From Diagnosis to Depth: Learning Case Formulation as a PMHNP

I was recently reading The Personality Syndromes by Jonathan Shedler, and one line stopped me in my tracks:

“Without a coherent case formulation, treatment can devolve into a haphazard ‘spaghetti-on-the-wall’ process, with the clinician trying one intervention after another, hoping something will ‘stick’. It can also devolve into aimless, directionless ‘supportive therapy’ in which the therapist has essentially given up on meaningful change.”

THIS! This right here is exactly how I felt when I first began offering psychotherapy as a PMHNP.

In school, we were taught how to diagnose. We might’ve been introduced to various therapy theories, watched tapes, and observed some sessions. But what I never truly learned, and what I now realize is a cornerstone of meaningful psychotherapy, was how to develop a case formulation.

Sure, we wrote up plenty of case studies using a biopsychosocial or medical model. We practiced writing SMART goals. But the deeper process of crafting a therapy case formulation? The kind that links symptoms to inner conflicts, defenses, attachment patterns, and early relational templates? I’ve either fully dissociated that from my program… or it just wasn’t there.

So now, this is the work I’m actively doing, learning how to conceptualize cases not just through a diagnostic lens, but through a psychotherapy lens.

What about you?
How were you taught case formulation (if at all)?
And how has your understanding of it evolved in your therapy work?

Let’s talk about it, because if you’ve ever felt like you were just tossing interventions at the wall, you’re not alone.