Identification of behavioral and other non-systemic interventions that could be used with your client

Treatment Interventions and Plan

Identify 1 family system model and 1 non-systems model that can be applied to your Client Case: Selection and Interview Preparation and Formulation paper from Week 2.

Write a 1,400- to 1,750-word plan describing the theoretical orientation of the models and how you plan to use them with your client case.

Include the following in your plan:

•Basic concepts of each model and how you would use these with your client case

•A detailed description of intervention strategies used within each model and any possible obstacles you foresee with your client

•How culture will influence the therapeutic involvement and engagement of parents in your intervention strategies

•Cultural considerations or limitations with each model based on your client’s needs

•Family system approach to addressing and treating behavioral problems and/or learning disabilities

•Identification of behavioral and other non-systemic interventions that could be used with your client

Clinical Case Studies 2018, Vol. 17(5) 296 –310

© The Author(s) 2018 Article reuse guidelines: DOI: 10.1177/1534650118790811


Case Study: A Transactional Analysis Model for a Single Mother and Her Adult Child With Bipolar Disorder

David J. Carter1

Abstract This case study describes a transactional analysis model based on the strain of a single mother with an adult son suffering from bipolar I disorder. The study examines interaction patterns within the clinical setting; the therapeutic view examines contextual factors that affect this mother and her adult son through assessment and recovery with transactional analysis therapy. The 16-session therapeutic experience of a client and his mother is presented. The subjects in the case study were administered the Sixteen Personality Factor Questionnaire (16PF) assessment tool during the second and 16th sessions. There was a significant change from pretest to posttest stens scores regarding increased scores in emotional stability from 2 (extremely low) to 4 (average), rule consciousness from 1 (extremely low) to 3 (moderately low), openness to change from 6 (average) to 8 (moderately high), and self-control from 1 (extremely low) to 4 (average). Decreased scores included apprehension from 9 (extremely high) to 7 (average) and tension from 6 (average) to 3 (moderately low). Behavioral changes after a 1-month follow-up included taking the bus to sign up for a college class, taking his medication as prescribed, getting a part-time job in the kitchen at the Veteran Administration Medical Center, and developing a budget to manage his disability check.

Keywords bipolar disorder, family, transactional analysis, assessment

1 Theoretical and Research Basis

Bipolar disorders are devastating mental health conditions that can virtually affect anyone. Researchers have investigated numerous aspects of mood disorders including etiology (Frangou, 2012; McKinnon, Cusi, & MacQueen, 2013), assessment (Hood & Johnson, 2007; Rush, Trivdei, & Ibrahim, 2003), suicide (Pompili, Gonda, & Serafini, 2013; Schaffer et al., 2017), diagnosis (American Psychiatric Association [APA], 2013; Ilgen, Bohnert, & Ignacio, 2010), pharmacol- ogy (Yerevanian & Cho, 2013), stigma (Lazowski, Koller, Stuart, & Milev, 2012; Thornicroft, Rose, Kassam, & Sartorius, 2007), treatment (Anderson & Lewis, 2000; Miklowitz, Otto, & Frank, 2007), quality of life (Zendjidjian, Richieri, & Adida, 2012), and relationships (Drapalski

1University of Nebraska Omaha, NE, USA

Corresponding Author: David J. Carter, University of Nebraska Omaha, Rosken Hall, Room 101E, Omaha, NE 68182, USA. Email:

790811 CCSXXX10.1177/1534650118790811Clinical Case StudiesCarter research-article2018

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et al., 2008; Granek, Danan, Bersudsky, & Osher, 2016). To date, little research has explored the influence between caregiver strain and their adult child’s healing from bipolar I disorder.

Almost 6 million American adults, or about 2.6% of the U.S. population, 18 years and older suffer from a bipolar disorder (Merikangas, Jin, & He, 2011). Many clients are first seen in therapy in their teens or early 20s when symptoms of a bipolar disorder first appear. Nearly everyone with a bipolar disorder develops the disorder before age 50 (Azorin, Bellivier, & Kaladjian, 2013). Clients with an immediate family member who has a chronic and persistent mental illness are at even higher risk. In clinical samples, about 80% of persons with a bipolar disorder were found to have a history of contemplating suicide and 50% attempted suicide. In the largest epidemiological study on the topic to date, the suicide attempt rate in persons with a bipo- lar disorder was twice that of individuals with unipolar depression (Pallaskorpi et al., 2017).

The initial responsibility for taking care of a family member with a mental illness falls on the parents, and research has shown that caregivers experience a severe disruption in their lifestyle (Zendjidjian et al., 2012). At the onset of the illness, the mentally ill and their families feel hope- less and helpless over lifespan events for which they feel a loss of control (Renn et al., 2017). An experiment conducted by Perlick et al. (2010) found that 90% of the 46 family members in the study reported high adverse emotional distress in relation to the severity of their adult child’s ill- ness and symptoms. Their emotional distress included symptoms of depression, anxiety, stress, financial strain, and limited use of support services, while their short-term coping skills included prayer, smoking, alcohol abuse, and pills.

Research conducted by Perlick et al. (2016) indicates that a large percentage of adults diag- nosed with a bipolar disorder return to live with their families after their first hospitalization. Returning home can be especially difficult for family members who may experience shame and guilt, as mood disorders can run in families (Romero et al., 2010). Families often deteriorate, resulting in divorce, due to the stress and frustration of coping with a family member with a severe mental illness. When this happens, the primary caregiver left to deal with the mental health issue is typically the mother (Smith, Hatfield, & Miller, 2000).

