Chapter 10
Application of CMS Theory To Treatment
Mary Ahern and A. J. Malerstein
Introduction
In 2005, Malerstein put his new book — Development of the Mind and Brain — on-line.
Several readers of the new book asked, "What is the practical value of Cognitive-Motivational Structure (CMS) theory: When treating a patient, how does it help to know the patient’s character type?" The on-line book referred readers who were interested in treatment to our earlier book — Psychotherapy and character structure — where we addressed treatment implications of our theory. For readers who might not read our earlier book, the following digest of how we think that CMS theory should influence psychotherapy follows. This paper, with minimal modifications, was published in Clinical Connections . As a stand-alone paper, the paper is not entirely satisfactory. Unless our theory of character formation is fully understood, as outlined in Chapter 9 or as presented in more detail in our earlier works, the nuances of treatment of the two case examples at the end of this chapter will not be clear.
Initially, Ahern and I found that clusters of behaviors, defenses, and symptoms defined three types of character structure. Later, we noted that the cognition of the three types paralleled certain stages of cognitive development in children. Patients whose motivational focus or concern was identity and attachment favored preconceptual thinking — thinking typical of children in Piaget’s Symbolic Phase (age 2-4). 1 Patients, whose focus was getting and having, favored egocentric thinking — thinking typical of children in Piaget’s Intuitive Phase (age 5-7) — when thinking about issues that truly concerned them. Patients, whose focus was function and control of function, favored operational thinking — thinking typical of Piaget’s Concrete Operational Period (age 8-11). Because of the parallels in cognitive structure, Piaget’s terminology was adopted to designate the character types — Symbolic. Intuitive, and Operational. And because the three clusters of behaviors, defenses, and symptoms that define the character types can be subsumed by one of three social cognitive styles and related motivational foci, the term Cognitive-Motivational Structure (CMS) was coined. During the past 17 years, we have been engaged is testing CMS Theory. In keeping with CMS theory, the three character types have been found to be reliably recognizable in different populations, and caretaking styles during the Concrete Operational Period predict CMS types better than chance.
We may now return to the question, what is the practical value of CMS theory?
Primarily, CMS theory has implications for treatment goals and for treatment approaches:
1. Although the CMS types — the Symbolic , the Intuitive and the Operational — were first recognized in patients, CMS theory proposes that none of the three are inherently abnormal. Thereby, this proposal extends the usual concept of normality.
The usual concept is that normality and sophisticated cognition and motivation are at one end of a continuum with abnormality and primitive cognition and motivation at the other end. Rather than seeing normal to pathologic as a single continuum — extending from normal to psychotic — we propose three normal to pathologic continua.
We propose no ideal CMS type. We propose that one type may be more adaptive to a particular culture or time than the other two. For example, an Intuitive — focused on getting and having — may be highly adaptive to the present consumer culture of the United States.
Most importantly, if none of the three CMS types are inherently abnormal, change of a patient’s type from one into another is not a goal of treatment.
2. Further, we propose that once a person’s CMS type is formed — sometime during the Concrete-Operational (Piagetian) or latency (Psychoanalytic) period — her CMS becomes set. Therefore, we do not believe a psychotherapist would be successful in changing the CMS type of his adult patients into one of the other types. We think that it is possible to modulate some aspects of a patient’s CMS type, but that it is not possible to change her type into one of the other types. For example, as a result of treatment, an Intuitive’s basic focus on getting and having may become modulated, in the hopes for greater or more secure payoffs, but her focus does not change.
3. Our general goal for treatment is to increase function and/or relieve emotional pain. And, it is our intent that these improvements last for an extended period — that the changes be reasonably stable. Our general goal follows from the definition of normality as satisfactory function in the world while experiencing minimal pain and while causing minimal pain in others.
4. Specific goals of treatment will differ, depending on the CMS of the patient, the problem presented, and what the patient wants from treatment. A goal of treatment for an Intuitive patient might be to help her to keep out of trouble while she still pursues situations, persons, or things that make her feel good.
