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.


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.


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.


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.


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.


From the very beginning, I realized from Ms. Q's feedback to me that she would respond better if I refrained from an analytic style and instead became more engaged, sharing my opinions and a few relevant experiences, judiciously.

She told me point blank that she did not want to be treated like a "case" but like a "real human being" and complained about the prior therapist who had listened and allowed long periods of silence, without ever offering an opinion.

My style with her was also influenced by her use of metaphors and humor, which I happily integrated into our sessions.

For instance, she used imagery of "valves" to help her integrate her roles of mother and creative artist, she mimicked the voices of other people when she described conversations, and she dramatized the voices of some of her inner parts in a playful, dramatic way.

Consistent with the "common factors" literature, I think that the strength of the relationship was a major therapeutic factor, and I monitored it closely.


I received direct feedback from Ms. Q that the "inner parts" way of viewing inner conflict and my cognitive approach during the first phase of therapy were both effective approaches.

She reported that she had had coped successfully by using these new tools when a very close friend 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] had been unavailable to her.

Whereas previously "it would have put me in bed for days with a breakdown," she was instead able to immerse herself in her creative work.

She used language from our parts work to explain this improvement: "My needy part was not going to take over just because I didn't get the comfort I wanted."


In another session, she described a "breakthrough" and showed that something I had suggested 5 sessions previously had borne fruit.

She was willing to talk about her ex-boyfriend's death and became very tearful.

In this session, as I wrote in my notes "she is letting me see the scared, trembling, overwhelmed kid inside, instead of presenting me with the smiling, articulate, poised, and in-control woman." Her belief that "I've already dealt with it" had yielded to "I need to stay with this in order to get unstuck." She said "I know this will make you happy" in a collaborative, cheerful way, indicating that she was not depriving me of that experience, as she would do with her mother.

In fact, after this session, she paid some visits to her mother and their relationship was more comfortable and equal, and she was able to test reality and learn that her mother was proud of her and thought she was a good parent.

These events gave me feedback regarding her maturation and differentiation from her mother - she no longer was stuck at age 17, when her mother had been an obstacle to her happiness.


In session #22 a bit of unintended psychoeducation had surprising benefit.

She confessed to me something she was very ashamed to have done, and I gave her a technical-sounding definition of the term "acting out": "It must be so hard for you to contain the overwhelming feelings that you're letting yourself experience, you used a common mechanism to deal with or avoid them." I was reframing her impulsive behavior from "something bad and shameful" to "a not-so-effective way of avoiding emotions." At the end of therapy, Ms. Q said that this was one of the most helpful moments because it motivated her to learn to tolerate her feelings and not push them away.

Similarly, my didactic explanations about the "selfobject" concept were beneficial in giving her an explanation for painful feelings as well as a conceptual framework for the weaknesses in both of her relationships.

At the time of my psychoeducational interventions, I had felt embarrassed over switching to the role of teacher and, in fact, had felt guilty about reporting these incidents to my supervisor.

I learned from this experience that the quality of an intervention must be judged by how it impacts the client and whether it produces positive change in her life.

Furthermore, since the client used the intervention in a way that exceeded my expectations, it underlines the importance of therapists listening carefully to our clients to discover the impact of our words.


I was fortunate that Ms. Q was quite direct in telling me her occasional doubts about the benefits of therapy.

For instance, in one session she asked "what's the use of therapy, is this really helping?" I asked her to think about it, and then a couple sessions later asked for her response.

She said "It's my time, I get to focus on myself.

Otherwise I'm fragmented and confused.

I feel confirmed." This feedback confirmed for me that she was experiencing benefits predicted by Kohut's theory, by developing capacities of a more mature self.


On three occasions, she brought in books and read passages related to gender roles and conflicts.

I noticed that the content and tone of her chosen excerpts had progressed from strident feminist male-bashing to an appreciation of the struggles of both men and women to develop 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] their fullest capacities.