Smith et al. (2000) looked at the link between mothers’ coping styles and their adult offspring mental illness, involving in-depth surveys with 157 mothers (M age 67 years) who were caretak- ers for an adult child (M age 38) with a serious mental illness. They reported that caregivers hope their offspring will get well enough over time to become independent. They also faced an impasse when they were encouraged by professionals to encourage independence and responsibility in their offspring. If they were reluctant to let go, they feared they would be seen as part of the problem instead of the solution. But if they did allow separation to take place and their offspring failed, they might criticize themselves for allowing it to happen. In addition, mothers may seek to maintain their offspring’s self-confidence by eluding situations that could result in failure (Neel, Kenrick, White, & Neuberg, 2016).

In a study conducted in 2007, Perlick selected caregiver subjects with 500 relatives suffering with a bipolar disorder. The majority of family caregivers reported experiencing subjective bur- den in relations to their bipolar relative’s illness symptoms and behaviors, role dysfunction, adverse effects on the household, and lack of productivity. The lower education levels of the individual with a bipolar disorder may reflect a lower earning capacity, even and especially dur- ing periods of symptom remission. This reduction in potential financial contribution increases the burden for caregivers by increasing the pressure on the caregiver to supplement income in some way. This compounds the financial strain of caregiving and the cost of having a family member with a bipolar disorder. Caregiver burden should be counted among the psychological and economic costs of the disorder.

The therapeutic alliance is very important when working with caregiver strain, as is the ther- apy’s effectiveness. A case study conducted by Queen, Donaldson, and Luiselli (2015) used cognitive-behavioral therapy (CBT) as an integrated approach for treating a 29-year-old male

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suffering from bipolar I and secondary social anxiety. Through cognitive restructuring and expo- sure therapy, the client was able to improve his relationship with his father and other family members after eight weekly sessions. He also reported significantly higher quality of life at 1-month and 3-month follow-ups. In a similar case study, Ordaz, Lewin, and Storch (2018) also explored the use of a CBT approach for a mother and her 18-year-old daughter suffering from a mental illness. Treatment consisted of 16 sessions that were attended by the client and her mother, consisting of psychoeducation, coping skills development, hierarchy development, and social skills training. One of the mother’s caregiver burdens was the daughter’s physically aggressive behavior toward her. Through the use of self-soothing and challenging her irrational thoughts during therapy, she was able to overcome her social skill deficit with her mother and become more independent and accepting ownership of her anger.

While many therapists utilize CBT when working with client’s suffering from a mental illness, transactional analysis therapy has the added benefit of exploring the transactions that take place between the client and their family members externally, and the client and himself or herself internally. Such an approach has been found to be efficacious for symptom reduction for mood disorders (Mclean, 2017). The goal of therapy is to restructure both the mother’s and the adult child’s systems of transactional rules, such that the interactional reality of the mother and adult child becomes more flexible, with an expanded availability of alternative ways of interacting with each other. Such transactions permit the system to mobilize its underutilized resources and to improve its ability to cope with stress and conflict (Haynes, 2017).

The single-parent family presented in this study was picked at random and does not represent the stereotypic, enabling mother/adult child family dysfunction that has been presented in the literature for decades (Hinshaw, 2011). While this case study only reflects the author’s views and experiences in working therapeutically with one family, it is hoped that it will help professional clinicians and educators become more knowledgeable and skillful in addressing the unique needs of this client population through a transactional approach and assessment.

The advantage of using the single case study is that it brings the reader to an understanding of the complex issue of implementing transactional analysis family therapy with a single mother and her adult son diagnosed with bipolar I disorder. This approach will extend the research expe- rience and add strength to what is already known, as research and educators have not addressed the step by step application of the transactional analysis family therapy in the clinical setting.

2 Case Presentation

Jack is a 32-year-old male, who presented for treatment of bipolar I disorder. He came to our specialized outpatient treatment clinic at the urging of his psychiatrist and his single-parent mother, who were both concerned about his health and safety. He reported four previous inpatient treatments at local psychiatric hospitals in the Midwest, the first at age 25, with his most recent admission being last year. He reported his symptoms were increasingly dysfunctional and nega- tively impacting his goals, as well as his relationship with his adopted mother. He is unemployed, was placed on social security, and lives with his mother. He is 6 foot, 2 inches tall and weighs 358 pounds and has a very passive temperament.

His current official diagnosis is bipolar I disorder, current episode manic with psychotic fea- tures (F31.2). The Committee on the Family of the Group for the Advancement of Psychiatry introduced the Global Assessment of Relational Functioning (GARF), a scale that describes and quantifies the relational context within which patients live and problems occur. The GARF is intended to serve as a device that alerts clinicians to pay attention to the evaluation not only of individuals but also of relational functioning. Jack’s initial GARF was 54. This indicates com- munication is frequently inhibited by unresolved conflicts that often interfere with daily routines; there is significant difficulty in adapting to family needs and transitional change.

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3 Presenting Complaints

During manic episodes, Jack reported entertaining himself by engaging in “dining and dashing” at a number of restaurants. “I liked being able to feel in control of ordering a large meal and walking out the door without paying.” He was finally caught and arrested and was very upset with his mother for making him promise to engage in counseling before she would pay his bail. His mother also reported that prior to this, he had stolen US$360 from his roommates and was behind in his rent. After she paid the US$360 that was stolen and US$400 for past rent, he was asked to leave the home. He is on disability for his disorder and spends most of his money on alcohol to self-medicate when he does not take his medication. Prior to moving back in with his mother, he was drinking five to six beers per night and a case of beer over the weekend. He now goes out to bars to drink and comes home late. He does not have a car so he walks to the bar close to home. His mother had originally decided to place him under a commitment order, but Jack convinced her not to. Jack’s self-reported symptoms were also observed by his mother and are consistent with a diagnosis of bipolar I disorder. Symptoms include heightened self-esteem, talkative, hyperactive, irritable, distractible, flight of ideas, delusional, limited need for sleep, and depression.

