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Transactional analysis psychotherapy for a
case of mixed anxiety & depression : a
pragmatic adjudicated case study –
‘Alastair’
Widdowson, MDJ
10.29044/v5i2p66
Title Transactional analysis psychotherapy for a case of mixed anxiety &
depression : a pragmatic adjudicated case study – ‘Alastair’
Authors Widdowson, MDJ
Publication title International Journal of Transactional Analysis Research
Publisher The European Association of Transactional Analysis (EATA)
Type Article
USIR URL This version is available at: http://usir.salford.ac.uk/id/eprint/32036/
Published Date 2014
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Transactional Analysis Psychotherapy for a Case of Mixed
Anxiety & Depression: A Pragmatic Adjudicated Case
Study – ‘Alastair’
© 2014 Mark Widdowson
Abstract have comparable outcomes (van Rijn and Wild, 2013).
Using an original method of case evaluation which Three previous case studies have demonstrated the
involved an analysis panel of over 80 Italian effectiveness of transactional analysis psychotherapy for
psychologists and included a lay case evaluation, the the treatment of depression (Widdowson, 2012a, 2012b,
author has investigated the effectiveness of transactional 2012c). In one of those cases (Widdowson, 2012c), the
analysis psychotherapy for a case of mixed anxiety and client appeared to have considerable anxiety; however
depression with a 39 year old white British male who this was not measured in the study and therefore
attended 14 weekly sessions. CORE-OM (Evans, conclusions regarding the effectiveness of TA for
Mellor-Clark , Margison, Barkham, Audin, Connell and comorbid depression and anxiety could not be drawn.
McGrath, 2000), PHQ-9 (Kroenke, Spitzer & Williams, This present case study examines the process and
2001), GAD-7) Spitzer, Kroenke, Williams & Löwe, 2006, outcome of brief, 14-session therapy with ‘Alastair’- a
Hamilton Rating Scale for Depression (Hamilton, 1980) white British man presenting with mixed depression and
were used for screening and also for outcome anxiety.
measurement, along with Session Rating Scale (SRS This case study draws on several research designs;
v.3.0) (Duncan, Miller, Sparks, Claud, Reynolds, Brown firstly, the case is presented using pragmatic design.
and Johnson, 2003) and Comparative Psychotherapy Pragmatic case studies focus on the clinical process in
Process Scale (CPPS) (Hilsenroth, Blagys, Ackerman, an attempt to elicit aspects of best practice (Fishman,
Bonge and Blais, 2005), within an overall adjudicational 1999; McLeod, 2010). The case study was evaluated
case study method. The conclusion of the analysis panel using an adjudicational method. Adjudicational case
and the lay judge was unanimously that this was a good studies rely on a quasi-legal framework drawing on a
outcome case and that the client’s changes had been as panel of judges for forming conclusions regarding the
a direct result of therapy. Previous case study research outcome of the case and possible factors which have
has demonstrated that TA is effective for depression, and influenced the outcome (Bohart, Berry and Wicks, 2011;
this present case provides foundation evidence for the Elliott, 2002; McLeod, 2010). This present case has
effectiveness of TA for depression with comorbid anxiety. utilised a novel approach for evaluating the case by
Key words drawing on a large group of psychologists and also by
anxiety, depression, case study research, Pragmatic the use of a lay judge. Although several published
Adjudication Case Study, transactional analysis adjudicated cases have suggested that there may be
psychotherapy value in recruiting lay judges in the adjudication process
(see Stephen and Elliott, 2011), the author is not aware
Introduction of any previous studies which have actually done so.
The evidence base for the effectiveness of transactional The aim of this present case study was to investigate the
analysis (TA) psychotherapy is rapidly gaining ground. process and outcome of short-term TA psychotherapy for
Two large scale studies have demonstrated the the treatment of mixed depression and anxiety. The
effectiveness of short-term TA psychotherapy for author, who was the therapist in this case, had developed
reducing overall distress, depression and anxiety a manual for the treatment of depression (Widdowson, in
symptoms (van Rijn, Wild and Moran, 2011; van Rijn and press) and a further aim of this case study was to provide
Wild, 2013) and have demonstrated that TA, gestalt, a pilot evaluation of the treatment manual for comorbid
person centred and integrative counselling psychology anxiety and depression.
