Object Relations Case Formulation

1. Identifying details Name: Katrina Katryn Age: 20 Gender: Female Marital status: Single Dependents: N/A Highest level of education: Matric Present occupation: Student (Psychology 1st year) Reason for referral: Self exploration, dealing with the past, improving interpersonal experiences. Referral source: Self-referred 2. Presenting problem She experiences considerable anxiety in interpersonal situations. In addition she has feelings of inadequacy, worthlessness and hopelessness. These difficulties lead to academic concerns and relational problems in her current situation.

Her self-esteem is extremely low and she expressed that she hates doubting herself constantly. 3. History of presenting problem. She was sexually abused when she was between 6 and 9 years old. The rest of the time she was emotionally and physically abused. She has always felt inferior and had low self-esteem as long as she can remember. She was diagnosed with depression at age 15 and was put on medication. She cannot remember the name of the anti-depressants and did not remember the exact diagnoses. The feelings of hopelessness and her academic problems has started relatively recently according to her. 4.

Past illnesses Psychiatric Mood disorder (She cannot remember the exact diagnoses. ) Medical Nothing significant Anti-depressants (unknown) Adaptive features and Strengths She is intelligent and ambitious. She has shown courage in confronting her father about the abuse and her decision to mend their relationship show courage. She seems to have insight into her difficulties and the processes that keep them alive. She seems to be willing to change and to explore these difficulties in depth. The fact that she removed herself from her deleterious environment in adolescences is indicative of her self-preservative abilities.

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She is currently in therapy on a self-referral which again points out these abilities. She has taken responsibility of protecting her siblings in the past and the present which indicate her compassion for others. She seems to trust me and it is likely that we will form a therapeutic alliance. 5. Personal history I. Birth and early development As far as Katrinais concerned she was a wanted and welcomed baby although the pregnancy was not planned. The pregnancy was normal at 40 weeks without any complications. She did not experience any serious illnesses and was not involved in any accidents.

She reached all her developmental milestones within the average intervals. This thus indicates a normal developmental trajectory throughout infancy. Katrina’s socio-emotional history was significantly compromised by physical, emotional and sexual abuse. She had an extremely wounding relationship with her father who mistreated her and then after the mistreatment behaved alluring towards her. She mentioned this several times during most of our sessions. She also had an ambivalent relationship with her mother during this time.

Her mother would at times be very loving, caring and supportive, yet at other times ignore her cries for help and her need for her affection. She did not enjoy any close knit friendships and it seems that the only person she shared a healthy relationship with was her grandmother. This relationship however was constantly under attack from her parents. She described herself as an obedient and shy girl who felt lonely and different. II. Childhood During her childhood Katrina lived in a very traumatic family situation full of psychological, sexual and physical abuse.

She mentioned that everything from her childhood was connected to a bitter feeling. She lived with her mother, father and younger sister. Her father was unhappy, aggressive, insecure, but in her childhood she experienced him as a powerful and great authority. Her father was sexually abused as a child. He was very strict and required discipline from his two children, especially from Katrina. He set strict rules and if these were broken, he beat Katrina. If she opposed him and objected to what he said, he hit her. When she was seven years old she was sexually molested by him on a regular basis.

This continued until she was 9 years old and then her father stopped the sexual abuse. The emotional and physical abuse nevertheless continued throughout her childhood until she emancipated herself from her parents. Katrina’s socio-emotional history was significantly compromised by physical, emotional and sexual abuse and by the response of her mother during this time. On the one hand her mother was a warmer person than her father but she was subordinated to Katrina's father. Her mother's attitude towards her was very variable.

Sometimes she was kind and interested in her, yet in cases when she did not like something she scolded, even hit her, which Katrina understood as the end of their relationship and love. But when her mother showed her compassion again, Katrina immediately forgave her. Her mother would at times be very loving, caring and supportive, yet at other times ignore her cries for help and her need for her affection. She did not enjoy any close knit friendships and it seems that the only person she shared a healthy relationship with was her grandmother.

