case study transactional analysis

Transactional analysis in organisations: A case study with a focus on internal communication

• Social Work and Arts

Research output : Thesis › Doctoral Thesis

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• Organizations Social Sciences 100%
• Analysis Social Sciences 100%
• Communication Social Sciences 100%
• Case Study Social Sciences 100%
• Internal Communication Computer Science 100%
• Organizational Aspect Computer Science 71%
• Humans Psychology 55%
• Organizational Structure Computer Science 42%

T1 - Transactional analysis in organisations

T2 - A case study with a focus on internal communication

AU - Wuersch, Lucia

N2 - Internal communication, embracing both technical and human organisational aspects, is an important function for organisational success. Transactional Analysis (TA) is an analytical framework for individual and social psychiatry used in an organisational context (TA-O) for personal and group development. This study explored TA's impacts on internal communication in a single case study of a Swiss public organisation with the mission to help jobseekers reintegrate into the workforce through counselling. Preliminary fieldwork uncovered the long-term adoption of TA principles in the organisation’s strategic policy, internal training, and workplace practices. The study was designed as three complementary ethnographic fieldwork projects.The first project focused on strategists' and TA experts’ understanding of TA’s contributions to the organisation’s strategic aims. Interviews with executives and TA experts revealed six 'strategic contributions' of TA. Thus, the strategic organisational contributions of TA as a relational approach for strengthening internal communication in the case study organisation are both human (i.e., people’s skills and attitudes, relationships, leadership, communication, collaboration and interaction) and technical (i.e., efficient and effective organisational structures); elements which lead to the implicit strategic aim of organisational sustainability. This combination helps the organisation because it stimulates employee motivation, wellbeing, and performance.The second project investigated leaders' and employees’ perceptions of the influence of TA in their work experiences. The interviews elicited participants’ stories. As a result, eight 'work experiences' emerged emphasising the dimension of self. In the case study organisation TA helped staff’s ability to engage in self-reflection constructively, more effectively manage their emotions, and be more collaborative and tolerant. TA supported staff to experience greater job satisfaction, build meaningful internal relationships, create a more positive working climate and team spirit, and resulted in a common culture in which TA’s humanistic values based on I’m OK/You’re OK are embedded.The third project explored TA’s contribution to the understanding of self and internal communication. Reflexive writing using analytic autoethnography allowed the researcher, as a full participant in the organisation’s TA training programs, to explore the cultural understanding of applying TA principles in the specific organisational setting. This experience ultimately transformed the researcher’s capability of ‘trusting self and others’. Thus, the thesis explains TA as a relational tool that may foster internal communication through strengthening trust in self, between staff and within the organisation.In conclusion, the three projects brought to light the human organisational aspects (e.g., skills and attitudes) and technical organisational aspects (e.g., structures) as areas of ‘win-win’ that showed TA to be beneficial. Examples demonstrated an interplay between both aspects: TA trained people engaged in improving organisational structures (technical organisational aspects); and complementarily, enhanced organisational structures supported TA training and the development of employees’ skills and attitudes (human organisational aspects). The essence of TA that improves organisational communication was shown to be the basic TA principle of I’m OK/You’re OK—that is, skills and desire to accept the other as a human being. Furthermore, TA was found to impact on all internal communication levels: participants experienced self-development at the intrapersonal level, which strengthened collaboration at the interpersonal and group level, and fostered a common understanding at the organisational level.

AB - Internal communication, embracing both technical and human organisational aspects, is an important function for organisational success. Transactional Analysis (TA) is an analytical framework for individual and social psychiatry used in an organisational context (TA-O) for personal and group development. This study explored TA's impacts on internal communication in a single case study of a Swiss public organisation with the mission to help jobseekers reintegrate into the workforce through counselling. Preliminary fieldwork uncovered the long-term adoption of TA principles in the organisation’s strategic policy, internal training, and workplace practices. The study was designed as three complementary ethnographic fieldwork projects.The first project focused on strategists' and TA experts’ understanding of TA’s contributions to the organisation’s strategic aims. Interviews with executives and TA experts revealed six 'strategic contributions' of TA. Thus, the strategic organisational contributions of TA as a relational approach for strengthening internal communication in the case study organisation are both human (i.e., people’s skills and attitudes, relationships, leadership, communication, collaboration and interaction) and technical (i.e., efficient and effective organisational structures); elements which lead to the implicit strategic aim of organisational sustainability. This combination helps the organisation because it stimulates employee motivation, wellbeing, and performance.The second project investigated leaders' and employees’ perceptions of the influence of TA in their work experiences. The interviews elicited participants’ stories. As a result, eight 'work experiences' emerged emphasising the dimension of self. In the case study organisation TA helped staff’s ability to engage in self-reflection constructively, more effectively manage their emotions, and be more collaborative and tolerant. TA supported staff to experience greater job satisfaction, build meaningful internal relationships, create a more positive working climate and team spirit, and resulted in a common culture in which TA’s humanistic values based on I’m OK/You’re OK are embedded.The third project explored TA’s contribution to the understanding of self and internal communication. Reflexive writing using analytic autoethnography allowed the researcher, as a full participant in the organisation’s TA training programs, to explore the cultural understanding of applying TA principles in the specific organisational setting. This experience ultimately transformed the researcher’s capability of ‘trusting self and others’. Thus, the thesis explains TA as a relational tool that may foster internal communication through strengthening trust in self, between staff and within the organisation.In conclusion, the three projects brought to light the human organisational aspects (e.g., skills and attitudes) and technical organisational aspects (e.g., structures) as areas of ‘win-win’ that showed TA to be beneficial. Examples demonstrated an interplay between both aspects: TA trained people engaged in improving organisational structures (technical organisational aspects); and complementarily, enhanced organisational structures supported TA training and the development of employees’ skills and attitudes (human organisational aspects). The essence of TA that improves organisational communication was shown to be the basic TA principle of I’m OK/You’re OK—that is, skills and desire to accept the other as a human being. Furthermore, TA was found to impact on all internal communication levels: participants experienced self-development at the intrapersonal level, which strengthened collaboration at the interpersonal and group level, and fostered a common understanding at the organisational level.

KW - Internal communication

KW - Transactional Analysis

KW - Autoethnography

M3 - Doctoral Thesis

PB - Charles Sturt University

CY - Australia

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Transactional analysis (ta): overview, examples, and effectiveness, thc editorial team february 27, 2022.

In this article

What Is Transactional Analysis?

The history of transactional analysis, transactional analysis and ego states, how does transactional analysis therapy work, when is transactional analysis commonly used, the potential benefits and effectiveness of transactional analysis, summary/key takeaways.

