In recent years, the field of psychological therapy has witnessed a growing interest in Compassion-Focused Therapy (CFT) as a treatment for individuals with severe depression. This therapeutic approach, developed by Paul Gilbert, focuses on helping clients develop self-compassion to manage distressing emotions and reduce self-criticism. In order to help therapists understand its application, here is a hypothetical (fictious) case study to illustrate one way CFT could be applied in the treatment of severe depression. The case study is written about an NHS therapist (and therefore sessions and resources are limited). PLEASE NOTE THAT IN THE UNLIKELY EVENT THERE ARE ANY SIMILARITIES BETWEEN REAL PEOPLE WHO HAVE ACCESSED THERAPY, THIS IS PURELY COINCIDENTAL.
Reason for Referral
Rachel was a woman in her early fifties who was under the care of a community mental health team in the South of England. She was referred to psychology for an extended assessment and formulation following a two-year history of severe depression and anxiety.
Assessment
An assessment period of two sessions was contracted collaboratively, followed by a final session to devise a formulation. It was agreed that intervention would only proceed if it was thought it was appropriate and likely to be helpful.
Family Background
Rachel lived at home with her husband and reported having a close marriage. Her parents were still alive and lived locally. Rachel did not have any siblings herself. She had three children and described having a good relationship with all members of her family.
Rachel reported having a happy childhood and did not report any difficult experiences. Drawing on the concept of circular questioning from the family therapy literature (Fleuridas, Nelson, & Rosenthal, 1986), the therapist asked questions such as, “when you fell over as a little girl, who tended to come and pick you up?” and, “what do you think your dad would say about your relationship with your mum?” Subsequently, Rachel reported that her family were very “strong” and “independent” and that they did not talk about their feelings. She said that if she fell over or something bad happened, she would not get much sympathy as a child and would have to pick herself up and “just get on with it”.
History of Presenting Problems
Rachel was diagnosed with depression two years ago after noticing a reduction in the pleasure she derived from daily life. She described it as having “lost” her emotions but could not identify any potentially triggers. Rachel said that depression had “taken everything” from her life, including her independence and social roles and that two years ago she took her doctor’s advice and resigned from her job. She said this job was very fulfilling and that she valued being relied upon by others.
When the therapist asked what interventions she had tried, Rachel said she had received cognitive-behavioural therapy (CBT) but decided to stop as it wasn’t helpful. Her medical history was unremarkable.
Presenting Problems
Rachel described the following difficulties that caused her distress: severe low mood; poor sleep; being either “on edge” or “cut off”; reduced appetite; and concern due to perceived difficulties with her memory and doing everyday activities such as walking or reading. However, the most prominent difficulty she reported was feeling numb. Rachel said she pretended she still felt emotions to spare others pain.
Rachel was very self-critical, most prominently when she spent time with her family or did something she used to enjoy, as it made it even more apparent to her how differently she felt currently. Rachel was curious about the origins of her self-critical thinking and she described being criticised regularly at primary school.
Rachel’s description of herself contrasted to how she described the “old Rachel”; someone who was “strong”, “caring”, “funny” and capable of fixing her own problems. The therapist discussed what it was like for her to seek support from mental health services, given these values. In the assessment sessions, she often cried and it was broached sensitively what it was like not to experience emotion but to still be able to cry. She said it was automatic and that there was “no feeling there”. Note the therapist did not try to trap Rachel into admitting she still experienced emotions (even though this seemed to be the case).
Rachel said she had tried everything other people advised but nothing had worked and that she was close to giving up. When the therapist asked her what she meant by this she disclosed having suicidal thoughts. However, she denied having a plan to act on these thoughts and identified her family as protective factors.
Assessment Measures
The therapist was curious about whether Rachel’s description of being cut off was suggestive a dissociative state. Dissociation, a disconnection between a person’s thoughts, memories, feelings, senses, actions or sense of who he or she is, has been suggested to be one way the mind copes with too much stress, such as during a traumatic event (Boon, Steele, & van der Hart, 2011). Therefore, the therapist administered the revised version of the Dissociative Experiences Scale (Carlson & Putnam, 1993) and Rachel’s score (65.2) was potentially indicative of a dissociative disorder. However, Rachel did not appear to dissociate at any point during the assessment sessions and, after discussing some of her answers with her (and in supervisor), the therapist did not think her presentation was consistent with a dissociative disorder. For example, she reported on the measure that she did not recognise herself in the mirror, but later explained that she meant this figuratively (i.e. that she feels like a different person to the “old Rachel”).
