1. Formulation in the PWC: a relational and Attachment Approach
Loyola McLean
Associate Professor Brain and Mind Centre
Consultant Psychiatrist and Psychotherapy Educator, SWaGS Psychiatry Training Network, WSLHD
Faculty Member Westmead Psychotherapy Program
Research Psychiatrist, C-L Psychiatry, RNSH
And thanks to Joan Haliburn and Tony Korner and colleagues at the Westmead Psychotherapy Program for their ongoing teaching on formulation
Thanks to Keryl Egan for the original self-disorder chart

2. We are often dealing with Dark Matter

3. The Orion nebula: Joining the dots makes a picture, tells a story

4. FORMULATION: the connecting story
Psychodynamic formulation is grounded in personality theory and psychopathology
Formulation is a concise but creative understanding of the patient and his/her problems in the light of historical information, emotional expression, coping strategies, and the manner of relating with others, past and present, including with the therapist in the here and now, which informs the therapist’s and dyad’s choice of how to proceed.
It provides a road map that can kickstart the collaboration, guide the therapeutic process and content of the technical interventions and overall management

5. FORMULATION -continued
Creatively organizing clinical data generated from the patient’s presentation of his/her problems, symptoms, difficulties and strengths, current and past significant relationships
The conversation to enquire, explore and understand these
The therapist is in a position to offer for collaborative consideration a succinct conceptualization of how problems in the here-and-now may be linked with the patient’s significant past and current relationships

6. The tasks of a healthy self
To manage reality with it’s stresses and strains
(The reality principle, Freud)
To rest, play, love, work. (Freud had the latter 2, Winnicott added play, infant research has implicitly added rest/soothing)
Learnt in relationship
To survive but also to live creatively
To manage stress so as to enjoy a sense of vitality: in touch with both external reality and inner life, integrated
To play in the world, story, dream
To engage: not just comply or disengage
To reflect and integrate information (the facts and the feelings) and experience of self and other

7. The tasks of a healthy PWC
To manage reality with it’s stresses and strains
To rest, play, love, work.
Learnt in relationship, modelled by the supervisor
To work and survive the case, but also to live creatively, collegially
To manage stress so as to enjoy a sense of vitality: in touch with both external reality and inner life of the training experience, integrated
To play in the world, story, dream
To engage with patient, self and supervisor; not just comply or disengage
To reflect and integrate information (the facts and the feelings) and experience of self and other with the support of a supervisor

8. KEY PRINCIPLES CHOOSE A CASE WISELY
Focus on one or two key themes that trainee and supervisor and patient feel are important to patient’s problems
Try to link important aspects of developmental experience (attachment, Eriksonian, self development, early loss/trauma/neglect, some positive experience) with presenting problems, predisposing, perpetuating and protective factors
Remember that ACEs and Attachment, Loss and Trauma have strong research bases
Understand the attachment states of mind and current attitudes to complexity and incoherent strategies: “Cannot Classify” as Ds/E and the importance of disorganization
Identify important stressors that may have served as triggers to the problem and broken down homeostasis or provided a challenge or stimulus for development
Identify unpleasant affective (bodymind) states that may have led the patient to seek treatment: understand negative affects, the fear cascade and dissociative states.

9. Patterns: eg. The single devastating blow or coup de grace
The straw that breaks the camel’s back
The fragile eggshell and the triggering tap
The earthquake
The call to growth
Finally there’s some solid ground to build the house!
Etc.

10. Assessing with an Ear/ Eye for Attachment
Listen for
Symptoms (self-regulation, relatedness, rest, work, play, love) and their patterns
story/attachment themes (the narrative) and HOW they tell it
Secure/dismissing/preoccupied/disorganised
Consider regulation/behaviour/cognition/discourse
states of mind/body/bodymind (shame, dissociation, fear cascade
attachment interpretation
management opportunities
Tune your empathy instrument and resonate
Use you observational skills and gather the data
Include the Movement and Feeling of the alliance: in vivo data

11. Attachment states of mind (McLean, 2004, 2008,2012)
A: DISMISSING
I have to do it myself as
Others are not helpful / reject me
I am shameful / contemptible when needy
I avoid /minimize feeling
I focus on:
being Independent/strong
achievements/fun/things
material success
B: SECURE
I am free to ask for help As
I am lovable
Others are useful and reliable
I am free to:
- Value relationships
- Express emotion openly & directly
- Express myself
- remember clearly
C: PREOCCUPIED
I can’t do it myself
But
Others are unreliable
I am untrustworthy
I feel :
Anxious/angry/blaming
- Lost in memories
- Helpless/hopeless/useless
If I scream they might hear
I remember too vividly
D:DISORGANISED
(I ) can’t do it
But
Others will make it worse !
Those who should help
- Are frightened/frightening
- I feel dreadful, disconnected,confused
- Bad, fragmented : AFRAID

