Description of Client
The client learned about the agency from a friend. The agency is dedicated to connecting mentally ill patients and their family members with the resources necessary to understand the nature of the condition. Furthermore, the agency has access to up-to-date health data and research about mental health. Also, it provides a forum where mentally ill patients and their families can speak, socialize, and connect with people experiencing similar challenges. Additionally, the agency is dedicated to giving a voice to millions of families and people living with mental health issues while assisting patients to improve the quality of their lives through reduced stigma and treatment. Also, they create awareness that mental health issues should not be an obstacle to a meaningful and balanced life. The primary goal of the agency is to advocate for people affected by mental health workers and professionals while ensuring they get adequate medical help.
The client exhibited various presenting problems. They included:
Excessive anger towards her children and husband.
She constantly felt sad and unhappy.
There was a significant sex drive change with her husband.
She had a reduced ability to concentrate at work and at home.
She has a major change in eating habits. She often woke up at night to eat while at times she could spend a day without eating.
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She was excessive worry about her family and extreme feelings of guilt.
Furthermore, she had become an alcohol addict over the past four months.
She had extreme mood changes of lows and highs such that her young children were afraid of her.
She also had problems sleeping, low energy, and significant tiredness.
Moreover, she experienced trouble associating and relating to people and situations.
Also, the patient that she was "seeing things that are not present.'
Finally, she was having challenges coping with stress and daily problems.
Due to confidentiality reasons, her name will be ABC. Patient ABC is a female aged 38, married with three kids, and African American. She had been jailed for three years for assault, and she began experiencing the symptoms while she was in prison. She is an alcohol addict for the past three months. She used a great relationship with her family until she went to prison and everything became quite different after she was released. Her husband filed for divorce about two months ago. Also, she does not have a family history of mental illness. ABC is currently employed at a grocery house. Her father was a preacher in one of the churches in Chicago. She believes that she is supposed to be ‘perfect' because she was raised to be a respectful and law-abiding citizen by her parents. ABC spends most of her day at work and taking care of her children.
The first step was a diagnosis of the condition. After a period of observation and working with other psychiatrists and other health professionals, ABC was diagnosed with clinical depression. Due to her incarceration, she was disappointed in herself because she believed that she was supposed to be ‘perfect.' Furthermore, due to her emotional changes, it affected ABC's relationship with her family to the extent that her young children feared her while her husband filed for a divorce. Her family's reaction to her emotional outbursts and changes made her feel like a failure. ABC is currently undergoing Cognitive Behavioral Therapy (CBT) so that she can understand her behavior and thoughts, and how it has affected her family. She is learning to evaluate how her past influenced her current situation. Also, she is learning how to overcome her negative emotions and how to behave when faced with challenges. According to the patient, there has been a significant improvement in her family relationship.
Ego Assessment
Bellak’s 12 Ego Functions
Reality testing : ABC experienced a mild or temporary distortion due to stressful conditions. It caused her to have temporary hallucination and delusions.
Impulse control: Due to the stressful situation, she was unable to manage her impulses and behaviors. Some of ABC’s symptoms include binge eating and alcohol use.
Judgment: She had limited ability to identify and evaluate the results of her behavior before acting. Her actions caused her young children to fear her.
Sense of reality: According to her symptoms, her ability to perceive and experience things correctly was slightly affected by her condition and alcohol abuse.
Object relations. The concept was affected because she had a positive view of her husband and family when she felt angered, disappointed, and frustrated by their behavior. She withdrew from interacting with her husband.
Thought processes. ABC had a goal of solving the problems she was experiencing so that she could live a meaningful and balanced life. She desires to have a stable relationship with her children and family.
Adaptive Regression: As a mother, she gave up trying to make her family love her as they used to and went for therapy so that she could improve herself. After some therapy sessions, her relationship with her young children becomes better.
Mastery competence: As a young child, she complied with all parental demands, and it compromised her ability to make independent decisions so that she could win parental approval. ABC feels so disappointed with herself because her actions made her family angry after she was incarcerated.
Synthetic-integrative function: It involves an individual's ability to organize and integrate contradictory situations. For instance, ABC loves her family, and that is why she went for therapy yet at times she is very angry at her family.
Autonomous functioning: Due to her conditions, ABC faces challenges concentrating at work and at home. When she concentrates on important issues, she constantly remembers her problems.
Stimulus barrier: She has fluctuating moods that affect her ability to work and relate with her family and friends. Her children feared her while her husband filed for a divorce.
Defensive functioning: A defense describes the unconscious attempts by ABC to protect her-self from reality. ABC uses denial and regression. ABC denied that she has a drinking problem and tried to explain that she has always been a good daughter to her parents and that she was a good mother to her children. Also, ABC attempts to regress to an earlier phase in her life before she was incarcerated and refusing to accept that her incarceration caused significant changes not only in her life but also in her family.