Transactional analysis (TA) is a theory informing a type of  psychotherapy  that psychologists use to facilitate growth and prosocial change in clients. TA can help people develop better  self-awareness , communication skills, and improve how they relate to others. Practitioners use ideas from several modalities, including psychodynamic, behavioral, and  Gestalt theories . 1

Transactional analysis is a psychological theory that focuses on how people interact with others, including the therapist, to demonstrate their ego states and the types of games and scripts they engage in within social settings. 2 Games  are patterns of social behavior that operate on an acknowledged social level and an unacknowledged psychological level and leave the participants of the interaction with inauthentic feelings.   Scripts  represent life patterns that people develop unconsciously based on decisions they made in early childhood. 1

Ego states  are systems of feelings that motivate sets of behavioral patterns. TA classifies interpersonal communication as falling into one of three ego states. 1  The system of  here-and-now  emotional analysis, or neopsyche, is termed the  Adult ; the system of introjected psychic material, or exteropsyche, is called the  Parent ; and the system of instinctual drives and basic needs is the  Child . 3

The therapist identifies which of the client’s ego states is present in a particular transaction.   The therapist will examine a transaction, identify the ego states present, pinpoint the games or patterns the client typically uses in their transactions with others, and perform a script analysis with the client of their unconscious patterns to discover the causes of the client’s emotional challenges. 2

Key assumptions that underlie TA include the following: 3

• People are Okay.
• Everyone has the capacity to think on their own.
• People decide their own destiny and these decisions can be changed.

Transactional analysis was developed by Eric Berne, a Canadian psychiatrist and psychoanalyst, during the 1960s. Berne referred to the basic unit of social interaction as a transaction. TA refers to the study of how individuals interact in social situations. Berne was influenced by empiricism, phenomenology, existentialism , and humanism. 3

Berne drew from Freud’s theory that the human psyche includes several components that interact to produce complex behaviors, beliefs, and  emotions . He used his background as a psychoanalyst to build upon Freud’s philosophical concepts and developed the observable ego states of Child, Parent, and Adult, drawing from Freud’s concepts of the id, ego, and superego. 1, 4  Although Berne’s ego states do not directly correspond to Freud’s concepts, Berne believed that people assume these roles in certain contexts. 2

Berne also noted that human communication is complex and emphasized that nonverbal communication—gestures, vocal tone, eye contact, speech rhythms, body posture, and facial expressions—is as important and valid a method of communication as verbal communication. 1  He believed that dysfunctional behavior occurs because of decisions people make during childhood that limit their social functioning in adulthood. These childhood decisions lead unconsciously to the creation of the life script, which governs how people subsequently live their lives. 1

A  transactional stimulus  refers to an interaction that a person initiates, usually verbally but sometimes using nonverbal cues. The other person’s reaction and reply is called a  transactional response . 1 Berne worked to identify the ego state from which clients interact with others to help them access their life scripts, understand how they developed their worldview, and make changes as needed. 5

The core principle of TA is splitting the ego into three separate states. The three ego states correspond to people’s internal Parent, Child, and Adult models.

Parent Ego State

The Parent ego state is related to parental figures in a person’s life. It deals with behaviors, thoughts, and feeling patterns of introjected parental figures, people for whom a person has unconsciously created an internal representation. Introjection is caused by early childhood experiences in which the child sees the parent as powerful or threatening. Rather than being an experience of the self, like the Child and Adult ego states, the Parent ego state relates to the past experiences of parental figures. The Parent usually follows one of two paradigms when it manifests in transactions: it can be the Critical Parent, controlling, demanding, setting limits, and creating rules, or it can be the Nurturing Parent, supportive, caring, and protective. 1

Child Ego State

The Child ego state relates to experiences of the self from the past and retains the patterns of thinking, feeling, and behaving of childhood. This concept is represented in other psychological concepts as the “ inner child .” There are several different child ego states: 1

• Adapted Child : This Child ego state responds to Parent demands either compliantly or rebelliously, rather than to its own needs.
• Free or Natural Child : Unlike the adapted child, this ego state responds to its own needs and is spontaneous.
• Rebellious Child : This category of the adapted Child rebels against the Parent’s demands.
• Compliant Child : This category of the adapted Child reacts positively to the Parent’s demands.
• Somatic Child or early Child ego state : This ego state reflects a time in childhood when body issues were prominent. When disturbed, it can cause somatic disorders.

Adult Ego State

The Adult ego state is the predominant state that deals with and responds to the here-and-now, current reality. The Adult can be assertive, rational, and practical, and is rarely aggressive. It engages in reality testing, or ensuring that the world is the way it thinks it is.   An analysis that reveals a steady speech rate, good diction, and relaxed expression can indicate the presence of the Adult. 1

Transactional analysis therapy helps clients strengthen and integrate their Adult ego states. The therapist first uses an intake interview to evaluate the client’s issues and willingness to change and grow through therapy. In TA therapy, the therapist must determine whether the client has enough available Adult ego state for change to occur. 1  TA also emphasizes the establishment of a therapist-client contract that details a client’s goals for treatment outcomes and provides a foundation from which the client can take responsibility for things that occur during treatment. 6 ,7

Berne highlighted observation as an important and necessary tool of TA therapy. He said that therapists should be present, focused, and intuitive. He believed that observation should involve that which the therapist can see and engage all the senses. 6

Four Stages of Transactional Analysis

Transactional analysis psychotherapy usually moves through four stages: 1

• The client is able to recognize and take control of their scripts and script behaviors, but the scripts still exist. They are able to manage and control their dysfunctional behaviors in social situations. The client achieves  social control,  the state in which the client’s control comes from the position of the Adult ego state.
• In the  symptomatic relief stage , the client begins altering their Child and Parent and is less likely to devolve into their scripts.
• The client and therapist engage in the  transference cure , where the client introjects the therapist as a replacement for their original parental figures.
• Finally, in the  script cure , the client can move away from the script entirely and make fundamental changes in the Child, with the support of the Adult.

TA aims to create an integrated Adult ego state. This includes integrating the valuable parts of the Parent and Child ego states with the Adult ego states. The ethos of the integrated Adult draws values and patterns from the Parent, and the pathos includes the Child’s experience. 1

TA therapy also seeks to foster autonomy in the client. It defines autonomy as  awareness , the knowledge that there are regressive parts, introjected parts, and here-and-now parts;  spontaneity , the freedom to express their awareness; and  intimacy , the capacity to be aware and spontaneous in the presence of others. 3

Transactional Analysis Techniques

Transactional analysis therapists use multiple techniques in their practices. During one of the most common TA techniques, script analysis, the therapist first identifies the ego states of their client in communication transactions and works with them to uncover their unconscious life scripts. The therapist explores the scripts their client developed in early childhood and helps them test the beliefs, attitudes, and emotions their scripts reinforce. 1

While analyzing the client’s script, the therapist explores the subtle messages that the client learned as a child, called injunctions. For example, if a child was given a negative attribution or told by their parent that they were stupid, they might have developed a “don’t think” injunction and learned that they should accept what others say rather than think for themselves. 1, 8 Once the subtle messages are identified, the therapist can work with the client to understand how they impact their interactions with others. Structural diagrams are commonly used as visual aids to help clients understand their three internal ego states and how they affect their social interactions and behavior. 1

Other techniques frequently employed in TA therapy include: 1

• Alliance : The therapist or a figure from the client’s past sides with the Child when confronting a persecuting Parent.
• Anger work : The therapist encourages the client to release their repressed anger.
• Cushion work : The client externalizes an introject or ego state onto a cushion so their internal processes can exist in the outer world.
• Guided fantasy : The client and therapist contact the client’s Child to elicit imagery depicting issues that the client is unable to talk about.
• Rechilding : The client regresses in age to form a new Child ego state with a positive experience.
• Sculpting : The client externalizes their unconscious thoughts and feelings onto a pattern in their environment representing their internal state, which allows the client and therapist to deal with the feelings symbolically.

