My son is addicted.”
“She has severe OCD.”
“He just won’t launch.”
Those are often the first sentences I hear when families or professionals reach out for consultation.
They’re also almost never where the story begins.
By the time someone seeks help, the presenting problem has usually become the organizing story. Addiction becomes the story. Depression becomes the story. Anxiety, school refusal, psychosis, or failure to launch gradually become the lens through which every other aspect of the person’s life is understood.
This is understandable. Families are frightened. Clinicians are appropriately focused on reducing suffering and stabilizing crises. Everyone wants to know the same thing:
What should we do next?
Over the years, I’ve found myself asking a different question.
What haven’t we understood yet?
That question has quietly become the foundation of the way I think about consultation.
When I receive a referral, I rarely begin by thinking about treatment recommendations. Instead, I begin sketching a developmental story. As families describe what has been happening over the past six months or two years, my mind often wanders much further back. I find myself asking where the story first began to change. I draw arrows between events that initially seem unrelated. I circle developmental turning points. I write questions in the margins. What strengths quietly disappeared from the narrative? Which explanations became accepted before anyone stopped to ask whether they were complete? What experiences shaped this person long before the symptoms demanded everyone’s attention?
Somewhere between those disconnected pieces, a different picture begins to emerge.
By the end of a consultation, we’re often talking about a different case than the one we thought we had at the beginning, not because the original concerns were wrong, but because they were incomplete.
It took me years to realize that what I was trying to build wasn’t simply a diagnosis or even a case formulation.
I was trying to build a clinical portrait.
A diagnosis is an essential part of that portrait, but it is only one brushstroke. The full picture includes developmental history, cognitive strengths and vulnerabilities, temperament, personality, trauma, neurodivergence, attachment, family relationships, cultural and religious context, identity, protective factors, and perhaps most importantly, the meaning a person has made of their experiences.
None of those elements exists in isolation; each changes the significance of the others.
Take the young man whose family calls because he has become dependent on marijuana.
The marijuana is real and the addiction is real, but it is rarely where my curiosity begins. Instead, I find myself wondering about the years before the substance ever entered the picture.
Was he the bright child who somehow never performed the way everyone expected? Were there subtle signs of ADHD or another form of neurodivergence that no one recognized? Did executive functioning challenges become interpreted as laziness, immaturity, or lack of motivation? Was school a place where repeated experiences of misunderstanding slowly became questions about intelligence, competence, and worth?
Sometimes these young men are remarkably articulate. They possess genuine intellectual curiosity, communicate thoughtfully, and connect easily with other people. Ironically, those very strengths can make their struggles more difficult to recognize. Because they sound intelligent, adults assume they should function at the level their verbal abilities suggest. When they cannot, inability is gradually mistaken for unwillingness.
What begins as an academic struggle often becomes something much more personal.
Failure is no longer experienced as something that happened.
It becomes something the person believes they are.
In communities where educational achievement, religious learning, or other developmental milestones carry profound personal meaning, those experiences extend far beyond school. They begin shaping identity itself. A young person may quietly conclude that they are disappointing, incapable, spiritually deficient, or somehow fundamentally different from everyone around them.
By the time marijuana enters the story, it is often serving far more than one function.
For one young man, it quiets a nervous system that has lived in a state of chronic overwhelm. For another, it offers temporary relief from shame. For someone else, it creates belonging after years of feeling different.
Others describe it as the first time their mind ever felt quiet enough to experience peace.
If treatment focuses exclusively on removing the substance, we may successfully address the behavior while leaving untouched the developmental story that made the behavior so compelling in the first place.
Sobriety remains essential. Yet lasting recovery may also require neuropsychological evaluation, trauma-informed therapy, family work, opportunities to experience competence, and perhaps most importantly, the chance to rebuild an identity organized around strengths rather than deficits.
Sometimes the next step isn’t simply helping someone stop using marijuana.
Sometimes it is helping them discover, perhaps for the first time, where they genuinely come alive.
The same process unfolds when the presenting problem is depression, anxiety, or what appears to be obsessive-compulsive disorder.
An accurate diagnosis matters. It provides clarity, guides treatment, offers a common language for clinicians, and, for many people, replaces years of confusion with understanding. Receiving the right diagnosis can be profoundly validating, opening doors to interventions and accommodations that might otherwise have remained inaccessible.
At the same time, every diagnosis is, by necessity, a simplification.
It organizes an extraordinarily complex human experience into a category that helps us communicate and make clinical decisions. It tells us what we are seeing, but it cannot, on its own, explain why those symptoms developed in this particular person, why they emerged at this particular point in their life, or what role they have come to play.
That is where formulation begins.
When someone tells me that a client has severe OCD, I certainly want to understand the nature of the obsessions and compulsions. But I also find myself wondering whether the current formulation fully accounts for what we are seeing. Could trauma be shaping a presentation that has been understood primarily through the lens of anxiety? Could autism better explain the person’s need for predictability, routine, or certainty? Could perfectionism represent an adaptation to years of shame rather than simply reflecting obsessive thinking?
The distinction is far more than academic because treatment grows out of formulation.
Two people may satisfy the same diagnostic criteria while arriving there through entirely different developmental pathways. Similar symptoms do not necessarily reflect similar mechanisms, and similar mechanisms do not always require the same intervention. Diagnosis tells us what we are looking at. Formulation begins asking why it developed, what has maintained it, and what will help this particular person move forward.