He reported that he looks forward to a manic episode because he feels like “he is on top of the world.” During his manic episodes, he spends a lot of time in bars fantasizing about how great his life will be in the future. It is during this time that he drinks heavily, spends money, and gets into trouble. He dreads the eventual depression which brings with it feelings of hopelessness and helplessness. When depressed, he isolates in his bedroom, stays in bed, does not bathe, and relies on his mother for comfort and support. Such symptoms result in poorer social competence and functioning, which then prompts Jack’s perceptions of social inadequacy, learned fear of social situations, and social avoidance. In turn, social averting lessens one’s social group and capacity to develop social functioning, resulting in the worsening of bipolar disorder symptoms, thereby reinforcing the cycle (Queen, Donaldson, & Luiselli, 2015).

4 History

The client’s family is composed of his mother (Betty), age 68, and her son Jack, age 32. She is a single mother who was never married. Betty was raised by a single mother after her father left when she was 4 years old. She has an older sister who helped take care of her, instilling in her the desire to help others. She worked in a number of health care jobs and eventually completed her college degree in social work. At the age of 36, her friend informed her that single mothers could adopt a child which motivated her to seek out an agency.

I didn’t care about the race or gender of the child I just wanted a child between the age of birth to two years old. At the time I was not prepared in any way to take care of a child. I was told that it would take 2 to 3 years to receive a child which I thought would give me time to prepare. I received a call 2 months later with a request to adopt an infant. He was 8 weeks old and had already been placed and removed from previous home placements. I rented an abandoned farm house in the country and became a mother. I learned by trial and error, Jack cried all the time and did not sleep well. After a year, he was becoming more comfortable with me and we settled in together.

In school, Jack struggled academically and was picked on because of his size, but he was always outgoing and friendly with others. In high school, he became involved in drama and wres- tling and was chosen for youth leadership. After graduation, he attended a small college for drama where he started to show signs of mental illness. His two roommates moved out because of his poor hygiene, he stopped bathing and brushing his teeth, and he had few friends. He began

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to drink heavily and was kicked out of his fraternity. He would not answer the phone and would skip classes and spend his day in the campus lounge watching television. He eventually dropped out of school and volunteered at a farm for the mentally ill in Maryland. When his mother visited him, she was shocked to see how filthy he and his room were and she could see that he was uri- nating out of his window because he was too lazy to go to the bathroom in the building. He was starting to show signs of depression, mania, and isolation. She took him home and made an appointment with a psychiatrist. The doctor diagnosed him with bipolar I disorder and prescribed psychotropic medication for Jack.


Medication management is a critical component of the therapeutic process when working with clients suffering from a chronic and persist mental illness like Jack. Once diagnosed by the psy- chiatrist, Jack was initially prescribed an anti-manic agent, lithium carbonate, at a low dose for reduction in duration of his manic episodes. At first, Jack noticed drowsiness, exhaustion, and weight gain. As his body adjusted to the medication, these symptoms lessened, but he became aware that he was becoming more agitated and quick to anger with his mother. Jack stopped tak- ing the medication all together.

Six weeks later, Jack saw the psychiatrist, again who this time prescribed divalproex sodium (Depakote) extended release to help with the manic episodes, agitation, and weight gain. He experienced minimal side effects and this medication seemed to work well for Jack in that he said that he could now function better and avoid the extreme highs and lows in his mood. When he returned a month later, the psychiatrist added an antipsychotic medication aripiprazole (Abilify) and an antidepressant medication bupropion (Wellbutrin). These medications were very helpful, reducing his depression and grandiose ideations. He was more focused and in control of his emo- tions. It seemed that finally the correct psychotropic treatment regimen had been found.

During the initial intake session, Betty had this to say about her son. “Jack will always be my baby boy but he can be so very irresponsible and dependent. He calls me 2 to 4 times a day, doesn’t take his medication, and I constantly worry that he is going to get himself into trouble. He lacks motivation to complete the projects he starts and then blames others for his failure.” For example, he was living in a house with college guys and he wanted to impress them. One of the roommates wanted to fly to his home town for the holidays but could not afford the cost of the ticket which was US$600 round trip. While in a manic state, Jack decided he would inform the roommate that he can get a great price on the tickets for US$300 and save him 50%. The room- mate gives him the money in good faith and Jack proceeds to spend the money on food and alcohol. It should be pointed out that during this manic phase, Jack truly believed that he could in fact find tickets for a better price.

When the time came for Jack to make good with his promise, he asked his mother if he could use the airline points from her travels for the ticket. She informed him that she does not have any points because she does not fly anywhere. As a last resort, he gets on the computer and looks for tickets at a lower price and finds that the tickets are now twice the price they were a month ago. “After sitting on this information for a few weeks, he finally tells me his story. He still doesn’t accept responsibility for doing anything wrong and assumes that I will fix the problem, and I do.”

Betty reported that her son thinks she needs therapy, not he; that it is his life and he can do what he wants alone, without the help of doctors; that doctors do not understand or help; that it is not his fault; and that others or circumstances are to blame. As a child, Jack was very passive in getting his needs met and Jack’s mother would sacrifice her own needs for the needs of her son. Betty dedicated the majority of her time to Jack as a way to keep him close and safe.

