Analyze This - Jan's real life cases: the story of Gill

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: Analyze This - Jan's real life cases: the story of Gill : What is the likely enneatype of Gill? What is the likely E-type of the therapist? What do you think of the treatment he applies? Why? : Because of lack of standardised enneastyle definitions it makes our forum discussion easier if you also can supply the corresponding DSMIV related character style as specified in dr. Oldham's book The New Personality Self-Portrait. Train yourself in using the E-types and post your analysis results on this forum so that we can have a discussion. : Jan : PS the word 'telic' used in the report means 'with regard to systematic planning aimed at achieving a certain purpose or goal. : The case of Gill. : Gill was referred for psychotherapy through a self-help group that specialized in the depressive and phobic problems in a particular community with which I have had considerable involvement. The referral occurred because of the concern within this group about the severity of Gill's depression. She had had no psychiatric or medical history that was relevant to her current state, according to the referral in- formation I received-which Gill later confirmed. She was then 28 years old, un- married, and not currently involved in relationships with males. Though in the past she had had many relationships, some lasting over three years, she claimed now to no longer need either the intellectual, emotional, or sexual fulfillment that such relationships had given. By any standards, Gill was middle class. She was an assistant manager for a group of stores selling clothes and cosmetics. She earned an income that rivaled that ofmost women in business of her age (app. F.8,000-a considerable income for a woman, or a man, in Britain). She owned a house, which she had inherited from her parents, and a sports car. She was always weIl dressed and attractive. She had re- ceived a college education in business studies up to the age of 21. : Gill was the only daughter of Sam and Mary. Sam had diedwhen Gill was 20 and he was 68 years old. Her mother had died when Gill was 24 and she was 56 years old. Gill said that the discrepancy between her parents' ages had not bothered her , though at the time of referral she was somewhat preoccupied by the fact that both her parents had died of coronary heart disease, which for her meant that she too was at risk. She ruminated on questions about the effect that she had had on her parents' life; in particular, she spent some time reflecting on the fact that her parents "had not expected to have any children-then I came along and they wanted another but never managed it." She said that she had never "envied those with brothers or sisters or both" and that she had been "quite happy" as a child. : The following extract indicates the nature of the presenting problem as seen by Gill in the first session. : PRESENTING ISSUES : P: I amjust going through the motions of being alive and around. Inside I feel empty, lost, and without purpose. I have no energy ...[silence for 18 sec- onds] I just can't find anything that. ..[silence for 11 seconds] : T: You say you have no energy and you let your speech drift off into silence. What other forms does this lack of energy take? : P: I forget what I am doing sometimes ...quite often in fact ...[silence for nine 8 seconds) I won't make decisions.. ...I am relying on others at work to, do more and more of the work ...and even small things (like shopping or going out) become things that I am un able to make decisions about. It's like having a black hole inside me that wants to engulf me and take me over The only response I can have to this is to feel engulfed and overwhelmed, and yet continue to ...weIl. ..just exist. : : This presentation of self was offered in a monotone. Though the language appears firm and clear, it was expressed without a feeling of firmness or clarity. The timed pauses actually seemed to be more substantial than the numbers indicate. In the first session I was able to establish: (a) that Gil1 was normal1y a serious person-she liked things to be planned and to be clear, she did not like spontaneity or practical jokes or unforeseen circumstance & she was .'.at her best' when she 'knew just what was going to happen'; (b) she sought out relationships with others that were largely undemanding of her- a good relationship was one in which "both knew where we were going and what it was we wanted from each other-if that was sex, that was fine ...if it was intellectual stimulation, that was fine ...as long as I know where I am"; (c) that her expectation of her own development was that she would simply continue to experience tbe social world she had always done and that she had '.passed the period of changes (her expression); and (d) that her current depression and inability to engage the social world or to obtain satisfactions from her actions was a sustained and painful experience that was both unique and extreme for her . Though she superficial1y appeared to be coping with her work, close inspection of her work behavior and performance would, she claimed, reveal that she was currently not working to the benefit of the company and she felt '.helpless to do anything about it. She was sleeping badly and not able to eat properly. She claimed to have lost 18 pounds in weight in seven weeks. : Detailed notes: : Behavior. Gill is not sleeping or eating weIl, she is losing body weight rapidly. She speaks in monotone and behaves in routinized ways. She has disengaged from social behavior and has not engaged in relationship building for some time. She presents a coping image to the world but does not behave as if she is coping in her own judgment. She finds holding a sus- tained personal conversation difficult, though is succinct in her language use. : Affect: Gill presents as if she is devoid of affect. Her monotone shows no anxiety or energy .She talks about her depression as if she was incapable of ever having experienced excitement. Any pleasurable affect in the past has been planned (telic) and deliberate-she now does not seem to have the energy or the "will" to engage in such planned activity. She presents her emotions as having been drained into a black hole. The overwhelming impression was of apathy (passionless existence; lack of interest or desire) layered with consid- erabIe pain and self-pity. : Sensation. Gill does not present herself as bored -she does not operate from a sensation-seeking or frustration mode- she is clearly apathy depressed in terms ofher extreme telic orientation. She is not trying to do anything that will raise her arousal; she seems to be seeking to maintain her arousal at the lowest possible level ( arousal avoidance is extreme) while expecting that this will lead to affective satisfaction. It is as if satiation of this state has occurred but that the reversal that normally fol- lows satiation has failed to materialize. This leaves her with a sense of depression both about the state and about the expe- rience of satiation. : lmagery. Gill uses two images in her self-presentations about her depression: (a) feeling as if she is being engulfed and overwhelmed by a black hole, which she finds immensely depressing, and (b) feeling trapped under the weight of her own depression. Occasionally, she refers to her state as "the drained coconut" or as "the sapling tree that cannot leaf." Clearly, the most powerful image is that of the black hole. (A subsequent analysis of the transcript of this first session shows that she used this image 26 times in 58 minutes to describe her depressed state.) : Cognitions. Gill had difficulty in identifying her own self-talk and cognitions. One was clearly evident: "There is nothing I can do about the way I feel, it's just how it is supposed to be." I explored with her the idea that "she had passed the period of changes," which seemed to consti- tute another belief. She said that she feIt no different now than when she was 18 (apart from the depression) apd that she certainly did not feel that she wanted to change. When pressed to express this as a single belief statement, she simply said, "Change is what happens when you're younger; when y ou get to my age y ou are how y ou are." This seems to me like an- other version of the irrational belief that unhappiness is a function of events outside the control of individuals. : Interpersonal. Gill has poor interpersonal skilIs, according to her behavior during this session. She has had relationships in the past (some of which have lasted up to three years), but these have to be planned and purposive. She cannot have casual relationships (she says) and needs to have a clear agreement about the parameters of a relationship before she feels comfortable. : Drugs. Gill is not seeing a doctor at this time and only takes an occasional pill (paracetamol or Anacin) when she has a headache. : Towards the end of the first session I asked Gill to complete the Telic Dominance Scale (Murgatroyd, Rushton, Apter , & Ray, 1978) and the Leeds Depression Inventory (Snaith, Bridge, & Hamilton, 1976). These revealed that Gill was extremely telic (a score of 13 on serious-mindedness, 11 on both planning orientation and arousal avoidance- highest score possible on any subscale = 14) and chronically depressed. We contracted for eight sessions of one and a half hours. A clear part of this contract was that Gill would complete homework assignments. At the end of the first session I asked her to keep a visual diary of her experience between appointments (which were weekly). This diary would involve her trying to capture her experience in drawings and words so that she could discuss these with me. I also asked her to bring photographs of herself that represented the way in which she thought of herself before she became depressed. I felt that these requests would provide me with more insight into Gill's phenomenological field while creating some arousal in Gill. Creating arousal was important for therapeutic progress-a part ofher depression related to the experience of extreme low arousal. Gill now writes that "these requests challenged me: It was as if I was being asked to go into the black hole and confront it. ...I found this very disturbing, but somehow managed to complete the tasks that I had been assigned." : In discussing this case with a colleague as part of my own supervision arrangements we explored the difference between apathy depression and boredom depression. What was clear about Gill was that she was a very serious and planning-oriented person and that her depression was very well described by the item on the Leeds Scale concerned with apathy ("1 have lost interest in things") rather than the item concerned with boredom ("1 am restless and I can't keep still') She made several statements about not having the 'energy' to 'invest' in her plans for the future or the patience to start new activities or relationships. She seemed both depressed and apathetic about her depression. She was a clear case of apathy depression. What made this clearer was the description of boredom depression provided by Apter (1982, esp. p. 251) as : having its origins in the paratelic state. Gill did not seem to have residual arousal that she was able to activate so as to become more spontaneous, action oriented, and sensation seeking (these being the qualitative features ofthe paratelic state) -she was not bored. : This hypothesis about Gill's presenting problem guided my thoughts about initial treatment goals. The first task was to encourage her to understand her depression in motivational terms. The second task was to encourage her to identify her motivational experiences and their structure. The final task was to facilitate a change in the way in which she experienced her own motivation and actions. Almost all of these would require Gill to experience higher levels of arousal than was the case at this first session. I intended that her arousal levels should provide a major focus for the process of therapy. I also decided that at the next session I would seek to explain the motivational theory in which I was working and to relate this theory to her depression. : I have grouped the second, third, and fourth sessions together since they form a natural developmental segment of the work with this client. This segment can be characterized by the phrase ..explora- tion and exaggeration" for reasons that will soon become clear . Gil1 presented at the second session in a more distressed and depressed state than at the first. She said that the homework assignment I had set had caused her ..a lot of pain" and that if therapy was going to make her more and more depressed, she was not sure that she wanted to continue. She said that she had become angry by the fact that I was "making her" go into the black hole and that I was "making her" depressed. She also said that she had undertaken the homework tasks with considerable reluctance and had only been able to complete them by using the "insomnia" time that was available to her-"it was one way of trying to get me distracted enough to sleep." She created an extension to one of her images -the homework had "been like an insecticide sprayed on me as a leafless sapling." : I used these statements to congratulate GilI on a clear identification of her symptoms and to encourage her to reveal more of the inner workings of her experience, since this was a central part of the process by which her depression could be