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This article presents a 3-phase integrated counseling model that draws from object relations and attachment theory for assessment and uses cognitive behavioral techniques to promote constructive client change. A case vignette is presented to illustrate implementation of the model.
Phase 1 — Assessment
Introjection. Introjection is the process of formulating internal working models derived from experience and interactions with significant others such as caretakers (Diamond & Blatt, 1994). If the child is continuously rejected when seeking comfort from a caretaker, the internal working model is composed of representations of a rejecting caretaker interacting with an unworthy self If the caretaker is nurturing, working models consist of representations of a loving caretaker interacting with a worthy self. Internal working models are based on introjections encompassing aspects of both the self and the other in the dyadic attachment relationship (Diamond & Blatt, 1994).
Splitting. Splitting involves viewing the world in an extreme negative or positive fashion (Hamilton, 1989). This primitive defense occurs when the child removes unpleasant qualities of the caregiver and stores them as negative or distressful categories or representations. This minimizes the child's anxiety because he or she relies on the caregiver for survival. In splitting, the child relates only to the positive qualities of the caregiver. Positive or pleasing images are stored as separate categories or representations. The child then identifies with either the positive or negative images as he or she develops a sense of self As the individual matures, he or she becomes unable to view himself or herself or others in a "whole" fashion (known in object relations theory as whole object relatedness), which requires accepting both negative and positive qualities within one person (Klein, 1975). This pattern of dealing with relationships will repeat itself in adulthood. People are related to as either all good or all bad; likewise, the self is viewed in this extreme manner.
Projection and protective identification. The ego attempts to control an imbalance of internal positive and negative representations through projection (Summers, 1994). Through this process, the person projects onto others aspects of themselves that are either negative or positive, but conflicting (Sussal, 1992). Furthermore, through projective identification, the individual behaves in a manner that elicits from another person the affects and self-images that are projected (Ginter £ Bonney, 1993). Adler and Rhine (1992) suggested that the projector gets rid of unwanted aspects of the self while identifying with and maintaining a relationship with the other person to control the projection. Through identification, it is possible that an individual may see a part of herself or himself in another person and then may feel the need to "join that aspect of herself [or himself] in the other" (Hamilton, 1989, p. 1554).
Adult attachment patterns. Sperling and Berman (1994) maintained that adult attachment is the tendency of an individual to establish relationships with specific people who provide the potential for physical and psychological security. Bowlby (as cited in Sable, 1992) described four adult patterns of insecure attachment: anxious attachment, insistent self-reliance, insistent caregivmg, and emotional detachment. Any of these patterns may result in vulnerability to interpersonal problems. Insistent caregiving is defined as the behavior of people who establish affectional relationships in which they devote themselves to caring for others. The person engages in close relationships but always as a caretaker. The childhood experience may have been one with a caregiver who was unable to nurture the child but instead welcomed or demanded care (Sable, 1992). Studies (Collins & Read, 1990; Feeney & Noller, 1990; Hazan & Shaver, 1987) have demonstrated that an early history of poor attachment with significant others predisposes individuals to difficult adult love relationships (also see Sperling & Berman, 1994). In short, what was necessary for the child's survival in early interactions with parents clearly affects personality development and may result in vulnerability to disappointing adult relationships. The interpersonal paradigm maintains that sexuality is a powerful vehicle for expressing relational patterns because of the social meaning it conveys. It can become a medium for connecting with others. The search for reassurance through sexuality may result in compulsive promiscuity (Summers, 1994).
Assessment goals. It is crucial that the counselor empathetically hear the client's story and establish a phenomenological understanding of the client's experience (Ginter & Bonney, 1993). Throughout the assessment process, the counselor builds rapport with the client. The counselor creates a holding environment to provide a safe and secure place within which the client can process painful memories. With the assistance of the counselor, the client can explore his or her "internal working model" or way of making sense of his or her life and how early experiences helped to shape life patterns and themes. A genogram is a useful assessment tool (see McGoldrick & Gerson, 1985). The counselor and client can graphically display the family configuration, including the various types of relationships between the family members and other significant individuals. Important events and transitional periods can also be depicted. This depiction can assist both the counselor and client in discerning and evaluating life patterns. Although the achievement of insight is a major goal within this model, it is insufficient in achieving constructive client change. Ginter and Bonney (1993) maintained that "insight is regarded as a major source of change but only when accompanied by affect and followed by some form of action within and outside of therapy sessions" (p. 154). Furthermore, Ellis described the powerful influence of cognitive processes on client change (Ellis & Dryden, 1987). Therefore, an additional focus of counseling must include exploration of client feelings regarding past and present circumstances and thought patterns influencing the client's interpretational system.
Phase 2 — Linking Insight With the Present: Experiential and Cognitive Techniques
Insight empowers the client to adaptively manage his or her affects, thoughts, and behaviors. This results in decreased anxiety because the client is learning to control his or her inner world. There is less fear about unknown processes within. The client comes to better self-understanding and uses the counselor as a supportive, growth-producing object (Pine, 1992). The counselor supports the client by establishing a "good object relationship" that is internalized by the client and, in turn, fosters a more positive sense of self (Buckley, 1994). With this support from the counselor, the client is able to face painful memories, feelings, and thoughts. Processing previously repressed and dissociated memories and feelings in counseling can lead to changes in perceptions of self and others (Delia Selva, 1992). Clarification and confrontation are useful techniques in assisting clients with changing perceptions.
Through clarification, the counselor assists the client in sorting through personal history, affirms responses to descriptions of situations, encourages recall of memories and feelings in which there is reluctance, and facilitates reinterpretation of misconstrued events (Sable, 1992). Hamilton (1988) defined confrontation as making an observation to a client about himself or herself As these observations are interpreted by the client and the counselor, the client either assimilates or rejects the interpretation. Interpretation becomes psychoeducational because the client learns to connect early patterns of relating to caregivers with present patterns of relating to others. The client examines inner representations and how they emerged as a result of past object relationships. This new understanding can then be integrated as the client begins to form new representations and to alter his or her worldview in a therapeutic manner. This is more direct and time effective than the usual psychoanalytic emphasis on working through transference as the means to change internal representations (Rothbard & Shaver, 1994).
Through cognitive restructuring, the client is introduced to new ways of thinking about life and interpreting situations. New perspectives coupled with more adaptive choices and worldviews are examined. "The client's life situation is cognitively restructured in ways that permit her [or him] to move actively [italics added] to improve it" (Blocher, 1980, p. 6), This restructuring promotes personal responsibility and a sense of self-efficacy within the client to foster growth. The client, in this phase, learns and uses such techniques as situational analysis, cognitive refutation, and goal attainment scaling. The client learns to calm himself or herself and think in a more adaptive and self-enhancing manner.
Phase 3 — Promoting Change: A Behavioral Approach
Assessment Of Intervention Effectiveness
Reflection Exercise #10