Patients were discharged 24 hours postoperatively after 1 dressing change and placement of a surgical bra and an elastic band with Velcro closure above the breast to prevent upward migration of the implant.

Patients were instructed to wear the elastic band for 30 days and the surgical bra (Yoga, Rio de janeiro, Brazil) for 45 days.


During the early postoperative period, patients were asked to rate their level of pain on a scale of 1 to 5, with 1 representing no pain and 5 representing pain that precluded routine activities (Table 1).

Six months postoperatively, patients privately completed an anonymous questionnaire to rate their satisfaction with the aesthetic appearance of their breasts and scars.

Patient satisfaction was scored on a visual analog scale of 1 (unsatisfied) to 5 (very satisfied, with no complaints; Table 2).

To assess symmetry of the


Between-group differences in postoperative pain, patient sat- isfaction, and fold symmetry were ascertained by the non- parametric Mann-Whitney test.

The parametric t test was applied to assess between-group differences in age, BMI, and operating time.

Statistical significance was defined as P < .05.


The mean ages of patients in the endoscopic (n = 17) and nonendoscopic (n = 17) surgical groups were 28 years (range, 20-32 years) and 26 years (range, 20-30 years), respectively.

There were no significant between-group dif- ferences in age or BMI (data not shown).

Mean operating times were 120 minutes for the endoscopic group and 70 minutes for the nonendoscopic group (P = .032).

Mean follow-up for all patients was 25 months (range, 12-34 months).

No patients were lost to follow-up.


There were no cases of seroma, infection, or capsular contracture in either group.

One patient in the nonendo- scopic surgical group had wound dehiscence (0.5 cm) with spontaneous closure and no major repercussions on scar quality.

One patient in the endoscopic group developed a hematoma of the surgical wound without extension to the mammary pocket.

The hematoma was drained in an outpa- tient procedure and had no major repercussions on scar quality.

See Table 2 for rating descriptions.

for rating descriptions.

See Table 1 for rating descriptions.


There was no significant difference between groups in reported level of postoperative pain (P = .70), and all patients reported improvement in pain level after 1 week (Table 3).

Between-group differences in satisfaction with- breast shape/volume and with scars at 6 months posto- peratively were not statistically significant (P = .14 and P = .67, respectively), and no patients indicated that they were unsatisfied or poorly satisfied with the shape/ volume of their breasts (Table 4) or with their scars (Table 5).


In the nonendoscopic surgical group, 14 of 17 patients (82%) had symmetric submammary folds, as determined by the senior surgeon.

The remaining 3 patients (18%) had folds considered asymmetric.

There were no cases of NAC Downloaded from https://academic.oup.com/asj/article/35/3/265/201054 by McGill University user on 16 May 2024 malposition in the nonendoscopic group (Figure 2).

In the endoscopic group, 15 of 17 patients (88%) had folds that were considered symmetric, and 2 patients (12%) had asymmetric folds (Figure 3).

The surgeon noted that the NAC was too low in 1 patient in the endoscopic group (6%).

There were no significant between-group differences in symmetry of the submammary fold (P = .65; Table 6) or in position of the NAC (P = .33; Table 7).


The transaxillary technique was developed as an alterna- tive to traditional breast augmentation for patients who wish to avoid incision scars on their breasts.

By concealing the scars in the axillae, this approach avoids the stigma associated with a visible incision scar indicating breast surgery.

Moreover, this technique retains the integrity of the mammary gland and the lactiferous ducts.

The results of nu- merous studies have demonstrated that adequate knowledge of the axillary structures and superficial dissection of this area improve the success rate of transaxillary breast augmentation while preserving normal lymphatic drainage.

13-16 However, concerns about performing this procedure without endo- scopic assistance persist.

Theoretically, the nonendoscopic operation may be associated with an increased risk of edema and hematoma caused by undermining and with poorer aes- thetic results due to less precise dissection of the lower pole of the breast.


Transaxillary augmentation mammaplasty with video-assisted endoscopy has been suggested as a safer alternative offering better control of dissection and bleeding, and consequently, more predictable results, fewer compli- cations, and better aesthetic outcomes.

17,18 Some authors also have noted that the endoscopic operation yields smaller scars, less postoperative pain, and a shorter recovery period.

19 Although the endoscopy-assisted transaxillary technique initially was intended for submuscular implants, it has also been adapted for implantation in the subglandular plane.


In comparative studies of mammaplasty, authors have assessed various types of incisions and planes for implant insertion and have investigated operating times, satisfac- tion with aesthetic results, and complication rates.

19-21 In the present study, we sought to determine whether im- plantation in the subglandular plane with video-assisted endoscopy resulted in a safer operation with superior aesthetic outcomes compared with the nonendoscopic operation.


Our study addressed surgical outcomes in women of childbearing age, which is consistent with the age range of patients who typically undergo augmentation mamma- plasty.

22 Although our study groups were relatively small, we applied rigorous inclusion and exclusion criteria to ensure group homogeneity and minimize sampling bias.

However, the exclusion of women with obesity, mammary ptosis, or previous breast alterations may have limited the applicability of the results.

Enrollment of a more heteroge- neous population would have required inclusion of more patients and possibly stratification into additional groups.

This process would have increased the duration of the study and likely would have introduced unavoidable bias.


Although established and popular, the Client Satisfaction Questionnaire 18 was not employed in this study because pa- tients reported difficulty in completing this questionnaire, possibly due to the large number of questions.

We substituted a shorter and more direct questionnaire that included a 5-point analog scale for evaluation of the aesthetic appear- ance of the breasts and scars at 6 months postoperatively.

Patients rated their pain as 1 of 5 levels according to their need for analgesics and their ability to execute routine ac- tivities; this rating system was well understood by respon- dents.

To avoid partiality, the aesthetic results of all patients in the study were analyzed by a surgeon who did not perform the operations.

This surgeon's analyses of sub- mammary fold symmetry and NAC position were per- formed and recorded in strict confidentiality.


No major postoperative complications, such as seroma or capsular contracture, were observed, and only 1 patient in each group (6% per group) reported a minor complica- tion.

In a 20-year review of reoperation rates associated with transaxillary breast augmentation, Huang et al 23 noted a very low rate of complications (eg, seroma and hemato- ma), consistent with the present study.

However, our follow-up period was much shorter than that of Huang et al 23 and was insufficient to identify reoperations due to capsular contracture.


Operating time was the only variable that was signifi- cantly different in endoscopic and nonendoscopic surgical groups.

Inclusion of endoscopy increased operating time by at least 1 hour.

According to Munhoz et al, 9 endoscopy also increases the demand for surgical materials and staff train- ing.

The results of our study indicate that the additional time, materials, and training did not translate to a de- creased complication rate or improved aesthetic outcomes.


Careful execution of transaxillary augmentation mamma- plasty by a surgeon who is knowledgeable about axillary and breast anatomy and who ensures appropriate positioning


The results of the present study indicate that inclusion of video-assisted endoscopy in transaxillary augmentation mammaplasty has no impact on the safety or predictability of the procedure or on aesthetic outcomes compared with the nonendoscopic approach.

Moreover, the endoscopic surgery is associated with a significantly longer operating time and involves greater cost and a longer learning curve than the nonendoscopic approach.


Another article appears, this time with “level 3” evidence, again professing endoscopic-assisted transaxillary breast augmentation isn’t a good procedure [1].

In this study it is purported to have increased operating time, on average, by nearly an hour per procedure.

The authors appear to have limited experience with the procedure (17 cases between June 2011 and March 2013, or less than one per month).

As a surgeon with more than 18 years of experience with this operation, I would ask, “What were they doing?”


Similarly, a study we have seen and heard quoted with some frequency (level 4 evidence) concludes “The risk of CC [capsular contracture] is significantly higher with transaxillary incisions than with periareolar or inframammary incisions” [2].

The transaxillary approach again gets a “black eye” from authors who have what appears to be little experience (47 breasts over six years).


In our personal experience, without any hint of rushing, the operation routinely takes between 35 and 40 minutes, from skin to skin (and not occasionally, less).

With smooth-shelled, gel-filled implants, this is facilitated with an insertion funnel.

( We have no experience with placement of textured devices via the transaxillary approach.) The operation is gentle, nearly bloodless, and complications are rare; in over 2500 cases since 1997 there have been seven hematomas and only one peri-prosthetic infection requiring explantation (16 years ago).

Contracture rates are also very low, in the range of 1% long term.


The power of statistics today is such that a higher level of evidence will accord a paper longevity, citations, and eventually canonization.

The adage “Lies, damned lies, and statistics” [3] can be negated in this environment by evidence-based medicine. But clinical experience will hopefully allow us to see the flaws and for reason to prevail.


First of all, the authors would like to thank Dr. Gelfant for his Letter to the Editor [1].

Ours was a level 3 of evidence article [2], based on the method utilized in evidence-based medicine to determine the clinical value of a study, but there is some misunderstanding about the aim of the paper.

Unlike you described in your letter, the objective of the study was not to evaluate if the endoscopic-assisted transaxillary breast augmentation is a good technique, but to compare both procedures (endoscopic-assisted and without endoscopic technique) when performing an axillary breast augmentation.

We cannot claim that the endoscopic-assisted technique is not a successful procedure, but the technique can be done without the use of the endoscopic device with the same results.

Endoscopic-assisted transaxillary breast augmentation has been an established method for breast augmentation for a long time.

Proving the contrary would have taken much more patients than proposed on the text.

However, this really was not the aim of this study.

Neither was showing the authors skills on performing a fast procedure (as we know that operative time has no correlation with good or bad aesthetic results).