Rachel also completed the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) and she scored 20 out of 21 for depression (indicative of clinical significance) and 11 out of 21 for anxiety (indicative of borderline clinical significance). The therapist chose these measures as there were previous administrations available in her clinical notes (which aided comparison). The results suggested there hadn’t been a worsening in symptoms over the past year, but confirmed the chronic nature of the condition.
Rachel expressed that she did not consider past events to be relevant to her presenting difficulties. However, the therapist incorporated questions from the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) into the assessment to screen for Post-Traumatic Stress Disorder (PTSD) symptoms. The assessment concluded that Rachel’s responses were not consistent with PTSD.
Rachel reported that she had recently screened her for dementia by a medical professional. She said this did not reveal anything to warrant further investigation at this time.
Provisional Hypotheses
It was the therapist’s impression that Rachel’s presenting problems were potentially being maintained by her beliefs about emotions (especially that they were “gone”); her attention rarely being on the present moment; potentially unresolved grief; self-critical thinking (such as her belief she was “weak”) and shame.
Formulation
When discussing how best to proceed, Rachel said she was not keen on the approach of CBT as she had tried it before and not found it helpful. It was therefore agreed to draw primarily on the approach of compassion-focussed therapy (CFT; Gilbert, 2010a; Gilbert, 2010b, 2013) when devising the formulation, as this model provided a suitable framework for exploring the potential origins and maintaining factors relevant to Rachel’s distress (e.g. self-critical thinking).
CFT considers the most important aspects of a formulation are: historical influences (comprising early experiences and emotional memories associated with care and safety); associated key threats and fears; safety strategies (for self-protection from these threats/fears); and the unintended consequences of these strategies that lead to more distress, safety strategies and self-critical thinking (Gilbert, 2010a). The following discussion shall be structured accordingly (integrating other compatible theories into the narrative as appropriate).
Historical Influences
CFT draws heavily on John Bowlby’s attachment theory (Gilbert, 2010a) and this was considered this alongside the family therapy literature regarding the beliefs families hold and the scripts that determine how to act in accordance with these beliefs (Byng-Hall, 1998). Rachel came to the understanding that her family had the belief that emotions were a sign of weakness and had a family script that emotions should not be talked about or paid attention to. As a child, Rachel learnt to manage difficult feelings by “just getting on with it”. Subsequently, she developed the belief that talking about emotions was unsafe, weak and something to be ashamed of. As she did not receive attention or sympathy when emotionally distressed, she learnt she had to cope on her own and was deprived of the feelings of safety and soothing that usually stem from receiving comfort and support from significant others. From a CFT perspective, Rachel probably did not fully develop her soothing system; an emotion-regulation system associated with feelings of well-being, peace and safety that evolved to help people rest and regenerate (Gilbert, 2013).
There were two events from Rachel’s past that appeared emotionally distressing as she became visibly upset when disclosing them. From a CFT perspective, it is plausible that these difficult past experiences over-activated her threat system; an emotion-regulation system associated with anxiety, anger and disgust that evolved to keep people hyper-vigilant and reactive to potential threat (Gilbert, 2013).
Rachel’s experience of being criticised at school were also included in the formulation as it was plausible this was the origin of her tendency to self-criticise. However, Rachel seemed reluctant to discuss her experience of school in more detail; she informed the therapist she didn’t think it was particularly significant as she “just got on with it”.
Key Fears
It was difficult to discuss fears with Rachel. However, she acknowledged being concerned about emotions, fearing she was to blame for her difficulties and believing she had to cope on her own but being powerless to do so.
Safety Strategies
In order to protect herself from her key fears, Rachel used a number of safety strategies that we suspected had origins in early childhood. As Gilbert (2010a) explains, self-criticism and self-monitoring are viewed within CFT as safety strategies. Because children can only control their own behaviour, not that of other people, they can learn to self-blame when confronted with an aversive outcome in order they can change their behaviour to prevent it happening again. Rachel acknowledged that much of her self-critical thinking and subsequent sense of shame was triggered by comparing herself to others (such as her mother) and to the “old Rachel” (forms of self-monitoring).