Transactional analysis may be used in multiple settings, including schools or corporations,  group  or individual counseling sessions, and long- or short-term counseling. 6  In therapy, it is typically used with clients who struggle with forming and maintaining healthy relationships because of behaviors they learned as children. TA is also used to facilitate improved social communication and interactions within groups.

Transactional analysis is used in many different fields, in addition to psychotherapy, including business management, education, and medicine. It is considered a highly effective method to enhance self-awareness and the ability to relate to others.

Many studies have been conducted on the effectiveness of TA in treating people with different issues and ailments. For example, a 2021 study sought to determine the effect of TA on incarcerated people’s communication with their spouses. Researchers from Alzahra University in Tehran, Iran, recruited 22 couples, half of whom received 10 sessions of TA treatment. The researchers found that TA improved the communication between the participants and their partners and reduced their communication issues. 9

A 2011 study researching the effects of a transactional analysis-based leadership training program on thirty Romanian automotive managers and leaders found that managers who attended the training program exhibited statistically significant improvements in emotional stability and social boldness, but not warmth. 10

A 2020 study examined whether TA was an effective intervention for people in treatment for methadone addiction. The researchers from Isfahan University of Medical Sciences in Iran, selected 24 men from an outpatient addiction clinic and gave half of them 10 sessions of TA intervention. After collecting data from the Young Schema Questionnaire; the Inventory of Personal Problems; and the Stages of Change, Readiness, and Treatment Eagerness Scales, the researchers found that TA treatment positively influenced interpersonal problems and readiness for addiction treatment. 11

Several other studies have demonstrated the effectiveness of TA in improving the symptoms of  anxiety  and  depression , reducing relationship issues, and increasing self-esteem. 12, 13 , 14

Transactional analysis is a widely-embraced and frequently used type of psychotherapy. It is a valuable resource for people who want to explore their ego states and unconscious life scripts to improve their communication skills and relationships. People willing to develop greater self-awareness and take responsibility for their decisions and actions may be suited to this therapeutic method.

• Tilney, T. (1998). Dictionary of transactional analysis. Whurr Publishers.
• Berne, E. (1996). Principles of transactional analysis. Indian Journal of Psychiatry, 38(3), 154–159.
• Hobbes, R., & Tudor, K. (2007). Transactional analysis. In W. Dryden (Ed.), Dryden’s handbook of individual therapy (5th ed., pp. 256–286). Sage.
• Segrist, D. J. (2009). What’s going on in your professor’s head? Demonstrating the id, ego, and superego. Teaching of Psychology, 36(1), 51–54. https://doi.org/10.1080/00986280802529285
• Stewart, T. T. (2011). Transactional analysis: Conceptualizing a framework for illuminating human experience. International Journal of Qualitative Methods, 10(3), 282–295. https://doi.org/10.1177/160940691101000307
• Grant, J. (2013). Short-term counseling and transactional analysis. Transactional Analysis Journal, 43(1), 58–67. https://doi.org/10.1177/0362153713486110
• Stewart, I. (2013). Transactional analysis counselling in action. Sage.
• Holtby, M. E. (1973). You become what I take you to be: R. D. Liang’s work on attributions as injunctions. Transactional Analysis Journal, 3(4), 25–28. https://doi.org/10.1177/036215377300300409
• Pourshahriari, M., Hashemi, S., Zarebi, A., Jafari, F., & Sharifi, G. (2021). The effectiveness of transactional analysis (TA) on couples communication patterns among prisoners and their wives, a randomized pilot efficacy trial. International Journal of Systemic Therapy, 1–14.
• Ciucur, D., & Pîrvuţ, A. F. (2012). The effects of a transactional analysis training programme on team leadership factors in automotive industry. Procedia-Social and Behavioral Sciences, 33, 667-671.
• Khalili, E., Kheirabadi, G., & Khodadadi, F. (2021). Effectiveness of transactional analysis intervention on treatment acceptance, primary maladaptive schema, and interpersonal problems in patients under methadone maintenance treatment. Journal of Substance Use, 27(1), 86–90. https://doi.org/10.1080/14659891.2021.1897697
• Widdowson, M. (2014). Transactional analysis for a case of mixed anxiety and depression: A pragmatic adjudicated case study – “Alastair.” International Journal of Transactional Analysis Research, 5(2), 66–76. https://doi.org/10.29044/v5i2p66
• Alkasir, M., Atadokht, A., Dehkordi, F. J., Mohammadkhani, P., & Sefat, E. S. (2017). Effectiveness of transactional analysis group training in reducing control-oriented behaviors of spouse in marital conflicts. Rehabilitation Journal, 15(1), 57–64. http://dx.doi.org/10.18869/nrip.irj.15.1.57
• Akbari, A., Azimi, Z., Khanjani, Z., Mahmoud Alilou, M., & Pour Sharifi, H. (2012). The effectiveness of transactional analysis therapy on personality states, self-esteem and clinical symptoms of people with emotional breakdown. Journal of Psychological Models and Methods, 2(8), 1–20. https://www.sid.ir/en/journal/ViewPaper.aspx?id=365273

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• Research article
• Open access
• Published: 13 January 2020

The effect of transactional analysis on the self-esteem of imprisoned women: a clinical trial

• Mahya Torkaman 1 ,
• Jamileh Farokhzadian 2 ,
• Sakineh Miri   ORCID: orcid.org/0000-0003-0785-3666 3 &
• Batool Pouraboli 4  

BMC Psychology volume  8 , Article number:  3 ( 2020 ) Cite this article

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A Correction to this article was published on 06 February 2020

This article has been updated

The imprisoned women usually have low self-esteem and suffer from various physical and mental complaints; they may suffer from feelings of emptiness, isolation, and depression. Transactional analysis (TA) is part of a comprehensive system attributed to the individual and social psychiatry for personal development of self-esteem among the imprisoned women. Therefore, the present study aimed to investigate the effect of TA group-training on the self-esteem of imprisoned women.