The objective of this paper was to compare two established techniques and to do that we had to point out some parameters to evaluate and compare [2].

One of the parameters we used was operative time.

We know there are others authors with a faster operative time than ours [3], thank you for your observation.


Although we have no capsular contracture cases, you have mentioned another article that states transaxillary breast augmentation is a higher risk surgery.

Despite the fact that there are not many articles correlating transaxillary breast augmentation with capsular contracture, there are many articles correlating that the use of textured implants reduces the incidence of postoperative capsular contracture [4][5].

We have not used smooth implants for a long time in our University or private practice to reduce the incidence of postoperative capsular contracture.

Capsular contracture is a low incidence rate event and when planning the study we already knew that capsular contracture rates were not the main reason for the paper based on the small sample.

You have a very low number of capsular contracture with the use of smooth gel implants, so this is not a concern in your practice.


At last, despite being a former surgeon, my experience with this technique is not restricted to 17 patients, but when planning a prospective study we must determine the sample number and this was the number we found to be statistically acceptable to accomplish the study.

I agree that statistics should not be more powerful than a surgeon’s experience, but we cannot totally deny evidence-based medicine.


Up to the submission date, a novel coronavirus (severe acute respira- tory syndrome coronavirus 2 [SARS-CoV-2], previously called 2019- nCoV) initially reported in Wuhan, China has been diagnosed in more than 200 000 people from 166 countries worldwide according to the World Health Organization (WHO).

SARS-CoV-2 is currently the world's most pressing public health threat and has a significant im- pact on the lives of people around the world.


SARS-CoV-2 is an enveloped, positively charged, single-stranded RNA virus belonging to the beta coronavirus genus.

SARS-CoV-2 en- ters cells via the angiotensin converting enzyme 2 (ACE2) receptor and is highly homologous to SARS-CoV. 1 Zhang et al 2 reported that ACE2 was highly expressed in oesophageal epithelial cells and the absorptive enterocytes from ileum and colon, suggesting possible faecal transmission.

Gastrointestinal symptoms such as vomiting and diarrhoea have been reported in SARS patients 3 and in COVID- 19 patients.

Currently, there are few data on the gastrointestinal manifestations of COVID-19.

The clinical case analyses on digestive manifestations and pathological findings of patients with COVID-19 published in China were reviewed in this paper with a view to pro- viding reference for prevention and control, as well as diagnosis and treatment of the disease.


We included data on COVID-19 patients who have confirmed in case reports and retrospective clinical studies relating to the digestive system that were published in English or Chinese from the end of December 2019 to the end of February 2020.

Studies that did not mention digestive symptoms were excluded.

Most of the patients were from China, including Wuhan city and areas outside Wuhan.


The review was based on PubMed and China National Knowledge Internet information sources including reports, publications and data collected by the WHO and National Health Commission of the People's Republic of China, and 'grey' literature information sources including Baidu Scholar and Google Scholar.

We performed exten- sive hand searching of reference lists of papers and reports.

The search terms used were '2019-nCoV', 'SARS-CoV-2' or 'COVID-19' combined with 'gastrointestinal', 'clinical feature', 'digestive', or 'pathological' and 'faeces' or 'stool'.


We reviewed eligible studies and extracted data on province or city, study time period, patient age group range, study size, severity of illness, symptom categories and the incidence of symptoms.

We also extracted sensitivity of faecal PCR test and time window be- tween faecal and respiratory PCR test, if mentioned.

When extract- ing information from the studies, pairs of researchers conferred to compare findings and reach consensus.

Where consensus was not reached, an independent researcher was consulted.


We identified data from 2023 patients where presence or absence of gastrointestinal symptoms had been reported.

Among COVID-19 patients, gastrointestinal symptoms reported during disease pro- gression varied widely.

The latest data 4 from Wuhan showed that up to 79% of the patients presented such gastrointestinal symptoms as diarrhoea, decreased appetite, nausea, vomiting, abdominal pain and gastrointestinal bleeding during the onset and subsequent hos- pitalisation.

Although the recent symptom proportion in Wuhan was high, the first clinical article about clinical characteristics of COVID- 19 mentioned that only 3% patients had diarrhoea.

5 Table 1 shows the current literature related to gastrointestinal features.

Anorexia was the most frequent digestive symptom in adults (39.9%-50.2%), while diarrhoea was the most common symptom both in adults and children (2%-49.5%), and vomiting was more common in children.

About 3.6%-15.9% of adult patients presented vomiting and 6.5%- 66.7% in children.

Nausea accounted for 1%-29.4%, and gastrointes- tinal bleeding was 4%-13.7%; abdominal pain (2.2%-6.0%) was more frequent in severely ill patients.


There are a few reports indicating that small number of patients only presented with diarrhoea and vomiting without fever and cough.

Ping et al 10 reported only nine adult patients with digestive symptoms and no other symptoms at onset.

During hospitalisation, four of nine patients never had respiratory symptoms or fever.

The other five patients developed a fever 2-4 days after onset.

Six of nine patients went to the gastroenterology clinic, and the other three patients went to other department clinics.

No one visited the Conclusions: Gastrointestinal symptoms are common in patients with COVID-19, and had an increased prevalence in the later stage of the recent epidemic in China.

SARS- CoV-2 enters gastrointestinal epithelial cells, and the faeces of COVID-19 patients are potentially infectious.

-CoV-2-infected patients and were confirmed by the throat swab test after screening.

One adult patient mentioned in another article presented with abdominal symptoms and was ad- mitted to the surgical department, and was presumed to infect more than 10 health care workers in this department and four hospitalised patients in the same ward.

One of the patients in the same ward was diagnosed as having SARS-CoV-2 infection after the appearance of fever, and found the initially hospitalised patient was infected with SARS-CoV-2.

All of the four patients in the same ward presented with abdominal symptoms and fever.

9 An article with 31 children mentioned that three children had diarrhoea as the first symptom and one had vomiting without fever and cough.

17 No mention was made of respiratory symptoms during subsequent hospitalisations.


Diarrhoea might be the first symptom before diagnosis, while some appeared after confirmation of SARS-CoV-2 infection.

Fang et al 4 found that diarrhoea occurred in 49.5% (146/295) patients, 55.2% of which occurred after admission and anti-virus therapy, and estimated 22.2% of patients presented diarrhoea before diagnosis.

Diarrhoea occurred from 1 to 8 days after the onset, with a median time of 3.3 days.

The mean duration of symptoms was 4.1 ± 2.5 days, and varied between 1 and 14 days.

The frequency of diarrhoea was 3.3 ± 1.6 per day, and up to nine times per day in some patients; 34.3% had yellow-watery stools.

4 Wang et al 17 found similar results; three of 31 children with diarrhoea had thin yellow stools, two to six times per day, and all had diarrhoea as the first symptom.

Laboratory faecal test results showed that 6.9% of the patients had faecal ab- normalities, with 5.2% positive for leukocytes and 1.7% for occult blood but no red blood cells, which is consistent with the charac- teristics of viral diarrhoea.

4 The relevant treatment strategy for di- arrhoea is usually symptomatic, and drugs used in the clinic mainly included dioctahedral montmorillonite powder and loperamide as appropriate to relieve the symptoms, probiotics mitigating intesti- nal microflora dysbiosis and antispasmodics if accompanied by ab- dominal pain.

Properly rehydration therapy as necessary to maintain electrolyte balance.


Contradictory results about digestive symptoms in severe and nonsevere patients have been reported.

Fang et al 4 found that 46 of the 305 patients were critically ill, accounting for 15.1%.

About 85% (17/20) critical cases had digestive symptoms and 44.7% (17/38) had diarrhoea.

The results were not statistically different from those of noncritical cases, where digestive symptoms in nonsevere patients accounted for 78.5% (142/181), of which 50.2% (129/257) had diar- rhoea.

A similar result was observed in the study by Guan et al 13 They reported a severe and critical rate of about 15.7% (173/1099).

There was no difference in these rates when compared with the propor- tion of gastrointestinal symptoms between severe and nonsevere cases (nausea and vomiting 6.9% vs 4.6%; diarrhoea 5.8% vs 3.5%).

However, opposite results were found in another study.

Wang et al 9 reported that the proportion of gastrointestinal symptoms, espe- cially anorexia and abdominal pain, was higher in ICU patients than in non-ICU patients (anorexia 66.7% vs 30.4%; abdominal pain 8.3% vs 0%), and there were statistical differences in the proportions.


We noticed that the proportion of severe cases (36/138, 26.1%) was much higher than that in the two studies mentioned above, and were even higher than the severe and critical rate (18.5%) in the Chinese Centres for Disease Control (CDC) report of 72 314 cases.

20 As mentioned in the CDC of China report, the epidemic curve of the onset of symptoms peaked between 23 January and 26 January 2020.

20 Noticeably, at the early stage of the epidemic be- fore 26 January, the proportions of patients with diarrhoea reported in Wuhan and other regions outside Wuhan were similar at around 2%-10%.

However, in the later stage of the epidemic, the propor- tion of patients with diarrhoea in Wuhan and areas outside Wuhan increased compared with the pre-epidemic stage.

The increase was even more pronounced in Wuhan which had 49.5% of patients with diarrhoea, 4 compared with 35.6% in Guangdong.

18 Children had a similar rate of diarrhoea (9.6%-15%) as adults but had a higher rate of vomiting.

One study reported up to 66.7% of children with vomiting, but only included six cases.

7 There were only two studies describing gastrointestinal bleeding.

Yang et al 6 observed two cases (2/52, 4%) of gastrointestinal haemorrhage in critically ill patients.

