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This chapter presents a case of personal construct psychotherapy addressing the serious problems of a man diagnosed with paranoid schizophrenia. It exemplifies therapy conducted using Kelly’s original techniques of self-characterisation, fixed-role therapy, and the values of acceptance and utilisation of the client’s ways of construing the world. The flexibility of the approach is exemplified through the use of music in the latter stages of therapy
KeywordsSelf-characterisation Fixed-role therapy Credulous approach Creative therapy
Brian, aged 30, was referred by his Consultant Psychiatrist for a general assessment of his personality and symptoms. The referral stated that he had been diagnosed as suffering from paranoid schizophrenia and was being treated with anti-psychotic medication. He was said to be very suspicious and to express thoughts of violence and revenge against people he thought were against him. He had spent much of the past six years as an inpatient with compulsory admissions after many years of heavy drinking, and had attended court on two occasions for being involved in fights and carrying a knife. He was first admitted, compulsorily, to psychiatric hospital after attacking two strangers, who he claimed had been following him in a car. He had not been offered any psychological therapy apart from ward groups. He was very opposed to these and never spoke in them.
He was seen by HP for an initial assessment. From this I recommended psychotherapy and we went on to work together for the next 18 months. All this happened many years ago whilst I was still in training as a clinical psychologist, and before many of the developments described in this book, but it was an important formative experience for me. The case illustrates many of the values and approaches to psychotherapy as originally advocated by George Kelly, which we shall describe and develop in the coming chapters.
Brian was shy and at first quite formal, avoiding eye-contact, but he soon began to talk freely about his experiences and ideas and we got on well throughout the time that I was working with him. I think he accepted me because I focussed with genuine interest on the way he saw things and avoided any talk deriving from medical discourse. Indeed, in the spirit of the personal construct approach, I never thought of his experiences in terms of ‘illness’, ‘symptoms’ or ‘schizophrenia’1 throughout the months that we worked together, but rather regarded him as a fellow human being struggling with the difficulties of life.
His father’s family were middle class, having owned a cider-making company, but this had been subject to a hostile takeover with the factory being asset-stripped. The money the family gained from the sale all went to his father’s sisters as his father himself had been seen as a ‘dropout’. There seems therefore to have been a significant downward step in social mobility for Brian’s parents. Brian was the fourth of five siblings and he had lost his younger brother in a road accident five years previously. Brian was married with two children of 12 and 10, and lived in a small terraced house in a run-down area of town. I wonder now whether the family’s loss of status and standard of living had contributed to his general sense of resentment of and antipathy towards other people.
Brian was clearly bright and articulate and had enjoyed school from an academic point of view, but he was bullied a lot and he saw everyone as false and hypocritical. He chose not to join the ‘grammar stream’2 because he hated the people in it so much. Although he was strong at maths, science and English, he left hoping for a better social life but was bitterly disappointed in this. He worked as a steel erector, and as a taxi and lorry driver but became very frightened when he began to think people were against him. He avoided claiming any benefits because he was frightened of the other claimants there. He was therefore financially dependent on his wife. He felt bad about not being able to support his family. His wife was getting very fed up with him, threatening to leave him. He said he would kill her if she left him and she believed him. He was very jealous, even of his wife’s previous boyfriends. If anyone in his family had any trouble with anyone, he would threaten to go and beat them up.
Brian’s Construing and Relationships
A central idea in Kelly’s approach is the personal construct system (PCS). It refers to the way an individual’s unique construing of the world and their ways of approaching things shape experiences. The PCS governs our anticipations and how we act, how we make choices and judgements. Therapeutic change and progress involve revising and altering it, developing new ways of seeing things. Kelly advocated many ways of finding how people construe the world. This word ‘construe’ is a deliberately broad term designed to cover how we see things, feel about them, how we act and relate to people (see Fig. 2.2 and Chapters 2 and 3). The main way of establishing a person’s construing is by listening carefully to them. In addition to talking with Brian, I gave him Kelly’s role construct repertory test. This ‘Rep Test’ is an early form of the repertory grid (see Chapter 6 for this and other assessment methods). The names of important people in his life were written on cards. He was invited to spread these out on the table and to talk about how the people were alike or different and to tell stories of his encounters with them. I also used two other tools that, although not devised by him, Kelly advocated: the Thematic Apperception Test (TAT),3 a series of evocative pictures about which the person is invited to tell a story, and the Rotter Incomplete Sentences Blank, in which one has to complete sentences from a series of words or phrases. Later, I got Brian to write a self-characterisation sketch (see Chapter 6). Brian also shared poems and a journal that he kept. They all proved to elicit a rich picture of how Brian construed his life, himself, and others.