This clinical trial was conducted among the imprisoned women in a prison in Southeastern Iran using pretest-posttest design. In this regard, 76 women were randomly allocated to the intervention ( n  = 35) and control ( n  = 41) groups. The TA group-training program was held for eight 90-min sessions for the intervention group. Data were collected using a demographic questionnaire and the Rosenberg’s self-esteem scale (RSES). Later, all participants were evaluated before and 1 month after the intervention.

In pre-test, the mean scores of self-esteem were 11.8 ± 4.67 and 7.97 ± 4.52 for the intervention and control groups, respectively. These scores showed low levels of self-esteem and the difference between the two groups was significant ( p  = 0.001, t  = − 3.61). In the post-test, the mean scores of self-esteem improved to the moderate level (22 ± 2.52) in the intervention group compared to the control group (8.92 ± 4.04). This indicates the significant improvement of self-esteem in the intervention group ( p  = 0.001, t  = 17.15).

Conclusions

The results showed that TA group-training had a significant effect on self-esteem. Therefore, the experienced and expert counselors and psychologists are recommended to hold transactional analysis group-training courses to enhance self-esteem among women prisoners.

Trial registration

Iranian Registry of Clinical Trials, IRCT20170725035289N5 Date registered: 25/08/2018.

Peer Review reports

Considering the rapid increase in the number of women prisoners, many studies have been conducted to understand their unique needs. The results of these studies showed that the pathway to prison differs between men and women [ 1 ].However, the low number of imprisoned women has led the authorities to neglect the problems and difficulties of these women; so, imprisoned women were put on the second rank of importance [ 2 ]. Women are often integral to families and the community health depends on them to a large degree, but many of them are faced with numerous unsolved problems and conflicts. Consequently, women’s misbehaviors and faults can threaten the stability and firmness of families [ 1 ]. Therefore, the self-confidence and mental aspect of the criminals, especially imprisoned women should be improved, so that they can restart a new and happy life after their imprisonment [ 3 ].

Self-esteem is a psychological concept that refers to an individual’s self-evaluation and indicates the extent to which people evaluate themselves as capable and worthy [ 4 , 5 ]. In other words, self-esteem is defined as individuals’ subjective emotional response towards themselves [ 6 ]. Psychologists usually define self-esteem as an enduring personality characteristic with possibly normal short-term variations. Self-esteem is a concept of personality [ 7 ]. In order to develop self-esteem, a sense of self-worth is required, which is achieved by embracing challenges that result in success [ 8 ].

High or low self-esteem causes numerous positive and negative effects on humans. Individuals with high self-esteem are always dutiful and responsible; such characteristics are created as the consequence of awareness about one’s actions and behaviors [ 9 ]. On the other hand, individuals with low self-esteem ignore their goals much more easily and move through the direction determined by others [ 7 ]. Self-esteem is an important factor for the individual’s progress and success throughout life. Individuals with positive evaluation of their characteristics have different great goals. They are also empowered with more enthusiasm and eagerness to face new successes [ 10 ]. Therefore, individuals’ “self-interpretation and ego state” can be considered as an effective factor in their self-esteem. In this regard, TA is introduced as a useful therapeutic approach for individuals with low self-esteem [ 11 ].

Eric Berne, the founder of TA, indicated that individuals manifest certain sets of thoughts, feelings, and behaviors at different situations [ 12 ]. Berne called these three sets as “Ego States” of Child, Adult, and Parent. Due to the fact that each state of Ego is considered as one of the sub-constructs of ego, each state would be adjusted and adapted if used in an appropriate situation [ 13 ]. Each Ego-state is characterized by a particular set of beliefs, emotions, and behavior responsible for social interactions [ 11 ]. The Ego-Child state is characterized by impulsivity, emotionality, expressivity, irrational behavior, and a self-centered attitude. The Ego-Parent state is characterized by a set of values, norms, orders, prohibitions, and obligations [ 14 ]. The Ego-Adult state is characterized by mostly logical constructive conditioning. This state is responsible for the reality analysis, estimation of the possible solutions, rational decision makings, and assertive relationship of the individual with others [ 15 ]. The literature showed that TA group-training method was an effective method in helping people to communicate and interact with other individuals [ 16 ]. In general, TA has been used to increase self-esteem [ 11 ], help anxious and abused women [ 17 ], and treat personality disorders [ 14 ]. Furthermore, it has been widely applied in clinical and therapeutic affairs [ 15 ], developmental psychology [ 18 ], and management communication of personality, behaviors, and relationships [ 15 , 16 , 19 ]. Although TA is one of the most effective psychological theories, it has not been considered much by the researchers [ 18 ]. Techniques of TA were designed to promote the independence and self-direction using one’s knowledge, self-motivation, and resources as an adult to solve problems [ 16 , 20 ]. The effectiveness of TA training on self-esteem was confirmed in some studies [ 15 ]. In Yugoslavia, a study over the alcohol and non-alcohol addicts indicated that the TA group-training had a positive effect on the psycho-emotional state of the alcohol addicts [ 14 ]. A research in Iran showed that addicted women had a low level of self-esteem, which hindered them from changes and reforms in life. The findings of the mentioned study recommended TA to improve self-esteem of the addicted imprisoned women [ 6 ]. Another study in Iran was carried out by Forghani et al. They reported that TA had a significant impact on the addicts and prevented addiction recurrence by enhancing the participants’ coping skills and mental functions [ 21 ].

The studies mentioned above were conducted to investigate the effect of TA on the self-esteem or other psychological characteristics of individuals. Women, as the main members of the society and family, have been neglected most of the time. To the best of our knowledge, the effect of TA group-training on the self-esteem of Iranian imprisoned women has not been investigated. Therefore, the present study was conducted to deal with the issue.

Study design & setting

This pretest-posttest randomized clinical trial was conducted in the Southeast of Iran. In the prisons of Iran, monitored by the prison-related organizations of each province, different specialists work, such as psychologists and psychiatrists to help the prisoners. Sports classes are also held by the authorities. According to the rules, imprisoned women can meet their families on certain days of week and in some crimes, they can have some leaves per in the month.

The target population of this study included al the imprisoned women at the time of data collection ( N  = 120). The study participants were 84 imprisoned women selected according to the inclusion criteria. The participants were randomly allocated to the intervention and control groups (42 participants in each group). The inclusion criteria of this study recruited the prisoners who were in prison for at least 6 months, whose jail sentences were up to the end of study, and who had at least elementary education. The exclusion criteria consisted of failure to complete the questionnaires due to any reasons and failure to attend the training sessions for more than one session. In total, 35 questionnaires in the intervention and 41 questionnaires in the control groups were collected and analyzed.

