Introduction & Literature Review
The aim of this research is to explore the lived experience of having psychotherapy as part of coping with a long term condition. The participant of this study, now 37 years of age, has had periods of profound anxiety and depression for most of her adult life and from her late teens until late 20s experienced severe eczema and Bulimia Nervosa as well as addictions to alcohol and smoking. It is through Rachel’s experience of therapy that an improved understanding of recovery from LTCs may result. Adopting an existential phenomenological perspective I will explore the lived experience of a person with a LTC. In doing so I hope to bring to life how that person makes sense, copes and relates to others. This research is likely to be of value to those whose starting point is the empowerment of the individual as being key to mitigating the effects of a LTC. With this in mind the following issues are pertinent to the literature review:
- Phenomenological experience of people with a LTC in therapy
- Phenomenological experience of people in therapy
- Benefits of therapy to people with LTC
- The lived experience of someone with LTCs
There are two key influences, work and personal, that have led to this choice of topic. I started working in the NHS in 1980 and continued in various roles until the present day. Throughout this 34 year period there have been struck by a number of factors, as follows:
- The manner in which conditions are treated in isolation of each other.
- The lack of recognition given to the inter-relationship between a condition and mental health issues.
My interest in long-term conditions (LTCs) arises from the belief that the significance of the above increases as the condition progresses over time as well in severity. In addition, at a personal level I have seen the progression of a LTC in my father for over 35 years.
The English/NHS definition of a LTC is defined as:
“…those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with a long-term condition is forever altered – there is no return to ‘normal’.” (NHS Confederation 2012, p3).
I find this definition controversial on two accounts. In the first instance, it places disproportionate emphasis on the condition not being curable thereby ignoring the mental health effects of a condition lasting decades but, in principle, curable. Secondly, depression whilst considered to be a LTC I personally believe it to be curable. Interestingly, the criteria adopted by Scottish health bodies is that the LTC lasts “a year or longer” (The Scottish Government).
This literature review was unsuccessful in finding research which focussed on the (existential) phenomenological experience of people with multiple LTCs (co-morbidity), whether they are in therapy or not. The focus of this review will therefore be on the public health context of LTCs and the way in which they are currently treated; thereby providing an insight into current perspectives of effective interventions.
From the perspective of the person with a LTC, “many…experience living with a long-term health condition as highly stressful. The psychological impact of chronic illness can include anxiety, depression, post-traumatic stress disorder, and relationship difficulties” (McLeod, 2013, p32). In addition, the current and projected prevalence are increasingly cause for concern given the expected pressures on the system. The increase in prevalence, it is suggested have arisen from “progress in the effectiveness of medical interventions means that patients live longer, with the result that there is a greater likelihood that they, and their families, will need to go through a process of coming to terms with a diagnosis of a serious health condition.” (Edelman, Lemon and Kidman, 2005, p32). The net effect of this change is that because people with LTCs “are the most costly group of patients that the NHS has to look after” (Goodwin et al, 2010) this means that “the management of people with long-term conditions is set to remain one of the most pressing challenges to the NHS” (Goodwin et al, 2010). Clearly there is an urgent requirement for a clear long-term strategy based on the premise that interventions and the associated investment will ensure effective and appropriate service delivery. Alarmingly though, “relatively little information exists on what constitutes best practice…” (Goodwin et al, 2010).
For many people, and of particular relevance to this study, there is the additional burden of co-morbidities. Whilst “research evidence suggests this is more often the rule” (Goodwin et al, 2010, p57) it is especially cause for concern that the same people also tend to “….have poorer quality of life, poorer clinical outcomes, longer hospital stays and more post-operative complications…” (Goodwin et al, 2010, p57). The need for improving the evidence base also arises from the research evidence of what works being even weaker than that for singular LTCs “because most research trials specifically exclude people with multi-morbidities” (Goodwin et al, 2010, p57).
Hence, although the evidence base is weak, the following policy drivers form a baseline of future service development for people with LTCs in the England:
- case management (Department of Health 2007) and continuity (Goodwin et al, 2010)
- a shared structured care management plan (Department of Health, 2007)
- scheduled follow-up (Department of Health, 2007)
- empowerment (Department of Health 2005) based on education, facilitated self-management (Department of Health, 2007) and provision of information (NHS Confederation 2012.) This is especially relevant for people who are depressed as “disempowerment, passivity and learned helplessness” often form a component of the condition. (Goodwin et al, 2010, p42).
With respect to the relationship between LTCs and mental health problems it appears to be recognised that the link is an important one (NHS Confederation 2012 & Goodwin et al 2010), though again poorly understood:
- Despite the increased need for coordination of services (Royal College of General Practitioners, 2009) “less progress has been made for depression” (Goodwin et al 2010, p8) in establishing collaborative care models
- Similarly, chronic disease management and follow-up are weak and in need of development (Goodwin et al 2010, p44).
