Extracts from a case study by Sylvia Rose
The following extracts are from a case-study of a client at a residential therapeutic community for severely emotionally disturbed individuals. The therapeutic model used is Transactional Analysis. For an introduction to the theory, see TA Today, by Stuart & Joines, 1987 (Lifespace Publishing). The name of the client in this study has been changed.
[Below are brief and very simplified explanations of some of the TA terms mentioned in the extracts. When ‘Parent’, ‘Adult’ or ‘Child’ are used with a capitalized first letter, they refer to ego states. Roughly, ‘Parent’ is an ego-state which reflects the thinking, feelings and behaviour of parental figures from a person’s past; ‘Adult’ reflects a state in which a person is responding to their current surroundings (reality testing) to inform their thoughts, feelings and actions; and ‘Child’ is a state in which a person is acting, feeling or thinking in ways that they used in their childhood.
‘Contamination’ is where a person believes themself to be in Adult (ie reality testing), when in fact they are discounting some aspect of the current situation, and responding in ways which limit them in some way. ‘Decontamination’ is when a person realizes that their response is self-limiting and based on their past, rather than their current, experience.
‘Script’ is a set of contaminated beliefs that forms a person’s internal frame of reference about the world and which they reinforce by discounting certain aspects of reality.
‘Kick-me’ is a strategy (in TA called a ‘game’) where a person gets negative attention (in TA called ‘negative strokes’) by setting up a situation, out of their awareness, in which another person gets annoyed with them for some reason. The person has developed this strategy in childhood when positive attention was largely denied them. A child has a survival need to get its existence recognized, therefore negative attention is used to meet this vital need. Later in life the person still employs this, now outmoded, strategy in situations where positive strokes or attention are readily available.]
Lisa was referred to the Community by the clinical psychologist at the psychiatric hospital she was attending as a day patient. She had been in and out of the psychiatric hospital for some eleven years and was not responding to drug therapy. She had become increasingly disruptive and had recently been threatening to kill herself in front of her children. The psychologist at the hospital believed that she needed a secure and stable environment in which she could develop a trust relationship before she would begin to calm down and change. The consultant psychiatrist at the hospital predicted that Lisa would become a ‘back ward’ patient if she continued on her present path and therefore agreed that she should be given the option of having psychotherapy at the Community.
When she came for her initial interview, Lisa looked like a lost child. She was dressed in ill-fitting and mismatched clothes. Her hair was malted, her fingernails dirty, and her teeth yellowed. Her movements looked uncoordinated and she turned her toes inwards as she walked. Her voice was high pitched and her speech was rapid. She appeared wide-eyed but every so often she would squint, put her head on one side and flinch, which gave her the appearance of a frightened rabbit. She believed that she was giving off poison and told us to stay away from her or else we would be poisoned. She also reported herself as hearing ‘the voices’ which commented on her circumstances and told her what to do. She told us that she was stupid and that she knew we would not like her, but that she had come to see us because her psychologist thought it was a good idea. She appeared to have some pride in the fact that they were finding her difficult to handle at the hospital.
Lisa was given up for adoption at six weeks old. Her adoptive mother was an alcoholic who acted out violently against her husband and her two adoptive children. She tortured Lisa both mentally and physically, locking her and her brother in a small room for days at a time. Once she held Lisa’s hands in boiling water “because they were dirty”. Lisa remembers that her skin came off her hands “like a pair of rubber gloves” and that she had them bandaged for weeks. Her mother had a fantasy daughter to whom she would compare Lisa unfavourably and taunt her with derisive comments. She forced Lisa to speak to this imaginary daughter and to apologise for being bad. Lisa’s lack of normal development was evident as early as eighteen months old, and she did not begin to walk until she was three. She remembers her mother bandaging her feet and tying her legs together to get her to “walk properly”. She also recalled her mother tying her to chairs for extended periods to make her “sit properly”.
Her adoptive father was also alcoholic. She reports that he was a passive, ineffectual man who was bullied by his aggressive wife. He sexually abused Lisa for as long as she can remember. (Medical evidence of early internal scarring suggests that she is right in believing that he started to abuse her as a baby.) She despised and yet loved him. She could and would manipulate him into being sexual with her as a way of getting physical strokes. Lisa married a man who is stern and critical of her. He treated her as if she was an inadequate child and took on the role of house-husband to the family as well as having a full time management job. She once attacked him with a broken bottle whilst he slept. Her three daughters were subjected to terrible ordeals at Lisa’s hands. For instance, when they cried as babies she would lock herself in the garden to stop herself from killing them. She would starve them or threaten to harm herself in front of them. They were on the ‘at risk’ register with Social Services.
