Clinical Theory Assessment, Planning and Intervention Methods

SW6425 Professor Nan Van Den Bergh

Ego Psychology

Ego Psychology Assessment: Ego Functions

• Ego Functions: – Reality Testing– Judgment– Sense of identity– Impulse control– Object Relations– Thought processes– Regression in Service of the Ego– Stimulus regulation– Defense Mechanisms– Autonomous functions

Ego Psych Assessment :Defense Mechanisms

• Denial• Displacement• Intellectualization• Introjection• Isolation of affect• Projection• Rationalization• Reaction formation• Regression• Repression• Somatization• Sublimation

Ego Psych Assessment: Psychosocial Development

• Awareness of developmental stage, i.e. according to Erikson, and mastery of developmental tasks, to date

EGO Psych: Intervention Goals

• Overall purposes of intervention:– 1) Acquire problem solving and copings skills– 2) Achieve insight through reflection about strengths, limitations, and

potential resources

• The above is achieved by:– Enhance ego functioning by building new ego strengths or enhancing

existing ego strengths (includes greater self understanding)– Modify or change environmental conditions– Improve “goodness of fit” between a person’s ego capacities and

environmental conditions

Ego Psychology Intervention Strategies

• EGO SUSTAINING• Exploration, description, ventilation: elicits clients thoughts

and feelings• Sustainment: empathic, active listening and encouragement• Person-Situation reflection• Advice and guidance (direct influence)• Partializing• Education• EGO MODIFIYING• Developmental reflection

OBJECT RELATIONS

OBJECT RELATIONS: Assessment

• Assessing is similar to ego psychology except for placing a closer focus on object relations

• Areas to assess:– Preliminary assessment of relational patterns. Positive relationships

with some? Or, are all close relationships conflictual?– Are relationship patterns rooted in present reality or is an old

relationship being repeated?– Do client’s behavior repeat early experiences with parents?– Do client’s behaviors represent efforts to master old traumas by

repeating them with other people?– Do client’s behaviors reflect accurately what occurred in childhood or

are memories distorted?

OBJECT RELATIONS: INTERVENTIONS

• Similar to ego psychology but a greater emphasis on:– Sustainment: worker must be able to sustain a positive clinical

relationship through periods of client anxiety, resistance, confrontation and limits’ testing

– Developmental reflection: explore developmental history and developmental milestones

• Early treatment: – Provide “holding environment to reproduce early parenting

experiences– Practitioners interpret patterns of behavior suggesting's their origins,

intentions and effects– Uses therapeutic relationship to show that relationships can survive

periods of conflict and negative interactions

OBJECT RELATIONS: INTERVENTIONS (cont.)

• Middle Stage:– Interprets clients maladaptive defenses such as splitting and projective

identification– Helps client to look inward to understand feelings and attitudes she is

trying to disown and project

• End phase:– Client helped to resolve major interpersonal conflicts and overcome

developmental arrests– Client is guided to corrective experiences with people in her own

environment– Opening explore the meaning of the ending of the relationship

• Review positive gains that have been made

Self Psychology

SELF PSYCHOLOGY: MAJOR ASSUMPTIONS

• Sense of self and self esteem are dependent on the quality of relationship s with parental figures who serve as self-objects

• Self-objects are persons who are experienced intrapsychically as providing an enduring sense of availability, which fosters the developing self

• Three important self-object relations– Mirroring self-object: recognizes a child’s unique capacities and talents– Idealizing self-object: an admired caregiver– Twinship self-object: provides a sense of sameness with the self object

that is essential to growth, attainment of skills and competence

• Self-objects perform adaptive functions of soothing and tension regulation

SELF PSYCHOLOGY: MAJOR ASSUMPTIONS (cont.)

• Transmuting internalization: person is gradually able to perform soothing and tension regulation tasks by herself

• When child does not have important self-object experiences, internalization of psychic structures cannot occur

• Shame and humiliation result from ongoing self-object failure• Individuals fears his expression of needs will diminish self-

object experiences– Result is falsely complying with the needs of other at the expense of

the development of the true self

• Merger bond is created that is an accommodation to the needs of the self– Failure to accommodate leaves the individuals feeling isolated and

depressed with no self-object support

SELF PSYCHOLOGY: MAJOR ASSUMPTIONS

• Early narcissistic needs are unmet– Person involved in an ongoing search for self-object experiences that

will provide what is lacking

• As the self becomes more strengthened through self-object responsiveness via therapeutic relationship, person is less shameful of self-object needs– Enables person to give without feeling anxiety about the needs of

another

• Self psychology defines maturity as the availability to evoke and engage in mutually enriching self-object relationships with others

Self Psychology Assessment

• Does presenting problem seem related to impaired sense of self?

• What is capacity of client to engage in self-soothing behaviors?– Lack of self-soothing suggests failure in capacity for transmuting

internalizations– Transmuting internalizations mean ability to take on care providers

mirroring and idealizing when by oneself

• Much emphasis on therapist’s awareness of dynamics within the transference/countertransference dynamics– What is it that the client appears to need through the relationship?

Self Psychology Assessment: Diagnostic Criteria

• Narcissistic disorder( DSM IV): pervasive pattern of grandiosity, need for admiration and lack of empathy that begins by early adulthood

• Diagnostic criteria for narcissistic personality disorder:– Grandiose sense of self importance– Preoccupied with fantasies of unlimited success, power, brilliance, beauty or

ideal love– Believe is one’s specialness and sense of only being understood b y other

special people– Requires excessive admiration– Sense of entitlement– Interpersonally exploitative– Lacks empathy– Envious of others and believes other are envious of him– Demonstrates arrogant, haughty behaviors or attitudes

Self Psychology Interventions

• Therapeutic goal: building internal psychic structures that enable the individual to move from early , narcissistic or self-referenced needs to attachments based on empathic connections appropriate to developmental stage

• Via empathy as the tool, therapist gathers psychological information– “vicarious introspection” is the ability of the therapist to investigate the

inner world of the patient

• The goal of treatment is to enhance the patient’s self esteem and restore her to a level of functioning prior to the loss of a self-object– Loss of a self-object weakens the sense of self and engenders

symptomology

Self Psychology Interventions (cont.)

• Through empathic investigation, therapist provides mirroring, idealizing and twinship functions

• Therapist offers needed self-object responsiveness which restores self-cohesion, and decreases symptomology

• Therapist helps patient appreciate the legitimacy of needs/feelings , promoting self awareness, understanding and self-acceptance

• Exclusive focus on client’s experience not helpful– Therapist needs to share her experience of the client, with the client

Self Psychology Interventions (cont.)

• By merging with calmness and competence of therapist, via transmuting internalizations client can develop capacity to:– Self soothe– Self-comfort– Empathize

• “Empathic failures” by therapist enable client to tolerate frustration and generate more mature psychic structures

• Rather than earlier needs for mirroring, idealizing and twinship, client can choose emotionally sustaining self-objects and provide such experiences to others