affected. In addition to giving her symptoms a positive connotation (see Minuchin & Fish- man, 1981, esp. pp. 33-34), I also reinforced her use of her "insomnia time," arguing that it was a constructive use of time she would otherwise have wasted and that, even though it made her angry, this was more constructive a use of her time than being depressed. This last comment is a variant on Haley's ordeal therapy method in which time "wasted" in negative emo- tional experiences has to be compensated for by the completion of behavioral tasks (Haley, 1974). : Providing two positive connotations for statements that Gill anticipated would be received negatively seemed to promote some arousal in her. She looked startled and confused. She had expected me to be angry as she had been. Here is some dia- logue from this session, which illuminates the impact of positive connotation and reinforcement: : P: you mean to say that you are pleased that I was angry?! : T: No, I am pleased about two things-your ability to be clear and precise in understanding just what is happening to you and the fact that you were something other than depressed. I am also pleased now to hear that your voice is ref1ecting your feelings and that you are completing sentences that describe precisely the way you are feeling. : P: This is something else! [Sits upright in chair, moves forward, and begins to gesticulate by pointing a finger] I do not like being angry and I do not like being depressed I just want to be me-we'd better understand this before we go much further. : T: Gill, am I right in seeing that you are aroused right now? Am I right in seeing you aroused and feeling that this is making you anxious? : P [hesitantly ]: Yes, yes you are. ..I suppose I am feeling aroused ...and upset. : T: Gill, please help me. I want you to focus on arousal and what happens to you when you experience arousal. I want you to describe what is happening to you now that this arousal is around. Do it quickly, Gill, before this arousal goes away. TeIl me, what's this arousallike? : P: Wel1 [sits more forward on the chair-on the edge] ...I feel my heart beat a littIe faster and I can feel the blood pulsing in my neck [puts left hand to her neck] ...I also feel my thoughts beginning to move a little quicker, as if I could get out of control if I don't watch it ...I feel I have to do something, say something or do something so that I stay in control. ... : T: Gil1, I want you to notice something. When I asked you what happens when you experience arousal, you described your feeling that you needed to control that arousal so that you could control your experience. This is another good insight into your experience, Gill, and I am grateful for your clarity. It shows me that your feeling of depression is about overcontrol1ing your experience of arousal. : P [f1ash of anger appears to produce this statementJ: What's this? Instant diagnosis! : T: Thank you for sharing your anger with me, Gill. It shows that you can get aroused quickly and that you can,show that arousal to others. Is that what happened right then ...you got angry? : P: [moves back into chair and looks directly into my eyes for the first time during these first 20 minutes of the session; pause for nine seconds; voice is quiet and hesitantJ: Yes, yes that's right. (pause for 12 seconds) I am sorry that I was angry with you. : T: I am happy that you can be angry with me, Gill. I am also happy that you were angry ...it shows me that you do become aroused and that you experience arousal in a particular kind of way. : P: Yes. but it alwavs makes me upset. ... : This interchange was a critical lead into two features that dominated the first session: (a) the fact that her arousal was experienced as something unpleasant indicated that arousal was being experienced in the telic state and was therefore being suppressed; and (b) we had established the focus on here-and-now issues for therapy rather than past or future issues. : : The remainder of this session was spent explaining the nature of reversal theory , with the emphasis being placed on the way in which arousal is experienced differently in the telic and paratelic meta-motivational states (arousal is felt as unpleasant in the telic state and as pleasant in the paratelic state). I asked Gill to work through the meaning for her of a curve shown a figure.. She clearly identified herself as at the extreme end of the telic curve-beyond relaxation and in a state of apathy. She related her drawings and photographs of herself to this figure and was able to further confirm that she was to be located in apathy at this time and on the telic curve 'when I am not this bad' : She showed herself dressed conventionally, doing conventional things, and minimizing the interest in photographs that could have had interesting features. She also discussed the quality of her relationships with men as being about safety and planned relationships. At the end of the second session I asked Gill to make a note in a notebook I had provided her of all the feelings that she experienced between this session and the next appointment. I asked her to be diligent and encouraged her to be explicit. I reminded her of her skills in self-observation (further positive rein- forcement ofher symptoms) and asked her to attend to the features of the telic state we had just explored; means-ends, the experience of time, and the intensity of her experience. : The third session built on this foundation and used her "feelings diary". Of particular importance to this period of continued : explanation was her realization that the experience of arousal in telic terms was only one way of experiencing motivation and emotion and there were alternatives. The following is an extract from her feelings diary: : Tuesday: Annoyed at how late the postman is becoming and at the fact that no one has writ- ten to me anyway. FeIt numb for most of the moming. FeIt a pain in the base ofmy back-put it down to stress after the therapy session. FeIt sad about being so depressed and then feIt de- pressed about being so depressed. : Wednesday: FeIt tired and exhausted as soon as I awoke. FeIt weak and limp and a little better. By 7:30 A.M. I wanted to scream with the pain of being so depressed. Then I slow I y began to feel angry: thought about this in terms of what we'd talked about-angry is aroused, isn't it, and that's what's wrong, I am not aroused enough! (Does this mean I am get- ting better?) : Thursday: Couldn't get out of bed today and feIt miserabIe. Thought a lot about this para- telic idea and tried hard to remember when I had Iet myself go. I recalled an incident when I was eight and was running wild in a field and got beaten for it and a sex thing with a girl and a boy from school when I was eight and