, for research pur-
poses (e.g., predicting patient responses to interventions across the course 
of a therapy), plan formulations have been developed on as little as a single 
intake interview. In clinical use, the therapist is well served by trying to 
90 HanDbook of PsyCHoTHEraPy CasE formulaTion
formulate a patient’s plan as early in the therapy as possible. However, 
unlike formulations developed for research purposes, when used by a thera-
pist, the plan formulation is not a static creation set in stone early in the 
therapy. Rather, it is a working hypothesis that is constantly evaluated and 
fine-tuned based upon such factors as the patient’s responses to interven-
tions and the emergence of new history.
CONCEPTUAL FRAMEWORK
As noted previously, both the PFM and the earlier PDM were developed 
in order to study a cognitive psychoanalytic theory of therapy (control-
mastery theory) developed by Joseph Weiss (Weiss, 1986, 1993; see also 
Gazzillo, 2016; Silberschatz, 2005a, 2017a). The control-mastery theory 
holds that psychopathology stems largely from pathogenic beliefs that, in 
turn, develop out of traumatic experiences usually occurring in childhood. 
Pathogenic beliefs are frightening and constricting because they suggest 
that the pursuit of certain goals will endanger oneself and/or someone else. 
Consequently, an individual is highly motivated to change or disconfirm 
these beliefs in order to pursue his/her goals. Irrational beliefs in one’s 
power to hurt others, excessive fears of retaliation, feelings of unworthi-
ness, and exaggerated expectations of being overwhelmed by feelings such 
as anger and fear are all examples of beliefs that can act as obstructions to 
the pursuit or attainment of goals.
In therapy, the patient uses the relationship with the therapist to 
attempt to disconfirm pathogenic beliefs. The therapist’s function is to 
help the patient understand the nature and ramifications of the pathogenic 
beliefs by interpretation and by allowing the patient to test these beliefs in 
the therapeutic relationship. The manner in which an individual will work 
in psychotherapy to disconfirm pathogenic beliefs, overcome problems, and 
achieve goals is called the patient’s “plan.” The plan is not a rigid scheme 
that the patient will invariably follow; rather, it comprises general areas 
that the patient will want to work on and how the patient is likely to carry 
out this work (see Weiss, 1986, 1993, for a thorough description of the the-
ory; also see Curtis & Silberschatz, 1986; Gazzillo, Genova, et al., 2019; 
Silberschatz & Curtis, 1986; and Silberschatz, 2005c, for further discus-
sion of the applications of the theory to clinical phenomena). Formulations 
developed according to Weiss’s theory have five component parts: (1) the 
patient’s goals for therapy, (2) the obstructions (pathogenic beliefs) that 
inhibit the patient from pursuing or achieving these goals, (3) the events 
and experiences (traumas) that led to the development of the obstructions, 
(4) the insights that will help the patient achieve therapy goals, and (5) the 
manner in which the patient will work in therapy to overcome the obstacles 
and achieve the goals (tests).
 Plan formulation method 91
MULTICULTURAL CONSIDERATIONS
To formulate an individual patient’s pathogenic beliefs and therapy goals, 
the therapist (or, in a research context, the formulating team) must consider 
the cultural and ethnic background of the patient (see, e.g., Bracero, 1994). 
One’s beliefs are shaped by the meanings attributed to experience(s), and 
the meaning of these experiences is shaped in some measure by the fam-
ily, as well as by the cultural environment. For example, at a very basic 
level, a child who grows up with boisterous, emotionally labile parents may 
respond differently (and attribute different meaning) to a parent’s emo-
tional outburst than will a child whose parents are typically quiet and 
undemonstrative. Similarly, a child who grows up in a culture that values 
and promotes filial respect and intergenerational dependency may develop 
markedly different beliefs (and different life goals) from a child raised in a 
culture that promotes independence and autonomy. However, by the same 
token, it is important not to assume that one’s cultural or ethnic back-
ground solely dictates the nature of that individual’s pathogenic beliefs or 
his/her goals. A plan formulation is case specific and, to be accurate, must 
be developed with an appreciation of cultural and ethnic differences but 
without preconceptions as to what the patient’s beliefs and goals are or 
should be. Thus it is important to understand what experiences were trau-
matic for the individual and why—and what beliefs developed out of these 
experiences.
A plan formulation can be developed for all individuals suffering 
from psychogenic psychopathology. For research purposes, the PFM has 
been applied to children (Foreman, 1989; Gibbins, 1989), adolescents, 
and adults of all ages (Curtis et al., 1994), including geriatric cases (see 
Silberschatz & Curtis, 1991). In addition, the PFM has been employed 
in psychobiographical research (Conrad, 1995) and in the study of fam-
ily and couples therapy (Bigalke, 2004; Rodomonti, Crisafulli, Mazzoni, 
Curtis, & Gazzillo, 2020). The majority of cases we have formulated in 
our research program have received DSM-III-R Axis I diagnoses of dysthy-
mia or generalized anxiety disorder, frequently accompanied by an Axis II 
Cluster C personality disorder (American Psychiatric Association, 1987). 
The cases have displayed mild to severe symptomatology, with moderate to 
catastrophic psychosocial stresses.
EVIDENCE BASE SUPPORTING THE METHOD
We have obtained excellent reliabilities applying the PFM to long- and 
short-term therapies from different settings (research programs, private 
practice, and hospital and university clinics) treated under differingtheo-
retical models (including psychodynamic psychotherapy, psychoanalysis, 
92 HanDbook of PsyCHoTHEraPy CasE formulaTion
interpersonal psychotherapy, and cognitive-behavioral therapy) (Curtis et 
al., 1994; see also Persons, Curtis, & Silberschatz, 1991; Silberschatz, Cur-
tis, Persons, & Safran, 1989). Across six cases reported elsewhere (Curtis et 
al., 1994), coefficient alpha (Shrout & Fleiss, 1979) averaged the following: 
goals, .90; obstructions, .84; tests, .85; insights, .90.
Other investigators have used the PFM with good reliability. Collins 
and Messer (1988, 1991) employed the PFM and obtained good interjudge 
reliabilities among their judges, who were generally less clinically experi-
enced than the typical judges used by our research group. We have found 
no significant differences between ratings of judges who have had previous 
experience with the PFM and those who have not, nor have we found level 
of clinical experience to be a barrier to learning this method (Curtis et al., 
1994).
The validity of the PFM has been tested in studies in which formula-
tions have been used to measure the impact of therapist interventions (Fret-
ter, 1984; Norville, 1989; Silberschatz, 1978, 1986; Silberschatz & Curtis, 
1993; Silberschatz, Fretter, & Curtis, 1986; see also Silberschatz, 2005b, 
for an overview of this research) and patient progress in psychotherapy 
(Nathans, 1988; Silberschatz, 2017b; Silberschatz, Curtis, & Nathans, 
1989). For instance, in several studies we have demonstrated that the 
“accuracy” of therapist interventions (defined as the degree of adherence 
of the interpretation to the individual patient’s plan formulation) predicts 
subsequent patient progress in therapy (Broitman, 1985; Fretter, 1984; Sil-
berschatz, 1986; Silberschatz & Curtis, 1993; Silberschatz, Curtis, Fretter, 
& Kelly, 1988; Silberschatz, Curtis, Persons, & Safran, 1989; Silberschatz 
et al., 1986; see also Bush & Gassner, 1986) and at outcome (Silberschatz, 
2017b). In preliminary studies, we have also shown that a case-specific out-
come measure, plan attainment, that rates the degree to which a patient has 
achieved the goals and insights and overcome the obstacles identified in his/
her plan formulation correlates highly with other standardized outcome 
measures and is a good predictor of patient functioning at post-therapy 
follow-up (Nathans, 1988; Silberschatz et al., 1989). These studies support 
the hypothesis that the plan formulation identifies important factors that 
influence the nature and maintenance of a patient’s psychopathology. The 
clinical relevance of these findings is reflected in the fact that, when thera-
pists respond in accordance with a patient’s plan, it leads to improvement 
both in the process and in the outcome.
STEPS IN CASE FORMULATION CONSTRUCTION
As noted above, a plan formulation developed for clinical use may be char-
acterized as a working hypothesis (or set of hypotheses) that is constantly 
being evaluated for its accuracy by the therapist. The therapist carefully 
 Plan formulation method 93
monitors the patient’s responses to interventions to determine whether they 
are in accordance with what is predicted by the formulation. If not, the 
formulation should be modified accordingly. A formulation may also be 
altered or elaborated based upon new data (e.g., memories, transference 
patterns) that emerge in the course of therapy. Indeed, just as the patient’s 
“task” or “work” in therapy entails testing his/her pathogenic beliefs, 
the therapist’s task is to test the accuracy of the formulation based on the 
patient’s responses to interventions.
In contrast, plan formulations developed for research purposes are 
based solely on transcripts of early therapy hours, with no additional infor-
mation (e.g., concerning the subsequent treatment or outcome) included. By 
restricting the data from which they are developed, these formulations can 
then be used, for example, to predict a patient’s response to a therapist’s 
intervention in the later hours of the therapy (e.g., Silberschatz, 1986; Sil-
berschatz & Curtis, 1993; Silberschatz et al., 1986). For a brief therapy, we 
ordinarily use an intake interview and the first 2 therapy hours of the case; 
for the study of a psychoanalysis, we usually employ the intake and first 
10 hours of treatment. However, we have reliably formulated individual 
psychotherapy cases based on as little as one interview (Curtis et al., 1994; 
Perry, Luborsky, Silberschatz, & Popp, 1989) and a family therapy case on 
the first two therapy sessions (Bigalke, 2004).
For our research, we typically use three or four clinical judges. The 
judges are all experienced with and adhere to Weiss’s control-mastery the-
ory of psychotherapy. We have used judges with widely varying degrees of 
clinical experience and of experience applying the theory to therapy (Curtis 
et al., 1994).
The PFM involves six steps:
1. Clinical judges are given transcripts of the early hours of a therapy, 
along with the PFM Manual–Step 1 (see www.sfprg.org/clinical_tools), 
which includes instructions for how to review the clinical material, precise 
definitions and examples of each of the components (goals, obstructions, 
tests, insights, and key traumas) of the formulation, and instructions for 
how the individual component items are to be written.
The clinical judges independently review the transcripts of the therapy 
hours, and each develops a formulation for the case. Each judge then creates 
lists of “real” and “alternative” goals, obstructions, traumas, insights, and 
tests for the case. “Real” items are those the judge believes are relevant to 
the case, and “alternative” items are those the judge thinks reasonable for 
the case but of lesser relevance (e.g., items of which they are unsure or items 
that they at one point thought were highly relevant but ultimately decided 
were of lesser relevance). The inclusion of “alternative” items is designed to 
cast as wide a net as possible in creating components. These “alternative” 
items are not simply “straw men” that can be readily discounted. Indeed, 
94 HanDbook of PsyCHoTHEraPy CasE formulaTion
these items are sometimes given high ratings by other judges. The judges do 
not identify which items they think are “real” or “alternative.”
All items in a plan formulation are written in a standard format to 
facilitate comparison between items and to help disguise which judge cre-
ated which item. In addition, this requirement results in more precise items 
that fit the definitions for the various components.
2. The judges’ lists are combined into master lists of traumas, goals, 
obstructions, tests, and insights, respectively. In the master lists, the authors 
of the items are not identified, and the items developed by any given judge 
are randomly distributed within the appropriate list.
3. The master lists of items are given to the original judges with 
instructions for how to rate the items and definitions of them (see PFM 
Manual–Step 2, www.sfprg.org/clinical_tools). The judges independently 
rate the items (goals, obstructions, trauma, insights, and tests) on a 5-point 
Likert scale for their relevance to the case (0 = not relevant; 1 = slightly 
relevant; 2 = moderately relevant; 3 = highly relevant; 4 = very highly rel-
evant).
