Case Formulation Using Object Relations Theory

1. Case Formulation Using Object Relations Theory Geoff Goodman, Ph.D.

2. I. Psychodynamic Case Formulation (Perry, et al.,) • Underlying understanding of purposes that symptomatology serves will influence the conduct of the treatment • Parts of case formulation • summarizing statement • description of nondynamic factors • psychodynamic exploration of central conflicts • predicting response to the therapeutic situation

3. C. Psychodynamic explanation of central conflicts • ego-- psychological-- id, ego, superego, reality • self--psychological-- ambitions, ideals, empathetic failures • object relations-- good, bad self and objects

4. Continued… 4. conceptualize patient’s wishes (sexual, aggressive, security, nurturance), defense mechanisms (projection, splitting, denial, repression, isolation of affect, displacement, minimization, intellectualization, sublimation) and object relations used for gratification of wishes and defenses against gratification (example of Kristen Mermoli’s patient who wanted to perceive her as a peer and fantasize that they will be together, defending against rejection if he acknowledged that she is the adult whose purpose is to help him with his problems) 5. influence of case formulation on future therapy

5. D. Discuss examples of case formulation • ego-psychological model • self-psychological model • object relations model

6. II. Advanced Psychodynamic Case Formulation (Messer & Wolitzky) • Multiple perspectives • dynamic-- major conflicts (wishes and defenses) • structural-- structures (id, ego, superego, mental representations) • genetic-- historical and developmental etiology • adaptive-- adaptive and maladaptive compromise formulations • topographic-- conscious vs.. unconscious status of conflicts • economic-- investment of psychic energy

7. Continued… B. Four attributes of drives • source-- somatic processes that make demand on mind • aim-- gratification through discharge • impetus-- drives intensity • object-- target (e.g., inanimate object, person, body)

8. Continued… C. Object relations model • affective coloring of interactions among mental representations • splitting processes among mental representations • human relatedness emphasized over drive discharge • pre-Oedipal experience emphasized over Oedipal experiences • patient’s recall of model scenes or scripts • contained in earliest memories • contained in transference phenomena • contained in enactment

9. Continued… D. Meaning of psychopathology • mask-- concealment (ego-- psychological model) • mask-- false self (object relations model) • dependent on model used

10. Continued… E. Working models of case formulation • commonplace working model-- implicit theory of personality • working model of oneself= commonplace + psychoanalytic • psychoanalytic working model • aggregate of one’s experiences with previous patients

11. F. Multicultural Considerations • psychopathology in Western cultures might be normative in non-Western cultures a. expression of hostile feelings b. need for individuation and autonomous strivings c. individuality vs.. dependency

12. Continued… 2. childrearing practices in Western cultures might differ between Western and non-Western cultures a. infant separations b. infant expression of needs-- signals of distress 3. different cultures cope differently with universal experiences of separation, loss, and death

13. G. Prognosis in exploratory psychotherapy • willingness to share personal thoughts and feelings • ability to experience and tolerate dysphoric affects • motivation for change • psychological mindedness, capacity for introspection • flexibility of defenses • degree and intensity of fixation at pre-Oedipal vs.. Oedipal level • positive response to interpretation

14. H. Treatment goals • autonomous ego functions-- understand symptoms • dynamic and self-related issues-- awareness and expression of wishes and needs • affects, drives, and defenses-- understand interplay between affects and defenses and the circumstances under which defenses occur

15. Continued… 4. object relations (general)-- understand roles patient plays with others and forces others to play with patient 5. object relations (parental introjects) understand roles patient plays with parents and forces parents to play with patient • object relations (partner interaction) I. Inherent subjectivity of case formulations

16. III. Assessing Relational Patterns (McWilliams) • Relational themes in the transference 1. how patient’s connections with primary objects expressed a. describe most important relationships b. what is marriage like? c. whom are you close to? d. what do you value in people? 2. patient’s connections expressed primarily in transference a. look for repetitive patterns and articulate them b. try to figure out the origins, meanings, motives and reinforcers of the pattern

17. Continued… 3. interviewer uses subjective experience to understand relational pattern that develops during interview • distinguish patient’s emotional reactions from one’s own • determine what kinds of relational patterns are absent as well as what kinds are present

18. B. Relational themes outside the therapy situation • previous relationships with therapists • avoid mistakes of previous therapists • predict mistakes to patients 2. take history of relationships in social, sexual, work spheres 3. make contract to avoid future therapy disruptions

19. Continued… 4. sexual relationship contain relational themes in a highly charged, condensed form • expressing dominant interpersonal pattern or • sequestered, partially dissociated relationship theme • interviewer needs to speak frankly to elicit patient relief • sexualization of other motives (central masturbation fantasy) 1) dependency 2) aggression (sadism) 3) narcissism 4) suffering (masochism)

20. C. Implications for long-term and short-term therapies • core relational themes expected to emerge more confidently in long-term therapy • more speculation involved in shot-term therapy

21. IV. Psychotherapeutic Applications of AAI Classifications (Slade) • Attention to narrative process in clinical listening • changes in voice • contradictions, lapses, irrelevancies, breakdowns in meaning • subtle, ongoing disruptions and fluctuations in structure and organization of discourse • how patient defends self against intrusion of unacceptable feelings or memories into conscious thought

22. Continued… B. Psychiatric diagnosis and attachment classification • Ds-- minimal free expression of particularly negative affect (obsessional, schizoid, narcissistic) • E-- relative absence of structures for regulating affect (hysterical, borderline) • F-- affects, including negative ones, “can be represented and acknowledged in a flexible and coherent way” (anxiety, depression) • U-- extreme form of E, incoherence and disorganization (dissociative disorders, PTSD)

23. C. Attachment organization and therapeutic relationship 1. Ds • cool and remote • dismiss importance of relationships and feelings • apparent good adaptation is superficial • deny need for help to protect self from possibility that caregiver will be unavailable

24. Continued… 2. E • inability to collaborate, take in words and support of therapist • maximize expression of attachment needs and feelings to insure care • needy and dependent-- demand advice and support

25. Continued… D. Attachment organization and countertransference-- therapist internal working models work better with their opposite (Ds with E, E with Ds); insecure more vulnerable to unanalyzed countertransference