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The Use of Object Relations Theory in Clinical Social Work Practice

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The Use of Object Relations Theory in Clinical Social Work Practice THE USE OF OBJECT RELATIONS THEORY IN CLINICAL SOCIAL WORK PRACTICE A CASE STUDY ELIZABETH KATHERINE WELCH University of Cape Town SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SOCIAL SCIENCE (CLINICAL SOCIAL WORK) IN THE DEPARTMENT OF SOCIAL DEVELOPMENT, UNIVERSITY OF CAPE TOWN, SOUTH AFRICA. 2004 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town DECLARATION OF ORIGINALITY. I hereby declare that the whole of this thesis, unless specifically indicated to the contrary in the text, is my own original work. }I� /0 2,6)04, ELIZABETH KATHERINE WELCH UNIVERSITY OF CAPE TOWN, SOUTH AFRICA. ABSTRACT. The purpose of this study was to explore the value of a particular theoretical framework in terms of several issues relating to clinical social work practice. The selected theoretical framework was that of Object Relations theory, specifically the works of Melanie Klein and Margaret Mahler. The method of inquiry was that of a single case study. The investigation centred around the theories' usefulness in clinical social work practice regarding: assessment, particularly in terms of the development of insight into and understanding of human psychological development, and guiding practice and informing intervention. The selected theoretical framework was also evaluated according to: its sufficiency, in and of itself, and the extent to which its utilization facilitates avoidance of stereotyping and pathologizing. The study was undertaken in a psychiatric unit, run according to the principles of a therapeutic milieu, in a local hospital. The subject of the study had been admitted to the unit after a para­ suicide attempt. He manifested many of the affects and behaviours associated with Borderline Personality Disorder, and was a transsexual who had undergone reassignment surgery. On ­ going assessment and intervention were undertaken in the residential unit on an individual basis and in group activities. Reference to literature, the writings of Klein and Mahler in particular, was a crucial and essential aspect of the study. The selected theoretical framework was found to be of great value in terms of the development of insight into and understanding of human psychological development, which in turn aided the assessment process. Whilst neither Klein nor Mahler wrote extensively or specifically of intervention , a model compatible with their opinions was identified in the literature and effectively used for this purpose. The approach used, both from a theoretical and a practical standpoint, encouraged expression and maintenance of individual uniqueness. The study highlighted the importance of a sound theoretical knowledge base underpinning clinical practice, particularly when practitioners are challenged by difficult cases. In addition, the need for practitioners to assume responsibility for continued dynamic learning, and the significant role of supervision were apparent. Further avenues for study and research were also identified. ACKNOWLEDGEMENTS Fortunately a journey such as this is not walked alone and I am therefore indebted to many for their support, encouragement and help along the way. Firstly I wish to extend my thanks to "Herman" for permitting me to make use of his material and our experience for the purposes of this study. With reference to Bion's injunction about time being limited and for us to not to rely on looking in books for the answers but rather to read people (Casement, 1990), I am grateful for all that I learned from our relationship, perhaps particularly from those instances when the going became really tough. I wish you well and may you find some of that for which you are searching. Lily Becker, my supervisor, opened the door to the world of Object Relations Theory for me, for which I am delightedly thankful. Exploration in this arena has presented new vistas for understanding as well as enriching my practice as a clinical practitioner. My thanks too for her support, enthusiasm, reassurance, belief in my ability and work, and guidance, as well as her patience. From the Department of Social Development at the University of Cape Town I enjoyed unwavering support from Elfie Sanson and Pat Halford, whose encouragement I sincerely appreciate. Linzi Rabinowitz assisted me in understanding the complexities of postmodernism and deconstructionism, and Roland Graser provided guidance in terms of methodological issues. I am most appreciative of their contributions to the development of my knowledge and understanding. Andre de Vos, my colleague and friend, has been a fellow traveler on this journey. Throughout he has been unstinting in his support, encouragement and understanding. Although he reached the finishing line of this marathon ahead of me, he has remained on the sidelines to cheer me on my way. I am truly grateful for all that he brings to a valued friendship. I have also been most fortunate to have had great support and encouragement from Dr. Gillian Graham in both my personal and professional growth. Her unfailing interest in and guidance of my development has been of inestimable value. I thank the staff of the therapeutic milieu who were present during my internship for their support and assistance. I am grateful to them for much of what I learned during that time. Special thanks are due to Chari Hattingh for his encouraging support throughout the course of this study, and for proof-reading the final draft and assisting with editing. My gratitude is also extended to Trish Southwood in this regard. I am most appreciative of the time they both devoted to this task and their useful input. Others not directly involved in this study have also helped to sustain me over the many, many months, and for this I thank them: my parents, sister and family who have unreservedly supported me in my endeavours with a belief in my ability to rise to the challenges of this study, and to complete it; and Sarah Goldstein and Ingrid von Stein who have proved to be good friends through their quiet support, knowing when to leave me be to continue with my work and when to be there as a necessary distraction. Finally but certainly by no means least, my four-footed, furry friends who have been a constant source of companionship and solace through the long, lonely hours. Their unconditional devotion and constancy are treasured gifts which I value greatly. I wish to dedicate my efforts in this study to the loving memory of my late husband, Dr Gary John Welch , former professor of social work at the University of Durban, Kwa-Zulu Natal. He taught me the value and importance of practice being guided by theory. TABLE OF CONTENTS Abstract Acknowledgments Chapter One - Introduction 1 Background to and Rationale for the Study • The Research Problem 2 • The Research Objectives 2 The Research Questions 2 Overview of the Research Design 2 Terminology 3 Overview of the Report 4 Chapter Two - Literature Review 6 Object Relations Theory 6 Origins and Overview 7 Melanie Klein 8 Developmental Stages and Associated Concepts 10 Problems and Pathology during Development 18 Margaret Mahler 21 Developmental Stages and Associated Concepts 21 Problems and Pathology during Development 27 Childhood Experiences Contributing to the Development of Borderline Personality Disorder 33 A Multifactorial Model 34 The Family and Social Environment 35 / Childhood Traumas and Abuse 35 -./Disturbed Parental Involvement 41 Family Types and Defense Mechanisms 41 vi>arental Loss and Separation 45 II Development of the Concept of Borderline Personality Disorder 47 Historical Overview 47 Current Trends 48 • The Clinical Perspective of Borderline Personality Disorder 50 Affect 50 Behaviour 54 Psychosis 55 Intrapsychic Phenomena 56 Ego Functions 56 • The Transference 58 Definition 58 Origins and Development of the Concept 59 Klein's Perspective of the Transference 60 • The Countertransference 69 Definition and Development of the Concept 69 Basic Types of Countertransference 71 Additional Types of Countertransference 71 Therapeutic Interventions 73 Models of Intervention 73 The Integrative Perspective 75 Transsexual ism 81 Definition 81 Prevalence 81 Developmental Stages and Clinical Features 82 Specifiers 84 Types of Transsexualism 84 Gender Features 85 Causative Factors 85 Transsexualism and Pathology 86 Interventions 87 Chapter Three - Methodology 90 Research Design 90 Characteristics of the Research 90 Stages of the Research 91 Objectives of the Research 92 iii Measures Used 92 Study Population 93 • Data Collection and Analysis 94 Philosophical Framework 94 Data Collection 99 Data Analysis 100 Therapeutic Intervention 100 Assessment of Strengths and Weaknesses of Methodology Used 101 Weaknesses 102 Strengths 103 Ethical Considerations 103 Informed Consent 104 Violation of Privacy 104 Actions and Competence of Researchers 105 Release of Publication of the Findings 105 Reflexivity 105 Chapter Four - Case Study 107 Introduction and Background Information 107 Reassignment Surgery 110 Admission to the Therapeutic Milieu 111 Course of Hospitalization 112 • Regressed Behaviour 115 Defense Mechanisms Utilized 116 The Transference 118 The Countertransference 119 Destructive Behaviour 121 Chapter Five - Discussion 124 • Object
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