Instrument and data collection

Data were collected using two questionnaires. The first one was a demographic questionnaire and the second one was the 10-item Rosenberg Self-Esteem Scale (RSES) developed in 1965. This scale evaluates the individual’s overall self-image. Each item in RSES is scored based on a four-point Likert scale including ‘totally agree’ (3 scores), ‘agree’ (2 scores), ‘disagree’ (1 score), and ‘totally disagree’ (0 score). The negative items (items from 6 to 10) were scored inversely. In RSES, higher scores indicate higher self-esteem levels and the attainable scores range from zero to 30. Additionally, low, moderate, and high levels of self-esteem are indicated by scores lower than 15, 15–25, and higher than 25, respectively. The Cronbach’s alpha for the original scale was measured as 74% [ 22 , 23 ] (Additional file 1 ). In a study by Rajabi et al., the internal consistency coefficient of the Persian version of the scale was calculated as 84% for the entire sample of students, 87% for the male students, and 80% for the female students. The correlation coefficients between the score of each item and the total score varied from 56 to 72%, which were significant at P  < 0.001. The construct validity of the scale was measured using factor analysis. Moreover, a negative and significant relationship was observed between this scale and the Death Obsession Scale (DOS) with a coefficient of − 0.34 for the entire sample, − 0.44 for the male students, and − 0.27 for the female students. This suggests the good validity of the Rosenberg’s Self-Esteem Scale [ 24 ].

Intervention procedure

Initially, the experimental group was divided into three sub-groups (14 participants in each). Then, sub-each group attended the TA training program in eight 90-min sessions weekly. The TA trainings were presented by the first researcher, a psychologist, a nursing PhD, and a psychiatric nurse using educational slides, lectures, group discussions, as well as questions and answers. The control group received no training during the study period. Table  1 represents the topics presented during the training sessions [ 25 ].

Statistical analysis

Data were analyzed using SPSS (version 20) and by running descriptive (percentage, mean, and standard deviation) and analytical statistics (chi-squared test, independent samples t -test, and paired-samples t -test and ANCOVA). According to the results of Kolmogorov-Smirnov test, data enjoyed a normal distribution. The level of significance was set at P  ≤ 0.05.

Demographic information

The results showed that the majority of participants were housewives in the age range of 21–40 years and experienced their first prison sentence. Most participants had elementary education, were married, and were prisoned for 3 years. According to the chi-squared test, no significant difference was observed between the intervention and control groups in terms of the demographic information (Table  2 ).

Self esteem

In the pre-test stage, the mean score of self-esteem in the intervention group (11.8 ± 4.67) was higher than that of the control group (7.97 ± 4.52) and the difference between the two groups was significant ( p  = 0.001, t  = −3.61). However, the results showed that the level of self-esteem was low for both groups. In the post-test stage, the mean score of self-esteem in the intervention group (22 ± 2.52) was significantly higher than that of the control group (8.92 ± 4.04) ( p  = 0.001, t =  17.15). In other words, the intervention group members were at the low level of self-esteem prior to the intervention, but after attending the educational classes, their self-esteem increased into the moderate level, which indicates the significant effect of the intervention (Table  3 ).

The covariance analysis test to control the impact of pretest on the self-esteem of women prisoners are presented in Table 4 . These results confirmed the results in Table 3 .

The purpose of this study was to investigate the effect of TA group-training on the self-esteem of imprisoned women. The results showed that the majority of female prisoners were at low levels of self-esteem before implementing the group-training program, which is consistent with the findings of many studies.

For example, a study among the addicted female prisoners in South of Iran represented that most prisoners had low self-esteem [ 6 ]. Arefi reported that female prisoners, especially those with commission crimes, had low self-esteem [ 26 ].The similarity of these results with those of the present study can be due to the same research population and data collection tools.

Furthermore, a reason for the low level of self-esteem among the imprisoned women can be attributed to the prison conditions and environment. In addition, the prisoners’ isolation and being away from their families, fear of rejection in society, and lack of social protection during and after their sentence are among some other effective factors. Alavi showed that Iranian female prisoners had a moderate level of self-esteem. Alavi also introduced low self-esteem as a predictive factor of drug abuse, robbery, and prostitution [ 27 ]. Moreover, Kamoyo reported that self-esteem was at a moderate level among the Kenyan female prisoners [ 28 ]. The discrepancy between results of the above-mentioned studies and the present study can be probably due to the different cultures of various societies in accepting women, especially female prisoners as well as the different data collection tools.

Results of our study indicated that TA group-training significantly improved the self-esteem of intervention group from the “low” level to the “moderate” Level. Unfortunately, no published study has ever examined the effect of TA group-training as a strategy to improve self-esteem and psychological well-being of the imprisoned women with mental health issues.

Other studies reported TA as an effective reconsideration method in life, which helps the individuals to feel valuable and solve their problems successfully [ 16 , 17 , 29 ]. Another study on the impact of TA group-training indicated improvement of the self-confidence and the ability to endure failures [ 18 ] among members of the intervention group. In several studies, participants reported more success in family life and social relationships [ 19 ], reduced mental and psychological stresses [ 30 ], increased self-esteem, better control of personal conflicts, and more decisiveness in achieving the goals and ideals [ 31 ].The results of a study by Riaz et al. showed that cognitive behavioral therapy (CBT) group programs increased the prisoners’ self-acceptance and self-admission and reduced their risky behaviors [ 32 ].Furthermore, Khodayarifard et al. conducted the individual and group (combined) cognitive–behavioral interventions and showed improvement in the psychological well-being of the prisoners. Finally, they concluded that these strategies increased the female prisoners’ self-efficacy and self-esteem [ 3 ].Perhaps, the similarity between the results of these studies can be due to similar intervention methodology and participation in the group discussion. In group therapy sessions, participants are exposed to other participants’ experiences and contributions. Therefore, they start to analyze and scrutinize their own problems. In addition, the inmates can benefit from other individuals’ opinions and discuss about their problems.

We also found that the imprisoned women in Iran were highly aware of their own low self-esteem and had a tendency to express it through avoidance behaviors. These participants used more emotion-focused than problem-focused coping strategies to overcome their low self-esteem (e.g., active coping, planning, and instrumental support).

Considering that female prisoners in Iran suffer from low self-esteem, which leads into their avoidance behaviors, special group programs, such as TA trainings should be conducted for them by specialties. Consequently, the female prisoners can adapt themselves to the conditions in the community and return to their families by self-acceptance and self-admission.