These changes corresponded with a more internal focus, less blaming of her husband as an "obstacle," and the ability to tolerate her own painful emotions instead of focusing on externals.


The case formulation is an essential framework for therapy, but rather than being an architectural blueprint it is an ever-evolving itinerary on an unpredictable journey.

It is modified through various influences and obstacles: the client's preferences, the therapist's interpersonal style, the real human relationship that develops between the two, and the impingement of real life events and reactions of other people outside the office.


Instead of being short-term/time-limited, or long-term/open-ended, the course of therapy was actually three separate episodes, with breaks in between resulting from vacations, what Cummings and Sayama (1995) might call "intermittent." The client's outcomes at the time of our last contact included satisfaction with her decision to terminate the marriage, pride in having not neglected her responsibilities as a mother, greater personal confidence and maturity, and success in engaging for longer periods of time in creative writing, her chosen career.

I believe that therapy contributed substantially to these successes.

However, major credit for positive change goes to factors out of our control: her husband found another girlfriend and didn't wait around for her to overcome ambivalence; this led to her mother and sister turning against him and becoming very supportive rather than blaming; and she gained external validation for her writing talents from the acceptance of her stories in magazines and the praise of other writers.


I began working with this client in a psychoanalytic institute that provided instruction and supervision in therapy based on Kohut's self psychology, emphasizing the development of transference.

I initially expected a selfobject (narcissistic) transference to unfold, in which I would be viewed by Ms. Q as someone serving functions to shore up her self, rather than as someone who is a separate individual with a separate point of view.

Some of the markers of that type of transference is the need for "mirroring" (uncritical acceptance), a rejection of ideas from the therapist that offer a new perspective, and an overreaction of rage to minor "empathic failures." Such is the pressure of training settings with a firm orientation that it would be easy for trainees to ignore the data from the client and make assumptions about the client's dynamics from the preferred theory.

Determined to resist that pressure, I attended to the client's reactions to me, and to the development of our relationship, and found that she was open to new ideas, very tolerant of my mistakes, and eager to change her perspective.

The pleasure of working with this client stemmed from the fact that she was intelligent, motivated, and, most important, viewed me as a "real" person and valued my contributions.

Since that time, I have always emphasized the importance of "developmental diagnosis" for understanding the client, creating the best relationship, and making appropriate treatment decisions.


Kohut's theory not only helped me evaluate her level of maturity in relationships, but also was an invaluable lens for understanding her difficulty separating from her husband as well as how her healthy, creative, "grandiose self" had been squelched and now needed support to 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] find its power and voice.

Thus the therapy process was enriched by my integration of Kohut's concepts, without my embracing his treatment methods.

Instead of functioning like an analytic therapist, I engaged in a more equal, collaborative, "real" relationship, often similar to what Kopp (1978) described as a "fellow pilgrim." I also took the expert consultant role when I implemented cognitive strategies, directed experiential inner parts activities, and offered psychoeduation.


I was aware of how my personal values were involved in the process of therapy.

When she talked about leaving her 8-year-old son with her husband, I had judgmental thoughts about her being a bad mother, and, trying not to sound judgmental, confronted her on her rationalizations ("my son doesn't need me any more"), and tried to strengthen the part of her that felt guilty.

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 said "How do you imagine he feels at night when you're not there to tuck him in?" In my view, in these sessions I was the advocate for her child, although I suspect that my approach would be labeled "countertransference" by others at the institute.


It was an enormously valuable experience for me to write this case report and re-evaluate the course of therapy from my current perspective.

At the time, I was trying to learn a psychodynamic orientation and frequently felt embarrassed and annoyed at myself for violating the rules: I spoke too often, I "broke the frame" by giving opinions and validation of the client's strengths, and I destroyed opportunities for transference to develop by being too spontaneous, self-disclosing, and genuine.

In hindsight, I see that I created a positive relationship, showed respect for Ms. Q's autonomy and maturity instead of emphasizing pathology, and exhibited flexibility and creativity.