When describing a recent incident in which her daughter had told her she loved him and she did not feel reciprocal affection for her, Rachel identified that she coped with this by “cutting off”. This was a safety strategy she had learnt to protect against her key fears; a way of disconnecting from the sadness and shame. We were curious about the origins of this strategy and Rachel acknowledged this is how she coped with difficult past experiences and appeared closely linked to the “just get on with it” approach she learnt in childhood .
In CFT, the drive system is the emotion-regulation system associated with feelings of drive and excitement that evolved to motivate people to seek resources important for their survival (Gilbert, 2013). The therapist was curious about whether Rachel’s unrelenting search for an answer to her difficulties could be an example of her drive system in action. This could be considered a safety strategy to protect against the feelings of powerlessness and shame associated with her not being able to fix her difficulties. Similarly, pretending to her family that she was okay was identified as another way of protecting against feelings of shame.
As Rachel valued independence, she felt shame about not being able to go for a walk independently or perform household duties such as cleaning. She reported that she had subsequently stopped engaging in independent activities due to the fear of failure, and Rachel agreed this was an additional safety strategy.
Unintended Consequences
From a CFT perspective, it is likely Rachel’s self-criticism had the unintended consequence of activating her threat system; releasing adrenaline that interfered with her appetite and sleep. As the threat system overrides the soothing system (Gilbert, 2013), it is plausible this prevented her from deriving pleasure from activities she used to enjoy. Perhaps this also played a causal/maintaining role in the reduction of positive feelings she felt towards her family, as the soothing system evolved to become “the system through which the calming and soothing effects of caring, love and affection would work” (Gilbert, 2013, p. 192)
Neuropsychologists recognise that impaired attention can impact negatively on a range of cognitive processes, including memory and executive function (Lyon & Krasnegor, 1996). Therefore, the therapist and Rachel wondered whether an unintentional consequence of her disconnecting from the present was that it exacerbated her difficulties with memory and independent living. Furthermore, discontinuing independent activities had the unintended consequence of impacting negatively on her mood and sense of shame, leading to a vicious cycle. Although it was not labelled as a safety strategy, retiring from her job had the unintended consequence of reducing her independence significantly and Rachel acknowledged this role transition was difficult to adjust to given she had always been somebody with a strong work ethic.
Rachel also wondered whether, whilst serving an effective strategy for coping with acute distress in the past, perhaps the “just get on with it approach” had the unintended consequence of the emotional pain building up over many years, to the point where it became too much to manage using the strategies that had formerly served her well. It was also hypothesised that her constant quest to fix her problems had the unintended consequence of her feeling “on edge” and impacted her mood when she did not succeed.
A diagrammatic version of the formulation was sketched collaboratively. Rachel’s strengths were added to this diagram to help her acknowledge her positive qualities which could potentially be drawn upon in therapy. Based on the formulation Rachel agreed that intervention was appropriate. Whilst Rachel spoke of her hopes of being able to reconnect to her emotions, it was agreed to direct intervention initially upon her focus of attention, given its potential maintaining role in her on-going difficulties. The therapist also suggested a focus on her self-critical thinking and shame, her independence and her strategies for managing emotional distress; with a view to improving her mood.
Evidence-Based Practice
Rachel had a diagnosis of depression and was taking antideppresant medication. National Institute for Health and Care Excellence (NICE; 2016) guidelines recommend that people with moderate or severe depression should be offered either CBT or interpersonal therapy (Klerman & Weissman, 1994) . However, Rachel had previously tried CBT and did not want us to use this approach in our work . Furthermore, interpersonal therapy was not appropriate as Rachel’s perception was that she did not have relationship difficulties.
There is a limited but growing volume of research demonstrating the effectiveness of CFT (Kolts et al., 2016). A recent systematic review by Leaviss and Uttley (2014) concluded that “CFT shows promise as an intervention for mood disorders, particularly those high in self-criticism” (p.927). However, the authors cautioned that more research is required before the efficacy of CFT can be assessed. CFT appeared to be a good fit with our formulation as self-criticsm was identified as an important maintaing factor in Rachel’s distress. Furthermore, CFT also targets attention; another important component of the formualtion.
Intervention
Rachel agreed to proceed with intervention, drawing primarily upon the approach of CFT. The therapist contracted 11 sessions of intervention and Rachel attended 10 of these.