- There is a perception that people with long-term depression “fall through the gap between primary and secondary care…” which may be partly explained by GPs feeling less confident “about managing patients with depression” (Ford 2006, p44).
- “…only 23 per cent of people meeting diagnostic criteria for a depressive episode, or mixed anxiety and depression, had received any form of treatment…” (McManus et al 2009, p44).
- A holistic approach to the tackling of an individual’s physical and psychological needs is lacking (NHS Confederation 2012, p4).
Whilst the above suggests that mental health problems are the poor relation in healthcare, this contrasts sharply with the nature of the problem:
- For people under 65 “…as much ill health is mental illness as all physical illnesses put together.” (Centre for Economic Performance’s Mental Health Policy Group, 2012).
- Generally speaking “a person with depression is at least 50% more disabled than someone with angina, arthritis, asthma or diabetes” (Centre for Economic Performance’s Mental Health Policy Group, 2012).
- As a net effect of under-detection and under-treatment (Coventry et al, 2011). “….only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions” (Centre for Economic Performance’s Mental Health Policy Group, 2012).
- “…mental illness accounts for nearly a half of all absenteeism” as well as for “nearly half of all people on incapacity benefits” (Centre for Economic Performance’s Mental Health Policy Group, 2012)
- Risk of depression is increased 2/3 fold for people with one LTC and 7 fold for people with 3 or more LTCs (NHS Confederation 2012).
With respect to available treatment the main interventions are anti-depressant medication and psychological therapy (Goodwin et al 2010, p42). Whilst some of the evidence suggests these interventions are equally effective this can be enhanced by allowing the patient to choose (Lin et al 2005, p42). Other evidence suggests that primary care treatment is predominantly anti-depressant medication in direct contrast to the wish of patients who through numerous surveys have expressed a preference for talking therapies (Goodwin et al 2010).
Having successfully negotiated the one’s way through the various barriers to gain the correct diagnosis and successfully accessed talking therapy treatment over medication the depressed patient is most like to be faced with a one-size fits approach as in the vast majority of cases only CBT is available on the NHS. Whilst other modalities are available in the voluntary sector their work has been undermined (van Rijn & Wild, 2013, p151) by national policy which favours CBT (Department of Health, 2002).
As implied above the evidence-base for talking therapies is at an embryonic stage of development but it is there. In one study, a number of modalities were compared for their effectiveness and the results:
“strongly demonstrate that transactional analysis and gestalt psychotherapies, integrative counselling psychology, and person-centred counselling can be used as effective treatments for anxiety and depression”. (van Rijn & Wild, 2013, p151).
Specifically related to TA there are key two studies which look at its effectiveness in treating depression as follows:
- Fetsch and Sprinkle (1982), “found short-term TA group therapy to be an effective intervention for men with mild-moderate depression” (Fetsch and Sprinkle, 1982).
- Widdowson (2012) found short-term individual TA therapy to have been effective in a single-case for the treatment of severe depression (Widdowson, 2012).
It is, however, the work of McLeod in which she reviews the effectiveness of TA for LTCs which is most relevant. Specifically, she states that the key determining element:
“appeared to be attributable to the adoption of a flexible, integrative approach that allowed clients sufficient time to explore different facets of the meaning of illness, in the context of a strong therapeutic relationship (McLeod, 2012, P40).
The adopted qualitative methodology for this research study is a phenomenological one using an unstructured interview to gather data. The latter will be analysed hermeneutically using existential themes and underpinned with ‘critical realist’ assumptions.
Being a qualitative case study provides an opportunity for gathering rich and detailed information about the perspectives of the participant. The adopted phenomenological approach will result in a focus on the “experienced meaning” (Polkinghorne, 1989, p184). To be successful this will require a genuine understanding of how the participants “world is lived and experienced” (Finlay, 2011, p3). Through the resultant exposition the intention is to establish what the client values most in the therapeutic experience.
Being a hermeneutic analysis, existential themes will be integrated into the interpretations whilst also attempting to retain the ‘essence’ of the experience. The key themes to be explored in the participants ‘existence’ will be their “sense of embodiment, self-other relations, time and space” (Finlay & Ballinger, 2006, p11).
Data collection and analysis
Data was collected and recorded at a single unstructured interview of 1 hour and 12 minutes with the participant. Although a prepared script of key questions had been drafted this was not referred to in the interview itself. The data was then transcribed (Appendix 2) and listened to repeatedly as a means to identifying themes for subsequent analysis. This latter process was also facilitated by the production of a mind-map (Appendix 3).
A diary was kept from the date of the interview as a means of recording my own experiential development.
The participant is a female called Rachel (pseudonym) and at the time of the interview was aged 37. She was born in Warrington but from the age of 8 she lived in Northumberland until she left home to go to university aged 18. The participant was accessed through my tutor and supervisor Steffy. The participant had been a client of Steffy’s for 17 years. The manner in which the client was accessed is important given the sensitivities involved. For any participant recalling and recounting their life experiences and how they have learned to cope and adapt in response to these experiences is a challenging and emotional experiences. It is particularly important, therefore, that the participant is sufficiently robust and able to self-sooth given the emotions such an interview is likely to evoke. Steffy was the ideal person to make this assessment. The participant was offered an additional therapy session paid for by me should she require it.