5. No single treatment approach is appropriate for all patients. Approaches should be tailored to the CMS type of the patient and the problem presented. For example, an abstinent approach — one in which the therapist is not directive, not self-revealing and avoids gratifying any of the patient’s bids to be dependent — can usually be effective with an Operational (whose focus is function and control of function), but ineffective with an Intuitive (whose focus is getting and having).
While we recommend specific approaches for each of the CMS types, most important is how an individual patient experiences the approach. Two persons with the same CMS type may experience an approach differently. One may experience the abstinent approach as deprivation, while the other may experience it as a benign, abiding interest.
We recognize our position that approaches be tailored to the patient and his problem is controversial. Many psychotherapists would consider taking different approaches with different types of patients as being "inauthentic." Many others who have been trained in a single approach are unable to use any other. It then becomes the task of a patient to "Meet the psychotherapist where he is" instead of the other way around.
Understanding The Patient’s CMS Type and Defining The Problem To Be Treated
Knowledge of a patient’s CMS type can guide a therapist’s understanding of what his patient wants and what is likely to suit that patient. Such knowledge is useful in planning treatment.
Determining the CMS type of a particular patient is not always easy. At first it might appear that a patient is an Operational, since the problem she presents is about function, not appearance; internalized, not externalized; specific, not global. Had she, at the outset, presented a problem about appearance, externalized the problem, and tended to globalize, the therapist would have thought that she was either an Intuitive or a Symbolic. In this case, however, it was not until a few interviews later that she mentioned that an elderly friend had died, and wondered who the other two would be. "Things like that always happen in threes." She knew this was so, because she had experienced it several times. Now, the therapist becomes aware of the possibility that he is not treating a pure Operational, but someone with an Operational-Symbolic CMS. Then, the therapist will watch for other manifestations of Symbolic thinking — for example, if two things exist at the same time they must be connected. He will also be alert to evidence of concerns about identity or attachment, and to hints about her early care-receiving experience. Very importantly, he will attend to the patient’s behavior in the psychotherapy situation and to his own internal responses to her, which may provide him with further clues to her CMS type.
Although the problem the patient presents and the CMS type of the patient are two different things, often, a patient’s CMS type is revealed in how she describes the problem. For example, if a patient says that she is suffering from depression, and then goes on to describe the depression as finding herself stuck in trying to work on an assignment — that is, concern about function — the likelihood is that she is an Operational. But, if she attributes the depression to the loss of a significant social role that leaves her feeling empty or not quite knowing who she is, it is likely that she is a Symbolic. If she says her depression comes from a threat of demotion at work because of being caught at falsifying records, it is more likely that she is an Intuitive. It is likely that she is someone who is concerned about loss of face and who is impulsive.
How the problem is presented by the patient and what the patient appears to be looking for in treatment — whether the problem is internalized or externalized, specific or global, and whether the patient is focused on function or appearance help distinguish the Operational from the Intuitive CMS. A problem, which contains a mixture of these sets of characteristics, clues the therapist that the patient is a Symbolic. More definitive of the Symbolic CMS is the complaint, "I don’t know who I am or where I’m going." Or "I have no direction or goals."
Other indications of the patient’s CMS type may be heard in how the patient describes the sense of her early care-receiving, whether her parents were invested in her best interests (Operational), suited their own interests (Intuitive) or seemed to need her to meet their needs in order to meet hers or in order for the care-receiving to be more stable (Symbolic.)
We recommend that the therapist take an abstinent approach as a beginning tactic. How the patient responds to the approach will give less contaminated information about the patient. However, Intuitives and Symbolics tend to experience the abstinent approach as depriving.
How the patient approaches therapy or the therapist may also be a clue to her CMS type. An Operational may start out by working on her problem. An Intuitive may try to make a deal, or try to get something out of the therapist. Symbolics are concerned about closeness and distance emotionally and sometimes concretely. One Symbolic, who had a wish for and fear of merger with the therapist, pulled her chair as far away as possible from the therapist. Another patient covered herself almost completely by a long coat, which she did not open.