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5 Assessment

Clinical Interview

A structured clinical interview from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) designed to provide detailed coverage of bipolar disorders and shown as a valid and reliable measure of mental health disorders was conducted with the client and his mother. Treatment consisted of 16 sessions that were attended by both Jack and his mother. Sessions typically lasted 60 min, with 45 to 50 min being spent with Jack and 10 to 15 min being spent with the mother.

Sixteen Personality Factor Questionnaire (16PF)

The 16PF was used in this study because it is found to be effective in a variety of settings where an in-depth assessment of the whole person is needed, and because the test–retest reliability coef- ficients over short periods range from .60 to .85 (Hood & Johnson, 2007). The 16PF is a 185-ques- tion comprehensive measure of 16 personality factors and five global factors. The primary and global levels of the 16PF traits combine to provide a comprehensive, in-depth understanding of an individual’s personality. The 16PF is based on a large amount of research both in the construc- tion of the instrument and in the examination of its reliability and validity.

Separate-sex and combined-sex norms are offered. Scores are provided in terms of “stens” stan- dard scores with a mean of 5.5 and a standard deviation of 2.0 and range from 1 to 10. The stens scores are transferred to a profile sheet and plotted. Stens of 5 or 6 are considered average. A stens of 4 or 7 would be considered slightly deviant from the norm; 2, 3, 8, and 9 are strongly deviant, while stens of 1 or 10 are considered extreme, as they occur so rarely in adults. Because the scales are bipolar, both high and low scores can be interpreted as reflecting a particular characteristic. Three different validity scales have been developed: one to identify random responding, one to discover faking-good responses, and a third to predict attempts to give a bad impression. Additional adaptations and computer-generated interpretations of the 16PF have been published and endorsed for use in marriage counseling with adolescents and mental illness (Cattell & Schuerger, 2003). Following the initial interview, Jack and his mother completed the pretest 16PF questionnaire.

6 Case Conceptualization

Table 1 shows the 16PF stens scores and differences between Betty and her son Jack. Betty’s scores on warmth (A = 7) and rule consciousness (G = 8) represents a woman who is good natured, warm hearted, determined, attentive to people, generous, and cooperative. Her social boldness score (H = 8) complements her previous scores with being carefree, emotional, and friendly, but can also lead to impulsive behavior and failure to see danger signals. This mother’s profile also indicates that she has very low emotional stability (C = 2), which can result in becoming emotionally changeable when frustrated and avoiding responsibility when overwhelmed. Guilt proneness is also remark- ably high (O = 9), indicating that she is a constant worrier. The Q3 of 3 suggests that she has limited ability to use coping mechanisms to address stress. And there is a naïve quality about her (N = 3) as reflected by her continual bailing her son out of trouble and believing that this enabling behavior will eventually motivate him to become more self-sufficient.

The interpretation of Jack’s 16 PF reveals that he is very emotionally sensitive (I = 9) result- ing in a strong mother-figure identification. High I scores are believed to stem from an overpro- tected early childhood in which there has not been much interaction with one’s peer group, or much participation in the rough and tumble of everyday life. In addition, the comparatively low score on tough-mindedness (TM = 3), combined with a Q3 of 2, implies relatively few effective

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cognitive controls and strong identity problems. His response patterns appear to be largely deter- mined by idiosyncratic and personal considerations. He is more prone to make rapid impulsive judgments, rather than well thought out accurate cognitive decisions when necessary. Individuals with a very low rule consciousness score like Jack (G = 1) will have a high punitive Critical Parent to keep them aware. However, Jack’s ego state does not serve to self-regulate when he makes bad decisions. When he behaves in unconventional ways, he will blame others for his actions and avoid responsibility (C = 2). His very low score on rule consciousness is accompa- nied by a high score of 8 on liveliness and this indicates someone who tends to dissociate and has an active fantasy life. His score on ego strengths is so low as to suggest that his ego defense organization does not possess sufficient emotional stability to face the hardships of everyday life. Jack’s score on abstractness (M = 9) demonstrates his preoccupation with fantasies that often cause him to get lost in his thoughts, misplace things, and lose track of time. In addition, Jack is very guarded and has a moderately high score on privateness (N = 8). He keeps problems to himself until he has no choice but to ask his mother for help. Particularly troublesome was his low score of 1 on self-control. He can be unrestrained and follows his urges without looking at the long-term consequences of his actions. See Table 1.

I concluded, therefore, that Jack was emotionally and cognitively delayed, resulting in his lack of responsibility for his actions as a grown man. I was encouraged that he might have a chance to improve, provided that he was willing to consistently and actively participate in therapy. My experience with client’s suffering from bipolar disorder who are open to change (6) and posses average reasoning skills (6) indicates that they tend to benefit from transactional analysis therapy as they like a challenge. Mother/son therapy would need to move in the direction of teaching him and his mother transactional strategies, including clear and concise restructuring of boundaries to

Table 1. 16PF Pretest Stens Scores and Differences.

Individual factor Mother stens score Son stens score Difference

A: Warmth 7 5 2 B: Reasoning 4 6 2 C: Emotional Stability 2 2 0 E: Dominance 5 6 1 F: Liveliness 6 8 2 G: Rule Consciousness 8 1 7 H: Social Boldness 8 7 1 I: Sensitivity 3 9 6 L: Vigilance 4 5 1 M: Abstractedness 6 9 3 N: Privateness 3 8 5 O: Apprehension 9 5 4 Q1: Openness to Change 6 6 0 Q2: Self-Reliance 4 6 2 Q3: Perfectionism 3 2 1 Q4: Tension 6 6 0 EX: Extraversion 8 6 2 AX: Anxiety 7 7 0 TM: Tough-Mindedness 6 3 3 IN: Independence 7 6 1 SC: Self-Control 5 1 4

Note. 16PF = Sixteen Personality Factor Questionnaire.