As a child he suffered a great deal from other children. He often found himself the centre of ridicule and was bullied to quite a degree. He used to give the bullies his toys and money in the hope that they would leave him alone. They didn’t. In the end he stayed away from school and ever since if anything threatens him, he stays away. He does not take these episodes at school lightly; he burns with a sullen anger and indulges in daydreams of revenge.
A word he used a lot to describe his feelings was ‘embarrassment’. He was embarrassed by sports, dancing, and woodwork. From an early age he felt different to other people. From a PCP point of view, all these descriptions, or ‘constructs’, clustered together in a ‘tight’ constellation (see Chapter 3) which distinguished ‘Me’ from ‘Them’. He even saw his wife as ‘one of them’. At one stage, early on, we went for a walk together whilst he described how suspicious he felt about people in the streets, particularly men. The fear that he felt led him to be very vigilant and on the lookout. He felt that he was stared at a lot by people with their ‘imposing eyes’. Sometimes he would even feel that people on television were referring to him. One card in the TAT is completely blank. He said, ‘can see the sea, waves coming in, just medium sized waves and on each wave is a face’. His response to others’ threatening attention was to turn away or to put his head down whilst still looking straight ahead with his eyes. Of course, this furtive behaviour would be likely to attract attention and make him appear different, their reactions validating his construing that people were noticing and staring at him. This kind of interactional loop can be usefully drawn up in a diagram known as the ‘bow-tie’ (see Chapter 4). His approach to people could also be seen as involving hostility as defined by Kelly—extorting evidence to prove one’s construction (see Chapter 3).
Death is his favourite subject, the idea he is most obsessed with. No other person I know has dwelt so constantly on it, and delved into it so deeply…these feelings make him want to be on his own and he finds it impossible to lead an ordinary existence.
He wrote a poem including the lines, ‘My coffin – oh polished wooden womb…and six feet south isn’t far to roam, for where I lie – I lie alone. In this place I can’t love the less, so lovely is the loneliness!’ Kelly (1955, p. 15) wrote optimistically, ‘no one need paint himself into a corner; no one needs to be completely hemmed in by circumstances, no one needs to be the victim of his biography’. However, unfortunately for Brian, he had apparently painted himself into a corner and was living an increasingly alienated life in the ‘career’ of a psychiatric patient.
One of the things Kelly insisted was that constructs are ‘bipolar’, they always have two ends or ‘poles’, providing a person with avenues of movement and choices between alternatives (Chapter 3). It is notable that all the words and descriptions Brian uses—false, insincere, against me, frightening—cluster at one end of a construct dimension. We never hear of what lies at the other end—could that be ‘sincere, trustworthy, genuine, kind’? We don’t know, and we should never assume that we know, what people’s contrast poles are. Fransella pointed out (Chapters 3 and 7) that if we have an elaborate set of ideas at one end of a dimension and almost none at the other end (e.g., being ‘fluent’ for the stutterer), we find it hard not to slip back into the familiar end where we have learnt to deal with things in spite of them being problematic. Brian instead saw himself in his self-characterisation as having two ‘selves’, ‘one the quiet family man interested in films and books, the other frightened, being obsessed with death, fear and predestined and inescapable doom’. These two aspects of himself were apparently dissociated from each other—two fragmented construct subsystems in PCP language (see Chapter 3). He seemed to be caught in an ‘implicative dilemma’ (see Chapter 6), preferring solitude and resenting interruptions and invasions of his privacy and yet, at the same time, craving for relationships.
JOHN ULVERSTON: FIXED-ROLE SKETCH
John Ulverston is a rather quiet individual most of the time but when he gets involved in a discussion that interests him, he becomes quite talkative and his eyes light up with enthusiasm. He treats his fellow human beings very much as equals and doesn’t like the idea of one person telling others what to do. This arises from his philosophy which he likes to think of as a “scientific” analysis of human behaviour. This is not to say he likes everyone; in fact, he is rather fussy about who his friends are.
John extends this “scientific” way of looking at things to all his areas of interest. He is interested in reading horror stories and science fiction because he likes to theorise about how authors dream up such weird fantasies. However, he doesn’t see this sort of thing as being important in everyday life.
His point of view has the advantage that it gives him the strength to let people have their own way. He is more interested in observing people and seeing how situations make them behave in certain ways. If someone boils over with rage he sits back and wonders how long it’ll be before they calm down. The trouble with this is that people tend to get a bit fed up with him and think he is a bit cold and clinical at times, but he takes this in his stride as well.