This case report illustrates how "core clinical hypotheses" influenced my therapeutic decisions, and how diverse ideas can be integrated coherently when the focus is on resolving problems and achieving desired outcomes.

B2: There are MEDICAL INTERVENTIONS (e.g., medication, surgery, or prosthetics) that should be considered.


B3: A holistic understanding of MIND-BODY CONNECTIONS leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind.


CS1: The client's symptoms constitute an EMERGENCY: Immediate action is necessary.


CS2: The client's symptoms result from identifiable recent SITUATIONAL STRESSORS, or from a past traumatic experience.


CS3: The client is at a DEVELOPMENTAL TRANSITION, dealing with issues related to moving to the next stage of life.


CS4: The client has suffered a LOSS AND needs help during BEREAVEMENT or for loss-related problems.


BL1: A behavioral analysis of both problem behaviors and desired behaviors should yield information about ANTECEDENTS (triggers) AND CONSEQUENCES (reinforcers) that will be helpful in constructing an intervention.


BL2: A CONDITIONED EMOTIONAL RESPONSE (e.g., anxiety, fear, anger, or depression) is at the root of excessive emotion, avoidant behaviors, or maladaptive mechanisms for avoiding painful emotions.


BL3: The problem stems from SKILL DEFICITS - the absence of needed skills -- OR the LACK OF COMPETENCE in applying skills, abilities and knowledge to achieve goals.


C1: The client is suffering from the ordinary "miseries of everyday life" and has unrealistic UTOPIAN EXPECTATIONS of what life should be like.


C2: Limiting and outdated elements in the FAULTY COGNITIVE MAP (e.g., maladaptive schemas, assumptions, rules, beliefs, and narratives) are causing the problem or preventing solutions.


C3: The client demonstrates FAULTY INFORMATION PROCESSING (e.g., overgeneralization, all- or-nothing thinking, and mindreading, or is limited by an inflexible cognitive style.


C4: The problem is triggered and/or maintained by DYSFUNCTIONAL SELF-TALK and internal dialogue.


ES1: The client is struggling with EXISTENTIAL ISSUES, including the fundamental philosophical search for the purpose and meaning of life.


ES2: The client is AVOIDING (or needing to utilize) the FREEDOM and autonomy that come with adulthood AND/or does not accept RESPONSIBILITY for present and past choices.


ES3: The core of the problem and/or resources needed for resolving the problem are found in the SPIRITUAL DIMENSION of life, which may or may not include religion.


P1: The problem is explained in terms of INTERNAL PARTS AND SUBPERSONALITIES that need to be heard, understood, and coordinated.


P2: The problem is a REENACTMENT OF EARLY CHILDHOOD EXPERIENCES: Feelings and needs from early childhood are being reactivated and patterns from the family of origin are being repeated.


P3: Difficulties stem from the client's failure to progress beyond the IMMATURE SENSE OF SELF AND CONCEPTION OF OTHERS that is normal for very young children.


P4: The symptom or problem is explained in terms of UNCONSCIOUS DYNAMICS.

Defense mechanisms keep thoughts and emotions out of awareness.


SCE1: The problem must be understood in the context of the entire FAMILY SYSTEM.


SCE2: Knowledge of the CULTURAL CONTEXT is necessary to understand the problem and/or to create a treatment plan that shows sensitivity to the norms, rules, and values of the client's cultural group.


SCE3: The problem is either caused or maintained by deficiencies in SOCIAL SUPPORT.


SCE4: Difficulty meeting demands for SOCIAL ROLE PERFORMANCE contributes to the client's distress and dysfunction.


SCE5: A SOCIAL PROBLEM (e.g., poverty, discrimination, or social oppression) IS A CAUSE of the problem.

Social problems can also exacerbate difficulties stemming from other causes.

You must avoid blaming the victim.


