Formulation: The Key to Difficult Conversations

I recently had the pleasure of interviewing Dr. Keri Brenner and Dr. Dani Chammas. We discussed their insightful approach to unpacking patient and family responses during difficult conversations. Just as we make patient assessments before creating hypotheses about what is medically wrong, they describe how formulations can guide our approach to communicating more effectively with patients and families.

Introductions

Dr. Keri Brenner, MD, MPA is a Clinical Associate Professor of Medicine at Stanford University and a palliative care physician and psychiatrist. Her work focuses on the psychological dimensions of serious illness care, including psychodynamic and existential approaches to communication, coping, and suffering in patients facing life-limiting illness.

Dr. Danielle Chammas, MD is an Associate Clinical Professor at UCSF and a palliative care physician and psychiatrist specializing in the psychological and existential dimensions of serious illness. Her academic work focuses on integrating psychotherapeutic frameworks into serious illness communication to help clinicians better support patients and families facing complex medical situations.

What are “formulations”, why do they matter, how do they differ from a diagnosis?

Keri:
Our formulation is our working hypothesis about the “why” beneath a patient’s thoughts, emotions, behaviors, and ways of coping. In medicine, assessment always comes before the plan. We would never choose a treatment without first understanding what is driving the clinical picture. Formulation brings that same clinical reasoning to serious illness communication.

Dani:
This matters because many challenging emotional or behavioral situations in oncology can look similar on the surface but reflect very different things underneath. A family repeatedly delaying a decision, for example, may be afraid of making the wrong choice, struggling with mistrust of the healthcare system, or holding out for a miracle. These represent three different formulations, each of which may best be served by different approaches.

Keri:
Once we understand what is driving the patient’s behavior, we can tailor our communication to best fit the patient’s unique needs. If the struggle is from fear of the wrong decision and feeling overwhelmed, a clear unambiguous recommendation may help. If the struggle is from mistrust, slowing down and building agency may work better.
Unlike a diagnosis, which is more certain and disease-focused, our formulation is flexible and evolving. It is not a label. It is a clinical hypothesis.

Can you give me an example of how formulations can change a communication strategy? 

Dani:
Sure. I had a recent patient who was repeatedly declining the in-home help that his family very much wanted him to accept. We were all so focused on explaining the reasoning of the services and the logistics of the services.
Only once we slowed down and took the time to formulate did we realize he wasn’t refusing for a logistical reason. Our formulation was that accepting in-home help symbolically felt like a threat to his lifelong identity of being an independent, competent person who never relied on others.
Once we shifted our communication style to being more identity-affirming – even using metaphors like “you are the captain of this ship, assembling a crew that can help you steer the ship” – did he become more open to the idea that he could accept help without it threatening his identity.

Keri:
I recently had experience with a young patient with metastatic gastric cancer who had been a Division I athlete, and his father was a coach. Our team initially approached them with a very open-ended emotional communication style, and it completely failed.
When I stepped back and thought about their coping style, I realized they wanted us to show up as a confident, coordinated team. That formulation prompted be to be much more direct and structured in our visits. I started referring to us as “Team Robinson,” laid out clear next steps, and adopted a more grounded, confident presence. Once we adjusted our approach to match what they needed emotionally, trust developed very quickly.

That is formulation in action: noticing whenever the interaction is not working, asking what may be going on underneath the surface, and adjusting the communication approach accordingly.

Can we talk about countertransference? 

Dani:
Countertransference is a term for the emotions and reactions that come up in us as clinicians when we care for patients. And whether we acknowledge it or not, it’s always present.

In medicine, we’re often trained to think of ourselves as neutral observers, but we’re not. Our own histories, personalities, fears, and experiences inevitably shape how we respond to patients and families. The goal isn’t to eliminate those reactions. The goal is to become aware of them.

Keri:
Many oncology clinicians have had the experience of walking into a room feeling perfectly calm and walking out feeling emotionally flooded, but we’re rarely taught to think about those shifts as clinically meaningful.

Once we become aware of our reactions, they become useful information. If I am feeling unexpectedly frustrated, protective, attached, or avoidant, I ask myself: What is at the root of this?

That reaction becomes a data point. It can change how I approach the interaction. Instead of reacting automatically, I can slow down, stay curious, and respond more intentionally.

Do you have any data that making formulations supports better outcomes?

Keri:
We have studied formulation through workshops and follow-up process rounds where clinicians present real, challenging cases and think through formulations together. What has been striking is how consistently clinicians report that formulation changes their clinical practice, even months later.

Clinicians describe feeling more confident and effective in difficult conversations and more thoughtful in how they approach emotionally complex patients. Importantly, most participants had no formal psychotherapy or psychiatry training. Assessment-informed communication is a learnable skill for any clinician in serious illness care.

Dani:
One reason it seems to stick is that people immediately recognize these situations from their own practice. They already know what it feels like to walk out of a room thinking, “Something about that interaction didn’t go well, but I am not exactly sure why.” Formulation gives clinicians a language and framework for understanding those moments instead of just reacting to them.

It seems that making formulations can really help clinicians maintain empathy for a patient and avoid compassion fatigue. Is that true?

Keri:
Very much so. One of the hardest parts of oncology is when interactions begin to feel repetitive or emotionally draining, and we lose sight of the person underneath the behavior. Formulation helps bring the patient back into focus as a human being with a particular response to stress and uncertainty.