The sketch is written without prescribing too many behaviours or reactions, leaving it sufficiently vague for creativity and spontaneity to operate, but under the new orthogonal theme of observing people for interest rather than checking for their hostility. The name helps to provide an ‘anchor’, to remind the person to maintain playing the role and to reinforce the make-believe nature of the exercise. The idea is not to ‘replace’ his character with a model, but to have him playfully engage in a relevant learning experience. He was intrigued by the task. Rehearsing the idea with Brian, we discussed how he, in the role of this character ‘John Ulverston’, would deal with different situations that he might encounter as he pretended to be John, enacting examples in the session, including swapping roles briefly. He was encouraged to read the sketch through several times a day and ‘become’ the person for two weeks. He was given an engaging science fiction novel to read over this period to accompany John’s interest in ‘scientifically’ observing the behaviour of other people.
We met five times over the fortnight period of the fixed role to check on how it was going and refine the experiment. Brian returned to these sessions saying it was a powerful experience and he was very enthusiastic. To his surprise, he (John!) had been able to enter various situations without fear. He had spoken to a neighbour, he went to the corner shop and chatted to the shopkeeper, travelled on a bus, and went to the cinema—things he had not done for a very long time. In the cinema, he had been pleased that he had avoided a confrontation with some noisy kids, when he felt that normally he would have become aggressive. Of the neighbours, he said, ‘I see their view now – I haven’t spoken to them for nine years!’ This is particularly significant as it involved what Kelly described as sociality—the ability to put himself in the shoes of his neighbours and see their point of view, rather than being totally absorbed in his own fears and suspicions about them. We will see how essential sociality is in our approach in the coming chapters.
A central process in the method is probably that a slightly different demeanour in the role-player leads others to respond to him in subtly different ways, modifying the usual interactional ‘loop’ that had been operating. This opens the door to different mutual construing between the participants. Of course, this is not a ‘magic cure’; Kelly argued that the aim of FRT is to set ongoing processes in motion rather than creating a new state. It provided new material to work with in the sessions subsequent to the experiment: John Ulverston often came up in the conversations we had in the following months.
Progress and Recovery
I continued to see Brian in regular sessions for the following 16 months, after which we had to stop because I was moving to a new job. During this time, two significant turning points occurred. The first, after a further eight months, was paradoxical. I received a letter from him saying he had decided not to come for therapy anymore and that ‘he realised he was unalterable’. I visited him at home and reassured him that I still wished to help him and urged him to continue. He agreed to persevere.
In the next session, he asked if he was still making progress, indicating a new reflection on how ‘alterable’ he might be. He appeared to have ‘hit bottom’, and in some profound way had ceased to strive for change. And yet, after this, all the issues of death, which had occupied much of our conversations, simply vanished from his concerns. I had raised the issues of goals and the fact that therapy would one day end. Some kind of spontaneous change in his construing seemed to have occurred, seemingly involving a reappraisal of his life. His interest in death was replaced by a new project involving a similar attention to detail—to take up learning to play ragtime guitar.
‘Well, it looks to me as though, assuming by the look on his face that that was his Dad’s violin. I think his Dad, well it appears from the way he’s looking at it, that he’s dead. Um, he’s just wishing that his Dad was here to play it. Um, wishes he could play it like his Dad did. That’s all….’ (is that all?). ‘He may be deciding that he’d learn to play it….’ (how did it turn out?) ‘He eventually learned to play the tunes that he knew his Dad liked’.
The transitions and elaborations of meaning through these sentences are notable, moving from missing his father (third sentence) to wishing he could do something as well as his Dad. He then describes a state of deciding to learn to play, with an outcome of having achieved approval from his father.
I suggested that he bring his guitar to our sessions and for a series of Thursday mornings, I also brought my guitar to the Psychology Department! We worked together for part of the hour, studying the finger-picking arrangements of the guitarist Stefan Grossman.6 I believe that the following months consolidated a trust and companionship between us that he had not experienced with anyone before. The music provided a vehicle for the meetings, during which he could reflect on his ongoing life and experiences without the embarrassment that a direct focus on them might have involved.
About four months after this, a second turning point occurred. He wrote a letter to me saying, ‘It’s about time I got off my backside and got myself a job like everyone else…I have been out of hospital for 15 months now which is the longest I’ve ever managed’. A very significant session occurred after this in which he talked a lot about his family and how his wife demanded more of him than he felt he could give. He still felt periods of paranoia from time to time but got a job driving buses, the very situation that had been so threatening to him. Terminating the therapy was difficult, but after I left, he kept in touch with me by letter and telephone for a further three years. During this time, he told me that he had been taken off his medication.
Review and Reflection
This case illustrates how the central focus of concern in personal construct psychotherapy is the construing of the client. We seek to understand the client’s understanding of the world in a non-judgemental way, what Kelly called ‘the credulous approach’. Everyone has a unique set of constructs, both in terms of the content (e.g. Brian’s seeing others as false, hypocritical, frightening, against him) and structure (how these constructs cluster together, for example in a tightly interrelated way—see Chapter 3 for a discussion of Kelly’s ‘professional construct’ of tight versus loose construing). Brian had approached the social world using a single major dimension of for me versus against me, a situation that has been described as monolithic construing. It was this that led the therapist to consider fixed-role therapy, revising and loosening this tight structure by temporarily encouraging him to consider people according to an orthogonal construct as we have described.