I find the same principle applies to young adults described as having “failed to launch.”
Families often present this as though it were an explanation, when in reality it is only a description of where someone currently finds themselves.
The more clinically interesting question is why adulthood has become so difficult to enter.
For one young adult, executive functioning challenges make the ordinary demands of independence feel overwhelming. Another has quietly accumulated so many experiences of failure that avoiding adulthood feels safer than risking another disappointment. Someone else has never had the opportunity to discover an environment where they experience genuine competence. Others remain caught within patterns of family accommodation, depression, trauma, anxiety, or social isolation that have gradually narrowed their world.
Although these individuals may appear remarkably similar from the outside, they are not standing in the same place psychologically.
That means they are not ready for the same intervention.
As consultations unfold, I find myself asking not only, “What has gone wrong?” but also, “What has gone unnoticed?”
Every consultation begins with a list of problems.
Far less often do I hear someone begin by saying:
“He’s exceptionally creative.”
“She’s deeply empathetic.”
“He’s remarkably verbal.”
“She comes alive when she’s teaching children.”
Yet those observations may be just as clinically important.
Not only because they balance the picture but because they often change it.
The strengths that disappear beneath years of discussing symptoms frequently become the very foundation upon which recovery is built. They point toward environments where competence can be experienced, identities can be rebuilt, and hope can begin to replace shame.
The more I practice, the more convinced I become that many people are not only living with symptoms; they are also living with interrupted developmental tasks.
Sometimes I find myself thinking less about diagnoses and more about questions like these:
Has this person ever experienced genuine competence? Have they developed agency Do they trust themselves? Have they discovered a place where they belong? Do they believe they have something meaningful to contribute?
The young man struggling with addiction may never have experienced himself as capable.
The young adult who has not launched may never have developed confidence through repeated experiences of mastery.
Someone whose life has become organized around fear may never have learned that uncertainty can be survived.
Treatment, then, is not always about helping people start something new, but about helping them resume developmental processes that were interrupted years earlier.
Formulation matters so deeply to me because it gives diagnosis context.
It asks not only what the person is struggling with, but who they are, how they arrived here, what has shaped them, what strengths remain hidden beneath the symptoms, and what capacities are still waiting to be uncovered.
By this point in a consultation, I often notice something interesting has happened.
The conversation has shifted.
We may have started by talking about addiction, depression, anxiety, or a young adult who cannot seem to move forward. Yet somewhere along the way, the focus has quietly changed. We are no longer trying to understand only the presenting problem. We are trying to understand the person who carries it.
That shift changes almost everything.
The treatment plan often becomes more individualized. The questions become more precise. Families begin seeing patterns they had never connected before. Clinicians begin recognizing that interventions which seemed ineffective may not have been the wrong interventions at all, they may simply have been directed at an incomplete understanding of the case.
This is why I often think of consultation less as solving a puzzle and more as studying a chessboard.
When we first look at a chessboard, we see pieces.
With time, we begin seeing position.
Two boards may contain exactly the same pieces while representing entirely different games. One player is defending. Another is preparing an attack. One has sacrificed material to gain position. Another is only one move away from checkmate. The pieces themselves tell only part of the story. Their meaning depends on how they came to occupy their current positions.
Clinical work often feels much the same.
Two people may carry the same diagnosis while occupying entirely different positions in their lives.
One may need stabilization before insight. Another may need family work before individual therapy. Another may need neuropsychological assessment before trauma processing. Another may need opportunities to experience competence before independence becomes a realistic expectation.
The question is not simply, “What diagnosis does this person have?”
Nor is it, “What treatment works for this disorder?”
The question is, “Given everything we now understand about this person’s story, what is the next move?”
That question cannot be answered by diagnosis alone. It requires a clinical portrait.
I sometimes think about how many people have spent years viewing themselves through the lens of a single word.
Addicted.
Anxious.
Depressed.
Lazy.
Difficult.
Unmotivated.
Defiant.
Those words may describe part of someone’s experience, but they can also become identities if they are never placed within a broader story.
Behind every formulation is a person trying to answer questions they rarely say out loud.
What’s wrong with me?
Why have I always struggled more than everyone else?
Why does this seem so much easier for other people?
Will I ever become the person I hoped I would be?
At its best, a thoughtful formulation does more than organize symptoms.
It replaces years of self-blame with understanding. It helps families move from frustration to curiosity. It helps clinicians move from reacting to symptoms toward understanding the mechanisms beneath them.
Most importantly, it allows people to begin seeing themselves through something other than the lens of their struggles.
My job is not to dismiss that problem. It is to widen the frame until the person begins to come back into view.
Because once we understand the person more fully, the diagnosis often makes more sense. The treatment becomes more individualized and te story becomes more coherent.
And the next step, whether that involves treatment, assessment, family work, rebuilding identity, or discovering strengths that have long gone unnoticed, becomes far easier to see.
For me, that is the purpose of building a clinical portrait. It is an attempt to understand not only what someone is struggling with, but who they are, how they arrived here, and what still remains possible.
Because the goal of treatment has never been simply to reduce symptoms.
It is to help people reclaim the lives those symptoms have obscured.
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