Brian, aged 30, was referred by his Consultant Psychiatrist for a general assessment of his personality and symptoms. The referral stated that he had been diagnosed as suffering from paranoid schizophrenia and was being treated with anti-psychotic medication. He was said to be very suspicious and to express thoughts of violence and revenge against people he thought were against him. He had spent much of the past six years as an inpatient with compulsory admissions after many years of heavy drinking, and had attended court on two occasions for being involved in fights and carrying a knife. He was first admitted, compulsorily, to psychiatric hospital after attacking two strangers, who he claimed had been following him in a car. He had not been offered any psychological therapy apart from ward groups. He was very opposed to these and never spoke in them.
He was seen by HP for an initial assessment. From this I recommended psychotherapy and we went on to work together for the next 18 months. All this happened many years ago whilst I was still in training as a clinical psychologist, and before many of the developments described in this book, but it was an important formative experience for me. The case illustrates many of the values and approaches to psychotherapy as originally advocated by George Kelly, which we shall describe and develop in the coming chapters.
Brian was shy and at first quite formal, avoiding eye-contact, but he soon began to talk freely about his experiences and ideas and we got on well throughout the time that I was working with him. I think he accepted me because I focussed with genuine interest on the way he saw things and avoided any talk deriving from medical discourse. Indeed, in the spirit of the personal construct approach, I never thought of his experiences in terms of âillnessâ, âsymptomsâ or âschizophreniaâ1 throughout the months that we worked together, but rather regarded him as a fellow human being struggling with the difficulties of life.
His fatherâs family were middle class, having owned a cider-making company, but this had been subject to a hostile takeover with the factory being asset-stripped. The money the family gained from the sale all went to his fatherâs sisters as his father himself had been seen as a âdropoutâ. There seems therefore to have been a significant downward step in social mobility for Brianâs parents. Brian was the fourth of five siblings and he had lost his younger brother in a road accident five years previously. Brian was married with two children of 12 and 10, and lived in a small terraced house in a run-down area of town. I wonder now whether the familyâs loss of status and standard of living had contributed to his general sense of resentment of and antipathy towards other people.
Brian was clearly bright and articulate and had enjoyed school from an academic point of view, but he was bullied a lot and he saw everyone as false and hypocritical. He chose not to join the âgrammar streamâ2 because he hated the people in it so much. Although he was strong at maths, science and English, he left hoping for a better social life but was bitterly disappointed in this. He worked as a steel erector, and as a taxi and lorry driver but became very frightened when he began to think people were against him. He avoided claiming any benefits because he was frightened of the other claimants there. He was therefore financially dependent on his wife. He felt bad about not being able to support his family. His wife was getting very fed up with him, threatening to leave him. He said he would kill her if she left him and she believed him. He was very jealous, even of his wifeâs previous boyfriends. If anyone in his family had any trouble with anyone, he would threaten to go and beat them up.
Brianâs Construing and Relationships
A central idea in Kellyâs approach is the personal construct system (PCS). It refers to the way an individualâs unique construing of the world and their ways of approaching things shape experiences. The PCS governs our anticipations and how we act, how we make choices and judgements. Therapeutic change and progress involve revising and altering it, developing new ways of seeing things. Kelly advocated many ways of finding how people construe the world. This word âconstrueâ is a deliberately broad term designed to cover how we see things, feel about them, how we act and relate to people (see Fig. 2.â2 and Chapters 2 and 3). The main way of establishing a personâs construing is by listening carefully to them. In addition to talking with Brian, I gave him Kellyâs role construct repertory test. This âRep Testâ is an early form of the repertory grid (see Chapter 6 for this and other assessment methods). The names of important people in his life were written on cards. He was invited to spread these out on the table and to talk about how the people were alike or different and to tell stories of his encounters with them. I also used two other tools that, although not devised by him, Kelly advocated: the Thematic Apperception Test (TAT),3 a series of evocative pictures about which the person is invited to tell a story, and the Rotter Incomplete Sentences Blank, in which one has to complete sentences from a series of words or phrases. Later, I got Brian to write a self-characterisation sketch (see Chapter 6). Brian also shared poems and a journal that he kept. They all proved to elicit a rich picture of how Brian construed his life, himself, and others.