As Kolts et al. (2016) describes, the broad aim of CFT is to help clients increase their compassion towards themselves and others and to develop their capability to work compassionately with suffering. However, it is not considered a set of techniques, but rather a series of “layered processes and practices that interact and strengthen one another” (p. 5). As Kolts et al. describe four layers (the therapeutic relationship, compassionate understanding, mindful awareness and compassionate practices), the following summary will follow this structure; mirroring the format that was adopted in therapy.
Therapeutic Relationship
The therapist tried to model the key qualities and attributes of compassion and to create an environment in which Rachel would feel safe. A major obstacle in the relationship was that the therapist often felt a pull to adopt the position of the expert. Therefore, in line with the recommendations from Kolts et al. (2016), the therapist tried to adopt the position of a facilitator of guided discovery; creating opportunities for experiential learning and using Socratic dialogue to help Rachel explore her experience.
Compassionate Understanding
The therapist provided psycho-education about CFT to help Rachel understand that evolution, genetics and the social environment she was born into have played an important role in the development of her brain and her life; none of which she chose. She discovered (to some extent) that because she did not choose the parts of herself and her life that she felt shame about, they were not her fault. However, she recognised that it was her responsibility to change them in order to improve her life.
Mindful Awareness
Rachel found it very difficult initially to engage with the present moment. However, by following the recommendations by Kolts et al. (2016), she practised exercises (such as mindful breathing) in sessions and agreed between-session tasks (such as going for mindful walks) .
Compassionate Practices
Following the recommendations by Kolts et al. (2016), Rachel engaged in exercises to help develop her self-compassion. This included some imagery work to help Rachel access her soothing system. She also discussed some of the beliefs she held about herself and she attempted to view these from a compassionate perspective. For example, she was able to recognise that she still cared for her family, even though she did not feel affection towards them.
Outcome
At the conclusion of therapy, Rachel’s score on the revised version of the Dissociative Experiences Scale (Carlson & Putnam, 1993) was 62.9 (a reduction of 1.7 since assessment). Waller and Ross (1997) provided a calculation for estimating a person’s probability of clinically-significant dissociation. At the conclusion of therapy, Rachel’s probability score (66.5%) had reduced by 2.2% which suggested there had not been a clinically-significant change.
The Hospital Anxiety and Depression scale (Zigmond & Snaith, 1983) was also re-administered at end of therapy: Rachel’s score on the depression subscale was unchanged. However, her score on the anxiety subscale was five points lower than it was prior to therapy. A cut-off score of eight is recommended for detecting clinical anxiety (Bjelland, Dahl, Haug, & Neckelmann, 2002) which suggested there had been a clinically-significant improvement.
Rachel acknowledged making progress. In terms of connecting to emotions, there were several occasions she identified experiencing sadness. This was the first time the therapist heard Rachel acknowledge feeling an emotion. Furthermore, she was able to use very descriptive language to describe this experience. She said she felt a pain around the area of her stomach; likening it to being hit with a “soft mallet”. She was also able to link this to thoughts she was having at the time.
By paying mindful attention to her surroundings, Rachel was able to go for walks independently, gradually increasing the distance each time. Subsequently, she was able to increase her independence gradually, culminating in joining a walking group. Rachel said she enjoyed this and that she was able to be herself around the others.
A difficulty encountered when the therapist tried to increase Rachel’s independence was that her family were concerned about her coming to harm (given how dependent upon them she had become). Rachel demonstrated compassionate understanding when she recognised they did this because they cared for her. However, it perpetuated her feeling of being dependent on others. In order to address this Rachel was referred Rachel to an Occupational Therapist at the conclusion of therapy, for an assessment of her independent living skills. It was thought this might provide objective evidence about Rachel’s capabilities for independent living that might increase her confidence (and reassure those close to her).
Diversity
Within supervision the therapist reflected on Burnham’s (2012) Social GRRRAAACCEEESSS model which is a tool commonly used in systemic family therapy for helping people consider aspects of difference (such as gender, race and religion). Drawing on the work of Divac and Heaphy (2005) the therapist considered their personal connection with diversity issues that they privilege, that is, characteristics associated with power and status that might present an unhelpful power dynamic when interacting people who do not share the them. The therapist realised that they rarely reflect on how gender impacts on the therapeutic relationship and this was explored with Rachel. It was realised that expectations about gender roles and identities were very different due to contrasting upbringings. The therapist had the implicit assumption that it was socially-appropriate for females to talk about feelings. However, Rachel identified that most of the females in her life rarely talked about emotions and she believed it was a trait she associated with weakness. By making this explicit, they gave each other permission to talk about feelings which strengthened their therapeutic alliance.