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help Jack develop more effective coping mechanisms, especially with regard to greater self- control and following rules. This would free his mother to live her life with less stress and enabling behavior, and more emotional stability.

7 Course of Treatment and Assessment of Progress

Jack and his mother participated in once weekly therapy sessions for 4 months, for a total of 16 sessions. The first assessment session lasted 90 min and all of the following sessions incorporated a transactional analysis therapy perspective and lasted 60 min. The primary purpose of transac- tional analysis is to explore the different ways the client engages with his mother and others in social interactions (Mohammadi, Hosseininasab, & Borjali Mazaandarani, 2013). Three ways that we interact with others is through our Parent, Adult, and Child ego states. The Parent (P), Adult (A), and Child (C) are truly felt states of being, not just roles played by the individual.

The Child

Everyone knows that we sometime act like children. When we are in the child ego state, we are not just putting on an act, we are really being children. We think, feel, see, and react as a child. The Child has the urge to touch others and generates all the feelings: fear, love anger, joy, sad- ness, shame, and so on. Due to its complexity, there are three types of child ego states: Natural, Intuitive, and Adaptive. When the Child is hateful or loving, impulsive, spontaneous, or playful, it is identified as the Natural Child (NC). The NC is the body we are born with and our spontane- ous capacity to experience our own, and others feelings. The Intuitive Child (IC) is thoughtful, creative, or imaginative, while the Adaptive Child (AC) is fearful, guilty, or ashamed. The AC is often the most problematic part in relationships because it develops reactively and continues to result in/stimulate knee-jerk reactions to stimulus that often have more to do with childhood issues than here and now problems (Alipieva, 2017).

The Parent

When the person is in the Parent ego state, she thinks, feels, and behaves like one of her parents or someone who took their place. The Parent decides, without reasoning, how to react to situations, what is good or bad, and how people should live. The Parent can be over-controlling and oppres- sive or life giving, supportive and tender. The Parent promotes values, morality, and ethical behav- ior. When the Parent is overly critical, it is called the Critical Parent (CP). The CP makes put-down statements like “You’re bad, stupid, ugly, crazy, and sick; in short you’re doomed, not OK.” The Nurturing Parent (NP) is the defender of the NC against its enemy. The NP is on the Child’s side and the CP is on the Child’s case. The NP loves the Child unconditionally and says things like “I love you,” “You’re a winner,” “You’re smart,” or “You’re beautiful.”

The Adult

The Adult engages in clear thinking, generates options to help with problem solving, planning, and productive procedures with clarity. The Adult has no emotion and makes its decisions based on data and logic. Being a mature human being or grown up is not the same as being in the Adult ego state, little children can be in their Adult as well (Alipieva, 2017).

Steps for the Transactional Model

Step 1: Alliance, assessment, and contract. The therapist conducted a genogram and a detailed intake assessment with both Jack and Betty. The 16PF was administered to both parties and they

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were informed that the results of the test would be shared at the following session. At that time, a contract was developed, in cooperation with the two parties, according to the results of the test and the goals identified. They were informed that the contracts involved an awareness that a problem exists, a decision (made by the Adult) to solve the problem, a plan of action related to their goals, and a means of evaluating the progress.

Step 2: Structural analysis. Structural analysis is the exploration of the Parent, Adult, and Child ego states which encompasses the client’s script and is the foundation of every interaction (Tudor, 2006). The primary purpose of this analysis is to establish the control of rational ego states and liberate Betty and Jack from contaminated ego states. They were informed that they can operate from any of the three ego states, but only one at a time. The active ego utilized at any time is called the executive and has select authority. Because one ego state can be in charge while another ego state is observing the behavior, an internal dialogue between the two is often taking place internally and/or externally.

Step 3: Script analysis. Injunctions are both negative and positive messages that children receive from their parents and other parent figures. These messages are conveyed both verbally and non- verbally and children can act them out throughout their life (Widdowson, 2018). Because the childhood decisions made from these messages often interfere with autonomy, the goal for Betty and Jack was to modify them through a process of resolution.

Step 4: Game analysis. Games are a time consuming interaction between people in which one player wins a payoff at the expense of another. Games are repetitive, devious series of transac- tions intended to get strokes. Unfortunately, the strokes obtained in games are mostly negative. Therefore, a game is a failed method of obtaining healthy strokes. Betty and Jack were able to look at their own games as well as the games of the other and their influence on their relationship (Chinnock & Minikin, 2015).

Step 5: Transactional restructuring. The behavior between two people, like Jack and Betty, is best understood if examined in terms of transactions (Bestazza & Ranci, 2015). This will help carve out new pathways from the Parent, Adult, and Child and explore with the client and his mother their life events as well as educate and modify decontaminated ego states to a more effective and efficient ego state.

Step 1 was addressed in the first three sessions consisting of the initial assessment, including a genogram of the family, education, and observing interactive patterns of behavior. During the interview, one of the first things that took place was joining in the therapeutic relationship. Throughout the sessions, the therapist explored with the couple the following questions: What ego states does Betty and Jack engage in? What ego states in each other are they trying to hook? What scripts or games seem to emerge? The two were asked to share what they each wanted changed and how the other person will know that the change has been made. Betty reported that she wanted Jack to be more independent. When asked what she wanted to change, she said, “I want to feel less stressed and not worry about my son.” She would know she had accomplished this when Jack saw her as a support and problem solver and not at a Critical and Rescuing Parent. Jack stated that he wanted to feel more in control of his life. When asked what that looks like, he said he wanted to be more independent, have a job, and attend college.