Finally, in defining the problem to be treated, the psychotherapist must determine whether the problem calls for psychotherapy. Not every patient who is referred for psychotherapy wants or needs it. One patient, who did not want psychotherapy, was doing well on a modest, regular dose of a narcotic. His internist needed to be reassured that no harm was being done. Sometimes, a person is so humiliated by the act of seeing a psychotherapist that she is best left alone, unless her defenses give way. Finally, sometimes it is the person’s situation that needs changing.
Differential Treatment Approaches and Goals of Treatment
Although the aim of clinicians who practice psychotherapy is to increase function and/or relieve emotional pain in their patients, how they go about accomplishing this depends, in some measure, on their concepts of normality (mental health) and abnormality (psychopathology). Their concepts of normality and abnormality are in-turn influenced by the values of culture in which they grew up, values to which they may still subscribe.
For example, the stated value of American culture has been that individual identity is superior to identity that is dependent on social roles — identity as a member of a group. Subscribing to this value may influence the goals which a psychotherapist sets and the treatment approach which he selects. Such a therapist, when treating a patient whose identity is dependent on her connection to a social group, may view his patient as having a part-identity. He may try to help that patient to develop an autonomous identity — an identity not dependent on relationships or social roles. This may not be what the patient wants or will experience as helpful.
For example, a psychotherapist was treating a patient who was a member of Alcoholics Anonymous — a patient whose identity rested on what she learned in AA — "I am an alcoholic." Not realizing that, prior to becoming an AA member, she had had a tenuous identity; the therapist tried to get her to understand that being an "alcoholic" was not all of her identity. Rather, she was a person who has a drinking problem — that an attribute is not the same as identity. To this person, they were the same. The intervention made by this therapist tended to undermine the identity that his patient had adopted.
If the therapist had held our view that each of our three CMS types exists on a range from normal to pathological, we would expect that, before intervening, he would have determined that he was treating a patient with a Symbolic CMS who uses particle-to-particle thinking, and that a significant part of her knowing-who-she-is is viewing (and naming) herself as an alcoholic. According to CMS theory, identity that is dependent on a social role is not pathological. Pathology occurs when the person has not found, or has lost, that on which her identity depended.
Treatment Approaches
We are not recommending new treatment approaches, but rather that the approach most appropriate to the CMS of the patient be selected from approaches already available. We believe that no single treatment approach is appropriate for all patients.
For Operationals, we recommend an abstinent approach. This approach is the orthodox psychoanalytic approach — an approach, defined above, in which the therapist largely confines his interventions to clarification and interpretation. Such an approach allows for the development of a pure, more recognizable transference (response to the therapist as if he were someone from the patient’s past), which can then be analyzed. It is also intended to allow the patient the autonomy to work in treatment. It should be understood that — in our practice, in the cases we supervised, and in our investigations — Operationals were uncommon.
An Operational is typically invested in doing the right thing in terms of her social functioning, such as being a good mother, a good employee, a good citizen. However, such a patient may take too many things into account when trying to decide what is right in a certain instance. She may "think" too much, weighing one side of an issue against another to the point where she is unable to make a decision and may even fall into a "funk" (a type of depression.) Advice, which can be effective with other CMS types, is not particularly helpful in solving her dilemma. It will be just one more thing to put on the scales, or something to struggle against. A better technique is interpretation. Interpretation of her unconscious conflict, conflict about who is in control of her function, would be aimed at giving her insight into that conflict.
We do not recommend taking the abstinent approach to treatment of Intuitives or Symbolics. Generally, Intuitives and Symbolics experience an abstinent approach as depriving, and an interpretation as a criticism. Of course, there are exceptions. As noted earlier, a Symbolic patient may experience the quietness and inactivity of the abstinent approach as a benign presence. For one patient, it recreated the sense that he had experienced as a child when his grandmother sat quietly by his side as he played. Another Symbolic patient experienced the interpretations of the therapist as feeding.