Lisa had made numerous suicide attempts, by overdosing, cutting her wrists and by lying in the path of oncoming vehicles. Once she attempted to jump from a multi-storey car park. She has also harmed herself by cutting herself, banging herself in the stomach and by hitting her own foot and breaking it with a hammer.
When Lisa entered the Community, she made the following contract:
The Community Members also entered into a contract with Lisa which complements hers.
- 1. I will work to solve my problems.
- 2. I will support other members of the community in solving their problems.
- 3. I will confront from a caring position and will respond appropriately to confrontation.
- 4. I will keep to the rules of the Community. (The rules include no violence and safety rules for self and others. There is also a no sexuality rule between residents, and between staff and residents.)
- 5. I agree to pay the fees. (The cost is met by the DSS but Lisa must collect it and hand it over.)
- 6. I agree to learn healthy ways of living and to follow the guidance of the staff in regard to these.
- 7. I agree to keep contracts that I may make in relation to my therapy issues.
- 8. I will ask for information if there is anything I do not understand.
Later in her residency, Lisa made a parenting contract with me as her therapeutic ‘mother’. This involves my accepting her as my ‘daughter’ with the only proviso that she use our relationship to get well. It is important to emphasise that I have my own safeguards in relation to ‘parenting’ contracts. I only develop Parent-Child relationships, with adults, in an environment where informed others can supervise, monitor and give feedback on the process between myself and the individual in question. I only make a parenting contract with someone who has already developed an attachment relationship with me and whom I want to relate to as my ‘son’ or ‘daughter’. I am not obliged to become the ‘parent’ of anyone and I will not reinforce pathology by becoming a ‘parent’ and ‘looking after’ them from a ‘should’ position. I will only take on a ‘son’ or ‘daughter’ who guarantees to live within the Community until they are well and able to live an independent life. This is to make sure that I have support, supervision and feedback during their treatment and that they have the support that they will need to do the psychic restructuring necessary. I would not expect to be financially responsible for any adult son or daughter, whether they were natural or contractual ‘children’. I will only take responsibilities which do not match the socially expected norm by contractual agreement. My ‘son’ or ‘daughter’ is only treated like a young child when, and because, they have contracted with me to be treated that way. When we are outside of that structure, or when they are well, then I treat them as autonomous adults with whom I have a deeply caring relationship. I have a natural child who is an adult, whom I care about and take an interest in, and I will treat my contract ‘children’ in the same way outside of meeting their therapeutic needs.
Lisa was diagnosed as Paranoid Schizophrenic. “Schizophrenia is characterised by a locked system of messages in the Parent, corresponding adaptations in the Child and an Adult unable to contradict it. The person has no exit from this system without external intervention.” (Schiff, J. et al, Cathexis Reader: Transactional Analysis Treatment of Psychosis, NY 1975) I decided to use Eric Berne’s treatment plan for the therapeutic treatment of psychosis.
It has seven stages:
1. Wait till the Child calms down. 2. Make friends with the Child. 3. Let the Child have her way first. 4. Make a firm Adult to Adult contract. 5. Decontaminate, clarify and strengthen the Adult. 6. Deconfuse the Child. 7. Supply Parental support if necessary. (Southey Swede, How to Cure, NY, 1977)
When Lisa moved into the Community, she gradually began to learn the rules, attend meetings etc. and all this helped her Child to calm down by giving her structure and boundaries. She started to take a closer look at me, but since she believed she was emitting a poison which could kill me if I touched her, she followed me round and watched me from a safe distance. I let her just be around me during this time, not wanting to make therapeutic moves until she had gained some confidence in me. She chattered incessantly to me, but she would usually reframe what I said to her into a negative comment. She would keep up the reframes, insulting herself until I would get frustrated and defend my position by saying, “No, I didn’t say you were stupid and I don’t think you are either. I don’t like it when you put yourself down, and I won’t go on listening to you if you are going to insult yourself or me.” At this point she would decide that I had rejected her. Many times I would go for staff support, believing I had not been OK for having been hooked into her game. The other staff would regale me with tales of other paranoid kick-me players they had known. They would laugh about the sense of frustration they had experienced in similar circumstances, and I would feel better about myself. Gradually Lisa’s Child made friends with me.