The interview itself was held at Manchester Institute of Psychotherapy (MIP). Not only did the participant request this but I also felt this was essential to the process for the following reasons:
- It was a place we both knew well and were comfortable with.
- It offered a place of relative neutrality for both of us and, given the participant had requested it, likely to be void of any contaminating associations; though I was concerned about the potential impact of also being the participant’s place of therapy.
- It would ensure that we were undisturbed and the discussion would be confidential.
In preparation for the interview, as well as explaining who I was and the purpose of the interview, with a view to protection I explained that I would ensure my questions are sensitive and appropriate but she could also:
- Stop the interview at any point.
- Refuse to answer specific questions.
- Go off in another direction if it felt relevant.
Rachel signed a consent form (Appendix 3 – as an attachment) covering key aspects of the interview process and production of this research. Although given the opportunity to choose a pseudonym she elected not to so ‘Rachel’ was my choice.
Three overarching themes were identified as follows:
- I was like broken glass (P106). Addresses her sense of embodiment. The constant ‘battle’ against the ‘hideous’ (two words used repeatedly throughout the interview).
- …it’s not making sense of awful things that go on in the world (P121). Work with Steffy to get better.
- So now I just need to decide what to do with my life (P196). Making sense of who she and how she relates to others.
1) “The fear is that hideous” (P67). Addresses her sense of embodiment.
In the main, this theme highlights Rachel’s strength of feeling towards her embodied experiences of her LTCs. As these experiences are explored the way in which her world was experienced as a child will be compared with that of being an adult. Throughout the interview I felt the repeated use of the word ‘hideous’ was said as if the word itself was could not quite encapsulate just how bad the situation was:
The fear is that hideous (P67).
Whilst Rachel to this day continues to struggle, “…I am miles better than I was but it’s still a constant battle” (P113), as has already been implied the nature of this ‘hideous’ experience has different phases. The phases whilst related chronologically have more to do with the nature of their somatic, psychological and behavioural expression. In essence, they can be summarised as:
- a) Home life/pre-adulthood/childhood.
- b) Pre-therapy
- c) During therapy and current.
- Home life/pre-adulthood/childhood.
From a young age Rachel’s existence was dominated by chaos and the behaviour of volatile ‘carers’ around her. In addition to the reality of having to care for the so called caregivers, little attention was given to her emotional and psychological needs:
“…as a child I used to put my Mum to bed with blood everywhere and sick and I was only about 7 and I remember lying in bed thinking my Mum’s going to be dead tomorrow, my Mum’s going to be dead tomorrow, my Mum…..and that was terrifying…cause I loved her…I was always waiting for her to be dead.” (P121)…
As well as the living with the fear and heightened insecurity of regularly believing her mum might die, she was also subjected to oppressive men, which also created ambivalent feelings to her mum who had chosen to be with her step-Dad:
“…my step-Dad was really nasty and never worked…” (P33)
“… my Dad who was exceptionally stifling and a drinker..” (P35)
Within this environment it is the lack of protection offered to the child which appears to be most powerful in Rachel’s recount of her experiences. It is indeed ‘hideous’ that on a regular basis over many years a child will be exposed to the trauma of believing their mum will be dead in the morning. Given Rachel receive could not rely on the love, affection and care from her mum the ambivalence also extended to the perception of her attachment to her mum:
“I loved my Mum but hated her for how inconsistent she was….” (P33)
Although we did not delve into to the nature of her relationship with her mum today, I was left with the sense that whilst she still loves her mum her relationship is a realistic one being bound within her mum’s own limitations as well as having accepted the past.
The net effect of this upbringing was that Rachel successfully contained and held the chaotic and volatile environment along with the lack of consistent protection and love with an act which in itself must have been exhausting:
“…it was hideous….hid everything behind this big smile (P36); “..would hide it very, very well.. (P29) & Hid it…kept it all down.” (P37)
In keeping with this strategy for coping and attempting to normalise her circumstances, Rachel made no mention of the impact it had made on her well-being pre-16. There was a significant shift, however, in the lead up to completing her ‘A’ levels. Rachel had a high degree of awareness of the unhealthy nature of the environment she was living in but not necessarily the impact this was having on her health and well-being:
“…went to university to …escape family…..I really believed …all the crap would disappear and I would suddenly magically become this lovely wonderful person…” (P26)
This belief of escape being the solution to all her problems drove Rachel to succeed had a profound effect on Rachel which remains to this day. Whilst the right decision made for the wrong reasons, her desperate attempts to succeed in her ‘A’ levels became self-destructive resulting in grades well below her capability:
“Really intense, frightened all the time, wouldn’t allow myself any joy. Put immense pressure on myself.” (P31)
The pressure Rachel put on herself combined with the lack of sensitivity, caring and protection from her mum was so traumatic that it undermines her confidence and aspirations to this day:
“…pressure had been so intense with no support….last exam I had to walk out of my last mock. …my Mum on the morning of the exam -”just get on with…just deal with it”…so I’ve had this ….anything to do with deadlines or studying ….deep intake of breath ….I just can’t do it. So although I am probably more than capable I can’t face it.” (P43)
As will be explored in the next section, Rachel’s psychological issues didn’t go away but once she left home the nature of her upbringing developed into somatic, psychological and emotional health issues.