For Intuitive patients, we find a coaching approach is helpful, conveying the sense that the therapist is on her side. The therapist might then give advice, which the patient would take as a message that the therapist cared about her and was offering what would be in her best interests. In this atmosphere, he may be able to encourage her to postpone immediate gratifications in lieu of even greater gratification later on. Care should be taken not to diminish an Intuitive patient’s self-esteem. The therapist may be able to make interpretations, if he can convey the idea that the trait or behavior he is interpreting makes her appear to herself as special or interesting. Otherwise, an Intuitive is vulnerable to what she considers criticism or attack and will have a tendency to think of the therapist as a bad person to negate the insult. And she may leave treatment without getting the help she needs.
For Symbolic patients, we find that managing the attachment or connection is most important. The nature of the attachment — whether it is avoidant, ambivalent, or need to merge — should be understood and managed. Some Symbolics do well, if the therapist maintains his distance; others do well if they are allowed to merge. The therapist must always be alert to the importance of connection to such a patient, both in her life and in the therapeutic relationship. Sometimes, the therapist inadvertently breaks the connection. If the patient suddenly behaves differently toward the therapist, he should suspect he has broken the connection and should hasten to correct her impression that he has lost track of her. He may apologize for his lapse. In some cases, usually with an Operational-Symbolic, he may attempt to interpret her vulnerability to loss of connection either in the psychotherapeutic situation or in her life in general.
Because there are subtypes of Symbolics (pure, operational, intuitive and mixed), it is often more difficult to know what approach to take in managing the attachment.
If a therapist is treating someone who is an Operational Symbolic, in addition to managing the attachment, he must also take into account whatever Operational characteristics are exhibited. For example, the patient, who was mentioned earlier, the one who had presented with a problem about function, but also had particle-to-particle thinking, might be treated with an abstinent approach. However, the therapist must also attend to issues of attachment which might arise. Such a patient might make use of interpretation as defining something about herself — reinforcing her identity — while the "curative agent" is attachment to the therapist, not insight.
In treating an Intuitive Symbolic a coaching approach may be used while attending to both issues of self-esteem — characteristic of Intuitives — and a need for or fear of merger — characteristic of Symbolics.
As mentioned, we favor an abstinent approach to begin with. If it is found that the patient can function in that atmosphere, the abstinent approach may be continued. We would expect it to be useful with most Operationals, who would probably not experience it as frightening, confusing, depriving, critical or withholding. But most patients experience it that way.
Treatment Goals
Goals for the three types differ. In defining the goal, the CMS type of a patient must be taken into account as well as the problem she is asking help with and what she wants from the treatment.
Usually an Operational presents with some problem about function or control of function — often, inhibition of function because of fear that someone will be hurt or confusion as to whether her function belongs to herself or to some authority. The goal of treatment is to bring insight into the inhibition or confusion. If an abstinent approach is adopted, it would be expected that the patient would project the conflict onto the therapist who could then interpret it.
Generally, an Intuitive presents with some kind of trouble she has brought on herself, often a result of poor impulse control. The goal would be to help her to get better control of her impulses in order to modify her behavior enough to stay out of trouble, while still satisfying her desire for getting the tangible or intangible supplies that she seeks.
The goal in working with a Symbolic, who usually presents with some issue of separation or loss, is to help her to establish or re-establish some connection, which would make her feel whole.
Our emphasis on differential goals and treatment approaches for patients with different Cognitive-Motivational Structures should not be understood to diminish the importance of such aspects of treatment as listening, empathy, handling transference and counter-transference (responding to the patient as if she was someone from his past) and resistance (e.g. responding to an interpretation of behavior with a rationalization). Resistance must be carefully evaluated since it is common for a therapist to view a patient as resistant simply because she is not in conformity with his own value system.