During the second session, Jack and Betty completed the 16PF pretest, and psychoeducation was provided during which the therapist explained the five steps to the transactional analysis therapy model and the rationale for treatment. During the third session, the results of the 16PF were discussed in terms of the similarities, differences, and factors that would be addressed in therapy and a contract was developed and signed. Betty developed a social contract designed to change behavior that interferes with satisfying social relationships. The 16PF factors addressed

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by this contract included emotional stability, apprehension, and perfectionism. Jack developed an autonomy contract designed to restructure personality to have more freedom to choose options available and to experience independence. His contract factors include self-control, sensitivity, emotional stability, and rule consciousness.

The next three sessions focused on Step 2 and structural analysis. During the sessions, I observed the visible and audible characteristics of the client and his mother’s gestures, manner- isms, facial expressions, and words. When Jack entered therapy and interacted with his mother, it became obvious that he was engaging in a Child to Parent structure. When he was discounted by peers in the community, he would say to himself, “That proves that I can only count on my mother for support,” and his Parent would answer, “That’s my good little boy!” This internal transaction has reinforcing enabling values, and at the same time supports the victim child posi- tion of Jack (Mclean, 2017).

Betty reported that when she paid her son’s rent (Rescuing Parent) because he spent the money on alcohol (Free Child), she kicked herself for being in the same situation as before (CP). As therapy progressed, the ego exchange became more appropriate. They explored the possible future event, when Jack approaches his mother asking for money (Powerless Child), she would help him set up a budgeting plan for the month (Adult) and reward him with dinner at her home when he follows the plan (NP).

The following three sessions concentrated on Step 3 and script analysis. Betty and Jack identi- fied their injunctions through the parental role-plays that took place in the sessions. Jack’s included Take Care of Yourself First and Don’t Grow Up. When he is drinking excessively, his injunctions include I’ll Show You. His mother’s injunction included Sacrifice for Others. During a role-play, Jack stated he wanted to change feeling incompetent. When he closed his eyes, he could see his mother and the message he was getting was “You can’t do anything right.” So he was instructed to answer the mother in his head and he responded, “Yes I can, I can do a lot of things right. I can connect with people in ways that you were never able to connect with me.” He went on to state, “I’m no longer a little boy, I’m a grown man who is capable of taking care of myself.” Betty agreed that she always saw him as her cute little baby boy. They both realized that when she was taking care of him as a little boy, it was the best time they both shared together. Jack realized that he was acting like a little boy to get her love and attention. She agreed to see him more like the adult that he was and he thanked her for doing the best job she knew how and for protecting him when he was a child. He told her that she could turn over the protection to him.

Factors that were affected by the injunctions and addressed during this step included Betty’s high apprehension and Jack’s low self-control. For example, during a role-play exercise, Betty shared with Jack her concerns for his drinking, “When you go out drinking and come home drunk and broke I worry that this will keep you dependent on me for money.” Jack’s response was, “I just drink because that makes me forget about my problems.” We worked on Jack listening to the content in the message sent by his mother and transacting from his Adult. Jack practiced stating, “I was not aware that you worried so much about my being dependent on you for money.” This opened up a dialogue between the two that was from the Adult and NP instead of the AC.

During Sessions 10 to 12, Step 4 was explored with a list of possible games that people play in relationships. It was explained to them that they may be unaware of the games they play because the games feel familiar, having been played since childhood. The games that Jack agreed to work on in session included Look What You Made Me Do and Yes, But. Games his mother worked on were I’m Only Trying to Help You, Look How Hard I’m Trying, and Kick Me. These games reinforced Jack’s high sensitivity and both of their low perfectionistic tendencies. In I’m Only Trying to Help You, Betty gives Jack some “well meaning” advice and Jack appears to take the advice; later messes up in some way, then returns to blame his mother because things did not turn out, increasing his sensitivity and playing a complementary game of Look What You Made Me Do. To address these games in the sessions, the two engaged in previous transactions where

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Betty stated, “I want you to start taking the bus places so that you don’t depend on me to drive you everywhere.” Jack took the bus as requested and responded, “The last time I took the bus I got drenched by the rain and it ruined my best suede jacket so you need to replace it.” We dis- cussed Jack’s responsibility to get an umbrella in preparation for the change in weather to strengthen his Adult decision-making skills. We also worked on Betty’s emotional stability when she feels to blame for Jack’s feelings, Kick Me, with the Adult statement, “I understand that your upset that your jacket got wet but that is your responsibility, not mine.”

Step 5 was the focus of Sessions 13 to 15. The final sessions involved transactional restructur- ing and maintenance. Betty and Jack learned that their transactions become contaminated when a desired response to a previous message interrupts communication and results in a crossed inter- action. For example, Betty began exploring with Jack’s problem-solving skills from the Adult, “When you eventually get an apartment and if you spend your rent money on other things, what are options you can implement to demonstrate independence?” Jack’s response was “I can ask my landlord for an extension or I will check into getting a payee to manage my disability money.” It was stressed by Betty that she would not be the payee if that option was the final choice. During the 16th session, Betty and Jack completed the 16PF posttest. Stens score differences between the 16PF pretest and posttest were discussed and celebrated, and a 6-month follow-up session was scheduled.

Assessment of Progress

There was a significant change from pretest to posttest for the following personality factors: Emotional Stability (from 2 to 5 for Betty and 3 for Jack), Apprehension (from 9 to 7), Rule Consciousness (from 1 to 3), Openness to Change (6 to 7 for both), Self-Control (from 1 to 3), and Tension (6 to 7 for Betty). This was supported in the sessions with therapist observation and Jack’s and Betty’s role-play and subsequent dialogue. Jack was willing to strengthen his self- control and rule consciousness by following a more Adult drinking schedule. This required limiting his drinking to the weekends and only drinking one drink an hour. Betty demonstrated the ability to reduce the number of times she assumed responsibility for things that are outside her control regarding Jack. She shared with him “It’s not my fault if you don’t take your medica- tion consistently. I will help you pick them up from the pharmacy but its your responsibility to take them.”

Jack also took more responsibility for getting started in college classes and strengthening his Adult to stay on task. He engaged less in attach-defend with his mother and asked for her opinion without dumping problems on her. In addition, he acted more mature by using “I statements” when expressing his needs with his mother. While he still had difficulty following strict rules, he was beginning to ask questions about the benefits and consequences of following specific rules that would impact his perception of personal freedom. His trust toward his mother was improving in regard to his past fear that he would have no say over future mental health decisions. He was reassured by his mother that she would be involved in decisions regarding his mental health care and recovery as an equal partner, not as the caretaker.

8 Complicating Factors and Limitations

The most challenging factor in Jack’s treatment was his inconsistency in taking his medication. He still has a fantasy that if he does not take medication then his mental illness is not so bad. This is a common barrier for many patients diagnosed with bipolar disorders, particularly manioc episodes, and often results in premature treatment termination. He has discussed with his psy- chiatrist the option of taking a longer lasting injection of his medication and Medipacs are being delivered to his new apartment monthly.

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While a major strength of utilizing transactional analysis with individuals and couples is its inter- and intrapersonal dimensions, it is limited in its communication, autonomy, mutuality, and co-creativity (Tudor & Hobbes, 2014). With little support given to the biological and spiritual drives that influence human interactions, the challenge exists to continue to develop the model to match the needs of modern society. One avenue is to recognize how modern therapy practice is moving toward diversity and social justice. Because CBT has been identified as the gold standard therapy approach when working with client’s suffering from mood disorders, future case study research could allow for a direct comparison of CBT and transactional analysis therapy to assess overall treatment efficacy.

Despite the fact that the 16PF has been utilized in treatment assessment for clients suffering from mental illness for years, very little research has explored its effectiveness with client’s suf- fering from mania. Caution should be exercised when attempting to generalize findings from a single case. Furthermore, ratings conducted by an independent observer, as opposed to the treat- ing therapist, would likely reduce rating bias. In addition, long-term medication efficacy, which is a critical part of any treatment with clients diagnosed with bipolar I disorder, was discussed but not emphasized in this study.

9 Follow-Up

The client and his mother attended a 1-month follow-up session and we conducted a bragging session. Jack shared that he was attending lifestyle sessions at the local Community Alliance day program and moved into his own apartment. He registered for a math class at the local commu- nity college and had the bus schedule worked out for his class. He stated that he was hired as a part-time dish washer at the VA Medical Center and was consistently taking his medication. Jack’s post GARF score was 82, reflecting the beginning of a shared understanding and agree- ment about roles and appropriate tasks. Decision making is established and there is recognition of the unique characteristics and merit of each person.

10 Treatment Implications of the Case

Over the 4-month family therapy period, Jack significantly increased his ability to communicate more effectively with his mother without getting defensive. He was able to begin accepting influence from his mother during weekly meetings. Jack used more NP and Free Child repair attempts in place of bids for attention, such as dealing with small problems himself instead of turning to his mother. Jack continued to struggle with engaging from the Adult with his mother. This is likely due to his long history of emotional disengagement to avoid rejection. Jack was willing to tell his mother that he was going to earn her trust by taking responsibility for getting his own emotional needs met through being open and honest instead of seeking approval through game playing.

11 Recommendations to Clinicians and Students

Working therapeutically with single-parent mothers caring for a mentally ill adult child is within the scope of practice for licensed marriage and family therapists, psychiatrists, psychologists, and professional counselors. This case study illustrates that both the mother of the adult son suf- fering from bipolar I disorder and the client are often able to lead independent and productive lives, usually with the help of pharmacological and transactional analysis therapy, as well as social support. The professional and the single mother–adult son system share the therapy roles and responsibilities in the following ways:

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1. Provide a comforting therapeutic environment with calm, straightforward questioning to pro- mote a trusting relationship. If they are not motivated, time must be spent developing trust.

2. Provide educational material and videos for family members where transactional analysis information is provided and questions are answered with the family member, diagnosed with a mental illness, present.

3. Expect the client to be suspicious of professionals who, in the past, may have initiated the process for commitment to a psychiatric facility. Provide active feedback about the feel- ings they may be experiencing. This can help free them from understandable resistances they have built up over the years.

4. The therapeutic contract needs to be based on change, not just information. 5. It is important, especially when working cross-culturally, to check the potential effects of

any goals in the contract within the client’s frame of reference. 6. Be aware of the deep emotions that affect stressed single mothers of bipolar adult children

and reassure them that these feelings are normal. 7. If the client is on medication, work closely with the patient’s physician (psychiatrist) to

help in the monitoring of pharmacotherapy and stay up to date with the current medica- tions and their side effects.

8. Stay actively involved with family members, friends, and extended social network to measure the social outcomes, quality of living, recreation, diet, volunteer, and/or employ- ment success to reduce relapse episodes.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


The author(s) received no financial support for the research, authorship, and/or publication of this article.