- b) Pre-therapy
Over the next few years it is hard to imagine how Rachel’s situation could have been more difficult. Over a prolonged period she engaged in a cycle of self-abuse through chronic bulimia and alcohol with the probable intention of trying to numb the pain. These behavioural manifestations were a counter and reflection to the psychological issues of depression and anxiety. The net effect of this existence was highly self-abusive, chronic and severe:
“Well I was sort of abusing anything I could come into…..” (P130)
“Yes. I was chronically bulimic. So it was making myself sick. That is…oh it’s just hideous because ….the compulsion to force food down to numb feelings and the guilt and the making myself….it was hideous…I could not control it and I couldn’t control my drinking.” P131
It was during the above account of her life at that time that Rachel seemed to find it particularly difficult to get across the gravity of her situation. She had trouble finishing her sentences and, as elsewhere used the word ‘hideous’ but said almost as this was not a powerful enough expletive.
Addiction was clearly a major aspect of Rachel’s coping mechanisms but these addictions also include anxiety, the very thing she trying to counter:
“I drank to take the anxiety away but then chased it.” (P59)
It is understandable how Rachel whilst despising the overwhelming negative effect of her anxiety might also be something she was and is addicted to; after all, anxiety whilst growing up was all she knew. ‘Will my mum be dead tomorrow, will she be in a good mood today, will I get what I need most, what horrible thing will my step-Dad say to me today’ might have been some of the day-to-day, hour-to-hour emotions she was living with. So, as stated by Rachel, better the devil you know. Much as she hated this way of being it was all she knew and at least it was familiar.
This is contradictory behaviour with alcohol was symptomatic of the chaotic nature of her life as a child resulting in the development of a weak locus of control:
“I was just stuck in this cycle of everything and then I try would numb everything so I would drink which would make everything worse again, my skin would flare up again…” (P134)
All these health problems were frustrated and compounded with a lack of knowledge and understanding of how to help herself never mind make herself better:
“I can kind of knew what it was related to, couldn’t…how…had so many years trying to get on top of it just didn’t know how to get better.” (P83)
Throughout her description of the various physical problems and her extreme difficulties in coping the statement I found the most powerful which seemed to encapsulate the psychological and emotional essence of how she felt about her life at the time was:
“I was like broken glass…shattered (P106)….I remember my heart just feeling broken.” (P107)
So for all the physical problems she was experiencing, the pain she endured with being septic from the eczema and the chaotic nature of her life it was the broken love which appeared to precipitate the shift into therapy and possibly the issue which was the most poignant for her. In summary, her life up to this point can be summarised as a being caught in a vortex of a ‘constant battle’ (P49, P50, P58 & P113) against the ‘hideous’ (P26, P36, P59, P67, P72, P131, P134 & P154) with no understanding of how to escape. That said, somewhere there must have been some hope of escape for Rachel to take up therapy.
- During therapy and current.
In describing the therapy process Rachel’s initial focus was on the way she dealt with her addictions one by one; bulimia, alcohol and smoking; respectively. To bring each one of these under control so decisively are each, in themselves, clear major achievements (the bulimia alone she had for 12 years) and Rachel was evidently proud. From the way Rachel reflected on these addictions it was clear that their damaging effect was clearly a motivator for change. From the outset of therapy, the health issue Rachel was keenest to address was the bulimia:
“… I just think that was the most damaging to me in terms of how abusive it is to your body….to make yourself sick so violently so often and the impact it had on my appearance and on my skin.” (P144)
This drive to address the bulimia initially appeared to be due Rachel’s perceived connection with eczema which had such a profound and debilitating effect on her life. For example, because the eczema confined her to her bed and because of the embarrassment, if not shame, of the way she looked it stopped her connecting with other people as well as losing much needed jobs.
At the time of starting the therapy Rachel “was really, really poorly!” (P52, P173 & P25) so much so that Rachel believed she would be in psychiatric care or dead if she had not struck up a successful therapeutic relationship. As became apparent during our discussion of the therapy itself, the overriding factor in determining success in the therapeutic process was the nature and quality of connection with the therapist. Hence, whilst this relationship was key in enabling healing and positive change it is also a source of ambivalence in Rachel as to how this happens.