ABC has a tripartite personality according to Freud's structural theory consisting of the Id, ego, and superego. As a way of coping with her condition, ABC indulges in alcohol abuse and excessive sexual drive. According to Freud, the Id is irrational, and a person feels pleasure after achieving its demands. On the other hand, ABC's superego consists of all the morals and values she learned from church, the society, and her parents. It includes her moral values, and that is why she feels very guilty because she was incarcerated. Also, ABC's ego attempts to mediate between her superego and Id. While the Id is unreasonable and chaotic, ego focuses on reason and seeks reasonable ways of satisfying the Id's needs. For instance, ABC seeks to solve her clinical depression. Her Id is irrational, and it causes her to have an alcohol problem while her superego makes her feel guilty because of her actions. ABC's ego influences her to seek medical help so that she can satisfy her inner need of treating her clinical depression and solving her internal and external problems.
Erikson’s Psychosocial Stages and Freud’s Psychosexual Stages
According to Erikson's Psychosocial Stages, ABC is still struggling with autonomy vs. shame and doubt. It is the stage where children learn to assert their independence by learning how to make decisions such as what to eat, and walking away from their parents. Erikson insisted that it is vital for caretakers to allow children to explore their abilities while creating an environment that is tolerant of failure. Although a parent should encourage their child to become independent, they should continuously support the children so that they can avoid constant failure. If children are constantly supported and encouraged about their increased independence, they become more secure and confident about their abilities. However, if they are not given an opportunity to assert themselves, are overly controlled, and criticized, their lack of independence projects to adulthood as observed in ABC. ABC lacks self-esteem, is overly dependent on parental approval, and doubts her ability to come up with solid choices.
According to Freud’s Psychosexual Stages, ABC is struggling with fixation in the oral stage. In the oral stage, the main source of interaction is through the mouth. Furthermore, infants feel pleasure because of oral stimulation through certain activities such as sucking and tasting. During the stage, the child is primarily dependent on caretakers and is required to feed the child. Additionally, children develop a sense of comfort and trust attributed to oral stimulation. The main conflict in the stage occurs during weaning when the child is forced to become less dependent on their caretakers. However, ABC seems to have experienced fixation at this stage, and that is why she has issues with aggression and dependency. She did not learn to make independent choices, and that is why she still seeks parental approval in adulthood.
Object Relations Theory
Donald Winnicott
ABC's condition can be evaluated using Winnicott's ‘Good Enough' mother theory. Winnicott stated that a normal devoted mother is not perfect and would seek to make amends in caring for her children ( Winnicott, 1986) . When she makes mistakes, she seeks to make readjustments and repairs that would improve her interactions with her child. According to the observation, ABC made a mistake of emotional outbursts with her children, and she is trying to repair the relationship through therapy.
In addition to ‘good enough' parenting, Winiscott's false self and true self can also be used to explain the ABC's situation. Winnicott insists that a child's emotional development is vital in a child's development and environmental failure can have a devastating impact in childhood. When a ‘not good enough' mother is unable to respond properly to a child's spontaneous behavior or true self, she tends to impose hew personal desires and wishes on the child ( Masterson, 2018) . Such actions may cause a child to adapt to their parents’ wishes and desires through compliance or false self. Later in adulthood, the child losses personal integrity and autonomy as observed in ABC.
Harry Guntrip
Guntrip insists that people are shaped by experiences from infancy ( Guntrip, 2018) . He explains that emotional nurturing has a bigger impact on a child’s character than their biology. How caretakers or parents express love to their children is essential to the personal and emotional development of a child. If parents fail to recognize the significance of a child’s emotional development, they also fail to appreciate the child’s individuality and uniqueness ( Guntrip, 2018) . Children who grew up in such environments may enter adulthood as victims of failed attachments and are at high risks of experiencing low self-esteem, depression, anxiety and an inability to have satisfying and close interpersonal relationships as observed in ABC ( Guntrip, 2018) .
Due to the controlling nature of ABC's parents, she failed to develop autonomy, and she became entirely committed to her parents and failed to form satisfying and close relationships with her children and husband. Due to her childhood experiences, ABC is unable to become truly attached to other people including her husband and children. Similar to Guntrip's experiences, love in ABC's home was dependent on her ability to comply with her parents' wishes who had domineering personalities and ABC's personality was not given space and room to develop. With time, ABC's need for intimacy was completely overpowered and disowned. It was her young mind's defense mechanism against her parents' domineering personalities.
Self-Psychology
According to Kohut’s self-psychology concept, ‘self’ should be the primary factor in a person’s life ( Kohut, 2009) . When a child's development surrounding or environment is appropriate, they will develop a healthy sense of themselves, and they will maintain consistent experience and patterns into adulthood through self-regulation ( Kohut, 2009) . However, when individuals fail to develop a healthy sense of self, they are highly likely to depend on others to satisfy their individual needs. As observed in ABC's situation, she is dependent on her parents and family's approval to satisfy her needs. Furthermore, self-objects are a significant part of a child's developmental process. However, after healthy development, self-objects can be internalized, and individuals will develop an ability to satisfy personal needs without seeking external approval ( Kohut, 2009) . However, ABC was unable to internalize self-objects, and it is the reason why she constantly seeks satisfaction through her parents and family's approval.
