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Transcript

A.M. LMFTA

Case Conceptualization

The Patient: "Jack"

The Patient

History Taking + Presenting Problem

Male - Age 64

History of Anxiety and Depression

Wife passed from Terminal Cancer in 2021

Two children with wife, adults

Grandfather to two with another on the way

Jack comes from a family of origin where his father was a minister. He grew up with a focus on faith, community, and family. Jack is the youngest in his family and is many years behind his closest brother in age. Jack talks of his childhood in ways where he doesnt remember much, and that he often felt untrusting of his mother and her feedback to him that was positive. Jack felt his father was not "manly" enough, and his father came out as gay when Jack was an adult. Jack spent the working force years as a police officer and then a DEA agent. Jack talks about those times as the best times of his life. When Jack retired, he developed a shake in his voice that turns out was an anxious response to his leaving the work force. Jacks'sense of self was direclty correlated to the job he was doing.

Themes

1. Resolve Unresolved Grief

Targeted goals

2. Accept the loss and increase social interactions and contact with family

F43.23: Adjustment Disorder with Mixed Anxiety and Depressed Mood

Diagnosis

Initially, Jack presented with F43.23 due to the recent death of his wife and his adjustment to this. He reported increased anxiety and depression since her passing and a sense of "loss of meaning."

After working wtih Jack over the course of nearly a year, therapist has identified narcissistic behaviors and transferences. There are themes with Jack of manipulation and control, sense of superiority, lack of boundaries, splitting, and fear of rejection.

Themes of wanting to move past negative feelings quickly, wanting to avoid vulnerability, defending against vulnerablity and loss of control by engaging thearpist to answer questions about herself.

Themes of guilt and shame related to clients ideas of sex and sexuality. Themes of splitting and ambivalence. Themes of equalizing and seeking to be the most "special" patient thearpist works with.

Psychodynamic Therapy

The Theory

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Object Relations Theory

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Attachment Theory

Foundations based upon the belief that the way we are in the world is directly related to our childhood experiences and that all behaviors, thoughts, and feelings serve a function.

Psychodynamic Therapy

Works upon the belief that because our unconscious mind is directly in conflict with our conscious mind, anxiety and defense mechanisms are created.

Psychdyamic Therapy is generally a longer term process that mostly uses what happens in the "room" between the therapist and the client as the foundation for assessment. Using a "here and now" philosophy, what the client brings to session (transferecen), and the countertransference from the therapist provides insight in regards to how the client relates in their world.

1.

Psychodynamic Therapy is generally a longer term process that mostly uses what happens in the "room" between the therapist and the client as the foundation for assessment.

Using a "here and now" philosophy, what the client brings to session (transference), and the countertransference from the therapist provides insight in regards to how the client relates in their world.

Transference and Countertransference will also give the therapist insight into who the client needs them to be (Projective Identification) as a result of insecure attachment.

Psychodynamic theory seeks to link split extremes of internalized and externalized worlds so that the client can feel less need for defensees that no longer serve them.

2.

Object Relations Theory

"Object" refers to the thing that will satifsy the need; according to St. Clair, the "object" refers to the significant person or thing that is the object or target of another's feelings or drives; object refers to interpersonal relations and suggest the inner residues of past relationships that shape an individual's current interactions with people," (2004, p. 1).

1.

Object relations is essentially the study of personality development as a result of the infants relational experience with the mother.

Since past experiences and relationships (starting with the "mother") leave a residue within an indivuals psyche and predetermines how the individual will relate to others, the "inner objects" that become internalized continually manifest in current relationships. "Individuals interact not only with the actual other but also with an internal other, a psychic representation that might be a distorted version of some actual person," (2004, p. 2).

Omnipotence: Contributes to the felt sense of security and control of creation of own world thru "good enough" responses from mother

True Self: When mother can respond consistenly to the omnipotent needs of the infant, the true self can develop

False Self: Inconsistent responses or lack of response; self becomes agreeable and compliant to how mother responds and therefore cannot get needs met; results in not feeling good enough and not able to be themselves or genuine in any relationship.

2.

Attachment Theory

Attachment develops as a result of how our caregivers respond to us when we are children and the meaning we in turn make from their responses about us.

These responses are directly linked to the shaping of how we see ourselves in the world and if we are viable humans worth of care and love.

Attachment translates to a persons ablity to seek and maintain emotional bonds with others.

Avoidant Attachment

*lack of distress when separated from their mothers

*can look like the "good baby" who may never cry or seem distressed

*though they may seem calm on the service, avoidant babies heart rates and cortisol levels are as high in stressful moments of separation from caregiver as babies who may cry or scream

*avoidant babies have learned from their attachment experience that their cries for attention and need are useless as the mother has not responded to them. They have given up and detached as a way to avoid the pain and suffering from having an unavailable mother.

Anxious, Ambivalent, Disorganzied Attachment

*these attachment styles have had unpredictable yet occasionally available mothers, and therefore, the child does not know what to expect. This leads to distress and chaos. The baby does not know whether or not to trust the mother and their own instincts for love and touch upon a reunion or after a call for attention, or to instead trust their own instincts of defense and rejection so as not to be "hurt" again by the mother. These babies feel insecure about exploring their world.

