The Role of Clinical Inference in Psychoanalytic Case Formulation

By Wolitzky, David L. | American Journal of Psychotherapy, January 1, 2007 | Go to article overview

The Role of Clinical Inference in Psychoanalytic Case Formulation


Wolitzky, David L., American Journal of Psychotherapy


This article examines the role of clinical inference in the construction of psychoanalytic case formulations. The principles of analogy, especially in the context of contiguity, the repetition and convergence of themes, the theoretical predilections of the observer, and the assumptions one makes about the operation of the mind are among the major factors that influence the nature of the clinical inferences generated by psychodynamically oriented clinicians. Several clinical examples are presented to highlight the operation of these factors and how they can lead to alternate theoretical formulations.

PREFACE

My aims in this paper are (1) to demystify further psychoanalytic clinical inference by explicating its nature and processes and (2) to revisit the topic of how different psychoanalytic theories lead to different clinical inferences. Clarification of these two topics may open the way to the researchable question of whether a therapist's capacity to explicate the implicit rules of clinical evidence, upon which inferences are based, has any bearing on the accuracy of the inferences (and interpretations) generated.

With regard to the second aim, the potential value of making explicit one's implicit clinical reasoning is that one can reexamine the legitimacy of the assumptions upon which it rests. If we are able to reconstruct how certain inferences are arrived at, it is possible to question whether the clinical material compels us to consider particular clinical phenomena from the perspective of one theory rather than another. We might then be more likely to consider more the merits of alternate hypotheses.

I hope that this kind of examination will encourage empirical research on the following unanswered question: are clinicians who can articulate the bases for their inferences (even if they claim they ordinarily proceed on of intuition) more apt to arrive at accurate inferences than those who cannot explicate the bases of their inferences? The further question to be pursued is the relationship between accuracy of interpretations and therapeutic outcome. Such a program of research would have to tackle the complex, thorny problem of which criteria one would consider legitimate indicators of "accuracy" of an inference.

At present, there is some evidence that what the therapist says makes a difference in the outcome of treatment. For example, Crits-Christoph, Cooper, and Luborsky (1988) reported a significant, positive correlation between the therapist's interpretive focus on the core confiictual theme, as judged by independent raters, and favorable therapy outcome. Some clinicians (Eells, 1997; Perry, Cooper & Michels, 1987) assert that it is useful, after the initial interviews but before therapy has begun, for clinical inferences to be woven into an initial, written dynamic case formulation that becomes a blueprint for the conduct of treatment. Thus far, however, there have not been any empirical tests of whether such a procedure enhances the outcome of therapy.

INTRODUCTION

A major challenge to the psychodynamic psychotherapist is to grasp the inner life of his or her patient. Although there have been several recent attempts to describe psychodynamic case formulation (e.g., McWilliams, 1999; Summers, 2003), these efforts have not focused on the centrality of clinical inference in the construction of dynamic formulations. Without clinical inferences about the meanings of the patient's behavior, we would have only a collection of observations. Even if a therapist were to conduct therapy according to a treatment manual, there would be no guidance concerning when and how to formulate a clinical inference, that is, on what basis to ascribe motives and meanings to the patient's behavior and verbal reports. Although Freud's writings relied heavily on inferences drawn from clinical observations, he did not systematically set out a method for arriving at inferences. As is well known, he advised (Freud, 1912) that the patient free associate and that the analyst listen with "evenly-suspended attention" (p. …

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