A woman in her mid-forties was avoiding leaving home because of intense fears. The therapist guided her to notice and describe what frightens her when she leaves home. It emerged that she was terrified of what she took to be signs of insanity: when away from home she would "know" that her former therapist (a woman who had gone to live far away) is close by, watching her. She becomes aware that she is imagining this woman's presence and yet regarding it as real, and then the idea that this is a psychotic delusion triggers intense anxiety. She stays home to keep this deeply disturbing experience from happening. 

In standard diagnostic terms this woman would be labelled not only agoraphobic, but also obsessional and delusional, with symbiotic separation anxiety and paranoia. However, a diagnostic label does not describe the phenomenology of the problem; it reveals nothing of the unconscious constructions that generate the symptoms.

The therapist, after showing understanding of how disturbing the problem was for her, immediately began working to discover the emotional truth of her delusion -- the compelling themes and purposes that made producing this delusion somehow necessary, even though this results in so much suffering.

The therapist asked her to imagine being in a typical situation of walking down a street alone, as if it were happening right now, and to see what happens if she doesn't start to think or feel that this woman is present. This is the symptom deprivation technique of having the client sample what develops if the symptom doesn't occur in the situation where normally it does occur. This is one way of rapidly bringing out the symptom's unconscious basis. The point of the exercise is not to get the client to desist forevermore from producing the symptom, but only long enough to find out what makes the symptom actually necessary to have.

She readily experienced what happens if she does not imagine that her former therapist is nearby: She started to feel a deep, old feeling of great loneliness, a very painful and frightening feeling of being left all alone. The therapist now understood the emotional truth of the delusion: it avoids this unbearable aloneness. The next step is for the client to experience and recognize this herself. To this end, the therapist said, "So if you don't imagine she's there, then you feel this painful feeling of being left all alone." This adds no new information; it simply focuses the client's attention on what she loses by being without the symptom, and as a result she said, "Oh; oh -- and I don't feel all alone if she's there too -- if I think she's there with me." 

In that moment it became clear to the her that she purposefully imagines her therapist is nearby, watching her, in order to avoid an old emotional wound of feeling alone and abandoned. She experienced this as her own emotional truth, not as an interpretation coming from the therapist. This realization by the client of her own symptom-generating position is a key milestone in the unfolding of DOBT.

The therapist responded, "Yes, and you've kept imagining her for this important purpose, even though you think that's insanity and even though that scares you so much. What do you make of that?" She thought momentarily and answered, "I guess it's more important to me to not feel that feeling of being so alone." The benefit of implementing the delusion to avoid feeling alone and abandoned far outweighed the accompanying cost in anxiety over seeing herself as insane. 

Between-session tasks of integration are an essential part of DOBT. In this case, the therapist wanted to come up with a task that would keep her fully aware, right in the problem situation, of her purpose for implementing the delusion. With such awareness, she would be in a position to grapple consciously with the real problem -- her old feeling of abandonment -- rather than automatically resort to her old solution, the delusion. 

The therapist said, "What's wrong with thinking about your therapist, to remind yourself that you have an important connection with her? But whenever you really do want to be free of the feeling that she's present, all you have to do is, ask yourself, really ask yourself, 'Am I willing to feel alone right now?'"

The question assigned here as a between-session task has the client focus on and consciously experience the emotional truth of the symptom at exactly those moments when previously she would unconsciously resort to the symptom. Conjuring up her therapist will no longer mean she is insane. It now simply means she feels painfully alone and wants relief from this feeling. The main trigger of her anxiety, the idea that this is psychotic, is gone.

Note that the assigned question, like all steps in DOBT, is not a message to the client to stop producing the symptom. It is a way to position her consciously in the emotional truth of the situation, making a new response possible.

One week later, in the next session, she said that as a result of asking herself the question, she immediately got control over imagining the presence of her therapist, and the anxiety about going out diminished rapidly. 

One might think that for this woman to face rather than suppress her feeling of aloneness would only exacerbate her anxiety, but it did not. She said that using the assigned question provoked a new awareness that she was going through life in the role of being an abandoned child. She said that even though she was 46, she didn't feel herself to be a grown-up, and that, although it took some courage, choosing to feel alone on the street began to open up a sense of being an actual grown-up who is no longer hoping for some parent to enfold her. So this work also forwarded the individuation issues in this woman's life, and she was now positioning herself less in the emotional reality of her child state, with its feeling of abandonment and helplessness, and more in an adult identity. 

In the next session, the third session, she reported that the anxiety, a problem that had troubled her for years, was completely gone. She said she was no longer imagining her old therapist at all. Ten months later she came in to deal with some other issue, and when asked if the previous work had held, she said it had. 

Although this was a problem with rather complex roots, the actual breakthrough took about 30 minutes. The breakthrough had great simplicity, and yet the rapidity and depth of the change did not involve any "tricks," strategic or otherwise. The client's emotional truth was brought to light using experiential methods, not through interpretation.

It turned out that the work with this woman did not need to go very far into her original wound of abandonment. With some clients the work does go more fully into major, unresolved emotional wounds carried since childhood (the topic of Chapter 2 in the book). In depth-oriented brief therapy the aim is to go only as deeply into unconscious constructs as is necessary for resolving the presenting problem, and no further, unless the client has motivation to do so and defines the further depth as a new focus for therapy.

Copyright © 2001 Bruce Ecker and Laurel Hulley