1. The Process and Outcome of Transactional Analysis Psychotherapy for the treatment of depression
Dr Mark Widdowson,
Teaching and Supervising Transactional Analyst, UKCP Registered Psychotherapist

2. Background Limited amount of TA research at the time
Desire to conduct research which examines outcomes but also explores what TA therapists do in routine practice
Use of a research method which can be readily replicated by other TA practitioners

3. ‘Although a series of well-designed studies might establish the efficacy of an intervention, unless it is effective in real-life clinical settings, it will not be useful’ (Nathan, Stuart and Dolan, 2000: 974)effective in real-life clinical settings, it will not be useful’ (Nathan, Stuart and Dolan, 2000: 974)‘Although a series of well- designed studies might establish the efficacy of an intervention, unless it is effective in real-life clinical settings, it will not be useful’ (Nathan, Stuart and Dolan, 2000: 974)

4. Participants
Qualified TA therapists working mostly in private practice, one in voluntary agency
Five clients, all independently and actively chose to engage in therapy
All clients with Major Depression (DSM-IV), not on medication
Minimal exclusion criteria
Naturalistic therapy protocol
16 sessions of therapy, plus six-month follow-up

5. Method Systematic Case Study Research
Combination of quantitative outcome measures and qualitative tools; BDI-II, CORE- OM, PQ, WAI, HAT, Change Interview, Structured Therapist’s Notes
Data used to form ‘rich case record’

6. Method
Hermeneutic Single-Case Efficacy Design (HSCED) (Elliott, 2001; 2002) used for analysis of four cases
Analysis of case and development of affirmative and sceptic arguments
Uses quasi-legal method of cross- examination of data and independent adjudication

7. Aims of a HSCED study
‘Evaluate(s) the efficacy of psychotherapy on a case by case basis by asking… [the following three questions;] Did the client change substantially over the course of therapy? Is this change substantially due to the effect of the therapy? What factors (including mediator and moderator variables) may be responsible for the change? ‘ (Stephen and Elliott, 2011: 231)

8. Case One: Peter
28 year-old, unemployed and somewhat socially isolated British male with severe depression and moderate functional impairment
Bullied at school, mother died when he was 13. Awareness of repressed emotions
Intelligent, articulate, psychologically-minded

9. BDI-II: severe depression, CORE-OM: Moderate global distress and functional impairment
Clinically significant change on CORE and PQ by end of therapy, reliable change on BDI
Improvement at 1 month follow-up, maintained at 6 month
Identified five changes which were important to him and which he felt unlikely to have come about without therapy

10. Peter: Judges Verdicts
Peter had experienced clinically significant changes, although had not fully resolved his problems, and that these changes were substantially due to therapy.
Good outcome case with client changing considerably-substantially and these changes were substantially due to therapy

11. Peter: Mediator Factors
Empathic, genuine therapist who was willing to become emotionally engaged with him ‘on a human level’ had been highly significant
Use of a explanatory and change framework (TA theory) had also been helpful

12. Peter: Moderator Factors
Client commitment to therapy and determination to overcome discomfort
Client motivation
Client belief in effectiveness of therapy (hope)
Matching of therapist and type of therapy with client preferences

13. Case Two: Denise
46 year old, white, British social worker with severe depression and moderate functional impairment
Off sick from work at point of entry into therapy
Feeling very taken for granted by her family – strong sense of ‘I’m not important’

14. Denise Severe depression (BDI-II) and moderate functional impairment
Clinically significant change on CORE-OM and PQ by end of therapy, reliable change on BDI-II
Continued improvement throughout follow-up
Identified ten changes she felt were extremely important and unlikely without therapy

15. Denise: Judges Verdicts
Unanimous verdict of the judges that the case was a clearly good outcome case, with mean certainty of 86%
Unanimous verdict that Denise had changed substantially and that this had substantially been due to therapy

16. Denise: Mediator Factors
Empathic, non-judgmental stance of the therapist.
Therapist’s willingness to provide a rationale or use theory to explain and support the therapy
Therapist’s focus continued challenging of Denise’s script, an attentiveness to how it might be manifesting in the therapy and avoidance of reinforcing script had also been a significant factor

17. Denise: Moderator Factors
Denise’s sense of hopefulness at the outset of therapy
Informed decision in choosing the right therapist
Well-motivated with clear goals for the therapy and a degree of insight from the outset
Courageousness and willingness to address difficult and painful material (e.g. sexual abuse) and her continued attempts to integrate the insights gained in therapy into her everyday life

18. Case Three: Tom
38 year-old, white, Male builder with comorbid moderate depression and social anxiety
Harsh parenting which had left him feeling ‘stupid’ and ‘useless’ and strong self-critical process
Very interested in TA- had read several books and active in use of TA-based self-help strategies

19. Tom Moderate depression and mild functional impairment
Clinically significant change on all measures by session 8
Maintained at 3 month, some decline at 6 month follow up
Identified eight ‘extremely important’ changes, unlikely without therapy

20. Tom: Judges Verdicts
Majority verdict that this was a good outcome case (two clearly good outcome, one mixed outcome)
Majority verdict that Tom had changed substantially and that these changes had substantially been due to therapy

21. Tom: Mediator Factors
An empathic, non-judgmental, highly active therapist approach had been important
Use of two-chair methods was pivotal in this case and helped Tom overcome his self-critical process, express emotions and see things from a different perspective
Practical strategies for improving communication were helpful
Use of TA concepts helped Tom to conceptualise his process

22. Tom: ModeratorFactors
Tom’s pre-therapy reading had been helpful and enabled him to make the most of the therapy
Tom’s motivation and readiness to change had been helpful factors
Tom’s determination and willingness to engage with painful emotions and experiences and actively make use of the therapy were also helpful

23. Conclusions I
TA effective in three positive outcome cases for treatment of depression, including severe depression
Empathic, highly active intervention approach of therapists which accounted for clients’ ‘life script’
Use of TA theory as an explanatory and supportive framework for conceptualisation and change

24. Conclusions II
Matching between clients preferences and therapist approach was helpful
Client well-motivated and willing to engage in the process, including pushing through initial discomfort

25. Conclusions III
Subsequent replication of positive outcome in the UK (Widdowson 2014)
Mixed/ poor outcome cases also reported (such as Widdowson, 2013)
Study being replicated in Italy, with and additional 6 positive outcome cases currently accepted for publication

26. Conclusions IV
Using criteria defined by Chambless and Hollon (1998) TA therapy is Possibly Efficacious for the treatment of depression
TA now meets basic criteria for consideration for ‘Empirically Supported Therapy’ status

27.
Original articles of all cases can be found in the International Journal of Transactional Analysis Research. See to read or download the articles for free.