2) “…it’s not making sense of awful things that go on in the world” (P121). Work with Steffy to get better.
It is a source of surprise and wonder to me that people often enter into a talking therapy a time of great crisis in their lives with little understanding of how therapy might help. This was also the case for Rachel who had reached ”rock bottom” (P58). The implied rationale for seeking therapy is therefore an act of desperation because everything else had failed and she had nowhere else to turn. What is even more impressive is that her overwhelming fear of going into therapy was only outweighed by the fear both of her own severe depression and highly self-abusive behaviours. Two factors which appear to have positively contributed to the decision to seek therapy were her openness to herself and others about her addictions as part of a desperate desire to want to change and at some level an awareness that her problems related to her upbringing and childhood experiences.
Having made the decision to seek therapy the next key foundation stone was Rachel’s understanding of the need to establish a strong connection with a mother figure (P172 & P173). This was particularly important in the early days of therapy because for the first time in her life it offered a place where Rachel could feel safe:
“…cause it was my only safety in the whole world and often I didn’t want to leave that room. I could have just lived there…only place I felt safe.” (P105)
“..at least one hour a week I feel safe.” (P107)
The awareness of ‘safety’ being a key issue for Rachel was also apparent earlier in the discussion when she reflected on this being an identified need in her university days. Hence, given her upbringing of volatility and chaos it is pertinent to note that these were the only times safe/safety were used.
Developmentally Rachel’s thinking appeared stuck at the time she was caring for her mother believing she was about to die. Clearly this was a traumatic period in her life when at a young age Rachel was unable to process the reality of the situation. Her thinking appeared to not to be related to any information that was currently available but instead driven by an irrational anxiety that almost came from nowhere. This links with the earlier comment about ‘chasing’ the anxiety. One key in which this anxiety expressed itself was an irrational fear of her own behaviour. The power of this anxiety was clearly overpowering but through the therapeutic process she was able to establish that more anxiety provoking an issue was the less likely it was that she would do it. Rachel’s propensity to anxiety was alleviated by the opportunity to rationalise and talk through the issue:
“….some days I would come in and be so …draws deep breath…frightened by an issue that I had made so big and I can’t even remember what these issues were now and then we would work through it …and it’s so long ago that I have had to work like this and then you would get to it and then it’s like a little knot, that’s what Steffy would say, and you would undo it and it would like oh is that it!” (P151)
Through the work done in therapy, Rachel was able to establish coping mechanisms as a means to maintaining her health and well-being. A key area of learning was the need to stay “connected with positive people” (P74). Initially the connection was only Steffy but over a period of time she has been able to form a series of healthy and supportive relationships through her partner and close friends. Rachel recognises that the grounding effect of this connection was particularly important to avert depression or to pull her out of a depressive episode as they provided an effective counter to the irrational and negative thoughts being drawn from her childhood. Much as Rachel highly valued the therapy, in fact she believed it saved her life, there was also a degree of ambivalence as to the process:
“….I don’t know because I never understand how therapy works it just does.” (P147)
Rachel herself threw some light onto this ambivalence by drawing attention to the protracted nature of therapy. Because the change happens over such a long period of time this makes it difficult to identify a single aspect of the process which ‘makes it work’:
“When you are that badly depressed there is no chance…it’s a real gradual coming out.” (P76)
As we delved in to this aspect of therapy a bit deeper Rachel was able to identify how the therapy enabled her to make sense of the world and develop her ‘here and now’ cognitive thought processes:
“As you sort of get to end of one issue another one cropped up and I suppose after years of unpicking and resolving things the need to do the things that were to stop you feeling those things fades I suppose because those issues have been resolved.” (P148)
These issues are not, however in isolation of each other as they have an identifiable source which can be reflected upon. As Rachel was able identify, it is this very analytical process which enables a better understanding of herself and why she thinks the way she does:
“….I understand what’s going on much more, I understand that this isn’t real..” (P123)
Whilst the therapy has been successful in addressing her unhealthy behaviours so that Rachel is able to be a loving and caring mother and partner, the negative thought processes are more resistant to change. A specific example of this was the worry that something terrible might happen, to her son, partner etc.:
“I know how to manage it better but it’s still a battle to keep well….constantly watching…depression is the worst for me….terrifies me because I have been so ill with it.” (P49)
Although there is clearly an ongoing struggle to avert depression she has been successful in avoiding to revert to self-abusive behaviours of old. To some extent this can be explained by the coping strategies which have been developed over the years. Primarily this involves staying connected based on a foundation of understanding herself which has enabled Rachel to develop an ability for rational thinking.
3) So now I just need to decide what to do with my life (P196). Making sense of who she and how she relates to others.