This relationship however was constantly under attack from her parents. She described herself as an obedient and shy girl who felt lonely and different. Katrina's parents often quarrelled with each other, although father was less often physically aggressive towards the mother than towards Katrina. Katrina blamed herself for being the cause of disagreements, e. g. when she wanted something, parents quarrelled, because her father prohibited it while her mother allowed. So Katrina preferred to suppress her wishes and remained quiet to avoid quarrels.

According to her conclusion there would be peace at home if she was a good girl. Even at her young age, Katrina had to assume responsibility for her younger sister. She was like her shadow and prevented her (Katrina) from relaxing completely. As mentioned earlier, Katrina’s only solace in her childhood years was her maternal grandmother. According to Katrina she was the only person she felt completely safe with. When Katrina was 9 the sexual abuse from her father stopped, Katrina told her grandmother about it and the father admitted to it and entered rehabilitation.

Her mother nevertheless stayed married to him for the meanwhile and Katrina was expected to share a life with him despite the abuses he committed against her. She expressed the wished to stay with her grandmother, who at that time stayed quite close to them. It was however her mother and father’s (I suspect her father’s) decision to move away. Katrina remembered feeling like her world fell into pieces when this event occurred. Katrina and her younger sister were informed that another sister is on the way during this time.

Katrina remembered that she was a shy little girl who found it difficult to make new friends. She remembered how difficult the move was for her leaving her friends and grandmother behind. III. Adolescence A stated previously although the sexual abused stopped her father continuously physically abused her until the age of 16 until she emancipated herself and went to live with her grandmother. Katrina explained that this was done despite protests from her mother and father. She went to visit her grandmother one holiday and never returned home.

She felt extremely guilty leaving her 2 sisters behind but felt that this was the only way she could fled from the abuse of her father. She is not sure whether or not her father had abused her little sisters sexually but stated that he never physically abused them. Her parents divorced after this and her mother moved to Botswana where she still lives today. Katrina stayed with her Grandmother until she finished school. She did however not speak about her grandmother a lot in our sessions and only mentioned a few superficial accounts. She expressed that she was ordinary in high school and could not remember anything that stands out.

She did however comment on the fact that she had a couple of boyfriends she referred to as “dominating idiots which she could not leave at will although she hated the relationships. She did have 1 or two close friendships. Her father remarried and Katrina has an ambivalent relationship with her stepmom who she describes as manipulating, controlling and mean. IV. Family data Katrina is the first born daughter of her biological parent’s first marriage. She has two younger sisters, X who is 16 and Y who is 13. Her parents divorced when she was a teenager. Her father remarried and has two boys with her stepmom.

Her mother and biological sisters stays in Botswana. Katrina sees them at least twice a month when she and her boyfriend go to visit them. Her mother had a boyfriend but they broke up recently when she was in therapy with me. V. Cultural features Katrina is a 20 year old Caucasian woman of the Christian religion. She is English speaking. VI. Social condition She is currently staying in the residence at the University she studies. She seems well looked after. She comes from a typical suburban middleclass background. She is dating a 20 year old guy, who I met.

Other than this she has not mentioned other friends. It seems that her boyfriend and her family is her only support system at the moment. 6. Personality Katrina is somewhat introverted and extremely dependent. She seems to be submissive and self-criticizing. She is shy, withdrawn and apologetic. Although she at times seemed optimistic it was clear that this is a mask for her underlying pessimism and distrust in people in general. 7. Mental status examination Katrina was orientated to time space and place. She did not exhibit delusions, hallucinations or cognitive disturbances.

She was dressed in line with the latest trends. Her appearance did not seem extravagant yet it was nevertheless neat. Her affect was a bit blunted initially and she did seem a little blocked off. This however changed throughout our sessions. 8. Diagnosis Axis I. Major depressive disorder, Recurrent, Moderate Axis II. Dependent Personality Disorder Axis III. None Axis IV: Problems with primary support group (victim of physical and emotional abuse in childhood; Disruption of family due to parents' divorce). Problems related to the social environment (inadequate social support).