Xiao et al 18 reported 10 cases out of 73 (13.7%) but did not discuss severity.


The first autopsy report was of an 85-year-old man with COVID-19.

This showed segmental dilatation and stenosis of the small intes- tine.

21 Degeneration, necrosis and shedding of the gastrointestinal mucosa of varying degrees were found histologically in another pa- tient who died of severe COVID-19.

19 Later, Xiao et al 18 reported no apparent mucosal epithelial damage in the oesophagus, stomach, duodenum and colorectum with H&E staining.

Histology indicated occasional lymphocytic infiltration in the oesophageal squamous epithelium, and abundant infiltrating plasma cells and lymphocytes with interstitial oedema in stomach, duodenum and rectum lamina propria.

ACE2 staining of pathological specimens showed that the positive areas were mainly distributed in the cytoplasm of gastric and intestinal epithelial cells and the cilia of glandular epithelial cells, but rarely observed in oesophageal squamous epithelial cells.

Viral nucleocapsid protein was detected in the cytoplasm of gastric, duodenal and rectal glandular epithelial cells, but not in oesophageal epithelium, suggesting that the gastrointestinal symptoms of SARS- CoV-2 infection might be caused by the direct viral attack as well as tissue and organ damage due to the immune response.


Substantial evidence from previous studies of SARS supported the gastrointestinal tract tropism of SARS-CoV, which was verified by viral detection in biopsy specimens and stool.

22 Similarly, SARS- CoV-2 was first reported in stool samples of the first case in the United States. 23 Yang et al 24 found that the stool specimens of three out of seven patients remained positive after a negative throat swab test.

The results were subsequently confirmed by other studies (Table 2).


The proportion of patients in whom stool samples tested positive was between 36% and 53% of all confirmed cases.

Zhang et al 26 reported high accuracy of nucleic acid detection in stool sam- ples.

The comparison of stool test results to clinical manifestations as well as disease severity suggested that the positive rate of the faecal test was not differentially related to disease activity or di- gestive symptoms.

The age of the patients with positive stool tests ranged between 10 months and 78 years, and the test lasted posi- tive for approximately 1-16 days.

25,26 Available studies also demon- strated a time window in positive tests of specimens from different tissues.

24,25 The faecal nucleic acid was often positive 2-5 days after the respiratory specimens were found to be positive, and 23%-82% patients continued to have positive faecal tests while their res- piratory specimens were negative.

24,25 The faecal test for patients treated with corticosteroids remained positive longer.

25 Recently, the isolation of infectious SARS-CoV-2 viruses from stool samples of COVID-19 patients 18 has directly proven that SARS-CoV-2 could be spread via faeces.


We found that anorexia was the commonest gastrointestinal symp- tom; this might be explained by the inflammatory state, hypoxia, liver function injury, depression or adverse reactions to therapeutic We noticed that the number of patients with diarrhoea in- creased in the later period of epidemic, which might indicate the reduced virulence of the virus in the process of transmission.

We lacked sufficient knowledge of the virus at the beginning of the epidemic when the primary findings were dyspnoea and hypox- aemia.

However, with an improved understanding of COVID-19, the digestive manifestations of the disease received much more attention; it is possible that drug-induced diarrhoea increased in the later stages.


This paper has a number of limitations.

First, most of the articles involved were necessarily single-centre, retrospective studies, and no large-scale clinical statistics report was included.

Second, as the epidemic developed, the continuously updated and improved diag- nostic criteria for COVID-19 resulted in differences among the cases enrolled between the early and later stages of the epidemic.

The ini- tial diagnostic criteria included epidemiologic history, fever, changes in COVID-19 imaging and lymphopenia, and ineffective antibiotic treatment in combination of virus gene sequencing.

However, the latest guidelines regarded patients having clinical manifestations but without epidemiologic history as suspected cases, and added RT-PCR detection and IgM/IgG antibody testing, so the diagnostic range for confirmed cases was expanded compared with the early stage of epidemic.

Third, the lack of medical staff and resultant in- complete medical history and clinical data at the early stages of the epidemic might have caused some selection bias.


Latest study of 204 cases by Pan et al 27 showed that 99 pa- tients (48.5%) had digestive symptoms, and 41 patients (20%) had a specific symptom (diarrhoea, vomiting and abdominal pain) ex- cluding anorexia, and it is consistent with the results of our anal- ysis.


They noticed seven cases (3%) manifesting only digestive symptoms without respiratory symptoms.

Patients with atypical primary symptoms or atypical first symptoms had also been re- ported in previous literature.

It was an indicator that could help us to identify COVID-19 early and prompt the gastroenterologists to strengthen self-protection to reduce the potential risk of infection.


Interestingly, they pointed out that patients with digestive symp- toms were inclined to have a worse prognosis than those without digestive symptoms (34.3% discharged vs 60% discharged).

We no- ticed that there were 74 (36%) critically ill patients in this paper and the severe and critical rate was much higher than the large-scale statistics rate in CDC report, which was 18.5%. 20 The results sup- ported our finding that critical patients with high severe rate were more likely to manifest digestive symptoms.


We may speculate that the high rate of severe cases indicated a high density and virulence of virus, which damaged the digestive system.

The reason for the phenomenon is unclear, and should be verified by a larger clinical data in future research.


The proportion of children with vomiting was higher than that of adults.

The vast majority of children with gastrointestinal symptoms were noncritically ill, only one of 57 children in the literature we re- viewed was critically ill.

7,11,17 Gastrointestinal symptoms were also present in critically ill children, 28 but no specific data on gastroin- testinal performance in severe children are currently available in the literature.

It was reported that 10% (3/31) of the children showed only gastrointestinal symptoms instead of respiratory symptoms at onset, 17 which was higher than 3% (7/204) of adults.

27 It can be speculated that children might be more prone to gastrointestinal symptoms than respiratory symptoms compared with adults.

One possibility is that the immature immune system in children might weaken the immune response in the respiratory system, leading to fewer respiratory symptoms.

However, due to the limited number of children cases reported in the literature to date, drawing definite conclusion is difficult and needs to be confirmed by more clinical data.


It was difficult to assess whether the digestive symptoms were primary or secondary outcomes of SARS-CoV-2 infection in critically ill patients.

Due to long-term hypoxemia, cell necrosis from tissue hypoxia may produce gastrointestinal mucosal cell injury, resulting in ulceration and bleeding.

In view of the extremely high risk of virus transmission through aerosol during endoscopy, only one published study discussed endoscopic manifestations, and contained no de- tails regarding mucosal damage.

In addition, treatments including corticosteroids and NSAIDs, and the physiological stress in patients with severe illness could have affected the mucosa of the digestive tract, making it challenging to trace the cause.


The time window noticed between faecal and respiratory spec- imen PCR tests suggested that virus particles survived longer in the gastrointestinal tract than in the respiratory tract.

When the viral load in the stool is high or in a virus-friendly environment, SARS- CoV-2 might spread easily via faeces.

Ong et al 29 offered a typical example of faecal transmission.

They collected samples from the bathroom of a patient with confirmed faecal positivity by RT-PCR and no diarrhoea.


Samples from the surface of the toilet bowl, inside bowl of the sink and the door handle were positive results, while post-cleaning samples were negative.

More details were given by von Doremalen et al 30 that viable virus existed for at least 3 hours in aerosols after their formation, and for up to 2 or 3 days on plastic and stainless steel surfaces.


Based on the high viral infectivity of SARS- CoV-2, we believe that exposure to a faecal-contaminated environ- ment, such as public toilets or areas with poor sanitation, may cause 'faecal-mucosal transmission' when individuals touch their mouth, nose or eyes with contaminated hands.

Alternatively, the virus may infect patients' healthy family members through the faecal-aero- sol-respiratory pathway by sharing toilets.


More clinical and experi- mental data about virus viability in faeces and varying environmental conditions such as temperature and relative humidity are needed.


Early studies indicated that individuals infected with SARS-CoV-2 might shed and spread the virus while they were pre-symptomatic or asymptomatic.

31-33 Considering that viral shedding might last for more than a month, 34 we should pay attention to minimise the risk of faecal transmission.

The latest treatment protocol in China stipulates that two RT-PCR tests of respiratory specimens carried out more than 24 h apart should be negative before a patient is discharged from the hospital, and that the patient should be isolated for 14 days after discharge.

19 In view of the possibility that stool samples of the discharged patient could still be positive, we suggest that the patient should implement a more thorough protocol for hand hygiene during isolation, thoroughly disinfect toilets and sinks, and try to avoid sharing toilets with family members.

Meanwhile, we recommend a test for faecal nucleic acid before a patient is released from isolation.

Medical staff who perform gastrointestinal endoscopy for isolated convalescent patients should consider all patients to be confirmed cases and take strict protective measures.

Proper disinfection of toi- lets is crucial in endemic regions; otherwise, sanitation facilities can turn into 'virus traps'.


We read with interest the article by Yuan et al reviewing gastrointestinal features in COVID-19 and the possibility of faecal transmission [1]. They reported that gastrointestinal symptoms are common in patients with COVID-19.

This may be due to SARS-CoV-2 combining with angiotensin-converting enzyme 2 (ACE2) to enter the host cell during invasion [2], and, since human intestinal epithelium is rich in ACE2 expression, virus directly invading the digestive tract might cause diarrhoea and vomiting [3].

Currently, the relationship between gastrointestinal symptoms caused by viruses and clinical outcomes of patients remains controversial [1].

Recently, we studied a large sample of consecutive patients with COVID-19 admitted to hospital to assess the association between gastrointestinal symptoms pre-admission and clinical outcomes.