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Author Biography

David J. Carter, PhD, is the Peter Kiewit professor in counselor education at the University of Nebraska at Omaha, Nebraska. He has provided transactional analysis therapy for families and adults diagnosed with bipolar disorder for over 35 years.



Client Case Assessment Scenario

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The client, 32-year old Jack, is a single male. He was adopted by his mother Betty, currently 68, when she was 36 and Jack was only 8 weeks old. Jack is currently not in a relationship and does not have any close friends since the ones that he had in college left him due to his untidiness and his negative habits during his manic episodes. Jack struggled academically in school and was additionally bullied because of his size but he always proved to be friendly and outgoing. He further participated in wrestling and drama during high school and was even chosen as a youth leader. His symptoms started developing when he was in college and worsened to the point where he had to drop out of school (Carter, 2018).

The main presenting problem is Jack’s Bipolar Disorder. The first signs of mental illness developed when Jack was in college. The disorder causes him to shift between manic and depressive episodes. During manic episodes, Jack reportedly feels like he is on top of the world which causes him to engage in various destructive inappropriate habits. Some of the times he engages in “dining and dashing” where he orders a large meal in a restaurant and walks away without paying. He managed to do this a number of times without getting caught although he was eventually apprehended and taken to jail. During this incident, his mother required him to agree to counseling before she could pay his bail, a fact that made him very upset with her. Other times during his manic episodes he got his friend to give him money to get a bargain that he knew he could not acquire. Another effect of his manic episodes is his attraction to bars where he spends most of the time fantasizing, drinking heavily, spending money and getting into trouble. On the other hand, his depressive episodes bring along feelings of hopelessness and helplessness. These feelings often lead him to stay in bed, isolate himself in his room, refuse to bathe and rely on his mother for support and comfort.

Alcohol abuse is another presenting problem, although related to the Bipolar Disorder. Jack has been observed to engage in high amounts of alcohol intake. One of the factors contributing to his alcohol intake is self-medication, in situations when he does not have the proper medication for his symptoms. Furthermore, his various moods, particularly the manic episodes, are also a contributing factor to the alcohol abuse.

The developmental needs for Jack mainly concern his emotional and cognitive delay. The primary result of this delay was his lack of responsibility for his actions as a grown man. There are numerous instances when Jack acted in a highly irresponsible manner that should have been reserved for someone younger than him. One of these involves the lack of bathing. As noted from the case study, one of the main reasons Jack split from his roommates in college was due to the fact that he did not bath nor clean after himself. This led to a situation where Jack and his surrounding were quite untidy and dirty, a fact that his roommates could not tolerate.

There are limited cultural considerations for the case since neither Jack nor his mother seems to hail from a unique culture that would require particular attention when addressing his possible treatment regime.

One effective therapeutic approach to take in maintaining alliance with the patient involves interpersonal and social rhythm therapy. This for of therapy comprises two components. The first part is the interpersonal therapy which focuses on how the patient relates with other people in their life. This is a vital component since Jack has shown to be friendless and to have problems in social engagement. Interpersonal therapy will therefore help Jack in stress reduction, hence mitigating the effect that stress has on his disorder as a trigger. The second component is the social rhythm therapy which aims at stabilizing Jack’s social rhythms so as to maintain stability in his moods. Social rhythms include activities such as eating, sleeping and exercising. Disruptions in these daily activities may have negative effects on an individual’s circadian rhythms, and consequently, their mood states.

The method used to assess Jack’s cognitive, psychosocial and moral development was the Sixteen Personality Factor Questionnaire. This assessment has been found to be effective in circumstances requiring in-depth evaluation of the individual. The sixteen factors tested include: tension, perfectionism, self-reliance, openness to change, apprehension, privateness, abstractedness, vigilance, sensitivity, social boldness, rule-consciousness, liveliness, dominance, emotional stability, reasoning, and warmth.

The primary interview questions to ask are one concerning the history of the presenting illness. Therefore, the questions will try to establish from both the mother and the patient the onset of the illness, its symptoms, consequences and possible stressors. As for the latter, although some disorders appear to commence spontaneously, there are events that often cause, precipitate, or worsen a patient’s mental issues. Consequences help in establishing the severity of the illness. Consequences range from those regarding marital and love relationships and interpersonal friendships to employment and legal issues.

An evaluation of suicide potential is also a significant part of the interview since all mental patients require such evaluation. As an interviewer, one should not worry about the risk of suggesting suicide to a patient since anyone with such thoughts will have already considered it and hence, the real risk lies in asking too late. The interview should also ask questions concerning the patient’s substance misuse due to the high rate of correlation between psychiatric illness and substance misuse. Substance abuse affects a large area of the patients life and hence the questions will have to focus on the medical, financial, interpersonal, legal and employment effects of the substance misuse problem.

An important initial diagnostic technique is the Structured Clinical Interview for DSM (SCID). This tool consists of a semi-structured interview that provides symptom thresholds, interview probes, and exclusion criteria information. The SCID has different modules designed to capture the core information regarding specific diagnoses. In this regard, there is a bipolar disorder SCID module which is quite reliable in diagnosing bipolar disease as compared to other similar tools. The Schedule for Affective Disorder and Schizophrenia (SADS) is another semi-structured interview tool with a high degree of reliability for both diagnoses and symptoms of bipolar. The tool has demonstrated particular effectiveness with regards to manic versions of bipolar disease, which Jack seems to mainly suffer from.

Carter, D. J. (2018). Case Study: A Transactional Analysis Model for a Single Mother and her Adult Child with Bipolar Disorder. Clinical Case Studies, 17(5), 796. doi:10.1177/1534650118790811


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