Axis V GAF: 55 :Moderate symptoms and moderate difficulty in social and occupational functioning. Comments: At termination GAF = 80 Good improvements in self-evaluation, self-esteem and assertiveness. Good reality testing and a sense of independence in her relationship with her father. 9. Prognosis Currently it seems that Katrina has dealt with a large part of her experience with the sexual abuse. She has gained some insight on the reasons she is overly dependent on people to make decisions for her and why she feels like she will lose relationships or love when she assert herself in interpersonal situations.

Although she will benefit to long term therapy I feel that we have dealt with key aspects in our 7 months together. 10. Case formulation The so called schizoid ego splitting can be noticed in Katrina. In her early relationships Katrina did not have safe attachments. She lived through mistreatment and lack of support, the consequence of which is that children hide their feelings and relational needs. This stops or slows down the process of integration and the ego gets fragmented (Klein, 1987, in Little, 2001).

This gives rise to the first degree of a split or withdrawal as described by Fairbairn (1952, in Little, 2001), where the ego splits into coping/every day self (central ego), which maintains the relation with the outer world, and the withdrawn/vulnerable self (libidinal ego), which hides itself. At an early stage of development Katrina could not display some parts of herself, like feelings of vulnerability, anger, playfulness, her own interests, the part connected with relaxation and enjoyment, because for all these she was punished with physical violence and emotional rejection.

She most probably hid and suppressed this part of herself and thus the withdrawn/vulnerable self-formed. Outwardly Katrina showed her coping/every day self, which listened to the parents, was good at school and at home, who did not object and had no interests of her own, while being active all the time. During the psychotherapy Katrina mentioned several times that she did not know at all who she was, that she did not know herself and that in interpersonal situations that provoked any form of anxiety she felt like she was falling to bits.

She described herself as an abused person and that that is all she is and nothing else. This might be because till then she mostly defined herself through others and through those specific experiences. This particularly describes the process of splitting into both previously mentioned selves, where the authentic self (vulnerable self) hid, while Katrina identified herself with the coping/every day self, which was more social self and represented her adjustments to the wishes of other people around her, like her mother and father. Simultaneously the splitting of external objects, i. . people who were important for her, occurred. The coping/every day self has to maintain a connection with important objects, otherwise the child could not survive on his/her own. This gives the child a sense of security (Little, 2001), which represents a very important need for Katrina, as will be further described in the following section. For Katrina to be able to keep a tolerably good connection with her mother, she had to separate bad experiences and internalize them, which suppressed her withdrawn/vulnerable self even more.

In this way the coping/every day self is connected with the idealized object (Little, 2001), which also holds true in Katrina's case. At the beginning of psychotherapy Katrina strongly idealized her mother; she spoke only of good experiences with her, not remembering unlikable experiences, since these were split off. Only with on-going therapy was she gradually able to integrate these experiences. She was also very loyal to her mother, defending her all the time, not being angry with her, which all shows a strong tie between the coping self and the idealized object.

An example of this the following : Katrina has received various complaints from her sisters and has experienced it for herself that her mother has sex with her boyfriend in the house where everybody in the house can hear everything. According to Katrina these events are quite explicit and make everyone extremely anxious and uncomfortable. She however defended her mother by saying that her mother deserves the happiness and pleasure and that Katrina wants her mother to be happy. “We can look past this because my mom deserves to be happy”. On the other hand Katrina had isagreeable memories of her father from the very beginning. She mainly blamed him for her ugly childhood, so that Katrina probably formed a split also between both parents (father thus representing the bad object, and mother the good one). Th e vulnerable self is in relation to the exciting/disappointing object (Little, 2001) and this represents the developmentally needed relationship between her mother and Katrina. Their relationship was very variable, i. e. her mother was warm and kind to Katrina some of the time. Katrina hoped that mother would satisfy her needs, but was later disappointed and rejected by her.