Case Examples
We will not offer an example of treatment of an Operational. We would just be repeating what may be found in orthodox psychoanalytic literature. We invoke the term orthodox , because, in recent years, the definition of psychoanalysis has been broadened to include what was once called psychoanalytically-oriented psychotherapy. We think there are some patients who benefit most from orthodox psychoanalysis characterized by the abstinent approach with the goal being insight into early formative experience. It should be understood that not every Operational who might tolerate and benefit from orthodox psychoanalysis needs or wants such extended treatment.
Case Examples
Mr. W — An Intuitive
Mr. W — discussed previously in A Piagetian model of character structure — was a salesman who was approaching his fiftieth birthday. He felt that he had achieved little in relationships or in business, and was fearful of dying. Many of his salesmen friends had died recently. He was depressed and unable to generate the enthusiasm to face some of the negative responses of the buying public or to sell his product to prospective customers.
Although he continually responded to impulses, he was facile with rationalizations and externalizations such that his responses appeared reasonable under the circumstances.
Trust and distrust were major issues for him. He was untrustworthy in a number of situations and often lived on the edge of the law. He also had major difficulty knowing whom to trust, especially in his work life. He continually manipulated others, and yet repeatedly allowed himself to be manipulated.
Mr. W was not task-oriented in the interview — in the sense of being directed toward increased understanding of himself and his problems. Initially, the therapist took an abstinent approach and considerable time was expended in a gentle fencing dialogue between Mr. W and the therapist. Each tried to get the other to choose a topic. After the fencing, he said that he guessed he was a restless sort of fellow and had not had any satisfactions from things that he should have — that he has come to this period of his life. And, all he has is a "big zero!"
His focus was on what he was getting and not getting. Being so much at the mercy of his impulses and his immediate perceptions, indeed he had attained little of lasting value. He also cited examples in which others had taken advantage of him.
The therapist recognized the abstinent approach that she was taking seemed to make Mr. W uncomfortable. He put it, that he was being put on the spot. Concerned that he would experience the approach as abusive, she turned to trying to clarify with him why he thought he got himself into abusive situations. Her questions and comments were meant to imply that he was not making careful evaluations of the people that he felt were exploiting him.
One of Mr. W’s major complaints was that he felt he was not able to have a close relationship with anyone, not with his bosses, his colleagues, his brothers, not even with his children or his wives. The therapist asked why he thought this was so.
He suggested that maybe he was too suspicious of others; he wasn’t sure that was it, but felt there must be something wrong with him if he is in a psychotherapist’s office (end-stage reasoning 2). He concluded that what was really wrong was that he was too idealistic and was disappointed when people did not live up to his expectations. Thus he externalized his problem in relationships to other people. He cited an example in which he did trust a business associate to whom he felt close, who betrayed him. So he has rationalized his suspiciousness. Despite his knowledge of his associate’s dishonesty in other situations, Mr. W was surprised when the associate betrayed him. Remarkably, he was now on the verge of going into another business venture with this same person.
The therapist did not question Mr. W’s externalizations or rationalizations. She attempted to engage Mr. W in looking at his lack of judgment about people who disappointed him, such as his business associate. "Were there any clues that he might not keep his end of the bargain?" Mr. W rationalized his judgment of this person as being basically a good person, asserting that he had treated Mr. W well before the disappointment. Further, one should not prejudge someone or consider a third person’s view of someone. One should not hold a person’s past against them. He judges another person on the basis of what is going on between the two of them right "now," "at this moment." It was proper to judge someone by the view presented. He takes surface for essence: He reasons from the end stage.
Realizing that Mr. W essentially had no ability to coordinate two dimensions — that is, past and present — the psychotherapist decided to take an approach intended to convey
that she understood and was sympathetic to his point of view — that she was on his side.