felt guilty ...but nothing else. By noon I was too tired even to be depressed. By 4:00 P.M. I was fitful and somber. Slept. Felt tired when I awoke. Felt bitter about another wasted day. Felt bitter about having to keep this diary. Felt bitter about everything. : The diary read as a kind of intellectual diary-feelings had become intellectualized and her emotions relegated to a set of standard statements that had literary merit. Her apathy was apparent as weIl as her bitterness. I feIt that the diary indicated the operation of a second pair of metamotivational states outlined in reversal theory-the negativism and conformity pair.. In particular, there is a high degree of "self-negativism" displayed in the diary material (and in the earlier drawings). Apter (1982) defines self-negativism in the following way: : If the self polarizes into the ..1" and ..me," then it is possible for the ..1" to see the ..me" as extemal to it in some way, and to see its requirements as coming ..from outside." Therefore under these conditions the .'1" can, when the negativistic state is operative, act negatively against the .'me." This will be referred to as self-negativism (p. 220). : There are a number of ways in which self-negativism can arise, but the most appropriate in this case is to : regard it as a form of retroflection (Perls, Heffêrline, & Goodman, 1973). Gill has substituted herself for her environment and acts against herself rather than those things in her environment which she would really like to react against. This observation adds a new element to my hypothesis-Gill is highly telic, satiated in this metamotivational state, and depressed because she cannot achieve a reversal to the paratelic state or achieve the satisfactions of the telic state, and now it is clear that she is also self-negativistic. : Once again I congratulated her on the clarity of her own understanding of her symptoms and on the diligence with which she had completed her homework task. I said that in this third session I wanted her to enable me to see and feel the kinds of experiences she had written about and that I wanted to use some drama work to achieve this. I explained that the way in which I wanted her to behave was risky for her-she would get aroused-but that this was all part of the therapy. The essential task was for her to portray, in as detailed andas elaborate a way as possible, the emotions she had recorded in her diary. I further observed that this way of working is derived from the work of Keith Johnstone (1981) and will involve her in having to improvise; I pointed out that this would not be too difficult since I wanted her to improvise being herself as described in her diary. At first she did not take me seriously. She asked, "Is this for real?" and I observed that her diary was for real, but this was to be an enactment of her feelings. Af ter some considerable persuasion, she agreed to "try this stuff' but did so with the feeling that it would not work. : I began by asking her to act out the scene in her diary in which she describes waking and feeling angry (see the Wednesday entry). To make matters easier for her I said that I would play at being a servant-1 intended to use this role to engage in some paradoxical interventions. Each time she offered a scene I (as the servant) complained that it was not de- pressed and exhausted enough-she did not really look like she was about to scream or that she was in pain-and I asked her to work harder and harder at being depressed. Af ter five or six tries at this scene the following encounter (with us both out of our role play) occurred: : P: Shit! It's me that knows what it's like to be me. I am the one that gets fucking depressed not you….so will you just stop badgering me and stop making me so fucking angry! God, it's awful and I'm paying for this ...charade! : T: You keep saying you're depressed, but y ou never show the depth of your depression. : P: What more do I have to do, for Christ's sake [shouting] ...cut my fucking wrist!Slit my throat! Would that make y ou happy? God, everyone always has plans for me and I never get to be my- self. : T: And what would being yourself mean, Gill? : P: Oh. ..not having to take responsibility all the time. ..being, weil, being the me I was never allowed to be as a child. : : Through the use of a dramatized paradoxical intervention (Riebel, 1984; Cole- man Nelson, 1962) in this third session I was able to achieve: (a) a display of negativism toward me, which highlighted this feature for both patient and therapists; (b) a high levelof arousal in Gill, which she experienced initially as anger and subsequently as exhilarating (as she herself reports below); and (c) a new statement of her experience of the social world, which seemed for her to encapsulate her depression. This session was to prove critical in her therapy, as we shall see. What was also critical was the attempts I made to ensure that she left this session in a state other than one of anxiety and anger . I did this by using a quick relaxation method (Murgatroyd, 1985b) and by talking her down and building an agenda for our next meeting. This session ran for two and a quarter hours. I did set Gill a homework assignment. It was to write a letter to me that should arrive the day before our next scheduled meeting. This is the letter she wrote: : Dear Stephen, I have thought a lot about the last session. y ou really got me angry! So angry that I didn't have time to be depressed!! For the first time in five months I feIt as if I had grown some foliage. I hope you will not be angry with me when we meet tomorrow-it alljust poured out of me. I feIt so angry at being directed and forced to be something that I don't want that I just had to scream at y ou. : (Do y ou know that I have never used those words before with another person present?) : Af ter I lef t the session, when you'd taught that quick relaxation method, I was still quite high. I feIt like I could be me for a while. Since then I have become more depressed. I think that what is happening is that I am feeling that it is okay to be me when I am pushed to be by y ou, but that I can't keep it up when I am out here. This is something I would really like to talk about when we meet. : One other thing, I would like to explore just where this thing about everyone else having plans for me comes from. I have not thought that way since I was around 14 or 8 and I am not sure what it means for me now. Anyway, don't be angry with me. : My objectives for the fourth session were discussed with my colleague and supervisor following the receipt of this letter. Both of us feIt that the fourth session would shape the direction of the therapy that followed. I feIt strongly that the essential task was to continue to generate