Brian felt resentment of and hostility towards other people, as we have noted, seeing them as false and hypocritical. He felt frightened of others and felt they were against him. Other words he used commonly were that people are insincere and that they ridicule him. When he was quite young, he saw a Santa Claus beard fall off, which proved to him the falseness of people. In his self-characterisation, written in the third person, from the point of view of a âsympathetic friendâ, as Kelly recommended, Brian wrote:
As a child he suffered a great deal from other children. He often found himself the centre of ridicule and was bullied to quite a degree. He used to give the bullies his toys and money in the hope that they would leave him alone. They didnât. In the end he stayed away from school and ever since if anything threatens him, he stays away. He does not take these episodes at school lightly; he burns with a sullen anger and indulges in daydreams of revenge.
A word he used a lot to describe his feelings was âembarrassmentâ. He was embarrassed by sports, dancing, and woodwork. From an early age he felt different to other people. From a PCP point of view, all these descriptions, or âconstructsâ, clustered together in a âtightâ constellation (see Chapter 3) which distinguished âMeâ from âThemâ. He even saw his wife as âone of themâ. At one stage, early on, we went for a walk together whilst he described how suspicious he felt about people in the streets, particularly men. The fear that he felt led him to be very vigilant and on the lookout. He felt that he was stared at a lot by people with their âimposing eyesâ. Sometimes he would even feel that people on television were referring to him. One card in the TAT is completely blank. He said, âcan see the sea, waves coming in, just medium sized waves and on each wave is a faceâ. His response to othersâ threatening attention was to turn away or to put his head down whilst still looking straight ahead with his eyes. Of course, this furtive behaviour would be likely to attract attention and make him appear different, their reactions validating his construing that people were noticing and staring at him. This kind of interactional loop can be usefully drawn up in a diagram known as the âbow-tieâ (see Chapter 4). His approach to people could also be seen as involving hostility as defined by Kellyâextorting evidence to prove oneâs construction (see Chapter 3).
Perhaps as a response to all these threats, Brian had retreated into a world in which he was obsessively fascinated by death, corpses, cemeteries, and the lurid writings of Edgar Allen Poe. His self-characterisation again:
Death is his favourite subject, the idea he is most obsessed with. No other person I know has dwelt so constantly on it, and delved into it so deeplyâŠthese feelings make him want to be on his own and he finds it impossible to lead an ordinary existence.
He wrote a poem including the lines, âMy coffin â oh polished wooden wombâŠand six feet south isnât far to roam, for where I lie â I lie alone. In this place I canât love the less, so lovely is the loneliness!â Kelly (1955, p. 15) wrote optimistically, âno one need paint himself into a corner; no one needs to be completely hemmed in by circumstances, no one needs to be the victim of his biographyâ. However, unfortunately for Brian, he had apparently painted himself into a corner and was living an increasingly alienated life in the âcareerâ of a psychiatric patient.
One of the things Kelly insisted was that constructs are âbipolarâ, they always have two ends or âpolesâ, providing a person with avenues of movement and choices between alternatives (Chapter 3). It is notable that all the words and descriptions Brian usesâfalse, insincere, against me, frighteningâcluster at one end of a construct dimension. We never hear of what lies at the other endâcould that be âsincere, trustworthy, genuine, kindâ? We donât know, and we should never assume that we know, what peopleâs contrast poles are. Fransella pointed out (Chapters 3 and 7) that if we have an elaborate set of ideas at one end of a dimension and almost none at the other end (e.g., being âfluentâ for the stutterer), we find it hard not to slip back into the familiar end where we have learnt to deal with things in spite of them being problematic. Brian instead saw himself in his self-characterisation as having two âselvesâ, âone the quiet family man interested in films and books, the other frightened, being obsessed with death, fear and predestined and inescapable doomâ. These two aspects of himself were apparently dissociated from each otherâtwo fragmented construct subsystems in PCP language (see Chapter 3). He seemed to be caught in an âimplicative dilemmaâ (see Chapter 6), preferring solitude and resenting ...