Episode 015 - Therapists Need Their Own Case Formulation

🎙️ Episode Linked Here

Overview:
After a long run of episodes on personality disorder prototypes, Ken and I found ourselves in an hour-long conversation we wished we'd recorded, so we hit record. This episode picks up mid-conversation and turns the lens around: if everyone has a case formulation, so does the therapist. We talk about blind spots and why we need others to reflect us back to ourselves, the irony of helping patients change while being unable to change our own families, and why knowing your own formulation builds patience for how slowly deep change really happens.

We also revisit the distinction between diagnosis and formulation, explore why attachment figures stay with us even after estrangement, and reflect on what it means to love differently rather than stop loving. Along the way, we share some of our own origin stories as clinicians and name a pattern many therapists will recognize: the helper or fixer whose sense of worth gets tied to whether patients change.

Who This Episode Is For

This episode is primarily for clinicians: therapists, psychologists, counselors, trainees, and supervisors who want to understand how their own history shows up in the room. It will be especially useful for anyone thinking about countertransference, supervision, or their own reasons for entering the field. Listeners outside the profession who are curious about how therapists think about themselves, or who are working through complicated relationships with family, will also find a lot here.

🧩 Major Themes and Discussion Points:

1. Blind spots need mirrors. It's far easier to map someone else's formulation than our own. Much of what we don't see in ourselves is protective. That's why therapists benefit from their own therapy, from training that includes knowing their own formulation, and from trusted colleagues who can reflect them back to themselves. Patients get the same gift in good therapy: a kind reflection that elaborates a part of themselves they couldn't see alone.

2. You can't be your family's therapist. Many of us came to this work because of what we learned in our own families. A common heartbreak is believing that becoming a therapist will let us go home and heroically change the system that shaped us. Inside a family, we have a different role, less clarity, and far less leverage. What happens there is not a measure of our clinical skill. Without that awareness, it's easy to slip into countertransference: watching a patient's process and wishing for something in our own life, or finding resonance with a patient instead of helping them take the next step.

3. Real change takes time, for patients and for us. IRT isn't a ten-session model, and it isn't about changing a single thought. It works with the organizing structure of how someone sees themselves and others. When you've had to let go of some of your own Red and build Green, you develop much more empathy and patience for what you're asking of your patients. Like grief, this work is iterative: new life events can activate old patterns, in patients and in therapists, whose caseloads can ping their formulation in ways they never anticipated.

4. Diagnosis tells you how someone is like others; formulation tells you how they're unique. Echoing a conversation between Allen Frances and Marvin Goldfried on the Talking Therapy podcast, we discuss why both matter. Diagnosis supports communication and research; formulation drives treatment. Everyone has a formulation, with or without a diagnosis, because everyone has attachment history. From a formulation lens, comorbidity isn't a problem to untangle; it's added nuance in one coherent story of how this person makes sense.

5. Loving differently, not loving less. From an IRT perspective, our attachment figures live in our minds, which is why estrangement rarely resolves what we're reacting to. The goal isn't to turn off love. It's to transform it: to move from living in spite of, because of, or in yearning for someone, toward a relationship that is mutual, adult, and authentic. That often means seeing caregivers as human, with their own histories and copy processes, without excusing harm and without swinging between idol and demon. Grief is part of nearly every one of these stories.

6. The fixer trap and choosing with awareness. A familiar therapist origin story is the child who was rewarded for being helpful. If your worth is tied to whether patients change, that's an essential piece of your formulation to know. Ken shares a centering lesson from Lorna Smith Benjamin: our job is not to make anyone change, but to ensure that even if someone chooses Red, they choose it with full awareness. For a therapist with a fixer history, letting patients make their own choices may itself be part of loving differently.

📚 References Mentioned in Episode:

Mentioned in this episode (for verification and linking):

• Talking Therapy podcast, Allen Frances and Marvin Goldfried — episode on diagnosis and formulation https://open.spotify.com/show/6OpdUxppI3QsZxz2dTaDKA?si=ae84780aa6784f3e

• Lorna Smith Benjamin — Interpersonal Reconstructive Therapy (IRT) and Structural Analysis of Social Behavior (SASB)

• Previous Loving Differently episodes: personality disorder prototype series

If you've ever wondered how your own history shows up in your clinical work, this episode is for you. Listen to Episode 15 of Loving Differently on Spotify or wherever you get your podcasts, and subscribe so you don't miss what's next.

Coming up, we're considering listener-requested topics including anger and staying connected, being a good partner, and parenting through an IRT and SASB lens.

Have a question or topic you'd like us to take on? Email us at podcast@irtinstitute.com.