Explanatory Understanding in a Single Case of Separation Anxiety Syndrome

The Method of Explanatory Understanding for Single-Case Studies

In a single-case study of a syndrome, therapy process, and treatment outcome this methodology can result in a sense of how symptoms are formed and why they ameliorate over time. Repeating this method across a series of similar cases can result in the development of prototype of change processes. In this case, the method shows how the patient gained in self-narrative and relationship capacities due to a combination of insight and new learning experiences.

Explanatory understanding requires a series of steps. The first step is observing state patterns. The second step is noting what topics and self-attributions lead to shifts in state. The third step is inferring how and why therapist actions might foster change. The fourth step is observing what happens after the therapist acts according to the formulation. I will discuss each of these steps in turn.

Observing State Patterns

States of mind are a configuration or pattern of verbal and nonverbal signs caused by a myriad of factors. In this patient, the state labeled as “fog” is such a pattern. The patient experienced his foggy state as having confusing lines of thought. The therapist observed that inhibition in expressing emotion was one sign of this foggy state. Labeling the state a “fog” with the patient started a process of clarification of the patient’s deeper attitudes.

Noting Topics and Self-Attributions that Lead to Shifts in States

Formulation of unconscious role-relationship models can occur once the surface pattern of a state is clarified. These person-schematic models contain attitudes about self and a potentially significant other person, as well as scenarios of transaction that are desired, dreaded, or used to avoid wish-fear dilemmas. The individual is formulated as having a repertoire of such role-relationship models and as using them to organize various states of mind, including transference states. The defensive state of fog in this case could be inferred as an avoidant maneuver that prevented emergence of an angry state.

Entry into an angry state occurred when the patient felt needy and yearned for care from another person. Feelings of hostility occurred because the other person was expected to frustrate the patient rather than gratify him. The fear that led to this defense of fogginess was that anger would lead to further abandonment or else harm the other. The patient had salient identity disturbances related to an irrational sense of vulnerability.

One version of this topic of threatened abandonment by an attachment figure caused a shift from a working state into the non-working state of fog. This episode occurred when changes in session times and days became a joint focus of attention. The therapist inferred and shared an interpretation of the role-relationship models.

One of these models portrayed the therapist as behaving hurtfully by threatening a separation. This scenario meant that the patient had to submit without expressing annoyance because the therapist would react with total rejection if the patient got angry. The fog defended against that danger. By observing the entrance into the foggy state, the therapist was able to make relevant interpretations of warded-off feelings.

Inferring How and Why Therapist Actions Might Foster Changes

The therapy process contained therapist actions leading to more reflective self-awareness by the patient. The patient’s self-other attitudes of irrational vulnerability were clarified as repetitive maladaptive patterns in three frames: (1) with the therapist, (2) with past developmental figures, and (3) in current relationships with both his domestic partner and his supervisor at work. Having the pattern under joint discussion was the therapist’s aim; in addition, the therapist was trying to help the patient find a safer sense of identity by constructing a cooperative therapeutic alliance and showing that the planned termination was tolerable. These formulations are aspects of the PFPP-XR manual meant to address problems with threats of separation from attachment figures.

The manual’s psychodynamic theory leads the therapist to expect to find certain warded-off mental contents and emotional potentials. The therapist is prepared by the manual to have a framework to use in formulating each individualized case. The expectation is that the patient will probably harbor personal schematizations of self as an insecure child needing attachment with a parental figure. Enduring as a configuration of role-relationship models into adulthood, these person schemas predict a personality colored by habitual but excessive fear of abandonment.

The generalized wish-fear-defense dynamic includes a wish to maintain a current attachment and a fear that anger expressed toward a frustrating other will lead to harm. The other will either reject the self for being too needy or will be harmed by aggression arising from the perception that one’s neediness is not requited. The usual defense is to inhibit anger and remain submissive to the other’s desires. The therapist is led by the manual to challenge such ideas, provide a corrective emotional experience by constructing a safe therapeutic alliance, and help the patient enhance a sense of being an assertive and competent adult.

The general expectation of the theory underlying the manual is that patients will have individualized assessments based on accurate evaluations of their relationship stories and transference feelings. Therapist and patient, in conversation, clarify the specific forms of dependency and passivity at play, as well as warded-off anger, often expressed in unconscious revenge fantasies. This expectation includes helping the patient learn how to tolerate and moderate anger even after the containment and safety factor of the therapeutic alliance ends with the impending termination.

Observing What Happens after the Therapist Acts According to the Formulation

In his individualized case formulation, the therapist predicted that the goal of mastery would be manifested by decreased self-criticism by the patient when expressing angry feelings, and less depression from self-deprecating and hopeless thinking. He looked for these to be signs of progress. Such change occurred in the case and was associated with both new and realistically assertive actions and less self-impairing submissiveness.

A good therapist also plans to be alert for early signs of negative therapeutic reactions. Negative signs include the emergence of additional symptoms such as undercontrolled states of self-loathing, defensive episodes of undoing, disruption of good-enough current relationships, or impairments to development of the therapeutic alliance.

In this case, the therapy pair found a way out of the defensive trap of fog; the way was to reappraise situations rather than deny the stress. The patient was encouraged to reflect on how to form and test for efficacy various new interpersonal and self-appraisal strategies. Suggestion and psychoeducation were used to augment attitude modifications and explore new relationship strategies and tactics.

Such learning of new scenarios began in the midst of transference expectations that any expressed anger would disrupt the therapy and upset the therapist. The therapist encouraged the patient to speak frankly of the emotions connected to his overall frustration. This new opportunity for safe discussions was contrasted with childhood memories and fantasies in which the child’s reactive anger had to be warded off because of the perceived risk of loss of attachment.

The therapist then suggested that such interactions could be carried over into his behavior in his current world outside the therapy. Instead of offering global guidance and a welter of specific instructions, the therapist elected to act only at key moments, so as to reduce dependent expectations. But the therapist did suggest middle-ground approaches that might be used rather than the polar dichotomies of the patient’s core attitudes.

One of the dilemmas of the patient was that he believed he had only extreme choices. He could either (1) stay in the deeply unsatisfying dependent relationship with Linda or (2) he could leave her and then feel terribly guilty that he had irreparably hurt her. The therapist suggested a middle ground. By telling Linda that he could not meet his own needs and goals if he stayed in the relationship, he might approach a separation from her in a friendly and compassionate way, reducing the expectation of harm to Linda were he to suggest she was unlovable.

Conclusion

Single-case reports resonate with each clinician reader, and to a degree we can imagine a consensual validation in our audience response. The inherent complexity of inferring unconscious mental structures and processes rests on such validations of inferences. That is why such a method of case analysis can be called explanatory understanding.

Current tasks for psychoanalytic theory include examining what changes happen, inferring how and why, and conveying an explanatory understanding of both the initial problems and their solutions during treatment. The individual case study then becomes a continuing educational tool. It is helpful when the single-case study is taken from a randomized clinical trial. In this instance, the PFPP-XR therapy demonstrated efficacy in terms of group means on symptoms such as anxiety, depression, and panic attacks. This single-case study provides an understanding of the process.

The many articles of Milrod, Busch, and colleagues, together with this case report, come at a time when evidence-based treatment guidelines are being developed. There are many more trials of cognitive behavioral therapies than of psychodynamic therapies, so the case presented by Busch and Milrod is particularly welcome. It shows the effectiveness of a time-limited dynamic psychotherapy in clinical trials, and this understanding can lead to improved therapy manuals and better evidence in the future.