SCE6: The problem is causally related to disadvantages or advantages to the SOCIAL ROLE OF MENTAL PATIENT.


Kohut's concept of "grandiose self" was important for understanding the creative drive; the fact that it was inadequately "mirrored" in childhood contributed to her need to protect it, and her assumption that it would be attacked and stifled by her husband.

As a child in her family she was initially in a very close relationship with her mother, where the normal roles were reversed, and she had to be sensitive to her mother's emotional needs, instead of getting the empathic attunement and calm, loving acceptance for her true self that she needed (Alice Miller's (1981) Drama of the Gifted Child is a good fit with this client's history) Her maturation over the 12 years of her marriage was an important factor in understanding the marital dynamics.

Initially, she had been immature and was satisfied with serving her husband's needs, deriving a sense of safety and worth by being his wife.

However, at the time of therapy she wanted to assert her own needs and fulfill her own talents.

She was having difficulty finding inner sources of self-affirmation, and wanted to separate in the way an adolescent wants to break away.

Her empathy for others was variable.


There is plenty of material in the history for speculation: rage at brother (for being born and stealing her mother) and father (for dying and abandoning her) may have contributed to her feelings towards her husband.

The guilt over her boyfriend's death was talked about, so it seemed conscious, but its persistence despite her awareness that it was irrational suggests that it persisted in limiting her ability to leave another relationship.


As the client matured and became more independent and assertive, it disrupted the marital equilibrium Her husband wanted to assert pressure to return things to the status quo, and did indeed seem to want to sabotage her career development.

Her desired solution of "cut off" was easier than the process of differentiating and standing on her own.


Her mother's hostile disapproval of the client's lifestyle choices stemmed from Latina/Catholic background.

The issue of gender was important to the client: men have an easier time pursuing careers and ignoring the needs of their families and she felt hampered by the traditional female role.


She had a good support system in her friends.

Her mother and siblings sided with her husband and pressured her to put family ahead of "selfish" goals.


Ingram (2009) presents a case study conducted within her model of psychotherapy integration, a systematic approach that takes several factors into account.

Within the integration field, Ingram’s model can be classified within the bounds of “Technical Eclecticism,” and is more encompassing than other similar approaches.

The approach can be improved by greater attention to cyclical factors among her categories, but it remains an important contribution.

Her interesting case study demonstrates how her system can be applied.


Ingram (2009) has described the interesting case of Ms. Q using her particular integrative approach, which I will hereafter refer to as the “Integrative Psychotherapy” model (see Ingram's [2006] detailed book on the model).

I am pleased to be able to comment on this presentation and, in doing so, will divide my remarks into two sections.

The first will place Ingram’s contributions within the general corpus of psychotherapy integration, and the second will be reserved for specific comments about the case.


Within the field of psychotherapy integration, there are four general types of models (e.g., Castonguay et al., 2004; Stricker & Gold, 2006).

These include Theoretical Integration, which strives to encompass previously quite different theoretical perspectives within a single, coordinated theory; Assimilative Integration, which maintains a single orientation but incorporates techniques from other orientations; Common Factors Integration, which strives to find and develop common elements from across different theoretical points of view; and Technical Eclecticism (also referred to as Technical Integration), which focuses on a combination of techniques drawn from different therapeutic systems without regard for any specific theoretical approach.

Ingram’s Integrative Psychotherapy can be classified within this last category.


Ingram’s model is far more specific in its details than a Common Factors approach, and her model’s lack of a guiding theoretical formulation rules out Theoretical or Assimilative Integration.

In Technical Eclecticism, therapeutic procedures are not attached to treatment methods or models, and this is clearly true of Ingram’s Integrative Psychotherapy.

It is comparable in approach to Prescriptive Psychotherapy (Beutler, Consoli, & Lane, 2005) and Multimodal Therapy (Lazarus, 2005a, 2005b).

In comparison to these two, Ingram’s model is much closer in style to that of Lazarus and Multimodal Therapy.