arousal which Gill could experience in a variety of different ways, the point being that the experience of arousal as anger , excitement, or frustration might induce either a shift in the telic state such that Gill would become more adept at handling the social world or a reversal into the par- atelic state, which would certainly lead to a lifting of the depression. My colleague, however, feIt that the issue of control ("everyone has plans for me and I never get to be myself') was so central to her experience ofthe social world and her self- evaluation that I should focus exclusively on this feature in the fourth session. I decided to combine both perspectives and to use some challenging and confronting techniaues to do so. : : When Gill arrived for the fourth session she looked a little more alert than usual. I noticed that her voice had far more modulation than had been the case during her normal conversation on previous sessions. I began by thanking her for her letter and explained that, far from being angry, the last session had produced some important material for us to work on. She agreed, noting that she had identified an issue in her letter to me which she felt was important and about which she had been thinking carefully. I said that I had observed that, but that I wanted her to engage in some more work first. I said that I had listed on a piece of paper six features of Gill which I would like her to look at. These were: (1) Gill the worker-efficient and enthusiastic; (2) Gill the daughter- alone and unsure; (3) Gill the planned relator; (4) Gill who has never said "fuck" with someone else present; (5) Gill the frustrated; and (6) Gill who can only be angry or depressed. I asked her to throw dice and talk for five minutes about whichever feature of Gill the dice indicated. I made clear that after five minutes I would ask her to throw the dice again and repeat the process. My aim in using this technique (developed from Luke Rinehart's The Dice Man [1972]) was to provide a frustrating opportunity for Gill to talk about different features of herself so that we could explore the meaning of her social world ang her motivation while at the same time increasing her arousal. I assumed that the uncertainty inherent in the procedure would be arousing as well as the fact that some ofthe content would generate arousal in its own right. Gill was persuaded to comply. The dice was thrown and landed on 3. Here is a transcript of the next few minutes: : P: H mm ...well, when I was small mother used to always brief me on how to be- have when we went anywhere. If I went to someone's house then I was expected to behave in a certain way and was always rewarded when I did so. lf I didn't do what she expected then I was punished-not physically ...perhaps I wouldn't have things I wanted or perhaps mother would become ill or something like that, but I knew when I had to behave. After father died it became more and more important to her that she knew just what I was up to. I used to plan my day and tell her about my plans and then she would check on my progress. When I went to college I was still living at home-mother used to plan my work and my time and my money and I just learned how to do it from her. : T: So your mother shaped your behavior, Gill. Tell me about your relationships with others. : P: Well, I found that on my first date this boy was, well what we call "keen" ...he kept feeling my breasts when we were dancing and making suggestions. I could feel myself getting worked up and I didn't know what to do. ..I was all confused and I hate that ...I told you, I like to know just where I am. ...So I decided that my relationships with men and with my friends (some of whom would drop their pants for anyone!) should be careful and planned. ... You'll not believe this, but I once wrote out a list of how to be with a boy. ..you know, date 1 holding hands and kissing with mouth shut; date 2 holding hands and kissing with mouth open; date 3 kissing with mouth open and letting him touch my breasts outside my clothes ...and I actually kept to that schedule ...it looks funny looking back at it. ... : T: ...but it is the kind of plan your mother would have expected? : P: Yes, well ...no. ..I mean, she wouldn't have expected me to ...well, you know. ..Anyway, since then I have been careful about the way I relate to others, and ... : T (interrupts) : It's time to throw the dice again, Gill. : Gill was clearly frustrated by having to curtail her exposition, but complied. The dice this time took her to item 5. Before she began to speak I reminded her that she only had five minutes. She got angry: : P: Now look, I have waited a week to tell you about this and you tell me we only have five minutes! What in hell's name is going on here? : T: I am listening, Gill, you have four and a half minutes. : P: Typical! Typical! All my life I have had to plan to get what I want and wellover half the time I get frustrated by other people. Now it's you! You sit there pon- tificating and telling me to do this and to do that and then I get pushed around. Well, I am not having it with you or anyone else, I am just through with it [begins to cry] ...I can't go on any longer . : T: You still have time to tell me something about it, Gill. : P: I haven't got time! I haven't! It would take over this whole session to tell you about my frustration, about the way I have screwed up my career and about the way my mother manipulated me and about how I feel trapped. ...I haven't got time and now it's too late. It's too late here and it's too late for anything, I am trapped. : T: ...and whenever you feel trapped like this, you get angry and then you start to get depressed, is that right, Gill? : P: Oh, we're back to the instant diagnosis again are we! : T: I asked a question, Gill. .. P: I heard you, for Christ's sake, I heard you! Well. ..[calming down] I suppose so. ..I suppose you're right. ..