He gave an example of placing his trust in a girlfriend who then "betrayed" him. This girlfriend was wealthy and, at that time, he was struggling. He asked her to buy a piece of equipment for his business for which he would repay her. He made it clear that repayment would be difficult for him. So, she offered to buy it for him as a birthday gift. He pretended to demur, saying it was too expensive a gift. She agreed and said that she would give him something less expensive. "At that point, I knew I could not trust her." Although he had been manipulating her, he felt betrayed. He had been considering marrying this woman, but had given up the idea now that he knew he couldn’t trust her. She would give him things and then take them away.
The therapist, seeing her opportunity, said, "What upsets you is when you depend on someone who then pulls the rug out from under you." Mr. W emphatically agreed with her. Up to this time, he had been somewhat uncomfortable and defensive; now, Mr. W began to pour out to the therapist many stories of disappointments and betrayals, including abuses at the hands of his first wife.
Once he got started he couldn’t seem to stop. He told of his mother’s neglect of his brother and himself when they were young, being too occupied with her church work to look after them. Their clothes were not washed. Their wounds were not bound. Many memories of neglect came back to him. Although it is unusual to hear such a description of parental neglect so early in treatment, once he experienced the therapist as being on his side, he seemed to want to tell her everything he had suffered as a child. Also, his history of early neglect confirmed that Mr. W was an Intuitive.
As treatment progressed the therapist took more of a coaching approach, sometimes giving him advice and warnings — always trying to convey that she was on his side and invested in his best interests. His depression abated very quickly, and he improved somewhat in his functioning in terms of being more straightforward in stating what he wanted rather than trying to manipulate to get it.
Whereas the therapist had earlier come to the conclusion that Mr. W did not believe anything was wrong with his judgment, he began talking everything over with her before making any definitive conclusions, including bringing his new lady friend to have the therapist take a look at her. Was the therapist the good mother-father-coach? Probably.
When he discontinued treatment, he was functioning satisfactorily and was no longer depressed or fearful.
Ms. S — A Symbolic
Ms. S — a beautiful, artistically attired, 39-year-old, divorced woman — was referred by a former fellow worker, who noticed that, since Ms. S had left her job, she seemed to be "different." Ms. S described herself as feeling "lost," and "longing, for what she did not know." She often found herself distracted and looking into space. She was never quite sure what she should be doing, and often felt confused.
From the beginning of treatment — taking into account Ms. S’s complaint — the therapist believed Ms. S. to be Symbolic.
Her mother had died six months before, and left Ms. S with a substantial income. So, she moved from her beautiful, self-decorated apartment to her mother’s home. She decided to give up the job that she had held for many years, a clerk in a law office, and take up classes in interior decorating. After a few weeks, she found that she was not interested in the classes. So, she thought she would spend her time investing her money. In a short time, she had it invested to her satisfaction, and found her self at "loose ends."
Ms. S had few friends, except for a boy-friend, whom she had recently lost interest in. She had married early, but divorced her husband for another man who was killed in an auto accident. She found herself thinking about her ex-husband, and called him a few times to see if she could persuade him to come back — her attempt to reestablish a connection. He had remarried, and was not interested in breaking up his marriage.
Ms. S was an only child. Her father had been the primary caregiver, because her mother was addicted to prescription drugs, and was often "out of it." When Ms. S was a child, she sometimes felt that she was looking after her mother (role reversal, not an unusual history for Symbolic), although her mother provided care when she was able.
A number of years after her father died, her mother joined a Narcotics Anonymous (NA) group. Ms. S accompanied her mother to the meetings, which the two of them continued until her mother’s death. Ms. S was very involved in the meetings--her role in the group serving as a type of distant connection. She was always welcomed and often gave inspirational talks to the group.
Ms. S’s depression was characterized by her feeling lost and a sense of longing and emptiness. The quality of depression supported the therapist’s beginning diagnosis that the patient was a Symbolic. Her early history of feeling she had to look out for her mother confirmed this diagnosis.