In my view, nothing in this practice is incompatible with a constructivist therapy. What is inimical is considering pharmacotherapy as a substitute for self-understanding, reflexivity, self-change, resistance against oppressive circumstances and problem resolution at more psychological levels. (R. Neimeyer, 2009, p. 103)
It is ironic that the term ‘schizophrenia’ includes under the same umbrella people who have very tight construct systems such as Brian and at the other end of the scale very loose systems, where the person’s constructs are vague and varying, a situation which has been reliably shown to characterise ‘schizophrenic thought disorder’ (see Chapter 7). If Brian’s construct system had been loose, fixed-role therapy would certainly not be indicated as it would probably have contributed to further loosening and chaotic experience for the client.
The therapy for Brian was helpful, and this underlines that psychological therapy such as personal and relational construct psychotherapy can be very effective and indeed is essential in people who have serious psychopathological diagnoses. It was possible to help him make profound changes and from a cost-effectiveness point of view, weekly expenditure of one-hour sessions of therapy prevented further admissions to inpatient treatment, which he had endured for six years. It enabled him to return to work. The psychiatrist reported after 11 months of treatment that he found him ‘much more communicative and friendly than on previous occasions. His relations with his wife appear to have improved’. The Hostility and Direction of Hostility Questionnaire (Caine, Foulds, & Hope, 1967), administered at the beginning and end of the therapy, indicated a significant reduction in various measures of hostility, although he remained quite critical of himself.
Probably, an important therapeutic factor was allowing him to experience a supportive relationship in which the therapist listened carefully to him, stuck by him through difficult phases, and provided a warm alliance with him that he appears not to have experienced before in his life. The fixed-role therapy was very helpful in kick-starting him back into an involvement with others, but I believe that the long period of subsequent therapy was essential in consolidating these changes. The two ‘turning points’ were indications of profound change in his construing of self, beginning to appreciate his own potential, and putting his interest in death matters behind him. The music therapy7 allowed him to find an area where he could develop new skills and ways of expressing himself. Also, learning to play the guitar seems to have allowed him to identify himself with a positive aspect of his father—his violin playing—and not just ‘all the bad qualities’. His comments indicate that his construing of his father was central to his identity. By learning to play the guitar, he may have found that he could at last share a love of music with the memory of his father, the shift in this crucial relationship enabling him to reconstrue himself more positively. This was likely to have had implications for his own current role as a father. Unfortunately, he is no longer with us—it would have been good to reflect with him on this.
This case was conducted before the therapist had become experienced in applying Kellian principles to working with families (see Chapter 9). If I were to tackle this case again, I am fairly sure that I would have placed family intervention more centrally, allowing us to address his marital issues and also problems with his daughter, who had started refusing school. However, Brian’s preference for tackling things by himself and his embarrassment about his state may well indicate that one-to-one individual therapy over an extended period would still be the treatment of choice.
The personal construct theorist Don Bannister (1968) had described schizophrenia as too diffuse and incoherent a term to be used in scientific research.
The higher level, where pupils would go on to further education.
The Thematic Apperception Test (Morgan & Murray, 1935) was recommended by Kelly (1955) as a good way of eliciting constructs. It consists of a series of pictures of situations in which the client is invited to tell a story about what is going on.
The work of Tom Ravenette with children is a particularly good example of the spirit of playfulness in PCP (see Chapter 5).
This can be seen by searching ‘TAT Violin’ on the internet.
30 years later, in 2008, I was lucky enough to meet Stefan Grossman at one of his gigs. I told him how important his guitar books had been in helping Brian make a recovery from serious mental health problems.
The music in therapy as well as the use of tools such as the Rotter test and the TAT illustrate how the construct approach is willing to use methods from any source, not just those developed within the tradition. In this way it can be seen as an integrative ‘meta-theory’ as well as a therapeutic approach in its own right (Procter, 2009).
- Caine, T. M., Foulds, G. A., & Hope, D. (1967). Manual of the Hostility and Direction of Hostility Questionnaire. London: University of London Press.Google Scholar
- Kelly, G. A. (1955). The Psychology of Personal Constructs. Vol. I, II. New York: Norton (2nd printing: 1991, London and New York: Routledge).Google Scholar
- Procter, H. G. (2009). Reflexivity and reflective practice in personal and relational construct psychology. In J. Stedmon & R. Dallos (Eds.), Reflective Practice in Psychotherapy and Counselling (pp. 93–114). Milton Keynes, UK: Open University Press.Google Scholar