That shift can make difficult encounters feel more meaningful and more manageable. Instead of thinking, “This patient is difficult,” a clinician using formulation might think, “This patient may be terrified and trying to regain control,” or “This patient may be mistrusting medicine because they have felt unheard.” This helps us respond with clarity and compassion rather than frustration.

Dani:
It also changes the way teams talk about patients and about themselves. When clinicians can openly reflect on what is happening emotionally in a case, it creates more space for support, curiosity, and collaboration instead of isolation. One of our favorite phrases is: “If it’s mentionable, it’s manageable.” When teams can openly reflect together about what’s coming up emotionally, the clinical work becomes much more sustainable.

Serious illness care is emotionally demanding work. If we do not have ways to process what is happening, those experiences can accumulate over time. Formulation gives clinicians a framework for making sense of difficult interactions rather than simply carrying them. That can be sustaining, both personally and professionally.

What are the safeguards here, so we don’t label patients?

Keri:
That’s such an important question because formulation is not meant to be a label. In fact, it’s really the opposite of labeling. A label closes down curiosity. Formulation is meant to keep curiosity open.

A formulation is always provisional. It’s fluid and evolving, and it changes as we gather more information about the patient and family. We might say to our team, “My current formulation is that this patient may be coping by trying to regain control whenever possible,” not “The patient is controlling.”

Dani:
We often say formulation is more of a verb than a noun. It’s an ongoing process of asking, “What might be happening with this patient? What might be their primary inner struggle right now?”

The moment we become too certain is usually the moment we stop seeing the patient clearly. The safeguard is humility: hold the current formulation lightly, stay open to new information, and revise it as the clinical encounters unfold.

How does practicing formulations change how you “show up” for patients?

Dani:
When we talk about “showing up,” we’re really talking about presence: tone, pacing, body language, eye contact, and the emotional stance we bring into the room. Patients pick up on all those non-verbal cues long before they process the actual words we are saying.

Once we start thinking about how the patient is responding to the difficult situation they are in, we realize that different patients need very different communication styles and approaches from us. Some need greater autonomy and choice. Some need a personalized recommendation. Some need more silence. Some need more structure or directive approaches.

Keri:
That’s why we teach a very simple three-step process:

1. Notice your emotions and inner reaction (countertransference)
2. Ask, “What might be happening beneath the surface for this patient? What does this patient need from us emotionally right now?”(formulation)
3. Choose the communication approach that fits the needs (therapeutic intervention)

A clinician can do this before entering the room, or when we feel a conversation becoming stuck. We might take a brief internal pause and ask: What am I feeling? What might this patient or family be trying to manage emotionally? What communication approach would meet their needs?

This process does not necessarily require more time. Often, it is a brief pause that shifts us from reacting automatically to responding more intentionally.

You talk about acting mindfully. Can you make that concrete for oncology clinicians?

Dani:
Acting intentionally or mindfully really means slowing down enough to think, “What does this patient need from us right now?” instead of simply reacting automatically in the moment. We sometimes call this the “differential use of self.” We’re not becoming fake or scripted. We are choosing which aspects of our clinical presence to emphasize based on what may be therapeutic for this particular patient.

For one patient, humor may help them feel connected and safe. Another patient may need a very calm, steady, grounded presence. Another may need us to be more direct and structured.

Keri:
Traditional communication training can sometimes unintentionally feel one-size-fits-all, as though there’s a single “right” way to communicate. But formulation reminds us that there isn’t one perfect communication style for every patient.

One way to make this practical is to pair a formulation with a communication strategy. If the formulation is, “This patient is overwhelmed by medical information,” the strategy might be to slow down and offer one clear headline: “I will share the big picture, and then we can pause and talk it through together.”

If the formulation is, “This family is trying to regain control,” the strategy might be to offer structured choices: “There are two reasonable paths moving forward. I will share details about each, and then you can decide which is most aligned with your father’s values. You are the expert on your father’s wishes.”

Anything I didn’t ask that I should have?

Keri:
One reality to emphasize is that clinicians are already doing pieces of this intuitively all the time. We’re continually adjusting our communication and sensing when something in a conversation feels emotionally charged or stuck. Formulation gives clinicians a framework and language for understanding those moments more consciously.

Dani:
Formulation works best as a collaborative process. Different members of the team often notice different things about how a patient copes. An infusion nurse, for example, may spend hours with a patient and notice patterns that completely change how we understand how the patient is responding emotionally to the illness.

When teams think together in this way, it helps keep us flexible and prevents us from becoming too attached to one interpretation. A simple team question can be powerful: “How and in what ways is this patient coping, and how should that impact our communication approach?”

Keri:
Ultimately, this isn’t about turning oncologists into psychiatrists or making every interaction psychotherapy. It’s about helping clinicians stay curious, connected, and thoughtful in difficult moments. When we better understand the human experience underneath the illness, communication becomes more effective, care becomes more personalized, and the clinical work is more meaningful and sustainable.

And finally, how can readers learn more about your work?

We are presently co-editing a special series for the Journal of Palliative Medicine series on “Psychotherapeutically Informed Serious Illness Communication.” We are also excited to launch ELEVATE in Fall 2026, an online educational program focused on psychological formulation and assessment-informed communication for clinicians caring for patients with serious illness. A link to learn more about that program is here: https://forms.cloud.microsoft/r/FAghPi4Fq4. We’d be delighted to welcome your audience.