Use PRESS to craft a concise psychodynamic formulation

More and more time is being allocated to training psychiatric residents in cognitive-behavioral therapy and crafting a cognitive-behavioral formulation. However, the psychodynamic formulation, once considered the backbone of psychiatry, should not be forgotten. The psychodynamic formulation is a cohesive portrait of an individual’s inner world based on the biopsychosocial approach.¹ The purpose in crafting a psychodynamic formulation is to create a succinct and focused case conceptualization that can guide treatment and anticipate possible outcomes.^2,3 To teach this in a simple, prac­tical, and relatable way, we propose an approach that can be summarized with the acronym PRESS.

Psychologically minded
Can the patient be introspective and contemplate his (her) thoughts and feel­ings before acting? Without the capacity to look within—distinct from intelli­gence—a patient could struggle with the psychodynamic approach and could benefit from a more supportive form of psychotherapy.⁴

Relationships
Examine the patient’s relationships with others:
• Who are the prominent people in his (her) life?
• What are his interpersonal relations like?
• How does he (she) recall important relationships from the past?
• Do these relationships appear to be recurring?⁴

Just as themes and patterns recur, so do relationships. Predict how the patient’s relationship pattern could be recreated in the therapeutic dynamic and how this could influence treatment. Then, by examining this transference and coun­tertransference data, you can illustrate a pattern from past relationships that is being recreated in the doctor-patient relationship.^3,5

Ego strength
Determining how the patient expresses or inhibits wishes and exhibits impulse con­trol can shed light onto how he operates on a daily basis:
• Does he have the ability to regulate his impulses?
• Is he capable of anticipating the conse­quences of inappropriate action?
• Does he show a lack of insight and judgment by exhibiting too many repetitive maladaptive behaviors?

Additionally, how does the patient keep unwanted fantasies, wishes, and memo­ries out of conscious awareness?

Identifying which constellation of defense mechanisms the patient is using can help categorize his level of functioning and personality type, and identify anxiety-provoking thoughts and events.^1,6 Often, one of these situations has consciously or subconsciously triggered the need for psychotherapy.

Stimulus
The hallmark of any psychodynamic formulation starts with a concise sum­marizing statement that describes the fun­damental details about the patient and his motivation for treatment.² Determining the patient’s impetus for treatment is 2-fold: Why does the patient want to receive treat­ment? Why now?

Superego
Review the patient’s ego ideal—what one should not do—and the moral conscience— what one should do.¹ Do there seem to be any deficits (recurrent shoplifting, crimi­nality, etc.)? Who contributed to his sense of right and wrong, and how harsh or lax is it? Is the patient self-defeating or self-punishing? Contrarily, does the patient seem to have little conscience?

Acknowledgment
Franklin Maleson, MD, provided advice and input to the authors.

Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.