12. The ‘breakdown’ at presentation
Of a life, of a sense of well-being
Of a relationship
Of a strategy
Of a self or a story of self
Of breakdowns of personal integrative function (Homeostasis):
reasoning/ discourse/ behaviour/ perception (trauma / loss markers)
Macrotrauma
Microtrauma
Need for urgent development
Finally space for development

13. The usual substrates -1 Genetic predisposition
Developmental/early life experiences
Vulnerable physiology

14. The usual substrates -2 Brain injury Illness, eg HIV, fractured NOF
genetics – short-changed on the short arm of the serotonin transporter
Epigenetics
Substance use

15. The usual suspects Loss Trauma Neglect/Deprivation Conflict
Too many stressors/ Too much stress!
Occasionally even positive valence experiences are too intense and stressful
New experience can trigger insight/ feeling/ memory re past difficult experiences

16. Loss, Trauma, Neglect Disorganizes, restricts consciousness
Breaks down reasoning, discourse, behaviour , perception.
Eg bereavement
Loss of spouse/parent/child (!)
Challenge to accept that the one who was there is gone and to reorganise to function and feel without their external presence

17. The usual symptoms Rest, Play, Work, Love Mood Anxiety Substance use
See the breakdowns (self, relatedness, reasoning, cognition, language, behaviour, perception)
Self-esteem
Self-cohesion and regulation and function breakdowns
see symptoms in this way eg sleep, appetite, energy, BP etc
Bias shifts (eg towards negativity)
Relationships
Rest, Play, Work, Love

18. dynamic/Longer Term/integrative therapies
Necessary to repair more prominent restrictions/ challenges to self
E.g more extensive problems with self-regulation
Necessary in treatment-resistant disorders
At times CBT or other therapy not acceptable/doable for patient or hasn’t worked
Fosters better coping styles/strategies
But 40 sessions is a “short” long case, can’t achieve everything
Be clear why this treatment is needed in this patient at this time, and nothing else will really do or that this is the wisest option

19. Similarities of Psychotherapy And Supervision with early attachment
Importance of the relationship:
reliability,
safety,
trustworthiness,
enough comfort, zone of proximal development!, scaffolding
Working towards being, thinking and “playing” together
mutual delight

20. Dynamic Formulation Considerations
Dynamics: use a model
eg attachment states of mind/ Or object relations point of view/Or self-psychology etc
Developmental stage
Eg self and affect regulation, modes of communication, Eriksonian
Level of self disorder and function
For the PWC needs not to be too severe
Track record in relationships
Needs some secure-base experiences in the past
Precipitating factors
Can we generate shared goals?

21. Severity/Level of Self disorder/Symptoms Orange: prepare to STOP Red: DO NOT GO THERE
Mild
Moderate
Severe
Very severe
Affectivity -
Mild Anxiety/
low SE
Restricted
alexithymia
flooding freeezing
Agency +
Ownership
boundaries
Continuity
+/-
Time /money problems
Significant Memory gaps
Cohesion
Fragmentation

22. Colour/affect
Affectivity/ affective colour: describes the range, richness and modulation of available affect which gives colour to experience and motivates.
It also has a relative fixity biologically and so gives continuity of experience across development

23. Agency/Choice
Agency: experiencing oneself as the centre of initiative in one’s life with a sense of authorship over one’s own actions and nonauthorship over the actions of others.
It comprises volition and choice.
It may well begin with the cocreated ‘illusion” of independence by parent and child (or therapist and patient/client) cooperating that then proceeds to greater autonomy over development.

24. Continuity
Continuity: which is the capacity to feel oneself over time, enduring and ongoing with respect to the past, despite change (what Winnicott termed the “going on being”).
Motor and affective memory are probably the beginnings of this with visual and verbal and true narrative/autobiographical memory developing later.

25. Cohesion: a sense of holding together in one’s experience;
an integrated physical and emotional whole with boundaries and a locus of action.
Stern describes coherence of both time and form
Needs affective and cognitive and somatic integration

26. Collaboration
Can the individual let in help comfortably and enjoy the process of creating a solution together?
In some ways this is a higher order system
Liotti argues collaboration is a human evolutionary achievement.
It builds however on the solidity of security but can be used to (re)build it.

27. Severity/Level of Self disorder/Symptoms
Mild
Moderate
Severe
Very severe
Affectivity -
Mild Anxiety/
low SE
Restricted
alexithymia
flooding freeezing
Agency +
Ownership
boundaries
Continuity
+/-
Time /money problems
Memory gaps
Cohesion
Fragmentation

28. FORMULATION: INITIAL PRESENTATION From “Starting the Long Conversation” (HETI film)
Anna a single woman in her mid thirties was referred for psychotherapy in the context of long-standing difficulties in coping despite medication and group therapy. She continued to experience chronic depressive and anxiety symptoms since childhood, difficulties with emotion regulation and problems in personal relationships and capacity to study or work. She was experiencing chronically low mood, an ambivalence about painful feelings, problems asserting herself in relationships and vulnerability to episodes of mood lability which she managed with binge eating or exercise. Medication had been partially effective in treating her mood symptoms, but had not changed her subjective sense of self, relationship struggles or her past experiences of rejection and invalidation. She had one significant overdose that had led to a hospital admission but that was twenty years previously and had not been repeated. Anna was motivated to engage to change her pattern of interpersonal relationships and to understand her past and feelings of depression and low self-esteem. .