Rachel seemed most relaxed and confident when talking about her son. The huge sense of pride, joy and love was clearly self-evident in both her body language and the way she spoke. Given how far she has travelled and what she has achieved I felt a degree of alarm that her role as a mother was a source of ambivalence with respect to her self-identity:
“My son has just gone off to full-time nursery…so he gave me a purpose and suddenly it’s like then what do I do. Haven’t got a clue.” (P49)
Whilst her self-esteem has clearly improved and was able to authentically recognise that she is “kind and loving” (P112) she also recognises at some level possibly given her intellect, abilities and drive that she has even more to offer. Whilst to some extent these aspirations may come from the example set by her mother who was a teacher and her sister who got good ‘A’ level grades, there was also a passion in the voice that demands more of herself. The resultant tension arising from this uncertain future as well as the desire for recognition of something other than being a mother appeared to be opening up a new chapter in her anxiety journey and possibly a contributor to her current depression:
“….I still don’t know where I am going in my life….” (P113)
Whilst initially her desire to succeed was to escape from home she now seems driven to make those decisions that typically would be made aged 18. In many respects Rachel’s life has been put on-hold for 14 years whilst she was ill and addressing her addictions. Having a family is a key indicator of the success she has achieved in overcoming these addictions but she now seems on the cusp of making the next step into defining herself in relation to others in the wider world. That said there is the inevitable ambivalence about such changes which entail planning and looking forward to a yet unknown and uncertain future:
“I think …..I stopped myself from dreaming a long time ago. I think that will come back but….” (P119)
Whilst the anxiety and fear still pose a threatening and sometime overwhelming force, the challenge of finding a purpose, now beyond motherhood, is in a significantly improved context compared to when she was 18. Rachel has created a positive support structure and she understands her past and why she struggles but she has also overcome profound addictions to the extent that she finds it relatively easy being a Mum. All this is far cry from the woman whose chaotic and self-destructive thinking whose past was determining her options and choices for herself:
“….even 10 years ago I just….the whole thought of family …just repulsed me because I always found it so ugly and stifling…” (P175)
A key strength in Rachel’s current lifestyle is she is still open to learning and has the opportunity to be real with the key trusted around her. By choosing friends who are positive and supportive, Rachel no longer has to act or pretend that all is OK when in reality she is full of inner-turmoil. Given her chaotic and inconsistent upbringing it is also incredibly positive for the long term future that neither appears to apply currently. Rachel seemed content with her current close relationships, which suggests she has developed a healthy inner-self in contrast to the younger woman who desperately wanted love but did not know how to find it:
“….I did drama with film and TV studies…but then I see now that the reason I went into that is because I just wanted people to love me…” (P38)
We can use Beck’s (1995) work on schema in order to put Rachel’s experiences in to a TA framework. The thinking would go something like Rachel developed an inflexible and persistent belief that the world is a frightening place full of uncertainty outside of her control. That, in order to keep herself safe, she must keep her feelings to herself. She also learned that other people tend to be unpredictable and fragile and it was only by appearing to be happy and content that she could create a degree of control on this volatile situation. Given this framework one can see a clear link between her suppressed and unmet needs leading directly to the development of anxiety and depression. Given the context of unmet needs, this schematic explanation of Rachel’s emergent depression is complemented by Steiner’s (1974) “theory that depression is linked to stroke deprivation” (Widdowson, 2011, p360) as well as the Gouldings’ work (1979/1997) that the cause of depression lies with a ‘don’t exist injunction’. With respect to the resistance to complete removal of the script’s influence (in this case, through depression), it should be borne in mind that the schemata’s associated neural pathways were laid from an early age and reinforced over a protracted period of time. Hence, it is possible to hypothesise that whilst new neural pathways can be laid down which potentially become the dominant ones, the older unhealthy ones cannot be completely be removed.
As well as helping us to understand the nature of the causal issue, TA theory also helps us understand the nature of the effect these experiences. Given Rachel’s enforced caring role at a young age she had to develop her nurturing parent almost from instinct. The lack of authentic expression of her free child combined with a don’t enjoy injunction would typically compromise a someone’s ability to enjoy her and now experiences. Certainly this was the case in her twenties but it is a testament to the transformative effect of her therapy that Rachel seems to be authentically enjoying so much of her life, in particular, time with her son. TA theory would say that a profound exclusion of the child ego state, such as that described above, would result in difficulties in being able to regulate her own emotions and difficulties in being able to regulate herself. The symptomatic anxiety, depression and self-abusive behaviours are all powerful examples of this prediction. Similarly, the reference to ‘broken glass’ as an overriding issue for Rachel can be linked to her unmet need around recognition hunger. The net effect of human beings drive for survival is the need to form attachments which offer security and stability. Ideally these attachments are healthy ones based on love and affection. Whilst Rachel was and still is very much driven to love those close to her, this love at best was not reciprocated in a consistent manner. It is both an area of ambivalence for me as well as demonstrative of the power of therapy, that whilst she may have been unable to cathect this love in the twenties it is certainly something she is able express healthily today.
Turning to the value of Transactional analysis, the basic therapeutic premise is that from our earliest experiences we make decisions as to who we are and how to function in the world. Whilst these early decisions made sense to us at the time they are often a poor fit later in life if they are not moulded or changed. The question remains as to how therapy enables us to achieve this insight. According to McLeod’s work it is the processes of ‘understanding’ and the development of a ‘strong therapeutic relationship’ (McLeod, 2013, p40) which are both key and this is strongly echoed in the findings of this study. An additional strength to this finding is that there is a significant amount of research covering a wide range of modalities supporting the view that it is the quality of therapeutic relationship which is overriding criteria for judging effectiveness. Within the confines of a qualitative methodology, this study has served to reinforce existing research. Many other areas of this study, however, lack such an evidence base.
In addition to the paucity of phenomenologically based research looking at depression there is also little specific coverage in the TA literature. Not only is this cause for concern given the prevalence but also the impact depression has is alone justification for greater attention. As the work of Widdowson has demonstrated:
“…depression is not just a form of sadness; it is a disorder that affects both brain and body, including cognition, behaviour, the immune system and peripheral nervous system…” p351
Rachel’s descriptions and, in particular, her regular use of word ‘hideous’ supports profound and overwhelming effect that depression has; as described above.
Another theme which emerged from the study was the value placed on understanding, particularly with respect to how Rachel’s past experiences were influencing her present day thinking. This adds to concern expressed elsewhere about manualized therapies such as CBT. For example, in commenting on low levels of maintained recovery, Morrison states that such therapies:
“…focus on a limited area of the client’s presentation, do not necessarily work with the client’s other presenting problems (co-morbidity), do not account for characterological problems, and/or do not provide therapy of a sufficient length to remedy such issues.” (Morrison et al, 2003).
Adopting a TA perspective on this issue, Widowson suggests that not addressing “underlying and unresolved script issues may lead to relapse or a return of symptoms.” (Widdowson, 2012, p355). This viewpoint echoes the experiences of Rachel’s as evidence by the transition from the dominating impact of her script on her health and well-being in her 20s to the present day healthy family life and absence of self-abusive behaviours.
A notable characteristic of the policy documents referred to in the literature review was the lack of attention given to and understanding of the person’s experience of coping with a LTC. This approach is highly typical of the medical model and, given the strong relationship between LTCs and mental health problems, may go some way to understanding the lack of a coherent and effective management and treatment programme in the NHS. Rachel’s experience of therapy demonstrates the need to for each chronic condition as well as mental health problem to be treated as a whole. The current option treating each condition in isolation is severely limited in its effectiveness. One effect of this study is to draw attention to need for more exploratory research which explores these interdependencies.
My immediate emotional response after the interview was that it was an honour and a privilege to have been party to Rachel’s reflective exploration of her experiences. This feeling stayed with me for some time and to some extent there was a sense of bewilderment at why Rachel would volunteer in the first place, especially given she had little insight as to what would happen. Clearly, her willingness was largely a symptom and endorsement of her relationship with Steffy. As I pondered this over the following months I was also struck by her generous and warm personality. Given her character, an additional motive might have been to help so that other’s might benefit. I feel humbled in this regard.
Rachel’s account of her living with LTCs and her experience of being in therapy have, above and beyond anything else, demonstrated the huge capacity of the human body to not only survive but also to heal. One limitation of this study was to not reveal the characteristics which bring people to therapy and to persevere with the huge challenges they face. I also believe the study has been compromised by my own lack of experience to ask key searching questions in the interview with such a giving client and rich subject matter as well as to sufficiently explore the existential and phenomenological themes. That said, I do believe the study has highlighted the huge potential and value psychotherapy offers in addressing the needs of people with LTCs.
The literature review identified two key issues for which there is positive and growing evidence base:
- Empowerment should be embedded in service delivery as it is key to the effective management of LTCs.
- The key to effective therapy is the quality of the therapeutic relationship.
As reflected in the work of Dusay, TA serves both these purposes very well. Whilst the basic framework of TA is easily communicated and understood (e.g. nature ego states, development of lifescript etc), the therapist also has freedom to develop the relationship based on his/her own strengths but more importantly in tandem with the personality of the client (Dusay, 1986). So, whilst the findings of this study suggests TA would be an ideal component of a service delivery model for people with LTCs, the paucity of an evidence base remains the key stumbling block.
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Widdowson, M. (2011). Depression: A Literature Review on Diagnosis, Subtypes, Patterns of Recovery, and Psychotherapeutic Models. Transactional Analysis Journal. Vol. 41. No. 4.
Widdowson, M. (2012). TA Treatment of Depression – A Hermeneutic Single-Case Efficacy Design Study. International Journal of Transactional Analysis Research. Volume 3 Issue 2 July pp. 3-14. Available at: http://usir.salford.ac.uk/30766/ Accessed at: 1 March 2014.
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Transcript of Interview.
See separate attachment.
Breakdown of Thematic Analysis
See separate attachments.
See separate attachments.