Process
CFT recognises that many clients have not experienced feeling safe and trusting within a relationship and highlights the importance of the therapeutic relationship in helping clients to feel safe enough to explore their suffering courageously and to learn how to maintain meaningful relationships with others (Gilbert, 2010a; Kolts et al., 2016).
Overcoming Obstacles to Engagement
An early obstacle the therapist faced working with Rachel was that their attempts to help her connect with her emotional experience often led to difficulties in the relationship. For example, she would often cry but, when the therapist encouraged her to connect with her emotional experience in the present, she found this invalidating and accused the therapist of not believing that she did not feel emotions. The challenge was how to validate her experience, whilst helping her consider an alternative perspective so that they could explore the processes that were occurring in the therapy room and the therapist noticed the temptation to avoid talking about process issues for fear it would damage the therapeutic alliance. This was especially powerful when, from the therapist’s perspective, Rachel appeared to become angry with them. On the occasions the therapist questioned how Rachel was experiencing them, and shared how they were experiencing her, Rachel appeared to become even more irate and often blocked attempts to explore this further.
Developing a formulation collaboratively was key to working with these challenges and the use of language was crucial. CFT provided the language to explore the tricky dilemmas. For example, Rachel insisted she did not feel fear or anger but appeared considerably more open to talk about her threat system.
By listening to recordings of sessions within supervision, the therapist discovered that they were often pulled into adopting the position of the expert. They noticed this most prominently when we discussed emotions as it was clear they had different understandings. They also realised that Rachel’s search for an answer, her reluctance to take an active role in the therapy and their shared eagerness for her to make progress pulled the therapist into making suggestions about potential solutions. Reflecting on this, the therapist’s motivation was not only about wanting Rachel to recover but that, by doing so, it would reflect positively on their competency as a therapist. However, the unintended consequence of this was that it was disempowering and reinforced Rachel’s belief about being powerless and dependent on others (leading to a vicious cycle). They overcame this by discussing this dynamic in therapy and realised that it was a pattern that had played out during Rachel’s previous contact with mental health services.
In early supervision sessions, the therapist used language such as “difficult” and “resistant” to describe Rachel. This was because they felt irritated after she appeared reluctant to engage in exercises during therapy and the therapist thought at times she was dismissive and condescending. Reflecting on this in supervision, the therapist realised this was a safety strategy but also that it tapped into their own insecurities as a therapist and activated their threat system. Only by remaining present and curious was the therapist able to work with their emotions of irritation and fear so that they did not cause a rupture in the relationship. Subsequently, the therapist’s supervisor commented on a shift in language that suggested the therapist had adopted a more compassionate, curious perspective. This was important as it helped model compassion to Rachel. It also helped the process of developing a shared understanding. As an example, an important understanding they came to was that perhaps Rachel’s emotions had not “gone” but rather she was disconnected from them. This validated her experience but gave permission to talk about present emotional experiences.
As it is important for CFT therapists to balance the role of a knowledgeable authority with that of a real human being (Kolts et al., 2016), the therapist found the use of humour and self-disclosure greatly improved our therapeutic alliance. However, this strategy was not always appropriate and a different approach was required when Rachel implied that she would commit suicide if therapy did not work. In these instances the therapist felt it was appropriate to “use authority as a containing process” (Gilbert, 2010a, p. 9) and set clear therapeutic boundaries and ensured risk issues were managed appropriately. They thought carefully about the ending of their work and completed a full needs assessment, a crisis plan (collaboratively) and liaison with professionals involved in her on-going care.
Mirroring
In supervision, the therapist noticed that their use of language and their fears often reflected Rachel’s. The therapist discovered they both shared the fear of her not recovering and the therapist would often invite their supervisor to be directive; requesting an answer about what they could do to help Rachel. They reflected upon the parallels with Rachel’s safety strategies and the unintended consequences of these. They realised that a lot of therapy time was spent searching for an answer to Rachel’s perceived loss of emotions and this realisation made it easier for Rachel and the therapist to detect when this was happening and to shift focus accordingly.