Ingram and Lazarus both begin with a careful assessment of the client and are guided by a comprehensive set of categories.

For Lazarus there are seven modalities of human experience and functioning that include the dimensions of Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drugs/Biological—which as a whole Lazarus refers to with the acronym “BASIC-I.D.” For Ingram it is a combination of four treatment models (Behavioral and Learning; Cognitive, Existential and Spiritual; and Psychodynamic) as well as three other areas that also generate hypotheses about causation (Biological; Crisis, Stressful Situations, and Transitions; and Social, Cultural, and Environmental).

I prefer Ingram’s list to that of Lazarus because of her willingness to acknowledge the potential contribution of Psychodynamic concerns and the explicit attention to Existential and Spiritual issues.


I also note the similarity of her approach to the three-tier approach that Gold and I have developed (Gold & Stricker, 1993; Stricker & Gold, 1988; Stricker & Gold, 2005) within our assimilative psychodynamic integration approach (Gold & Stricker, 2001; Stricker & Gold, 2002; Stricker & Gold, 2005).

In the three-tier approach, we divide our concerns into behavior, conscious experience (perception and cognition), and unconscious dynamic factors.

Ingram has anticipated a clear difficulty in our approach by acknowledging the important role of Social, Cultural, and Environmental factors, and we will include these in future works. I also applaud her explicit concern for Existential and Spiritual issues, which might fit within our tier concerning conscious experience, but deserves the specific attention that she gives to them.


One area with which Ingram (and Lazarus) does less well with is an acknowledgment of the interrelated nature of all of these areas of concern.

It is important to recognize that Ingram’s seven categories are not seven independent areas to be explored, but rather that each one impacts the other.

As a result, we become clear that it is of little concern where our initial intervention occurs because of the synergistic effect that each area has on the other.

Without the concepts of interrelatedness and cyclical impact (Wachtel, Kruk, & McKinney, 2005), a more mechanical pattern of interventions arises.


It is interesting to note Ingram’s experience in choosing her integrative theoretical approach in treating Ms. Q: Prior to this client, I had effectively integrated ideas and treatment methods from cognitive and existential approaches in my work as a staff member and part-time independent contractor for university and community clinics.

After taking a course in the [Self Psychology] work of Heinz Kohut at a psychoanalytic institute, I decided to enroll in a postdoctoral training program to learn more about this theoretical model.

When I started seeing the client, my intention was to put aside my prior methods and techniques, and wholeheartedly embrace the psychoanalytic approach that I was studying.

Instead, I discovered that I was constitutionally incapable of not being integrative.

Fortunately, I had a supervisor for this client who saw me in his private practice office and who accepted that I was seeking to integrate what I was learning rather than to convert to a new orientation.

( pp. 1-2) This description precisely reflects the experience of many people who identify with psychotherapy integration, in that they recognize the value of orientations other than their own, but want to work in a variety of ways that best serve the client rather than to convert to a new set of narrow convictions.

Ingram thus clearly belongs in the tradition of psychotherapy integration, as she recognizes, and it is now time to turn to the application of this imaginative system to the particular case that she presented (Ingram, 2009).


Before beginning a review of the case of Ms. Q (Miscue?), there are several important issues to cover.

First, Ingram notes that she has changed several details to protect the anonymity of Ms. Q, “in the extremely unlikely event that she should read this article.

” The changing of names and of inconsequential details is common practice and raises no concerns.

However, this ordinarily is done to protect the client from being revealed to others who may read it, a less unlikely scenario.

As for protecting the client herself, in my view the much better action is to ask the client, if available, for permission to use her data for a case report, allowing her to read it if she wishes, and abiding by whatever her wishes might be. I have done that several times, have always received permission (a question may be raised about whether there is implicit transferential coercion, although I always try to minimize it), and usually there is a positive benefit from this obviously mutually respectful and collaborative intervention.


The structure of the sessions with Ms. Q varied over time and setting.