I n my judgment Katrina's mother had great difficulties in getting attuned to Katrina. This resulted in the exciting/disappointing object to be experienced as painful and dangerous by Katrina, which meant that she suppressed this aspect into her unconscious as the disappointment. The withdrawn self, splits further to create the internal saboteur (Fairbairn, 1952, in Little, 2001), which serves to keep the vulnerable self, hidden and repressed. The saboteur's function is to precede criticism of other important persons and thus regulates a child's behaviour (Erskine, 2007).

It is that is to say easier to bear inner criticism than criticism by important other persons, because this would signify an end of a vital relationship. Katrina on several occasions mentioned that she was afraid to speak her mind in her significant relational circumstances because she feared that it would mean the end of that relationship. It is also too painful to incessantly repeat disappointments due to unmet needs; therefore the inner saboteur blocks these needs and even denies their existence. In Katrina the inner saboteur (anti-libidinal ego) formed, manifesting itself in Katrina's excessive self-criticism.

As early as primary school she criticised herself for her looks, clothes and shoes, her behaviour and her inferior abilities, and she worried that other children might not like her. Through her inner saboteur Katrina constantly controlled herself, her vulnerable self, e. g. , she forced herself to be strong, not to show emotions and to be well-behaved. She kept convincing herself that she didn't lack anything. Therefore Katrina created an inner saboteur to be able to survive with a violent father and aloof mother.

The inner saboteur is in relation with the rejecting/attacking object, which attacks the vulnerable self so that the latter would remain suppressed (Little, 2001). Rejecting/attacking object in Katrina was formed by aggressive reactions of her mother and father, the violence (physical, sexual and emotional blackmail), daily criticism, humiliations etc. This part contains numerous contents, so the inner saboteur is very powerful. In my judgement then her dependent personality developed as a result of the above dynamics and within her early relational experiences described above.

Her dependent tendency creates significant anxiety and difficulty in her current relations with people, especially in her relationship with her father from which she cannot separate completely. 11. Management plans The first few sessions were focussed on normalizing her feelings of ambivalence in relationships and her over dependence on other people’s decisions. I also highlighted her strengths for her in our early session. For instance the fact that she took the initiative to emancipate her from her parents at age 16 and that she entered counselling out of her own accord showed resilience and strength and would be useful in our sessions.

Key aspects to work on and therapeutic goals (a) Help Katrina to talk about the abuse; (b) validate the Katrina's experience and feelings; (d) help to correct misperceptions of blame and responsibility for the abuse; (e) encourage Katrina to formulate and reach goals for personal coping and healing The first phase focused on stabilization and mastery: building the therapeutic relationship; reduction and containment of stress-related symptoms; establishing safety; and coping with current life problems. The second phase we dealt with integration of traumatic memories.

The final phase was concerned with self-development, relational development, and adaptation to daily life. PHASE 1: THE THERAPEUTIC ALLIANCE Katrina was hesitant about returning to counselling. She was sceptical about her safety in a therapeutic environment as a result of her previous experience in therapy. I was aware that Katrina had been dealing well with the impact of the sexual abuse, but her adult desire for stable relationships and being able to assert herself in these relationships called for therapy from a mature perspective.

I worked to establish positive rapport. Employing a person-centred approach throughout the first few sessions established a safe environment. Katrina chose the topics for the initial sessions. I used open-ended questions to avoid leading her, and helped her determine which difficulties were of primary importance. Treatment had to deal with both the underlying history of trauma and the current symptoms. Once rapport was firmly established, Katrina felt she was safe and her feelings were understood. PHASE 2: ADDRESSING PAST TRAUMA SYMPTOMS

Examples of associated problems that need to be understood within a diagnostic and treatment approach for childhood abuse are a pattern of disrupted development, loss of self-sustaining identity. In this phase we explored her ambivalent feelings toward her parents and her ambivalent self-concept or self-experience. We also explored ways she has come to understand her childhood abuse. I was aware of transference and my own counter transference in our sessions. I interpreted the transference for her and we worked on integrating her identity.

