I recently attended a webinar on case formulation in therapy led by a senior clinician whose work I respect.
What stayed with me was not just the psychodynamics of the case, but a parallel process in the group that seemed to reflect a broader cultural difficulty. What happens to clinical thinking when certain observations become hard to name?
In this case the webinar was taught through the use of role play. Anonymised role plays can provide excellent training opportunities, as the patient and therapist dynamic is brought to life for all participants to observe and become a part of. Immediately noticeable was the therapist’s use of she/her pronouns after her name. As psychotherapists, we are trained to notice presentation and the feelings that can be inspired as part of our ongoing discipline to discover what unconsciously gets communicated and why.
Pronouns have been widely debated in recent years, making it clear that they are not clinically or culturally neutral, and in fact mean quite diverse things to different people. In some clinical contexts, for example, pronouns have come to symbolise aspects of a past identity that are fraught or unresolved. Some therapists who do this may be signalling “I am kind and safe”, though the meaning received may differ from the intention.
The case presented was of a trans man using they/them pronouns who had undergone a mastectomy. This was stated as well as the therapist’s difficulty in naming and formulating the direction of the therapy. The main topic was intrusive sexual thoughts that were causing the patient distress.
In psychodynamic therapy, when intrusive sexual thoughts are experienced as distressing, this often points to underlying conflict. Multiple lines of enquiry naturally open up. Questions might arise such as: What might the therapist’s pronoun signalling mean to this particular patient? Why was this therapist chosen? One might also wonder about the distress associated with embodiment and identity, or about anxiety around being perceived “wrongly”. In such a context, signalling can function as reassurance, perhaps even as pre-emptive soothing in the face of meeting another who is separate, with the inevitable risk of misattunement. It could be experienced as respectful. It could be experienced as submission. It might even be experienced as engulfing.
I noticed a growing feeling of constraint and care within the webinar presentation itself and the parallel group chat that was emerging. There was a sense of caution. What struck me was not that the interpretations were wrong. They were sensible, compassionate, and defensible. What struck me was the narrowing of thought. The discussion moved quickly towards safer abstractions: shame, inner criticism, and affect regulation. These are important concepts. But something else hovered at the edge of articulation, unspoken. At one point, the experienced webinar leader accidently misgendered the patient, promptly correcting himself and apologising. It felt as though making a mistake carried big consequences. The general feeling was restrained as the role play continued.
When Case Formulation in Therapy Narrows
In Freud’s essay Civilization and its Discontents, he addresses the price of being “civilised”. Where do aggression and sadistic impulses go when they can’t be metabolised in the light? Freud suggested that civilisation does not eliminate aggression; when certain instincts become morally unthinkable, they may return in disguised, eroticised, or compulsive forms.
When we work deeply with patients, as we know from our own analyses, we are often drawn into repeated dynamics. There can emerge defensive structures that constrain thought but keep us safe. Separateness, that which is warded against, can produce unbearable contradictions. Meeting another can stir up feelings of loss of control, and anxiety about one’s own aggressive impulses, particularly towards ambivalent objects. As Freud pointed out, what is disallowed can return indirectly. One form this can take is control and submission dynamics.
When someone in the chat tentatively named what others avoided by formulating around what could be happening between the therapist and patient vis a vis pronouns, it illuminated why the therapist was possibly struggling with a formulation. Freedom to think was strained; the collective super-ego seemed present. When this perceived pressure finally broke, what ensued was aggression between members, in-group/out-group identification and a certain excitement at transgression. Those emboldened to speak their mind were reprimanded by others in the group. This escalation of tension can therefore be thought about as a displacement of what was happening in the interaction between the therapist and the patient, but also between the webinar leader and the role play. The tension between curiosity and compliance emerged in the group itself.
Of course we know that speaking freely in therapy always carries risk. The question is not whether the risk exists, but whether it can be held without collapse into defensive certainty or compliance.
It is nothing new that psychoanalytic spaces have struggled under the pressure of their own projections and constraints. One only has to recall the intense reaction to Freud’s formulations around sexuality in the repressed society of the nineteenth century. For all of our advances, similar themes around taboos and control seem to re-emerge. It is also worth considering how much we, as well-meaning psychotherapists, may struggle ourselves with these constraints. Wherever you stand on this issue, whatever your formulation of the case would have been – I speak from my own psychoanalytic tradition– it should be equal parts concerning and interesting to us when ideas are no longer fertile, but experienced as intrusive, with curiosity narrowing.
Ironically this concerns the whole topic of the webinar itself: Case formulation. A case formulation in therapy requires freedom, creativity and risk: to allow one’s mind to truly roam in the dangerous terrain of unconscious feelings and fantasies, too dangerous to be metabolised by our patients but, with our help, hopefully worked through. When curiosity itself becomes risky, then formulation collapses. As depth therapists, this is not an unfamiliar fight, as we have borne witness to the uselessness of reducing complex people to formulaic and rigid diagnostic manuals that flatten complexity and truth.
In this case, if I were to imagine a freer analytic space, it would include thoughts about the eroticisation of control, the toleration of sadistic impulses and incestuous fantasy without collapse, the meaning of bodily alteration without affirmation or condemnation, and also the allowance of a separate subject, the analyst, not as someone who submits, but as someone with their own thoughts and ideas. That would be risky, but also real work. If psychotherapy is to remain a space where the unconscious can be thought, it must also remain a space where difficult observations can be spoken.
Sophie Frost is a psychodynamic psychotherapist based in Berlin and working online. Her writing explores clinical thinking and the tensions that arise within contemporary psychotherapeutic practice. She works with individuals and couples seeking depth-oriented psychotherapy.