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Formulation as a Basis for Planning Psychotherapy Treatment, Second Edition

Mardi J. Horowitz, M.D.

  • ISBN 978-1-61537-218-8
  • Item #37218

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Formulation as a Basis for Planning Psychotherapy Treatment utilizes a step-by-step structure and copious case illustrations to teach psychiatrists, residents in psychiatry and psychology, social workers, and marriage and family counselors how to plan treatment after the initial diagnosis. This new edition arrives two decades after the first, with revised content, updated case studies, and new insights gleaned over the author's noteworthy career. Clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualization of the information obtained from a clinical assessment. Although formulation systems vary by different schools of psychotherapy, the author has adopted and here explores a systematic approach based on an integrative effort. This system of configurational analysis combines concepts derived from psychodynamic, interpersonal, cognitive-behavioral, and family system approaches.

After an overview of psychological change processes, each of the five steps of configurational analysis is covered systematically:

  • Step one involves selecting and describing the patient's currently most important symptoms, signs, problems, and topics of concern. For example, symptoms may consist of trouble sleeping or feelings of depression; signs may include discordant verbal and physical expression; problems may include reluctance to go to work or care for family members; and topics of concern might be unresolved grief the patient feels helpless to process without assistance. Since both patient and therapist want to know if these observable phenomena are changing, this list is modified as treatment progresses.
  • Step two entails describing states in which the patterns of phenomena do and do not occur, with attention to patterns of shifts in states, especially maladaptive state cycles. The therapist is taught how to aggregate and organize this information by describing states of mind—for example, undermodulated (e.g., unthinking rage) or overmodulated (e.g., numbness and lack of affect).
  • Step three involves describing the challenging topics that patients may both approach and avoid because they are conflicted or unresolved, as well as the obstacles patients may create to divert attention from those topics. For example, patients may avoid a topic or shift attention from it by changing the subject and so forth.
  • Step four entails describing the organizing roles, beliefs, and scripts of expression and action that seem to organize repetitions in each state, with an effort made to identify dysfunctional attitudes and how these may have evolved from past attachments and traumas.
  • Finally, step five involves figuring out how to stabilize working states by enhancing the therapeutic alliance and helping the patient contain and master emotional attitudes. At this point, the clinician plans how to counteract avoidances by direction of attention and promotes adaptive social cognitive capacities.

From surface observation to deeper inferences, Formulation as a Basis for Planning Psychotherapy Treatment transcends DSM diagnoses, helping clinicians to use information gleaned in the immediacy of the moment to make sound, sensitive, and effective psychotherapeutic decisions.


  • Foreword
  • Introduction
  • Acknowledgments
  • Chapter 1. Formulation: STRATEGIES AND TACTICS
  • Chapter 2. Phenomena
  • Chapter 3. States of Mind
  • Chapter 4. Topics and Obstacles
  • Chapter 5. Self and Relationships
  • Chapter 6. Personality Functioning and Technique
  • Chapter 7. Focusing Attention
  • Glossary of Terms
  • References
  • Index


    Glen O. Gabbard, M.D.

About the Authors

Mardi J. Horowitz, M.D., is Distinguished Professor of Psychiatry at the University of California, San Francisco. He is past president of the San Francisco Psychoanalytic Institute, the San Francisco Center for Psychoanalysis, and the Society for Psychotherapy Research.

Dr. Horowitz' new book illuminates a grey area in psychotherapy practice about which too little has been written: how to construct individualized, carefully thought out treatment formulations, and their impact on how to conduct psychotherapy to best promote the personal change patients seek. Lucid and well written, the book approaches individualized case formulation using perspectives from a wide range of clinical domains with detailed descriptions of differing formulation approaches. The book is a must-read for early psychotherapists and provides detailed guidance to structuring psychotherapy.—Barbara Milrod, M.D., Professor of Psychiatry, Weill Cornell Medical College

Mardi Horowitz is one of our most original, insightful, and enduring quantitative and qualitative researchers, theoretical scholars, and outstanding clinicians concentrating on empirical aspects of psychodynamic and psychoanalytic psychiatry. Here, in lucid trans-theoretical language he illustrates how practitioners can configure key clinical phenomena including fluctuating states of mind, life events, thematic concerns, obstacles, shifting self-concepts, cognitive, coping and attachment styles, relationships, and other clinical data to create nuanced biopsychosocial formulations, proceed with therapy in the trenches, and focus patients' attention on what matters most. Clinicians at every level, from novices to experienced hands, will be greatly enriched by his wise words, informative clinical examples, and practical guidance.—Joel Yager, M.D., Professor, Department of Psychiatry, University of Colorado School of Medicine, Professor Emeritus, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Professor Emeritus, Department of Psychiatry and Behavioral Science, University of New Mexico School of Medicine

The overall quality of this book is high. It is concise but complete and a highly relevant introduction to using formulation as a basis for psychotherapy in an individualized manner. It is a welcome addition to formulation guides, which are often overly detailed for therapists early in their training or excessively rigid in their application to the point of depersonalizing formulation. The book meets its objectives by remaining focused on the uniquely human stories, unconscious forces, problem behaviors, current states of mind, personality schemas, and defenses present in therapy. It encourages a flexible approach to formulation that is open to revisions, as an important reminder to early therapists. By distancing itself from a checklist approach to formulation and elucidating how to use more organic observations and listening for themes that the patient is revealing, the book emphasizes a more useful and intuitive approach to formulation that likely gives therapists better guidance on areas of focus and pacing of therapy and has a more human feel than other methods.—Daniel M Tuinstra, M.D., Doody's Book Review

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