Treatment followed the increasingly common pattern of extended sequential therapy rather than a single continuous episode.

As such, this may be viewed as two or three therapy episodes rather than a single one.

There is some value in this emerging pattern, for it allows the client time to consolidate therapeutic gains and focus on new issues.

Usually, as in this case, this pattern is brought about by external factors, such as payment policies and changes in living arrangements, but it rarely is destructive to the flow of treatment.

The point I want to note is that Ingram continued the treatment at the same fee.

I applaud her for this decision.

All too often, I have seen candidates in psychodynamic training settings, such as Ingram in this case, or young therapists moving from clinic settings to private practice, who agree to continue with their patients but only at an increased fee.

Given the powerful nature of the therapeutic relationship, there is the potential for exploitation in this offer, and it is noteworthy that Ingram resisted the temptation to do so. I also have some concern (about typical candidates, not Ingram) when the patients, who are being treated at a reduced fee, are made to feel in a second-class status by the juggling of their appointment times in favor of more privileged full-fee patients.


Ingram notes that her sources of data, besides what the client told her, included external information about Ms. Q’s writing and about her husband.

There are no ethical issues raised by this as long as Ingram did not seek out information from others about the husband (and there is no indication that she did), but there is a very interesting therapeutic point that it raises.

How important is such external confirmation? As long as Ms. Q is committed to a career in writing, must we (can we) judge how talented she is? As long as she sees her husband as stifling her growth, does it matter whether he really is doing so? I certainly can see arguments that claim that such information is important because they would help to introduce reality into the treatment planning, but there also is a point of view that suggests that the only reality that matters is that of the patient.

My position is somewhat intermediate, but it matters less what I think; what is most important is to raise awareness and encourage discussion of this issue within the psychotherapy community.


Finally, at least for these pre-treatment comments, it must be noted that a case study inevitably leaves out data and changes some things that are included to protect anonymity.

As a result, any of my comments may turn out to be incorrect because of a lack of sufficient information, and Ingram may have done exactly what is suggested but failed to record it for reasons of space or privacy.

For Ingram, psychotherapy begins with a thorough assessment and the establishment of outcome goals that are directly related to the identified problems.

No specific mention is made of necessary attention to the establishment of a therapeutic alliance, but the goals and tasks that are mentioned are two of the necessary components of an alliance (Bordin, 1979).

The third component, the bond, although not specifically mentioned, almost surely was established given the description of the case.

It is critical to establish mutually determined goals that can be altered in the course of therapy, as this strengthens the bond, provides the basis for a treatment plan and subsequent interventions, and allows for feedback about progress.


In terms of Ms. Q’s treatment goals, it isn’t clear how the attainment of subjective goals such as making good decisions can be evaluated without a judgmental dimension entering into the treatment.

Other problems, such as Ms. Q’s lack of confidence and frustration, are better divided into two so that they can be worked on and evaluated separately.

In regard to the judgmental dimension, this is particularly apparent in the instance when Ingram asked Ms. Q about her child’s feelings when she failed to tuck him in at night.

She appropriately referred to as an example of countertransference.

This occurs again when Ms. Q decided not to enroll in the writing program, but instead to rent an apartment and live on her own while pursuing her writing career.

Ms. Q was very proud of this choice, and it seems as though Ingram agreed as well.

However, was this a good choice? Who can say? I would be inclined to support the patient’s choices whether or not they agreed with my preferences, as long as they weren’t obviously destructive.

However, here again, the threshold for perceived destructiveness will vary as a function of the attitudes of the therapist.

The acceptance of the approach of the client is consistent with Client-Directed Therapy, a new and interesting common factors approach to integration (Duncan, Sparks, & Miller, 2006).


One obstacle to blending cognitive and psychodynamic approaches is that the former is more directive and the latter more expressive.

Providing direction, such as with Ingram’s regard for the welfare of Ms. Q’s son, may serve to compromise a stance that encourages free expression.

This is an inescapable concomitant of an integrative approach, and it is necessary to recognize that techniques that mean one thing within a home approach may mean something entirely different within a different or more integrated approach.

I applaud Ingram’s focus on strengths, as this too is often overlooked.

It is the patient’s strengths that can be the basis of constructive developments within treatment, and also the recognition of strengths is helpful in promoting the therapeutic bond and increasing the patient’s hope of success, which often is integral to therapeutic gains.

The strengths that are listed include both internal strengths, such as Ms. Q’s intelligence, and intra-therapeutic strengths, such as her ability to provide feedback within the treatment.

It is important to keep both in mind, as they both contribute to success in the treatment.


During the first session Ingram asked Ms. Q to consider both individual and couple therapy.

This is an often overlooked aspect of treatment that should be required as part of informing the patient about the risks of treatment.

Ms. Q clearly preferred individual treatment and valued her growth more than her marriage, but that is a choice each patient should be allowed to exercise, and the only correct answer is the one that is consistent with the patient’s goals.

Problems arise when the patient is not alerted to the difference between the two modalities, and to the likely effect of the choice on the patient’s individual growth and relationships.


Ingram does use the technique of asking for examples when Ms. Q thought her husband would become symptomatic if she were to become more successful.

This was very effective in correcting a misperception of the consequence of success.

Interestingly, Ingram refers to this as cognitive therapy, and it is, but it also is an intervention that would be very comfortable for a psychodynamic therapist.

Similarly, in discussing Ms. Q’s feelings toward her husband, Ingram used techniques that she accurately sees as consistent with Greenberg’s Emotion-Focused Therapy (Elliott & Greenberg, 2007), which, in turn, is a derivative of Rogerian thought.

It is interesting to note that the work of Kohut (1977), which also influenced Ingram, is very similar to that of Rogers (Kahn, 1985).

They agree on the central role of empathy in the therapeutic relationship, a point also emphasized by Ingram in her description of the treatment.

Very often techniques from entirely different theoretical orientations are similar to each other, and this makes the task of integration a good deal easier if one is not caught up in the rigidity of any single system.

However, the previous caution about the changing meaning of similar techniques when placed in different theoretical systems is particularly appropriate here.


The use of chair work, a technique familiar to humanistic therapists and often integrated in the work of therapists with other approaches, was resisted by Ms. Q, but the patient’s idea of accomplishing the goals of chair work without changing seats was accepted by the therapist.

This is a good example of flexibility, as the goal of the technique is more important than the actual execution.

The goals were consistent with Ingram’s “inner parts” hypothesis, and often chair work is used whenever ambivalence is an issue.

Ingram uses a technique of cognitive labeling that I find very useful.

It helps to normalize some behavior, as it did in the case of Ms. Q, and also to help her to develop better skills.

I also have found that labeling serves many other purposes.

By identifying and naming an emotion, it conveys empathy and thereby strengthens the therapeutic alliance.

It also gives the patient a sense of mastery, as a named emotion is also an acknowledged and thus owned one.

Normalization takes the feeling out of the realm of the mysterious, which tends to reduce the helplessness that accompanies the unknown.


During the second phase of treatment, Ms. Q was able to access a sense of never having gotten anything without having to work for it.

I can imagine that this was an important insight and very moving for the patient.

However, I also wonder whether she had been given a good deal without having to work for it before her brother’s birth, and it was the contrast between her rich early years and the subsequent deprivation that was so difficult for her.

This brings up some fascinating questions.

Is this reformulated insight superior in any way to the one that Ms. Q achieved? Does the “historical truth” of the observation matter if the “narrative truth” is meaningful to the patient? ( On this distinction, see Spence, 1984.) In line with the latter, I am inclined to think that the most important thing is to provide the patient with a coherent and credible attribution for feelings and actions, and these can be the vehicle for therapeutic progress even in the absence of historical correlates.