4. When all the judges have completed their ratings, the level of agree-
ment of their ratings is calculated. Because different formulations are devel-
oped for each case, there tends to be relatively little overlap of items across 
cases. Consequently, reliability is measured for each of the five plan compo-
nents (goals, obstructions, tests, insights, traumas) for each case by calcu-
lating an intraclass correlation for pooled judges’ ratings (Shrout & Fleiss, 
1979). Two figures are calculated: the estimated reliability of the average 
judge (r(1)—referred to by Shrout & Fleiss as ICC 3,1) and coefficient alpha, 
the estimated reliability of K judges’ratings (r(K)—referred to by Shrout & 
Fleiss as ICC 3,K).
5. After determining reliability, items rated as being of lesser relevance 
to the case are dropped from the lists. This is done by taking the mean 
of judges’ ratings per item, determining the median of the mean item rat-
ings per category (goals, obstructions, etc.), and then dropping all items 
within each category that fall below the median rating for that category. In 
our experience, this is a conservative criterion; the final items usually have 
received mean ratings falling at or above the “highly relevant” range. As 
each plan formulation is case-specific, the number of goals, obstructions, 
tests, insights, and traumas identified varies from case to case; there is no 
optimal number of these items.
6. In the next step in the formulation process (PFM Manual–Step 3, 
www.sfprg.org/clinical_tools), the lists of relevant items are distributed to 
 Plan formulation method 95
the judges with instructions for them, working independently, to eliminate 
redundancies and to note the relationships between the different compo-
nents that have been reliably identified for the case. To eliminate redundan-
cies, the judges simply identify which items seem similar and then delete all 
but one of them from the list(s). Then, to describe the interrelationships of 
the components, each of the components is attached to one or more “inte-
gration rubric(s).”
For example, each trauma is associated with one or more pathogenic 
belief, goal, insight, and test (see PFM Manual–Step 1 for definitions and 
examples of each of the components, and see PFM Manual—Step 3 for an 
example of an integration rubric). The integration step both ensures the 
interrelatedness of all of the items created for the case and presents the 
items in a narrative format (as contrasted with lists of individual items). 
Finally, if a judge identifies a component that does not seem to fit in any 
schematic, that item is eliminated. Clinicians may vary on how they orient 
the rubrics they create. For instance, some may focus on goals and build 
their rubrics around them; others may start with obstructions or trauma. 
Cases may also vary as to what focus they “pull” for. Although judges 
invariably differ in how they combine items in the rubrics, their final prod-
ucts are all variations on consistent themes.
 
 
GOAL(S) 
 
 
 
 
 
 
 
 Transference 
 
TEST(S) PATHOGENIC BELIEF(S) INSIGHT(S) 
 
 Passive-into-Active 
 
 
 
 
 
 
 
TRAUMA(S) 
FIGURE 4.1. Integration rubric.
96 HanDbook of PsyCHoTHEraPy CasE formulaTion
The final plan formulation is cast in the following format: There is a 
description of the patient and of the patient’s current life circumstances, and 
a narrative of the patient’s presenting complaints, and a brief history. Then 
each schematic is written as a paragraph, integrating all the components into 
a comprehensible narrative (see the case example later in the chapter).
The process for developing a plan formulation for clinical use is essen-
tially the same as that employed to develop formulations for research. Of 
course, Step 2 is eliminated, as the clinician typically is formulating alone 
and not interested in determining reliability. We believe that clinicians can 
benefit from using Step 1 of the PFM when formulating their own cases, 
especially as following the instructions can sharpen the clinician’s use of 
concepts and assist in avoiding sloppy thinking. Completing the integration 
rubric(s) in Step 3 can identify areas that may require further exploration or 
attention as well as lacunae in a formulation that may require re-evaluating 
one’s clinical impressions.
TREATMENT PLANNING AND PRACTICE
A basic assumption behind the development of a plan formulation is that 
a clinician cannot and should not proceed to treat a patient without an 
understanding of that individual’s true goals for therapy and the conflicts 
that have inhibited the patient from obtaining those goals. As with all for-
mulations, the plan formulation contains the clinician’s understanding of the 
causes and manifestations of the patient’s symptoms and conflicts. Accord-
ing to the control-mastery theory, the causes can be discerned from the trau-
mas that the individual has experienced (Curtis & Silberschatz, 2005; Silber-
schatz, 2005a; Weiss, 1986, 1993). The identification of traumas can alert 
the therapist to potential issues in the therapy, in particular to pathogenic 
beliefs that suggest the pursuit or attainment of goals will endanger oneself 
and/or others. For instance, individuals who have experienced neglect and 
abandonment are likely to work on issues of basic trust and worthiness, as 
manifested in beliefs that they lack self-worth and should not trust others 
(Silberschatz & Curtis, 1991; Weiss, 1993). Similarly, a patient who comes 
from a family in which members experienced significant losses or disabili-
ties might have survival guilt stemming from pathogenic beliefs that having 
personal success in life would hurt others (Bush, 2005). Thus an aware-
ness of the traumas experienced by a patient can alert the therapist to the 
obstructions, or pathogenic beliefs, that that individual will want to work 
on in therapy. An understanding of the patient’s pathogenic beliefs can often 
clarify the patient’s true goals for therapy, as well as the meaning and ori-
gins of symptoms. Without a formulation, the therapist cannot determine 
whether the patient’s stated goals represent true treatment goals or compro-
mises (i.e., less ambitious goals) or even false goals (e.g., when guilt about 
true goals leads a patient to present with goals that may even be the opposite 
 Plan formulation method 97
of their real aspirations; see Curtis & Silberschatz, 1986, 2005). Although 
a plan formulation usually identifies a number of goals that a patient might 
want to work on in therapy, it is the patient, not the therapist, who deter-
mines the focus of the treatment. A basic premise of the plan formulation 
and its application is that the formulation identifies the patient’s plan in 
order to assist the therapist in helping the patient to enact that plan. In other 
words, it helps the therapist follow the patient, not lead the treatment.
Identifying the traumas endured by a patient and the consequent patho-
genic beliefs that developed can be essential to understanding the meaning of 
a patient’s behaviors. Such an understanding enables the therapist to respond 
to these behaviors appropriately. A good illustration is a patient who tests the 
therapist by turning from passive into active—that is, a patient who has been 
traumatized by the behaviors of others enacts similar behaviors with the 
therapist. For example, a patient who was repeatedly browbeaten by a par-
ent may be critical and argumentative with the therapist as part of an effort 
to master this childhood trauma (see Weiss, 1993, and Silberschatz, 2005a, 
2017a, for a thorough explanation of testing). At such times, the patient may 
appear to be resisting or even sabotaging the treatment. However, an under-
standing of the patient’s pathogenic beliefs and of the manner in which these 
beliefs might be tested in the therapy can assist the therapist in seeing these 
behaviors for what they really are: the patient’s active attempts to work on 
and master a problem by literally bringing it into the therapy.
On a broader level, the case formulation can help the therapist to deter-
mine what degree of activity on the part of the therapist will be appropriate 
and helpful to the patient. For example, a patient who was traumatized 
by intrusive parents may feel similarly traumatized—or, minimally, have 
important tests failed—by an active therapist. On the other hand, a passive, 
“neutral” therapist might traumatize a patient who has experienced neglect 
or abandonment. Finally, a formulation is necessary to evaluate the prog-
ress of the therapy.Without clear-cut goals and a sense of what must tran-
spire for the patient to achieve them, the therapist cannot assess progress, 
and the therapy is likely to falter. When the therapy is not going according 
to the formulation, it suggests either that the therapist is not using the for-
mulation appropriately or that the formulation is wrong and needs to be 
revised. Patients do not change their basic plans. They may change how 
they go about trying to achieve their plans—for example, they may try new 
testing strategies if the therapist consistently fails certain types of tests or 
work on different goals if the therapy does not help them progress in cer-
tain arenas (see Bugas & Silberschatz, 2005; Curtis & Silberschatz, 1986). 
However, these may be seen as shifts in focus, not a change in the patient’s 
overall plan. (See Curtis & Silberschatz, 1986, 1997; Silberschatz, 2005a; 
Silberschatz & Curtis, 1986, 1991; Weiss, 1986, 1993, for more through 
discussions of how the plan formulation is used in psychotherapy.)
Should the therapist share the formulation with a patient? In a sense, 
the course of therapy may be seen as the unfolding and explication of a 
98 HanDbook of PsyCHoTHEraPy CasE formulaTion
patient’s plan. However, how and when this is done can be tricky. It may 
take time for the therapist to feel confident with a formulation, for, as 
noted above, the therapist is also, in a sense, testing the formulation in the 
course of the therapy. Certainly, sharing an inaccurate formulation with a 
patient would be problematic. Sharing an accurate formulation can also be 
troublesome if, for example, doing so discourages the patient’s testing and/
or identifies unconscious conflicts of which the patient is not yet aware or 
ready to consider. Thus questions about when and how to share the formu-
lation with a patient are best answered by considering what the formula-
tion suggests about how the patient is likely to hear and respond to both 
the words and the therapist’s actions (for a detailed clinical illustration, see 
Bloomberg-Fretter, 2005).
CASE EXAMPLE
The following case is drawn from our ongoing research on the process 
and outcome of time-limited psychodynamic psychotherapy (Silberschatz, 
Curtis, Sampson, & Weiss, 1991). The patient, Rene, was referred to the 
research project by a senior citizen medical screening clinic. She felt anx-
ious and depressed about her job and her relationships with her coworkers 
and grown children. Her social life was constricted, and she was unable to 
enjoy life outside of work. Rene initially met with an independent evalua-
tor to complete various clinical rating forms and for an intake interview 
to determine her appropriateness for time-limited therapy. She was then 
referred to a therapist for a 16-session treatment. The therapist, a 32-year-
old White male psychologist, was not privy to the information collected in 
the intake. He was instructed to carry out the treatment as he would with 
a patient in his private practice.
The plan formulation for Rene presented below is not that of the 
therapist—though it is quite similar to and consistent with the therapist’s 
formulation of the case. This formulation was developed more than 35 
years after the termination of therapy by a team of five clinicians based 
upon written transcripts of the intake interview (with the independent 
evaluator) and the first 2 therapy hours. The formulating clinicians knew 
nothing about what happened in the later hours of the case, nor about the 
outcome. They were also blind as to the identity of the therapist.
Plan Formulation for Rene
Presenting Complaints
Rene was a 60-year-old Hispanic widow who lived by herself. She had 
three grown daughters, all married and living away from home. Her young-
est daughter suffered from debilitating bipolar disorder and frequently 
 Plan formulation method 99
approached Rene for financial and emotional support for her and her 
daughter (Rene’s granddaughter). Rene was employed as a systems analyst 
for a large corporation.
Rene’s presenting complaints included dissatisfaction in her work-
place. She had been quite successful in her career and was in a managerial 
position; however, she felt she had been passed over for a promotion and 
questioned whether she was the victim of sexism and racism at her job. She 
worked many more hours than she was paid for, often going to the job on 
weekends and holidays, and she found herself at loose ends and unable to 
enjoy herself outside of work. For instance, she had recently gone to a resort 
for a vacation, but, once there, felt compelled to return home and check on 
her children. She described her relationships with her three daughters as 
being unstable and fraught with misunderstandings. Her older two daugh-
ters seemed to want little to do with her, and her youngest daughter was a 
constant source of worry due to her frequent psychotic episodes and chaotic 
and unstable lifestyle.
Brief History
Rene grew up in the desert of the southwestern United States. Her family 
was impoverished and lived in a rural three-room house. Rene described 
her father as a chronically unemployed, womanizing ne’er-do-well who was 
rarely at home and provided no emotional or financial support to the fam-
ily. Rene’s mother was “wonderful,” but Rene never felt close to her because 
she was always busy taking care of her husband and the nine children in 
the household (five were younger siblings of her parents and the remainder 
were offspring of this union; Rene was the second born). Rene recalled a 
household scene from growing up in which her mother, who suffered from 
varicose veins, was hopping around on one foot, attending to the needs of 
Rene’s able-bodied but indolent father. Rene’s mother died when she was 45 
years old “of old age.” Her father lived until Rene was in her late 50s.