For example she felt like an abused person and it was so strongly related to her self-concept that it took over her life. We worked on redefining herself as someone who just happened to be the victim of abuse. Example of countertransference: I had a feeling that I wanted to give Katrina advice and wanted to give her solutions. I also had the feeling like I have to protect her in some way. I tried to meet Katrina’s need for security by setting clear limits of therapy, by concluding a therapeutic agreement with her, by informing her of the characteristics of the therapy and by telling her that there are no right and wrong answers.

I accepted her in her wholeness, including her depressive, gloomier part and her history of abuse. I did not denounce her when she thought I would. All this contributed to creation of a sense of safety in the therapy; she felt that she could show herself such as she was, without causing my respect towards her to diminish or without my criticizing or rejecting her. All this helped her to be less reluctant to continue with psychotherapy. During that phase of therapy Katrina gradually expressed her anger better, particularly in her relation to father.

It was a great achievement also that she expressed anger to her mother to whom she previously never set limits. Katrina found out that each expression of anger does not necessarily provoke conflict, violence and termination of a relationship. Katrina still finds it hard to experience anger with parents, as feelings of guilt and self-blame appear. What follows are examples of our sessions: Session 6 Katrina surprised me by bringing her boyfriend with into our session. It was noteworthy as the supposed reason for our sessions has nothing to do with him.

She did not involve him in the session and he was more like an observer. I commented on his presence and asked if he will join us each time. They both said no. This is something I would like to explore further in our future sessions. We explored strategies to deal with her insecurity in interpersonal situations. I asked her to name 5 rules she lives by relating to her relations with people. Most of them seemed to point to a certain notion that there is condition upon if other people would accept her contributions to any interaction.

She does this in our sessions as well, for example: she would say something like the following: I want to ask you something but I am afraid that you would think I am crazy and stupid for asking it. I know it’s not the right thing for me to be thinking of and I am afraid you will think less of me. I asked her to think of other relationships in which she engages with this thinking in. She identified that this is why she came for counselling. That she feels that if she is not perfect and always the way other people would like her to be they (everyone) would not accept her.

She went as far that she fears that people would totally reject her and banish her from their lives permanently. I ended the session by giving her homework. She had to identify some of her rules that she feels is operating in her relationships with others. I then asked her to write them down and next to each one write down an alternative to this rule one that is in essence contradictory. . Session 7 We discussed her homework and I commented on her resourcefulness in coming up with good alternatives. It made her feel empowered. I thought to try and relate what we have discussed in our previous session to her bringing her boyfriend to therapy.

I asked Katrina on the incidence of bringing her boyfriend with. She said that she felt safer when he is around. I hypothesised that our previous session made her feel vulnerable as we explored where her interpersonal mistrust and anxiety could’ve emerged and she related this to her relationships with both her parents. I asked if that she felt exposing these quite personal details at me she felt that I would reject her and related it to the rules that we discussed in session 4. It was in this session that she cried and really showed strong emotion when she spoke about her father and even more so her mother.

A definite area to explore more!!!!! PHASE 3: Self-development, relational development, and adaptation to daily life. Session 6 Having not seen each other for over a month as a result of exams and the holiday and we did some catching up. She said that she felt better and feels that she can handle the interpersonal insecurities she felt better. In session 4 we spoke about being aware when these feelings, which we agreed to, call uncertainty, emerges. Then immediately challenging them with something like there are no conditions of people’s acceptance of me. They will accept me and my decisions and contributions for who I am and for what it is.

