Psychoanalytic Case Formulation: - PowerPoint Presentation

Slide1

Psychoanalytic Case Formulation:Attachment Styles and Ego Defenses

Vanessa Snyder

Regent UniversitySlide2

Dr. Nancy McWilliams:Professor at Rutgers University

Author:

Psychoanalytic Diagnosis Psychoanalytic Case FormulationPsychoanalytic Psychotherapy: A Practitioner’s GuideAssociate Editor:Psychodynamic Diagnostic Manual

Introduction to Psychoanalytic Case Formulation

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY:

The

Guilford Press.

McWilliams, N. (1999). Psychoanalytic Case Formulation. New York, NY: The Guilford Press.Slide3

Introduction to Psychoanalytic Case Formulation:

Nuts vs. Not

nuts

orHow nuts? In

what particular way?

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY:

The

Guilford Press. Slide4

Case Formulation Protocol

Intake/Interview

Assessment:Things that cannot be changedDevelopmental issuesEgo defenses

Affect statesIdentifications

Relational patterns

Self esteem

Pathological beliefs

Case formulation example

See Sample Case Study (1)

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press. Slide5

Assessing Developmental Issues:Think Developmentally!!

Sigmund Freud

Erik EricksonJohn BowlbyMary AinsworthSlide6

Freud: PsychosexualErickson: Psychosocial

Psychosexual Stages

Oral StageAnal StagePhallic StageLatent StageGenital StagePsychosocial Stages

Trust vs Mistrust

Autonomy vs Shame/Doubt

Industry vs Inferiority

Identity vs Role Confusion

Intimacy vs Isolation

Generavity vs Stagnation

Integrity vs Despair

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press.

Mitchell, S. A., & Black, M. J. (1995). Freud and Beyond. New York, NY: Basic Books.

Erik Erickson’s Stages of Development. Retrieved from http

://youtu.be/dGFKAfixHJsSlide7

Attachment Theory

and

Assessing Attachment Style

John Bowlby:

The

“Father of Attachment

Theory”

Proximity, Protection, & Separation

Mary Ainsworth

Attachment, Communication, and the “Strange Situation”

Bretherton, I. (1992). The origins of attachment

t

heory: John

b

owlby and mary ainsworth.

Developmental Psychology, 28,

759-775. Retrieved from

http://www.web.ebscohost.library.regent.edu

Lopez, F. G. (July, 1995). Contemporary attachment theory: An introduction with implications for counseling psychology.

The Counseling Psychologist, 23

(3), 395-415. doi: 10.1177/0011000095233001Slide8

Mary Ainsworth: Attachment and the Growth of Love (Davidson Films). Retrieved from http

://

youtu.be/SHP_NikTkaoWallin, D. J., (2007). Attachment in Psychotherapy. New York: The Guilford Press.Assessing Attachment StyleSecure Attachment(Autonomous)

Insecure Attachment:Resistant or Ambivalent(Anxious – Preoccupied)

Avoidant

(Dismissing)

Disorganized/disoriented

(Unresolved/disorganized)Slide9

Attachment Style Chart

Attachment Style

Parenting

Self/Other Thoughts

Secure

Loving / Consistent

Good with love and trust

Insecure - Avoidant

Rejecting

Cannot trust

Insecure - Ambivalent

Inconsistent

Wants love desperately

Insecure - Disorganized

Abusive

Fears others

Attachment Style

What is attachment theory? Retrieved August 27,

2011 from http://www.terrifictop10lists.com/articles/attachment.htmlSlide10

Thorough History-taking

Genogram

Adult Attachment ScaleAdult Attachment InterviewAttachment to God Inventory

Dykas, M. J., Woodhouse, S. S., Cassidy, J., & Waters, H. S. (September, 2006). Narrative assessment of attachment representations: Links between secure base scripts and adolescent attachment.

Attachment and Human Development, 8

(3), 221-240. doi:

10.1080/14616730600856099

Lopez, F. G. (July, 1995). Contemporary attachment theory: An introduction with implications for counseling psychology.

The Counseling Psychologist, 23

(3), 395-415. doi:

10.1177/0011000095233001

McDonald

,

A.,

Beck

,

R.,

Allison,

S., Norswortby, L. (2005). Attachment to god and parents: Testing the correspondence & Compensation Hypotheses.