[wiping her eyes and beginning to take control of herself1 ...if I am not angry then I am depressed ...and recently, weIl until I started seeing you, I have just been depressed ...it was as if I couldn't even be bothered to get angry any- more. ..that's how depressed I was. : T: Time to throw the dice again, Gill. : p [looking defiant and on the edge of tears]: I'm sorry, I can't go on with this ...it's too much ... : T: What you are saying is that you won't go on with this, is that right, Gill? It's not that you can't go on with this, it's that you don't want to, isn't it, Gill? : P: I don't want to go on with this ...no. T: Are you clear about what it is that you : do want, Gill? : p [sobbing]: ...No. ..I don't know where to start. ... : T: Are you missing your mother's guid- ance, Gill? : [At this point Gill cries for about two minutes continuously.] : This interchange provided a further element for my hypothesis about Gill. The hypothesis can be thought of as having the following components: (a) Gill is a highly telic person who plans ahead and seeks to avoid arousal; (b) Gill has planned ahead and sought to avoid arousal for so long that she is satiated within this meta-motivational state (telic) but appears unable either to shift within this state or to achieve a reversal into another state; (c) this failure to achieve a reversal or a shift is the source of her depression, which in turn is producing a degree of self-neg- ativism; (d) the self-negativism is in itself arousing, and this leads her to experience anger ~s the learned alternative to depres- sion-increasing the number of anger in- cidents in therapy appears to be revealing more about the underlying dynamics of Gill's life; (e) the self-negativism and the depression are both related to her current frustration to perceive future goals and her consequent feeling of entrapment; and (0 in the past, her failure to perceive new goals and tasks has been something which others gave attention to, but now she has no one to provide new goals or purposes for her and this too adds to her feelings of depression. The consequence of this interpretation for Gill is that she will con- tinue to alternate between depression and self-negativism or anger while she per- sists in her feeling of pointlessness. The consequences for therapy are that it is time to choose between seeking out new goals that make sense to Gill and restore the satisfactions of her telic orientation or seeking to promote some reversals be- tween the telic and paratelic states. Given that our contract was for a brief thera- peutic intervention {only eight sessions), I feIt that the first of these therapeutic options was the most appropriate for Gill. It is also the option most likely to be attainable. : I ended the fourth session of her therapy by sharing my hypothesis about her depression and negativism and by draw- ing her attention once again to the im- portance of goals in her life. I observed the role her mother had played historically in the development of goals and how the need for goals had so permeated her life that she had lost the ability to relax in the telic state ó r to see goals in the context of change and development occuring throughout adult life. I pointed out that her essential reason for depression was that she had achieved the goals she had set herself and was now empty of goals. She needed more if she was to continue to develop as a person. What is more, she needed to feel that she "owned" these goals-that they were genuinely from within her-and that they were not im- posed from outside. To recognize and own some new goals would enable her to feel satisfaction in itself, even before she be- gan to work on achieving the goals. : Throughout my exposition ofthis inter- pretation, Gill remained motionless but very attentive. At the end of the exposi- tion she said simply, "The black hole has a white star and the leaves are growing." The hypothesis appeared to be accurate. I asked her to consider what goals were : important tor her and to give thought not to how she could achieve them (or to the problems associated with them) but to just what the goals might be. She agreed to come to session 5 with some goals. : So far the therapy with Gill had used explanation, interpretation, and paradox ical intervention using drama and a dice-based confronting strategy .All these therapeutic tools were intended to increase arousal, to create a need for Gill to experience that arousal and interpret it for herself, and to facilitate the release of negative and positive emotions. Another way ofsaying this is that a variety of methods were employed to test a hypothesis that in itself was derived from the theory of psychological reversals. The next stage of therapy would require the use of other strategies. : Sessions 5 to 8 : I had decided that the goal of therapy was to restore active coping in the telic metamotivational state-achieving reversal was a goal for a therapeutic contract with Gill other than the one under which I was now working. This meant that I needed to facilitate: (a) the identification of goals and tasks and the ownership of the significance of these; (b) the restoration of relaxation; and (c) the removal of self-negativistic responses to arousal. All these therapeutic tasks derive from my understanding of reversal theory. I shared these observations during a routine supervision session. My colleague agreed that these tasks were appropriate for Gill given the way in which the therapy had developed. He suggested that some form of relaxation training may be appropriate, since he feIt strongly that Gill needed to be taught that relaxation was a realistic alternative to depression once goals had begun to be worked on and she feIt that arousal was low. : Gill arrived at the fifth session 15 minutes early. She looked much more confident than she had been on the previous two occasions and her conversational tone was normal and her voice modulated appropriately during conversation Gone was th. outward portrayal of apathy and depression. Before 1 could begin the session, Gill took command: : P: Right now, before we start, Stephen, I have something to say. On the last two occasions we have met you have pushed me into a corner and I have become angry and been very upset. So angry that I swore at you and that I have cried. Since I saw you last I have decided that I am old enough to be able to deal with the kind of anger that you generated, and I want you to know that I am not going to even start playing any of your games this week. Is that clear? : T [smiling, and humorously ]: Perfectly, ma'am. : P: What I am going to do is to talk to y ou about what I have decided to do. .. : Gill then outlined three goals she had decided were appropriate for her. The first was to sell the house her mother had left her-"too many memories and too much pain ...in any case, I need the money and do not need a four-bedroom house. ..also, I think a two-bedroom apartment is much more manageable. ..." She had already placed the property in the hands of a real estate company. The second goal was to work toward opening her own business-"After all, I have virtually run the one I work for and I am qualified in business. ...I am sure that I can manage. ..." Her final goal was by far the most ambitious, at least to : Me .'The next thing is that I am going to stop being so miserable about myself. ...I've wallowed in self-pity and pain for too long." She looked pleased with herself. The session progressed as follows: : T: 'Do you mind if I speak now?' : : P: Of course not, I haven't shocked you? T: Why should you shock me. ...No, I