It was very obvious that her Child craved nurturing physical contact, but she feared it too after the sexual and other abuse she had experienced in the past. She had used her poison story to keep people away. I needed to find a way to let her Child have safe physical contact. One day I noticed that her hair looked knotted and unkempt. “I could brush it for you if you like,” I said casually, offering her an option for physical contact without wanting to scare her by appearing overly keen. To my surprise Lisa took me up on this offer. She fetched the brush and I brushed her hair. She had made her first move against her Parental directive, not to get close, and towards being in physical contact with me. She eventually asked me to hold her, which I agreed to do as part of letting her Child have its way. She was stiff and looked completely terrified. “Are you going to kill me now?” she asked in a frightened little voice. “No, I’m not going to kill you now or ever. You are safe even though you are scared right now.” After this she experienced a lot of lashback from her internal Parent via ‘the voices’ which started to tell her to kill herself because she was disgusting. She reported this to me and I put her on a be-with structure for protection, which meant that she was to ask someone to be with her at all times. I told her that she must stay on this structure until she knew that she was safe and would not act out on what she was telling herself via ‘the voices’. It was noticeable that Lisa felt protected by my intervention and began to trust me more over the next few months.
During her fifth month of treatment, Lisa asked me to be her ‘mum’. I knew that she was attached to me and I now wanted to offer her that security. After gaining the approval of the staff, there was a formal ceremony in front of the whole Community to establish the contract. By virtue of this contract, Lisa made a commitment to take on my definitions about the world until she is well. After that she will be able to test reality sufficiently to make autonomous decisions successfully. This commitment to getting well was my only proviso in making the parenting contract with her.
By now Lisa was being held regularly and had also initiated to be regressed and have bottles. One day she cried whilst having her bottle and I realized that the milk was too hot, and had cooled it down before offering her any more. When I fed her the cooled milk, she stopped crying and gurgled with pleasure. After I brought her out of the regression, she told me what she had experienced whilst having the bottle, clearly relating from her Adult to mine. She told me that she had realized that she could feel when she was a baby with me, because she believed that I would respond to her when she cried in pain. She believed that her adoptive parents had not responded to her cries of pain and that she had decided not to feel, because of this. This realization explained her lack of discrimination of temperature, which had earlier led to me insisting that she get another person to check all water she used to wash and any hot drink she had, to prevent her from scalding herself. She was excited about having fathomed this out for herself, and I stroked her thinking. It was a breakthrough in her Adult reasoning.
Over the next year, Lisa’s work showed that she was decontaminating her Adult effectively and was taking in new Parenting. She now feels the difference between her Adult knowledge and her Child beliefs, and finds it uncomfortable to maintain the script messages against reality. She displays a greater level of maturity in her relationships with other members of the Community. She has developed and improved her relationships with her three daughters, who come to visit for the weekend once a fortnight, so much so that they have all begun to change markedly too. The difference in Lisa’s appearance and behaviour is remarkable. She now displays a calm, grounded attitude and a friendly manner. This is in sharp contrast with her presentation at the start of treatment.
I have learned a great deal from Lisa and have done many pieces of personal therapy which have directly related to the work she has been doing at the time. I have learned to make and keep boundaries, after being faced with the sheer bombardment and intensity of the emotional manipulations that Lisa would use to attempt to draw me into her frame of reference. She would test me by attempting to provoke me emotionally. Somehow she would find any unresolved issues I had and touch on those raw points until I would respond. It seemed like I worked on nearly as many issues as Lisa, but usually at a far less intense level. Learning to ask for help by reaching out to others for support during those difficult times has been a significant and important growth for me. Lisa and I have grown together during the past three years and we both continue to grow and change as our relationship develops. She has certainly helped me to improve my technique and approach as a therapist. I feel proud of my ‘daughter’ and proud of myself as her ‘mother’.
Sylvia Rose is a Transactional Analyst with a private psychotherapy and training practice in Birmingham. She previously lived and worked for five years in the TA Community mentioned in the article, and remains ‘Lisa’s mum’.
Contact numbers: Sylvia Rose – ph: 0044 121 449 2822, THAT (Trident Housing Association Therapeutic) Community – ph: 0044 121 449 2204, ITA (Institute of Transactional Analysis) information – ph: 0044 181 958 2553.