Journal

of Psychology & Christianity,

24

(1), 21-28. Retrieved from http://www.web.ebscohost.com.library.regent.edu

AssessmentsSlide11

Theological Positioning on Attachment

Attachment

theory may be an appropriate framework for abeliever's relationship with a God figure.One's attachment to Godresembles other attachment relationships.McDonald, A., Beck, R., Allison, S., & Norswortby, L., (Spring, 2005). Attachment to god and parents: Testing the correspondence vs. compensation hypotheses. Journal of Psychology & Christianity, 24(1), 21-28. Retrieved from http://www.web.ebscohost.com.library.regent.eduSlide12

Assessment of Defensive Processes

Primary (Primitive

Secondary (Higher order)Anna Freud: Ego PsychologyMcWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press. Spielman, R. (

June, 2002) The ego and the mechanisms of defence. Australian & New Zealand Journal of Psychiatry,.36(3), 430-434. doi: 10.1046/j.1440-1614.2001.01067.xSlide13

Primary Defense Mechanisms

Lower Order

Boundary between the self and the outer worldTo qualify:reality principle not attained“Lack of appreciation of the separateness and constancy of those outside the self” (McWilliams, 1994, p. 98)Slide14

Primary Defense MechanismsPrimitive

Withdrawal*

Denial*Omnipotent Control*Primitive, Idealization, and Devaluation*Projection & Introjection*IdentificationSplitting of Ego*

Dissociation*

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press. Slide15

Secondary Defense Mechanisms

Higher Order

List of secondary defenses are different for different theorists McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press. Slide16

Secondary Defense MechanismsRepression*

Regression

Isolation*Intellectualization*Rationalization*MoralizationCompartmentalizationUndoing*Turning against the selfDisplacement*Reaction Formation*Reversal

IdentificationActing Out*SexualizationSublimation

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press. Slide17

Defense Style QuestionnairePersonality Assessment Inventory

Derogatis’ Symptom Checklist 90-R

California Psychotherapy Alliance ScaleAssessmentsAzibo, D., (2007). Mechanisms of defense: Nepenthe Theory and Psychiatric Symptomatology. Negro Educational Review, 58(1/2), 49-67. Retrieved from http://www.web.ebscohost.library.regent.eduBond, M., & Perry, J., C. (September,2004). Long term changes in defense styles with psychodynamic psychotherapy for depression, anxiety, and personality disorders. American Journal of Psychiatry, 161

(9), 1665-1671. Retrieved from http://www.ajp.psychiatryonline.orgSlide18

Multicultural PerspectiveAzibo (2007) explores the Nepenthe Theory and the defense mechanisms utilized by blacks in America .

Azibo, D., (2007). Mechanisms of defense: Nepenthe Theory and Psychiatric Symptomatology.

Negro Educational Review, 58(1/2), 49-67.Slide19

Theological Positioning on Ego Defenses

“As originally created, humans were truthful. They apparently had no need for self-protective mental process because the Garden of Eden was some sort of idyllic haven free from the stresses and burdens that followed human sin.” (p. 176) A consequence of sin, Adam and eve felt the need to protect themselves. Then came the 1st

maladaptive psychological defense of man “The woman you gave to me, she gave me from the tree, and I ate.” Protection from the pain of taking responsibility for one’s actions.

Johnson, E. L., & Burroughs, C. S., (2000). Protecting one's soul: A christian inquiry into defense activity

. Journal of Psychology and Theology, 28

(3), 175-189.Slide20

ConclusionCase Studies, Teaching assignments

And

For further information…Slide21

Purpose: As we all know, obtaining personal therapy is one of the most effective tools a therapist can utilize in establishing rapport with a client and maintaining a healthy therapist/client relationship. Without an understanding of the defenses that we utilize personally, as clinicians we will have a difficult time recognizing countertransference in the context of the therapeutic relationship. Secondary to this, the practitioner/educator who is able to continually practice self-awareness will be able to understand and teach it more effectively to clients and students alike.

Learning Objective: We are born with defenses that are healthy and enable adaption in a creative way. It is when we attempt to avoid anxiety, grief, anger, fear, shame, guilt, pain, worthlessness, or other negative emotional states that the function of the defenses becomes maladaptive.

Instructions: Take a piece of paper, write out, and answer the following questions. If you answer with a response such as “I just allow the feeling to run its course and experience it for what is truly is”, then ask yourself what you would have done 10 years ago before you became free of defenses.Questions:1. What do you do when you are feeling anxious?2. How do you comfort yourself when you are upset?3. Are there any old family stories of you that you feel capture your personality?4. What do other people say about you? (Criticisms, complaints, or other observations)

5. If you had a personality disorder, what would it be?6. How do you find yourself reacting to these questions?

Final thoughts: What good is it for a counselor to be aware of his/her own defense mechanisms?

Teaching Activity 1

Insight Exercise: How do I defend my “self”?Slide22

Purpose:

Drawing an image of how a person sees himself in relationship with God is an exercise that enables the student/client to put into picture his perception of the image God and their relationship as he experiences it; the God attachment.

