1.2
Psychodynamic Diagnosis and Case Formulation
Some Core Principles for Psychotherapists
Neil Brast, M.D.
1. We treat people, not disorders.
2. Assessment must inform treatment, both in the beginning and ongoing.
a. Because a patient is referred to you with a diagnosis, you are still obligated
to conduct your own assessment. Form your own opinion. Don’t confuse the
patient with what it says in the chart or what was said by the person
referring the patient to you.
b. Be curious, continually attempt to understand the patient, whom you cannot
know a priori. Tolerate the uncertainty and anxiety associated with not
knowing. Let yourself be surprised. Avoid premature closure in your
thinking.
c. Take your time. Except in an emergency or crisis, don’t speak to the patient
of treatment until you have progressed far enough in your assessment to
have some idea of what the patient needs. Then you can convey what you
understand and what you recommend. Feel free to say, “We are working
together to understand what is wrong and what might help. That takes
time.”
d. Construct hypotheses to test, instead of rushing to premature closure and
expedient certainty.
3. Tailor the treatment to the patient, not the patient to the treatment.
4. Everyone has a personality, which includes a repertoire of psychological capabilities.
a. Though we may initially be successful at alleviating symptoms, we must aim
for lasting change, change that increases resilience, limits relapse, and frees
the patient from constrictions in living.
b. Lasting change involves strengthening of the patient’s mental capabilities
and engaging the patient in understanding themselves and becoming
active in bettering their own lives.
5. Therapeutic progress is not predicated on the theory system in the therapist’s mind
or the brand of therapy the therapist purports to practice. Rather, it depends on the
therapist’s ability to engage with and deeply understand the patient. From that
treatment flows.
6. We treat patients, not their histories. Often, because of our own discomfort with
the patient's distress and not knowing what to do, we focus on the patient’s past
and lose sight of the patient’s current suffering and difficulties in living, which
motivates the patient to seek our help.
Neil Brast, M.D.
9/24/2023