29. FORMULATION: INITIAL PRESENTATION From “Starting the Long Conversation” (HETI film)
She a family history and likely genetic vulnerability to depression in that her mother had known postnatal depression. In addition to Anna’s biological predisposition to depression, she believed that her problems started during childhood where she described a poor attachment with a depressed mother and a critical father. It is postulated that the ongoing neglect and rejection by her mother and the criticism of her father led to impaired internal working models of herself and others. A shy personality coupled with the trauma of domestic violence in her early relationships, and an academic decline after early success had further impact on her low self esteem, difficulty with interpersonal relationships and difficulty regulating her negative emotions. A significant school move in childhood and betrayal by friends made it difficult for Anna to establish positive affiliations in the field of school and the community. Those difficulties in the adult world continued with an inability to finish study, find work and establish a safe ongoing partnership. She remained prone to suicidal ideation.

30. FORMULATION: INITIAL PRESENTATION From “Starting the Long Conversation” (HETI film)
It is proposed that Anna’s fragile sense of self, insecure attachment, shy personality and chronic complex trauma led to the development of immature and maladaptive coping mechanisms. She was prone to period of disorganization with dissociation based on the early disorganizing experiences with her depressed mother. This would be likely retriggered by relational conflict/loss and certain trauma triggers. Anna ongoingly utilised idealisation as a defence, but with devaluation of herself. She also utilised neurotic defence mechanisms such as avoidance to avoid painful affects. She had become at times preoccupied in an anxious, angry and ambivalent way with events with both parents. This underlying instability in her attachment organization, moving between dismissing and preoccupied strategies was likely to drive the instability in her personal organization and affect regulation and increase her vulnerability to depression. Recurrent periods of triggered disorganization, with likely relational triggers, would leave her vulnerable to dissociation and psychiatric symptoms and presentations with periods of poorer function and a disturbed sense of self.

31. FORMULATION: INITIAL PRESENTATION From “Starting the Long Conversation” (HETI film)
The current trigger to referral appears as a desire to try once more to change her circumstances in the light of group feedback that individual psychotherapy might be helpful and some achieved connectedness there. Despite vulnerability, she had a history of resilience and a reasonable level of premorbid functioning with recent attempts to improve her situation with group therapy. She had formed a good connection with her older sister who functioned as an attachment figure. This seemed protective with regards to her psychological development. Anna was intelligent, had good enough impulse control to be determined to not repeat past suicidal gestures and was well engaged and motivated to make psychological change. She had demonstrated ability to make a commitment to regular group work. At interview she demonstrated more cohesion and brightening with empathic attunement. These factors suggested a positive prognosis.
The treatment of twice weekly psychotherapy in the Conversational Model was chosen to address the difficulties in self-regulation and to foster greater self coherence through a psychodynamic model that has demonstrated capacity to foster self development and in time integrate relationally traumatic experiences.

32. Formulation-1- extended
The story that gives a coherent and collaborative synthesis of the data from the History of the case including the MSE and then frames the management plan
Who: Demographics ( deidentified and disguised)
What: Important particulars (again deidentified for presentation) of the person/problem/predicament
How and why: Precipitating, predisposing, perpetuating and protective factors, including developmental and relationship experiences BIOPSYCHOSOCIOCULTURAL
Patterns identified, linking past to present including deep past to here and now suggesting pathways to recovery/ integration/ growth
This is a fundamental professional and career skill!

33. Basic Attachment Reading – But it will go a long way
*Hesse Erik. ‘The Adult Attachment Interview: Protocol, Method of Analysis and Empirical Studies’. Handbook of Attachment: Theory, Research and Clinical Applications, 2nd ed, edited by Jude Cassidy and Phillip Shaver, New York: The Guildford Press, 2008. 
*Hesse, Erik and Mary Main. ‘Disorganized Infant, Child and Adult Attachment: Collapse in Behavioural and Attentional Strategies’. Journal of the American Psychoanalytic Association 48 (2000):
Fonagy, Peter and Target M., ‘Attachment and Reflective Function: Their Role in Self-Organization’. Development and Psychopathology 9 (1997): 679–700. 

34. Suggested Reading For the conversational Model
Meares R et. Al (2012). Borderline Personality Disorder and the Conversational Model: A Clinician’s Manual
See ANZAP Website for other journal articles
See the HETI films on (Starting the) Long the NSW HETI website under the Psychiatry programs: