Part I

Historical, Theoretical, and Clinical Perspectives

Chapter 1: Object Relations Theory and Self Psychology

Their Scope and Significance

A person-in-situation perspective has been a defining characteristic of social work practice historically. The social work profession has relied on numerous distinctive theoretical frameworks that help to explain the nature of person-environmental transactions during the lifelong developmental process (Goldstein, 1983). Psychodynamic theory has occupied a prominent position in this knowledge base. Although its place as an underpinning to social work practice has waxed and waned over the years (Goldstein, 1996; Specht & Courtney, 1994; Strean, 1993), it has provided practitioners with important insights into human motivation, needs, capacities, and problems and has played a major role in shaping social work practice from the 1920s to the present.

As we begin the twenty-first century, psychodynamic theory is by no means the only theoretical paradigm that is available to social workers, but it continues to have significance for social work practice. It has moved far beyond its Freudian and ego psychological base, however, and reflects newer and more diverse views of personality development and the nature of human problems. Psychodynamic thinking and treatment principles are applicable to a broad range of clients, in both short-term and long-term intervention, and across a variety of treatment modalities. This broad and varied framework can be used to complement other formulations that inform social work practice, such as ecological, cognitive-behavioral, family systems, and group theories. Evidence that psychodynamic theory has stood the test of time can be found in a study of practitioners drawn from the 1991 National Association of Social Workers Register of Clinical Social Workers. Respondents said they utilized 4.2 theoretical bases in their work, but 83 percent reported using psychodynamic or psychoanalytic theory (Strom, 1994: 80-81). Additionally, it is common for social work students and practitioners to seek to advance their knowledge of psychodynamic theory and treatment principles by taking academic courses, participating in in-service training programs, enrolling in psychotherapy institutes, and attending professional workshops and conferences.

The Assimilation of Psychodynamic Theory Into Social Work

Sigmund Freud's classical psychoanalytic, or drive, theory was the first psychodynamic framework that was introduced into social work during a period called "the Psychiatric Deluge" in the 1920s (Woodroofe, 1971: 118-51). Throughout the next several decades, Freud's writings had a dramatic impact on social workers, particularly on the East Coast, who belonged to the diagnostic school associated with Mary Richmond, Gordon Hamilton, Lucille Austin, Annette Garrett, Florence Hollis, and others (Goldstein, 1995a: 31-33). Many social work practitioners underwent psychoanalysis and sought supervision from psychoanalysts, some of whom had recently emigrated from Europe. Enthusiastic about their own treatment and educational experiences, social workers began to employ Freudian theory and psychoanalytic treatment principles in their practice (Hamilton, 1958). The only competing psychodynamic framework at this time was Rankian theory, which provided the theoretical underpinnings to the functional school associated with Jessie Taft and Virginia Robinson and the Pennsylvania School of Social Work (Brandell & Perlman, 1997; Goldstein, 1995b).

The Expansion of Psychodynamic Theory

Beginning in the late 1930s and especially after World War II, Freudian theory underwent major modifications and transformations as social workers began to become familiar with ego psychological writings. Throughout the 1950s to the 1970s, ego psychology, which focused on the more autonomous and rational aspects of the ego, led to major changes in the diagnostic approach and its successor, the psychosocial model. It also contributed to Perlman's problem-solving approach, crisis intervention, the task-centered approach, and the life model (Brandell & Perlman, 1997; Goldstein, 1995a & b; and Strean, 1973).

In the last several decades, psychodynamic frameworks and treatment models that present alternatives to Freudian theory and ego psychology have captured the attention of social workers and other mental health professionals. Among the most significant of these formulations in today's practice arena are object relations theory and self psychology, which arose in reaction to and have a different philosophical base from Freudian drive theory and ego psychology. They have expanded psychoanalytic thinking to encompass the whole person rather than the drives or ego functions alone, a person's here-and-now functioning as well as childhood fantasies and experiences, the strengths and resilience of people alongside or in addition to their areas of pathology or weakness, and the impact of interpersonal, social, and cultural as well as intrapsychic factors on development and personality functioning.

Object relations and self psychological treatment approaches have moved traditional psychoanalytically informed treatment beyond its earlier rigidity and narrowness of focus and in some ways, they have provided a theoretical basis for many of the tried and true principles that have been characteristic of clinical social work practice. These newer frameworks have led to ten important changes in the ways in which psychodynamically oriented treatment is carried out.

1 Treatment has moved away from the traditional psychoanalytic stance that requires that the therapist be neutral in his or her interventions, abstinent with respect to gratifying patients' needs, and anonymous in terms of revealing personal information. Therapists are encouraged to be more empathic, involved, real, and genuine in their responses.

2 The treatment structure is more flexible and individualized.

3 The use of the therapist's self in engaging the patient and in providing a safe and accepting therapeutic holding environment and a reparative and facilitating relationship that offers opportunities for participation in new, more positive interactions is a crucial component of treatment.

4 The repertoire of treatment interventions has expanded beyond the use of insight-oriented techniques to encompass a broad range of developmentally attuned interventions that include active efforts to meet some of the patient's developmental needs, to facilitate and support the patient's growth, and to provide environmental supports. It is recognized that insight-oriented techniques, such as confrontation and interpretation, too early in treatment are not suited to work with many patients.

5 The therapist pays greater attention to the patient's subjective experience and personal narrative than previously and is advised to adopt a collaborative rather than authoritarian stance in the treatment relationship.

6 Treatment is based on revisions and expansions of personality theory so that it considers the impact of early relationships and self-development in influencing the nature of a patient's strengths and pathology.

7 The concept of transference has been expanded to include more recent views on the type of relational patterns and selfobject needs that patients bring into the treatment relationship.

8 The concept of resistance has been broadened to encompass the fact that many factors may be influencing what appear to be patients' difficulties in using treatment. These may stem from their efforts to maintain safety in the face of fear, hold on to coping mechanisms that have seemed to work for them in the past, sustain their attachment to internalized relations with others, and deal with what they feel to be realistic threats to their well-being. Moreover, impasses in the treatment may reflect a therapist's lack of correct attunement and responsiveness to the patient's concerns.

9 The concept of countertransference has been reconceptualized to encompass not only the therapist's reactions that stem from unresolved unconscious conflicts and other developmental issues but also those that stem from the impact of the patient's personality on the therapist. Additionally, there is recognition that the therapist always brings his or her own personality and organizing principles to the treatment relationship and this affects how he or she perceives and interacts with the patient.

10 There is greater appreciation of the need to understand patients' total biopsychosocial situation, which includes the nature of their cultural and other types of diversity, the effects of oppression, and the impact of the difficult and sometimes traumatic and tragic circumstances of life that patients have experienced.

Object Relations Theory and Self Psychology Defined

Like Freudian theory and ego psychology, object relations theory and self psychology are developmental in nature and view adult personality characteristics as dependent upon early childhood experiences. In contrast, however, to Freud's emphasis on biological instincts as the driving force behind personality development, all object relations formulations are relational -- that is, they share the view that human beings are social animals and that interpersonal relationships have a major impact on development (Aron, 1996). They describe the process by which the infant takes in (internalizes) the outside world, thereby acquiring basic perceptions of and attitudes toward the self and others that become structuralized within the person. Many object relations theorists have put forth somewhat different formulations, so that there is not a fully unified set of concepts.

Although the term object relations originally referred to the quality of a person's actual or external interpersonal relationships (Bellak, Hurvich, & Gediman, 1973), it was later used to describe the internal images or representations of the self and others (objects) that a person acquires in the course of early development. As noted by Greenberg and Mitchell (1983: 10), "people react to and interact with not only an actual other but also an internal other, a psychic representation of a person which in itself has the power to influence both the individual's affective states and his overt behavioral reactions."

The following six propositions characterize object relations theory's view of human development, psychopathology, and treatment.

1 Early infant-caretaker interactions lead to the person internalizing basic attitudes toward the self and others, characteristic relational patterns, and a repertoire of defenses and internal capacities. Important developmental processes involve attachment, separation-individuation, early object loss, experiences with frustrating or bad objects, and the move from dependence to independence.

2 Characteristic underlying problems that result from early object relations pathology include maladaptive attachment styles, separation-individuation subphase difficulties, borderline, narcissistic, paranoid, and schizoid disorders, severe and chronic depressive reactions, and false self disturbances. These difficulties also may present in clients who show a variety of clinical symptoms and syndromes.

3 Patients bring their pathological internalized object relations, primitive defenses, developmental deficits, as well as their capacities and strengths to the treatment situation.

4 Treatment can modify pathological internal structures or create facilitative and reparative experiences in which new and stronger structures are acquired.

5 Change processes in treatment result from both reparative and new experiences within the treatment relationship itself and from insight into and modification of entrenched object relations pathology.

6 Providing a therapeutic holding environment, pointing out dysfunctional relational patterns and defenses, engaging in a range of developmentally attuned techniques, and focusing on transference-countertransference dynamics, particularly with respect to what the client "induces" in the therapist or is "enacting" in the relationship are important components of treatment.

In contrast to object relations theory, self psychology places the self rather than internalized interpersonal relationships at the center of development. Whereas object relations theories tend to view the self as reflecting what the child takes in or internalizes from the outside, self psychology defines the self as an innate and enduring structure of the personality that has its own developmental track. It views the self as possessing organization, initiative, and potentialities, regulating self-esteem, and giving purpose and meaning to the person's life (Wolf, 1988: 182).

The following six propositions characterize self psychology's view of human development, psychopathology, and treatment.

1 Infants are born with innate potentialities for self development but require the responsiveness of the caretaking environment in order to develop a strong, cohesive self. The individual needs to have idealizable caretakers, experiences of validation, affirmation, a sense of feeling like others, and other forms of empathic selfobject responsiveness.

2 When the self-structure is weak and vulnerable as a result of unattuned, neglectful, or traumatic caretaking, both the self-concept and self-esteem regulation become impaired. The person may be at risk for developing self disorders and narcissistic vulnerability that lead to chronic problems or to periods of acute disruption later in life.

3 Clients bring their early unmet or thwarted selfobject needs to treatment, which provides them with a second chance to complete their development.

4 Treatment aims at strengthening self-structures, creating greater self-cohesion and self-esteem regulation, and enabling increased self-actualization and enjoyment of life.

5 Change results from the worker's empathic attunement to the client's subjective experience, optimal responsiveness to the client's needs, and empathic interpretations of the link between the client's current needs and problems and his or her early experiences with unattuned caretakers.

6 Engaging in empathic attunement and responsiveness, helping the client to develop and maintain a selfobject transference, exploring past caretaker failures and their sequelae, and removing obstacles to the worker's ability to be empathic to the client's selfobject needs and their manifestations, even when they appear to be demanding or unreasonable, are important components of the treatment.

Because both object relations and self psychological theories address the impact of interpersonal relationships on personality development, there are those who do not view these two frameworks as fundamentally different from one another (Greenberg & Mitchell, 1983; Bacal, 1991). Nevertheless, Kohut, who originated self psychology, saw his formulations as distinctive from those of object relations theory, and many of his followers have continued to hold to his position (Ornstein, 1991). Throughout the book, however, I shall strive to show how both theories can contribute to understanding and working with particular individuals.

Object relations theory and self psychology are not unitary frameworks. Object relations theory is a broad term that encompasses diverse concepts, and it has generated different and sometimes conflicting treatment approaches. For many years, the American object relations theorists such as Edith Jacobson and Margaret Mahler -- who showed loyalty to Freud and his daughter, Anna -- were highly critical of the writings of the British object relations theorists such as Melanie Klein, W. R. D. Fairbairn, D. W. Winnicott, and Harry Guntrip for rejecting many Freudian tenets. More recently, other theorists such as Otto Kernberg and Stephen Mitchell have attempted to put forth integrative models. Likewise, since the death of Heinz Kohut, who originated self psychology, some of his associates and followers, including Daniel Stern, Michael Basch, Arnold Goldberg, Howard Bacal, Joseph Lichtenberg, Robert Stolorow, Frank Lachmann, Beatrice Beebe, and Morton and Estelle Shane, have extended his ideas, and others have branched into different directions that have led to refinements and modifications of his views on development and the nature of treatment.

Significance for Social Work Practice

Object relations theory and self psychology are holistic frameworks that are consistent with the humanistic stance, values, and person-environmental focus of the social work profession and fit well with the existing body of clinical social work theory and practice.

1 They are biopsychosocial theories that address the interplay among a person's innate endowment and interpersonal, familial, environmental, and cultural factors in shaping behavior.

2 They focus on a person's here-and-now functioning as well as on how past development has contributed to a person's capacities, talents, ambitions, values, patterns of relating, and sense of self.

3 They recognize the strengths and resilience of people and their push for growth as well as what goes wrong in the course of development.

4 The treatment approaches that stem from object relations theory and self psychology require a more human therapeutic environment and are optimistic about the reparative and facilitating role of the treatment relationship. They emphasize the importance of an individual's subjective experience, the therapist's need to be where the client is, and the mutual and reciprocal impact of client and worker.

5 Object relations and self psychological concepts apply to a broad range of problems, including life crises and transitions, the effects of physical and sexual abuse and other types of trauma, emotional disorders, substance abuse, physical illness, disability, loss of loved ones, violence, parenting and family problems, and work issues. They have implications not only for individual long-term treatment but also for crisis and short-term intervention and work with couples, families, and groups.

Along with Freudian drive theory and ego psychology, object relations theory and self psychology comprise the contemporary psychodynamic base of social work practice. Because of their divergent elements and emphases, no simple theoretical integration of these four frameworks is possible at present (Phillips, 1993; Pine, 1988). Yet, it is likely that each formulation has some value and no one particular perspective constitutes the only truth about human behavior. Consequently, it is important for practitioners to be competent in their understanding and use of diverse theoretical formulations and treatment models so that they can utilize them differentially depending on the needs of a given client. This eclecticism is necessary because it is likely that clients have difficulties at multiple and different levels, that some aspects of their problems may be more prominent at one time than another, and that some of their problems may be more readily explained and worked with from one framework than another. The need for flexibility in the use of a particular approach may result in confusion and stress for the practitioner because it is difficult to decide when to do what to whom.

Impetus for the Book

There are numerous reasons for my choosing to write about object relations theory and self psychology despite my having been associated with ego psychology for over fifteen years. The book received its impetus from my long-standing interest in demonstrating the applicability of the major concepts and treatment principles of contemporary psychodynamic theory to social work practice. In the years following the publication of the first edition of Ego Psychology and Social Work Practice (Goldstein, 1984), which became a widely used social work text and resource, object relations theory and self psychology gained popularity in the social work and therapeutic community. The second edition (Goldstein, 1995a) commented on new directions in personality theory but it was beyond its scope to consider these fully. The growing interest in object relations theory and self psychology has generated numerous books by social work authors (Applegate & Bonovitz, 1995; Berzoff, Flanagan & Hertz, 1996; Brandell & Perlman, 1997; Edward & Sanville, 1996; Elson, 1986; Jackson, 1991; Levine, 1996; Mishne, 1993; Rowe & MacIsaac, 1989; Seinfeld, 1990, 1991, 1993; Siegel, 1992). In most instances, these are geared to more advanced clinicians engaged in psychotherapeutic work. Despite their value, there is a need for a basic social work text that describes the main concepts and treatment principles of object relations theory and self psychology and shows their application to a broad range of problems encountered by social work practitioners.

A second reason for undertaking the task of writing this book arises from my own interest in and use of object relations theory and self psychology in my work with clients and supervisees. Employing these frameworks has expanded my ability to understand and relate to a wide range of clients and has produced fundamental changes in the ways in which I listen, what I observe, where I focus, and how I use myself in the treatment process. I cannot imagine working without drawing on these perspectives and believe that a knowledge of these frameworks will help other social work practitioners.

A third motivation for writing this book stems from concerns about the current state of education for direct practice. In contrast to earlier times, currently there is little, if any, curriculum space allocated to the teaching of psychodynamic theories. Consequently, students graduate without acquiring even basic understanding of this body of thought. Upon graduation, many social workers take courses at psychodynamically oriented training institutes, but they are taught by members of other disciplines who are not conversant or identified with the nature of social work practice and with the types of clients that social workers generally see in agency practice. It is my hope that a basic social work text that describes the major concepts of object relations theory and self psychology and their implications for social work practice will provide trainees and instructors with a resource that can guide their learning and teaching of those important frameworks.

There is an old joke that aptly conveys one of the consequences for the practitioner of the multiplicity of psychodynamic theories that exist at present. As the story goes, a man visits a psychiatrist and complains of stress at his place of employment, explaining that his job is to sort the oranges, grapefruits, and melons that roll down a chute by putting each type of fruit in an appropriate container. When the psychiatrist asks, "But what is hard about that? It seems so simple," the client replies, "Doctor, you don't understand. All day long it's decisions, decisions, decisions."

Although this book may not make treatment decisions any easier, I hope that it will enrich practitioners' knowledge base and that it will be read not only by those social work practitioners, students, and instructors who are interested in working within an object relations or self psychological framework but by all those who are committed to direct practice. The ideas generated by these theories offer new ways of understanding the needs and problems, struggles and triumphs, of our clients and open exciting and creative approaches to the interventive process.

The Focus and Plan of the Book

This book is written primarily for social work students, practitioners, and educators as well as for trainees and members of other mental health disciplines. It will focus on the practical use of the concepts and treatment principles of object relations theory and self psychology to the clinical situation. Although it presents these two frameworks as distinctive, it attempts to show how they each can be used in a complementary way to work with a broad range of clients and client problems. I have tried to write in a hands-on, user friendly style. In most instances, the numerous case examples and excerpts that I have utilized throughout the book are based on my own practice, supervisory, and teaching experience. They have been disguised and edited and sometimes reflect composites of similar client situations.

The book is divided into two parts as follows:

Part I first describes the significance of object relations theory and self psychology and traces the evolution of this body of knowledge, considering both the similarities and differences among these frameworks and their recent trends and new directions. It then describes their major structural and developmental concepts, views of psychopathology, and treatment principles and techniques.

Part II discusses and illustrates the implications of object relations theory and self psychology for social work practice. It starts with a discussion of the nature of assessment and treatment planning and moves to a consideration of beginning phase issues, particularly the establishment of a therapeutic holding environment, overcoming obstacles to developing a positive relationship, and the use of selective techniques. It then discusses important middle phase issues, including the ways in which the worker addresses disruptions, enactments, and resistances that arise in the course of treatment. The book shows the application of object relations and self psychological concepts to the treatment of clients who are undergoing life transitions, illness and disability, loss of significant others, and other stressful life events, and to those manifesting special problems such as substance abuse, child maltreatment, and the effects of childhood sexual abuse. It concludes with a chapter on couple and family treatment.

Although the process of helping clients to improve their lives has been challenging, it has been personally gratifying. It has expanded my "self" more than I could ever have imagined. It is my hope that this book will prompt students and practitioners to try out some new ideas and to enrich their work with clients.

Copyright © 2001 by Eda G. Goldstein