Formulation as a Basis for Planning Psychotherapy Treatment

With decreased funding for supervision of medical and psychology training programs, clinicians have focused on case formulation involving short-term interventions, brief therapy, and/or short-term psychotherapy. More recently, some clinicians have argued for psychotherapy case formulation focusing on longer-term psychotherapy models of care (1). In an era of managed care, psychotherapy is a lost art/science in some sectors of the mental health community. There is a need for senior supervisors and master clinicians to present their ideas to a general audience. Dr. Horowitz’ book Formulation as a Basis for Planning Psychotherapy Treatment is just such an enterprise. Whatever the book’s shortcomings, it provides trainees with access to the thinking of a senior clinician who provides an expert supervisory model for approaching treatment planning in a psychodynamically oriented psychotherapy involving the goal of changing the structure of one’s self.

Over the years, Dr. Horowitz has provided his readers with an array of books on important topics in psychopathology and treatment. In this highly condensed, slim volume, he presents some very complicated ideas about how psychotherapy can effect real change in self structure. He does this with a unique supervisory style in a highly schematic context that provides us with many clinical gems. What is lacking in this tome is a rich array of clinical material and verbatim clinical process notes that would have offered more clarity to the process of how psychotherapy case formulation leads to change.

Dr. Horowitz says the goal of his book was “to teach a hypothetical trainee to go beyond diagnosis to the kind of formulation that helps facilitate adaptive change in psychotherapy.” The main chapters of the book focus on the following: examining the phenomena under investigation; delineating the individual’s states of mind; observing themes of conflict and defensive control processes; inferring core pathological beliefs and relating them to contradictory identity, relationship, and value experiences in different states; and looking at treatment planning in terms of “what can this patient change now?”

Unless one is familiar with Dr. Horowitz’ core concept of a self state, which he has focused on in earlier writings, the ideas presented in this book may be too confusing for the “hypothetical trainee” to comprehend—especially the material on self states and the concepts of modulation of self states (well-modulated, undermodulated, overmodulated, and “shimmering”).

Dr. Horowitz has established himself as an expert in the areas of psychotherapy, defensive-control processes, neurotic functioning, and characterological issues in psychotherapy. His concept of cognitive psychodynamics is well regarded and woven throughout most of the themes in this book. However, the examples and texts given in this volume are so schematic and diagrammatically presented that, at times, the clinical gems can be lost in the tables and diagrams of the role relationship model. Chapter 6, however, is excellent and should be required reading in a course of psychotherapy planning.

The phenomena of self states and self coherence are critical concepts for clinicians. These concepts underscore the crisis in current psychotherapy. For many clinicians, psychotherapy has become mere symptom stabilization (influenced by a managed care approach to brief interventions) involving short-term or brief psychotherapy to stabilize the patient’s acute symptom presentation. Horowitz is focused on the more enduring aspects of the self and its conflicts. He sees the need for understanding and working through the psychodynamic conflicts that may have led to impaired self states or self fragmentation. Working with pathological self states in psychotherapy can led to real change in self states and self functioning. This goal characterizes the core issues of Horo-witz’ cognitive psychodynamic psychotherapy.

During the past two decades, the field of long-term psychotherapy has been broadened and widely influenced by the dovetailing of rich traditions in psychodynamic psychotherapy, self psychology, object relations theory, cognitive behavior therapy, and relapse models from the addiction literature. All of these traditions seem inextricably related to Dr. Horowitz’ main theses, and it would have been helpful for such an integration to have been made in the text and references. For example, Dr. Horowitz’ identification of symptom triggers seems identical to the use of triggers in the relapse prevention models in addiction, and acknowledgment of those traditions would have been expected.

Writing shorter-length books has its shortcomings. Throughout the book I found that the ideas presented were too schematized and condensed. Dr. Horowitz is a marvelous clinician, and a longer book would have allowed more breadth and depth to include more rich case examples. Fans of Dr. Horowitz may forgive him for the array of complex diagrams he uses to depict how to formulate the goals of psychotherapy and focus instead on the clinical insights and gems, which occur regularly in this book.