Our study had a number of limitations. First, the imprisoned women had short-term leaves, family visits, communication with counselors, clinical psychologists, and social workers in prison. These factors could affect the results, but were out-of-control. Second, we could not find a precise instrument to assess the self-esteem of the imprisoned women, therefore, RSES was used. Third, the researchers had access to the prisoners for only 3 months and could conduct only one follow-up 1 month after theintervention. One month is a very short period to assess the impact of TA on a complex behavior such as self-estem. Fourth, the therapist was not permitted to conduct the therapeutic sessions in a separate room. The only available space was a room next to the jailer’s office. Furthermore, some security staff attended the ongoing sessions. These factors disturbed the privacy of the intervention group. Fifth, the results might have changed in the case that the control group received some kinds of training, such as strengthening the back muscles or excersizing. Sixth, since the differnce between the two groups was significant at the pre-test with regard to the self-esteem scores, future researchers are recommneded to select participants based on their pre-test mean scores of self-esteem, instead of a random allocation to the intervention and control groups. In this way, both groups would have women with comparable mean scores.

Therefore, further research are suggested using a valid and reliable tool to assess the self-esteem of the imprisoned women. Moreover, longitudinal studies should be conducted bycontroling the confounding variables.

Results of the present study showed that TA had a significantly positive effect on the imprisoned women in the intervention group. Therefore, prison managers are recommended to conduct TA group-trainings with the help of psychologists and psychiatric nurses to strengthen self-esteem of the imprisoned women.

Rehabilitative programmers are also suggested to employ the self-esteem strategy in prisons to improve the prisoners’ self-esteem. Furthermore, the prison environment should be modified to allow for more frequent presence of social support groups. In this regard, we recommend other researchers to carry out quantitative and qualitative studies on the effective strategies to overcome the barriers against self-esteem among female prisoners. Future studies can also examine the effect of TA group-training on other psychological aspects of the imprisoned women in various cultures and contexts.

Availability of data and materials

The datasets generated and analysed in the present study, are available upon request to the corresponding author after signing appropriate documents in line with ethical application and the decision of the Ethics Committee.

Change history

06 february 2020.

Following publication of the original article [1], the authors advised that the name of the 4 th author had been submitted incorrectly; the author has the family name ‘Pouraboli’, however, their article was originally published with the family name (mis) spelled as ‘Pouraboili’.

Abbreviations

Rosenberg’s self-esteem scale

• Transactional analysis

Fajarwatia A, Tyas Wulan Meia E, Hasanatia S, Saria IM. The productive and reproductive activities of women as form of adaptation and post-disaster livelihood strategies in Huntap Kuwang and Huntap Plosokerep. Soc Behav Sci. 2016;227:370–7.

Article   Google Scholar  

Heras Santos JL. Women’s reformatories and prisons in the early modern age: morality, welfare and repression of women in the 17th and 18th century. Soc Behav Sci. 2014;161:176–83.

Khodayarifard M, Shokoohi-Yekta M, Hamot G. Effects of Individual and Group Cognitive-Behavioral Therapy for Male Prisoners in Iran, vol. 54; 2009.

Google Scholar  

Ticusan M. Low self-esteem, premise of depression appearance at adolescents. Soc Behav Sci. 2012;69:1590–3.

Phillips D, Hagan T, Bodfield E, Woodthorpe K, Grimsley M. Exploring the impact of group work and mentoring for multiple heritage children’s self-esteem, well-being and behaviour. Health Soc Care Community. 2008;16(3):310–21.

Article   PubMed   Google Scholar  

Torkaman M, Miri S, Farokhzadian J. Relationship between adaptation and self-esteem in addicted female prisoners in the south east of Iran. Int J Adolesc Med and Health. 2018. https://doi.org/10.1515/ijamh-2017-0168 . [Epub ahead of print]. Retrieved January 7, 2020, from https://www.ncbi.nlm.nih.gov .

Liu JY, Yang JP, Yang Y, Liu YH. The relationships among perceived organizational support, intention to remain, career success and self-esteem in Chinese male nurses. Int J Nursing Sci. 2015;2:389–93.

Ghasimbaklo U, Mohammadyari G, Mahmodzadeh M, Mohammadzadeghan R, Mokhtari M. The relationship of social support and self-esteem with recidivism among prisoners. J Res Health. 2014;4:818–26.

Maltesea A, Alesia M, Giuseppa A. Self-esteem, defensive strategies and social intelligence in the adolescence. Soc Behav Sci. 2012;69:2054–60.

Liu H, Zhang X, Chang R, Wang W. A research regarding the relationship among intensive care nurses’ self-esteem, jobsatisfaction and subjective well-being. Int J Nursing Sci. 2017;4(3):291–5.

Bąk-Sosnowska M, Naworska B, Owczarek A, et al. Coping with overweight strategies, self-esteem and body-esteem in the context of transactional analysis. Psychiatr Pol. 2014;48(3):477–87.

PubMed   Google Scholar  

Ciucur D. The Ego states and the “big five” personality factors. Soc Behav Sci. 2012;78:581–5.

Nayeria A, Lotfib M, Noorani M. The effectiveness of group training of transactional analysis on intimacy in couples. Soc Behav Sci. 2014;152:1167–70.

Hadži-Pešica M, Mitrovica M, Brajovic Carb K, Stojanovic D. Personality of alcohol addict according to the theory of transactional analysis. Soc Behav Sci. 2014;127:230–4.

Yonder Ertem M, Kececi A. Ego states of nurses working in psychiatric clinics according to transactional analysis theory. Pak J Med Sci. 2016;32(2):485–90.

Temple S. Celebrating functional fluency and its contribution to transactional analysis theory. Trans Anal J. 2015;45(1):10–22.

Widdowson M. Transactional analysis psychotherapy for a case of mixed anxiety & depression: a pragmatic adjudicated case study – ‘Alastair. Int J Transact Anal Res. 2014;5(2):66–76.

Ciucur D. A transactional analysis group psychotherapy Programme for improving the qualities and abilities of future psychologists. Soc Behav Sci. 2013;78:576–80.

Kovacevic I, Panic B, Vujosevic M, Kuzmanovic M. Application of transactional analysis in bullwhip effect analysis. Amfiteatru Econ. 2013;33:210–23.

Beekum SV. A new formulation of transactional analysis theory in the field of organizations. Sage J. 2015;45(3):167–78.

Forghani M, Abadi BAGH. The Effect of Group Therapy With Transactional Analysis Approach on Emotional Intelligence, Executive Functions and Drug Dependency. Iran J Psychiatry Behav Sci. 2016;10(2):e2423.

Ramiro MT, Teva I, Bermúdez MP, Buela-Casal G. Social support, self-esteem and depression: relationship with risk for sexually transmitted infections/HIV transmission. Int J Clin Health Psychol. 2013;13(3):181–8.

Rosenberg M. Society and the adolescent self-image. New Jersey: Princeton University Press; 2015. Retrieved January 7, 2020, from https://press.princeton.edu .

Rajabi G, Bohlol N. Assess the reliability and validity of self-esteem in students' Vznbrg in the first year should be Chamran University. Psychol Educ Res. 2008;3(2):33–48 [in persian].