APPENDIX 3 Research Project Proposal Form
Name: Martin Loughna
The working title for this research is as follows:
“To explore and analyse the benefits Transactional Analysis psychotherapy has had for an individual with at least one long term condition.”
The rationale for this research proposal can be summarised as follows:
- Long term conditions (LTCs) represent an ever increasing financial cost to NHS and local authority services as well as to the client due to loss of earnings either as a client or as a carer.
- People with LTCs experience disproportionate mental health problems which in themselves create profound financial and emotional costs both to the client as well as additional financial costs to public services (e.g. co-morbidity accounts for a third of people with LTCs).
- There is increasing evidence to suggest that where people are able to cope mentally with their LTC this can have beneficial effects with respect to their recovery and/or the impact that the LTC has on their day to day lives.
- The formal inclusion of psychotherapy in the LTCs commissioning pathway is very much in its infancy (e.g. the IAPT programme will only be expanded to include LTCs in 2014).
The above statements are supported by a high number of recent research and government policy documents (e.g. NHS Confederation. Mental Health Network (2012); The Centre for Economic Performance; Naylor, C., M. Parsonage, D. McDaid, M. Knapp, M. Fossey and A. Galea (2012) & Imison, Candace, et al. (2011)).
As further testament to the points made above, LTCs represent 55% of GP appointments, 68% of outpatient attendances, 72% of inpatient bed days, 58% of A&E attendances, 59% of Practice Nurse appointments and 40% of calls to the 111 service (NHS Networks).
For this research study the adopted qualitative methodology will be the phenomenological approach in order to maximise on opportunities for exploring the participant’s lived experience. Given this aim I will use an unstructured interview with the participant. The data will in turn be analysed hermeneutically using existential themes with a view to analysing the “participant’s sense of embodiment, self-other relations, time and space” (Finlay & Ballinger, 2006; p. 11). The analysis will also be underpinned by ‘critical realist’ assumptions.
How will you prepare your participant and minimise any risks of harm to your participant?
Duty of care to the participant will be paramount in this research study and will supersede the needs of the research at all times. I recognise that discussion about a LTC which, in all likelihood, will have preceded therapeutic interventions and will also still be an issue for the participant is therefore likely to evoke strong emotions. Whilst the participant may have been successful in ameliorating the mental health issues associated with their LTC it is important to recognise that they are unlikely to be fully resolved. Hence, whilst it is the participant’s prerogative to express their emotions as part of the interview my responses, whilst sensitive and appropriate, will have to be confined to objectives of the research; as opposed to being therapeutic interventions.
As well as ensuring the participant understands the nature of the research process, it will also be important to brief the client as to the purpose of the research and the way in which the information will be used. Hence, in terms of informed consent the participant will be fully informed as to what to expect from the interview process as well as the nature of the research as a whole including their right to withdraw at any point. Should there be any need to deviate from the agreed process the participant will be consulted in the first instance.
Whilst confidentiality will be respected and maintained as much as possible the participant will be briefed as to the circumstances that confidentiality might be compromised.
The participants will be debriefed at the end of the session to ensure their personal safety so that at the end of the interview they are able to keep themselves safe and protect themselves. A psychotherapy session will be made available to the participant should they wish to discuss therapeutically any issues that may have arisen as a result of the interview.
The participant will be selected through MIP and the approval of both Bob Cooke and Linda Finlay will be sought before proceeding.
The Centre for Economic Performance. How Mental Illness Loses Out In The NHS. http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdf Last accessed on 31st August 2013.
Finlay, L. & Ballinger, C. (2006). Qualitative Research for Allied Health Professionals. Challenging Choices. Chichester: John Wiley & Sons Ltd.
Imison, Candace, et al. (2011). Transforming our health care system: ten priorities for commissioners. London: King’s Fund, 2011
Naylor, C., M. Parsonage, D. McDaid, M. Knapp, M. Fossey and A. Galea (2012). Long-term conditions and mental health: The cost of co-morbidities. The King’s Fund and Centre
for Mental Health.
NHS Confederation. Mental Health Network (2012). Long term health gains: investing in emotional and psychological wellbeing for patients with long-term conditions and medically unexplained symptoms. Briefing; 237 (April 2012) London: NHS Confederation, 2012. http://www.nhsconfed.org/Publications/Documents/Long_Term_Health_Gains_Briefing.pdf
NHS Networks: http://www.networks.nhs.uk/nhs-networks/commissioning-for-long-term-conditions/about-us Last accessed on 31st August 2013.
NHS Confederation. Mental Health Network (2012). Investing in emotional and psychological wellbeing for patients with long-term conditions and medically unexplained symptoms. London: NHS Confederation, 2012. http://www.nhsconfed.org/Publications/Documents/Investing%20in%20emotional%20and%20psychological%20wellbeing%20for%20patients%20with%20long-term%20condtions%2016%20April%20final%20for%20website.pdf
Signed: Martin Loughna Date: 31st August 2013
Approval given by: Date: