Transactional Analysis Journal

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A Case of Severe Depression

Anna Rotondo Maggiora

To cite this article: Anna Rotondo Maggiora (1987) A Case of Severe Depression, Transactional
Analysis Journal, 17:2, 38-44, DOI: 10.1177/036215378701700208
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Continuing Education
A Case of Severe Depression
Anna Rotondo Maggiora

Abstract cy. He referred to his mother as an active per-

This article describes treatment for a case son with a strong sense of duty; she managed
of severe depression. After describing the to keep the family together in spite of difficul-
case and offering some general observations ties with the client's father, "a very energetic
on the characteristics and definitions of but childish man. " However, for several years
severe depression from a TA perspective, the D.'s mother had suffered from depression and
author discusses the therapeutic relationship was treated for it several times.
and the three phases of treatment (body re- After obtaining a degree, D. worked for sev-
found, reliability, and day-to-day life). In- eral years and was an active trade unionist in
dications of TA techniques to be used in this a large company. At a certain point, "afraid
process are provided. of being stuck in a too-structured lifestyIe," he
left his job; with the help of a small inheritance,
he realized his long-standing dream of setting
Introduction up his own business.
The case described in this paper has stimu- Before coming to the Berne Centre he had
lated much learning and research for me; been to many psychiatrists and psychothera-
among other things, it taught me to limit my pists, including a hypnotist. He said for several
therapeutic expectations and my dreams of om- months he had felt depressed and unable to look
nipotence. I want to thank Carlo Ravasini and after himself to the extent that he could not stay
other colleagues at the Berne Centre in Milan home for fear of hurting himself. He eventual-
for their accurate observations and confronta- ly asked his family to have him treated in a
tions which helped me overcome impasses and clinic.
other difficulties in my work with this client. At the time of the first interview he was tak-
My main goal in this article is to demonstrate ing antidepressants and anxiolytics. He said his
how each therapeutic intervention can be linked depression had started a few months before
to the clinician's theoretical framework and after an incident at the beach. He had saved a
diagnostic tools. This is the best way I know friend from drowning by bringing him back to
to improve research and to ensure the logic and the shore with great difficulty; other friends at
effectiveness of the intervention itself. the beach had not noticed anything amiss. From
that point on he had a strong feeling of insecuri-
Case Description ty, that' 'the world is selfish." His difficulties
D., a forty-one-year-old single man, was liv- communicating with others increased; he felt
ing alone when he began treatment with me at "extraneous" and isolated. His loneliness
the Berne Centre in Milan. He came from a weighed on him heavily, but "nothing in-
good, urban, middle-class family in which he teresting happened" to him to shake him out
was the second of four children. He had a good of it.
relationship with his family of origin, par- D. had had a relationship with a woman for
ticularly his mother and a younger sister. D. four years which ended some months before.
did not remember serious traumas in his infan- Although he had never been faithful to the rela-
tionship and did not want it to become perma-
This paper was originally published in Italian nent; he felt guilty about this and saw it as his
in the June 1985 issue of Neopsiche. It was incapacity.
translated and submitted to this publication by In the first session, and indeed the first few
the author. months of treatment, D. wept silently and con-

38 Transactional Analysis Journal

 A CASE OF SEVERE DEPRESSION

tinuously , felt weak, and had trouble remain- such as the family environment. As Arieti and
ing attentive. He appeared to be absorbed in Bemporad (1978) point out, depressives tend
himself and following his own internal train of to be very receptive.
thought. He was slow to reply to questions and Fromm-Reichmann (1959) suggests that the
sometimes appeared not even to hear them. families of depressives tend to have rigid rules
During this period he had recurring night- regarding "good behavior, " and that the par-
mares in which he was being tried in court and ents (particularly the mother) attend to what the
condemned to death. As a result, he had diffi- child does rather than what he or she is. Am-
culty falling asleep at night and getting up in mon (1973) attributes to the "depressogenic "
the morning; at times he did not get up at all mother object relationships that lack affect. In
unless someone came to take him out. D. neg- looking at the early history of depressed clients
lected his body, failed to eat or ate too much, he also found mothers who did not understand
did not exercise, and had no sexual interest or the child's needs; as these children reached the
stimuli. He said his head felt stiff and that he end of their first year, these mothers moved
had a lot of tension in his back. from warm concern to a cold request for reali-
D. was tormented by his loneliness, especial- ty that emphasized social adjustment and com-
ly at night when' 'nobody sees me and I might petitiveness. Thus the child was denied the
throw myself out a window. " He avoided driv- warmth, devotion, and confirmation he or she
ing and his friends, obsessing about how to needed.
spend his time since he did not feel like doing In discussing life scripts and the stroke econ-
anything. He felt responsible for his shop and amy, Steiner (1974) connected depression to
guilty about not working there or looking after the loveless script. Depressives have difficul-
it: "1 had to leave it to others and sometimes ty self-stroking and in accepting unconditional
1 wouldn't go there for days." positive strokes (Woollams & Brown, 1978).
D. remembered an episode of depression From earliest childhood they make themselves
some years before that was ameliorated with loved and accepted for what they do and how
drugs, but he had no history of hospitalization they respond to environmental expectations. As
or prior psychotherapy. a result, they lose sight of their real needs and
authentic emotions. They prevent themselves
from being themselves, from showing what
General Observations on Depression they feel, and from obtaining satisfaction for
Having treated other depressed clients, 1 intimacy and contact needs. Thus, when de-
recognized many of the charateristics D. re- pressives speak of their loneliness and estrange-
vealed. It is important for clinicians working ment, they refer first to their estrangement from
with such clients to understand these charac- a sense of themselves and what they feel. This
teristics and the role of the internal dialogue "loss" then keeps them from establishing in-
in defining the self and reality. timate and lasting contact with others. Depres-
Depressive clients are often plagued by a sed people are constantly looking for something
negative, dominating internal dialogue fed by or someone to fill the emptiness left by this loss,
an internal Parent with strong expectations and and at the same time they seem to have decided
pretensions of perfection. In response, de- that neither they nor anyone else can supply a
pressed clients feel inadequate and guilty; even remedy for their pain.
though they attempt to live up to this ideal, they For depressives, the internal dialogue reflects
do not succeed in "making it." This failure is all this as well as the frustrating repetition of
experienced like a series of "falls" from what their incapacity and impotence. Feeling inter-
depressives think they should be and do to what nally inadequate, not-OK, and victims of their
they actually are and do. They lack a true sense guilt, depressives sometimes try to make
of self-awareness and self-appraisal, instead amends by assuming the role of the world's
oscillating between strong, omnipotent, inter- Rescuer. However, when these efforts do not
nal expectations and disappointing experiences succeed, they return with anger and frustration
of impotence. This negative internal dialogue to their dramatic feelings of impotence. Thus
can result from input the depressive has ac- depressives are unable to sustain growth rela-
cepted and introjected from an external source tionships with external objects nor to use their

Vol. /7. No.2, April /987 39

ANNA ROTONDO MAGGIORA

initiative and creative capacity to maintain The Therapeutic Relationship

lasting relationships of trust and hope with
During my first interview with D., I took the
things and people.
initiative in defining and delimiting our rela-
Diagnosis tionship. My statement, which I was careful to
make slowly in a clear and precise tone of
With depressed clients, the negative internal
voice, indicated that I comprehended him in his
dialogue is present to a greater or lesser degree,
suffering. I used some of my "emotional
and evaluating its intensity and repetitiveness
responses," as Racker (1968) calls them when
i~ a key element in defining the type of depres-
referring to countertransference, to tell D. that
sion, I prefer not to use the distinction between
I recognized his suffering as real and accepted
reactive and endogenous depression (Arieti,
it for what it was, that I was not forcing him
1959-1963), but instead am more at ease with
to appear different from how he felt at that mo-
Arieti and Bemporad's (1978) language and
ment (depressed). This was intended to give
definitions: " ... I propose calling depression
him permission (Crossman, 1966) to be where
either severe or mild on the understanding that
he was.
s~vere depression may be accepted by the pa-
tient as a way of life and so be syntonic, the I went on to set limits: IfD. decided to work
mild will not be accepted and so be dystonic. " with me, he had to stop "going round" to dif-
(p. 78) In this sense the severe depressive does ferent therapists. I wanted him to know I was
not fight the depression but lives it and actual- prepared to take him on, but not without limits
ly seems to nourish it. and rules. In this way, I hoped to establish
In D. 's case, many elements indicate a severe myself as an effective, realistic Parent (Loomis
depression. In the beginning of treatment he & Landsman, 1981) who would take care of
seem~d immersed in his own depressed,
him in a realistic way by setting precise limits
negatIve thoughts as if they were syntonic; he and protecting the therapeutic relationship both
used his memories and experiences to reinforce from D. 's grandiose expectations and from the
these thoughts and to remain anchored to his possibility that I would feel "sucked in" and
racket feelings (Erskine & Zalcman, 1979) of "emptied" (Ping-Nie Pao, 1979). Looking
sadness. Reflected in his difficulties taking care back today, three years later, I believe that
of his body was his experience of it as a many of the issues we were to confront and
"koerper" or "object" body rather than as a work on together were "decided" in that first
"Leib" or "living" body (Borna, 1983, p. interview.
315-320). His slow, heavy, uncared for body Within the context of the therapeutic relation-
seemed to participate in and reflect the ex- ship we also discussed the use of drugs and the
perience of impotence, despair, and guilt in f~rm and ~requenc~ of sessions. After giving
which he felt imprisoned. him some information about the compatibility
. A~ditional si~ns of the severity of his depres- of pharmacotherapy and psychotherapy in his
sion included his sleep disturbances and the way case (D'Andrea, 1981), I suggested he consult
he presented himself as locked in an eternal pre- a psychiatrist colleague of mine for phar-
sent deprived of future projects and macological advice. We established a twice
possibilities. . weekly schedule for the first few months, with
the o~tion of renegotiating later. It seemed ap-
Treatment propnate to see him individually to give him
In discussing treatment I want to focus on two a chance to accept and live for a while in an
closely connected aspects of the process: the ongoing I-You relationship (Arieti & Bem-
therapeutic relationship and phases of treat- por~d.' ~978) before considering group
ment. The former is the basic vehicle by which parucipanon,
the treatment evolves and consists of a series Unlike the Gouldings (1979), who make ear-
of elements making up the relationship between ly no-suicide contracts with depressed clients,
the therapist and the client. The latter involves I chose not to go after such a contract, nor did
!he stages of the therapeutic plan and each phase I find it necessary later. Noticing the fear he
IS related to change objectives and the tools expressed of hurting himself, I preferred to
used to achieve them. stress his positive resources and my trust in

40 Transactional Analysis Journal

 A CASE OF SEVERE DEPRESSION

them. By asking him "how he could protect omnipotent and utopian jumps with correspond-
himself, " I encouraged him to recognize both ing depressive falls.
his own resources and those available to him My functions as therapist during this phase
from the environment. included mediating, controlling, and checking.
In terms of a therapeutic contract, I decided I avoided any confrontation that D. might view
it was important to be flexible, and I therefore as criticism and therefore absorb into his
accepted a general and generic contract which negative internal dialogue. With the help of a
stated his desire to "come out of the depres- colleague who is an expert in this field, I taught
sion." As soon as I considered it opportune, D. to do body exercises for relaxation, tension
I would come back to this issue and renegotiate reduction, and "grounding" (Lowen, 1980).
a more specific contract. He began to move more confidently, looked
after himself better, paid attention to his diet,
The First Phase of Treatment, or and started losing weight; in short, he became
The Body Refound aware of his body again and to look after and
The initial phase of therapy lasted seven or love it.
eight months, during which time it was difficult The first phase of therapy ended as summer
to set objectives toward which to work. D. holidays began. We spent two months talking
spent the sessions crying quietly, sometimes for about and planning for D.'s holidays. During
the entire hour, his attention span was limited, these last months D. seemed "born again"; he
his body was uncared for, and his movements moved his refound body well, slept soundly at
were slow. All I could do was be there, listen, night, stopped taking medication, began hav-
not be invasive, and not ask him to do things ing expectations for his future, smiled often,
he could not do. However, I had a deep, firm and began substituting for his silent crying an
hope that we would eventually succeed. intelligent and sharp irony, the first sign of his
As soon as I saw the chance of getting his forbidden feeling of anger. However, he still
attention, a sign he was listening, I introduced had difficulty getting up in the morning, in
some brief guided fantasy work, similar to maintaining a durable interest in his work, and
"guided waking dreams" (Desoille, 1961) in starting relationships.
which emphasized ascent and light rather than
descent and darkness. I wanted D. to gradual- The Second Phase of Treatment,
ly get used to "seeing" upwards, forming or Reliability
positive images, and detaching himself for a D. returned happy from his holidays. He had
while from his suffering which was so full of started a relationship with a woman (which was
sensations. This work soon bore fruit: D. could to continue for more than a year), and was thus
tell me his dreams, and very delicately we were involved sexually once again. He wanted now
able to do some Gestalt work with them such to resume the friendly and affectionate relation-
as inventing other endings or playing the parts ships he had neglected the year before, but this
of characters in the dreams. time he wanted to choose "reliable" people.
Slowly the heavy gray cloud of suffering He also began asking himself questions: On the
seemd to disperse. D. was able to pay atten- whole he was alright, his moments of depres-
tion longer, and he cried less. We made some sion did not frighten him as they had before,
small behavior contracts, which I judged to be and he felt capable of coping with them. But
the open door to treatment (Ware, 1983), tak- if the "great depression" came back, how
ing care that they were realistic contracts that would he face it? Would he be able to be
he could fulfill without returning to a "reliable" and solid? What about his relation-
framework of force or obligation. For exam- ship with his work? How could he structure it,
ple, there were commitments about his taking how "reliable" could he be in this area, too?
care of his daily diet, his body, how often and D. indicated he still had difficulty starting up
long he would exercise, etc. The objective of in the morning, and that at intervals he sensed
these contracts was twofold: to start referring in his relationships with others that he was dif-
to the existence of time and therefore the ferent, which made him feel lonely and like he
possibility of structuring, using, and planning did not belong.
it, and to do this in a realistic way, avoiding By now D. was speaking clearly and logical-

Vol. 17. No.2, April 1987 41

ANNA ROTONDO MAGGIORA

Iy, he was present in our relationship, and he could. And, he started to love it. In his choice
answered questions without redefining. He used of friends he was more careful, choosing peo-
language full of irony and subtle understate- ple from whom he could expect closeness and
ment, as if he needed to laugh about his affairs, friendship as he gradually renounced his role
thoughts, and projects. as rescuer. In terms of his depression itself, I
At this point I sometimes felt a sense of made sure to "pass on to him" information
heaviness and difficulty about the work, as if about his depressiogenic morning thoughts so
in the face of his great expectations I felt anx- that he could recognize and forestall signs of
iety and impotence. I understood that I might depression. My objective in doing this was to
run the risk of identifying with my client's om- reinforce his Adult and thus help him contain
nipotent expectations, and thus it seemed the his fear of falling back into the" great depres-
appropriate moment to protect our work with sion" by making him more solid and reliable.
a concrete and realistic change contract. This phase of treatment continued for the en-
D. eventually contracted to look into the tire second year. The overall result, in addi-
meaning and application of the term "reliabili- tion to those things just mentioned, was an
ty" in his life: He resolved to "reconstruct" alleviation of the perfectionistic and persecu-
an aspect of his Parental contents and values. torial contents of his internal dialogue.
In this phase of treatment I used self-
reparenting (James, 1974) techniques, some The Third Phase of Treatment,
developed by Muriel James and others that 1 or Day-to-Day Life
created and used when suitable. At the end of the second year of therapy, D.
Generally speaking, we were guided by the asked me if he could take part in one of my
following outline: Which behavior, qualities, therapy groups. I took my time in responding
and attitudes did D. connect with the term to his request. Although it seemed a positive
"reliability"? When and by whom has he seen sign that, after experiencing a one-to-one rela-
them used? Which of his parents could be called tionship he wanted to widen it to include others.
responsible? How did he or she behave when I was also concerned that he might use it as a
reliable? How do reliable people behave? On distracting escape. Therefore, we spent some
which occasions had D. felt himself to be time talking about his objectives for taking part
reliable? What would D. be like, what behav- in group. D. said he needed to confront his feel-
ior, thoughts, and attitudes would he have if ing of being "different and extraneous" in rela-
he were the reliable parent of a child? What tion to what he held to be the "banality and
would D. be like ifhe were reliable toward his repetitiveness" of others' lives, i.e., day-to-day
work? Toward his depression? And so on. existence. On the basis of this understanding,
We spent considerable time on this work, and I agreed to let him proceed with a group
at times D. was not prepared to respect his con- experience.
tract. Sometimes he treated what he was doing Initially D. had a lot of difficulty joining the
ironically or undervalued it. At other times he group. His companions did not always under-
became disheartened and appeared absent for stand him, and he sometimes shrank from con-
most of the session. My response remained the tact and communication, isolated himself, and
same: I avoided confronting him, I listened to did not talk about his problems. He was more
him, I waited for him, I contained my anxieties comfortable providing feedback for others than
around being impotent, I did not rebel when asking directly for time and attention for
faced with his irony, and I carefully avoided himself. He was often confronted by me and
competitive attitudes. At times I had the im- others in the group on these problems. At first
pression he wanted to test my reliability to see he refused confrontations as if they were
ifI would continue to accept him as he was and criticism or attacks, showing his anger through
as he showed himself, to find out if he could irony. Gradually he learned to listen to and ac-
really trust me and therefore let himself go. cept what his companions had to say to him,
The biggest change during this phase of and he referred to the group as his "point of
reparenting was D.'s relationship to work: He reference" with regard to everyday life and
began going daily and looking after it, not as routine. He was attracted to the reassuring
perfectly as he wanted to, but as well as he repetitiveness of everyday things, and at the

42 Transactional Analysis Journal

 A SEVERE CASE OF DEPRESSION

same time he rebelled and refused "to be like send reprint requests to Dr. Maggiora at Cen-
the others who fall in love, get married, have tro Berne, Via M. Bandello 18,20123 Milano,
children, etc." In the group, through confronta- Italy.
tion and information, in an attentive, healthy,
noncompetitive climate, D. increased his REFERENCES
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Vol. 17, No.2, April 1987 43