The "Growing" Process
Overview of the Study
Clinical Case Study Dissertation Structure
The Rationale for Clinical Case Study Dissertation
Diverse Contentions
Emotional Abuse/Maltreatment
Winnicott's Relational Model Theory
Bowlby's Attachment Theory
Kohut's Self-Psychology
CASE PRESENTATION
Theoretical Basis for Case
Conceptualization
Winnicott's Relational Model Theory
Bowlby's Attachment Theory
Kohut's Self-Psychology
CHAPTER IV:
Shania's Presenting Problems
Early Stage: Development of Therapeutic Relationship and the Holding
Environment
Middle Stage: Transference and Counter-transference
Late Stage: Differentiation and Individuation
Termination
CHAPTER V:
CONCLUSION
Necessary Insight
Recount of Clinical Case Study Dissertation Results
APPENDICES
REFERENCES
LIST of FIGURES and TABLE
Figure 1: Differences Between Discipline and Abuse 10
Figure 2: Donald Winnicott 13
Figure 3: John Bowlby 18
Figure 4: Heinz Kout 25
Figure 5: Representation of Girl Feeling Alone and Sad 38
Figure 6: Three Self-object Functions 49
Table 1: Physical and Behavioral Indicators of Abuse 11
OBJECT RELATION, ATTACHMENT THEORIES, and SELF-PSYCHOLOGY
CHAPTER I
INTRODUCTION
"! have always held the view that the internal world is a reflection of the external world and there is a constant interaction you can't understand one without the other."
Bowlby, 1985, p. 20; cited by MacDonald, 2001, ¶ 3)
1.1 The "Growing" Process
In the treatment of the patient, Bowlby (1985, p. 20; cited by MacDonald, 2001, ¶ 3) purports, one cannot understand a patient's internal world without examining his/her external environment, as the two constantly interact. During the process of "growing" this clinical case study dissertation, this researcher utilizes Object Relation, Attachment Theories, and Self-Psychology to explore the internal and external world of one particular patient, a 43-year-old female, presenting concerns apparently evolving from paternal relations she experienced during her childhood. In the book, Writing Your Doctoral Dissertation: Invisible Rules for Success, Brause (2000, p. 12) compares the dissertation process to several experiences, including "gardening" and "a coming of age." This researcher contends the process utilized to complete this clinical case study dissertation compares to a combination of both. In the gardening model, as the doctoral candidate notes on growth process from seed to flower, he/she recognizes needs for figurative:
patient weeding, fertilizing, watering, and constant monitoring to adjust for unpredictable factors such as weather conditions and the speed of seed germination. (Brause, 2000, p. 12)
As a "reward" for invested attention to the "growing" of a garden/dissertation, the gardener/dissertation candidate ultimately reaps flowers or fruit.
Brause (2000, p. 12) notes that during the process: "The doctoral candidate may select the seeds to plant, based, for example on knowledge about the climate and soil conditions."
This metaphor, albeit, views the process as an intellectual and emotional growth process not allotting for the researcher's mental contribution. A coming of age experience, albeit brings the doctorial candidate through a stringent mind-challenging experience, (Ibid.) which in time results in the researcher perceiving the world with fresh insists, as it readies him/her face even more challenging challenges.
Through completing a dissertation, Brause (2000, p. 3) notes, the process ultimately helps the researcher learn:
more about his/her discipline;
to enhance his/her learning experience by writing to an audience beyond the professor teaching the course;
how to organize large trucks of information;
how to complete original research;
how to organize his/her time to become more productive.
Likewise, this researcher contends, the therapy process may also be compared to growing a garden for both the therapist and patient, while simultaneously constituting a "coming of age" experience for the patient. During the therapy process, the therapist and patient have to weed through experiences that would hinder the patient's recovery/growth, as well as fertilize and water positive, healing components. The therapist additionally must constantly constant monitor the patient's progress and adjust for unpredictable, as well as predictable factors that potentially compliment or hinder the patient's healing/growth process. During the course of the patient's mind-challenging healing process, he/she starts to figuratively come of age and begins to perceive the world with new, more positive insights; ready to face life's challenges.
1.2 Overview of the Study This clinical case study dissertation portrays treatment of a 43-year-old depressed female (patient), utilizing theories of Winnicott, Bowlby, and Kohut, who, during her childhood, experienced a painful, conflicted relationship with her father. In addition to this patient's current preoccupation with catastrophic events, which results in manifestations of fear and dread, her relational deficiency contributed to her separating from her husband and son, constantly experiencing a sad mood, regularly feeling hopeless and helpless, and on one occasion, attempting suicide.
During this case study, this researcher demonstrates how theories by Winnicott, Bowlby, and Kohut translate into clinical applications, and prove applicable to treatment for this particular patient. To effectuate this explanative effort, this researcher initially reviews literature relating to the aforementioned theorists/theories. To illustrate theoretical framework for the conceptualization of this case study, this researcher further translates these theories into clinical interventions to explore how the patient's earliest experiences with her caregivers evolved to affect her current relationships. In addition, this researcher demonstrates how the patient's relatedness to early objects and attachment styles resulted in deficits in intimate relationship. Subsequently, this researcher further evinces how relational deficits prove contributory to major depressive, anxiety symptoms, and suicidal ideations. Approximately 906,000 children, who are victims of abuse and neglect each year in the U.S., experience rational deficits. The rate of victimization, according to National Child Abuse Statistics (2006), averages 12.3 children per 1,000 children; however, nearly 3 million child abuse reports are filed annually. The National Clearinghouse on Child Abuse & Neglect Information. Long-term Consequences of Child Abuse & Neglect 2005 reports that 80% of young adults who experienced abused "met the diagnostic criteria for at least 1 psychiatric disorder at the age of 21 (including depression, anxiety, eating disorders, & post-traumatic stress disorder)." (National Child Abuse Statistics, 2006)
1.3: Clinical Case Study Dissertation Structure
CHAPTER I: INTRODUCTION
1.1 Treatment of the Patient: In this section, this researcher introduces the premise for this clinical case study dissertation.
1.2 Overview of the Study: This segment relates details of the patient; noting that theories of Winnicott, Bowlby, and Kohut translate into clinical applications.
1.3 Clinical Case Study Dissertation Structure: In this section, this researcher presents a brief overview of the chapters included in this study.
1.4 Rationale for this Study: This researcher relates the reasons for this study's focus.
CHAPTER II:
LITERATURE REVIEW
2.1 Diverse Contentions
2.2 Emotional Abuse/Maltreatment
2.3 Winnicott's Relational Model Theory
2.4 Bowlby's Attachment Theory
2.5 Kohut's Self-Psychology
CHAPTER III:
CASE PRESENTATION
3.1 Client History
3.2 Theoretical Basis for Case
Developmental History
Presenting Problem & Symptoms
Initial Diagnosis
3.3 Conceptualization
Winnicott's Relational Model Theory
Good-enough mothering
False self
Bowlby's Attachment Theory
Depressive symptomatology as a result of insecure attachment
Search for attachment and connection
Kohut's Self-Psychology
The Development of the Self
Internal and external objects
CHAPTER IV:
TREATMENT / DISCUSSION
4.1 Early Stage: Development of Therapeutic Relationship and the Holding Environment
4.2 Middle Stage: Transference and Counter-transference
4.3 Late Stage: Differentiation and Individuation
4.4 Termination
CHAPTER V:
CONCLUSION
This clinical case study dissertation's final chapter recounts the success of this process relating Object Relation, Attachment Theories, and Self-Psychology to the case highlighted through this study effort.
Recount of Clinical Case Study Dissertation Results
APPENDICES: This study segment contains material either too voluminous for a particular relevant chapter and/or relates pertinent examples.
1.4: Rationale for Clinical Case Study Dissertation Child abuse and neglect, some experts warn, constitutes a hidden epidemic. Although approximately 3 million reports of child abuse are reported annually in the U.S., experts estimate the genuine number of incidents of abuse and neglect ranges three times higher than reported. (National Child Abuse Statistics, 2006) in light of these critical contemporary concerns for youth, this researcher chose to document the application of Object Relation, Attachment Theories, and Self-Psychology to clinical practice, specifically focusing on a patient who experienced abuse when a child. Consequently, this researcher contends this clinical case study dissertation proves to be vital venture, which will contribute to enhancing research in the field of psychology.
For this clinical case study dissertation exploring Object Relation, Attachment Theories, and Self-Psychology, along with researching information for the application of these theories to clinical practice, this researcher answered the following research questions.
Research Questions
What is Winnicott's Relational Model Theory?
What is Bowlby's Attachment Theory?
What is Kohut's Self-Psychology?
How may components of these three theories be applied to the clinical case chosen for this clinical case study dissertation's focus?
Enhancing Understanding
During the course of this study, as this researcher implements the previously identified, purported principles in an effort to treat, as an adjunct to anti-depressive medication, a 43-year-old woman, referred to this researcher by her psychiatrist for individual psychotherapy, the introductory thought by Bowlby (1985, p. 20; cited by MacDonald, 2001, ¶ 3) serves as poignant pointed prompt. While conducting this study, holding the view that a patient's internal world reflects their external world and that "there is a constant interaction," this researcher regularly recounts the fact that understanding one of the patient's world mandates that this researcher understands the other. During the next chapter of this clinical case study dissertation, the Literature Review section, this researcher relates accessed information that contributes a sampling of previous research to begin to enhance the understanding needed to help a patient "grow" not only in therapy, but also in life.
CHAPTER II
LITERATURE REVIEW
The theories and techniques used in psychoanalysis are very diverse; Freudian analysis is only one approach."
Thomas and McGinnis, 1991, ¶ 1)
Diverse Contentions
One recent University of New Hampshire study indicated that 63% of more than 3,000 surveyed American parents surveyed reported experiences of one or more instances of verbal aggression toward children in their homes. A Child Protective Services study, albeit reported that only 6% of child abuse cases involved "emotional maltreatment," form of abuse in which verbal abuse constitutes the most common form of maltreatment. The apparent low number of "official" verbal abuse cases likely relates to the fact verbal abuse signs prove more difficult to recognize and prove than the more obvious signs of physical abuse. (Vardiganm, 2008)
During this clinical case study dissertation's Literature Review chapter, this researcher presents information, as well as diverse contentions accessed from a barrage, more than 25, of credible sources, including books, journals and websites. Themes explored during this study's segment include emotional abuse/maltreatment, along with theories and techniques other than Freudian, specifically those relating to Object Relation, Attachment Theories, and Self-Psychology.
2.2 Emotional Abuse/Maltreatment
According to Vardiganm (2008) in his web post article, reviewed by Bruce Linton, PhD, a psychoanalyst specializing in marriage and family counseling in Berkeley, California, the following denote signs that a child is or has been verbally abuse.
Negative self-image: This sign denotes "the most common and pervasive effect of verbal abuse." child may verbalize statements such as "I'm stupid," or, "Nobody likes me."
He/she may appear withdrawn, sullen, or depressed, other signs a person possesses a poor self-image. The National Committee for the Prevention of Child Abuse defines emotional abuse by explaining that "attacks a child's... sense of self-worth." (Vardiganm, 2008)
Self-destructive acts: "Cutting," using razor blades or knives to cut oneself, and numerous other forms of self-injury, as well as a number of reckless activities that put a child in danger indicate a problem exists.
Antisocial behavior. According to the New Hampshire study, verbally abused children exhibited more physical aggression, delinquency, and interpersonal problems than children who were not verbally abused. Verbally abused children may hit their siblings and friends. They may quarrel regularly with their classmates, and/or abuse/torture animals.
Delayed development.
A verbally abused child may display delayed development signs in his/her physical, academic, social, and/or emotional development. he/she may experience problems making/keeping friends. he/she may also fall behind in his/her schoolwork, and/or engage in regressive acts as bed-wetting, rocking, and thumb-sucking. (Vardiganm, 2008)
Discipline vs. Abuse
May (2008) points out a number of differences between discipline of a child and abuse, as the following figure (1) portrays. He also stresses, albeit, that both discipline and abuse are taught by example.
Figure 1: Differences Between Discipline and Abuse (adapted from May, 2008)
The following table (1) depicts numerous physical and behavioral indicators of abuse.
Table 1: Physical and Behavioral Indicators of Abuse (May, 2008)
Type of Abuse
Physical Indicators
Behavioral Indicators
Physical Abuse
Unexplained bruises (in various stages of healing)
Unexplained burns, especially cigarette burns or immersion burns
Unexplained fractures, lacerations or abrasions
Swollen areas
Evidence of delayed or inappropriate treatment for injuries
Self-destructive
Withdrawn and/or aggressive - behavioral extremes
Arrives at school early or stays late as if afraid to be at home
Chronic runaway (adolescents)
Complains of soreness or moves uncomfortably
Wears clothing inappropriate to weather, to cover body
Bizarre explanation of injuries
Wary of adult contact
Physical Neglect
Abandonment
Unattended medical needs
Consistent lack of supervision
Consistent hunger, inappropriate dress, poor hygiene
Lice, distended stomach, emaciated
Inadequate nutrition
Regularly displays fatigue or listlessness, falls asleep in class
Steals food, begs from classmates
Reports that no caretaker is at home
Frequently absent or tardy
Self-destructive
School dropout (adolescents)
Extreme loneliness and need for affection
Sexual Abuse
Sexual abuse may be non-touching: obscene language, pornography, exposure - or touching: fondling, molesting, oral sex, intercourse
Torn, stained or bloody underclothing
Pain, swelling or itching in genital area
Difficulty walking or sitting
Bruises or bleeding in genital area
Venereal disease
Frequent urinary or yeast infections
Excessive seductiveness
Role reversal, overly concerned for siblings
Massive weight change
Suicide attempts (especially adolescents)
Inappropriate sex play or premature understanding of sex
Threatened by physical contact, closeness
Emotional Abuse
Emotional abuse may be name-calling, insults, put-downs, etc., or it may be terrorization, isolation, humiliation, rejection, corruption, ignoring
Speech disorders
Delayed physical development
Substance abuse
Ulcers, asthma, severe allergies
Habit disorder (sucking, rocking, biting)
Antisocial, destructive
Neurotic traits (sleep disorders, inhibition of play)
Passive and aggressive - behavioral extremes
Delinquent behavior (especially adolescents)
Developmentally delayed
Crises Considerations
In regard to crises situations, such as suicide attempts, when perceived as "situational mediators that place an individual's typical defenses and resistances in question," a crisis state can help facilitate dynamic change. Winnicott's contributions to psychoanalytic theory provide positive groundwork in this area. His idea of a time-limited therapeutic consultation proves particularly useful for the brief nature of crisis work. When individuals experience suicidal ideations involving the use of a gun, according to Kohut (1971; cited by Romano, 2004), this type scenario portrays an idealizing self-object transference. The use of a gun permits the person to feel in control and exert dominance over other individuals in his/her life. (Feldman & Johnson; cited by Romano, 2004) Often within suicide attempts or other crises' contexts, the present crisis depicts only one of numerous unconscious expectations and reactions to external events perpetuating the situation. Change at a dynamic level can negate the necessity of repeating crisis-precipitating behaviors in the future. (Jerry, 1998)
May (2008) notes the following acronym proves helpful for parents, verbally abused as children, who may struggle with the possibility they too may verbally abuse their child/ren.
A ecognize your feelings.
A mpathize with your child.
A hink of the situation differently. (Try using humor.) ear what your child is saying.