Critique
The outcome measures suggested that therapy did not improve Rachel’s mood but did improve her anxiety. Although reducing anxiety was not an explicit goal, the outcome could be interpreted from a CFT perspective by considering that anxiety is an emotion associated with the threat system (Gilbert, 2010b). Potentially, as Rachel learnt to increase her self-compassion and activate her soothing system, her sense of threat decreased; reducing her anxiety. The formulation might also shed light on why her mood did not change, as reduced pleasure was identified an unintended consequence of disconnecting from the present; a safety strategy that potentially dated back to childhood. Therefore, it would be understandable that Rachel had difficulty changing this lifelong strategy in a relatively short space of time. This might also explain why there was not a clinically-significant change in the outcome measure used to assess dissociation. However, as Rachel interpreted the questions on this measure figuratively, its validity in this case is questionable. It would have probably been more appropriate to monitor Rachel’s sense of being cut off”from the world with a mindfulness measure such as the Mindful Attention Awareness Scale (Brown & Ryan, 2003). It would also have been useful to monitor Rachel’s self-critical thinking using a CFT-specific outcome measure (e.g. Gilbert, McEwan, Matos, & Rivis, 2011) and, given the challenges to the therapeutic relationship, to have incorporated a process outcome measure such as the Session Rating Scale (Duncan et al., 2003).
Qualitatively, Rachel made some important changes during therapy. She reported having more confidence in her ability to do things independently, being better able to connect with her sadness and better able to connect with the present moment. Successfully going for walks and doing simple tasks provided evidence that she was capable of living a more independent life which, potentially, reduced some of the shame and self-criticism she experienced from being dependent on others. Although her initial goal of “restoring” her emotions was not achieved, the shared understanding was about her still having emotions (but being “cut off” from them) and this shifted her focus away from this [potentially unhelpful] goal. It was agreed this was an important change as it was identified in her formulation that pursuing this objective might have been maintaining her difficulties. The therapist believed her new goal of gradually increasing her self-compassion, awareness and independence would likely lead to further gains after therapy (as much of her self-criticism and shame stemmed from being dependent and “cut off” from others). This was hopefully be assisted by the referral to Occupational Therapy.
The therapist felt the therapeutic relationship developed over course of therapy and, towards the end of the work, Rachel appeared more open to discussing emotions and how she experienced the relationship. In the penultimate session, Rachel expressed hope about the future.
Reflecting on the case, the therapist thought it might have been useful to draw more on additional models. Attachment theory considers that developing close emotional bonds with caregivers has evolved to serve a survival function and that failure to form these bonds in childhood can result in insecurity, fear and difficulty maintaining relationships in later life (Bowlby, 1988). The therapist drew on this perspective to a certain degree in the work because, as Gilbert (2010a) describes, CFT draws on attachment theory and the concept of a secure base (Bowlby, 1988). Part of the CFT therapist’s role therefore is to act as a secure attachment figure by creating a secure base for their clients to explore uncertain and difficult experiences in the knowledge that they can return to the safety and comfort of their secure base at any time (Kolts et al., 2016). The therapist tried to create a secure base for Rachel by offering her warmth, acceptance and unconditional positive regard. However, it might have been useful to have given more explicit consideration to attachment theory when devising the formulation. Perhaps Rachel’s reluctance to discuss difficult past experiences suggested that she did not feel safe enough in therapy and the therapist wondered if there was more they could have done to help with this.
Unfortunately, Rachel was reluctant to discuss her past which prevented them from exploring factors potentially important to her on-going difficulties, such as unresolved grief and trauma. Perhaps considering alternative theoretical perspectives could shed light on this. From a psychodynamic perspective, the triangle of conflict (Malan, 1995) could be applied to Rachel’s case by considering that Rachel had a hidden feeling of sadness/grief that resulted in anxiety because it represented a conflict with the part of herself that believed emotions were weak and unsafe. Therefore, she could have suppressed her emotions and developed the firm belief that she did not feel emotions as a defence to avoid the threat presented by the internal conflict. It is plausible that when the therapist attempted to increase her awareness of the hidden feeling or challenged her defences, she reacted with hostility in order that they withdrew and that the hidden feeling remained hidden.
Figure 2 The triangle of conflict (Malan, 1995)
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