Although generally uninvolved with the family, Rene’s father favored 
his first son and one of Rene’s sisters, who had blond hair and was fair-
skinned. In contrast, Rene had dark skin and hair and felt that her father 
was prejudiced against her. The family was poor, and all of the children 
were expected to work and give their money to the father. Rene was a good 
student and graduated from high school at 15 years of age. Though she was 
given a college scholarship, she was unable to attend because of financial 
pressures (she was still expected to contribute to the household). Instead, she 
developed secretarial skills and did clerical work until she moved away from 
home at age 21 years. She joined the armed services and received training 
in computer sciences. While in the service, she met her husband, and they 
subsequently married. Though she described it as a successful union, she 
also reported that her husband demanded that she do his bidding and that 
she not be independent. They had three children before he died of cancer.
100 HanDbook of PsyCHoTHEraPy CasE formulaTion
Plan Formulation for Rene
A formulation for Rene was developed using the methods described above. 
Using five judges, excellent reliabilities (coefficient alpha; Shrout & Fleiss, 
1979) were obtained for each of the components of the formulation: Goals, 
.86; Obstructions, .74; Tests, .83; Insights, .62; Traumas, .74. The individual 
items of each of the components were incorporated into “integration rubrics” 
by each of the judges. The plan formulation for Rene that follows is presented 
as three rubrics that are oriented around the goals identified for her.1
Enjoying Life
Rene would like to feel entitled to the things she has earned (G). She would 
like to enjoy herself more (G), to pursue her interests and pleasures (G), 
and to devote time and money toward her own leisure/enjoyment (G). Rene 
grew up watching her mother lead a long-suffering, self-sacrificing life 
devoted to work and taking care of others. Consequently, out of loyalty to 
her mother, she believes she too must devote her life to work andtaking 
care of others (e.g., her children; Tr). Rene’s family experienced many losses 
and lived in sustained financial insecurity. Consequently, she has difficulty 
spending money and time for her own enjoyment, believing that to do so 
would threaten her family (e.g., survivor guilt; Tr). Rene provides for others 
at her own expense because she believes she should be self-sacrificing like 
her mother (O), and she keeps herself from having fun because she believes 
it is a betrayal of her long-suffering mother (O). She does not pursue things 
she might enjoy because she believes she does not deserve to enjoy life (O). 
To test these beliefs, Rene may cautiously describe experiences of personal 
enjoyment to see whether the therapist will support her in feeling deserving 
of these experiences (TT). She may talk about going out with friends or 
attending social gatherings to see whether the therapist disapproves of her 
pursuing her own interests and desires (TT). She may place her own needs 
above others—especially her children—to see if the therapist disapproves 
(TT). Rene may make demands on the therapist (e.g., scheduling changes) 
to work on her belief that she is not entitled to have or express her needs to 
others (TT). Insights that would help Rene pursue her goals include becom-
ing aware that she works excessively out of identification with her mother 
(I) and that she limits her experience of pleasure because she would feel 
guilty having greater enjoyment than her parents did (I).
Work
Rene would like to recognize and appreciate her intellect and competence 
(G) and to feel comfortable displaying her competence around others (G). 
She would like to assert and advocate for herself at work (G), to be less 
 Plan formulation method 101
stressed at work (G), and to be respected at work (G). Rene’s talents and 
abilities were discounted by her father. Consequently, she does not believe 
she really is talented, despite evidence to the contrary (Tr). Rene’s siblings 
competed for limited attention, and Rene humiliated her older sister by 
surpassing her in school. Consequently, Rene believes that expressing her 
abilities and being competent would be threatening or diminishing to 
others (Tr). Rene’s family was large and impoverished, and she was pres-
sured to work to help support her younger siblings. She became extremely 
self-sacrificing (giving up a university scholarship) out of the belief that to 
pursue her own interests would be selfish and neglectful of her family’s 
needs (Tr). She discounts her talents and abilities because she believes she 
does not deserve to be successful (O). Rene avoids competing with others 
because she believes she will hurt or humiliate her competitors if she wins 
(O). She hides her skills and accomplishments because she believes others 
will feel put down by them (O). She holds herself back from presenting 
competing ideas to her manager because she believes it would devastate 
him (O). She does not pursue opportunities because she feels guilty about 
surpassing others, especially men (O). Rene keeps herself from looking for 
a better job because she believes she does not deserve one (O). She may test 
these beliefs either by denigrating her skills and capabilities to see whether 
the therapist needs her to be weak and ineffectual (TT) or, on the other 
hand, displaying her competence to see whether the therapist is challenged 
or has to put her down (TT). She may also test these beliefs by express-
ing excessive pride in her abilities to see whether the therapist is upset or 
threatened by these expressions (TT). She may exaggerate her ambitions to 
see whether the therapist is put off by or disapproving of them (TT), or, at 
the other extreme, she may question her intellect and competence to work 
on the belief that she does not deserve recognition (TT). She might express 
her own ideas and insights about her problems to see whether the therapist 
is upset by her independent formulations (TT). She may make fun of and 
put down her managers during therapy to test the belief that she does not 
have the right to be critical of others (TT). Insights that would be help-
ful for Rene include that she is deserving of success (I) and that she holds 
herself back from boldly expressing herself because she falsely believes it 
would harm or distress others (I). For instance, she holds herself back from 
asserting/advocating for herself at work so as not to hurt/threaten her boss 
(I). She plays down her strengths because she falsely believes others cannot 
tolerate her being strong (I), and she questions her competence because she 
feels guilty about surpassing others (e.g., weak men, envious sister) (I).
Relationships
Rene would like to feel more deserving of others’ admiration and caring 
(e.g., with a man, at work) (G), to be able to ask more from others (G), and 
102 HanDbook of PsyCHoTHEraPy CasE formulaTion
to be able to make friends (G). Rene got very little affection or attention 
from either parent; her mother was too busy taking care of her demanding 
husband and her many children, and her father clearly preferred his blond-
haired daughters who did not look Hispanic. Consequently, Rene feels 
undeserving and thinks that people will not like her (Tr). Rene’s father was 
extremely narcissistic, yet incompetent. Consequently, she became passive 
and self-deprecating, believing that self-assertion and competence would 
threaten others as it did her father (Tr). Rene sees her father as weak—a 
failure in both love and work. Consequently, she believes men in general 
are weak and cannot tolerate her being strong, bold, and independent (Tr). 
Her mother was excessively loyal and obedient to her father. Consequently, 
Rene believes she has to be loyal and subservient to males (especially boy-
friends and bosses) (Tr). Rene saw how unhappy and dysfunctional her 
parents’ marriage was. As a result, she believes, out of loyalty to them, 
that she does not have the right to have a good relationship with a man 
(Tr). Because of these experiences, Rene chooses and stays with partners 
who are unavailable because she believes that she is not entitled to indi-
vidual care and attention (O). She is overly compliant to others’ demands 
because she believes that to assert her own needs or wishes would upset 
others (O). Rene has not pursued relationships with worthy men because 
she believes she should be self-sacrificing and obsequious like her mother 
(O). She prioritizes others’ needs and interests because she believes that to 
pursue her own interests would be selfish and neglectful of others’ needs 
(O). Rene may test these beliefs by expressing excessive pride in her abili-
ties to see whether the therapist is upset or threatened by these expressions 
(TT). She may make demands on the therapist (e.g., scheduling changes) 
to work on her belief that she is not entitled to have or express her needs 
to others (TT). She may propose ending therapy or otherwise attempt to 
withdraw to test whether the therapist will see her as deserving (TT). Rene 
may cautiously describe experiences of personal enjoyment to see whether 
the therapist will support her in feeling deserving of these experiences (TT). 
Rene will talk about going out with friends or attending social gatherings 
to see whether the therapist disapproves of her pursuing her own interests 
and desires (TT). Insights that may be helpful to Rene include becoming 
aware that she is deferential to others out of identification with her mother 
(I), that her feeling undeserving is in compliance with how she was treated 
growing up (I), that she has kept herself from having an enjoyable intimate 
relationship with a man out of loyalty to her parents (I), and that she has 
kept herself from developing an enjoyable social life out of loyalty to her 
long-suffering mother (I).
Application of the Formulation to the Treatment of Rene
As noted earlier, a plan formulation identifies goals a patient may wantto 
pursue, but it is the patient, not the therapist, who determines which goal(s) 
 Plan formulation method 103
to pursue and how to work on them in the therapy. Over the course of her 
therapy, Rene focused on three broad, interrelated families of goals: feeling 
less burdened by and responsible for others, especially her grown children; 
allowing herself to pursue pleasure and enjoyment in her life; and recogniz-
ing her competence at her job and feeling less oppressed and burdened by 
work.
Over the first 3 hours of the 16-session therapy, Rene discussed her 
reasons for seeking therapy. She described the difficulties she had allowing 
herself to have fun and to enjoy herself. At times she would say that she 
did not know what she would enjoy doing; at others, she would identify 
a potentially enjoyable activity but then give reasons why she could not 
pursue it or why she would likely not enjoy it if she did. Rene also talked 
about her daughters and the issues she had with them. Essentially, she felt 
that they all disapproved of her in varying ways—according to them, she 
was either too involved in their lives or not involved enough. Her youngest 
daughter suffered from bipolar disorder and lived with her drug-addicted 
husband and child. This daughter had had numerous severe psychotic epi-
sodes requiring multiple hospitalizations, and she and her husband were 
in chronic financial distress. Finally, Rene discussed her work as a systems 
analyst in a large company. She described working long hours, frequently 
going into work on weekends and holidays, and having difficulty maintain-
ing a work–life balance. Though apparently well respected in the company, 
she felt she had been the victim of sexism and racism as evidenced by her 
not being given a promotion recently. Of interest, in discussing her work, 
Rene often employed technical jargon to describe complex computer appli-
cations that she was in charge of overseeing. This appeared to be a test of 
whether the therapist would be intimidated by and/or critical of her exper-
tise and competence.
In these early hours, and often in response to questions by the thera-
pist, Rene also reported her personal history (see previous sections). The 
therapist’s focus on getting a history reflected his stance that in order to 
know how to intervene with Rene, he needed a formulation, and in order 
to formulate her case he needed a history. In this regard, he differed from 
many therapists working in a time-limited format who feel that there is too 
little time available to get a thorough history. Such therapists inevitably 
end up intervening based upon their theory of therapy rather than upon a 
theory of the patient (cf. Gazzillo, Dimaggio, & Curtis, 2019).
In the third session, Rene spoke of her concerns about her youngest 
daughter. She feared that her daughter was decompensating and worried 
about the safety and well-being of her grandchild. The daughter’s husband 
was in a drug-addled state and of no help to his wife or child. Rene’s other 
two daughters refused to intervene in any way, having been worn out by 
previous episodes. Rene struggled with what she should do. She considered 
taking time off work and/or canceling weekend plans to try to assist this 
daughter but anticipated that her efforts would be rejected. She felt unable 
104 HanDbook of PsyCHoTHEraPy CasE formulaTion
to take care of her own needs. In this session, the therapist made an inter-
pretation that would be repeated across the course of the therapy: He drew 
parallels between how Rene was responding to her daughter and how her 
mother was obsequious to her father.
Therapist: You know, it reminds me in a way or strikes me that there 
are parallels in some respects between what you’re doing and the way 
you described your mother as being. And I’m thinking in particular of 
that scene you described of her hopping across the floor on one foot 
to take care of your father when he was healthy and able to take care 
of himself. That, as you described it, it was as if she drove herself into 
the ground taking care of him and maybe other people in your family. 
And it sounds as if you may be feeling compelled to do a little bit of 
that yourself.
Rene: I never thought of that. I, uh, I am inclined to um, be a little bit of 
a martyr, and I used to recognize that in her and tell myself I’m not 
gonna be a martyr.
