Object Relations Case Formulation

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1.Identifying details

Name: Katrina Katryn
Age: 20
Gender: Female
Marital status: Single
Dependents: N/A
Highest level of education: Matric
Present occupation: Student (Psychology 1st year)
Reason for referral: Self exploration, dealing with the past, improving interpersonal experiences.
Referral source: Self-referred

2.Presenting problem
She experiences considerable anxiety in interpersonal situations. In addition she has feelings of inadequacy, worthlessness and hopelessness. These difficulties lead to academic concerns and relational problems in her current situation. Her self-esteem is extremely low and she expressed that she hates doubting herself constantly.

3.History of presenting problem.
She was sexually abused when she was between 6 and 9 years old. The rest of the time she was emotionally and physically abused. She has always felt inferior and had low self-esteem as long as she can remember. She was diagnosed with depression at age 15 and was put on medication. She cannot remember the name of the anti-depressants and did not remember the exact diagnoses. The feelings of hopelessness and her academic problems has started relatively recently according to her.

4.Past illnesses

Psychiatric
Mood disorder (She cannot remember the exact diagnoses.) Medical
Nothing significant
Anti-depressants (unknown)

Adaptive features and Strengths
She is intelligent and ambitious. She has shown courage in confronting her father about the abuse and her decision to mend their relationship show courage. She seems to have insight into her difficulties and the processes that keep them alive. She seems to be willing to change and to explore these difficulties in depth. The fact that she removed herself from her deleterious environment in adolescences is indicative of her self-preservative abilities. She is currently in therapy on a self-referral which again points out these abilities. She has taken responsibility of protecting her siblings in the past and the present which indicate her compassion for others. She seems to trust me and it is likely that we will form a therapeutic alliance.

5.Personal history

I.Birth and early development
As far as Katrinais concerned she was a wanted and welcomed baby although the pregnancy was not planned. The pregnancy was normal at 40 weeks without any complications. She did not experience any serious illnesses and was not involved in any accidents. She reached all her developmental milestones within the average intervals. This thus indicates a normal developmental trajectory throughout infancy.

Katrina’s socio-emotional history was significantly compromised by physical, emotional and sexual abuse. She had an extremely wounding relationship with her father who mistreated her and then after the mistreatment behaved alluring towards her. She mentioned this several times during most of our sessions. She also had an ambivalent relationship with her mother during this time. Her mother would at times be very loving, caring and supportive, yet at other times ignore her cries for help and her need for her affection. She did not enjoy any close knit friendships and it seems that the only person she shared a healthy relationship with was her grandmother. This relationship however was constantly under attack from her parents. She described herself as an obedient and shy girl who felt lonely and different. II.Childhood

During her childhood Katrina lived in a very traumatic family situation full of psychological, sexual and physical abuse. She mentioned that everything from her childhood was connected to a bitter feeling. She lived with her mother, father and younger sister. Her father was unhappy, aggressive, insecure, but in her childhood she experienced him as a powerful and great authority. Her father was sexually abused as a child. He was very strict...
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