Notably, Kohut insists that transference insists that transference plays a crucial role in self-psychology. He explains transference as the process where an individual in treatment redirects their desires and feelings experienced in childhood to a new object ( Kohut, 2013) . Additionally, he explained that there are three types of transferences that indicate unsatisfied self-object needs: mirroring, idealizing, and twinship ( Kohut, 2013) . Mirroring describes a type of transference where other people act as a reflection or mirror that indicates self-value and worth ( Kohut, 2013) . In such a case, ABC uses other people to evaluate her self-value and worth. In idealizing, people often need other individuals who will allow them to feel comfortable and calm ( Kohut, 2013) . As observed in ABC, she constantly seeks her parents’ so that she can feel comfortable and calm. In twinship, people desire to experience a sense of likeness with other people ( Kohut, 2013) . ABC seeks to modify her behavior so that it can mimic her parents’ behavior and expectations.
Furthermore, Kohut argued that narcissism is an integral part of a child’s development ( Kohut, 2013) . He added that such tendencies should be encouraged in childhood so that as they develop, children realize that they had inflated perspectives about themselves and their parents ( Kohut, 2013) . When children develop a healthy level of narcissism, they are highly likely to weather disappointment and frustration leading to a more resilient and secure self. However, insufficient parental empathy may cause a child to develop a narcissistic personality ( Kohut, 2013) . A parent exhibits insufficient empathy when they do not adequately nurture or react to a child’s needs while failing to meet the self-object needs of their children ( Kohut, 2013) . When a child’s self-object needs are unmet in childhood, they are at risk of failing to meet their self-needs in adulthood ( Kohut, 2013) . According to ABC’s condition, her parents failed to meet her self-object needs in childhood, and it made her unable to meet her self-needs in adulthood.
Cognitive and Behavioral Theory
ABC's primary distorted thinking is that her happiness is dependent on fulfilling the needs of other people. Whenever she failed to meet the needs of her parents and family, she became depressed. Cognitive behavioral therapy (CBT) is essential for ABC to understand how her feelings and thoughts affected her behavior. During the treatment, she will learn how to identify and modify disturbing and destructive thought patterns that have an adverse impact on her emotions and behavior. The objective of CBT is to teach patients that although they cannot change or control their environment or world, they have significant control over how they interpret and react to particular factors in their environment.
Notably, one of the key elements if CBT is modifying negative thoughts that greatly contribute to anxiety, difficulties, and depression, some of ABC's negative thoughts have existed since childhood, were accepted as true, and adversely affected her emotions and behavior. Through CBT, the patient will identify and analyze such thoughts while looking for alternatives or options that refute such negative thoughts. By finding alternative or positive thoughts, ABC will develop a more realistic and objective look at the factors that caused her feelings of anxiety and depression. As ABC becomes aware of the unrealistic and negative thoughts that influence her moods and feelings, she will gradually develop healthy thinking patterns. The most effective therapy for ABC is multimodal therapy that focuses on treating the psychological issues affecting the patient by focusing on seven different but interconnected issues affecting ABC such as drug considerations, behavior, interpersonal factors, cognition, affect, imagery, and sensation.
Relationship between Worker and Client
The relationship between the client and me has been stable and cordial. The client has been quite honest and open about her experiences. Furthermore, she insists that due to therapy, her relation with her children is improving and she is seeking to win back her husband although she thinks it will be a tough task. During therapy, there was a transference reaction from the client where she always sought my approval when making choices. Moreover, she used to be quite happy when I was satisfied with her progress. While working with the client, I was sad initially because of the impact of childhood experiences on ABC's relationships with her family in adulthood. However, her determination and progress under therapy made me quite happy, and I understood the role of cognitive and behavioral therapy in assisting people to overcome negative childhood experiences. Subjective countertransference occurs from personal history and issues rather than the client's history and issues while objective countertransference occurs due to the client's personal history and issues. One of the countertransference reactions that I need to explore is my childhood experiences and how they affect my relationship with clients.
While working with the client, I remembered many childhood experiences. Although my parents were not religious, they also had domineering personalities. They were quite strict, and I sought their approval by always complying with the rules. However, as I grew up, I realized that I had spent my entire life seeking satisfaction through my parents' happiness. I had lost my personality and could not make independent decisions without evaluating whether my parents would approve my choices. The countertransference reactions made me quite close Owith the client because I understood her situation. Due to my experiences, the client became more open and honest during our interactions, and she looked up to me for guidance throughout her treatment.
References
Guntrip, H. (2018). Schizoid phenomena, object relations, and the self . Routledge.
Kohut, H. (2009). The restoration of the self . University of Chicago Press.
Kohut, H. (2013). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders . University of Chicago Press.
Masterson, I. (2018). Winnicott and Parenting. Retrieved from https://iahip.org/inside-out/issue-24-spring-1996/winnicott-and-parenting
Winnicott, D. W. (1986). The theory of the parent-infant relationship. In P. Buckley (Ed.), Essential papers in psychoanalysis. Essential papers on object relations . 233-253.
