In advanced psychoanalytic training, “formulation” is often treated as a document: a coherent story you can present in supervision, polish over weeks, and revise with hindsight. In applied psychoanalytic practice, formulation is something else entirely. It is a mode of action in the session—a way of selecting what counts as signal, deciding what to hold, and choosing an intervention that fits the patient’s psychic moment. A formulation is not a portrait; it is a compass.
From Explanation to Orientation
A clinically useful formulation does not aim to explain everything. It aims to orient you toward the next right move. It answers four questions:
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What is the patient doing to survive? (defenses, strategies, self-organization)
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What is the patient trying to protect? (vulnerability, longing, shame, dread, annihilation anxiety)
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What is being repeated here—with me? (transference, enactment, attachment pattern)
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What kind of change is currently possible? (insight, symbolization, integration, rupture/repair)
Notice that none of these are purely descriptive. Each implies a technical stance.
The Multi-Axial Formulation (Not a Checklist—A Set of Lenses)
A contemporary applied formulation usually runs on several axes at once:
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Dynamic/conflict axis: wish–fear–defense–compromise. What desire is dangerous? What prohibitions organize guilt, shame, or dread?
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Structural/deficit axis: capacities for regulation, symbolization, play, and reflective function. Where does the mind fail to form?
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Developmental/attachment axis: proximity–distance strategies, separation distress, epistemic trust, secure-base demands. How does the patient manage dependence?
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Trauma/dissociation axis: state shifts, unmentalized affect, procedural “parts,” collapse, intrusion. What cannot be remembered because it is still happening internally?
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Relational field axis: mutual influence, enactment, recognition, the ethics of the frame. What is being co-created that neither of you “chose”?
The point is not eclecticism; it is diagnostic pluralism with technical discipline.
The most common advanced mistake is not “bad theory,” but wrong dose. A conflict formulation often tempts interpretation; a trauma formulation often requires pacing and containment before meaning can be metabolized. A deficit formulation may call for reliability, empathic attunement, and minimal frustration; a relational formulation may require naming what is happening between you rather than what is happening “inside” the patient. Formulation, here, is a theory of when.
A Micro-Example: One Event, Two Formulations
A patient abruptly cancels after a good session.
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Conflict reading: progress mobilized guilt or forbidden longing → cancellation as resistance, superego retaliation, fear of dependency.
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Trauma/dissociation reading: increased intimacy triggered state shift → cancellation as protective dissociation, autonomic overwhelm, loss of reflective capacity.
Same event; different action. In the first, you might interpret the fear of closeness. In the second, you might first restore safety and mentalization, then slowly link cancellation to overwhelm.
The Clinical Test of a Formulation
A formulation is “true enough” when it changes your listening, reduces acting-out, and creates interventions the patient can use. If your formulation makes you feel clever but leaves the patient more defended, more collapsed, or more compliant, it is not yet applied. In contemporary psychoanalytic practice, formulation earns its keep only when it becomes a tactful form of care.