A ntegrate your love with your angry thoughts.
A otice your body's reactions to feeling anger and to calming down.
A eep your attention on the present problem. (May, 2008)
Winnicott's Relational Model Theory
Donald Winnicott, a British psychoanalyst, pediatrician, and child psychiatrist who lived from 1896 to 1971, worked at the Paddington Green Children's Hospital in London for more than 40 years. In 1923, Winnicott became interested in child psychoanalysis and during his professional pursuit in psycholanalysis, Melanie Klein's work significantly influenced him. Winnicott, in turn impacted object relations theory, particularly with his 1951 essay "Transitional Objects and Transitional Phenomena," which focused on familiar, inanimate objects children utilize during times of stress to stave off anxiety. ("Donald Winnicott," 2008, ¶ 1) the following figure (2) relates a photo of Winnicott.
A figure in file Mark is to send
Figure 2: Donald Winnicott (Robbins, 1999)
Winnicott purported that the success or failure of therapy ultimately evolved from the therapist:
every failed analysis is a failure not of the patient but of the analyst." (from "Clinical Varieties of Transference," 1955-56; cited by Robbins, 1999))
Along with emphasizing the psychoanalysts' responsibility in the therapy process, Winnicott stressed that "play" proved to be a prominent part in psychotherapy, not only when treating children, but also adults, in therapy.
Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play." (from "Playing: Its Theoretical Status in the Clinical Situation," 1971; cited by Robbins, 1999)
In treating children, Winnicott noted, children possess various levels of attachment to their primary caregivers. "The 'good enough' attachment meets the needs of both the parent and the child.." (Winnicott, 1960; cited by Feld, 1996-2001) Problems may evolve, albeit when a disruption in the relationship occurs, but the attachment proves strong enough to withstand that break. When the parent and child experience a maladaptive attachment relationship with a potential for change, work with both the child and caregiver to strengthen their attachment bond generally constitutes the recommended treatment course. When the relationship proves maladaptive without potential for change, albeit the therapist needs to implement individual therapy and focus on helping the child develop positive attachments. (James, 1994; cited by Feld, 1996-2001) Winnicott, like Fairbairn, conceptualized that the psyche of the child develops in relation to a real, influential parent. For a child to develop a healthy, genuine self, rather than a false self, Winnicott argued, "the mother must be a 'good-enough mother' who relates to the child with 'primary maternal preoccupation'."
He contended that a good-enough mother permits her infant to be used her so he/she may develop a healthy sense of omnipotence, which as the child grows and matures, will naturally be disturbed.
Winnicott's theory regarding "his conceptualization of the psychic space between the mother and infant, neither wholly psychological or physical, which he termed the 'holding environment' and which allows for the child's transition to being more autonomous" (Ibid.) proved innovative. Winnicot's "holding environment" concept led Winnicott to him developing his famous theory of the "transitional object."
Robbins (1999) relates the following relevant quotations by Winnicott
It is sometimes assumed that in health the individual is always integrated, as well as living in his own body, and able to feel that the world is real. There is, however, much sanity that has a symptomatic quality, being charged with fear or denial of madness, fear or denial of the innate capacity of every human being to become unintegrated, depersonalized, and to feel that the world is unreal." (from "Primitive Emotional Development," 1945)
If we are to become able to be the analysts of psychotic patients we must have reached down to very primitve things in ourselves." (from "Hate in the Transference," 1947) suggest that the mother hates the baby before the baby hates the mother, and before the baby can know his mother hates him." (from "Hate in the Transference," 1947)
It is in the space between inner and outer world, which is also the space between people -- the transitional space -- that intimate relationships and creativity occur." (from "Transitional Objects and Transitional Phenomena," 1951)
When symbolism is employed the infant is already clearly distinguishing between fantasy and fact, between inner objects and external objects, between primary creativity and perception." (from "Transitional Objects and Transitional Phenomenon," 1951)
The good-enough mother...starts off with an almost complete adaptation to her infant's needs, and as time proceeds she adapts less and less completely, gradually, according to the infant's growing ability to deal with her failure..." (from "Transitional Objects and Transitional Phenomena," 1951)
One has to include in one's theory of the development of a human being the idea that it is normal and healthy for the individual to be able to defend the self against specific environmental failure by a freezing of the failure situation. Along with this goes an unconscious assumption (which can become a conscious hope) that opporunity will occur at a later date for a renewed experience in which the failure situation will be able to be unfrozen and reexperienced, with the individual in a regressed state, in an environment that is making adequate adaptation. The theory is here being put forward of regression as part of a healing process, in fact, a normal phenomenon that can be properly studies in the healthy person." (from "Metapsychological and Clinical Aspects of Regression within the Psychoanalytic Setup," 1954)
In the cases on which my work is based there has been what I call a true self hidden, proteceted by a false self. This false self is no doubt an aspect of the true self. It hides and protects it, and it reacts to the adaptation failures and develops a pattern corresponding to the pattern of environmental failure. In this way the true self is not involved in the reacting, and so preserves a continuity of being. However, this hidden true self suffers an impoverishment that derives from lack of experience." (from "Clinical Varieties of Transference," 1955-56)
The patient makes use of the analyst's failures. Failures there must be, and indeed there is no attempt to give perfect adaptation..." (from "Clinical Varieties of Transference," 1955-56)
Maternal failures produce phases of reaction to impingement and these reactions interrupt the 'going on being' of the infant. An excess of this reacting produces not frustration but a threat of annihilation. This in my view is a very real primitive anxiety, long antedating any anxiety taht includes the word death in its description." (from "Primary Maternal Preoccupation," 1956)
The first ego organization comes from the experience of threats of annihilation which do not lead to annihilation and from which, repeatedly, there is recovery." (from "Primary Maternal Preoccupation," 1956)
With the care that it receives from its mother each infant is able to have a personal existence, and so begins to build up what might be called a continuity of being. On the basis of this continuity of being the inherited potential gradually develops into an individual infant. If maternal care is not good enough then the infant does not really come into existence, since there is no continuity of being; instead the personality becomes built on the basis of reactions to environmental impingement." (from "The Theory of the Parent-Infant Relationship," 1960) the true self does not become a living reality except as a result of the mother's repeated success in meeting the infant's spontaneous gesture or sensory hallucination." (from "Ego Distortion in Terms of True and False Self," 1960)
The true self comes from the aliveness of the body tissues and the working of body functions, including the heart's action and breathing. It is closely linked with the idea of the primacy process, and is, at the beginning, essentially not reactive to external stimuli, but primary." (from "Ego Distortion in Terms of True and False Self," 1960) it is only in recent years that I have become able to wait and wait for the natural evolution of the transference arising out of the patient's growing trust in the psychoanalytic technique and setting, and to avoid breaking up this natural process by making interpretations. It will be noticed that I am talking about the making of interpretations and not about interpretations as such. It appals me to think how much deep change I have prevented or delayed in patients in a certain classification category by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of having been clever. I think I interpret mainly to let the patient know the limits of my understanding. The principle is that it is the patient and only the patient who has the answers." (from "The Use of an Object and Relating Through Indentifications," 1969) there are many patients who need us to be able to give them a capacity to use us." (from "The Use of an Object and Relating Through Identifications," 1969)
The potential space between baby and mother, between child and family, between individual and society or the world, depends on experience which loeads to trust. It can be looked upon as sacred to the individual in that it is here that the individual experiences creative living." (from "The Location of Cultural Experience," 1967)
In individual emotional development the precursor of the mirror is the mother's face....What does the baby see when he or she looks at the mother's face? I am suggesting that, ordinarily, what the baby sees is himself or herself. In other words the mother is looking at the baby and what she looks like is related to what she sees there." (from "Mirror-Role of Mother and Family in Child Development," 1967)
Bowlby's Attachment Theory
Bretherton (1992, p. 759) reports that attachment theory evolved from joint work of John Bowlby and Mary Ainsworth. (Ainsworth & Bowlby, 1991)
Bowlby drew from ethology, cybernetics, information processing, developmental psychology, and psychoanalysts' concepts to formulate the basic tenets of attachment theory. Consequently, Bowlby revolutionized perceptions regarding a child's tie to his/her mother and disruption of the bond through separation, deprivation, and/or bereavement. Mary Ainsworth innovative methodology empirically tested some of Bowlby's work and also helped expand attachment theory.
Ainsworth perceived the attachment figure as a sound base from which an infant may explore his/her world. In addition, Ainsworth amalgamated maternal sensitivity concepts to infant signals and the concepts' role in developing infant-mother attachment patterns.) the following figure (3) reflects a photo of Bowlby.
A figure in file Mark is to send
Figure 3: John Bowlby (Hoover, 2004)
Early successful attachment, according to Bowlby, becomes organized into a collection of complex social behaviors and, by extension, the capability for successful relationships of various. Basically, through successful early attachment to one person, a person learns to tune his/her behavior to the subtle social cues of a number of other individuals. In turn, this tuning transforms via development and experience into a person's "ability to engage in social relationships, to make friends, and, to eventually attain physical intimacy. (Hoover, 2004)
Hoover (2004) purports that the reciprocal attachment between caregiver and child proves vital as "the part of the brain that regulates social behavior, including but not limited to relationship-building and sexuality, does not develop to its full potential in the absence of these bonds."
This understanding began to gain recognition during the 1950s and 1960s with Harlow's groundbreaking work with rhesus monkeys. This work revealed that in primates, devoid of critical-period attachment bonds, play, other social behaviors, and mating responses do not mature. Bowlby (cited by Hoover, 2004) traces changes in the sophistication of a person's behavior, designed to attain closeness, to the primary caregiver. He presents a clear perspective regarding the significance of attachment in personality development:
young child's experience of an encouraging, supportive, and co-operative mother, and a little later, father, gives him a sense of worth, a belief in the helpfulness of others, and a favorable model on which to build future relationships... By enabling him to explore his environment with confidence and to deal with it effectively, such experiences also promote his sense of competence.
The appropriately attached relationship between the mother and the toddler serves as a safe platform from which the infant explores her environment. Because regulation of the system requires feelings of discomfort when social distance becomes too great, it is reasonable to assume that detached toddlers will find themselves perpetually anxious. Since this state inhibits learning, successful attachment also probably predicts efficient learning during the earliest stages of life.
But what is the importance of reciprocal attachment between caregiver and child? Simply, the part of the brain that regulates social behavior, including but not limited to relationship-building and sexuality, does not develop to its full potential in the absence of these bonds. Starting with Harlow's groundbreaking work with rhesus monkeys in the 1950s and 1960s, it has been shown that in primates, play, other social behaviors, and mating responses do not mature in the absence of critical-period attachment bonds.
The failure of human infants to bond with a primary care-giver is no less damaging -- though perhaps manifested more subtly -- given human behavioral flexibility. Bowlby even argues that early successful attachment lies at the core of such later manifestations of reciprocity as perspective taking (i.e., empathy). He may have carried the point a bit far in his favorable analysis of later discredited theories about autism by such psychoanalytic-oriented writers as Bettleheim. Early on, writers "blamed" autism on failures of attachment - notably emotionally cold and cognitively unpredictable mothers. We understand now that the autistic spectrum disorders are organically caused. (p. 378; Hoover, 2004)
Detached and abused children, Bowlby (cited by Hoover, 2004) purported, will either deride contact with other humans or come to fear and loathe connections with other individuals.
Attachment and Therapy
Psychoanalysts repeatedly note that a person with derisory, rigid working models of attachment relations will more likely inappropriately inflict these models on interactions with his/her therapist, which constitutes a phenomenon known as transference.
When this occurs, the therapist and client share the mission to understand the origins of the client's dysfunctional internal working models of self and attachment figures. In these scenarios, therapists may best help the client by serving as a reliable, secure base for beginning the challenging task of examining and amending his/her internal working models. Bretherton (1992, p. 767)
Reality vs. Fantasy
In the contemporary psychoanalysis, theoretical arena, attachment theory merits growing awareness, particularly from psychoanalysts concerned with empirical research.
John Bowlby initially introduced attachment theory, which basically deals with a child's tie to his/her caregivers, and also aims to explain individual variations in attachment merits, during the late nineteen fifties and early sixties, albeit this may be considered joint effort of Bowlby and Mary Ainsworth. (Bretherton, 1991; cited by Gullestad, 2001, p. 4) Mary Main and Peter Fonagy and others also elaborated on attachment theory though their work. The key notions of attachment theory arouse controversies within psychoanalysis; albeit "attachment" comprises a key concept in psychoanalysts' understanding of development. The concept of "attachment" refers to "a continuous tie to a specific person that the child turns to when feeling vulnerable and in need of protection." (Gullestad, 2001, p. 16) Although Freud and Bowlby disagree regarding their image of Man, ideas developed within attachment theory, nevertheless possess parallels to those of psychoanalytic object relation theories with regard to the conceptualisation of motivation, as well as the understanding of psychological disturbances' origins.
Instead of focusing on the patient's fantasies and constructions of narratives, Bowlby's concerns concentrates on interpersonal and traumatic origins of psychological disturbances. (Gullestad, 2001, p. 16) When Bowlby challenged Freud's legacy, what a number of analysts perceived as "true" psychoanalysis, his ideas met extreme strongly negative reactions within the psychoanalytic world. Contrary to Kleinian psychoanalysis, and other leading psychoanalysts' contentions, which strongly stressed a person's inner fantasy world, Bowlby emphasized external life events, like separation and loss. Gullestad (2001, p. 3) notes that some read Bowlby as if he focused only on external events, not on the way the individual registers them. "Bowlby's ideas seem to have been rejected by psychoanalysts believing that mental pain originated in the internal rather than the external world." (Ibid.)
Anna Freud, for example, reacted to Bowlby's paper on grief and mourning by responding that psychoanalysis does not "deal with the happenings in the external world as such but with their repercussions in the mind, i.e. with the form in which they are registered by the child." (a. Freud, 1960, p. 54 cited by Gullestad, 2001, p. 3)
Bowlby purports that the origins of psychological disturbance theory constitutes the greatest difference between the attachment perspective and classical psychoanalysis.
Attachment-informed' listening is directed towards 'what the patient has actually experienced in the past, or has repeatedly been told' (Bowlby, 1988, p. 141; cited by Gullestad, 2001, p. 16), and not towards unconscious fantasies." vital contribution of attachment theory emphasises interpersonal experience in explaining psychopathology.
Attachment theory, albeit may simultaneously create an artificial antagonism between real experience and personal constructions of meaning, between reality and fantasy. The child's subjective experience, consisting of the attitudes, values etc. Of the object, along with the interaction with the object comprises the basis for internalisation of interaction with caregivers. This occurrence, Gullestad (2001, p. 16) contends, may evolve from the parents' unconscious attitude and communication instead of his/her verbally conveyed message.
A child, for instance, may "capture' and internalise an unexpressed ambition or a judgmental attitude of his father's, contrasting with the father's declared attitude and values." (Gullestad, 2001, p. 16) in addition, a child's personal aggression toward his/her father may color his/her internalised image of his/her father. Consequently, the child's "inner" father may transform into a more merciless man in his strictness than the "real" father. In time, this inner father may radically mark the child's attitude, toward him/her self and toward other individuals. As internalised object relations depict copies of observable interaction patterns, not objective constructions of such interactions, internalisation represents an active, "creative" process.