1406 COVID-19 patients were included in the final analysis.

Of these, 138 (9.82%) presented with at least one gastrointestinal symptom; 86 had only diarrhoea, 34 had vomiting and/or nausea and 18 had diarrhoea and vomiting.

Comorbidities, including chronic liver disease (10.87% vs 5.6%, P = 0.014) and diabetes (13.04% vs 6.94%, P = 0.01), were significantly more frequent than among those without gastrointestinal symptoms.

Among patients with pre-admission gastrointestinal symptoms, 15.94% and 13.04% developed severe and critical COVID-19, respectively, compared to 10.88% and 5.44% among those without gastrointestinal symptoms (Figure 1A).

In addition, patients with gastrointestinal symptoms were more likely to experience water and sodium electrolyte disturbances [4], with a significantly higher proportion exhibiting a low serum sodium level than in those without gastrointestinal symptoms (26.81% vs 17.82%, P = 0.01).


We further assessed the association between gastrointestinal symptoms pre-admission and clinical outcomes of patients with COVID-19.

The primary outcome was defined as a composite endpoint consisting of mechanical ventilation, ICU admission or death [5].

The crude hazard ratio (HR) for the composite endpoint was 2.51 (95% CI, 1.49-4.22) for patients with gastrointestinal symptoms compared to patients without (Figure 1B).

Inverse probability weighting via a propensity score model was used to adjust for imbalances between the two groups [6].

Thus, our data show that gastrointestinal symptoms pre-admission were associated with increased severity of COVID-19.


These results are consistent with other recent studies [4, 7, 8], but mostly these had not considered other potential confounding factors.

There have been some contradictory reports [9, 10].

This may in some instances be due to inclusion of patients with gastrointestinal symptoms caused by medical treatment during hospitalisation [9], which could have skewed the overall results.

Patients with gastrointestinal symptoms are more likely to have serious adverse consequences of COVID-19 and should be given careful attention and appropriate intervention.


Editors,


We have read with great interest the article by Yu et al on the correlation between pre-admission gastrointestinal symptoms and the severity of COVID-19 [1].

We agree that some GI symptoms may indicate a more serious disease course and the associated pathophysiological reasons are probably multifactorial.


First, SARS-CoV-2 may directly invade gastrointestinal cells, given the presence of ACE2 receptors, as proven by endoscopic biopsies from COVID-19 patients.

Lin et al reported that the virus was detected at various GI locations in 3 of 6 patients with GI symptoms, and that the virus was present throughout the GI tract in two patients with severe disease [2].


Second, hypercoagulability induced by inflammation and diffuse endotheliitis may lead to mesenteric vascular thrombosis.

Bhayana et al. reported that pneumatosis or portal venous gas in 4 of 20 CT scans performed on ICU patients [3].

Pathological analysis revealed bowel necrosis with small vessel thrombosis involving submucosal arterioles [4].


Moreover, the systemic inflammatory state and hyperinflammation seen during the cytokine storm in critically ill patients also play an essential role.

A study including 186 patients of a multisystem inflammatory syndrome associated with COVID-19 reported that the digestive system was the most commonly involved organ system.

Specifically, 92% (171/186) of the patients developed GI symptoms, and 80% (148/186) of them received intensive care [5].


GI symptoms can occur at any point in the disease process.

Some patients showed GI symptoms at the onset of illness, and some developed symptoms as the disease progressed [6].

However, whether GI symptoms persist after a patient recovers has rarely been reported.

One study reported that fatigue, dyspnoea, joint pain and chest pain persisted in 87% of patients two months after recovery [7].


We noticed that an elderly woman confirmed with COVID-19 developed diarrhoea during the course of her illness.

The diarrhoea improved after recovery, but abdominal distension and constipation later developed and persisted for more than three months after recovery.

We speculated that the patient might develop IBS after infection possibly due to autonomic dysfunction.


Hence, we surmised that another potential pathophysiological mechanism for GI symptoms may be injury to the nervous system involved in digestion.

Structures responsible for food intake and control of nausea and vomiting belong to the dorsal vagal complex located within the lowest region of the brainstem, which also controls several autonomic activities, including the heart and breathing [8].

SARS-CoV-2 is neurotropic and neurologic symptoms are more prevalent in patients with severe disease [9].


Our understanding of the virus is still limited; assessments of the long-term effects of COVID-19, particularly in patients with severe disease, are needed.


The authors' declarations of personal and financial interests are unchanged from those in the original article [10].


As part of my training experience, I kept detailed written notes for every single session, notes of my meetings with my supervisor, and additional jottings and diagrams to organize the database and develop my conceptualization.


For the first 8 months, I saw the client in a training setting where clients were selected for suitability for psychodynamic therapy.

Sessions were twice weekly, and the fee was based on a sliding scale.

When we terminated at the end of my program, I gave the client information to contact me. She did so, and we resumed therapy in a private practice office, with the same fee.


The only source of clinical data was my personal contacts with the client.

I had access to data that confirmed for me that she was a highly talented writer: her writing was selected by a very selective publisher and received favorable critical reviews.

I also had information about her husband from a credible, independent source that confirmed the accuracy of her description of his professional accomplishments and his style of interacting.


I have changed and omitted many facts and details to conceal the identity of the client and assure that her confidentiality is not breached.

The changes I made do not compromise the accuracy of the description of the therapy process.


Ms. Q was an extremely attractive, fashionably dressed, dark-haired, slender 36 year old woman of mixed Asian and Hispanic ethnicity.

She had been married for 12 years to a very successful economics professor, who was about 10 years her senior.

Her 8 year old son was attending a selective private school, and she had not worked outside the home since her marriage.

For the past three years she had been enrolled in creative writing courses, and had just had a short story accepted by a prestigious publication.


Ms. Q was self-referred because of uncertainty over whether she wanted to stay married or live independently, and fear that she would succumb to her tendency to "flee" without reflecting on consequences.

Her stated goal was to make a decision "that feels solid, not impulsive." She wanted to devote more time and energy to writing, moving from short stories to a novel, and saw "family responsibilities" as an obstacle.

She described her husband as a very reserved, intellectual man who "withdraws when he is angry and doesn't communicate about feelings," and complained that he treats her writing with condescension and objects to her aspirations to be more than a wife and mother.


She talked rapidly, in dramatic story-telling fashion, with vivid details.

Although I did not know this initially, she had applied for a six-month writing program in another state and was hoping that therapy would allow her to make a guilt-free decision to leave her son and husband to attend.


I have always resisted pressure to "choose an orientation" and believe that every client deserves a unique, personalized treatment plan.

Rather than facing a new client with a treatment strategy in mind, the therapist should learn about the unique client and develop a case formulation that draws from ideas from the entire range of available models of human functioning and change.


The development of my clinical thinking stems from a clinical placement at a VA hospital in the second year of my Ph.D. program.

Distressed by my incompetence in facing new clients, and frustrated with the lackadaisical humanistic approach to supervision of the staff psychologist I was assigned to meet with, I sought help from the director of the psychiatry education program, George Saslow, who had co-authored an influential article on "behavioral diagnosis" (Kanfer and Saslow, 1965).

I was thrilled to be invited to participate in the training program provided to the psychiatry residents.

I learned about the application of the "problem- oriented method" (POM) to psychiatry (Weed, 1971), which included the "SOAP" acronym that was used for notes in patient charts: "S" and "O" stand for two kinds of data, subjective (what the client says) and objective (what the clinician observes or accesses through charts, tests, and professional reports); "A" stands for assessment, which in this context means conceptualization and formulation; and "P" stands for plan for intervention.

This method assures accountability (plans must focus on resolving problems, progress towards goals must be documented) and incorporates both scientific principles (e.g., data separate from theorizing) and practical problem Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] solving skills.

At the same time, I learned about the use of "core clinical hypotheses" in an article by Aaron Lazare (Lazare, 1976): "A core clinical hypothesis" is a single explanatory idea that helps to structure data about a given client in a way that leads to better understanding, decision- making, and treatment choice.

Based on these educational experiences, the foundation of my future clinical work was the development of a case formulation for each client that involved clear specification of "problem titles," and the selection of clinical hypotheses that best fit the data.


When I began my career 30 years ago as a faculty member in a clinically-oriented Master's program, I was determined to teach students the skills of creating case formulations.

I developed a list of "core clinical hypotheses" and a set of instructions for defining problems, specifying outcome goals, developing a coherent integrative conceptualization for each problem, and selecting interventions that followed logically from the conceptualization.

The result of my teaching and constant revision of my training manual was the publication in 2006 of a book explaining my approach to case formulation, with detailed step-by-step instructions for developing formulation skills and writing case formulation reports.

In the book I explained each of 28 hypotheses, providing for each of them a set of treatment recommendations, suggestions for integrating other hypotheses, and lists of recommended readings.

Table 1 presents the list of hypotheses with definitions and Figure 1 gives an overview of the steps of the formulation process.


In this section, I will highlight the processes, which will be described in detail in the following sections on assessment and formulation, as they apply specifically to the client.


It takes several sessions to gather enough data to begin creating a formulation.

In the first session it is important to check to see if there is an emergency issue (e.g., suicidality, symptoms of organicity, an acute stress reaction) and if not, the unfolding of information should occur by allowing the client to tell stories in her own way, while the therapist "tracks," and shows empathic understanding.

The visual tools of a timeline and a genogram are helpful for organizing data.

The therapist can gather data through experiential activities, homework assignments, and written assessment tools.

It is important to distinguish data from theorizing, and to solicit multiple concrete examples when the client uses abstract language.

