Case Conceptualization - JACQUELINE
Case Study: Jacqueline
Overview of the Case
The case is about a 48 year old woman who is struggling about the situation she is experiencing in terms of personal matters. The client is a divorced fashion consultant who underwent a radical mastectomy because of the discovered malignant tumor on her left breast. Being a very well known individual from her high school life and from her work because of her beauty, Jacqueline is now struggling about what had happened to her which affects the way she perceived herself and the way she interact with other people including her daughters.
This client was chosen for the following areas of interest: (a) her perception to herself and (b) her social behavior. Through a relation model, I will be using Object Relations theory in my analysis of my work with this client. I intend to develop hypotheses regarding the problems and issues encountered, to enhance awareness of how her health condition has influenced the quality of behavior and her relationships with her family, specifically her family and parents. In addition, this will also attempt to determine some counter-interference issues that must be considered which may hinder the efficient treatment for the client.
In this case, the existing problems that can be considered are the problems of the client regarding her health condition which affects the way she interact or relate with other person. In addition, the problem of the client is in line with the way she perceives herself. Being a gorgeous lady, Jacqueline felt that she has turned into an ugly and old woman who affects her behaviour and self-confidence and self-esteem.
Analysis of the Problem
The client, as described above, is a 48 year old woman who is experiencing problems in terms of her social behavior and her family relations as well as her self perception. As mentioned Jacqueline had her surgery for mastectomy and this has been the major caused of her outlook in life. From being a gorgeous lady, Jacqueline is now living in a misery for the incompleteness in her. Aside from this, the problem of Jacqueline is rooted from her believed that she will not be accepted by people who know her before. This thought triggers depression and frustration in the part of the client.
The client was self-referred for a consultations part of the post-surgical management of the healthcare provider to help herself adjust to her situation and to prevent further problems. She presented with a flat affect and expressed anxiety related to interpersonal situations and tasks. Interpersonally she was withdrawn and socially isolated. Behaviorally she was inactive, unable to socialize with other people.
The client’s psychosocial functioning was somewhat impaired by the interaction of her health condition and her methods of coping. The client struggles throughout her relationship with her daughters and colleagues. Depression was ever-present and unwelcome companions.
In the development of personality, some authors found that the notion that people in having different problems is because of three issues: (1) the inability to trust oneself and others, the fear of loving and forming close relationships, and low self-esteem; (2) the inability to recognize and express anger, the denial of one’s own power as a person, and the lack of a sense of autonomy; and (3) the inability to fully accept one’s sexuality and sexual feelings, and difficulty in accepting oneself as a man or woman. According to the Freudian psychoanalytic view, these three areas of personal and social development – love and trust, dealing with negative feelings, and developing a positive acceptance of sexuality – are all grounded in the first 6 years of life.
The focus at the commencement of therapy was to create a safe, supportive, and non-judgmental environment in which to talk and to alleviate the client’s feelings regarding her situation; how it contributes and influences her situation as well as her subsequent adjustments with her relationships. I present three conceptual additions to the model and probably based my work upon them: (a) describing the experiences of the client through the use Kohut self-psychology through mirroring self-object early in the therapy.; (b) examine the client’s problematic experiences using dialogical sequence analysis, an intensive method for studying the moment-to-moment process through the psychosocial aspect of depression and Bowlby’s attachment theory; and c) I extend the developmental stages to describe the inter-subjective exchange between client and therapist by introducing Winnicott object relation theory.
First, Kohut (1984) implies that providing mirroring self-object experiences early in the therapy will be a great factor for its success. Kohut's work has formulated into the investigation of self-object experiences. This experience which is usually with other people that encourage the self and which give meaning to the experience of the self as well as self-esteem. Through the analysis and investigation of the background of the service user (client), it shows that her experiences from her situation, made her self-esteem became lower because of her feeling that no one in the society will fully accept her and her condition. Furthermore, clinical experiences with patients who had idealizing or mirroring changes led to initially observe that there were two types of self-objects. These include those that respond to an approval that the child’s innate sense of vigour, greatness and perfection which is mirroring). The mirroring transferences rooted from repeated and relative mirroring failures of the clients or parental substitutes that happened during the client’s childhood. Accordingly, it is as if the client is missing a part of her and is in need of other people to ensure her self-esteem. For instance, Jacqueline has no other fond memories with her parents or mother except during the time when the mother is dressing her to enhance her looks. During this stage, the client continuously turns to the support of the therapist’s or social worker’s response so as to identify how important and worthy she may be. The client tries to seek approval and affirmation from other people to overcome her sense of anxiety. Apart from mirroring, the other form is the idealizing transference which includes those people to whom the client can look up for support and with whom the service user can merge as an image of calmness, infallibility and power or influence. But, this session had focused only to the use of mirroring in assessing the problems of the client by which the client’s position is to view herself upon her own experiences or situations.