The therapist felt that Rene’s response to this intervention and her sub-
sequent associations supported the accuracy of his formulation of her cen-
tral conflicts. Rene went on to say that she felt critical of her mother, saying 
she was not a good mother and that she thought she herself could raise 
children better than her mother could. She said her mother just took the 
father’s abuse, and she thought she had identified with her mother and just 
“takes it” when others are abusive (daughters or at work). She then spoke 
of trying to take better care of herself, which then made her feel guilty, as 
if she was not taking care of others—but she was nonetheless focusing on 
doing more for herself. This appeared to be a test of whether the therapist 
would be critical of her placing her own needs above others. At the end of 
the hour, she worried about the therapist eating late (they met in the eve-
ning). He said that it sounded as though she was worried about him. She 
said she was. When he replied that he could look after himself, she laughed 
and wished him a good night.
Over the next several sessions, Rene returned to the issue of how she 
should respond to her youngest daughter’s problems. She expressed concern 
for her daughter’s well-being but felt especially worried about her grand-
daughter, for whose safety she seemed to have well-founded concerns. She 
questioned whether she should let her daughter and grandchild move in 
with her, though she knew that her daughter would be combative, unpleas-
ant, and difficult to live with. Moreover, Rene lived in a small, efficiency 
apartment, and it would be impractical for three people to live there. The 
therapist felt a strong pull to share Rene’s concerns and consider how she 
might intervene to rescue or take care of the child. However, guided by his 
 Plan formulation method 105
formulation, he felt that to do so would feed Rene’s omnipotent feelings of 
responsibility and reinforce her pathogenic belief that she should give up 
her life to take care of others. He noted:
Therapist: .  .  . you are seeming to feel, uh, or to question whether you 
need to give up your own happiness and comfort in order to step in and 
take care of this situation that’s really beyond your control.
Rene: And I don’t want to. I, I like my nice quiet place, like to be able to 
read my paper and have . . . I have rough days, so when I get home it’s 
very nice. I try to figure how can I help her? How can I have my cake 
and eat it, too? How can I help her, and yet not have to have her here?
Rene then related how, both currently and in the past, professionals 
involved in her daughter’s care thought that the daughter’s child (Rene’s 
granddaughter) should be considered for placement away from the mother. 
Rene felt guilty that she felt incapable of taking on the care of an infant. She 
noted that within her family of origin there was the attitude that one should 
look after other family members, regardless of the consequences, and that a 
child should never be placed outside of the family. “When my mother died, 
my two aunts pretty much stepped in and took care of the children. There 
were five younger children. They pretty much gave up their lives for them.” 
Later in the session she added, “I was feeling you know, my favorite thing is 
to kick myself around, so I was telling myself, you know, how awful it was 
for me to be enjoying my nice, warm, cozy place, when she [her daughter] 
was suffering.”
In hour 7, almost the midpoint of the therapy, Rene was discussing her 
daughters’ marriages, in particular her sons-in-law.This prompted memo-
ries of her marriage:
Rene: . . . When we were getting married, I didn’t wanna get married. I 
wanted to get married because it bothered me not to be married. But I 
didn’t want to, I didn’t want to give up my name. I didn’t want to give 
up—I felt I was giving part of me up by getting married. In some ways 
it was a relief when I was by myself again.
Therapist: Why did you have to give something up?
Rene: Well, for one thing my husband demanded it. Demanded. I couldn’t 
be independent. We had to go his way.
Therapist: What did you feel you had to give up?
Rene: I felt that I had to change myself to do what would please him. Oth-
erwise, things would not work out.
Therapist: And have you continued to do that?
Rene: Well, I’m doing it the same—uh, in a kind of the same sense I’m 
106 HanDbook of PsyCHoTHEraPy CasE formulaTion
doing it with [her new manager]. I’m trying to accommodate myself to 
him, so that things will be easier at work.
Therapist: I was thinking also though—like with your children. With 
your daughter for example, when she makes demands upon you that 
you think are unreasonable and have felt compelled a bit to go along 
with those demands, even though you’re also feeling more comfortable 
now not doing so. But if in both situations there is a sense that you 
should or ought to give up your wishes and your independence and 
your ideas and feelings.
Rene: It just seems to be the right thing to do.
Therapist: Is it the right thing to do because that’s what your mother did?
Rene: Probably. My mother and my aunts. That was—that was the way 
it was.
Therapist: Even though what you wanted to do was just the opposite.
Rene: Here I felt I had broken away since I had gotten into the service and 
gone away. I didn’t (chuckle). I just put miles, but not, not uh, other-
wise I didn’t change.
Therapist: Well, did you feel a need to undo those changes that you had 
made, or in a sense compromise?
Rene: Probably. Uh, compensate for it.
Therapist: So you could move away from home, but then maybe get in a 
relationship somewhat like that which you left behind.
Rene: Yes, my husband and my father were similar.
Once again, Rene’s responses seemed to support key elements of the 
formulation. In subsequent hours she expressed more worries about her 
youngest daughter and questioned whether she should let her daughter and 
grandchild live with her in her one-bedroom apartment. The therapist again 
noted that Rene was struggling with the feeling that she should give up her 
comfort and well-being to take care of her daughter and grandson. After 
some discussion, she introduced alternatives (e.g., a halfway house) that 
her daughter could pursue, which would in fact be better for all involved.
Sessions 9–13 coincided with Thanksgiving and Christmas holidays, 
which in turn led Rene to confront conflicting demands from her chil-
dren about how to spend the holidays. During this time she also described 
improvements in her relationship with her boss. She expected that he would 
be upset with her when she took time off work for the holidays, especially 
as he would have to cover for her. In fact, while covering for her, he had 
to address issues she commonly confronted at work; he expressed greater 
appreciation for her expertise, and their relationship improved.
In the final sessions of the therapy, Rene focused on the conflict 
 Plan formulation method 107
between pursuing her own interests and pleasures versus taking care of 
others. She identified various activities she would like to engage in but felt 
guilty pursuing. The therapist made the following intervention, a variation 
on the theme he had introduced early in the therapy:
Therapist: There are a lot things that you’d like to be doing in fact, or can 
imagine doing . . . and yet when you think of doing those, then this 
idea of well, then I’d be—uh, I wouldn’t be taking care of my kids or 
worrying about my kids. And when you say well I don’t know what 
would happen if I didn’t have my kids to worry about, I don’t know 
what would happen with my life, that seems to be a way of denying 
all those other dreams and wishes that you have. What it seems that it 
would mean would be that you could then spend some time pursuing 
interests that you might have and developing new ones. But it would 
also mean going against this image of the mother being the person 
who sacrifices everything for her children and doesn’t enjoy anything, 
and it strikes me that the bottom line on it is that you feel very guilty 
about kinda going against what your mother did and showing that 
that isn’t necessary. That life doesn’t have to be constant struggle and 
self-sacrifice.
Rene: And no fun. I used the other Waves [Women’s Air Force] when I 
was in the service, I’d go away for weekends and I, I used to, you 
know, I would almost think, “Is that moral, is that legal, is that right?” 
(Laughs.) Can you do things like that? Because we [her family] never 
did anything like that.
Rene focused on these issues in the remaining sessions. She discussed 
how she felt her background had inhibited her and how she had identified 
with her mother in not letting herself have pleasure and in depriving herself 
for the benefit of her children. In the last session, she spoke about her desire 
to be more in touch with what she deemed her Spanish culture. The thera-
pist saw this as a repudiation of Rene’s father’s put-downs of her for having 
dark skin and hair and as a test of how he would react to her expressing 
pride and self-acceptance. This led to the following exchange:
Rene: .  .  . why do I have this thing about Spanish, you know, I turned 
my back on it a long time ago. I married a non-Spanish. I raised my 
children as non-Spanish. Why do I have this thing now, you know, to 
go back? And I was thinking, maybe you’re trying to find your mother 
again, you know. Maybe you feel that you have held her up to ridicule, 
you know, hopping on one foot, and you’re trying to find her and 
reassure her, you know. I wasn’t too sure what I was thinking. But it 
almost seems like I’m trying to go back. Which I think a lot of older 
people do.
108 HanDbook of PsyCHoTHEraPy CasE formulaTion
Therapist: Go back for what reason?
Rene: To their roots, to their, to their . . . 
Therapist: You say you held your mother up to ridicule?
Rene: Well, I almost felt that I had betrayed her.
Therapist: How?
Rene: By picturing her—by giving you the picture of her hopping on one 
foot. . . . I almost felt disloyal (voice cracking).
Therapist: What was disloyal about that?
Rene: (verging on tears) Mm, maybe it’s . . . we all think she’s a very won-
derful person. She’s the one that was the glue that held us together. 
And she’s the one that, that pushed for us to get an education and to 
do something with ourselves. And in comparison to the other people 
in the neighborhood [where Rene grew up] we have all been able to 
accomplish something. Do something with ourselves. And it just didn’t 
seem the right way, the right picture to give to people. The right image 
to give to people.
Therapist: Well it sounds like she didn’t want you—and again I’m using 
this as a metaphor—she didn’t want you to. . . . 
Rene: To do the same thing.
Therapist: To hop around on one foot.
Post-therapy evaluations with the independent evaluator were con-
ducted 1 month, 6 months, and 1 year after therapy. In all of these evalu-
ations, both Rene and the evaluator rated her as greatly improved. Rene 
reported the following observations in her post-therapy evaluation: “I feel 
I have choices”; “I have a sense of freedom I did not have before”; “I like 
my life”; “I like myself more”; “I feel I am making progress in changing 
things I do not like”; “Two of my children have said they like me more 
now.”
LEARNING THE METHOD
As noted, although the PFM was developed to study the control-mastery 
theory of psychotherapy, it has been applied by other researchers who 
adhereto a different theoretical stance (Collins & Messer, 1991) and to 
therapies conducted under widely varying theoretical orientations, both 
psychodynamic and nonpsychodynamic (Curtis et al., 1994; Persons et al., 
1991). Thus, for purposes of training in the PFM, the first consideration 
is that the clinicians share and be well versed in a common theoretical 
position. It should be noted that this is often easier said than done. One of 
 Plan formulation method 109
the interesting findings from adapting the PFM for use by other research-
ers is that theories and their applications are often poorly operationalized, 
and clinicians who think they share a common perspective may find, after 
applying the PFM, that they differ widely in how they understand or apply 
that perspective (Collins & Messer, 1991; see also Seitz, 1966). We see 
this as a strong point of the PFM; it does not allow for sloppy thinking. 
Once a group of clinicians share a common, well-operationalized theoreti-
cal perspective, the PFM can be applied with good reliability (Collins & 
Messer, 1988; Curtis et al., 1994). Even relatively inexperienced clinicians 
have been able to develop plan formulations with reliabilities approaching 
those of more seasoned veterans of the procedure (Curtis et al., 1994).
NOTE
1. The individual items created by the judges are identified in parentheses in the 
text: G = goal; Tr = trauma; O = obstruction; TT = transference test; PA = 
passive-into-active test; I = insight (no PA tests were identified in the formula-
tion for Rene).
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 113
5
The Cyclical Maladaptive Pattern
Jeffrey l. binder
Ephi J. betan
If therapy is to end properly, it must begin properly . . . 
 —Jay Haley
HISTORICAL BACKGROUND OF THE APPROACH
The proper beginning of psychotherapy is generally considered to be the 
development of a hypothetical picture of the patient that serves as an initial 
guide to treatment. Many clinicians believe that the most useful guide is a 
formal diagnosis. But the act of “diagnosing” is no more than an algorith-
mic process of impersonally gathering clinical data in order to identify the 
distinguishing features of particular taxonomic categories (Peebles, 2012). 
The diagnostic method does help recognize the severity of psychopathol-
ogy that is present, facilitates efficient communication between colleagues, 
and promotes patient safety. The clinician conducts a structured, com-
prehensive search for “red-flag” problems, such as suicide risk, psychotic 
decompensation, substance abuse, or serious environmental problems. A 
primary goal is to identify and stabilize patients with precarious personal-
ity functioning or environmental situations. However, there is no empirical 
evidence that choosing a diagnosis or diagnoses is associated with conduct-
ing more effective psychotherapy (Messer & Wolitzky, 2007). Psychologi-
cal diagnoses provide little or no guidance in choosing relevant content to 
explore in therapy or what therapeutic stance to assume.