For instance, if the client says "my husband abuses me," the therapist must ask for examples and definitions to get a clear sense of the specific interactions and behaviors that she labels "abuse."


Problems are the targets of therapy-- impairments, symptoms, syndromes, difficulties, dysfunctions, and emotional suffering.

The book Change (Watzlawick, Weakland & Fisch, 1974) made brilliantly clear how important it is to correctly define the problem and to recognize that clients will bring problems that are the results of their faulty attempted solutions.

For instance, the frustrated parent of an adolescent takes a normal developmental change (increased independence of the child) and has attempted to "fix it" with increased restrictions and attempts to maintain power.

The parent sees the problem as "my inability to control my rebellious Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] teenager" whereas the therapist needs to identify the problem as "difficulty adjusting to developmental changes, and ineffective methods of responding to normal adolescent behaviors."


The problem list needs to be complete and comprehensive.

The process of problem identification begins with a comprehensive list of problems that were either reported by the client and or recognized by the therapist.

Formal problems are defined by combining certain problems into a cluster with a specific title ("lumping") and by recognizing subproblems within a single item on the list ("splitting.") As the client develops trust, and as the therapist asks questions to elicit more data, it is common for new problems to be identified, and for the initial problem definition to be supplanted with a more refined one.


Good problem titles meet the following standards:


• Problems are defined so that they are solvable targets of treatment.


• Titles refer to client's current, "real world" functioning.


• Titles are descriptive, designed for a specific client, and are justified by the data.


• Problem titles do not contain theoretical, explanatory concepts.


• The therapist is not imposing cultural or personal values in problem definitions.


• "Lumping" and "splitting" decisions are justified in that they lead to good treatment planning.


The outcome goal is directly related to the problem title, and describes how things will be in the future when the problem is sufficiently resolved for the client to function without the help of the therapist. " Process goals," which are the in-therapy achievements that stem from the therapist's formulation, is part of the plan.

The process goals are part of a roadmap for achieving outcome goals, and at the time the outcome goal is written, the therapist is not ready to formulate that roadmap.

By keeping process goals and outcome goals separate, the therapist (and supervisors and consultants) can discover diverse routes to the desired end point of therapy.


The evaluation of therapy requires the specification of outcome goals: Without an outcome goal, the term "effectiveness" is meaningless, and there is no way to know when termination is appropriate.

Good outcome goals meet the following standards:


• They are consistent with the client's values.


• They refer to "real world" functioning.


• They do not contain formulation ideas.


• They are realistic and are not "utopian."


• They do not contain the "how" of the treatment plan (process goals or strategies).


In the initial sessions with a client, the starting place may be setting outcome goals rather than creating problem titles.

For instance, the client may state "I need to make a decision," or "I want to be able to …" As the plan is implemented, the therapist gathers data about changes in the Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] client's life to see whether the therapeutic strategy is leading toward the desired outcome.

This description should not convey the idea that the outcome goal is rigidly set in the beginning; in the course of therapy, clients can change their minds about what they truly want and events outside of the client's control may lead to modification of outcome goals.


As explained previously, I developed a list of 28 core clinical hypotheses to be used as building blocks in designing formulations.

This list is presented with definitions in Table 1 and as a blank form for use with clients in the Appendix. ( All tables, figures, and the appendix can be found at the end of this paper.)


There are several skills for using hypotheses:


• Listening to the client talk and recognizing the goodness-of-fit of each hypothesis.

This means ruling out those that do not match, and retaining those that are consistent with data.


• Using various strategies to gather more data to either confirm the fit of a specific hypothesis, or to rule it out. ( In Figure 1 the bidirectional arrow with "data gathering" indicates that hypothesis-generation guides the gathering of data, and data determine the relevance of hypotheses).


• Brainstorming hypotheses, using the chart in the Appendix, as demonstrated in Table 2.

Before closing in on one or more preferred hypotheses, it is useful to systematically examine each one.


• Selecting one or more hypotheses for the preliminary formulation.

Formulations can be formally expressed in essay form, or informally captured in bullet- point notes for the private use of the therapist.

In training settings, I believe that students benefit most from being required to write a formal assessment discussion, using their highest level of writing skills, because the process of writing forces them to improve their thinking.

If they use theoretical jargon, they need to be sure that it enhances rather than detracts from understanding and does not contribute to tautological explanations.

As preparation for such a formal presentation, and as a useful tool for experienced formulators, I recommend the use of a three column worksheet, as illustrated in Tables 3-5.


Standards for a good assessment include the following:


• It integrates hypotheses that are consistent with the prior database.


• It does not introduce new data.


• The focus is on the specific problems, rather than being a discussion of the client's personality.


• It does not include all possible hypotheses, just the ones that are useful in developing intervention plans.


The sole purpose of the case formulation process is the development of good plans.

The plan addresses the format and treatment modality (e.g., individual, group, couple, family), the setting, the frequency, and the expected duration (e.g., short-term, time-limited, open-ended.) Standards for a good plan include the following:


• It focuses on resolving the identified problem and achieving outcome goals.


• It follows logically from the assessment discussion and does not introduce new data or hypotheses


• It provides clarity regarding process goals, intermediate objectives, strategies, specific techniques, relationship issues, and sequencing of interventions


• It is tailor-made for the specific client.

Such factors as gender, ethnicity, and personal values are considered.


• It is appropriate for the treatment setting, contractual agreements, and financial constraints.


• When there are multiple problems, it addresses issues of priorities, sequencing, and integration of plans.


• It recommends community resources and referrals, if appropriate


• It addresses legal and ethical issues, if relevant.


The overall treatment plan is like an itinerary on a proposed trip.

You can make statements about priorities, sequences, and contingencies.

However, once the journey begins, you will be faced with frequent decision points: do I continue on the path I started or is this an opportunity to move in a different direction?


As plans are implemented, the therapist gathers data from in-session responses by the client as well as the client's reports of out-of-session progress (or lack thereof).

The therapist needs to be flexible and be able to create a variety of plans for a given hypothesis, realizing that the ineffectiveness of a technique does not invalidate the usefulness of the hypothesis.

Sometimes new data are presented or there are changes in the client's life situation that will lead the therapist to switch to different hypotheses.


The processes of assessment leading to a complete formulation include: (a) identifying problems and setting outcome goals; (b) recognizing strengths; (c) organizing the life history, including the recent history leading to the entry into therapy; and (d) brainstorming hypotheses.


Ms. Q identified her ideas of her problems in the first sessions:


(1) I am not able to engage in creative pursuits as much as I desire;


(2) I have a tendency to leave difficult situations in an impulsive way;


(3) I neglect my own needs and show over-sensitivity to needs of others; and (4) I am not sure if leaving my marriage is the best decision.


After gathering data and separating conceptualizations from problem statements, three formal problems were defined.

Following my general model, I assigned each problem an official title (written as a phrase rather than a complete sentence) that is free of theoretical jargon, followed by explanatory sentences.

For each problem, an outcome goal is specified in a few sentences, as shown below.


Ms. Q described that there were several times between the ages of 17 and her marriage when she chose to "flee" difficult situations instead of using a reflective approach to decision-making.

Her main reason for therapy was to avoid this pattern.


The outcome goal for Problem 1 is for Ms. Q to engage in ongoing deciding about her career and family based on emotional self- awareness, rational thinking processes, a sense of personal responsibility for her choices, and consideration of values and morals.

This goal includes Ms. Q making a good decision about how to pursue creativity without hurting anyone.


Problem #2: Lack of confidence in her ability to succeed in her chosen creative career and frustration over obligations that impede full time dedication.

The client believes that her marriage is an obstacle to devoting herself to writing, and that she will not be able to succeed unless she completely isolates herself, yet she is very devoted to her son. ( This problem includes her view of her husband as an obstacle; other marital issues are addressed in Problem #3)


Outcome goal: The outcome goal for Problem 2 is for Ms. Q to develop the ability to pursue creative activities to the fullest extent without sacrificing competing goals and interests, and to engage in effective problem solving when faced with obstacles.


She reports being frustrated for a long time with her husband's lack of emotional connection.

( The view of her husband as an obstacle to her writing is addressed in Problem 2.

It was important to keep the two issues separate.)


Outcome goal: The outcome goal for Problem 3 is for Ms. Q to make decisions based on an understanding of her needs and feelings, an examination of data about her husband and marriage, and a consideration of the needs of her child.


Throughout the time that I worked with Ms. Q, she experienced depressed moods and episodes of high anxiety.

These could have been treated as problem titles, but instead were viewed as natural emotions for someone struggling to make major life decisions.


Ms. Q's strengths included the following:


• She was highly intelligent, very verbal, quick to learn, and eager to apply new concepts to understanding herself.


• Except in sessions when she was highly emotional and needed to "vent" without interruption, she was genuinely interested in hearing a new perspective.


• She formed a good, collaborative relationship with the therapist and her stories indicated emotional connection in many friendships.


• She had a good sense of humor.


• Her aspirations were realistic: she had the necessary talent and commitment to succeed at her career goal.


• She was a good mother who genuinely cared about the wellbeing of her child.


• She gave feedback about what was helpful in our sessions.


• She understood the importance of experiencing her emotions without trying to numb or medicate them away.


The timeline diagram in Figure 2 shows highlights of Ms. Q's history.

Her father was born in Malaysia, came to the US with a relative as a teenager, completed his education, and worked as an engineer in an aerospace company.

He never talked about his past and she never knew any of his relatives.

Her maternal grandparents met and married in a Latin American country and came to the US prior to having children.