Although Bowlby stresses the patient's constructions and misconstructions prove vital, he also emphasizes that therapeutic listening should prioritize external circumstances to actual experiences. Bowlby (1988) seems to indicate that the internal and the external perspectives need to receive different emphasis in different contexts. When attempting to understand general principles of personality, the therapist is to stress external events. As unconscious perception, emotional reactions and fantasies mark psychic reality and the therapist deals with this psychic reality in psychoanalytic treatment, the therapist has to acknowledge that a person's inner object scenarios represent intrapsychic structures, relatively independent of their surrounding environment, resistant to change. In analysis, an internalised scepticism may comprise a continual resistance. (Gullestad, 2001, p. 16)
Good-Enough Mothering
Trust. Janoff-Bulman (2002, pp. 13-14) purports, serves as the marker for three intersecting representations the child derives from his/her earliest experiences. When a responsive caregiver meets the child's earliest needs, the child's "world," reflected by individuals who care for the child, is a benevolent one. A responsive caregiver responds to the infant's behavior (e.g., crying), and in turn provides the foundation for the child's earliest understanding of the person - outcome contingency.
Though providing care in meeting the child's needs, a responsive caregiver helps the child begin to understand that he or she is worthy of care; giving the infant a basis for self-worth. Basically the infant starts to understand: "there is some one good who cares for me, and I can do certain things to bring about a caring response from this person... I must be worthy of care." (Janoff-Bulman, 2002, p. 14)
Kohut's Self-Psychology
History of Self-Psychology
Self-psychology is a theoretical framework for understanding the psychological development of a child (Pessein & Young, 1993). The theory evolved from Freud's psychoanalysis, which examined mental processes, a body of psychological knowledge and a method of treatment for psychological illnesses. Post-Freudian analysts further developed and modified psychoanalytic theory, but stayed within Freud's theoretical framework. Heinz Kohut, the so-called "father" of self-psychology, revised the basic tenets of psychoanalysis by focusing on empathy and introspection (Kohut, 1959). This shifted the focus of understanding the individual from the psychobiological foundations of the id, and the drives central to psychoanalysis to the psychological considerations of the self, it's development and tribulations. He developed self-psychology as a study of the self and its relationship to selfobjects.
In contrast with earlier theories, the self is seen, not as a representation or product of activity of the ego, but in itself an active agent (Greenberg & Mitchell, 1983). Freudian psychoanalysis focused on examination of the inner life of a person, examining psychic structures such as the super ego as a response to unexpected changes of drive discharge patterns. Neo-Freudians, including Klein, Fairbairn, Guntrip, Winnicott, Horney, Fromm, Sullivan and Fromm-Reichmann modified the classic theory to include the influence of the environment and external objects.
Kohut viewed self-psychology, not as an interpersonal or object relations framework, but intrapsychically dynamic, placing selfobject theory at the center of self-psychology. "The most fundamental finding of self-psychology is that the emergence of the self requires more than the inborn tendency to organize experience." (E.S. Wolf, 1988, p. 11). The primary psychological task, for self-psychology, is the maintenance of the self, and the relationships between the self and selfobject are at the center of development from birth to death (Tolpin, 1986).
At the base of self structure is self-esteem (Peoples, 1991).
Kohut believed that the rudimentary development of the self begins at about eighteen months, when the child's needs are narcissistically based. In order for normal development to occur, these powerful needs must be met in certain ways, or psychopathology can develop (Lynch, 1994). (Feld, 1996-2001)
Kohut's Self-Psychology Perspective
Heinz Kohut, Vienna born, Chicago transplanted psychoanalyst, first conceptualized psychology of the self. Self-psychology, primarily based on work by Kohut (1971, 1977; Kohut & Wolf, 1978; cited by Romano, 2004), ultimately considers the state of the self. It embraces an object relations perspective in which the therapist understands the self and the self-object relationship as vital for the state of the self. (Bacal and Newman, 1990, p. 231; cited by Romano, 2004) According to Kohut (1984, p. 153; cited by Romano, 2004), understanding self-psychology proves central to the concept of the self. Kohut argues: "We define therapeutic progress toward mental health not primarily by reference to expanded knowledge or increased ego autonomy, but by reference to the laying down of permanent self structure." Kohut's views of transference tend to focus on the client and therapist relationship.
Feld (1996-2001) explains that this consequently triggers the client's unmet developmental needs. (Feld, 1996-2001) the following figure (3) reflects a photo of Kohut.
A figure in file Mark is to send
Figure 4: Heinz Kohut (Heinz Kohut, 2007)
Kohut's thoughts about the scientist's appropriate attitude seems to be the best way to set the tone for this section. In his 1977 book Restoration of the Self, Kohut notes that in all he had written on the psychology of the self, he had purposely not defined the self, knowing that some would be critical of him for that omission. He explained his omission in the following way:
My investigation contains hundreds of pages dealing with the psychology of the self - yet it never assigns an inflexible meaning to the term self. But I admit this fact without contrition or shame. The self is, like all reality, not knowable in its essence. We can describe the various cohesive forms in which the self appears, can demonstrate the several constituents that make up the self...and explain their genesis and functions. We can do all that, but we still will not know the essence of the self as differentiated from its manifestations.
These statements...express my belief that the true scientist - the playful scientist as I put it before - is able to tolerate the shortcomings of his achievements - the tentativeness of his formulations, the incompleteness of his concepts. Indeed, he treasures them as the spur for further joyful excursions.... A worshipful attitude toward established explanatory systems...becomes confining in the history of science - as do, indeed, man's analogous commitments in all of human history. Ideals are guides, not gods. If they become gods they stifle man's playful creativeness: they impede the activities of the sector of the human spirit that points most meaningfully into the future." (Heinz Kohut, 2007)
Kohut and Wolf (1978; cited by Romano, 2004) purport the self, a psychic structure, to reside at the core of a person's personality.
Kohut (1971; cited by Romano, 2004) contends that the process of the development of self process starts at an individual's birth and hinges on his/her environment. As a person's self emerges as "either a firm and healthy structure or as a more or less seriously damaged one," (Kohut & Wolf, 1978, p. 20; cited by Romano, 2004), that emergence depends on interactions between the self and its self-objects in a person's childhood. According to Kohut (1984; cited by Romano, 2004), from a person's birth to his/her death, self-object relationships form the essence of his/her psychological life.
Self-Object Functions the self-object functions, which occur between the self and the self-object, serve as an origin of the self's structure and cohesion.
Mirroring response, idealizing response, and twinship response, three types of self-object functions, may develop. "These functions contribute toward the individual's self to be organized and cohesive." (Kohut, 1971; cited by Romano, 2004) Kohut (1984, p. 61; cited by Romano, 2004) purports that the self-object function never disappears, but undergoes transformation and maturation. He stresses that outside a mold of self-objects - a self cannot exist (Ibid.) When a person's early self-objects do not provide nurturing experiences to contribute to his/her sense of self, significant severe developmental arrests occur. (Baker & Baker, 1987; cited by Romano, 2004)
Self-object mirroring functions. Within self-psychology, being mirrored refers "to all the transactions characterizing the mother-child relationship, including not only the reflections of grandiosity, but also constancy, nurturance, a general empathy and respect" (Kohut, 1977, pp. 146-147). The parents' mirroring responses influence the maintenance and development and maintenance of self-esteem and self-assertive ambitions. Their response mirrors back to the child a sense of worth, which in turn creates an internal self-respect. This mirroring response provides a foundation for the individual's development, by providing an affirmation of self-worth for the individual. The child internalizes the self-object mirroring functions, and in the future, will be able to provide this approving function on his or her own (Kohut).
Self-object idealizing function. With the idealizing function, the self has the need to merge with or be close with someone who he/she believes will make him/her safe, comfortable, and calm. Kohut (1971) referred to this all-powerful self-object as the idealized parental imago. There is a developmental process of maturation of idealizing needs. Initially, there is a need to merge with the idealized parental imago, then there is a wish to be near the source of such power. Eventually, the mature individual is satisfied knowing that friends and family are available in times of stress (Baker & Baker, 1987).
Self-object twinship function. Within the twinship self-object function, a need is provided for the self to feel a degree of alikeness with other people. Initially, the closeness sought may have a merged quality; however, through development, greater toleration for being different is accepted (Baker & Baker, 1987). (Romano, 2004)
Self-object transference relationships depict a person's unmet self-object needs, Kohut contends. In therapy, in relation to the therapist, the patient's experience acquires the self-object transference experienced he/she experienced with caretakers in childhood. Kohut (1977; Kohut, 1971; cited by Romano, 2004) defines the three types of self-object transferences: mirroring transference, idealizing transference, and twinship transference:
Mirroring transference evolves from recurring, vital mirroring failures from the person's parents or parental substitutes that he/she experienced during his/her childhood.
The child believes his/her inadequacy caused the lack of mirroring responses, and in turn in attempts to compensate may try to be perfect or wonderful. (Baker & Baker, 1987; cited by Romano, 2004) Goldberg (1989; cited by Romano, 2004) explains that these patients appear to be missing a part of their self; that they need others to confirm their self-esteem. To conquer his/her sense of worthlessness, the patient attempts to secure affirmation and approval from other people. During the mirroring transference, Nighorn (1988; cited by Romano, 2004) notes that the patient repeatedly recounts the therapist's response to ascertain how valuable, worthy, and good, he/she may be.
In Idealizing transference, Kohut (1977; cited by Romano, 2004) explains, the self searches for other people to admire. As long as the person is able to attach to another person who possesses power or prestige, his/her self feels a sense of safety. During the idealized self-object transference, the individual recovers his/her self-esteem through the idealization of and identification with external objects.
Twinship transference, according to Kohut (1984; cited by Romano, 2004), develops when the self only feels confirmed when the self-object experiences identical values, thoughts, and appearance. "Within the context of the transference, an outline will gradually come to light of a person for whom the patient's early existence and actions were a source of genuine joy; the significance of this person as a silent presence, as an alter ego or twin next to whom the child felt alive will gradually become clear." (Kohut (1984, p. 104; cited by Romano, 2004) This occurs when the patient assumes his/her therapist will feel and act as he/she feels and acts. (Romano, 2004)
Self-psychology's Nine Phases f Human Development
Feld (1996-2001) reports that the following nine phases of human development constitute the self-psychology framework:
The archaic infantile phase: During early infancy, the child simultansouelsy experiences himself and the world. "Needs for mirroring, idealizing, twinship and efficacy begin and continue throughout the course of life."
The Oedipal phase:
This phase uses infantile needs to build up a child's gender identification and self structure.
The latency phase: Twinship and alter-ego needs prove to be important to the development of social skills during this pahse.
The prepubertal phase: During this phase, self-objects expanded during a child's shifting away from his/her primary care givers as symbolic substitutes for the selfobject persons / toward his/her peers, teachers.
The adolescent and young adult phase. During this period, self-psychology combines cognitive development and permits the acknowledgment of parental deficits and consequently, development of peers as selfbojects continues.
The marital phase: Spouses utilize each other during this phase to meet a various selfobject needs.
The parenting phase: If / when adults possess a cohesive and solid self, this time occurs when children are included as selfobjects. Also, during this time, a fragile self structure could become more pronounced and lead to increased fragmentation.
The middle-age phase: This phase usually constitutes a time of introspection and self-evaluation, and constitutes a time when an individual needs selfobjects accepting of the self's readjustment of goals. When this is not present, a "mid-life crisis" may develop in response to the dearth.
The old-age phase: During this season of life, individuals need to be idealized by their selfobjects to confirm the value/purpose of their life. (Feld, 1996-2001) (Feld, 1996-2001)
Empathy Empathy, which may be defined as "the ability to understand the experience of another," (Bachrach, 1976; cited by Romano, 2004), according to Kohut (1959; cited by Romano, 2004) vitally contributes to an individual's development of self. Empathy, a crucial constituent of each psychological observation, Bjorklund (2000, p. 93; cited by Romano, 2004) further asserts, comprises "the sustained immersion of oneself in the experience of the other, attempting to understand how others see and experience themselves and their worlds, putting this into words, and checking one's understanding." Recurring empathy failures between the self-object and self, at the root at all psychopathology, contribute to fragmentation. (Kohut, 1971; cited by Romano, 2004)
Healing Past "Healers," according to Renaurd (2003) in practices devoid of modern drugs, invested more time considering their patient's illnesses than most doctors today. From their probing, numerous healers found that a number of physical diseases intimately related to an individual's emotions and his/her personal relationships. Consequently, they began to believe that a person's good health evolved from him/er people living in harmony with themselves and their environment. For an individual to be healthy and grow, they determined, a person must be able to confront life changes and adversity with a positive attitude.
During the next chapter of this clinical case study dissertation, the Client History, this researcher relates historical factors leading to this case study's focus. In addition, the patient's presenting problem, along with her initial diagnosis are reported. Ultimately, this researcher utilizes theories and techniques from Object Relation, Attachment Theories, and Self-Psychology, in a number of ways dissimilar to Freudian analysis, to approach, analyze and afford appropriate answers to encourage healing and positive growth in/for the patient's internal and external worlds.
CHAPTER III
CASE PRESENTATION
Children build working models in their world and themselves through their relationship with early attachment figures." (attributed to John Bowlby; cited by Janoff-Bulman, 2002, p. 14)
3.1 Client History
The client focus for this clinical case study dissertation, Shaina Rachel Lieberman, a 43-year-old Jewish woman, emigrated from the former Soviet Union during 1997. Currently, Shaina, who holds a Bachelor's degree in Business Administration, is seeking full-time employment. She was referred to this researcher/therapist by her psychiatrist for individual therapy sessions as an adjunct to anti-depressant medication.
This researcher selected this particular patient on the basis of the following areas of interests:
Shaina's inability to relate maturely to men, irrationally ending stable relationship to avoid possible rejection; as evidenced by her current separation from her husband and son.
Shaina's inability to tolerate criticism; as evidenced by her repeated disruptions of friendships, as well as the loss of several promising employment positions, due to misinterpretations of even constructive comments from others.
Shania's preoccupation with finding an older man as a substitute for the lost relationship with her father;; as evidenced by affair with a man older thanher father;
Shaina's fear of having a stable relationship; as evidenced by her repeated relations interactions with others, particularly males, reflecting identical conflicts Shaina experienced with her father when she was a child.
Shaina's desire to "escape" from current confrontations and/or challenges, as evidenced by her one suicide attempt.
Shaina, the older of two sisters, grew up in a harsh, strict environment, more specifically; Shaina's father did not permit her to experience any relationships outside their nuclear family. Along with regularly verbally abusing her, Shaina's father constantly criticized her for participating in any activities he perceived as autonomous.
As a result of experiencing a disparaging, negative relationship with her father, Shaina felt helpless and entrapped. Consequently, in an attempt to escape the credible, constant conflict, when old enough to leave home, Shaina hastily married a man she did not love. Instead of finding the freedom she craved, however, to her surprise, Shaina began to experience the same pattern of relationship with her husband she experienced with her father during her childhood. Shaina's husband, she reported, constantly criticized and belittled her. After experiencing nine years of severe conflicts and domestic violence in her marriage, Shaina engaged in an extramarital affair with a man older than her father. Shaina, currently separated and in the process of divorcing her husband, despite ongoing challenging conflicts, earned a BA in business administration and secured full-time employment.
Along with her challenges and accomplishments, Shania reports a history of one psychiatric hospitalization for an attempted suicide. Shania's suicide attempt resulted in her husband obtaining full custody of their ten-year-old son.