International Journal of Transactional Analysis Research Vol 5 No 2, July 2014 www.ijtar.org Page 66
Client and Case Formulation expectations, and for the therapist to conduct a mini
Case Context diagnostic interview. His therapist identified a persistent,
Alastair had weekly individual psychotherapy with a chronic low-grade depression and some anxiety using
therapist in private practice. He independently sought out DSM-IV criteria (American Psychiatric Association,
his therapist, who was the author was the therapist in this 1994).. There was no indication of any other disorder. He
case. At the time of conducting the therapy, the therapist was screened using CORE-OM (Evans, Mellor-Clark,
was a 39 year old white British male with 16 years of Margison, Barkham, Audin, Connell and McGrath, 2000)
clinical experience. The therapist is a teaching and PHQ-9 (Kroenke, Spitzer & Williams, 2001) and GAD-7
supervising transactional analyst and a post-doctoral (Spitzer, Kroenke, Williams & Löwe, 2006). His initial
psychotherapy researcher. CORE score was 15 indicating mild levels of global
Client distress and functional impairment. His PHQ-9 score
To preserve the client’s anonymity, some details have indicated mild depression and his GAD-7 score indicated
been changed: however the client description and severe anxiety. Therapist scored Hamilton Rating Scale
for Depression (Hamilton, 1980) score was 15, also
description of the therapy process are still ‘close enough’ indicating mild depression. Alastair completed CORE-
to give the reader a clear sense of the client and the OM, PHQ-9 and GAD-7 every fourth session and also at
therapy. Any changes made do not adversely affect the his final session and at follow-up intervals of one month,
validity of the case study or change crucial variables. three months and six months.
Alastair was a 42 year old senior executive who initially Strengths: Alastair was warm, friendly and energetic (in
presented for therapy for “problems with self-confidence spite of his anxiety and depression). He was an intelligent
and self-esteem”. He was well-dressed in a stylish suit and articulate man who appeared to be very open and
and well-groomed, suntanned, and had a warm, friendly receptive to new experiences and had a curiosity about
manner about him and the therapist found him to be the world. Although he initially struggled with identifying
instantly likeable. Alastair grew up in a small town in rural and expressing his feelings, he engaged well with this
Scotland and was the eldest of three children. His aspect of the therapy. His initial apprehension about
parents had divorced when he was ten years old, and to therapy soon disappeared and he enthusiastically
some extent he had blamed himself for this. He had not participated in the process. He was very active and
enjoyed school and after the divorce felt different to the committed to the therapy process and consistently
other children. He also became aware of his parents not performed all negotiated homework tasks with
having very much money when compared to families in considerable care, attention and effort. Prior to attending
the area who were largely middle-class and relatively therapy, Alastair had read a number of self-help books,
affluent. He reported having a “decent” relationship with which he had found interesting, but which had not
his parents and siblings but said that they were not very resulted in any change in how he felt. Nevertheless, his
close or warm or affectionate with each other. He had left reading had given him some insight into what he might
school at 16 and gained an apprenticeship in a local get out of therapy and in identifying issues he could
engineering firm where he had done exceedingly well. He address in sessions.
completed day-release degree education whilst working,
gradually gaining promotions and seniority in the Case formulation
company. Six months prior to attending therapy he had Alastair’s depression and anxiety were conceptualised
been given a substantial promotion onto the board of as sharing a common introjective pathway (Blatt, 1974).
directors. Although his work performance was excellent, This resulted in a highly self-critical ego state dialogue
he was personally struggling with this and in particular (Berne, 1961; Widdowson, 2010, 2011). It was
with feelings of inferiority, of “not being good enough” and considered that for therapy to be effective this introjective
was concerned that he would eventually get demoted or process would need to be dismantled and replaced. The
fired. He was particularly struggling with his feelings self-critical introjective process was influenced by his
relating to and stirred up by frequent board meetings and script beliefs (Stewart and Joines, 1987) which were
presentations he had to make. It was these concerns formed from implicit learning during childhood, and then
which had prompted him to seek out therapy. He was subsequently reinforced through distortions and negative
married, with two boys aged 9 and 7. He reported a good interpretation of events which was replayed via his script
relationship with his wife, but felt that he did not quite system (Erskine, 2010). This had negative interpersonal
know how to relate to his children and was afraid that consequences which repeatedly reinforced his core
they would grow distant over time. Socially, he was quite script belief of “not being good enough”. Furthermore,
isolated, seeing a small group of friends fairly positive feelings such as joy and pride were disallowed.
infrequently. He said that he had never spoken to anyone These factors combined meant that Alastair had
about how he felt before and was a little apprehensive developed a self-perpetuating system which he was
about therapy. unable to challenge alone.