Ms. Q's mother was the third of five children, and was very close to her extended family until she got married.

Her parents disapproved of her marrying an Asian man, despite the fact that he shared her Catholic religion.


When Ms. Q was born her two older brothers were 10 and 12 and her mother, who had wanted a daughter, formed a very close bond to her.

For the first six years of her life she was inseparable from her mother, who spent time reading to her, helping her develop a passion for reading.

This happy period of her life ended when a brother was born who had multiple disabilities, and her mother shifted her focus to meeting his needs, which Ms. Q experienced as a "huge betrayal."


During her elementary school years she tried to get her mother's approval by doing well in school and being helpful around the house, but her mother never verbalized any affection or praise.

She described her mother as emotional, dramatic, controlling and critical, and her father as quiet, undemonstrative, hardworking, and patient.

Her father died when she was 14 after a year-long battle with cancer.

Her mother dealt with the loss of her husband by focusing more attention on her young son and targeting the client with anger and criticism.


During high school, Ms. Q studied sporadically but still got good grades, and began to develop an interest in creative writing.

She was very popular but found her classmates too immature, and at 16 started secretly dating a 24 year old musician.

Right before her 18 th birthday, after completing high school, she moved in with him.

Her mother and brothers called her a whore and refused to talk to her.

She spent two years in this relationship, and then when her boyfriend's alcoholism and verbal abuse became intolerable, she ended it abruptly by leaving a note, packing up, and moving in with a girlfriend.

She refused to talk to him, and then, 2 months later, heard that he had died in a car accident while driving in a heavily intoxicated state.


She went to therapy at that time, dealing with grief and guilt, but was not able to let go of the belief that he would be alive if she hadn't broken up with him. When asked what she learned from that therapy, she spoke about how she discovered that she was emotionally strong and that she had focused so much on her boyfriend's needs that she hadn't set any personal goals for herself.

This therapy helped her decide to enter college.


In her second year of college, she took a job as a research assistant, and began an intense romantic relationship with her future husband.

Six months later he asked her to join him on a sabbatical in a different state, so she discontinued school after only 3 semesters.

They got married after living together for a year, and she focused on being "a perfect wife." She felt that her husband adored her and they lived a very comfortable lifestyle.


When her son was born after four years of marriage, he became the "center of my life," and she wanted to make him feel loved and secure. When he started school she began to use her free time to take courses in literature and creative writing.

She received encouragement from teachers and began to form the ambition to be a writer.

She won a short story competition and then another story was published in a prestigious journal.

Her husband at first was very patronizing about her goals and didn't take her ambitions seriously; then when her story was published he was embarrassed because he felt that the husband in her work of fiction was based on him, and was not a very flattering portrayal.


She began to experience the desire to "flee" her marriage about six months prior to coming to the counseling center.

She identified with Virginia Woolf's idea of a "room of my own," and was frustrated that she couldn't put aside all her family responsibilities and write full time.

Now that her son was in third grade, she felt that he no longer needed her - and that now is The following diagnosis reflects my view of this client as a high functioning individual whose intermittent symptoms of anxiety and dysphoria were related to her self-imposed pressure to make major life decisions.

She was in therapy for "growth needs" rather than "maintenance needs," using the terms of Maslow.


In my conceptual model, a transitional step between assessment and formal case formulation is the brainstorming of hypotheses based on the data gathered by the clinician.

In Table 2 I illustrate the use of the chart that can be found in the Appendix: thoughts about the relevance of each hypothesis to the client's problems and goals are presented in the right column.


The following conceptualizations are based on hypotheses that not only fit the data but also were compatible with the client's values, preferences, and interpersonal style.


• The primary focus on the existential/spiritual issue of finding her own path, making choices and accepting responsibility, accepting her commitments as chosen and not imposed, and pursuing the meaning and creativity she found in creative writing (ES1, ES2, ES3)


• The need to explore and resolve inner conflict among conflicting "parts" (P1)


• The necessity of emotional reliving of past experiences of her ex-boyfriend's death and her mother's rejection of her, both of which are both consciously and unconsciously related to her fear of separating herself, literally and emotionally, from her husband (P2, P4)


• The relevance of the concept of the "self" as it relates both to the development of creativity and to the ability to stand alone and pursue her needs, while maintaining connections to others (P3, SCE1) • The influence of core schemas about the fragility of men and her responsibility for their happiness;

the faulty belief that marriage and creativity are incompatible; and the faulty conclusion that she was responsible for her boyfriend's death, leading to the faulty belief that if she left her husband, he would die (C2)


• Emotional conditioning and defense mechanisms kept her from experiencing painful emotions and revisiting the events in which she formed her faulty beliefs (BL2, P4)


• Difficulties asserting independence based in part on her sex role socialization, which was influenced by the Hispanic and Asian cultures of her parents (SCE2)


• The need to develop new skills in decision making, management of emotions, and communication with her husband as an equal instead of as a rebellious child (BL3)


• The need for a work environment where she can shut out reminders of family responsibilities and focus on her writing (SCE7)


The basic principles for formulating each problem separately are these:


• To assure accountability of therapy, each problem must be addressed.


• The formulation is for the problem, not for the person.


• Each hypothesis is consistent with the data, helps explain the problem, and provides a foundation for a treatment plan.


• Plans focus on achievement of goals.

Tables 3-5 present, for each separate problem, treatment ideas that follow logically from the relevant hypothesis.

For this particular case, to illustrate the logic of the overall model, these charts were designed retrospectively, based on notes that were written during various phases of treatment.

In usual practice, the formulation of each problem would be done based upon assessment data collected at the beginning of therapy.

These formulations might then be modified by new data that emerge in ongoing therapy.


I am presenting the details of the course of therapy with as much accuracy as possible, given that I have eliminated information that would identify the client or would cause her discomfort in the extremely unlikely event that she should read this article.

Core clinical hypotheses are put in boldface.


Ms. Q was seen for 75 sessions over a period of two years and four months.

The initial phase of treatment was in an outpatient clinic as part of postdoctoral training in psychoanalytic therapy, for five months for a total of 28 sessions, with weekly supervision.

At the time I was a licensed psychologist with several years of clinical practice, as well as an associate professor in a graduate clinical psychology program, but in the eyes of the client when she first met me, I was a postdoctoral fellow in a training institute, receiving supervision.

In this initial phase, I met her in In the second phase of treatment, which consisted of 8 weekly sessions over 3 months, Ms. Q met with me in a private practice suite, where I rented a room that was decorated by another therapist.

This office arrangement continued through the last phase of therapy, which lasted 38 sessions over 14 months.


Ms. Q entered therapy with presenting problems, in her words, of being "pressured by family responsibilities," "fear of not being able to develop her own creativity," and "need to make a decision about whether to separate from her husband." I asked her to consider the pros and cons of individual versus couple's therapy, and she was adamant about wanting individual sessions.

Her choice of a psychoanalytic setting was deliberate and based on knowledge of therapeutic alternatives; she wanted insight as well as protection against her tendency to act impulsively, stating that she "has a history of fleeing situations" when she feels pressured to make a decision.

Our preliminary goal was "to focus on sorting things through so she can make a decision that feels solid rather than impulsive; to stay and talk, not run away, and to increase her understanding." We agreed to initially meet two times per week so that we could fit 7 more sessions in before I left for a two-week vacation.


The first 5 sessions were used for history gathering, where I learned about her difficulties separating from her mother in adolescence, her first boyfriend's death, and the story of her marriage.

Her stories focused on her relationships, family and romantic, and there was little sense of her as a separate person exercising volition.

She claimed that her husband was "stifling her development" and that he "refused to respect her as a separate person" with creative talent and ambitions.


The relationship between us was warm and "in tune": We spoke with similar tempo and intonation, and sat with casual postures, both leaning forward with similar facial expressions.

She talked at great length, filling in circumstantial details, and I was careful to stay empathically attuned and let her know that I wanted to hear everything she had to tell me.

I offered a few interpretive comments about her inner parts in conflict (P1) - her "strong side" which doesn't want to dwell on feelings and the voice of her "fear of craziness"- both of which served to keep her talking rapidly and not wanting to get close to feelings.

She confirmed that she believed "the whole thing will topple if she lets feelings [from ex-boyfriend's death] out, again." I was silently hypothesizing about her schemas (C2) about men's fragility, and speculated about unconscious dynamics (P4) in the possibility of schemas out of her awareness, such as "If I leave him, he will die" and "I don't deserve happiness and fulfillment because I am responsible for killing my boyfriend." My earliest intervention was to try to get her to express her needs and feelings, and to explore why it was so hard for her to do this, explaining that it was impossible to make a good choice without considering them (E2 freedom and responsibility).

responses by the therapist that were not perfectly attuned and in agreement with her point of view.

Such a person would not be able to take the point of view of others, soothe her own emotional distress, or tolerate challenges by the therapist to take a critical view of her own behaviors and choices.


In a key incident in our 8 th session, Ms. Q demonstrated some of her more mature capacities.

When she said "I think the 'true me' wants to leave my marriage," I invited her to check in with other parts, and asked "which part would feel guilty if you left?" She accused me of meaning "you should be happy with what you have." Without any intervention on my part, she quickly recognized that she had distorted my words, mistakenly assuming that I would give her the response she gets from family and friends when she expresses emotional torment about her life.

The fact that she recognized her own incipient negative transference disconfirmed the hypothesis that she functioned on the narcissistic level in her relationships.

In fact, when she told anecdotes of relationships with friends, she seemed very capable of empathy and able to handle minor ruptures in the relationships in an effective way. When we heard from her "thinking parts," it was easy to identify faulty thinking (C2).

