When Formulation Outweighs Diagnosis: 13 “Moments” in Psychotherapy

The psychiatrist renders a diagnosis, comes up with a formulation, and then simultaneously uses both frameworks to treat patients. In clinical situations, however, there are times when one is in ascendancy while the other lies temporarily dormant. This article deals with the doctor's particular emphasis. It presents 13 cases in which treating the "formulation"--at least temporarily--outweighs treating the "diagnosis." Furthermore, the authors present their ideas according to what circumstances favored "formulation" over "diagnosis" in three ways: (1) when the child needed to achieve trust; (2) when the child needed to deal with an inner conflict; (3) and when the child's identity was at risk. Thus, in the 13 cases described, the authors demonstrate that the doctor's quick, timely, often intuitive, and sometimes unexpected, use of monologues, metaphor, play, jokes, secrets, revelations, and just-plain talk all serve to create climactic turnarounds in children. The common thread running through all these cases is that "formulation" outweighs "diagnosis" when a child's difficulty is largely psychological or developmental.