3.2 Theoretical Basis for Case
Developmental History
Shania, grew up with her biological mother and father, both educated, and her younger sister, who struggled with a learning disability. The family unit, albeit, proved to be dysfunctional. Consequently, the early emotional abuse, neglect, and emotional voids of her family environment created challenges for Shania. Shania's object relations were distorted; her attachment formation was disturbed. In time, this contributed to Shania's inability to set healthy boundaries and trust others. Shania's mother worked as a newspaper/book editor, while her father, an engineer, worked in a space laboratory, so family finances were described as stable. Shania described her home environment as harsh and strict, due to her father being an extreme authoritarian. Shania reported that her father forebode her to have any types of relationships outside their home. As the only relationship she was permitted to have was with her younger sister, Shania felt extremely isolated. Reports from Shania regarding her relationship with her sister seem to suggest the has been a parentified child, indicating Shania's parents not only appointed her to serve as academic help to her sister, but also as a parent. More specifically, Shania describes her responsibilities as follows:
caring for her sister, helping her sister complete hygiene issues, putting her younger sister to sleep, playing with her younger sister, feeding her younger sister, studying with her sister, and whatever else needed to be done.
Despite Shania's efforts to please her parents and fulfill the heavy responsibilities her parents imposed upon her, her father constantly harshly criticized her. Although Shania did not experience physical abuse during her childhood years, she admitted to being regularly verbally and emotionally abused. Shania's mother, described as passive, distant, aloof, and disengaged, regularly displayed fear of her husband's (Shania's father's) anger.
Shania reported her mother avoided conflicts with him at all costs, stating: "My father's word was law in our household." According to Shania, due to her father's authoritarian stance and the fact visitors were rarely allowed in their house, her family remained isolated. On the other hand, her father frequently took their family on outings such as visits to museums, movies, vacations, etc.. This researcher noted, albeit, the only people present on these trips were the father, Shania and her sister. The wife/mother was always absent during the "family" outings. Despite Shania's efforts at home and school, her father was never satisfied with her performance. He ruthlessly criticized her. When her grades dropped, for example, Shania's father became enraged.
To try to avoid his explosive angry outbursts, Shania felt compelled to lie, or hide her report book. In addition, Shania's father practiced favoritism in that he did not treat his youngest daughter as harshly. In other words, Shania appeared to be the sole "scapegoat" of the family; the recipient of blame for every misfortune or mishap in the family.
The most traumatic incident occurred on the night of Shania's prom. Shania, at the age of 16, and her mother had secretly purchased a prom dress in preparation of the prom-party.
When her father discovered Shania daughter planned to attend the prom without his permission, he rushed to the prom location. Here, he dragged Shania away from the prom, pulling her by her hair, in front of the other prom attendants. Shania stated this proved to be the most painfully embarrassing incident she experienced in her life and that she had never before or after felt so and humiliated. After graduating from high school, while attending a local university, Shania secretly began to date. For the first time in her life, she also began to cultivate friendships. However, Shania was unable to maintain any of these relations, as each of her new relationship appeared doomed to fail. At the age of 25, Shania met her husband-to-be. When Shania's father met her fiance, he immediately expressed his disapproval of this relationship. Along with his disapproval, criticized Shania so harshly, she felt even more entrapped and helpless. Despite her father's negativity, Shania married a man she did not love. Her marriage, she admitted, was an attempt to escape the constant conflicts with her father. In retaliation, Shania's father did not attend her wedding. He also forbid Shania's mother and sister to attend. After several years of marriage, Shania began to realize the same hostile, relational patterns were occurring in her marital life. She found her husband regularly criticizing and belittling her. Just as her father had done in her childhood, Shania's husband blamed her for their familial misfortunes. Moreover, he opposed the prospect of them having children. Shania, however, wanted a child. During this time, Shania's husband put pressure on her to migrate to the United States.
He proposed a compromise regarding the migration and having a child, conditionally agreeing with Shania: "If you move with me to the U.S., then you can have a child." Shania agreed as she believed that having a child would fill the void; that her child would be someone with whom she could build a more genuine relationship. After moving to America, Shania gave birth to her son. During this same time, however, her relationship with her husband became unbearable.
The relationship, once consisting of constant verbal and emotional abuse, with shouting barrages, escalated to include domestic violence, as Shania's husband began to also physically abuse her. Following nine years of violence and conflict, Shania engaged in an extramarital affair with a man old enough to be her father. When Shania's husband discovered her affair, they mutually agreed to begin the divorce process. The court process terrified Shania as her husband convinced her that the court would take away their of her 10-year-old son because of her adultery.
Shania's fear led to her experiencing a deep depression. She seldom ate while she went for several days at a time without beign able to sleep. She no longer fixed herself up; usually lying around the house in her pajamas. She refused to answer the phone.
If someone rang her doorbell, she ignored them. All essential routines of her life abruptly halted. On her first scheduled court date, Shania attempted suicide by driving her car into opposing direction of traffic on the freeway.
Fortunately, she did not injure herself or anyone else, when two other vehicles forced her car onto the road's shoulder and summoned police. The crises response counselor recommended Shania be hospitalized in a psychiatric unit. Here, she began receiving treatment for her depression and suicidal ideations/attempt. Shania began taking anti-depressant medication and attending group therapy sessions in the psychiatric unit. As a result of her depressive state, Shania's psychiatrist diagnosed her as gravely disabled. At this time, the court awarded custody of their child to her husband, exactly what she had feared the most.
Following her discharge from the psychiatric hospital, Shania attended monthly follow-up sessions with a psychiatrist. During this time, Shania manifested the following symptoms:
preoccupation with fears and catastrophic thoughts related to the outcome of court proceedings;
feelings of hopelessness and helplessness, loss of interests and initiative;
significant self-doubt; low self-esteem; sad mood with depressed affect.
The following figure (1), not an actual picture of Shaina, nor an accurate portrayal of this scenario, reflects a girl possibly experiencing feelings Shaina regularly felt as a child..
A figure in file Mark is to send
Figure 5: Representation of Girl Feeling Alone and Sad ("Majority of Parents," 2007)
Presenting Problem & Symptoms
Shania presented to this researcher/therapist with symptoms of anxiety and depression, related to her forthcoming divorce and custody battle in court. She reported that her husband initiated the divorce process after he discovered she was having an extramarital affair with a man, several years older than her father, also a close relative of her husband. During this period, Shania reported she was experiencing repetitive and vivid dreams, in which, after she appeared naked in court, she was lynched by a group of judges.
These dreams became unbearable to the extent Shania feared going to bed and falling asleep. In turn, she experienced long-term sleeplessness, fatigue, and constant worries, leading to Shania experiencing a deep depression; accompanied by feelings of helplessness, hopelessness, worthlessness, along with an extreme sense of guilt and shame. In conjunction with these features, Shania lacked any semblance of social and/or moral support. Shania related the account of her serious suicide attempt when she drove her vehicle into opposing traffic on the first Thursday in April of 2007, the date she was scheduled to attend court for the custody determination of her 10-year-old son. Shania's suicide attempt necessitated a 5150, a 72-hour observational hold, she reported. When her mental status did not improve, her condition described as profound to the extent her LPS, based on both danger to self and the disability to care for herself, activated an additional 14-day hold in the psych hospital. Due these critical care concerns, relating to potential child neglect, DCFS became involved, and determined to place her son in her husband's custody. Shania's psychiatrist prescribed Prozac, but this drug was discontinued due to adverse side-effects.
Next, her psychiatrist prescribed Lexapro, which proved efficacious. While receiving treatment in the hospital, Shania attended group therapy sessions, which she disliked to participate in these sessions.
She denied any prior history of substance abuse, and also denied any family history of alcohol, substance abuse, or substance dependence. She denied any familial history of imprisonment or incarceration. Shania presented to this researcher/therapist dressed neatly, clean, and well groomed.
Her gait and posture were unremarkable and she did not exhibit any signs of involuntary movements or spasms. Shania's speech rate, accelerated with loud volume, contrasted prosody, within the normal range. Her mood appeared to be dysphonic; with congruent affect which vascilated from anxious to irritable modes.
Shania did appear to be responding to internal stimuli. Her thought process did not seem idiosyncratic. She denied insomnia, poor appetite, and diminished libido. She also denied currently experiencing any suicidal ideations, intent, or plan. Furthermore, she denied having any homicidal ideations, intent, or plan. Moreover, she denied experiencing any auditory, visual-, and tactile hallucinations. Shania's response latencies were within the normal limits. Her attentional functions seemed slightly deficient, in that she tended to be readily distracted. Her memory and recognition were within the normal range. Her insight and judgment were unremarkable. Her impulse control function was adequate, with obvious signs of rigidity, inhibition, and tension. Shania presented with an anxious, depressed mood, primarily preoccupied with the pending divorce process; along with the custody determination of her ten-year-old son.
In session, she tended to actively analyze marital problems, blaming her husband for their relational discord. She simultaneously lacked in empathy and appeared emotionally absent; revealing clear signs of alexithymia. As the session progressed, it became more obvious Shania was utilizing the divorce process as a refuge, i.e, she would avoid talking about any emotional aspects of her ordeals. Rationalizing problematic affective recollections was common place for Shania.
For example, she tended to focus more on the financial aspects when custody issues surfaced. She would elaborate about percents, expenses, mortgage payments, and custody arrangements.
Initial Diagnosis
Shaina presents symptomatology, consistent with the following DSM IV-TR Diagnoses:
Axis I
296.32 Major Depressive Disorder, Single, Moderate
300.02 Generalized Anxiety Disorder
V61.1 Partner Relational Problem
Axis II
799.9 Diagnoses Deferred on Axis II
Axis III
Thyroid dysfunction is ruled out. Otherwise unremarkable.
Axis IV
Problems related to lack of social support system, marital discord.
Axis V
GAF = 62
Conceptual Diagnoses
As noted in Shania's client's history, she had been a parentified child, whose capabilities as a child were obviously stretched well beyond her developmental abilities. She endured an inordinate amount of criticism, lack of mirroring, and rejection. These factors, in turn, may have paved the way for introjecting the rejecting object. Hence, Shania, as a child would desperately try to gain the object's approval and affirmation. Further rejection, apparently continued to occur, which in turn, resulted in Shania's rage, anger, helplessness, hopelessness, and sadness. In contrast, Shania's desire for mirroring and being accepted did not cease to exist, which is to say, Shania came to learn to split her need to be loved and accepted apart from her need to retaliate. This researcher/therapist contends this appears to constitute the foundation for Shania's ambivalence. Conseqently, Shania;s development of the true self has been thwarted since she has felt she must be exclusively attuned to the needs of others in the family system. Because her childhood holding environment did not recognize her needs and uniqueness, Shania's false self emerged. This false self strives to suppress her individuality and molds itself to the needs of others. This may explain Shania's eager-to-please attitude.
Conceptualization
Winnicott's Relational Model Theory
Good-enough mothering
For a child to develop a healthy, genuine self, as opposed to a false self, Winnicott felt, the mother must be a "good-enough mother" who relates to the child with "primary maternal preoccupation." Anticipating the insights of Kohut and self-psychology, Winnicott felt that a good-enough mother allows herself to be used by the infant so that he or she may develop a healthy sense of omnipotence which will naturally be frustrated as the child matures. Winnicott's theory is especially innovative regarding his conceptualization of the psychic space between the mother and infant, neither wholly psychological or physical, which he termed the "holding environment" and which allows for the child's transition to being more autonomous. This concept of the "holding environment" led Winnicott to develop his famous theory of the "transitional object." Winnicott felt that a failure of the mother -- the not-good-enough mother -- to provide a "holding environment" would result in a false self disorder, the kind of disorders which he saw in his practice. (Robbins, 1999)
False self
Winnicott's theory of "false self disorders" is uncannily similar to Laing's description of the schizoid personality in the Divided Self. Winnicott also felt that the therapist's task is to provide such a "holding environment" for the client so that the client might have the opportunity to meet neglected ego needs and allow the true self of the client to emerge. (Robbins, 1999)
Bowlby's Attachment Theory
As noted during this study's literature review, Bowlby purported that early successful attachment organizes into a compilation of complex social behaviors, which through extension, constitute the capability for successful relationships of various types. Through successful early attachment to one person, an individual learns to tune his/her behavior to subtle social cues a number of other individuals display. Consequently, through development and experience, this tuning transforms into a person's "ability to engage in social relationships, to make friends, and, to eventually attain physical intimacy." (Hoover, 2004)
Emotional stability is built upon confidence in the availability of attachment figures, which develops slowly throughout childhood and adolescence. As children begin to realize that they are separate from their mothers, they are able to transfer the dependent attachment onto a transitional object, which serves to help maintain the bond with the mother. A child needs to feel trust and closeness to the parents, which gradually promotes autonomy (Baker & Baker, 1987). The value a parent places on the quality of attachment transfers to the child. Parents who value autonomy have autonomous children. Those parents who value dependency will have dependent children (Karen, 1990). Allowing the child to have some privacy and autonomy is important to the development of the self. Parents need to balance stimulating their children's needs while allowing them to have their own experiences and make their own mistakes, which are necessary for growth and development.
When the primary care giver is inconsistently unresponsive or unavailable to a child, anxious attachment occurs. Anxiously attached children often exhibit behaviors that alienate their peers and adults with whom they are in contact, which can reinforce their feelings of insecurity (Karen, 1990). The more predictable and stable a child's environment is, the more likely the child's attachment will be secure. Securely attached children are able to show appropriate anger and other negative feelings toward others without fearing abandonment. An insecure child does not have the confidence in the permanence of relationships.... (Hoover, 2004)
Depressive symptomatology as a result of insecure attachment child's sense of self begins and grows in the attachment relationship (James, 1994). Attachment to the mother or primary care giver, referred to as archaic heritage (Greenberg & Mitchell, 1988), is the basis by which a child is able to develop other relationships and how he or she will interact in those relationships (Bowlby, 1976, 1971, 1988). A child's self state, one of security, anxiety, or distress is largely determined by the accessibility and responsiveness of a primary attachment figure (Bowlby, 1973). (Hoover, 2004)
Kohut's Self-Psychology
Empathic failures inevitability occur during both child development, as well as in the therapeutic relationship. A person's negative response to these lapses in empathy is perceived as the foundation of psychopathology. As interventions in treatment are made while accepting, instead of challenging the client's feelings, in turn, the feeling of being understood frequently produces a powerful effect on the client. This experience may be equated to the calmness an agitated child may experience when his/her caregiver hold him/her firmly held." (Ornstein & Ornstein, 1990, p. 333; cited by Feld, 1996-2001)
Feld (1996-2001) purports, "The interactive experience between therapist and client, of understanding and being understood, increases trust in the therapeutic relationship and encourages the client's increase of self-cohesion." The empathetic of empathy between the therapist and client serves as a curative agent, and accent the essential therapeutic task to reenter the development course of self-selfobject relationships where they were traumatically interrupted in early life. (Kohut, 1980, p. 45; cited Feld (1996-2001).
Empathic selfobject experiences are necessary for the gradual development of the self and encourage structural cohesion and the energetic vigor of the self (Greenberg & Mitchell, 1983, p. 353, E.S. Wolf, 1988). The concept and function of the selfobject differ in definition. Young children conceive their primary selfobjects, usually the mother, as an extension of themselves and relate to her as if she has no feelings or preoccupations other than their own. Her function is to accept and participate in this interaction, which is a necessary part of the development of the ego.