am pleased that you have taken my advice to identify goals so seriously, though I do hope that you haven't moved too quickly in seeking to implement them. Remember, I asked you to look at what the goals might be not how you might achieve them. But no, what strikes me, Gill, is this ...where has all this energy come from? When you first came here it was like looking at and talking to a China doll whose batteries were flat! Now I feel that I am receiving messages from a ghetto blaster! : p [laughs]: ...I don't know where this energy is coming from, I only hope it can last [looks serious]. It will last, won't it? : T: That is up to you and the way in which events unfold. ...None of what you have mentioned sounds easy and all will be challenging. ... : It is obvious from these extracts that the tone and focus of this session are markedly different from those of sessions 1 to 4. What is more, at no time in this session did Gill show any signs of anger , apathy, depression, or fear. Instead, the session was characterized by calmness, occasional amusement, and a kind of certainty that had not been evident before. : Toward the end of the session I suggested that some activity intended to release energy and, at the same time, to promote relaxation would be beneficial. I indicated that I feIt that Gill had a reserve of energy which remained underutilized and that a particular form of dynamic meditation (Rajneesh, 1983; Murgatroyd, 1985b) would be a valuable skill to develop. I gave some instruction and provided her with a tape especially made for the meditation, which involves shaking, dancing, swirling, and total relaxation. I asked her to engage in this activity each evening for the remainder of the therapy and to regard this as a task that I attached importance to on her behalf. She agreed to undertake the meditation, but not on these terros. She said, "I do have energy and I will try your suggestion ...if I like it I will continue, if I don't I will return your tape in due course." I began to suspect that she had been to an assertiveness training course since I saw her last! : In many ways, this was a remarkable session. It marked an abrupt change in Gill, which can only be accounted for by events outside the therapy. One of these, I learned later, was her decision to finally get rid of her mother's belongings and clothes (except for photographs and jewelry), which had remained in the house since her death. Another was the decision of her company to reduce the number of stores in the area - Gill feIt that one of these was a viabIe business concern that she could make profitable if the overheads were reduced. These two events were significant for Gill. She later wrote about them: : ...What the therapy did at this stage was make me more sensitive to events outside me. I felt that the therapy challenged me and led me to want to find a challenge. Both the decision to break my ties (which were still very physical-clothes and furniture) to my mother and the decision to become a business entrepreneur were the result of looking for a chal- lenge. I am not sure, looking back, whether the therapy I had had (which hurt Iike heIl for the first few sessions) made me want to prove something to Stephen. ..but I certainly wanted to prove something to myself. : This letter (written to a friend, and shown to me by Gill for the purpose of completing this case study) makes clearthat she had made her mind up to work with some goals and tasks that she feIt she owned. By ses- sion 5, then, a major task of the therapy had been achieved. : The sixth session was spent discussing her reaction to the meditation technique I had asked her to try. She said that she at first found it strange. The technique is physically very demanding. It begins with the person shaking for 15 minutes, fol- lowed by 15 minutes of dancing, then 15 minutes of relaxation, and then 15 min- utes of swaying and gently rocking. The audiotape I had provided is a tape ofmusic specially recorded for this purpose. Gill had completed this meditation each day for seven days. She said that "it gave me so much energy and I feIt so calm that I have enjoyed the sensation of relaxation more than anything else I have experienced in the last five or six months." She said that the use of an hour a day for the purpose of deliberately trying to relax while at the same time using a lot of energy had had a kind of purging effect. We explored the meaning of "purging" for her-she made clear that it involved, at least at this stage in her life, "getting rid of all the feelings of being destructive to herself," which I saw as a statement about actively seeking to rid herself of her self- negativism. I used this observation to explore with her the idea of retroflection and the objects in the social world which she really feIt negativism toward. It became clear that the objects were largely her own lack of spontaneity and her feeling of a lack of direction in her employment and in her social life. The session ended by me asking whether she needed further sessions. We agreed that she should come in the next week and that the eighth session would be a month af ter the seventh-a follow-up session. : The seventh session was a detailed exploration of her emotional experience of being active again. She made clear that the plans and tasks she had set herself had a high levelof ownership for her and that she was "restored." I asked her how she dealt with frustrations and uncertainty and with the need to be more spontaneous, now that she was running her own business {she had bought her store). This is her reply and the exchange that folIowed: : P: I have given this some thought. I think I am more willing to take risks, some- how. One reason is that I really feel, perhaps for the first time, that I am doing things which I planned and I de- cided upon. Almost everything else I have achieved was under the direction of my mother. I hadn't realized just how significant that was for me, until I decided that it was time I made my own mind up. Now that I have sold the house, sold her things, started on my own as far as work is concerned and started to relax for the first time in my life (at least it feels like that), I am much more able to take each day as it comes. So, I think I am slowly being able to live an easier life, though it is hectic. : T: Gill, can I ask you something. Did you attend your mother's funeral? : p [looks mournful and a little hurt at this question]: No. ..no. ..I didn't. ...I made all the arrangements and made sure that all the practical things had been taken care of. ..but on the morn- ing itself I. ..I. ..just collapsed and couldn't face it ...that was four years ago ...I have felt guilty about it since : T: But now you feel that you have at- tended to the