Psychoanalytic Case Formulation: Attachment Styles and Ego Defenses

1. Psychoanalytic Case Formulation:Attachment Styles and Ego Defenses Vanessa Snyder Regent University

2. Introduction to Psychoanalytic Case Formulation • Dr. Nancy McWilliams: • Professor at Rutgers University • Author: • Psychoanalytic Diagnosis • Psychoanalytic Case Formulation • Psychoanalytic Psychotherapy: A Practitioner’s Guide • Associate Editor: • Psychodynamic Diagnostic Manual 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.

3. Introduction to Psychoanalytic Case Formulation: Nuts vs. Not nuts or How nuts? In what particular way? McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press.

4. Case Formulation Protocol • Intake/Interview • Assessment: • Things that cannot be changed • Developmental issues • Ego defenses • Affect states • Identifications • 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.

5. Assessing Developmental Issues:Think Developmentally!! Sigmund Freud Erik Erickson John Bowlby Mary Ainsworth

6. Freud: PsychosexualErickson: Psychosocial Psychosexual Stages Psychosocial Stages Trust vs Mistrust Autonomy vs Shame/Doubt Industry vs Inferiority Identity vs Role Confusion Intimacy vs Isolation Generavity vs Stagnation Integrity vs Despair • Oral Stage • Anal Stage • Phallic Stage • Latent Stage • Genital Stage 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/dGFKAfixHJs

7. Attachment Theoryand 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 theory: John bowlby 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: 10.1177/0011000095233001

8. Assessing Attachment Style • Secure Attachment (Autonomous) • Insecure Attachment: • Resistant or Ambivalent (Anxious – Preoccupied) • Avoidant • (Dismissing) • Disorganized/disoriented • (Unresolved/disorganized) Mary Ainsworth: Attachment and the Growth of Love (Davidson Films). Retrieved from http://youtu.be/SHP_NikTkao Wallin, D. J., (2007). Attachment in Psychotherapy. New York: The Guilford Press.

9. Attachment Style What is attachment theory? Retrieved August 27, 2011 from http://www.terrifictop10lists.com/articles/attachment.html

10. Assessments • Thorough History-taking • Genogram • Adult Attachment Scale • Adult Attachment Interview • Attachment 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

11. Theological Positioning on Attachment Attachment theory may be an appropriate framework for a believer's relationship with a God figure. One's attachment to God resembles 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.edu

12. Assessment of Defensive Processes Primary (Primitive Secondary (Higher order) Anna Freud: Ego Psychology McWilliams, 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.x

13. Primary Defense Mechanisms Lower Order Boundary between the self and the outer world To qualify: reality principle not attained “Lack of appreciation of the separateness and constancy of those outside the self” (McWilliams, 1994, p. 98)

14. Primary Defense Mechanisms • Primitive Withdrawal* • Denial* • Omnipotent Control* • Primitive, Idealization, and Devaluation* • Projection & Introjection* • Identification • Splitting of Ego* • Dissociation* McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press.

15. 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.

16. Secondary Defense Mechanisms • Repression* • Regression • Isolation* • Intellectualization* • Rationalization* • Moralization • Compartmentalization • Undoing* • Turning against the self • Displacement* • Reaction Formation* • Reversal • Identification • Acting Out* • Sexualization • Sublimation McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press.

17. Assessments • Defense Style Questionnaire • Personality Assessment Inventory • Derogatis’ Symptom Checklist 90-R • California Psychotherapy Alliance Scale Azibo, 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.edu Bond, 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.org

18. Multicultural Perspective Azibo (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.

19. 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.

20. Conclusion Case Studies, Teaching assignments And For further information…

21. Teaching Activity 1Insight Exercise: How do I defend my “self”? • 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?

22. Teaching Activity 2:Attachment & God Image 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.

23. 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.

24. Case Study (2) • 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)

25. Discussion Guide Instructions: 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/UpL3ncoK99U 2) First meeting: http://youtu.be/JQf7O3GeHVk 3) Park Scene: http://youtu.be/qM-gZintWDc 4) It’s Not Your Fault (Note: syncing is off): http://youtu.be/pF6-JUohCWg 5) You Won’t Be There: http://youtu.be/gGX6KbworY8 Questions 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??