Psychodynamic therapists are more apt to believe that if no “red-flag” 
situations have been found, the most useful guide for developing an ini-
tial treatment plan is a case formulation: “One gathers historical data and 
114 HanDbook of PsyCHoTHEraPy CasE formulaTion
elaborates hypotheses, in the form of a narrative, about the predisposing, 
precipitating, and perpetuating influences on the patient’s current distress” 
(Peebles, 2012, p. 20). Indeed, a basic tenet of psychodynamic therapies 
is that a case formulation is necessary to determine what psychological 
issues to address (Bornstein, 2018; Cabaniss, Cherry, Douglas, Graver, & 
Schwartz, 2013; McWilliams, 1999).
The Origins of Psychodynamic Case Formulation
Psychotherapy case formulations grew out of Freud’s style of writing clinical 
case histories; his cases read like personal short stories, with the narrative 
structure organized and enhanced by theory-inspired formulations of the 
“lead” character’s psychological dynamics (Messer & Wolitzky, 2007). Fol-
lowing the evolution of Freud’s clinical theory, which became progressively 
detailed, abstract, and comprehensive, psychoanalytic case formulations also 
became increasingly broad, detailed, and abstract. The ultimate extension 
of this trend was Anna Freud’s “metapsychological profile” (Freud, Nagera, 
& Freud, 1965). This awesome template for searching for and identifying 
clinical data included more than 60 topic headings and subheadings. Orga-
nized around the major domains of Freud’s metapsychology (i.e., dynamic, 
structural, genetic, adaptive, economic) and untethered by the constraints 
of empirical data, speculation about a patient’s personality functioning 
was limited only by the psychoanalytic clinician’s imagination. The profile 
was viewed as an invaluable tool for initial treatment planning. Due to the 
attempt to include all of the details relevant to the patient’s psychopathology, 
clinicians assumed that it would take an extended period of time to complete. 
This feature was not seen as a problem, since psychoanalytic clinicians com-
monly assumed that treatment would last for several years.
Contemporary psychoanalytic theories—such asobject relations the-
ory, self-psychology, relational theories, and interpersonal theory—have 
inspired changes in case formulation models. Contemporary psychoana-
lytic case formulations are couched in language that reflects the way peo-
ple actually think and talk. They also are relatively more parsimonious, 
although they still require a challenging number of topic areas to address. 
For example, Cabaniss and colleagues (2013) propose addressing “pat-
terns of thinking, feeling, and behaving” from five dimensions (e.g., self, 
relationships) and “developmental experiences” from six perspectives (e.g., 
trauma, conflict and defense, relationship with others). In her book on psy-
choanalytic case formulation, McWilliams (1999) proposed a formulation 
composed of eight domains of functioning (e.g., central affects, identifica-
tions, self-esteem regulation).
Clinicians who advocate for comprehensive case formulations assume 
that a more detailed formulation provides a more useful guide for planning 
and launching a treatment. However, a comprehensive case formulation can 
also impede the beginning of psychotherapy, because gathering the prescribed 
 The Cyclical maladaptive Pattern 115
clinical data can be time-consuming and treatments are not so frequently 
long term as in the past. Another problem is that the volume of gathered 
data may be hard to manage. The developers of comprehensive psychoana-
lytic case formulation models typically do not provide specific guidelines for 
synthesizing the prescribed clinical data into a coherent narrative about the 
patient’s psychological functioning, which makes the task increasingly dif-
ficult as more data are obtained. The process of organizing a voluminous 
amount of clinical material into a case formulation is a severe challenge to 
teach.1 The traditional psychoanalytic case formulation is an idiosyncratic 
product, and, consequently, it is virtually impossible to obtain respectable 
reliability across therapists working with the same clinical material. Further 
problems are that a large volume of clinical data increases the difficulty in 
sorting relevant from irrelevant clinical data, and the early process of gather-
ing comprehensive clinical data may unwittingly train the patient to assume 
a passive stance, waiting to answer the therapist’s questions (Peebles, 2012).
A comprehensive case formulation takes an indeterminate number of 
sessions to construct. Meanwhile, the most critical time for establishing the 
beginning of a working relationship with a new patient is the first couple 
of sessions, because it is during this time that a patient is most likely to 
drop out of treatment (Westmacott, Hunsley, Best, Rumstein-McKean, & 
Schindler, 2010). And the establishment of a strong therapeutic alliance 
begins in the first one to three sessions (Flückiger, Del Re, Wampold, & 
Horvath, 2018). So how, in the first one or two sessions, does a therapist 
convey to a patient that he or she has some understanding of what ails the 
patient? The current guidelines for constructing traditional psychoanalytic 
case formulations address domains of psychological development and func-
tioning that provide the organizing structure for these formulation models. 
The narrative content of a formulation typically is dealt with as though, in 
the welter of clinical material presented in the first couple of sessions, it is 
self-evident which content is relevant for beginning to construct a patient’s 
personal story. Yet even experts in traditional case formulation admit that, 
especially in the first meeting, the construction of an initial formulation is 
unlikely: “Especially an intake interview—involves a kind of not knowing 
. . . [skill at synthesizing clinical information] operates only in retrospect, 
not in the immediacy of clinical contact, where I can be completely baffled 
and inarticulate” (McWilliams, 1999, pp. 46–47).
Time-Limited Psychodynamic Psychotherapy and the Cyclical 
Maladaptive Pattern
Everything should be made as simple as it can be, but not simpler.
 —Albert Einstein
Starting in the 1970s, research addressing psychodynamic therapy process 
and outcome began to gain momentum. For research designs requiring 
116 HanDbook of PsyCHoTHEraPy CasE formulaTion
case formulations, psychodynamic researchers found that the nature of 
traditional psychoanalytic case formulation models presented insurmount-
able obstacles enumerated earlier. In order to overcome these limitations, 
various psychodynamically oriented treatment research teams developed 
“structured” case formulation models.
Two members of the Vanderbilt Center for Psychotherapy Research,2 
Thomas E. Schacht and Jeffrey L. Binder, developed a structured case 
formulation model named the cyclical maladaptive pattern (CMP). This 
formulation model was the tool used to identify a content focus for the 
brief psychodynamic/interpersonal treatment model, time-limited dynamic 
psychotherapy (TLDP; Strupp & Binder, 1984). This model has been fur-
ther developed by clinician/researchers (Binder, 2004; Binder & Betan, 
2013; Levenson, 1995, 2017). The CMP has several clinical and research 
advantages over traditional psychoanalytic case formulation models: (1) It 
requires a relatively small volume of content; (2) relevant content is rela-
tively easy to identify because of the small number of standardized content 
categories; (3) organization of content into a coherent narrative is facili-
tated by a predetermined sequence for the categories; (4) identifying con-
tent requires a low level of inference. All of these features contribute to the 
relative ease of teaching the formulation method, of obtaining relatively 
reliable results, and of operationalizing the results for analysis.
CONCEPTUAL FRAMEWORK
If you don’t know where you’re going, any road’ll take you there.
 —The Cheshire Cat in “Alice in Wonderland”
The conceptual framework for TLDP is based on psychoanalytic/rela-
tional and attachment perspectives. Adult psychological difficulties origi-
nate in the infant’s and child’s attempts to adapt to parental figures who 
are not adequately in tune with their offspring’s developmental needs. 
These early adaptations become “life lessons” (Hanna Levenson, personal 
communication, 2020) that are carried forward and unwittingly become 
the template for interpersonal relating, especially with significant oth-
ers. This interpersonal template, consisting of dysfunctional strategies for 
thinking and managing emotions, along with corresponding maladaptive 
modes of relating, are represented by a structured formulation model, the 
CMP. The narrative structure that characterizes a CMP describes human 
actions embedded in the context of interpersonal transactions. Actions 
include both private actions (e.g., thoughts, feelings, images) and public 
actions (e.g., speaking, moving). One person’s actions are portrayed as 
explicitly evoking the other person’s actions. These complementary trans-
actions, in turn, are organized into a cyclical psychodynamic pattern: 
 The Cyclical maladaptive Pattern 117
self-perpetuating, inflexible, repetitive maladaptive interpersonal pat-
terns that have been a recurrent source of problems in living as well as a 
current source of distress and dysfunction (Strupp & Binder, 1984; Wach-
tel, 2014).
The CMP, then, provides the therapist a working mental model (Peter-
freund, 1983) of a central or salient pattern of interpersonal roles in which 
patients unconsciously cast themselves, the complementary roles in which 
they cast others, and the maladaptive interaction sequences, self-defeating 
expectations, and negative self-appraisals that result. The patient is guided 
by unquestioned assumptions about self and others that repeatedly influ-
ence interpersonal transactions, often regardless of context or situation. A 
recurring assumption about other people is that they will be as intolerant 
of certain private and/orpublic actions as the patient perceived her sig-
nificant others being when she was a child. The CMP also represents how 
the patient’s defensive efforts to avoid anticipated negative responses from 
others paradoxically evoke reactions that confirm her negative expecta-
tions. The reactions of others then further reinforce the patient’s negative 
schemas of self and others, leaving her yet again in touch with a core inter-
personal pain. This is how the recurrent maladaptive interpersonal pattern 
becomes a vicious cycle.
Specifically, the CMP articulates how a patient’s wish or intention is 
thwarted by an anticipated negative reaction from significant others; then, 
in the form of a self-fulfilling prophecy, she is primed to unwittingly act in 
ways that evoke reactions from others that reinforce her negative expecta-
tions. Negative expectations are further reinforced by her interpretations 
of the motives behind others’ reactions, which are usually in line with her 
expectations. Ironically, the negative reactions of others are produced by 
the patient’s unconscious defensive strategies deployed to protect her from 
the very negative reactions to which she is exposed. These defensive strate-
gies are represented in the CMP by the category acts of self-protection.3 
Finally, the responses of others, as perceived by the patient, serve to rein-
force her negative self-image as well as reinforce the neglectful or self-criti-
cal/self-devaluing ways in which she treats herself (see Figure 5.1). The five 
CMP categories are enumerated below:
1. Wishes/Desires/Intentions.4 The CMP first identifies the inter-
personal need or desire that the patient feels is continually unfulfilled or 
thwarted in relationships. This captures the patient’s core pain associated 
with unmet interpersonal wishes and longings that contribute to negative 
feelings (e.g., “I want my feelings to be acknowledged. I want my resent-
ment to be understood.”).
2. Expectations of Others. The individual’s expectations of distress-
ing interpersonal and/or emotional experiences get in the way of fulfilling 
118 HanDbook of PsyCHoTHEraPy CasE formulaTion
one’s needs and desires in relationships (e.g., “My feelings will be ignored. 
If I express my dissatisfaction, I will be ostracized.”).
3. Acts of Self-Protection. Expecting a negative response from oth-
ers based on early interpersonal experiences, individuals may be primarily 
concerned with protecting themselves against feeling hurt by others and/
or against the pain of disconnection. Self-protective efforts typically work 
against the patient’s most pressing interpersonal needs and wishes because 
they are meant to suppress what has been denied or prohibited by caregiv-
ers (e.g., “I will act as if I don’t care about what happens.”).
4. Perceived Acts of Others. Here, we are interested in the patient’s 
recollections and reports about the actions and intentions of others, captur-
ing others’ actual responses, as well as how the patient may idiosyncrati-
cally perceive others’ behavior (e.g., “Other people don’t ask for my reac-
tions, probably because they don’t care about my opinions or feelings.”).
5. Introject (Acts of Self toward the Self). One’s self-concept is 
grounded in interactions with others, and dissatisfying interpersonal expe-
riences are likely to leave an individual prone to powerfully negative self-
directed feelings and treatment (e.g., “I don’t have much to contribute to 
planning. I am not going to bother to go to their party.”).
FIGURE 5.1. Cyclical maladaptive pattern (CMP).