The therapist understood the precipitants to her symptoms to be the loss of structure resulting from her giving up her job, discontinuing the NA group when her mother died, and leaving the apartment which she had created and which was "part of her." She had also lost the role of caretaker of her mother.
The goal of treatment for this patient was not to change her dependence on external structure for identification — that is, for knowing who she was and what her goals were. Rather it was to help her to find someone or something to connect to and someone or something to identify with — hopefully, relationships that promised to be stable.
The patient made an immediate attachment to the therapist, and he recognized that it was within this context that the work would be done. She spoke of her dead father, and it became clear that her lost and longing feelings were for him: She wished she could again experience her pleasure in having him talk to her, doing things and going places with him. Sometimes, she imagined him sitting across the table from her: Though he said nothing, she felt his presence. At times, she felt there were "signs" that he was there, such as a cup in a different place than where she remembered leaving it. Keeping in mind the aim of treatment was to restore function and reduce pain, not correcting her thinking, the therapist refrained from either interpretation or reality testing.
In his task to her to find an object for identification — something which would give structure to her life — the therapist brought up the subject of a job. She had no interest in either paid employment or volunteer work. She said that she needed something to "inspire" her. He wondered if it might be inspiring to decorate her new home. But this did not appeal to her either.
Then, she started working in her garden, which was badly in need of weeding. She felt that she was "clearing a space" in which to "create" something. She didn’t know what. She began to marvel at how, when she planted something, it grew. She felt there was something more than the ground and her effort. The therapist knew she was not talking about principles of botany. He suggested "Mother Nature." She agreed but, after thinking it over, she decided it was a male presence that was at work in the garden with her. She felt it was God. Here, the therapist might have made an oedipal interpretation of the God-father, if the goal of treatment had been insight. But, since the goal was establishing and supporting connection, he refrained.
By this time, Ms. S was feeling much better. But the therapist was concerned about the stability of her recovery. She had only the most casual of social contacts. Most of the time, she spent alone. He wondered if she might not seek some group or organization. She obliged by joining a church and participated to a limited extent — taking her turn bringing baked goods to have with coffee after the service. But she soon said that she felt no "connection" with this, as she had in the N A group. The therapist wondered if she might still be welcome in the NA group, even though her mother was gone. She called one of the members, who invited her to accompany her. Soon, she was going to the meetings again on her own. They welcomed her "inspirational" talks. She had reestablished a connection.
Still, except for the twice a week meetings, she spent most of her time alone. The therapist suggested a pet. She went to the SPCA and took home a cat. She did not make a connection to the cat, and gave her away to a neighbor. Then she got a dog, which she named Robert. Ms. S and Robert became almost inseparable. They went for two walks a day; on one walk they bought their groceries. They ate all their meals together, the same food. She took very good care of Robert, often referring to him as her son. She had recovered her caretaker role.
One day, while on their walk, she saw a sign in front of a church she often passed. It was a notification of a service coming up. In the context, it contained the words "God within." Ms. S took this to mean that the same God, who worked with her in the garden, was to be found within this church. She attended the advertised services, and became "inspired." She took instructions and joined the church. It was the practice in this church for selected members to read a part of the service each Sunday. Ms. S expressed interest in this. And, because of her speaking ability, she was deemed worthy of training, and became one of the regular readers, which made her proud and happy. She had found her "place." Ms. S met a widower at the church, and they began seeing each other regularly. He was interested in marriage; she was not. After awhile they parted.
Although Ms. S continued to believe in "signs" and to depend on external structure for identification, she also was able to maintain the level of functioning that she had achieved, and felt reasonably satisfied with her life. While the success of the treatment might be attributed to the patient’s transference to the therapist, the goal was reached without exploring or interpreting the nature of the transference.
The goal of treatment for this patient had been met.1 All ages are approximate.
2 End-stage reasoning is characteristic of the Intuitive’s style of reasoning. Additionally, examples of typical Intuitive defenses — externalization and rationalization — follow in the paragraph.
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