While separation anxiety is common during early childhood, the chronic failure of a child's selfobject experiences results in prolonged separation anxiety and an immature awareness of self-boundary (Meares, 1988). During the earlier years of childhood, a child's ability to think is concrete, things are viewed as good or bad and right or wrong. At this age a child is not yet able to reason abstractly the many shades of gray that separate the colors (Brothers, 1992). Persistent selfobject failures during childhood can leave an individual in a chronic state of evaluating trust vs. mistrust (Erikson, 1973). This can be the foundation for characterological disturbance.... (Feld,1996-2001)
Some contend that Kohut's theories of development appear to hold a parent responsible for not providing his/her child/ren with adequate selfobject experience/s. Kohut, however, made it plain that parents are not to be blamed for their child/ren's emotional experiences. (Young, 1994 p. 84).
Kohut purported that parents desire and do the best they can for their child/ren. He perceived parents unable to adequately meet their child/ren's needs to be limited by their personal selfobject disorders and/or dearth of child development knowledge. He did not deem parents not responsible in a "moral sense" (Young, 1994, pp. 84-86; cited by Feld, 1996-2001)
The Development of the Self
As a child grows and this function changes (Meares, 1988). The "self" begins to take over the archaic selfobject functions, "becoming self-soothing, self-knowing and accepting, self-confident or admiring, and able to regulate tension." (Cooper, 1992, p. 148). Selfobject failures are a natural and necessary part of child development and become pathological or pathogenic when the development of the self is impeded (Baker & Baker, 1987, P.H. Ornstein, 1993). Some children are intrinsically more able to handle empathic failures, although chronic selfobject disappointments often have a cumulative effect on the self structure. (Feld,1996-2001
Internal and external objects
If "the child does not acquire the needed internal structure, his psyche remains fixated on an archaic self object, and the personality will throughout life be dependent on certain objects in what seems to be an intense form of object hunger (Kohut, 1971, p. 45). The therapeutic process allows the client to express narcissistic rage, which during childhood would have "destroyed the tenuous emotional contact with the most important people in his life." (a. Ornstein, 1992, p. 24). (Feld,1996-2001)
In reviewing Shaina's history and diagnoses, her childhood reflects the introductory quote for this chapter by Bowlby (cited by Janoff-Bulman (2002, p. 14) as she built working models in her world and herself through her relationship with her early attachment figure, her father. During the next chapter of this clinical case study dissertation, this researcher relates treatment phases for Shaina, applying components, applying components from Winnicott's Relational Model Theory, Bowlby's Attachment Theory and Kohut's Self-Psychology.
CHAPTER IV
TREATMENT/DISCUSSION
While no therapeutic method can prevent external events from building to a point of crisis, psychodynamically informed crisis intervention can allow a client the insight necessary to prevent or reduce the impact of internal factors that might exacerbate external factors, thus diffusing future potential crises." (Jerry, 1998)
Shania's Presenting Problems
Based on Shania's presenting problems, this researcher/therapist determined to utilize the therapy situation as the holding environment, in which Shania would reorganize herself. (Winnicott, 1958) in symbolic terms, this researcher/therapist functioned as a container in which Shania could begin to grow and unfold.
At the same time, this researcher/therapist attempted to be the "good enough mother" in an effort to helping Shania to restructure and reestablish the good object. To this end, this researcher/therapist attempted to listen empathically, and when appropriate validated Shania'a earlier experiences that contained anxiety and uncertainty. Furthermore, as the therapy process progressed, this researcher/therapist encouraged Shania to express her feelings and affects, as well as speak in the "I" voice to help the development of the self.
Part of the primary goal at this stage was to recreate relational materials in therapy that was designed to mimic the original relationships to the objects.
In other words, this phase of the treatment strives to provoke the emergence of transferences to the original archaic object that had evolved along the acceptance vs. The rejection trajectories. This researcher/therapist attempted to contain the expression of the repressed object relationship, so Shania was enabled to modify and rework aspects of rejection and indifference.
This researcher/therapist utilized the theories explored in this study to operationalize the conceptual framework of the therapy structure, with the chief concept consisting of understanding the nature of unconscious objects relationship and how they come into play in the present. Counter-transference and transference were constant phenomena that emerged throughout the whole psychotherapy process. In the initial phase of the treatment, Shania exhibited a great sensitivity to criticism and rejection. In order for her to escape these kinds of affects, she began to dress like this researcher/therapist. She also appeared eager -to-please this researcher/therapist, and agreed to everything this researcher/therapist verbalized.
Despite these behaviors, and contrary Shania's apparent imitations of this researcher/therapist, she constantly attempted to provoke criticism from this researcher/therapist, in that she persistently requested to reschedule her appointments. In addition, Shania demanded this researcher/therapist provide her with cognitive behavioral psychotherapy and simplistic hands-on solutions to her problems. As the good-enough mother, this researcher/therapist attempted to interpret actions Shania displayed during interactions with this researcher/therapist and their unconscious roots, related to developmental aspects of objects relations. Also, this researcher/therapist focused on nurturing Shania, in an attempt to promote uniqueness, acceptance, and the emergence of individuality.
In the later stages, however, this researcher/therapist emphasized the interpretation of Shania's actions stemming from objects relations.
The approach this researcher/therapist implemented to understand Shania's underlying problems was based on perspectives of object relations, with emphasis on developmental aspects. Theories of relational development were utilized to understand the failure to securely attach resulting in depressiveness, the failure to establish a secure object representation, and the establishment of the false self.
This researcher/therapist further understands that Shania was not arrested in a primitive developmental stage. As therapy progressed, it became obvious that the priamry problem included a matter of miss-attunement and that Shania's caregiver was not considered as a good-enough mother, capable of dyadic repair to minimize a negative arousal.
It became obvious that even the negative arousal had been ignored, leaving Shania to develop only as a cognitive being. Hence, expressions of alexithymia and a defense mechanism of rationalization, are clear consequences of Shania not being mirrored, in conjunction with failure to be reaffirmed as an emotional and affective being.
4.1: Treatment History: Early Treatment Stage and the Holding
Environment
During the early stage of treatment, presented in this clinical case study dissertation, along with ensuring Shania did not currently present a danger to herself or others, this researcher/therapist focused on establishing a holding environment Shania, as well as a therapeutic alliance with her. Even though as the introductory quote for this chapter by Jerry (1998) notes, "...no therapeutic method can prevent external events from building to a point of crisis," the investment of establishing an empathetic environment/relationship with Shaina helped create a safe milieu so she would be less likely to experience an immediate crisis. This initial effort also helped prepare Shaina to be able to tolerate the forthcoming uncovering of anxiety-provoking material, such as her unconscious patterns of immature relations. Also, in the early stage of therapy, as Shania presented with intense fears related to the court proceedings, she experienced difficulty with trusting this researcher/therapist as a therapist, fearing harsh judgment and rejection. During this phase, this researcher/therapist invested significant efforts to deal with Shania's current crisis and stabilize her condition. At that point, Shania was still living with her husband and their 10-year-old son. Interventions primarily addressed the prevention of domestic violence and the establishment of escape routes, as well as a safety plan. This early stage of treatment, albeit as noted earlier included focus on establishing a holding environment and therapeutic alliance to create a safe milieu so Shania would be able to tolerate the uncovering of anxiety-provoking materials, such as her unconscious patterns of having immature relations.
Bjorklund (2000, p. 93; cited by Romano, 2004) asserts that empathy, comprises "the sustained immersion of oneself in the experience of the other, attempting to understand how others see and experience themselves and their worlds, putting this into words, and checking one's understanding." During the initial sessions, this researcher/therapist purposed to immerse herself in Shaina's experiences, attempting to understand how she sees and experiences herself and her world. To do this, this researcher/therapist verbalized experiences Shaina related, repeating this researcher's/therapist's understanding against Shaina's perceptions to endure this researcher/therapist comprehended Shaina's world.
4.2 Middle Treatment Stage: Transference and Counter-transference
In the middle phase of treatment, this researcher/therapist attempted to increase Shaina's capacity to tolerate interpretations of transferences, reflecting early experiences with her father (the bad object). In addition, this researcher/therapist focused on facilitating the internalization of the good object representation. In this stage, this researcher/therapist interpreted Shaina's negativistic attitude and anger towards this therapist/therapist for her, as these transferred feelings related to Shaina's early experiences with her father. This modeling of a tolerant and non-retaliatory stance by this researcher/therapist paved the way for Shaina to, in turn internalize this researcher/therapist as the good object. From a self-psychology approach, this researcher/therapist focused on aspects of Shaina's life that stimulated dimensions of his self-representation linking to feelings of cohesion. Shaina's feeling that this researcher/therapist understood her activated a dimension of her self-representation, she had experienced in a comforting relationship with maternal uncle.
One assignment Shaina completed with positive results involved planning a visit with her maternal uncle. From this interaction, Shaina determined to initiate more regular telephone contact with her maternal uncle. Recounting the comforting relationship Shaina experienced with her maternal uncle proved to be a catalyst for beginning to see past the prolonged abuse she had experienced with her father. Regarding Shaina's prior suicide attempt, when she attempted to kill herself by driving the wrong way toward oncoming traffic, this researcher/therapist related this act to be similar to one threatening to shoot him/herself. As noted in this study's literature review, Kohut (1971; cited by Romano, 2004), described this type scenario as idealizing self-object transference: "The use of the gun allows the individual to feel in control and exert dominance over others." (Feldman & Johnson; cited by Romano, 2004)
Understanding the self-object function of Shaina's car to represent, in a sense, possessing the same destructive potential as a gun, enabled this researcher/therapist to better understand the significance of Shaina's estrangement from her son. From this poignant perception, this researcher/therapist began to discuss Shaina's subsequent feelings of vulnerability, as well as her lack of control over her current situation, regarding custody of her son. To address Shaina's "lack of control," this researcher/therapist listened during session interactions and accepted Shaina's comments reflective of her feelings of hopelessness, not only regarding control issues, but in emotional relations (e.g., her descriptions of her inability to be emotionally intimate with her husband or bond as she wanted to with her son.
What enhanced the understanding of this researcher/therapist was the fact Shaina did not receive the mirroring response she needed when a child to develop a healthy self-esteem. As a result of this deficit, she "had to" to resort to acceptance/approval by others in her environment to validate herself.
For the first time in Shania's life, during this middle stage, she allowed herself to express and to re-experience her earliest relationships with her significant others. er father emerged as the most momentous figure. Shania simultaneously feared, loved, and hated him. Considerable amount of ambivalence to the father-figure emerged as important unconscious material. Consequently, derivatives of splitting started to be manifested in the therapy room in form of transferences. In this regard, Shania engaged in idealization of the therapist figure. At the same time, however, she expressed dismay with regard to lack of hands-on practical help, which according her, was not offered to her in therapy. This researcher/therapist responded with interpreting the nature of Shania's defenses, unraveling the unconscious meaning; helping her to work through them.
As an example, this researcher/therapist would indicate for the client that she both admired and devalued me as a therapist. The essence of the interpretation this researcher/therapist presented, however, constituted an attempt to show Shania that she was admiring and devaluating the same person at two different times. In addition, this researcher/therapist would further indicate that these defenses stemmed from Shania's childhood experiences, in which the object sometimes times served a source of gratification, while at others, it constituted a source of frustration. Part of the long-term goal at this stage was to facilitate the emergence of internalization and reintegration of the object. In the middle phase of treatment, efforts were made to increase Shania's capacity to tolerate interpretations of transferences reflecting early experiences with her father (the bad object). Furthermore, focus was placed on facilitating the internalization of the good object representation. Also, during this stage, Shania's negativistic attitude and anger towards the therapist were interpreted for her, as they related to her early experiences with her father. The modeling of a tolerant and non-retaliatory stance paved the way for Shania to internalize this researcher/therapist as the good object.
By exploring her feelings of hopelessness, Shaina verbalized stated that she felt "unimportant."
This researcher/therapist acknowledged to Shaina that her needs were in fact important. This acknowledgment provided Shaina the mirroring she needed and she began to address her patterns of immature relations. During following interactions, Shaina's hopeless presentation began to gradually dissipate, as interactions between us provided Shaina with her self's mirroring needs
Self-Object Functions the following figure (6) portrays the three self-object functions Romano (2004) notes.
A figure in file Mark is to send
Figure (6): Three Self-object Functions (adapted from Romano, 2004)
As Shania did not experience successful early attachment to either of her parents, an experience Bowlby noted in his Attachment Theory to be vital for a person to develop his/her "ability to engage in social relationships, to make friends, and, to eventually attain physical intimacy," (Hoover, 2004), Shania did not mature in these areas. Also, as a person's earliest interactions with sensitive caregivers provide a foundation for proverbial representations about the world and the self and Shania's did not confirm that the world is good and meaningful, and the self is worth, (Janoff-Bulman, 2002). 13-14), as a result, she needed to learn how to begin to grow learn her self value.
4.3 Late Stage: Differentiation and Individuation
Eventually, in the late stage of therapy, as aspects of guilt, shame, and worthlessness reemerged reflecting the inner voice of the superego, analyses of these materials indicated interojection of Shania's father's voice. Although Shania, along with her mother and sister were terrified of Shania's father, whom they considered a tyrant in his own home, Shania never blamed her father for her past and present unhappiness.
Instead, she had learned to blame only herself to escape retaliation from her father. When Shania criticized the therapeutic style this researcher/therapist utilized, this researcher/therapist responded with understanding, respect, and acceptance. Despite clinical interventions, albeit, Shania continued to expect that bad things would happen to her. Her most feared prophecy was losing her child in a custody battle. Even though Shania, a bright woman, possessed a quick perspective mind, which she used successfully in her work, her judgment failed her when it came to herself and to her own needs. She experienced herself as a bad little girl in that chaotic, hostile, frightening world in which she grew up.
In the late phase of treatment, I encouraged the expression of affects and focused on helping Shania to differentiate affects. The neutralization of her narcissistic wounds and rage were unraveled and interpreted to promote differentiation of self-representation as separate from the object. During this stage Shania manifested just enough ego-functioning in relation to this researcher/therapist as a good-enough-object; in that she continued to attend her sessions and contributed to therapeutic alliance, sufficient to support an emergence of repressed object-relationships. Also during this last phase, Shania became more collaborative in the therapy room; her relationships became more stable; her clinical symptoms decreased, she became more self-aware and assertive, and made more appropriate choices in relationships. In addition, she became more composed, organized, and more secure to the extent that she was capable of attending court proceedings until the court concluded with a verdict of granting child custody back to her. What proved particularly surprising was that Shania broke away from her relationship to her older lover, and decided to spend more time with her son and to plan ahead. Object Relation Theory helped this researcher/therapist to understand the power of the situation in the person. In other words, what is "outside" a person gets "inside" and shapes the way a person grows, thinks, and feels. Winnicott (1956) believed that a drive or an impulse can be gratified without the relationship being all that important, whereas a need has to be met by a person, thereby placing their relationship at the center of the experience.
Important needs have to be met, including the need to be seen and valued as a unique individual, to be accepted as a whole, with both good and bad aspects, to be held tight and to be let go, and to be cared for, protected, and loved.
4.5 Termination
During therapy sessions, this researcher/therapist implemented a number of particular efforts Winnnicott, Bowlby and Kohut purported.