Second, Bowlby (1988) in his attachment theory advances a multidisciplinary stance in which psychoanalysis is integrated with ethology and socio-biology, psychobiology, the cybernetic theory of control systems and modern structural approach to cognitive development. Affectional bonds are formed as a result of interactions with the attachment figure, that is to say, between child and parent or partners. Emotional life is seen as dependent on the formation, maintenance, disruption, or renewal of attachment relationships. In acquiring this theory in this study, it has evidently shown that the depression that the client had faced was due to the reason that her relationship with her family is struggling and that her relationship with both her parents during her childhood is not that tight. She has a problem within her situation due to her perception that nobody really cares and loves her and nobody really understands her current situation even her children. Her relationship with her children is a reflection of what she had been during her childhood with her mother.
Third, Winnicott (1965) stresses the importance of establishing the holding environment. Object relations theory is an offshoot of psychoanalytic theory that emphasizes interpersonal and social relations, in the client’s history, she is depressed by the fact that she cannot lived up with her relationship with her ex-husband and the lack of support from her parents. Object Relation Theory (Winnicott, 1965) used in this study aims to identify the significant person that is the object or target of another's feelings or intentions of the client which is nonetheless, her daughters, ex-husband, and her parents. With the analysis of the client’s depression she is longing for interpersonal relationns that would allow her to feel what she had missed with her relationship and this suggests that the residues of her relationships really affect her being at the present. Object relations theorists are interest in inner images of the self and other and how they manifest themselves in interpersonal situations.
In order to some the issues of the counter-transferences mentioned earlier, treatment will focus on establishing the therapeutic alliance so that the client felt safe in exploring her relationship with her mother and its effect on past and her current issues (attachment issues). Emphasis will also be placed on providing a holding environment and providing mirroring self object experiences early in the therapy and the intersubjectivists). As therapy progressed, the focus on treatment will is the elucidation of character structure (personality) and the defenses constructed by the client to regulate affect and to protect against re-traumatisation. Mirroring, idealizing, and self-delineating self-object experiences will also be provided. In the first 6 months, focus will be on affect recognition, discrimination, and tolerance, a focus that will be diverted by the health conditions.
This study draws on the work of Kohut, Winnicott, and others to emphasize and integrate central themes in the case of the client. Those themes were explored through the process of mirroring. The visual and sensory power of the image deepens the my understanding to the problems that the client is facing and brings her back to life through in the daily clinical practice. Within the following sessions, the work was done by the use of self psychology and object relations theory to know the client’s holding environment and containment, her transitional space and her transitional objects. In the following weeks as the monitoring continues, the aim of treatment became the illumination of the nature and functioning of the personality of the client in context of herself regarding her personal relationships; to understand the client’s disturbed part, i.e. antisocial, functioning of human nature (defenses); her aggression and inability to love and co-operate consistently; and her tendency to disrupt the socialized community life she so much needed (Bowlby,1982, Kohut,1984,Winnicott,1965), mirroring, idealization and twin-ship, the self and internal objects.
Bowlby, J 1988, a secure base: Parent-child attachment and healthy human development. New York: Basic Books.
Hallett, C. (ed), 1989. Women and Social Services Departments. Wheatsheaf, Hemel.
Homer A 1984, Object relations and the developing ego in therapy. New York: Aronson.
Kohut, H 1984, How does analysis cure? Chicago: University of Chicago Press.
Winnicott, D 1965, The Maturational Processes and the Facilitating Environment. Madison, CT: International Universities.
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