 Learning Objective: Much like the projective House-Tree-Person personality test, this exercise provides of measure of attitude towards God, self-perception, and self in relationship with God.

 Directions:

Draw a picture of God as you really think of Him in your mind and place yourself in the picture with Him. If possible, try not to use stick figures. It doesn’t matter how well you draw, you cannot draw it “wrong” as there is no right or wrong way to draw your picture.

Questions for Reflection:

The questions that you will develop will be directed by the drawing.

An example of this exercise is given on the following page. The sample exercise is a case study from Client “L”.

“

L” is a 32 year old single white female who has been coming to therapy weekly for 3 years. She was born to a borderline mother who divorced her father when she was 5, and blamed her for all of her broken relationships. At 9, “L” was sent to live with her youth pastor, his wife, and 2 little girls. Over the next 7 years, “L” was systematically sexually abused by the youth pastor. At the age of 16, her cherished Father died of cancer. Three weeks later, her mother found her journal that described the abuse. She then sent her on her own to the police. The DA chose not to press charges as it was “he said vs. she said”. When she went home and told her mother, Mother called her a liar and then blamed her for the abuse.

Teaching Activity 2:

Attachment & God ImageSlide23

Teaching Activity 2:

Attachment & God Image

Sample Exercise: Client “L”

Questions Asked:

Therapist: Is that you in the bottom corner?

“L”:

Yes.

Therapist: And that is God’s hand reaching out for you?

“L”:

I guess.

(Visible upset, going in the direction of dissociating)

Therapist: Was this a difficult exercise?

“L”:

Yes.

Therapist: Why was it so challenging?

“L”:

It didn’t turn out like I thought it would.

Therapist: What were you expecting?

“

L”:

I always thought God abandoned me.

Therapist: But…it looks like He is there, waiting for you.

“L”:

Mmm

hmm.

Therapist: Do you know why your back is turned away from God’s hand?

***After bouts of dissociation and grounding exercises, the client was able to explain that she could not look at God, because she still felt the abuse was her fault and was too ashamed.Slide24

Clinical Scenario: Will Hunting is a macho young man from a working class neighborhood in Boston. To outward appearances, his life revolves around low-skilled jobs, hanging out with friends, fighting, and getting into trouble with the law.

But

Will spends a lot of time at home alone reading books, storing information in his photographic memory. His intelligence is exceptional and he can easily solve problems of higher mathematics that elude famous math professors. An orphan, Will grew up in a series of foster homes in which he was repeatedly beaten. As a result, Will has classic attachment disorder. He cannot form trusting relationships with adults or with women. He cannot control his anger. He cannot integrate his intelligence into his relationships with others in either social or work environments. Will's only affectionate attachments are to a group of three young men from his neighborhood who cannot begin to match his intelligence. Good Will Hunting traces the successful treatment of Will's attachment disorder, providing an excellent basis for studying the origin and treatment of this psychological condition. Filled with wisdom and compassion, the movie shows the power of talking therapy and gives an example of the life-changing insight that can be provided by psychology. The film is also a springboard for discussions about the role of dependence, independence, and interdependence in human life and the importance of love and consistency in parenting.

The movie also shows the young male culture of cruelty and demonstrates that the need to be tough, to never show vulnerability, weakness, hurt, or sadness, leads to a dead end. Will's friends are loyal and want the best for their friend — the essence of a caring friendship. The film can also reach some of the several students in every class (as many as a third) who have been physically or sexually abused. (www.teachwithmovies.org)

Case Study (2)Slide25

Discussion GuideInstructions:Watch the following YouTube videos in order. What you will witness is the destructive power of insecure attachment and the defenses that come into play.

***Please note: This film is rated R and uses the F-word more than the average rated R movie. However, the power of this movie to give clear examples of attachment and defenses is too useful not to share.

1) Failed Therapists: http://youtu.be/UpL3ncoK99U2) First meeting: http://youtu.be/JQf7O3GeHVk3) Park Scene: http://youtu.be/qM-gZintWDc4) It’s Not Your Fault (Note: syncing is off): http://youtu.be/pF6-JUohCWg

5) You Won’t Be There: http://youtu.be/gGX6KbworY8Questions for Consideration:

1. What type of insecure attachment style does Will Hunting live out in his relationships and why?

2. What are the primitive defenses that Will Hunting exhibits in his relationships with friends, girlfriends, professors, and therapists?

3. What are the higher order defenses that Will Hunting exhibits in his relationships with friends, girlfriend, professors, and therapists?

In

what ways are Will Hunting’s insecure attachment style changed at the end of the movie? Who/What helped to redefine his attachment style and how

?

How do you like them apples??