By accepting both tendencies, proposed by Winnicott, to devaluate and admire, this researcher / therapist attempted to show Shania acceptance and care, holding her tight in therapy - no matter how many times she attempted to cancel or reschedule her appointments.
Eventually, albeit, when Shania demonstrated she was ready, this researcher/therapist released her; confident she would continue to grow.
Diffusing Future Potential Crises
Throughout the course of Shaina's treatment, this researcher/therapist did not note any external event potentially building to a point of crisis. In fact, the growth Shaina experienced during her treatment process, helped her gain, as Jerry (1998) notes as a sign of positive growth in the introduction for this chapter, "insight necessary to prevent or reduce the impact of internal factors that might exacerbate external factors, thus diffusing future potential crises."
During the next, final chapter of this clinical case study dissertation, this researcher/therapist recounts this study's process, Shaina's future prognosis and conclusions regarding the growing process of both.
CHAPTER V
CONCLUSION
To be healthy is to be able to face changes and adversity with positive and challenging attitudes." (Renaurd, 2003)
5.1 Necessary Insight
In the past, physical "Healers," as noted in this clinical case study dissertation's literature review, without contemporary potent drugs, invested time required to circumspectly contemplate their patient's maladies and gain necessary insight to best help them. In turn, they discovered physical diseases intimately related to a person's emotions and his/her personal relationships. (Renaurd, 2003) as the introductory quote notes, these healers of the past understood that for a person to be healthy, he/she needed to face his/her life changes and adversities "with positive and challenging attitudes."
5.2 Recount of Clinical Case Study Dissertation Results
During the course of this clinical case study dissertation, this researcher/therapist initially introduced the premise for this clinical case study dissertation, relating details of Shania's case, noting that theories of Winnicott, Bowlby, and Kohut translate into clinical applications.
The Literature Review Chapter examined the themes of Emotional Abuse/Maltreatment; Winnicott's Relational Model Theory; Bowlby's Attachment Theory; Kohut's Self-Psychology. Shania's History, along with the case's theoretical basis were presented during this study's third chapter. Shania's developmental history, her Presenting Problem & Symptoms, the Initial Diagnosis were also portrayed in this section. In addition, the case's conceptualization, which included Winnicott's Relational Model Theory, Bowlby's Attachment Theory and Kohut's Self-Psychology were depicted in the third chapter.
The fourth chapter of this study presented the four stages of treatment, the early stage: development of therapeutic relationship and the holding environment, the middle stage: transference and counter-transference, the late stage: differentiation and individuation and termination.
This final chapter, the Conclusion, recounts the dissertation process, along with a final review of Shania's case. As this clinical case study dissertation which explored Object Relation, Attachment Theories, and Self-Psychology, and researched information for the application of these theories to clinical practice, closes this researcher purports that along with answering the initially proposed research questions, this researcher/therapist also grew. The early stage of treatment, related in the previous chapter of this clinical case study dissertation, proved challenging to this researcher/therapist; particularly the process of establishing a holding environment for / building a therapeutic alliance with Shaina. Nevertheless, this researcher's/therapist's investment of establishing an empathetic environment/relationship with Shaina ultimately contributed to her avoiding an immediate crisis and helped her prepare to tolerate the ensuing uncovering of anxiety-provoking material. As this researcher/therapist immersed in Shania's experiences, verbalizing them and checking her understanding, as Bjorklund (2000, p. 93; cited by Romano, 2004) asserts, the ensuing empathy contributed the therapist/client bond and Shania's healing process. In the middle phase of treatment, while attempting to increase Shaina's capacity to tolerate interpretations of transferences, reflecting early experiences with her father (the bad object), this researcher/therapist experienced repeated bouts of rejection by Shaina. Consequently, however, as this researcher/therapist repeatedly focused on facilitating the internalization of the good object representation and continued to interpret Shaina's negativistic attitude and anger towards this therapist/therapist, this modeling of a tolerant and non-retaliatory stance by this researcher/therapist ultimately contributed to Shaina internalizing this researcher/therapist as the good object. This researcher/therapist found final phase of treatment on differentiation of Shaina's choices and affects, as well as individuation of the self to be the most successful. With the neutralization of Shaina's narcissistic wounds and unraveling of her rage during sessions, she learned to interpret and promote differentiation of self-representation as separate from the object. As noted in the last chapter, Shaina's clinical symptoms significantly decreased and her relationships became more stable. Her growth in self also contributed to strengthening her not only in making more consciously appropriate choices in relationships, but most significantly in choosing to values herself.
Shania's Future Potential
Shania initially presented to this researcher/therapist as depressed, anxious, helpless, hopeless, despairing, agitated, disorganized, and filled with guilt, and shame. In order to help her, this researcher/therapist utilized object relational and attachment theories, as well as self-psychology as a framework to conceptualize Shania's underlying problems. The end result of implementing these particular theories to conceptualize Shania's treatment plan, this researcher/therapist contends, proved to be a positive investment.
Throughout the treatment process for Shania, this researcher/therapist, in a sense similar to Healers back in time, invested time required to circumspectly contemplate Shaina's psychological maladies. Shania, as many adults, who were detached and abused children, as Bowlby (cited by Hoover, 2004) purported routinely occurs, grew to deride contact with other humans feared connections, particularly emotional bonding, with other individuals. Utilizing components of Object Relation, Attachment Theories, and Self-Psychology, the therapy implemented ultimately empowered Shaina to face her life changes and challenges with a challenging, positive attitude. As the course of Shaina's treatment closes, this researcher/therapist predicts that Shaina's prognoses promises to be a positive process of continuing to grow.
The process of completing this dissertation taught this researcher/therapist what Brause (2000, p. 3) notes; that the study process ultimately helps the researcher. Along with the massive amount knowledge gained through this study process, this researcher/therapist learned:
more about the discipline of psychotherapy; to enhance the learning experience by writing to an audience beyond the professor teaching the course; how to organize large trucks of information; how to complete original research; how to organize time to become more productive.
From experiencing the barrage of benefits, evolving from completing this clinical case study dissertation, as noted at the start of this clinical case study dissertation, this researcher/therapist concurs that doctoral process can be compared to gardening. In this dissertation model, this researcher/therapist/doctoral candidate cultivated the process of the original dissertation idea to the fruit of the finished product.
This dissertation also served as figurative coming of age experience for Shania. As she progressed through the mind-challenging therapeutic experience, she gained necessary insights to begin with a healthier self, to view the world with new, more positive perceptions, not only ready to face adversities and new challenges, but also to anticipate and expect the best in life.
APPENDIX a Using Self-Psychology with Children ©1996-2001 Amy S. Feld, PsyD
Self-Psychology Terms
Attachment Theory
Self-Psychology History
The Therapeutic Process
Criticism of Self-Psychology
References
Self-Psychology in Terms
Self-psychology refers to a particular group of developmental theories. This body of theory is characterized by emphasis on changes in the structure of the self and the associated experiences of selfhood, both conscious and unconscious (E.S. Wolf, 1988). The essence of a person's psychological needs is seen as the individual's need to organize personal experience into a cohesive structure, of self, and to establish relationships that evoke, maintain and strengthen the self.
Self-psychology defines the self as the core of personality. A number of self states, or types of self-concept can be present, depending on the level of development of one's self. The virtual self is an infant's self as seen through the parents, which determines how the parent treats the child. The cohesive self describes a stable structure and the "normal" and "healthy" functioning of the self. The grandiose self describes the early infantile presentation of the self viewed as omnipotent and the center of all existence. The fragmented self refers to a less cohesive self, resulting from faulty selfobject experiences. This can be seen on a spectrum from anxiety to panic at the total loss of self structure. The empty self is one that has lost vigor and is depressed, a result of depletion of energy for lack of joyful selfobject responses. The overburdened self is unable to self soothe, because it has not experienced merger with an idealized selfobject. The overstimulated self is predisposed to recurrent states of excessive emotion or excitement as a result of unempathically excessive or phase-inappropriate responses from the selfobjects of childhood (E.S. Wolf, 1988).
Objects, meaning others, are needed to induce the emergence and maintenance of the self, termed selfobject experiences or selfobjects. Infantile selfobjects are what upholds the self during infancy. When these selfobjects are evoked during adulthood, they are referred to as archaic selfobjects. Mirroring selfobjects sustain the self by providing acceptance and confirmation. Idealized selfobjects support the self through a merger with the calmness, power and goodness of an idealized person. Alter-ego selfobjects provide the self an experience of similarity to another's self. Adversarial selfobjects sustain the self by providing experiences of nondestructive conflict.
Selfobject disorders, many of which are more commonly known as personality disorders, develop when a child has encountered severe or chronic selfobject failures. Psychosis occurs when serious damage to the self is permanent and there are no defense structures to cover the defect. A biological predisposition is usually seen in conjunction with the environmental factors. Borderline states occur when the self has experienced serious damage and experiential manifestations are masked by complex defenses (E.S. Wolf, 1988). Narcissistic behavior disorders are temporary and restorable through therapy. The individuals are seen as attempting to control the environment through their behavior, to meet selfobject needs. Narcissistic personality disorders can also be restored through therapy. Symptoms express tensions associated with damage to the self and the autoplastic attempts to restore selfobject functioning (e.g., addiction, delinquency) (E.S. Wolf, 1988). Depression is conceptualized into three types. Preverbal depression is described as "apathy, a sense of deadness, and the diffuse rage related to primordial trauma" (E.S. Wolf, 1988). Empty depression is depletion of self-esteem and vitality that occurs as a result of inadequate selfobject responses. Guilt is depression characterized by self-rejection and self-blame, resulting from a lack of idealized selfobject experiences.
Empathy or an empathic stance, defined as affective attunement to the client (Ornstein & Ornstein, 1990), is a central tool used in self-psychology. This refers to the therapist's ability to recognize complex emotional states that may be inarticulately or incompletely expressed (Kohut, 1971; B. Wolf, 1992). Empathic failures occur when the selfobject is experienced by the child as unattuned to his or her feelings. Affective attunement, the first step in the empathic process, is the ability of the therapist to shift the focus of attention from a behavior to the motive behind that behavior.
Selfobject transference is the client's displacement on the therapist of archaic selfobject characteristics or needs. There are five types of such transfers. Merger transference occurs when the client seeks to reestablish an identity of an archaic selfobject through the relationship with the therapist. Alter-ego transference occurs when the clients attempt to reestablish latency needs of being seen and understood by someone like themselves. The term mirroring transfer is interchangeable with merger transference, alter-ego transference and mirror transference. It is used to describe validation clients seek for whom they are. Idealizing transfer occurs when the client derives temporary strengths from feeling merged with what he or she sees as the therapist's greatness and power (Orienstein & Orienstein, 1990). Transference of creativity is the need of creative people to merge with a selfobject while engaged in strenuous creative tasks.
Mirroring refers to interactions characterizing a healthy mother-child relationship, including reflections of grandiosity, consistency, nurturance, a general empathy and respect (Kohut, 1977). A person's need to experience sameness or likeness with another person is known as twinship, while alterego is the experience of sameness or likeness within a group (Detrick, 1986). The twinship merger occurs in childhood as a child receives mirroring experiences with other children. Parents and other adults are also able to provide this in part, but peer relationships, which begin during the toddler phase of development are necessary for this process. This function, through support, mirroring and acceptance, serves a reparative function for the self system (Kriegman & Solomon, 1985).
Transmuting internalization is the process by which the self structure is formed. Selfobjects are internalized under the pressure generated by optimal frustration. The integration of self object relations, known as transmuting internalization, can be observed on a continuum with the state of well being on one end of the pole and anxious depression at the other end (Greenberg & Mitchell, 1983; E.S. Wolf, 1988). Personality is determined by the content of these poles and their relationship to each other. Kohut also conceptualized the bipolar self, with ambitions and goals representing the two poles (Kohut, 1971). He later added a third pole to include talents and skills. This became known as the tripolar self (Kohut, 1984). The imbalanced self is loosely cohesive with one of the poles overshadowing the others.
Efficacy need is one's need to experience the self as capable of evoking a selfobject response. Efficacy pleasure is the feeling a person has knowing the self has been strengthened through the experience of efficiency and effectiveness.
Narcissistic rage is anger directed toward a selfobject failure, which is experienced as threatening to the cohesion of the self. Narcissistic rage does not disappear when the threat to the self disappears. It recurs when the self is threatened again, even when the threat is minor to the self. Narcissistic rage can be seen as unresolved anger that dissipates when another selfobject's empathic understanding can be trusted again (E.S. Wolf, 1988).
The self can split horizontally or vertically. A horizontal split occurs when painful or unacceptable thoughts are originated from the psyche and kept out of consciousness. A grandiose fantasy about the self may be kept repressed by an individual who believes that it is "wrong" or "bad" to have such thoughts. A vertical split occurs when the precepts of external reality are disavowed or denied (E.S. Wolf, 1988). For instance, a man may consciously know that his dog has died, but say that his dog is alive to protect himself from the painful impact of the loss. The term curative fantasy is defined as an organized set of hopes for recovery and optimism in the therapeutic process that has to be recognized by psychotherapists as essential aspects of the treatment process (a. Ornstein, 1992). Transference can be viewed as the client's experience of the therapeutic relationship (Gill, 1982) and countertransference is seen as the therapist's experience of that relationship.
Defense mechanisms are automatic, unconscious psychological activities that people use to exclude unacceptable thoughts, threats or impulses from awareness due to the fear of negative outcomes. Reaction formation occurs when a person adopts feelings or behaviors opposite of negative ones. An example of this is a person who acts unnaturally kind to mask feelings of anger. Denial is a primitive defense used when a person is unable to acknowledge negative thoughts or situations which are perceived as intolerable. Displacement is seen when a person directs an impulse or thought from one object to a less threatening object. A man who is angry with his boss, but yells at his children is an example of this defense mechanism. Projection, another primitive defense, is when a person disowns his or her attitudes, ideas or feelings by seeing those attributes in another person.
Attachment Theory child's sense of self begins and grows in the attachment relationship (James, 1994). Attachment to the mother or primary care giver, referred to as archaic heritage (Greenberg & Mitchell, 1988), is the basis by which a child is able to develop other relationships and how he or she will interact in those relationships (Bowlby, 1976, 1971, 1988). A child's self state, one of security, anxiety, or distress is largely determined by the accessibility and responsiveness of a primary attachment figure (Bowlby, 1973).
Emotional stability is built upon confidence in the availability of attachment figures, which develops slowly throughout childhood and adolescence. As children begin to realize that they are separate from their mothers, they are able to transfer the dependent attachment onto a transitional object, which serves to help maintain the bond with the mother. A child needs to feel trust and closeness to the parents, which gradually promotes autonomy (Baker & Baker, 1987). The value a parent places on the quality of attachment transfers to the child. Parents who value autonomy have autonomous children. Those parents who value dependency will have dependent children (Karen, 1990). Allowing the child to have some privacy and autonomy is important to the development of the self. Parents need to balance stimulating their children's needs while allowing them to have their own experiences and make their own mistakes, which are necessary for growth and development.
When the primary care giver is inconsistently unresponsive or unavailable to a child, anxious attachment occurs. Anxiously attached children often exhibit behaviors that alienate their peers and adults with whom they are in contact, which can reinforce their feelings of insecurity (Karen, 1990). The more predictable and stable a child's environment is, the more likely the child's attachment will be secure. Securely attached children are able to show appropriate anger and other negative feelings toward others without fearing abandonment. An insecure child does not have the confidence in the permanence of relationships.
When the environment is particularly chaotic, boys often exhibit aggressive attachment, becoming belligerent, defiant and exhibiting poor impulse control, whereas girls are more likely to show anxious attachment (Moore, 1971). When the primary care giver threatens to withdraw love or abandon a child if he or she does not behave, anxious attachment occurs in a deeper, more pathological manner. Threats of abandonment can be direct or indirect and are seen to have an extremely frightening effect on children (Bowlby, 1971), even when these threats are communicated as teasing.
Children who are physically, emotionally or sexually abused have complicated and confused attachment behaviors. Children who are molested by a primary caretaker, while being told that they are loved and special, will likely view attachment with mixed emotions. Similarly, a child who is beaten, later receiving affection or gifts from the guilt-ridden parent, is likely to misinterpret the actions of others they meet outside the home (Karen, 1990).
A child's reaction to the loss of a parent through abandonment is complicated by the surviving parent's reaction to that loss (Bowlby, 1980; Rosen, 1991), and can cause the child to tremendously yearn for the nurturance of the remaining parent (Rosen, 1991). This can be emotionally draining for the surviving parent, who is also struggling with the loss. Empirical studies of social development in children with and without a permanent mother figure have found that those without a consistent mother figure were significantly more anxious in their attachments and significantly more afraid of strangers (Schnurmann, 1949; Tizzard & Tizzard, 1991).
As children grow, they begin to direct their attachment toward subsidiary attachment figures, while maintaining the importance of their attachment with their mother. This depends primarily on the composition of the household and who cares for the child (Bowlby, 1969). Attachment figures are sought out when the child is in need of nurturing, tired, hungry, sick or afraid. The child will look to friends for social interaction when confident of the proximity of the attachment figure. When children have a healthy attachment to their primary caregiver, they are able to seek out secondary attachment figures and social companions.
Erikson (1971) conceptualized child development as occurring in stages. The first stage is basic trust vs. mistrust, which begins in infancy. This central developmental task, is not only the first task of the ego, but is also a developmental task of the mother. Attachment is a learned trait, developed during the first years of a child's life. Attachment behaviors that develop incompletely or less than optimally can change as arrested developmental needs are met. When a child has had an inconsistent history of attachment with a primary care giver, the therapist often functions as the attachment figure, which allows the child to reexperience the developmental stages not experienced during infancy and toddlerhood (Farber, Lippert & Nevas, 1995).
Psychopathology is understood by self psychologists to be reflective of disturbances and interference in relationships with others (Greenberg & Mitchell, 1988). The ego is defined as a set of functions, similar to what other theorists have referred to as self (Greenberg & Mitchell, 1988). The process of psychotherapy is an attempt to restore the ability of the patient to make direct and full contact with others. Fairbairn (Greenberg & Mitchell, 1988) theorizes that the psychological state of the child stems from a merger with the mother during the earliest months and attributes interference with the mother-infant bond as a major source of problematic relationships later in life. For children to mature and become comfortable in relationships with others, they must feel loved and believe that their own love is welcomed and valued.
Children seen in therapy have various levels of attachment to their primary caregivers. The "good enough" attachment meets the needs of both the parent and the child. Problems can arise when there is a disruption in the relationship, but the basis of the attachment is strong enough to withstand that break (Winnicott, 1960). When the parent and child have a maladaptive attachment relationship with a potential for change, working with both the child and caregiver to strengthen the attachment bond is usually the recommended course of treatment. When the relationship is maladaptive without potential for change, individual therapy focusing on helping the child develop positive attachments is necessary (James, 1994).
A back to the beginning
Self-Psychology: History
Self-psychology is a theoretical framework for understanding the psychological development of a child (Pessein & Young, 1993). The theory evolved from Freud's psychoanalysis, which examined mental processes, a body of psychological knowledge and a method of treatment for psychological illnesses. Post-Freudian analysts further developed and modified psychoanalytic theory, but stayed within Freud's theoretical framework. Heinz Kohut, the so-called "father" of self-psychology, revised the basic tenets of psychoanalysis by focusing on empathy and introspection (Kohut, 1959). This shifted the focus of understanding the individual from the psychobiological foundations of the id, and the drives central to psychoanalysis to the psychological considerations of the self, it's development and tribulations. He developed self-psychology as a study of the self and its relationship to selfobjects.
In contrast with earlier theories, the self is seen, not as a representation or product of activity of the ego, but in itself an active agent (Greenberg & Mitchell, 1983). Freudian psychoanalysis focused on examination of the inner life of a person, examining psychic structures such as the super ego as a response to unexpected changes of drive discharge patterns. Neo-Freudians, including Klein, Fairbairn, Guntrip, Winnicott, Horney, Fromm, Sullivan and Fromm-Reichmann modified the classic theory to include the influence of the environment and external objects.
Kohut viewed self-psychology, not as an interpersonal or object relations framework, but intrapsychically dynamic, placing selfobject theory at the center of self-psychology. "The most fundamental finding of self-psychology is that the emergence of the self requires more than the inborn tendency to organize experience." (E.S. Wolf, 1988, p. 11). The primary psychological task, for self-psychology, is the maintenance of the self, and the relationships between the self and selfobject are at the center of development from birth to death (Tolpin, 1986). At the base of self structure is self-esteem (Peoples, 1991).
Kohut believed that the rudimentary development of the self begins at about eighteen months, when the child's needs are narcissistically based. In order for normal development to occur, these powerful needs must be met in certain ways, or psychopathology can develop (Lynch, 1994).
The self-psychology framework identifies nine phases of human development. The archaic infantile phase occurs during early infancy, when the child experiences himself and the world as one and the same. Needs for mirroring, idealizing, twinship and efficacy begin and continue throughout the course of life. The Oedipal phase utilizes the infantile needs to develop gender identification and self structure. During the latency phase twinship and alter-ego needs are important to the development of social skills. Selfobjects are expanded during the prepubertal phase, shifting away from the primary care givers toward peers, teachers, and symbolic substitutes for the selfobject person. Self-psychology combines the adolescent and young adult phase. During this period cognitive development allows the recognition of parental deficits and thus; the continued development of peers as selfbojects. During the marital phase, spouses use each other to meet a variety of selfobject needs. If adults have a cohesive and solid self, the parenting phase is a time when children are included as selfobjects. This is also a time when a fragile self structure can become more evident and lead to increased fragmentation. The middle-age phase is usually a time of introspection and self-evaluation. This is when a person needs selfobjects who are accepting of the self's readjustment of goals. An absence of this can create a "mid-life crisis." During the old-age phase, individuals need to be idealized by their selfobjects to confirm that their life has been purposeful.
Empathic failures are an inevitable occurrence in both child development and the therapeutic relationship. The individual's negative response to these lapses in empathy is seen as the basis of psychopathology. Interventions in treatment are made while accepting, rather than challenging the client's feelings. The feeling of being understood often has a powerful effect on the client and "can be compared to the calmness an agitated child may experience upon being firmly held in the arms of a care giver" (Ornstein & Ornstein, 1990, p. 333). The interactive experience between therapist and client, of understanding and being understood, increases trust in the therapeutic relationship and encourages the client's increase of self-cohesion. Ornstein and Ornstein (1990), compare affective attunement to the "key that opens the door to the inner world of an other" and empathy to "the light that illuminates the content of the room that is behind the door" (p. 328). The bond of empathy that occurs between the therapist and client functions as a curative agent. The essential therapeutic task is "reentering into the course of the line of development of self-selfobject relationships at the point where it had been traumatically interrupted in early life" (Kohut, 1980, p. 453).
Empathic selfobject experiences are necessary for the gradual development of the self and encourage structural cohesion and the energetic vigor of the self (Greenberg & Mitchell, 1983, p. 353, E.S. Wolf, 1988). The concept and function of the selfobject differ in definition. Young children conceive their primary selfobjects, usually the mother, as an extension of themselves and relate to her as if she has no feelings or preoccupations other than their own. Her function is to accept and participate in this interaction, which is a necessary part of the development of the ego. As a child grows and this function changes (Meares, 1988). The "self" begins to take over the archaic selfobject functions, "becoming self-soothing, self-knowing and accepting, self-confident or admiring, and able to regulate tension." (Cooper, 1992, p. 148). Selfobject failures are a natural and necessary part of child development and become pathological or pathogenic when the development of the self is impeded (Baker & Baker, 1987, P.H. Ornstein, 1993). Some children are intrinsically more able to handle empathic failures, although chronic selfobject disappointments often have a cumulative effect on the self structure.
While separation anxiety is common during early childhood, the chronic failure of a child's selfobject experiences results in prolonged separation anxiety and an immature awareness of self-boundary (Meares, 1988). During the earlier years of childhood, a child's ability to think is concrete, things are viewed as good or bad and right or wrong. At this age a child is not yet able to reason abstractly the many shades of gray that separate the colors (Brothers, 1992). Persistent selfobject failures during childhood can leave an individual in a chronic state of evaluating trust vs. mistrust (Erikson, 1973). This can be the foundation for characterological disturbance. If "the child does not acquire the needed internal structure, his psyche remains fixated on an archaic self object, and the personality will throughout life be dependent on certain objects in what seems to be an intense form of object hunger (Kohut, 1971, p. 45). The therapeutic process allows the client to express narcissistic rage, which during childhood would have "destroyed the tenuous emotional contact with the most important people in his life." (a. Ornstein, 1992, p. 24).
Fragmentation and emptiness of the self occur when faulty selfobjects are prominent in a child's life. Repeated failures of selfobjects to meet the needs of a child affect vigor, assertiveness, playfulness and affectionateness (Tolpin, 1986). Kohut believed that psychopathology in both children and adults stemmed from multiple selfobject failures early in life which created structural deficits leaving the individual "depleted, deflated, disillusioned and prone to fragmentation" (Tolpin, 1986, p. 125). Some children, whose mirroring, idealizing and selfobject needs are not met by parents, are able to find those selfobject needs from others (Tolpin, 1986).
Psychological and affective development of a parent begins with the pregnancy. It continues to develop through the birth and ongoing growth of the child in the context of the relationship with the child. Parenting is viewed as a developmental stage where the parent first experiences double identification. The new mother's identification with her own mother is reactivated when her child is born. As the new mother identifies with the baby's needs, she relates to both her child and her mother at the same time. New mothers who are overwhelmed with past conflicts can regress to negative identification, becoming the "bad mother" to her child and the "bad child" to her mother (Wagner, 1994).
Parenting is more than the sum of behaviors (Eldridge & Schmidt, 1990). "Children are a burden, and if they bring joy, it is because they are wanted, and two people have decided to take that kind of burden; in fact, have agreed that it is not a burden, but a baby" (Winnicott, 1976, p. 131). Parents who have had deficits in their selfobject relationships as children, often find fulfilling their parenting roles to be difficult.
Parents who are unable to provide adequate selfobject experience for their children, often have had failures with their selfobject relationships during childhood. Parents with disorders of the self, including personality disorders and compulsions with food, sex, or substances, are unable to serve as empathic selfobjects and cannot provide the necessary stimulation for the development of a child's healthy self. A healthy self is able to regulate self-esteem and self soothe, while the unhealthy self has not developed the necessary internal structures to accomplish this. To an extent, all children meet some narcissistic needs of their parents. This becomes pathological when the parent uses the child to meet archaic selfobject needs and the parents place his or her narcissistic needs above the child's (Miller, personal communication, July 15, 1996). "When self objects are too needy, depressed or anxious to give the self what it needs the power and structural integrity of the self and selfobject alike will suffer" (Tolpin, p. 125). In response to this, children often develop problems, as they struggle to make use of whatever selfobject responsiveness they can find.
When there is no adequate selfobject, children sometimes retreat into a fantasy world, creating their own fictional versions of competency and structure (Slade & Moskowitz,1988; Miller, 1996). While creativity and fantasy are normal processes in child development, psychopathology occurs when the child is not able or does not wish to distinguish fantasy from reality. The child who is abandoned has fantasies of self blame, needing to find other ways of stimulating the memories and fantasies that form self structure. If this does not happen, psychosis can occur. (Miller, 1996). If the child is in psychotherapy, the therapist can often become that selfobject, with the goal being to "resume the thwarted developmental process, forming internal structures that assume the functions provided by selfobjects" (Baker & Baker, 1987, p. 7).
Most children grow up in an environment that is usually responsive to their selfobject needs. Empathic failures are present in all relationships and "good enough" parents are able to balance this with empathic responses, leaving the self diminished, but not destroyed (Baker & Baker, 1987). It is important to remember that the empathic failure is not the root of psychopathology, rather the child's response to that emapthic failure. Children seen in therapy are generally not those of "good enough" parents, but individuals for whom the parent-child interaction seriously failed to meet the child's selfobject needs.
Children who have not been able to bond with their primary care giver due to chronic empathic failures usually emerge from that experience with one of three personality types. Merger hungry individuals long to attach themselves to an appropriate selfobject. These are often the adults who remain in abusive relationships or are labeled codependent, as they are unable to differentiate between their own needs and the needs of the selfobject. A therapist is often the first healthy merger that the client encounters. Contact shunning personalities avoid social interactions, fearing further empathic failures. These individuals are typically difficult to engage in the therapeutic process. Mirror hungry people are the least pathological of the three personality types. They continually seek confirming and admiring responses and are often quite needy. These individuals often alternate between states of depression and acting out rage.
While Kohut's theories of development may at times seem to hold the parents responsible for not providing the child with adequate selfobject experience, he was "unambiguously clear that parents should not be blamed for their child's emotional experiences" (Young, 1994 p. 84). He believed that all parents want and do the best they can for their child. Kohut viewed parents who were unable to adequately meet their child's needs as limited by their own selfobject disorders or lack of knowledge of child development and not responsible in a "moral sense" (Young, 1994, pp. 84-86). back to the beginning
The Therapeutic Process
Psychotherapy is the process of, first establishing a curative self-selfobject transference, then working through the client's issues, using that selfobject transference (Muslin, 1986). Psychotherapy is concerned with restoring a sense of vitality, cohesion or harmony to a self that has been injured through narcissistic assault or fears the disruption of a selfobject tie (Baker & Baker, 1987).
Heinz Kohut conceptualized a framework that views individuals as "struggling to establish and maintain an all encompassing cohesive self throughout life" (Jackson, 1994, p. 1-2). This begins, first, with teaching the client that there is such a thing as a sense of self, that it is safe to have a sense of self and that he has a right to have that (James, 1994). Change occurs in an empathic environment, "fostered by the use of therapeutic interventions of acceptance, understanding and explanation. Empathy is seen as an important intervention in the self psychological therapeutic process (Donner, 1994).
Understanding, acceptance, and explanation are also important therapeutic tools and interventions. Acceptance refers to clients as they are, with the symptomology they present, which can be conveyed through active listening, reflective responses, tone of voice, facial expression and body language (Donner, 1994). The therapist must strike a balance between accepting the client, while recognizing the cognitive or behavioral changes that need to be addressed. Understanding is expressed through the therapeutic dialogue as the therapist speaks in an interpretive mode, choosing words that convey understanding and explain and interpret the client's subjective experience (a. Ornstein, 1986b; Ornstein & Ornstein, 1990; Donner, 1994), through empathic responsiveness (P.H. Ornstein, 1980) or optimal responsiveness (Bacal, 1985). The process of understanding is not to determine what the client is leaving out of the conversation, but an attempt to join with the client to understand what he or she is experiencing. Empathic explanation of the client's symptoms and interactions increases self-awareness and insight and is an important part of the treatment process (a. Ornstein, 1986; Donner, 1994). The ability of the therapist to accurately attune himself to the client's subjective experience is central to the process (Schwaber, 1981). Psychic structure is acquired in the context of the therapeutic self-selfobject relationship (Jackson, 1994, p. 2).
Certain principles are used in psychotherapy with a self psychological framework. A weakened self is seen as the center of psychopathology and the treatment process should center around strengthening the self. The depleted self results from faulty selfobject relationships during important developmental stages. The empathic failure of a fragile self force it to use defenses, which is often maladaptive and which interfere with present relationships. While no therapeutic experience can undo events of the past, a self-psychology perspective aims to diminish the emotional scars that resulted from those unaffirming selfobject experiences. This is the disruption-restoration process (E.S. Wolf, 1988). If a client is to improve, the therapist must be friendly and responsive, which allows the client to feel comfortable enough to re-experience archaic self needs through the transferential relationship. Finally, a focus on the client's experience and not the content of the information shared by the client, is essential for the therapeutic process to be successful (E.S. Wolf, 1988).
The goal of treatment can be described in structural terms "as increasing the cohesion and wholeness of the self through transmuting internalization" (Wolf, 1988, p.103) for some clients, just being in the presence of an empathic therapist is healing. Wolf (1988) argues that this approach is not a corrective experience, as described by Alexander (1958) and others, because the therapist is not perfect in his responses. Through the empathic handling of inevitable selfobject failures that occur between clinician and client, the therapist can provide a more understanding forum for the client to experience these failures. Restoration of the self occurs through mirroring, and the affective regulating of affective functions that the therapist promotes (Peoples, 1991). A motivation to change is necessary for success in any form of therapy, including self-psychology. Failure in therapy can result from an incompatible match between therapist and client, the therapist's inability to provide enough empathy, and clients who are so psychologically damaged that the self is too fragile for the rigors of an introspective process.
The concepts of mirroring, idealizing and twinship transferences, self, selfobject functions, transmuting internalization, and self-selfobject relationships, are central to the understanding of the therapeutic process (Donner, 1994; Lynch, 1994; Nicholson, 1994). Mirroring must be developmentally appropriate to the child. While it is an accomplishment for a toddler to remain dry at night for the first time, praising a seven-year-old child, who has been dry at night for four years, is inappropriate and destructive.
Defense mechanisms are understood as a person's attempt to protect his or her "self" from harm (Ornstein & Ornstein, 1990). Using a self-psychology framework, defenses are " appreciated as the glue that holds a vulnerable or fragmentation-prone self together" (p. 334). Defenses are not conceptualized as having to be removed for the therapist to understand the client's core issues. Defense mechanisms naturally diminish as the client experiences a greater level of self cohesion, creating a sense of safety that reduces the need for defensive behavior. "Defense activities are undertaken in the service of psychological survival....The patient's attempt to save at least that sector of his nuclear self, however small and precariously established it may be, that he has been able to construct and maintain despite serious insufficiencies in the development-enhancing matrix of the selfobjects of his childhood" (Kohut, 1984 p. 19). By viewing the client's defense mechanisms as positive strengths that have become painful, the therapist is able to enhance the therapeutic relationship.
Curative fantasy is important to the success of therapy. One such fantasy of cure is that one's feelings and actions, whether positive or negative, will be accepted and understood. The curative fantasy is often uncovered during therapy when the client experiences empathic failures with the therapist. Examples of curative fantasies outside the therapeutic context include; a woman's who believes that if she wins the lottery, all of her problems will go away or a couple that believes having a baby will save their marriage.
Children who are brought into therapy for such issues as hyperactivity, behavior problems, poor social skills or affective disorders, have crucial selfobject needs that have been unmet (Elson, 1986). Elson (1986) discounts the notion of unruly drives as the root of these problems. She focuses on the failure of the child's selfobject needs being met, noting that the caretakers of these children have often experienced inadequacy of the selfobjects in their childhoods. Children presenting with such issues as dependency, anxiety, depression and other states of depletion often have disturbances in the cohesion of their self structure (M. Tolpin, 1971). Injured cohesion can also present symbolically in the form of phobias or sexually precocious behavior (Elson, 1986). The decision of whether to work with the parent and child together or focus on individual treatment involves "the nature and depth of the parental deficit, and the degree of cohesiveness in the self of the parent and the self of the child" (Elson, 1986, p. 79).
The understanding of the significance the child places on of therapist and other people in the child's environment as self objects "guide the therapist's use of himself in the treatment relationship with the child and also leads to interventions designed to correct or alleviate specific forms of empathic failure within the child's current self object milieu" (Young, 1988, p. 245). Young (1994), discusses using self-psychology with children, both with and without parental involvement to provide understanding and self object functions, as well as to modify the child's self object milieu. He described the child's relationship with the therapist is "an opportunity to reactivate arrested developmental needs for mirroring, merger with an idealized source of strength, and twinship" (pp. 79-80). The therapist is seen, not as an anxious, unreliable selfobject, but as a selfobject that mirrors the need of the client to desire and work toward his or her own goals (C. Goldberg, 1993).
Therapeutic regressions can be seen when the client is overcome by feelings and is unable to access the defenses he or she normally utilizes. During such regression the client will say everything that comes to mind, relinquishing some control over speech. The regression interferes with "learned logico-cognitive thought processes and lessens the firmness of the self's boundaries, making them more permeable to empathic communications" (E.S. Wolf, 1988, p. 118). In particularly vulnerable people, severe regressions may become uncontrollable and progress to a psychotic-like state. A therapist who is aware of clients with extremely fragile self structures can take steps to slow the regressive process until the client has built enough defenses to access during periods of fragmentation.
Kaplan (1990), describes her work with an adolescent girl who did not have the support of her parents during treatment. The role of the therapist was to serve as a stable adult that provided necessary selfobject functions, consistency, reliability, and the provision unconditional acceptance. These functions were different from those provided by the girl's parents. The therapist allowed her warm feelings for the client emerge and the interactive process of sharing feelings had a positive effect on the client. It allowed for the experience of healthy interpersonal communication from which to use as a model for the client's outside relationships.
Anger in the therapeutic relationship is not viewed as the client's displacement of past feelings, but as a vehicle for exploration of his or her subjective experiences of feeling angry. The issue is the client's ability to "contain and regulate the affect of anger," not the ability to differentiate past from present (a. Ornstein, 1986b, p. 28). Kohut saw intense narcissistic rage, or intense anger in the therapeutic process, as serving the client's purposes of "communicating selfobject needs, narcissistic repair, revenge against negative selfobject experiences, restitution of selfobject bonds, the creation of a more responsive selfobject and working through a reevoked experience of loss or deprivation" (Patrick, 1994, p. 183). This is often expressed by the client's criticism or intimidation of the therapist.
Depression is approached from a self psychological perspective introspectively, focusing on the meaning of the experiences or thoughts that produced the feelings. Depression can be described "as reflective of an experience of something felt to be missing" (Palombo, 1985, p. 35). It is seen, not as a reaction to the loss of an external object, but from the emotional meaning of a sustaining relationship (Lewis & Lewis, 1979). Depression is understood as a "depletion of the self, associated with a deficit in the self or as resulting from an irreconcilable yearning within the self for a missing selfobject function" (Palombo, 1985, p. 33). The goals in the treatment of depression are correcting the state of depletion, when possible, depending on the specific dynamics of the individual and the illness.
Transference and Countertransference
Kohut (1984) viewed the transferential relation between therapist and client as an interactive process where both therapist and client impact and influence each other. As they examine the failure of selfobject experiences and the effort at restoration, the therapist interprets the selfobject relationship between them. What is transferred is the expectation that the therapist, functioning as the "perfect" selfobject, will provide the client what was missed in his or her emotional development. (a. Ornstein, 1992). This two-dimensional view of transference is a central element of self-psychology.
Idealizing transfer is a process conceptualized by Kohut (1971) as:
the state, after being exposed to the disturbance of the psychological equilibrium of primary narcissism, the psyche saves a part of the lost experience of global narcissistic perfection by assigning it to an archaic, rudimentary (transitional) object, the idealized parent imago. Since all bliss and power reside in the idealized object, the child feels empty and powerless when he is separated from it and he attempts, therefore, to maintain a continuous union with it." (p. 37).
More simply put, this is the need to merge with someone who the individual believes will make him feel safe, calm and comfortable (Baker & Baker, 1987). Children attach themselves to the idealized parental imago, thus becoming able to cope with negative experiences and disappointments. As they experience success with this, they gradually integrate the idealized object with their own personalities and build up the necessary internal structures to combat conflict. This developmental sequence occurs in three stages; "a merger with the parent ideal, a deidealization of the idealized omnipotent selfobject, and a gradual building of internal structures which carry on the function with the archaic selfobject relationship with the idealized parent" (Kriegman & Solomon, 1985, p. 242). This process is seen in the therapeutic context as the corrective emotional experience of repairing the developmental task that was uncompleted in childhood.
Clients express a number of needs through the transferential relationship with the therapist, including wishes to be comforted, stimulated, admired, preferred and forgiven (Basch 1980, 1984). These needs are to be understood in both their present and archaic contexts. Self-psychology stresses that transferences are not the client's confusion of the therapist as a parent, but the client's legitimate need for a new selfobject in the present to his needs for structure building (Elson, 1986).
Transference is the phenomenon that both causes and allows healing through the disruption-restoration process. The first stage in this course is resistance analysis in which the therapist must try to understand the client's archaic selfobject needs, how they are manifested as defenses, and what, if any, parts of the defense mechanisms are resisting using the therapist as a selfobject. The second step is the "spontaneous mobilization of the patient's selfobject transferences" (Wolf, 1988, p. 112). The client is still conflicted between the need for positive selfobject responses and the fear of the self being injured. The third stage is the disruption of the transferential relationship. The therapist inevitably causes a narcissistic injury to the client's self, which can cause anger, disappointment and other feelings that trigger archaic injuries to the self. Temporary transference regressions result from this as the client struggles again with needs for positive selfobject experiences and fears of being hurt. In order for the most positive out come to be achieved from the disruption-restoration process, the regression must be deep enough to loosen the self's structure without endangering it's cohesiveness. Transference is restored as the therapist explains and interprets the events that caused the disruptions and empathically responds to the client's feelings caused by that disruption.
When doing psychotherapy with children, the therapist needs to be perceptive of the parents' transference toward him or her. A parent may feel threatened by the relationship between the child and the therapist. Therapy is an hour of undivided, focused, positive attention that the child may not receive outside that hour. Many a child in therapy comes home saying, "I want to go live with my therapist," which can cause the parent to have a negative reaction to the therapist and the treatment (Miller, personal communication, July, 15, 1996).
Both transference and countertransference are important to the therapeutic process. Countertransference occurs when the therapist is fearful of narcissistic injury and emotionally defends himself against that injury (Kriegman & Solomon, 1985; Shane, 1992; E.S. Wolf, 1988). This can become problematic when therapists have their own needs for excessive mirroring, possible due to archaic needs. If the therapeutic content is frustrating, the clinician may regress to the point where he or she is unable to access empathy. This can occur when clients are so absorbed in their own needs that they fail to remember to interact with the therapist as a person.
Another possibility of the therapist's inability to be empathic is as a defense against the client's idealizing of him or her. Additionally, the therapist's personal life may be so stressful and frustrating that the overburdened self cannot function adequately in the session. A client who excessively needs selfobject experiences can evoke countertransferential feelings, as well. The phenomenon of countertransference can serve as a reminder to the therapist that he is just as vulnerable to the feelings the client has with the transferential relationship. Another self psychological view of countertransference views the phenomenon as a reaction by the therapist to the client's transference of expectations to the therapist. These expectations exert pressure on the therapist, which results in the countertransference reaction (Elson, 1986).
Criticism
Critics of self-psychology often cite the framework as attempting to "cure through love" and to "provide a corrective emotional experience," finding fault with "indulging in the patient's transference wish" by providing an "emotional echo or approval" (Wolfe, 1992). Greenberg and Mitchell (1987) found several problems with Kohut's model of self-psychology. The authors note that while his theoretical model is similar to other relational theories, Kohut does not address these similarities and presents himself as if he were working in a vacuum. Kohut's description of the relationship between an infant and his primary caregiver resemble Sullivan's concepts. His emphasis of the effect of characterological disorders in parents on their children was previously noted by Fairbairn, Winnicott, Guntrip, Mahler, and Jacobson. Greenberg and Mitchell (1987) also note that Kohut's vision of emotional health is unattainable because it hinges on having perfect selfobject experiences in childhood. Kohut visioned the possibility of a world without conflict. Similarly, his views of healthy child development are unrealistic, as no person is able to provide perfect selfobject experiences. Another weakness of his theory is it's narrow interpretive focus, basing development solely on "narcissistic" issues in terms of idealization and mirroring (Greenberg & Mitchell, 1987).
Miller (1996) also found problems with some of Kohut's model of development and suggested changes to address the inconsistencies. Miller (1996) believes that infants are unable to have a grandiose self or idealized parental imago, because they are not yet capable of cognitively formed thoughts of attributes, which occur during the second year of life. While Kohut defined mirroring as admiration, Miller (1996) expands on this definition to combine admiration, understanding, and validation. Miller (1996) envisioned two types of admiration; elicited and unelicited. When a child is spontaneously praised for being cute or smart, this is unelicited. When a child says, "Look at me run.," this is elicited. Both types of mirroring are important for the child's development.
Miller identified the concept of an ambivalent selfobject, in addition to positive and negative selfobjects. An ambivalent selfobject is one that serves to maintain an individual's self structure by providing neither positive nor negative experiences to the self. A selfobject may be perceived by others to be nurturing and positive, but the individual's perception of the selfobject experience determines it's classification as positive, negative or ambivalent (Miller, 1996; personal communication, July 15, 1996).
Greenberg and Mitchell (1987), also criticized Kohut's theory of development, which is seen as a linear progression. The authors interpret the process of transmuting internalization as a move from "addictive dependence to resilience and independence" (p. 369). Kohut's view of an infant's anxiety is seen as a secondary process resulting from disturbances in the primary self-selfobject relationship.
Kohut refers to the mother as performing the mirroring functions and the father as functioning as the idealized parent. He did not mention the child's need to be mirrored by the idealized parent as well. His theory seems paternalistic, assuming that the father is the stronger, more protecting parent. While Kohut addressed parental abandonment and parental death, he did not speak of the many children who are born to single mothers without contact with the father of or infants without maternal contact. The abandonment of a child implies more than empathic failure, because a parent who is not present cannot "make things better."
Kohut also did not address the concept of negative selfobject functions. Children who are victims of the trauma of physical, sexual or extreme emotional abuse experience more than empathic failure, they experience assaults on their development. Miller's (1996) definition of selfobject, "the selfobject may either enhance the self attributes of esteem, continuity, power, image, and cohesion or diminish them," differentiates positive from negative selfobjects (p. 54-66). Children who experience a parent as a negative selfobject may also view that parent as a positive selfobject, as parts of the relationship may not be abusive or neglectful. A negative selfobject effect can result from transference or displacement, when current relationships or interactions trigger traumatic memories from another relationship, leading to fragmentation. This contrasts with Kohut's views of transference, which tend to focus on the relationship between client and therapist that is triggering unmet developmental needs.
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