Kafi M, Melazadeh Esfandiani R, Noori Khajavi M, Salehi I. Effectiveness of group therapy by cross-sectional analysis method on marital adjustment and prevention of recurrence of detoxified persons. New Psychol Res. 2011;6(23):111–32 (Psychology, University of Tabriz) [in persian].

Arefi M. The comparison of psychological factors (locus of control, self-esteem, and personality disorders) between normal and prisoner women with emphasis on prostitute women. J Psychol Stud. 2010;6(4):125–46.

Alavi HR. The role of self-esteem in tendency towards drugs, theft and prostitution. Addict Health. 2011;3(3–4):119–24.

PubMed Central   PubMed   Google Scholar  

Kamoyo J. Effects of Imprisonment on Self-Esteem Among Female Inmates in Selected Prisons in Kenya. Eur Sci J. 2018;14(17):165.

Ciucur D, Pîrvuţ AF. The effects of a transactional analysis training programme on team leadership factors in automotive industry. Procedia Soc Behav Sci. 2012;33:667–71.

Widdowson M. TA treatment of depression - a hermeneutic single-case efficacy design study - ‘Denise’. Int J Transact Anal Res. 2012;3(2):3–14.

Neac u V. The Efficiency of a Cognitive-Behavioral Program in Diminishing the Intensity of Reactions to Stressful Events and Increasing Self-Esteem and Self-Efficiency in the Adult Population. Soc Behav Sci. 2013;78:380–4.

Riaz R, Agha S. Efficacy of cognitive behavior therapy with deliberate self-harm in incarcerated women. Pak J Psychol Res. 2011;27(1):21–35.

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Acknowledgments

The authors appreciate the prison officials and all women who participated in this study. We also appreciate Mrs. Chakameh Navard and Mr. Fathi, the clinical psychologists, who cooperated with us during this study.

This research received no specific grant from any funding agencies in the public, commercial, or not-for-profit sectors.

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Department of Psychiatric Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Haft-Bagh Highway, PO Box: 7716913555, Kerman, Iran

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Contributions

MT, SM, JF, and BP contributed in the research design. The data were collected, analyzed, and interpreted by MT and JF. MT organized the group training. MT, SM, JF, and BP contributed equally in composing and approving the final manuscript. All authors read and approve the final version of this manuscript.

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Correspondence to Sakineh Miri .

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The present research was conducted after obtaining the ethical code (IR.KMU.REC.1395.1670) from the Ethics Committee of Kerman University of Medical Sciences and the clinical trial code (IRCT20170725035289N5) from Iranian Registry of Clinical Trials (IRCT). In order to conduct the study, the first researcher presented an introduction letter to make the necessary coordination with the prison authorities. Later, written consent forms were obtained from the authorities. Prior to data collection, the included participants were provided with a cover letter explaining the purpose of the study and the procedure of data collection. Then, written consent forms were obtained from the participants and they were ensured about confidentiality and anonymity of the data. They were also explained about voluntary participation in the study.

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Rosenberg Self-Esteem Scale

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Torkaman, M., Farokhzadian, J., Miri, S. et al. The effect of transactional analysis on the self-esteem of imprisoned women: a clinical trial. BMC Psychol 8 , 3 (2020). https://doi.org/10.1186/s40359-019-0369-x

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Case Report: Individualization of Intensive Transactional Analysis Psychotherapy on the Basis of Ego Strength

Irene messina.

1 Universitas Mercatorum, Rome, Italy

2 Centro Psicologia Dinamica, Padua, Italy

Francesco Scottà

Arianna marchi.

3 Department of Philosophy, Sociology, Education and Applied Psychology, University of Padua, Padua, Italy

Enrico Benelli

Alessandro grecucci.

4 Department of Psychology and Cognitive Sciences, University of Trento, Rovereto, Italy

Marco Sambin

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

In intensive transactional analysis psychotherapy (ITAP), intensity is obtained with both technical expedients and the relational manner with the patient. In ITAP, the therapist modulates pressure and support commensurately to the patients' ego strength. In the present article, we contrast two clinical cases of young adults in which ego strength produced different therapy outcomes and processes. We present excerpts of the psychotherapy process that illustrates technical aspects of ITAP as well as the therapist's attitude that we describe as holding. We show quantitative therapy outcomes consisting of effects size values of changes in Clinical Outcome in Routine Evaluation—Outcome Measure scores in baseline, treatment, and follow-up phases and qualitative outcome evaluated with the Change Interview at the end of the therapy. In the patient with high ego strength, we observed a rapid improvement and a complete recovery at the end of the therapy, whereas the results of the patient with low ego strength were less consistent (more fluctuations in Clinical Outcome in Routine Evaluation—Outcome Measure scores including deterioration but good qualitative outcome). We conclude that quantitative and qualitative outcome data, together with process observations, are required to have a complete picture of therapy effectiveness. Moreover, we conclude that qualitative ego strength is not a limitation for the use of expressive therapy such as ITAP, but rather, it is an important variable that should be considered to dose confrontations and support.

Introduction

Intending to increase intensity in therapeutic intervention, intensive transactional analysis psychotherapy (ITAP) is short-term psychodynamic psychotherapy that integrates transactional analysis (Berne, 1961 ; Schiff, 1975 ; Goulding and Goulding, 1979 ) with brief psychodynamic psychotherapy approaches (Malan, 1976 ; Davanloo, 1994 ; Fosha, 2000 ; Abbass, 2015 ). In ITAP, intensity is considered to be related to the therapist's activity, which is enhanced with both technical expedients and the relational manner with the patient.

At the technical level, the intrapsychic triangle and the interpersonal triangle are used by ITAP therapists for the optimization of interventions in a psychotherapy session. The intrapsychic triangle guides the therapist in analyzing intrapsychic dynamics among impulse, anxiety, and defense (Menninger, 1958 ; Malan, 1976 ; Davanloo, 1994 ). According to the psychoanalytic tradition, an impulse is a manifestation of the Id (Freud, 1923 ). In the ITAP model, it is broadly defined as any spontaneous manifestations of the functioning of the person, including a person's emotions, needs, creativity, and aspirations. Anxiety is a negative emotional activation that emerges in the presence of an obstacle to the satisfaction of impulses. Thus, anxiety is a signal of internal danger for the person (Freud, 1923 ). Educational and social restrictions are examples of obstacles to the satisfaction of impulses. Against impulse and related anxiety, the person may unconsciously use defenses (Frederickson et al., 2018 ; Grecucci et al., 2020a , b ). Several defense mechanisms have been described in psychoanalysis, from forms of avoidance of disturbing thoughts or memories (e.g., denial or suppression) to severe distortions of reality (e.g., projections or delusions) (Vaillant, 1992 ). In ITAP, the therapist aims for impulse emersion. In pursuing this aim, he/she notes every anxiety manifestation as a signal of a covered impulse, and he/she confronts the patient with defenses that blocks the emersion of the impulse.