The purpose of the initial meeting was to clarify his This case formulation is consistent with the framework
presenting problems, form a working alliance, conduct presented in the TA treatment manual (Widdowson, in
induction into the tasks of therapy and clarify process press) on which this therapy was based. The author had
International Journal of Transactional Analysis Research Vol 5 No 2, July 2014 www.ijtar.org Page 67
previously conducted a case series which investigated been surprised by her positive response to this. The
the use of TA psychotherapy for depression. This case remainder of this session and session 5 continued with
was used as ‘proof of concept’ pilot study to test out more exploration of his self-limiting narrative and script
whether the principles of the manual would work in beliefs around not being good enough. Alastair was
practice and specifically if they would be suitable for invited to pay attention to when this belief was influencing
mixed anxiety and depression. The treatment manual him, and to actively question whether or not the belief
places great emphasis on the intake procedure and client was valid. The therapist conceptualised this as
role induction. decontamination (Berne, 1961; Woollams & Brown,
Therapy Process 1979), which would weaken the influence of the script
Alastair attended a preliminary mutual assessment belief and start to interrupt Alastair's self-critical ego state
session. The therapist engaged Alastair in some initial dialogue. Alastair was also invited to experiment with
exploration regarding the problems he was seeking help wondering what it might be like if he did see himself as
for in therapy, a mini diagnostic interview and some good enough, and what the negative consequence of this
discussion about the tasks and process of therapy as would be, if any. This was seen by the therapist as a
part of the role induction procedure. The therapist also strategy which would challenge the limiting narrative of
raised the potential for Alastair to engage in research in his script, and also continue the process of deconfusion
this meeting. by encouraging a surfacing of Alastair’s anxieties and
Child fantasies around issues of worth.
The first therapy session was spent on some further Session 6 focused on deconfusion, and in particular how
history-taking, problem formulation, goal setting and the Alastair prevented himself from feeling joy, pride and
therapist explaining how the therapy would work, and self-confidence. The therapist engaged Alastair in some
clarifying expectations. Part of the problem formulation discussion of these 'forbidden feelings', and Alastair
process involved the generation of a basic case explained how he was afraid that if he experienced joy
formulation, which the therapist checked with Alastair for that ”things would go wrong”, and that pride would
purposes of verification and consensus agreement. automatically lead to being arrogant and narcissistic. The
In the second session, Alastair described his chronic therapist considered this to be a key dynamic in Alastair's
feelings of inferiority which he had felt since childhood. depression. The therapist's approach was not to
The therapist gave Alastair several positive strokes challenge or confront this directly, but to invite Alastair to
(Steiner, 1974) during the session and noticed how spend the week noticing whether stopping oneself from
Alastair deftly discounted them (Schiff et al., 1975). This feeling joy would actually prevent anything bad from
was explained by the therapist as a strategy which happening, and also whether people who felt a sense of
maintained Alastair’s sense of inferiority, and he invited pride were always arrogant, narcissistic and selfish. This
Alastair to practice simply and graciously accepting would generate experiences which would cause
positive strokes which came his way. This was framed by cognitive dissonance (Festinger, 1957) and thus facilitate
the therapist to Alastair as accepting a gift which was
freely given, and that just as he enjoyed doing things the change process. The therapist’s stance here was of
empathic enquiry (Erskine, Moursund and Trautmann,
which made other people feel good, his acceptance of 1999; Hargaden and Sills, 2002), and inviting Alastair to
strokes would likely enable others to enjoy the good develop a more self-compassionate stance and
feelings they produced in him. It was also suggested that understand how these beliefs were born out of positive
if he found any adverse consequences to practicing intentions.
stroke acceptance he could quickly reverse his
behaviour. Alastair arrived for session 7 clearly excited and bursting
Session 3 began with more detailed exploration of the to tell his therapist “some good news”. He had been out
with his friends a few evenings previously and decided to
origin of Alastair’s feelings of inadequacy in childhood, tell them that he had struggled with feelings of
and his script decision to remain “closed” to other people. depression and anxiety for many years, and also that he
Alastair felt that if he opened up to others, they would was in therapy. Their reactions astounded him. Instead
think less of him, and thus confirm his inferiority. The of judging him, as he expected, they were warm and
therapist proceeded with deconfusion (Berne, 1961, accepting. Two of his friends disclosed that they too had
1966; Hargaden & Sills, 2002, Widdowson, 2010) and similar feelings, and one was also in therapy. The terrible
assisted Alastair in expressing his sense of shame, and rejection he feared did not happen, and instead he found
his historic sadness and fear. To support this, the his relationships were strengthened. The session went
therapist explained the interpersonal nature of feelings on to explore how he had often felt responsible for the
and how attuned responses from others can change happiness or unhappiness of others, and the origin of this
emotions. The session concluded with some behavioural in his fantasies of blame around the time of his parents’
contracting around “letting other people in”, in particular, divorce. Following on from the previous session, he
his wife. described how he had realised that bad things would
Alastair started session 4 by reporting that he had started happen, regardless of whether he felt happy or
experimenting with opening up more to his wife, and had depressed, and that worrying about them only had the
International Journal of Transactional Analysis Research Vol 5 No 2, July 2014 www.ijtar.org Page 68
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