*secure babies have a balance of exploration from their "secure base" and also the seeking out of comfort when they need it. When distressed, they are immediately reassured and comforted by their caregivers. Secure attachment allows for flexibility and ease where signals from baby and response from mother are smooth

Secure Attachment

Session #16

Client: You know the most comforting image to me is a beautiful woman.

Therapist: What about that is comforting to you?

Client: I saw the most beautiful woman I had ever seen on the street one day, then, I got closer, and she wasn't so beautiful after all. And I was confused. It was like, I was dissapointed because I thought she was so special. I felt sort of exposed for thinking she was so cool.

Session Transcripts

1

Therapist: Who did she remind you of?

Client: (big pause). Well.... my Susan. That's who.

Therapist: Who else?

Client: (big pause). My mother. I was always dissappointed by her. I didn't trust her. I didnt' trust that she loved me - that I was special and good and wanted. I think she lied to me a lot. Also you, I think. It's hard for me to trust you.

Session Transcripts 2

Session #16 Continued

Session #30

Session Transcripts 1

Client: I've realized that its not just an infatuation with you, it's that I"m in love with you. I want and wish to be in session every week, with you, and I dream about it in between. I feel lovesick. I want to know you. I want to know you're thinking about me, too.

Therapist: We've talked about transference before. We've talked about that when you feel vulnerable, you use your percieved feelings about me to evade the vulnerablity. What do you feel is happening now? I'm wondering how you want me to respond to you, Jack.

Client: I know you think that this is all an unconscious projection, but I disagree. I've never met anyone as brilliant or as perfect as you.

Therapist: I'm wondering if this is a test - a test to see if I reject you -I wonder if you are testing my rejction of you, my potential abandonment of you, as your wifes" death was an abandonment in itself perhaps. Perhaps I'm your connection to the way you find your grief.

Session #30 Continued

Therapist: I am wondering if you're beginning to feel too dependent on me, and this relationship. Youve idealized me, instead of being vulnerable with me. What are you feeling?

Client: (emotional) Like you're my Susan, and I miss loving her. I dont want our sessions to end. I just want to get out of my own way. Huh. Well how about that.

Session Transcripts 2

How Does Change Occur?

Change occurs when the therapist can first create a frame for the client that is consistent, including the time, place, day, fee and room of where therapy takes place. A strong frame equals a strong therapeutic alliance. When there is trust and strong alliance, deeper transference and countertransference can occur. The tracking of what the client shares and identifying the theme that is present in the clients material is one of the steps for creating change.

The Therapist

How Do People Get Better?

How do we resolve traumas and make meanings? The therapist is the containter for the client. We are the container through which we make experiences palpable to the client. Therapist is about helping clients speak the truth. We can't move on without the truth. We are the courage to name things that the client can not.

Working With Transference

*Therapist framed for client that a relationship with therapist outside of therapy will never happen

*Therapist consulted wtih supervisor to review and process

*Therapist and supervisor agreed that, for client, he seemed to be on precipice of a breakthrough from evading his vulnerablity and grief surrounding wifes death and continuing to work with him may be the best thing for the client

*Therapist checked in wtih self to ensure she felt safe and willing to continue the work

*Therapist and client met, reviewed boudnaries, and planned to continue the work together.

The Rupture

Since Session #30...

The Repair

Client has been more open, more clear, more emotional, and less dependent on therapist.

Client has allowed a deeper dive into his childhood with therapist and his feelings about his parents, uncovering his early splitting in response to his parents

Client has identifed a deeper sense of guilt and regret for how he valued his wife in his marriage and the amount of time his job took him away from her.

Jack

Jack is seeking to resolve grief but also unresolved attachment to his mother. I often feel in the room like his mother. He is looking to me to feel special, have approval, and have intimacy with that he can trust. When Jack tries to "protect" me by ensuring the office is safe, he is feeling dependent and needy - his defense becomes to be the protector instead. When Jack uses sex to evade in session, he is looking to not feel dependent and instead, be in control. Jack is constantly in defense of feeling he "needs" someone.

1.

I am listening in each session for:

1. The wish

2. The Fear

3. The Defense

For Jack, the wish is usually closeness by way of being needed, being good enough, being special. The fear is of rejection, or feeling that he may need someone. The defense is usually sex or equalizing dynamics to remind him he is powerful and in control.

Healing through Containment

2.

I must be Jacks' object as a "secure base" from which he can experience attachment differently than he did as a child. This will allow him to freely explore his conscious and unconscious mind, to uncover desires and projections, interalizations and envious feelings. To have a secure base to return to, we are actively healing the attachment wound of trusting other emotional bonds and therefore truly experiencing love and self love.

I remain nonjudgemental, curious, consistent, and empathetic while also interpreting the latent content in sessions and giving it voice. I am provacative as well as intutive. Therapy is not linear. It is an intuitive process that requires thinking, processing, and connecting. Ultimately, when client is able to re-experience difficult, painful situations in the context of an emotionally contained space, client can experience change.

Clients'projections onto and into therapist are there as unconscious impulses of directed feelings that is meant for the mother they are angry at, or the friend they are envious of. The therapist seeks to idenfity who and what they are to client, what the client is "doing" to them, and who the client wants the therapist to be.

Projections

The therapist will become "good" and "bad" objects (mother) for the client and this will allow processing of the client's past experiences. If the client is able to securely attach to the therapist, there is also a starting point for change.

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