 
Protection of Others 
Acts of Self
Expectations 
of Others
Acts of Self- 
Protection
Perceived Acts 
of Others
Introject
 The Cyclical maladaptive Pattern 119
Beginning to Construct the CMP
Over the years, the CMP has proven to be a relatively useful tool for con-
structing an initial content focus for psychotherapies of any length. But like 
any tool, the CMP is more useful for some situations than others. In our 
experience, regardless of how valuable it turns out to be over the course of a 
particular treatment, rarely are we able to construct a complete CMP in the 
first interview—sometimes not for several interviews. We highlight the first 
session because, as noted earlier, what transpires in this initial encounter 
immediately affects whether or not a therapeutic alliance develops (Hilsen-
roth & Cromer, 2007); if an alliance does not begin to form in the first 
treatment session, patient-initiated premature termination is more likely 
to occur (Fernandez, Salem, Swift, & Ramtahal, 2015; Roos & Werbart, 
2013).
At other times, we have not been able to use the CMP format at all. We 
have come to the conclusion that, although case formulation models are use-
ful guides over the course of a treatment, it routinely takes several sessions 
for a CMP to be fully developed. We wondered whether there was a more 
reliable method in the first session for making a connection with the patient. 
In the case of Margot (discussed later in the chapter), we can see that the 
therapist developed a CMP piecemeal over several sessions. Although this 
may not illustrate the most artful formulation of a case, we contend that it 
represents the typical development of a structured case formulation.
In the past few years, our dynamic/interpersonal (i.e., “relational”) 
theoretical orientation has been influenced by the psychoanalytic narrative 
perspective that emerged into prominence for a brief period of time in the 
1960s and 1970s (Mayman, 1968; Schafer, 1992). We view the core con-
tents of the mind as sketchy storylines that are the residue of internalized 
interpersonal experiences since birth, which are organized thematically. 
These storylines always involve an interaction or relationship, reflecting 
the brain’s development in continual interaction with primary caregivers 
(Cozolino, 2010; Siegel, 2010). As a corollary, “free association” repre-
sents the innate human urge to communicate a personal story. The stories 
told by a patient provide clues to her recurrent interpersonal struggles and 
idiosyncratic view of the self in relation to the world: the dominant inter-
personal motif. As we shall see, based on her narrative in the first session, 
for Margot this motif appeared to be searching for nurturance, acceptance, 
and love (Summers & Barber, 2010). Over the course of therapy, this motif 
is elaborated into a salient maladaptive personal storyline—a narrative arc 
in the epic drama that is the patient’s life. The narrative structure at the 
core of this maladaptive personal story line is the CMP. The process of 
personal story construction begins in the first treatment session by iden-
tifying the patient’s dominant interpersonal motif. Once this motif is cho-
sen, the therapist looks for representative narrative fragments that resonate 
120 HanDbook of PsyCHoTHEraPy CasE formulaTion
with the patient. These narrative fragments are the initial components for 
a personal storyline that captures the narrative context for a patient’s cur-
rent problems. In the first session for Margot, an empathically enhanced 
narrative fragment could be: Your father gave you so little of his time, you 
yearned to win his approval and wondered what was wrong with you that 
you couldn’t gain his love.
These narrative fragments should be articulated as much as possible 
as though the patient were talking to herself; in other words, as though 
what is being examined is seen through the patient’s eyes. The method of 
articulating these components of an initial case formulation is akin to the 
literary style of “indirect free speech”: the author assumes a third-person 
perspective along with the essence of first-person direct speech (Rzepka, 
2017). There are minimal introductory clauses introducing the character’s 
thoughts. This is a literary style used by such varied authors as Goethe, 
Austen, Flaubert, Kafka, Joyce, Woolf, Lawrence, and Hemingway and 
elevated to a fineart by Elmore Leonard in such novels that were made into 
popular movies as Get Shorty, Hombre, and 3:10 to Yuma and popular 
television shows such as Justified. An example of this literary style is a seg-
ment from Leonard’s novel Pronto, in which a main character, Harry Arno, 
an aging sports bookie, is contemplating retiring:
One day pretty soon now his players would be making phone calls asking, 
“What happened to Harry Arno?” realizing they didn’t know anything about 
him. He’d disappear and start a new life, one that was waiting for him. No 
more pressure. No more working for people he didn’t respect. Maybe have 
a drink now and then. Maybe even a cigarette in the evening looking out at 
the bay at sunset. Have Joyce there with him. Well, maybe. It wasn’t like 
there weren’t any women where he was going. Maybe get there first and settle 
in and then if he felt like it, send for her. Have her come for a visit. He was 
ready. Had passports in two different names, just in case. Saw a clear field 
ahead. No problems. (Leonard, 1993)5
In the context of psychotherapy, a therapist articulates the narrative frag-
ment of a patient’s personal storyline by suggesting the patient’s thoughts 
as mediated through the therapist’s voice—the patient “speaks” through 
the therapist’s voice.
These narrative fragments are similar to the “chronically endured 
pain” that James Mann would identify as the focus of his 12-session “time-
limited psychotherapy” (Mann, 1973). Both statements are meant to con-
vey an empathic connection with the patient rather than an explanation. 
On the other hand, Mann’s “chronically endured pain” is meant to capture 
a patient’s core issue, which typically takes several sessions to articulate; 
in contrast, a narrative fragment identified in the initial treatment session 
is merely the first attempt to construct a personal storyline. We call this 
initial effort at case formulation the descriptive CMP.6
 The Cyclical maladaptive Pattern 121
The descriptive CMP stays close to the clinical data—what the patient 
reports and what we can observe in the patient’s behaviors, nonverbal cues, 
and emotional reactions or lack thereof. In narrating a patient’s experience, 
the therapist must strive to tell how the patient feels in words that are emo-
tionally meaningful and immediately evocative. The therapist needs a rich 
vocabulary and language when describing the patient’s subjective experi-
ence and internal world in experience-near, meaningful expressions that 
convey the therapist’s empathic connection and understanding. We propose 
that realistic goals for the initial session or two of dynamic psychotherapy 
are (1) identifying a dominant interpersonal motif and (2) articulating nar-
rative fragments of a potential personal storyline that resonates with the 
patient. We envision this activity as an empathic and collaborative process 
that facilitates early development of a therapeutic alliance (Hilsenroth & 
Cromer, 2007).
This initial empathic connection also serves as the foundation for 
constructing a more thorough and elaborate formulation that we call the 
inferential CMP. This version of the CMP includes theory-guided hypoth-
eses about the origins of the patient’s problems, as well as the factors that 
contribute to their persistence. Guided by theory, professional and personal 
experiences, and ongoing dialogue and experiences with the patient, the 
therapist makes inferences about the patient’s early relationships with care-
takers and other significant people and the subsequent prepotent relational 
schemas that contribute to the patient’s dysfunctional perceptions of self 
and others, as well as to her maladaptive patterns of relating to others. The 
inferential CMP serves as the core of a progressively elaborated picture of 
the patient’s unique personality, interpersonal style and mode of interper-
sonal relating, repressed, disavowed, and dissociated emotions, as well as 
relevant sociocultural factors—all of which are facets of the patient’s per-
sonal storyline. The case formulation progressively acquires structure and 
details over time at a pace that varies over patients, therapists, and thera-
peutic dyads. The therapist keeps this case formulation process in mind as 
a method for maintaining a content focus. As a rule, the case formulation 
is complete when therapy is finished.
MULTICULTURAL CONSIDERATIONS
Cultural upbringing and sociopolitical factors, including discrimination or 
oppression, have a profound impact on psychological functioning, patterns 
of relating, and personal narratives. Furthermore, psychotherapy unfolds 
within highly personal and cultural contexts that shape understandings of 
a patient’s difficulties. Comprehensive case conceptualization incorporates 
both cultural and individual dynamics as interrelated dimensions of one’s 
identity and functioning. Culture has a profound influence on the stories 
122 HanDbook of PsyCHoTHEraPy CasE formulaTion
we construct of our relationships, our self-presentations, and the dynamics 
that feed maladaptive patterns of relating. Developing a culturally sensitive 
CMP considers the degree to which cultural expectations may account for 
a patient’s presentation and interpersonal narrative.
The CMP revolves around expectations of another’s availability and 
support and how one manages insecurities in this regard. Interpersonal 
dynamics are set early in life in the context of attachment experiences with 
caregivers and their responsiveness and management of developmental 
needs. Cross-cultural studies of attachment have described culture-specific 
constructions of caregiving and bonding. There exist cultural differences 
in approaches to interpersonal dimensions of, for example, independence, 
self-reliance/self-definition, exploration, dependency, control, obedience, 
and harmony. Availability of caregivers, emotional expression (including 
physical and verbal demonstrations of affection), and communication styles 
are all mediated through cultural values and assumptions. Given these cul-
tural differences, the definition and manifestation of sensitive, responsive 
caregiving depend on the values of a particular culture. This, in turn, dif-
ferentially influences the child’s key relational experiences and emerging 
relational patterns and schemas. From a cross-cultural perspective, what 
counts as deficit, intrusion, inconsistency, or ambivalence in early caregiv-
ing experiences, presumed to be at the root of insecure or maladaptive inter-
personal functioning, may be very different across cultures (and even these 
concepts may be more or less relevant, depending on the cultural context).
One’s interpersonal narrative embodies the particular cultural values, 
visions, and idioms of what is believed to be right or possible for interac-
tions and relatedness. Consequently, a patient’s beliefs or behaviors may 
not necessarily reflect psychological disturbance or maladaptive modes of 
relating. Working with culturally diverse patients may involve suspend-
ing customary diagnostic constructs and focusing instead on culturally 
relevant explanations of distress (Lewis-Fernández & Díaz, 2002). The 
CMP conceptualization is already highly personalized to an individual. 
As such, the CMP framework is sufficiently flexible to weave in cultural 
considerations as part of the patient’s interpersonal narrative. The CMP 
template outlines the structural components of interpersonal interaction, a 
template that explicates the cyclical links between those interpersonal and 
intrapsychic actions that occur in relationships. However, the content of 
a given patient’s CMP—her interpersonal themes, core pain, motivations, 
and actions—belongs uniquely to that patient. In this way, the CMP can be 
understood as a highly individualized story that appreciates multiple mean-
ings and influences of diverse personal, social, and cultural pulls.
From this perspective, we encourage awareness of the powerful holdof 
cultural and familial expectations. As one example, an individual may be 
strongly rooted in cultural values and mores, and what may seem to be rigid 
behaviors or expectations may in fact be a cultural reality. One’s patterns 
 The Cyclical maladaptive Pattern 123
of relating are based in part on preexisting cultural norms. Cultural rules 
and norms provide structure and boundaries for interpersonal interactions. 
Furthermore, these rules of relating are communicative acts that lead to a 
sense of predictability and belonging. Consequently, aligning oneself with 
cultural norms fulfills one’s needs for affiliation and identity. In this regard, 
appreciating the potential for loss and alienation as an individual chooses 
to depart or is pulled away from her cultural roots is an important facet of 
culturally responsive case conceptualization and treatment.
EVIDENCE BASE SUPPORTING THE METHOD
The case formulation method based on the CMP was a component of 
TLDP (Strupp & Binder, 1984), which was developed particularly to 
treat “difficult” patients (i.e., those with personality disorders) in a large 
research project aimed at improving the skills of therapists treating those 
sorts of patients. The focus was on the impact of the training protocol used 
to enhance the therapists’ skills. The CMP method was not a focus of the 
researchers, and no empirical studies were conducted to test the role of the 
CMP method in therapy process or outcome. Subsequent clinical research-
ers, however, have studied the impact of the CMP case formulation method 
on therapy trainees’ development. For instance, clinical instructors in Israel 
used the CMP method of case formulation as part of an integrative inter-
personal therapy training program. The treatment approach views current 
problems in living as a consequence of maladaptive interpersonal patterns 
that have persisted because they worked well in important interpersonal 
situations during personality development and thus have become difficult 
to change (Levendosky & Hopwood, 2017).
A few studies looked at the impact on therapy process of the CMP case 
formulation method. For example, Scott and Lonborg (1996) studied how 
their respective case formulation methods influenced Donald Meichen-
baum’s and Hans Strupp’s conducts of therapy. Strupp used the CMP case 
formulation method, which was shown to be associated with his technical 
approach of fostering insight by linking current maladaptive interpersonal 
patterns with past patterns from childhood.
At the time the CMP was developed, a remarkably similar case for-
mulation method developed by Lester Luborsky already was in use (Lubor-
sky, 1977, 1984, 1997).7 Lester Luborsky, Paul Crits-Christoph, and 
their research team have subjected the core conflictual relationship theme 
(CCRT) method to extensive study (Luborsky & Crits-Christoph, 1990). 
For example, Crits-Christoph, Gibbons, Temes, Elkin, and Gallop (2010) 
found that in supportive–expressive therapy, when the content of therapist 
interventions were congruent with the CCRT formulated for the patient, 
treatment outcome tended to be positive.
124 HanDbook of PsyCHoTHEraPy CasE formulaTion
Other researchers continue to study the role of the CCRT in psycho-
therapy and, more broadly, in mental life. In a study using clinical train-
ees conducting supervised therapies, the CCRT was used to demonstrate 
that a maladaptive interpersonal pattern identified in the trainees’ personal 
lives tended to manifest as countertransference in their supervised therapies 
(Messina et al., 2018). In another recent study, the CCRT case formulation 
method was used effectively to guide the choice of therapeutic technical 
strategies (Leibovich, Nof, Auerbach-Barber, & Zilcha-Mano, 2018). Since 
the content categories and category sequence of the CCRT are essentially 
the same as the CMP, we contend that the research findings associated with 
the CCRT method can also be applicable to the CMP case formulation 
method. The CCRT method was more systematically operationalized than 
the original CMP method. However, Binder (2004) attempted to introduce 
more systematic steps for CMP construction, in order to render the CMP 
more conducive to study.
STEPS IN CASE FORMULATION CONSTRUCTION
All persons are puzzles until at last we find in some word or act the key to the man, 
to the woman; straightway all their past words and actions lie in light before us.
 —Ralph Waldo Emerson, “Journals” (1842)
The objective of developing a case conceptualization is to raise the patient’s 
awareness of a dominant, repetitive pattern of dysfunctional thinking and 
a corresponding maladaptive pattern of relating that contributes to disrup-
tions in the patient’s sense of self, mood, and coping style. Initially, patients 
divulge unwieldy amounts of information or bewildering accounts of long-
standing unhappiness. To maximize efficient and effective understanding 
and interventions, selective attention must be given to certain informa-
tion in order to establish workable boundaries around the problem area—
a therapeutic content focus. “To be more than a stroll in the park or a 
good conversation, psychotherapy needs the discipline of focus” (Vaughan, 
1997, p. 34). From a relational perspective, the focus is constructed in the 
form of a narrative structure in which a welter of clinical data are sequen-
tially organized into a predictable pattern of interpersonal experiences and 
actions. Information about recurrent patterns of interpersonal transaction 
is gathered from the ongoing flow of therapeutic dialogue. The therapist 
then sorts, interprets, organizes, and assembles these raw data about inter-
personal transactions into a coherent outline of a repetitive problematic 
interpersonal transaction pattern, using the CMP format. This narrative 
structure is the foundation of the patient’s personal storyline. The per-
sonal storyline has prepotent influence on development of the patient’s per-
sonality, as well as the quality and direction of her life. It instrumentally 
 The Cyclical maladaptive Pattern 125
contributes to explaining her distressing symptoms, impairments in func-
tioning, and interpersonal problems.
The CMP is developed from the stories told by the patient about the 
problems that brought her to therapy. The first step in developing a CMP 
is to refrain for a while from doing so and, rather, to listen to the patient 
telling her story in her own language, her own time, and with her own 
structure. The therapist’s listening stance allows for initial assessment of 
the patient’s spontaneous capacity for gaining access to her inner life, for 
organizing her life story, and for determining the salient content of her sto-
ries. In her remarkable text on initial psychotherapy assessment and treat-
ment planning, Peebles (2012) cites the fictional master detective Gamache, 
who, on one of his cases, is asked how they are solved. Gamache responds 
that in addition to collecting evidence, “We listen . . . we listen really hard 
. . . we just listen.”8 This “hard listening,” of course, must be balanced with 
questions evoked by curiosity about details.
The therapist listens for wishes, intentions, needs, expectations, and 
fears that recur in the patient’s descriptions of her interactions and rela-
tionships. The therapist seeks to identify a recurring theme that runs like 
a “red thread” through the patient’s concerns, complaints, beliefs, emo-
tional reactions, and ways of interacting with other people. This salient 
theme is the kernel of a personal storyline that will be the heart of the case 
formulation. This storyline will be developed by gathering, from stories 
told by the patient, narrative fragments that can be pieced together into 
a coherent personal story shaped by a CMP. The therapist identifies criti-
cal scenes, recurring “characters” and scenarios, salient emotional states, 
and central concerns. In addition, she draws relevantclinical data from 
the manifest content of and associations to fantasies, dreams, and memo-
ries. These sources of information are especially helpful during times when 
useful information from the patient’s ongoing narrative diminishes. All of 
these sources of clinical data comprise the content of a therapeutic inquiry; 
that is, what is being talked about, the literal understanding of the subject 
matter.
Often, therapeutic process—how the conversational relationship is 
proceeding—is a primary source for detecting the presence of a maladap-
tive transactional pattern. The therapist becomes aware of a salient interac-
tion pattern characterizing her relationship with the patient.9 Sometimes 
content and process combine, as when the therapist first detects a transfer-
ence–countertransference enactment through “disguised allusions” to the 
therapeutic relationship in the content of the patient’s conversation (Strupp 
& Binder, 1984). It should be noted that for most patients, their personal 
storylines are more readily identified in verbal reports of outside relation-
ships. Even when facets of a personal storyline are manifested in transfer-
ence–countertransference enactments, reports of outside relationships most 
often provide a more complete narrative context (Peebles, 2012). Finally, 
126 HanDbook of PsyCHoTHEraPy CasE formulaTion
like pieces in a picture puzzle, a therapist organizes all of these different 
types of information into a progressively elaborated and detailed personal 
storyline.
When listening to the patient’s narrative, the therapist should picture 
specific scenes in her mind’s eye in as much detail as possible. Visualizing 
the narrative depends on pursuing the kinds of specificity gleaned from 
concrete examples of interchanges between characters in the story. The 
patient’s stories should be examined in exhaustive detail. As little as possi-
ble should be assumed. The fictional homicide detective Columbo, from the 
late-20th-century television show of the same name, was particularly adept 
at spotting gaps, vagueness, and inconsistencies in the flow of a suspect’s 
narrative. He would focus in on those narrative irregularities and question 
them rather than “smoothing over” them. A therapist who can visualize the 
story in vivid detail as it develops will be more likely to judge what aspects 
are especially meaningful to the patient.
A continual challenge for the therapist is selecting what clinical data 
are relevant for her therapeutic focus. She looks for salient themes reflect-
ing the patient’s personal storyline. Salience can be represented by clini-
cal data that stand out like figure from ground, and functionally by what 
exerts prepotent influence on the way a patient deals with life. The thera-
pist also looks for high or low frequency and/or intensity of an action or 
experience, which can often reflect rigidity or preoccupation with particu-
lar topics. Contextual indicators of salience include job changes and pro-
motions, health issues, changes in family life, losses, and so forth. Salience 
also may be indicated both by what is omitted from a patient’s behavior 
and/or experience and by what is invariably included. On the other hand, 
important areas of difficulty are not being discussed if average expectable 
responses are omitted from the patient’s repertoire (e.g., failure to grieve 
following the death of a loved one).
A therapist’s most useful mental resources for constructing a case for-
mulation are curiosity and common sense. Curiosity focuses a therapist’s 
attention on what a patient is saying, as well as on how she characteristi-
cally conveys information and relates to others. Faced with any hint of 
vagueness, ambiguity, or inconsistency in a patient’s conversation, the curi-
ous therapist inquires about precise details, meanings, implications, and 
about those inconsistencies. A therapist applies her common sense when 
she appraises the degree of fit between a patient’s ways of construing the 
world and of conducting her life and what the therapist, representing a 
hypothetical consensus of reasonable persons, would consider to be reason-
able and predictable under the circumstances. This mindset is especially 
useful for novice therapists who do not have much professional experience 
and well-integrated theoretical prescriptions upon which to draw, but who 
often see relevant similarities between the patient’s circumstances and their 
own prior experiences.
 The Cyclical maladaptive Pattern 127
Transforming information about an individual’s subjective distress 
and impaired functioning into a formulation about a circumscribed prob-
lem area requires a collaborative effort between therapist and patient. A 
therapist encourages her patient to talk about herself and her life. The ther-
apist listens and eventually responds with questions, observations, com-
ments, and attempts to reflect, with enhanced clarity, greater elaboration, 
and possible implications, the personal story being told by the patient. The 
therapist also encourages her patient to correct and revise the content of 
any interventions made by the former.
In order to generate clinical data that can be used to construct a CMP, 
the patient is encouraged to provide anecdotes about interactions with 
other persons. If she tends to dwell on discrete actions, symptoms, or intra-
psychic experiences (e.g., emotions, fantasies), the patient is encouraged to 
describe the interpersonal contexts in which these phenomena occurred. 
There are four standardized sets of questions that frequently can be used to 
generate content that illuminates the five categories of the descriptive CMP:
1. Acts of Self: What are the patient’s wishes and intentions regarding 
the other person? How does the patient behave toward the other 
person? What is the nature of the patient’s sentiments about the 
other person?
2. Expectations of Others: What does the patient assume or expect 
will be the other person’s actions, intentions, and sentiments toward 
her?
3. Acts of Self-Protection: What maladaptive interpersonal strategies 
does the patient use to avoid the anticipated negative reactions of 
others?10
4. Perceived Acts of Others: How does the patient perceive and inter-
pret the actions and intentions of the other person? What are the 
patient’s reactions?
5. Introject (Self-Image and Self-Treatment): How does the patient’s 
experiences of the interactions and relationship with the other 
influence the manner in which she views and treats herself?
TREATMENT PLANNING AND PRACTICE
An essential feature of a patient’s CMP is its rigidity, marked by a self-
fulfilling prophetic interpersonal pattern of expecting, unwittingly evok-
ing, and then reacting to negative responses from others. Treatment, 
therefore, involves increasing the patient’s awareness of how she is relating 
to self and others. The goal is to create possibilities for relating in more 
satisfying and emotionally meaningful ways by increasing insight through 
shining a light of detailed understanding on her CMP and by creating 
128 HanDbook of PsyCHoTHEraPy CasE formulaTion
opportunities for corrective interpersonal experiences in significant rela-
tionships and within the therapeutic relationship.
The case formulation is a conceptual map of the problem context that 
provides an initial direction and continuing guide for treatment. Without 
a formulation, a therapist would be navigating in the dark, diminishing 
the potential efficiency and effectiveness of her work. However, it is not a 
final understanding of the patient’s problems; rather, it is a heuristic guide 
for inquiry to organize clinical data that otherwise may appear unrelated 
and discontinuous. The case formulation is always partial and preliminary 
and therefore subject to continued scrutiny and revision as necessary. A 
therapist is wise to maintain a tentative attitude toward the CMP, because 
people’s lives are complex and multifaceted. Therapistscannot hope to 
achieve an exhaustive or final understanding of a patient, no matter how 
long therapy were to continue (Strupp & Binder, 1984).
The process of gaining an understanding of a patient’s problems over-
laps the efforts at resolving these problems. Diagnostic and intervention 
activities should always proceed simultaneously. To paraphrase Donald 
Schön (1983), a social scientist who studied the performance of profession-
als across different knowledge domains: The problem situation is changed 
in the process of understanding it, and it is understood in the process of 
changing it. For instance, pointing out the inconsistent and illogical com-
ponents in a previously unquestioned pattern of thinking and behaving can 
elicit useful diagnostic information and, at the same time, instigate thera-
peutic self-reflection and self-questioning.
In choosing a content path to explore, a therapist often is faced with 
several possible paths and needs to choose the one path that appears to 
offer the most productive route by which to understand the patient’s cur-
rent predicament. Choosing the content of the CMP involves clinical judg-
ment, which can be aided by the following criteria:
1. The narrative theme represented by a CMP provides a plausible and 
meaningful explanation of the patient’s symptoms and associated 
problems in living.
2. The components of the pattern recur frequently and often with 
noticeable emotional intensity.
3. The pattern is part of what appears to be a predominant dysfunc-
tional style that contributes to interpersonal difficulties and leaves 
the patient feeling anxious, depressed, and unfulfilled.
4. The interpersonal pattern represents a plausible, meaningful, and 
heuristically useful facet of the patient’s life story.
Congruent with our view of the nature and role of psychotherapy case 
formulation, it is not presented to the patient as a finished product. Ini-
tially, identified elements of it are presented to the patient in the form of 
 The Cyclical maladaptive Pattern 129
fragments of an incomplete story that requires elaboration or in the form of 
a question about some narrative inconsistency or contradiction that arouses 
the curiosity of both therapist and patient. Although the therapist may have 
hypotheses about an elaborated version of her patient’s personal storyline 
and CMP, as treatment proceeds, she is always open to revisions of her ini-
tial predictions, as well as to unexpected data that change the complexion 
of the story. The therapist’s and patient’s judgments about clinical improve-
ments are the primary measures of therapeutic progress and indirect assess-
ments of the validity of the developing case formulation. However, empiri-
cal tools for evaluating ongoing clinical improvement, such as the Outcome 
Questionnaire 45 (OQ-45; Lambert, 2010), can provide a valuable second 
opinion about clinical improvement and thus the usefulness of the case 
formulation.
CASE EXAMPLE
Introduction and Presenting Concerns
Margot, a 28-year-old, White, married, heterosexual woman, presented 
to treatment with painful and paralyzing self-doubts and difficulty estab-
lishing her career. She entered therapy with a mid-career therapist who 
maintained his own private practice. He was trained in TLDP as part of 
the “Vanderbilt II” research project (Strupp, 1993). The two met for 25 
sessions, and both participated in the research protocols. At the start of 
the therapy, Margot reported symptoms of depression: feeling increasingly 
sad, unworthy, uninterested, unmotivated, and generally lethargic. She was 
tearful as she described a sense of disappointment in herself and an expec-
tation of criticism and rejection from others. She spoke of herself as lazy, 
criticizing herself for not finding a job after moving a year earlier. Feeling 
sensitive to how others related to her, she indicated that she readily picked 
up on hints of what she perceived as rejection. She also described herself as 
deferential, immediately agreeing with what others said without consider-
ing what she thought. Her self-consciousness and deference, however, were 
matched by a sense of superiority regarding her intelligence and capabili-
ties, emerging in statements that she had always done well in school and 
“nothing can be that hard.” Furthermore, she spoke of having high stan-
dards for others and often feeling disappointed, particularly by authority 
figures.
Margot cried easily at the start of therapy, and she indicated feeling 
as though she could not control her crying. Yet Margot spoke with a con-
trolled voice that conveyed a rather intellectualized, analytical manner. 
She was clearly very bright and highly verbal and articulate. She tended to 
laugh quite a bit and regaled the therapist with stories or observations in 
a rather coquettish manner. She was concerned with making progress in 
130 HanDbook of PsyCHoTHEraPy CasE formulaTion
treatment, conveying that she wanted to be “fixed” immediately. At the 
same time, when she shared her feelings or thoughts, she tended to provide 
herself reassurance or normalize her feelings just as a therapist might, if 
Margot did not already do so. She expressed uncertainty about whether 
therapy was an unnecessary “indulgence” and complained mildly that the 
therapist was not doing enough or getting it right.
Identifying Margot’s Dominant Interpersonal Themes
As noted earlier, TLDP case conceptualization begins with identifying 
dominant interpersonal themes. We listen for interpersonal themes as the 
patient describes significant others in her life and relays stories of her inter-
personal interactions. In Session 1, Margot relayed that, as a child, she 
experienced her father as demanding, expecting great accomplishments 
and perfection from his daughter. She noted that she could achieve for him 
in her schoolwork and musical performances:
“My father, he traveled for his work, so he was gone a lot, 8 months at 
a time. Looking back on it, it was tough to reestablish a relationship 
every time he came home. I think it was hard for me to perform the 
way he wanted me to (tearful) because we didn’t connect that well. 
I probably felt like I was performing for him. I think that’s how he 
was trying to show me that he cared about me, by being proud of 
my achievements. And I think what I wanted was for him to love me, 
whether or not I achieved something fantastic.”
Margot’s father was relatively absent, but he took on a large presence 
in her mind. Margot recalled that she learned to anticipate what her father 
wanted, feeling as though he didn’t really know her or see her as her own 
person. Margot stopped talking to her father 2 years prior to the treatment, 
apparently frustrated that he did not regard her needs and feeling as though 
he simply assumed she would accommodate him.
Margot described a close relationship with her mother, increasingly so 
after her parents divorced. She indicated that she idealized her mother, but 
in time, it would become clear that she was also critical of her mother. Fur-
thermore, she conveyed that her mother was critical and insensitive. Mar-
got seemed minimally aware of this contradiction and her ambivalence, 
perhaps another example of her efforts to please others while suppressing 
awareness of her own experience.
Her story of her relationship with her husband was comparatively 
bland, but also reflected how she seemed to gloss over her disappointment 
and ambivalence in favor of preserving some semblance of a relation-
ship. There was a sense of emotional distance as she described her mar-
riage. In the same breath, she spoke casually about considering leaving 
 The Cyclical maladaptive Pattern 131
her husband, while also indicating that they were compatible and had a 
good marriage. Yet, Margot reported she was “frigid,” referring to hav-
ing little interest in sexual intimacy with her husband, and he seemed to 
have accepted this.
“Lately, I really thought a lot morethan I ever have before of leav-
ing him. For years and years and years, my husband didn’t think he 
wanted children at all. Over the years, I thought, if I just wait—if it’s 
really important to me, eventually he will come to want the same thing 
too.”
In Session 2, Margot’s experience of authority figures emerged, when 
Margot told the therapist she was angry with him for not understanding 
her level of distress:
“At first I was angry at you and then I realized what do I have to be 
angry at him for? But I didn’t have a real good reason. I have these 
incredibly unrealistic standards for authority figures—bosses, instruc-
tors. I think I’d put you in that category too. Over and over again, 
you know, these people in my life have failed to live up to the stan-
dards, which they don’t even know what they were. I get angry, and 
it’s crazy.”
These stories contributed to the developing understanding of a salient 
interpersonal narrative. Margot’s attunement to her father became a tem-
plate for how she related to others, and also what she wished from others. 
Margot indicated she often felt angry with authority figures who disap-
pointed her expectations. She also spoke of difficulties assuming authority, 
because she worried about how others would see her. Linking her frustra-
tion with authority figures to her therapist pointed to a possible under-
standing that the patient was sensitive to feeling she was not being taken 
seriously, or cared for sufficiently, by him.
It is important to recognize the duality of the patient’s interpersonal 
narrative. As much as the patient insisted she had difficulties with author-
ity and could not express her anger or needs, we cannot ignore that she 
began the second session stating that she was angry at the therapist. It 
appears that she had the capacity to psychologically identify with the 
authority figure and assert her expectations and demands as an authority 
figure might. At the same time, she may have been trying to please the 
therapist by anticipating and fulfilling his interest in transference. She was 
making an effort to not gloss over her more negative feelings, but this may 
have been in an effort to be a good patient/good girl. The dominant inter-
personal themes focused on authority, expectations, criticism, acceptance, 
and availability.
132 HanDbook of PsyCHoTHEraPy CasE formulaTion
Margot’s CMP
Wishes/Desires in Relationships
Margot described her wishes to be loved and recognized regardless of her 
abilities and achievements.
Expectations of Others
Margot indicated that she anticipated criticism and rejection if she did not 
perform well.
Acts of Self-Protection
With a tendency toward intellectualization, Margot tended to avoid shar-
ing her emotions and needs with others. Instead, she strove for perfection 
and wished to please others by anticipating what they wanted from her. She 
came across as confident and resorted to being critical of others when she 
was less in touch with her own sense of insecurity.
Acts of Others
Margot often described others, particularly authority figures, as neglecting 
to recognize her in some manner (teachers did not call on her, the therapist 
misunderstood her). Because Margot was likely to come across as self-suffi-
cient, given her efforts to be successful, others were apt to miss her need for 
reassurance and her sensitivity to feeling criticized or rejected.
Acts of Self toward the Self
Without recognition of her own desires and needs, and missing praise that 
fed her self-worth, Margot was vulnerable to feeling inadequate and empty, 
and she struggled with a fear of being discovered as a fraud. She was also 
apt to feel angry with herself and others.
Conceptualization over the Course of Treatment
In Session 3, Margot further weaved themes of authority, disconnection, 
and criticism related to her parents. She seemed to paint a picture of her 
mother as hypercritical, and, in turn, Margot saw herself as hypersensitive. 
Her father was emotional and dramatic; he apparently displayed intense 
feelings that “colored his perception.” Margot felt she was often in a posi-
tion of having to tell her father to calm down. The therapist pointed out 
that the patient was “working on your father’s issue of feeling intensely, and 
your mother’s issue of being critical, and that those things are really clob-
bering you.” Margot’s follow-up response echoed the therapist’s notion of 
 The Cyclical maladaptive Pattern 133
split identifications, as she spoke of needing to integrate “two very different 
parts of me.” This deepened the case conceptualization to include both the 
patient’s vulnerable self-image associated with feeling hurt and rejected and 
her mode of being critical and dismissive of others, a way of relating that 
unwittingly contradicted her core wish to be close to and known by others.
In Session 4, Margot reported that she was considering applying to 
graduate school but feared that she would not be admitted or that she 
would procrastinate. She shared that she attended a highly prestigious pri-
vate university but left because she didn’t always receive high marks. The 
therapist challenged her perfectionism: “So you have this view of yourself 
that you’re not nearly good enough, and that you should be at the top. How 
are you going to put those two things together?” The therapist was help-
ing the patient explore how she held onto wishes for perfection in order to 
maintain her connection to her father.
In Session 5, Margo shared that she felt jealous of her mother’s friend, 
a hint of her underlying yearning for her mother’s attention. She also spoke 
of feeling embarrassed about how her mother interacted with others. The 
therapist used this opportunity to encourage the patient’s development 
toward more mature relating, which he defined in terms of allowing her 
parents to have their own lives. This way, she could have her own life with-
out the pressure to be perfect for her parents. Thus the conceptualization 
was further deepened with an understanding of how Margot’s perfection-
ism fed her internalized connection to her parents but disrupted her capac-
ity for mutual relatedness.
Session 6 evidenced a pattern in which Margot struggled to please the 
therapist as an authority figure and then became profoundly angry with the 
therapist about her lack of progress. At the end of this session, she announced 
she would quit treatment, but then she returned at the next session. Margot 
presented a dream of being a little girl in a classroom, but in which there 
is no desk for her because no one paid the tuition. She interpreted, “I’m 
rushing around, trying to please authority figures. On the one hand, being 
unwilling to give authority figures what they want [i.e., the tuition], but 
on the other hand, expecting some special recognition from them.” They 
discussed the patient’s efforts to please the therapist and then being angry 
with him. Margot quickly took it on herself. The therapist encouraged her:
Therapist: Let’s see if we can talk about us without putting you down.
Margot: (tears) Either I should be working and using the time, or I 
shouldn’t be here.
Therapist: But isn’t that what you’re doing right now? Dealing with the 
issue of making me okay and making you not okay. Isn’t that what it’s 
all about? What if we made real progress on that?
Margot: (sigh) Yeah. (sigh) I guess I do one or the other—either I reject 
the other person and make myself the superior one. Or, the other way, 
134 HanDbook of PsyCHoTHEraPy CasE formulaTion
I’m inferior. It’s so much easier to be superior. The only way I know 
how to get along is to be the good kid. I don’t want to do that anymore. 
I don’t like it. I wound up rejecting and being unable to learn from 
people. Have so many standards and people can’t meet them.
Here, Margot articulated her ways of protecting herself against the dreaded 
experiences of emptiness and self-criticism when she had not managed to 
receive