burial as well. Is that what the sale of her clothes and pos- sessions was about, Gill? : P: Yes, yes, I think so. I had wanted to feel as if I was no longer dependent on her. You see, I had achieved all the ambitions she had for me. ..I had got what she wanted ...but somehow this left me feeling empty. Now, well, what I feel now is that I have my own plans. ...I mean, I am grateful for the guidance and help and love my mother gave me. ..don't get me wrong. ..but now I feel, well, I am on my own ...and I should enjoy it. : T: You are no longer willing to feel guilty about having plans of your own? : P: That's it. [smiles] y ou know me very weIl. don't y ou, Stephen? : As is often the case with depression of this type, unresolved issues were at the core of the depression. In this case, the loss-grieving process (see Murgatroyd & Woolfe, 1982; Parkes, 1972) had not been completed, and grief and locus of control issues had remained unresolved for Gill. I used this observation to begin the discussion with Gill about the impact of the termination of therapy. She said that, though I had provided a trigger for her to snap out of her qepression, she feIt that she had achieved a great deal on her own and was feeling capable of overcoming any difficulty about termination. In any case, she said, we were seeing each other in a month's time and this would provide a basis for her rehearsing life without therapy. : A month later Gill arrived promptly for her final session. She said that she could only stay for an hour (the session was planned to be an hour and a half), but that she thought this would be adequate. She explained that she had been extremely active since I last saw her. She had moved house, her business was beginning to work in a way that she found acceptable, and she had starled to go out with a female friend -Jenny- whom she had met through the community group that had referred her to me. They met each Friday and went to a yoga class and then on for a drink. She said that she had enjoyed Jenny's friendship and had not feIt that it needed to be something that was controlled and planned. One ofthe things that she had learned in therapy, she said, was that even careful plans about what would happen can come to nothing if the other person does not fully share the plan or the need to plan. She referred parlicularly to session 4 in this discussion. : I asked her to review her therapy. She said that the most critical experience was being forced to realize that the only alternative to depression that she could produce was anger. She particularly identified with the feelings ofnegativism, which she feIt she was strongly directing toward herself. She realized that this must be some kind of displaced anger or hostility. It was only later that she realized that this anger was directed at her mother. The other thing that she feIt was important to her was having some features of her person- ality recognized in the beginning (session 2). For her, knowing that the work we completed was grounded insomething she herself could understand ("it wasn't all mumbo-jumbo and black magic") meant that she was willing to trust me when I asked her to do some drama work or the dice work. : Af ter an hour of this discussion and evaluation, the session ended, and my contact with Gill was over-at least so I thought. Three months later Gill wrote to me a kind of thank you and evaluation letter . Here is the text: : Dear Stephen, It is some time since my last session. It occurs to me that I did not really thank y ou. When I came to y ou I was very depressed and so exhausted that I feIt near to the point at which life would seem pointless-you made me feel that there was an explanation for how I feIt and that I could overcome the depression. You challenged me in a number of ways. I understand now that y ou were trying to get me back on the telic curve (1 hope that's the right term); at the time, though, I thought y ou were cruel and hard on me. I kept hearing my mother say that "nice" people are always kind and considerate and that your behavior meant that y ou were not a nice person. So, I thought bad thoughts about y ou. Hut then I started to think about the way I had always been controlled by mother and about the way in which I feIt that, even though she was dead, she still controlled me. : The one thing I have given a lot of thought to since we met (we've been very busy at work) is why I did not go to her funeral. It seems to me that I was afraid of seeing her being cremated and knowing that, from that moment, I was on my own. I think a lot of the anger 1 had was about knowing that I was free from her inf1uence and yet not knowing what to do with my freedom. You helped me find this issue, so I have to thank you for that. : One more thing. I do really want to thank you for the meditation. I still do it each day (unless something else has happened). It gives me such a tranquil feeling and it's so reliable that, well, I think you should tell all of your clients to do it! : So, thank you, Stephen. If you ever need any cosmetics let me know. : : This was my last significant contact with Gill. Though there appear to be many unresolved issues in her life that she may one day wish to discuss, Gill is certainly not currently depressed. : CONCLUDING COMMENTS : This case study indicates the way in which a body of theory about the person and about the structural impact of therapy CMurgatroyd & Apter, 1984, 1985) can be used to provide a rationale for eclectic therapy. In my work with Gill I used a variety of techniques from paradoxical intention to meditation as devices for changing the way in which Gill experienced arousal. In terms of her depression, : changing both the levelof her arousal experience and the way in which these experiences were interpreted by her was critical to the change in her phenomenal field. These interventions were derived from my understanding of her presenting problem in terms ofthe theory of reversals and in terms of my understanding of the likely impact of these therapeutic inter- ventions on both her arousal and motivational systems. Reversal theory thus guided my hypothesis about Gill and my assumptions about the impact of therapy on Gill. : Other cases using reversal theory have been published (Blackmore & Murga- troyd, 1980; Murgatroyd, 1981; Murga- troyd & Apter, 1984, 1985) which illuminate the way in which the theory of psychological reversals offers a frame- work for eclectic practice. The case re- ported here illuminates some limited features of the eclectic model-the other reported case illuminate different facets of this approach. It is hoped that the case ofGill illuminates the nature ofstructural phenomenological eclectic practice

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