Diagnosis or Plan Formulation?

Susan is a 45 years old woman who asks for my help because she feels depressed. She is overweight, has never had a significant love relationship, does not have any close friends, does not work very much, her income is pretty low and she lives with her old and sick parents, taking care of their health. She says that she cannot go and live by herself because she does not have the necessary money and cannot leave her parents alone. She says that she has no hope of finding a better job because she does not think she is a good enough worker – though my impression is that she is sensitive and clever.   She says that she wants to get better but has lost any hope of finding a man who can fall in love with her and adds that her life arrangement cannot be changed. I am her third therapist.


David is a 40 year old man who lives with his girlfriend and her 6 years old daughter and works in a small company. He has had 11 years of psychotherapy and for 6 of these years he has also taken medicines for his depression and anxiety. Moreover, for several years he has suffered of a paraphilia and in different periods of his life he has suffered also of compulsions: he had to plan and check several times all he did, from everyday tasks such as making the bed to work tasks and decisions. All of his psychic life is centered around the idea of being worthless, inadequate and less capable than all the people he knows. He thinks that he is too introverted and slow, too passive and not “cool” enough to be liked by the right people. For this reason, he feels depressed and becomes very anxious any time he needs to deal with a new task.


Sara is a 28 years old woman who sought therapy because she felt very depressed after the ending of a relationship she had hoped that could have become a real love story. Apart from crying very often because she thought that the ending of her relationship was her fault, biting her fingers and make them bleed, and having difficulties to sleep, Sara has lots of good friends, is a very good worker, loves her job and practices a lot of sports. She spendt most of the sessions of her first year of therapy crying and accusing me of being a liar: she has no hope of finding another man who will be as good as the lost one, and she accused me of being deceptive when I disagreed.

All these patients, when they started therapy, met the criteria of a depressive disorder. Susan also believed she had attention-deficit disorder; David met also the criteria of a generalized anxiety disorder, an obsessive-compulsive disorder and a paraphilia, a dependent personality disorder and showed also significant traits of a narcissistic personality disorder.

But … are these diagnoses in some way useful for planning their treatment? Does it make any sense to think that these patients need similar treatments, maybe empirically supported, for overcoming their depression? May we think that the multiple problems of David, and of so many other patients, should be considered as different and independent problems, each one to be treated per se with a different EST?

My response is: no. The psychic condition of a human being is not a puzzle of unrelated pieces of psychiatric diagnoses. It is the outcome of their stories and of their adaptation efforts. So, let’s try to make sense of their problems looking at the core elements of their plans.


Susan grew up in a family full of violence, suffering, and emotional blackmail. She was the younger child, and her father had been physically violent with her mother and siblings, but not with her. Her mother lost one of her children when Susan was very young and asked her to spend their time together in order both to alleviate her grief and to protect her from her violent husband. One of her sisters decided to share with Susan the “secret” of being abused by one of their brothers. Both an older brother and an older sister during adolescence developed psychiatric problems. Because of all these traumas, Susan grew up with strong survivor guilt toward her siblings and mother and strong feelings of separation guilt toward her parents, which have prevented her from developing a life of her own and severely affected her self-esteem. Even now, she feels guilty at the idea of leaving her parents’ house and not taking care of them anymore (her mother used to say to her: “If you were not with me, I would die”); moreover,  she feels that she got more from her parents than her brother which , has caused deep resentment, pain and rage in him.  She tests her pathogenic beliefs mainly with behaviors which show her compliance with her pathogenic beliefs, hoping to find someone that will support her right to have a life of her own.

From a certain perspective, it would be crazy not to be depressed while keeping on living a life such as the one she is living. It is her life that needs to be changed and to do so she needs to disprove her pathogenic beliefs and to overcome her guilt.


Daniel’s problems come from the fact that his mother, since he was very young, used to compare him with his older sister finding him always inadequate and inferior. It was she who had always told him that he was too slow, introverted and not “bright” enough for having a successful life. His mother was always insensitive to David’s suffering and complaining, saying that she was simply trying to help him become a better person. And now Daniel is convinced that his mother is right, and he is able to point to evidence of this fact. When confronted with a new task, he becomes very anxious and his anxiety negatively affects his performance, and this becomes further evidence of the fact that he is not adequate, which makes him feel depressed. He cannot sleep because he needs to “prepare” himself for any problem he might have to deal with the following day, and his paraphilia seems to be an expression of this same basic theme: in order to get excited, he needs to be humiliated by a prostitute with a phallus while he touches her socks or sucks her (plastic) penis. The core of his pathology is his self-hate, and he tends to propose transference tests by compliance and passive-into-active tests hoping to find someone who believes in him and is not too upset by his devaluations.


Finally, Sara has been deeply affected by the continuous fights among her parents, and by the fact that she has been able to find her way in life and leave her parents’ apartment while her younger chronically depressed brother continues living with their parents and does not seem to have any aspiration or life goals. Because of her strong survivor guilt, whenever a possible love story comes to an end Sara becomes depressed because she believes that she will always be alone or that she needs to learn to be content with an unsatisfying relationship. Her problems relating with men are an expression of an identification with the worst aspects of her parents, identification which comes out of her survivor guilt. She needs a strong and optimistic therapist who is able to stand her pessimism and criticism.


I think that Plan Formulations, even such rudimentary ones, are much more useful than a DSM or psychiatric diagnosis for understanding the nature, origins and meaning of the difficulties of our patients, and they provide a much more precise guide for treating them. It is also clear that, on the basis of the formulation of their plans, each of the above described patient needs a quite different kind of treatment in order to overcome her/his “depression”, and a quite different attitude from the therapist. Susan needs a strong, supportive but relatively detached therapist who helps her overcome her separation guilt and change her life; David needs a strong and accepting therapist who is able to appreciate him and help him to overcome his powerful self-hate; and Sara needs a therapist who seems to be independent, lucky and happy and helps her in legitimating her own happiness and her right to have a satisfying love relationship.


Plan Formulations, much more than diagnoses, enable us to understand and treat our patients; they help us in being more empathic and sensitively attuned to their needs, and provide a useful  map whose efficacy is empirically supported.