With her all-or-nothing thinking, she wanted to embrace the male role, and accused me of using cultural stereotypes when I assumed that she would have guilt feelings if she left her child.


I attempted to challenge all-or-nothing beliefs such as "it is impossible for a woman to develop her creativity and at the same time, be a good wife and mother." I pointed to the evidence that she had just received a very positive response from a publisher for a story she had submitted, and that she had achieved this success without neglecting her obligations to her family.

While recognizing the cognitive distortions, I also saw these thoughts through the lens of the cultural hypothesis, SCE2.

She was expressing gender disparities as well as describing the role that her Latina mother had enacted in her family of origin.

In one session she brought in a book about gender differences and we had a conversation about society, socialization, and social change that would be indistinguishable from an academic classroom or a reading group.


In the next few sessions, we focused on her relationship with her husband.

She described him as unresponsive to her needs, appreciative only of the functions she served for him, and belittling of her creative ambitions.

My goal was to move her from describing her thoughts about him to expressing her feelings about his treatment of her.

She began to express anger that had been building for a long time, and I attempted to maintain the focus on feelings.

After a period of intense emotions, she admitted that she knew that her anger towards her husband was excessive, and that, as difficult as it was, she had to talk about the death of her ex-boyfriend.


For several very emotional sessions I tried to just stay with her and let her describe and relive the period after the death.

I had been influenced by Eugene Gendlin and wanted to stay with her moment-to- moment experiencing, and trusted that if she stopped avoiding the painful feelings, she would experience a positive transformation.

The premises I was operating on are very similar to those of Leslie Greenberg's Emotion-Focused Therapy (Elliott & Greenberg, 2007; Greenberg & Paivio, 1997), derived from Rogerian, Gestalt, and existential frameworks, but at the time I did not have the benefit of Greenberg's clearly articulated theoretical framework.

As I reflect on the process of this stage of therapy, I can see the relevance of the conditioned emotional response (BL2) hypothesis: "exposure" to her painful feelings was accompanied by my acceptance, warmth, and understanding, and she gradually reduced her fear of her own feelings.


The emotion of guilt was a focus of a few sessions, and I asked questions that gently challenged her cognitive map (C2) - that she was the only support he had (his parents were aware of his problems), that a person's drinking can be caused by another person's decision to break up, and that it was her duty to subjugate her feelings to make him happy.

A significant cognitive change occurred that could be classified as a "redecision" (Goulding & Goulding, 1979).

Whereas after the death she made the implicit decision that she was responsible and Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp. 1-42, 04-06-09 [copyright by author] deserved to suffer guilt, she was now able to believe, "I was not really responsible for his death - my leaving a man does not automatically kill him, and I have the right to make that choice." After these sessions she no longer needed to make her husband the bad guy to justify her leaving him.


In session 18 she reported that she had received a fellowship to attend a prestigious 6 month creative writing program in another state, which would begin in September. She had not previously mentioned applying for this fellowship, and admitted that she had done it as an impulsive gesture when she was in her "I must run away" state, and hadn't talked about it because she hadn't expected a positive response.

She felt that she would benefit from not being in the shadow of her husband.

To her amazement, her husband supported the plan of her going on her own, leaving him in charge of her son.

At this point, she realistically could no longer view him as an obstacle to her creativity, and was motivated to look at her internal barriers.


For several sessions we focused on her fear of "being trapped" and losing artistic momentum.


Using the conceptualization of the "grandiose self" from Kohut's self psychology (P3) combined with the methods of inner parts work (P1), I helped her to experience her "grandiose, creative self" by inviting her to talk from that part, in the present tense.


She experienced the "scary excitement" of her "creative strength." She accepted the interpretation that she looked to external restraints (her husband, Motherhood) to keep this part in check.


When the artistic self emerged in the session, or the vulnerable part that wanted its own true needs to be honored, I was "mirroring" in the sense of listening, accepting, putting words to inarticulate feelings and needs.


She remembered as a little child that the family would clap for the achievements of the children; it was only in school, when she was teased by her classmates for being praised by the teacher, that she learned not to boast and to feel afraid of her joy in her creations.


As her "inner artist" began to feel powerful, she applied the magical thinking of a two- year-old child to her decision-making process.


She stated "I know I can have it all," and went on to detail how her husband will change, she will get whatever she wants, and there will be no negative consequences.


Then a more rational inner voice asserted itself, reminding her that her husband very rigid in his approach to life, and her fears and qualms emerged again.


A key incident occurred when she confessed in a halting, shaky voice that she had engaged in impulsive behavior which she was very ashamed of, and appeared to be expecting my moral disapproval, or an analytic approach to expose deep psychological defects.

In a spontaneous move on my part, I made a psychoeducational intervention, and said, "that sounds like 'acting out' behavior," and I gave a didactic explanation of how people often behave impulsively when it is hard to deal with the emotional internal conflict.

She seemed appreciative of this information, and we went back to the prior topic.

I was quite embarrassed about what I had done since it was unplanned and seemed too academic and lecture-like in its execution, but from the fact that, in future sessions, she used the word "acting out" and her desire to avoid it, I realized that this cognitive label (C2) was very useful, not only because it normalized behavior she was disgusted with, but because it gave her a framework for developing better skills (BL3) for coping with intense emotions.


Continuing the cognitive focus, I invited her to explore her beliefs. " What do you fear would happen if you became extremely successful without leaving your family?" " My husband would fall apart," was her immediate answer.

She firmly believed that her husband's mental health depended on her downplaying her own talents and abilities, and that if she surpassed him in any respect (not just professionally and creatively) she would have to feel guilty about inflicting great harm.

When I repeated back her words to her, she immediately recognized that her feelings of responsibility for her boyfriend's death were fueling her belief.

I asked if there was evidence that her husband developed symptoms as she became more successful, based on the family systems hypothesis, SCE1.

She admitted that he could very well tolerate her success, and laughed as she concluded that he would probably give her more appreciation than her mother had.

Here it can be seen that I was implementing cognitive therapy in the style of Aaron Beck, helping her to become a better "personal scientist."


In an important session she recognized an internal part that opposed the creative part (P1) - she identified a "need to nest." Speaking from this part, she expressed how much she loved puttering around the house, baking, relaxing on the couch in front of the TV, and noted that this part resented the demand to lock herself in a lonely room and engage in the painful process of writing.

This awareness helped her understand why she felt she needed to get away to be creative - she found this "homebody" part too easily overpowered the "writer." Significant progress also occurred when we recognized that the part that had been treated as the "creative" voice was actually an alliance between two different parts - the "Creative Artist" and "Glorified Impulsivity." I pointed out that although she had come to therapy to reflect and avoid fleeing, she was expressing her glorification of a lifestyle guided by "pursuit of impulse" and a disdain for one guided by "devotion to duty." The concept of "duty" triggered a discussion of "good wife" and "good mother" in our society, and introduced issues of gender, cultural history, and her intercultural background (SCE2)


My termination from the clinic would occur at the middle of July, so we agreed to use our final sessions there to focus on the decision - to go or not to go? She wrote a letter to accept a place in the writing program, and felt that she had until the end of August to make a final decision.

She saw that she didn't "have to escape" to pursue writing, but she was presented with a valuable opportunity and wanted to make a good choice.

This statement of goal invited a strategy based on the existential and spiritual hypotheses (ES2 and ES3): She had the freedom to make choices, but she also had to accept responsibility and live with the consequences of her choice.

She wanted to minimize the negative effects on her son of leaving him for six months, and I repeatedly challenged what I viewed as faulty thinking.

For instance, when she said "Being a good mother comes naturally to me, I know there's no danger of my hurting my son," I asked "How do you imagine he will feel at night when you're not there to tuck him in?" In one session she accused me (accurately, I admit) of trying to make her feel guilty, and I responded by explaining the difference between "neurotic guilt" and guilt that stemmed from her own, freely chosen moral values.

I believe these interventions ultimately benefited her, but I was aware that my motivation could be classified as countertransference.

As a child of 5 (3 years younger than her son) I had been sent to summer camp for two months, and, based on the intensity of my Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp. 1-42, 04-06-09 [copyright by author] suffering, I believed that 6 months away from his mother would be equivalent to torture.


In the next session, I chose to self-disclose about that experience, in the framework of explaining why I was focusing on her son's feelings.

To my surprise (and gratification), my disclosure caused her to recollect how she felt when her brother was born (she was 6), which led to much greater empathy for her son.


In our last session, she had not reached a decision, but I felt that she had an understanding of all the pros and cons of either choice, and was relatively free of self-deceptive rationalizations.

She understood that she was welcome to see me in my private practice, and we agreed that we would have a follow-up meeting in the beginning of September.


She arrived at my office, and after conversation about my new surroundings (spacious, sunny, nicely furnished), she announced proudly that she had made a decision to not enter the program.

Instead, she had rented a studio apartment in a community an hour away from her home.

She would spend weekends with her family, and spend the week away from them, writing.

Her husband would be assisted by a housekeeper, who would be there five days a week.

This was a fait accompli, and, in her mind, a mature compromise.

When asked about her goals for continuing in therapy, she said "I want to go deeper into my past and my fears of abandonment and hurting people.

I want to face who my husband really is, apart from my projections, and decide if we can be happy together in this marriage." With this statement, she indicated her openness to the hypothesis that unconscious dynamics (P4) were affecting her ability to make mature decisions.


This was the first time she had ever lived alone, and she had upsurges of strong feelings - panic, euphoria, desperate loneliness, and excitement.

We focused on inner parts work - and identified the "Super-competent Caretaker" who holds everything together and the "Desperate Little Girl" who feels she is falling apart.