She asked my advice on a decision she had to make after a disagreement with her father over the weekend about her 21st birthday party. I asked her if it would make a difference if I told her what to do. We went back and forth on this and I asked her if it is important for her for me to think that she is making the right decision. She said that she thinks that I am “clever” and educated and that if I agree with her she would know it is the right decision. I asked her if she always feel the necessity to check in with other people before she makes decisions.

She said that she always feels uncertain, especially when it comes to her father as he is manipulating and knows how to make her feel guilty about her decisions. She said that this has always been the case. I told her that my advice would be irrelevant and asked her to give me the options and the outcomes of decisions regarding this situation. This opened up a space in which we could discuss her relationship with her father and her story about this relationship in depth. She told a story of her father being a loving and caring father if she was exactly the way he wanted her to be and did what he expected of her.

If she disagreed with him he would tell her that she has to choose between his view points or she could pack her stuff and leave his home. This is still the case and it is a huge fear of Katrina that when she shows any disagreement with her father’s wishes he would completely reject her and shut her out of his life permanently. I asked her the following questions to confirm my hypothesis that she might fit into the dependent personality diagnosis. •Some people enjoy making decisions. Others prefer to have someone they trust guide them. Which do you prefer? Her response : I would prefer someone guiding me. Do you seek advice for everyday decisions? Her response : Always •Do you find yourself in situations where other people have made decisions about important areas in your life, e. g. what to wear, where to go out to, what to study ect.? Her response : All the time. •Is it hard for you to express a different opinion with someone you are close to? What do you think might happen if you did? Her response. Our relationship will end…. Ummm well maybe not end but they will leave me and I’ll have to beg them to stay. •Do you often pretend to agree with others even if you do not? Why?

Do you think it could get you into trouble if you disagree? I always agree, especially with my mom and dad. I don’t want them to leave me because they think I am a rebel or something. •Do you often need help to get started on a project? No •Do you ever volunteer to do unpleasant things for others so they will take care of you when you need it? If I think about it I have done it often in the past. •Are you uncomfortable when you are alone? Are you afraid you will not be able to take care of yourself? I have to be around at least one other person. I am terrified of being alone. Have you found that you are desperate to get into another relationship right away when a close relationship ends? Even if the new relationship might not be the best person for you? I had boyfriends who abused me, just like my father did but I stayed with them for a long time. I have never been single not once since high school, since I started dating no matter how bad the relationship was before the new one I always quickly found a new boyfriend. The one that I have now is the best thing that ever happened to me. •Do you worry about important people in your life leaving you?

I am very anxious that they will especially my boyfriend, my father and my mother After these sessions we began to set real life goals like for example. Asking her dad for coffee in a public place and talking to him about what concerns her. She was very scared to do this but she did it and disconfirmed her beliefs regarding him leaving her if she speaks her mind. He actually embraced it and their relationship has become more realistic and reciprocal. He now phones her and she could decide what she wanted to do with her 21st birth day party something he had took over from her.

She has also confronted her mother about her concerns about the example her mother sets for her sisters when her boyfriend stays over and they get, well a little loud in the bedroom. She spoke to her lecturers regarding her bad marks and attempted to rectify her poor academic performance. Although she still fails the subject she feels good about trying to do something about it and having the courage to face the lecturer. We discussed termination and I suggested that we see each other on a bi-weekly basis. I did not want her to become dependent on me and on the therapy.

She then suggested that we terminate in our next session as she felt “ready to take on her responsibilities and face the music”. I suggested that we see each other for two more sessions just to reflect back on our journey and top identify the resources she is now able to utilise. 12. Issues for discussion Did I follow a suitable therapy journey with her. References Erskine, R. G. (2007). Unconscious process, transference and therapeutic awareness. Workshop on Institute IPSA. Ljubljana, Slovenia. Little, R. (2001). Schizoid Processes: Working with the defences of the withdrawn child ego state. Transactional Analysis Journal, 31 (1), 33-43.

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