She admitted that our sessions together were dominated by the first personality "I come in here and I sound so confident, then I go out and nothing is clear." She decided to bring in her journal and read from it so I can see the "Basket Case" side of her.


We discovered another part, "Inner Peace," who she felt was at the center, and who "doesn't have to respond and rush back and forth like a gypsy to pacify, placate, control and manage." In learning to access this part when she was feeling confused and overwhelmed, she was finding spiritual resources (ES3) to manage her emotions.

In these sessions, I applied Kohut's concept of "selfobject" (P3) to explain that she was experiencing for the first time her disconnection from people who served the functions of maintaining her inner calm, and was facing the deficiencies in her ability to sooth herself.

She announced in a session that she suddenly recognized that she had been emphasizing how men need her and she becomes responsible for them, but the truth was that it is she who needs the man to help her "keep it together."


I used this new awareness as an invitation to teach her about Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, She lit up and began describing how this concept made sense of many things in her relationships.

She recognized how her episodes of chaotic emotions occurred when she was deprived of connection to her "selfobject." We discussed how in the first 7 years of their marriage, she was meeting her husband's needs and serving as his selfobject - he would ignore her when he didn't need her and expect her to be available when he wanted her.

She saw the connection of the selfobject concept to her perception that her husband had used her as his trophy and ego-booster, rather than being aware of her as a separate person. She also realized how her ex-boyfriend had needed her as a selfobject.

Something clicked for her then: it was not her responsibility to serve that role, and if he had lived a little longer he would have found somebody else to fill the same functions.

She recognized that it now made sense that she wanted to hold on to her husband because of the security he provided.


In the next two sessions she talked about her experience of losing her special relationship with her mother as a little girl, when her brother was born.

She narrated how she had been forced to suppress her true feelings and felt responsible for "keeping my mother glued together." She got emotionally in touch with the "hungry starving child" and had a very tearful session, over "being 35 and never having experienced that someone would actually want to give to me without my having to work for it." In discussing her childhood I used concepts from Alice Miller's The Drama of the Gifted Child (Miller, 1981), describing for Ms. Q how she had been exquisitely empathic to her mother's pain because of her natural gifts, and that this was the same sensitivity and awareness that she was now channeling into writing.

She had a moment of recognition when she started laughing - "It's my sensitivity to others' pain that causes problems, and I keep blaming them for trapping me."


For several sessions, we focused on her writing and how productive she was, living in her own home/studio.

She felt that she had found an environment (SCE7) where her true self was expressed, and she described the spirituality of her creative process (ES3).

She announced that she wanted to take a break from therapy to put all her energy and creativity into writing.

I suggested we meet for two more sessions, and used these to review her progress.


After six months, she called and expressed an urgent need to resume therapy.

We decided to meet twice a week.


Her husband had entered individual therapy in order to work on the faults she had accused him of (e.g., inability to connect with her emotionally).

She was angry that he wanted her to commit to their marriage and return to living together, and said that he was threatening to fall apart if she doesn't stay with him.

Her mother and brother were taking her husband's side Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] and she felt "they think I'm doing the wrong thing, and they will never forgive me." Although her stated goal was to "settle the conflict I have over what to do with this marriage," I believed her goal was to strengthen her courage and resolve to leave the marriage without fear or guilt, and she wanted my seal of approval.

She was proud of her increase in confidence and self- sufficiency: "When we met he was my strength and stability, I used to be so dependent I thought that if he would die I would be nothing, and now I think I can survive alone." She claimed that her only reasons for staying in the marriage were "not wanting to destroy him," and "not wanting my son to lose a father."


In this phase of therapy, I chose a cognitive focus, and challenged her beliefs about the obstacles to divorce.

She realized that her son would not lose a father, and that in fact the more likely scenario would be that her husband would want custody (which was essentially what their current living situation was like.) She needed to remind herself again and again that her fear of destroying her husband was based on the faulty beliefs (C2) formed when her ex-boyfriend died.


I also wanted her to test the beliefs that her husband could never meet her needs.

She agreed to keep a daily journal and write at least a sentence a day to address what she defined as key questions for her decision: "Is he capable of the kind of intimacy I need? Can he ever understand me? Can he ever touch my emotional core?" In session #39 she proposed to revisit the period after the death of her boyfriend, saying "no matter how I try to avoid it, we always seem to go back there." Later in the session she went back to the pain for her childhood.

She stated that she didn't see why she should be so afraid of being alone, because "I have always been alone, I have always covered my pain and presented a good show to others."


She began to review events in the marriage that she had brushed aside.

For instance, her husband had problems with alcohol and had neglected many responsibilities.

She expressed her desire for an unrealistic solution: to keep the marriage, live separately, have total freedom, and share parenting.

( This falls into the category of utopian thinking, C1).

My goal was to listen, ask questions, let her bring out her feelings and thoughts, and to keep the focus on her and her inner conflict, instead of letting her drift off to talk about other people.

Her greatest pain seemed to be over her family siding with her husband.

She reported that her son asked her about divorce, and that was the first time that word entered our sessions.


It was at this point, when she was satisfied with her path as an artist and that no one could take it away, that she brought her parenting concerns into the session.

She announced that she was no longer satisfied with the arrangement and was going to live full time with her son again.

She explained that she had "needed to strengthen my sense of being an independent self in order to face how much he needs me," and "if I had let myself think about it earlier, it would have totally stopped the process." We examined her definitions of "nurturing" as being "sucked," forced to make sacrifices, and being incapable of functioning as an independent self.

One of the metaphors she used was "valves" - she needed to know that she could turn off the mothering valve and get fully into her own (creative) needs and then turn the mothering valve back on, as needed.

Similarly, she needed to know that she could turn on and off the "creative artist" valve at will.


When she told her husband she wanted to move back home, instead of embracing this chance to restore their family, he expressed relief that now she could care for their son and he could accept a visiting professor opportunity at a prestigious east coast university.

That response shocked her and triggered feelings of rejection.

Then she learned from a friend that her husband had started a relationship with a woman who was affiliated with that university, and that he was intending to live with her during his leave of absence.

Ms. Q's outpouring of rage was mingled with laughter and relief.

Her husband's infidelity made it easy for her to view him as having made the decision for her.


She announced to her husband that she wanted to divorce.

She spent several sessions becoming comfortable with her decision and feeling the joy and fear of standing on her own and choosing her own direction.

She expressed gratitude for the growth that allowed her to realize how stifled and unhappy she had been.

She decided to take her son on a trip to Europe for the two months in summer, and to resume therapy when she came back.


At the session after her return from vacation, she announced that she had accepted that her husband had changed and described her lethargy and grief over the finality of the split.

She was insightful and introspective about her failure to grieve her first ex-boyfriend's death, and accepted responsibility for many of the problems in her marriage.

She identified her goal of working out details of child custody and division of property in a calm, businesslike way.


During the eight months until her divorce was final, we met at a frequency that was very flexible - sometimes twice a week, sometimes twice a month.

We identified the need for better communication and emotional management skills (BL3).

Through role playing, she practiced how she could ask him questions to get him to express his thoughts and use "I messages" to express what she wanted.

We did some parts work to find a self-soothing part, a voice that would calm her emotional reactions.

When she tried to speak from this part, she recognized that she was hearing the "Be quiet" messages she got as a child.

This was a significant breakthrough, and we talked about it for several sessions.

She realized that she had bundled together "creativity," "freedom," and "out-of-control emotional tantrums," and felt that a message to suppress the latter was an attack on the other two.

We discussed alternate ways for her to express a self- soothing message that would not be experienced as an attack, but as a helpful voice that would help her function more effectively.

She made the connection to the need to "flee" and the lack of an inner "voice of calm." She also recognized that whenever her husband said "calm down," she became enraged as if she were fighting for survival.


As part of the divorce agreement, they sold their house and she received a substantial financial settlement.

She decided to move to a coastal town about three hours away, and we set the termination date of therapy at the end of July, two weeks prior to her departure.

This made the total course of therapy 23 ½ months, spread over 2 years and 4 months.

In the second to last session she reported going to visit her mother and siblings and being able to stay calm and not respond to behaviors that would have triggered outbursts in the past.

She was pleased that they were furious at her husband for his "deceit and betrayal," and were now saying that she should have divorced him years ago.

This validation seemed to relieve her of a burden of guilt and regret.


I wanted to use the remaining sessions to review her progress in therapy, invite her to express her feelings about terminating, and help her prepare for the future. I reminded her that the initial goal was to make a decision about her marriage with reflection, instead of impulsively running away. She said that she had gotten exactly what she wanted (living separate from her husband) but that thanks to therapy she hadn't abandoned her child, and felt satisfied that she and her husband will be able to work cooperatively as parents.

She found it difficult to express any emotions about ending therapy, claiming she was overwhelmed with the shopping and packing she had to do.

I suggested that we focus on her achievements during the course of therapy and what specific gains she was taking with her.

She stated that the biggest gain was that she had given up the game of suppressing herself and living for others.

She called it her "caretaker addiction" and noted that she no longer felt that if she pursued her creativity that it meant that people would abandon her and that she would end up alone.

She said that she had gained a new awareness of having a "solid strong core" and that the "crazy hysterical out of control self" that she used to fear was her core was just one part of her, and that she was no longer afraid that it would take over.


In general, I view the monitoring process as ongoing.

The client's response gives immediate feedback to the appropriateness of an intervention or the quality of the therapist-client bond, and the client's report of out-of-therapy experiences provides data of positive change, deterioration, or maintenance of the status quo.