The intrapsychic triangle is used jointly with the interpersonal triangle, which guides the therapist in analyzing repetitive relational patterns in the person, exploring such patterns across different relational situations (Menninger, 1958 ). Here-and-now relational difficulties reported by the patients ( current relationship ) are explored, comparing them with relational experiences with the therapist in psychotherapy sessions ( therapeutic relationship ) and with past relationships in which repetitive relational patterns may have been formed as an effect of traumatic experiences. Thus, in the ITAP model, psychic functioning is described as interconnections of impulse, anxiety, and defenses, which have originated in past relationships and which can be enacted in here-and-now relationships (current relationships and/or therapeutic relationship) (Sambin, 2018a ).

At the relational level, the therapist modulates the technique based on the level of the patient's anxiety manifestations, holding the patient during the exploration of intrapsychic and interpersonal triangles. The concept of holding refers to a relational attitude characterized by the full presence of the therapist in the relationship, with a moment-by-moment evaluation of the resources made available by the patient throughout the session (Scottà, 2018 ). On the basis of available resources, the therapist modulates pressure —a very active attitude, which intensifies psychotherapy sessions by moving the attention of the patient through the various vertexes of the ITAP triangles—and support (Sambin, 2018b ). In other words, the therapist applies pressure and support commensurately according to the ego strength, a psychodynamic concept referring to a set of capacities including individual resilience, identity integration, personal resources, ability to maintain satisfactory interpersonal relationships, and self-esteem (Freud, 1923 ; Lake, 1985 ). Thus, ego strength may strongly influence the actual duration and intensity of ITAP, as well as the evolution of the psychotherapy process toward the psychotherapy outcome.

Psychotherapists have long realized that treatment should be tailored to the individuality of the patient. As part of the what works for whom approach (Roth and Fonagy, 2006 ; Norcross and Wampold, 2011 ), the identification of effective methods of adapting treatment to the individual patient (other than diagnosis) has become an object of investigation in psychotherapy research. Among individual factors, ego strength has been reported previously as being predictive of psychotherapy outcome (Barron, 1953 ; Conte et al., 1991 ; Laaksonen et al., 2013 ; but see also: Getter and Sundland, 1962 ). Also, variables attributable to ego strength, such as personality impairments in the patient (Hersoug et al., 2013 ), self-concept, and quality of object relations (Lindfors et al., 2014 ), have been associated with worse outcomes. With the present article, we contribute to this line of research by contrasting two clinical cases in which ego strength—the main element of calibration of intensity in ITAP—produced different therapy processes and outcomes. We consider that single-case methodology can be particularly suitable for the investigation of individual factors (Messina et al., 2018 , 2019 ). It allows longitudinal evaluations with a large number of observations to look in detail at how change unfolds over time during the therapy of each specific patient. Also, a single-case methodology is compatible with the use of qualitative measures that may be helpful in clarifying the influence of individual and contextual factors. In addition to quantitative and qualitative outcome measures, we also present excerpts of the psychotherapy process that illustrates (a) the impact of the use of ITAP triangles on impulse emersion and (b) therapist's attitude that we describe as holding.

Instruments

Assessment of ego strength.

Patients' ego strength was evaluated by the research team using the structure axis of the Operationalized Psychodynamic Diagnosis system (OPD-2; OPD Task Force, 2008 ). According to the Structure axis of the OPD-2 system, the psychic structure of the patient (or his/her ego strength) can be classified as well-integrated, moderately integrated, low integrated, or disintegrated, on the basis of the following markers: (a) Cognitive abilities (self-perception and perception of the object); (b) Regulation (self-regulation and regulation of the object relation); (c) Emotional communication (internal communication and communication with the outside world); (d) Attachment (internal objects and external objects).

Quantitative Assessment of Psychotherapy Outcome

Psychotherapy outcome was evaluated quantitatively through the Clinical Outcome in Routine Evaluation—Outcome Measure (CORE-OM). The CORE-OM is a widely used scale for the routine evaluation of psychotherapy outcomes (Barkham et al., 2001 ; Evans et al., 2002 ). It is composed of 34 items that are scored on a 0–4 scale (from 0 = “ Not at all ” to 4 = “ All or most of the time ”). CORE-OM global scores allowed the classification of the patients on the basis of their distress level: healthy (score <0.6), low-level (score between 0.6 and 1.0), mild (score between 1.0 and 1.5), moderate (score between 1.5 and 2.0), moderately severe (score between 2.0 and 2.5), or severe (score >2.5). Moreover, four subscales allowed the evaluation of four outcome variables: well-being, psychological problems (depression, anxiety, somatic problems, and trauma), functioning (general functioning and functioning in close relationships and social relationships), and risk (risk to self and others). The Italian version of the CORE-OM shows good acceptability, internal consistency, and convergent validity (Palmieri et al., 2009 ).

Qualitative Assessment of Psychotherapy Outcome

Psychotherapy outcome was evaluated qualitatively through The Change Interview, a semi-structured interview that provides qualitative descriptions from patients of perceived change reported at the end of the therapy (Elliott et al., 2001 ). Patients are asked to identify the most relevant changes they made during the therapy and to evaluate them on a five-point scale: (a) if he/she expected the change (from 1 = expected change to 5 = surprising change ); (b) how likely these changes would have been without therapy (from 1 = unlikely to 5 = likely without therapy), and (c) how important he/she feels these changes to be (from 1 = slightly important to 5 = extremely important ).

Participants

Two young adult patients differing in ego strength as evaluated with the OPD-2 were selected from a larger clinical study testing ITAP efficacy. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis was provided for each patient, and they were asked about the goals of their therapy before starting the treatment. For both patients, this was the first experience of psychotherapy, and they were not treated pharmacologically.

Maria was a patient with a well-integrated structure according to the OPD-2 diagnosis. She was a 25-year-old female student. In her therapy, she focused mainly on her relational difficulties. She reported having difficulties in regulating her emotions with others. On the one hand, she suffered because sometimes she was aggressive with others, and then, she felt guilty as a consequence of this aggressiveness. On the other hand, she perceived not being free to express herself with her family, and she wanted to feel free to make her own decisions. She also suffered from anxiety and loss of concentration. In addition to these emotional difficulties, she wanted to cope with the loss of her dog (which was living with her ex-partner). With regard to the diagnosis, she saturated the DSM-5 criteria for dysthymic disorder and generalized anxiety disorder (American Psychiatric Association, 2013 ). Maria's CORE-OM scores at baseline were in the clinical range, except for the functioning score that was in the normal range (see Table 1 for scores). The total CORE-OM score was situated in the mild range of distress.

CORE-OM scores at baseline and treatment + follow-up.

Interpretation of Effect Size (ES) value: >0.02 = small effect; >0.50 = medium effect (*); >0.80 large effect (**); >1.30 very large effect (***) .

Fabio was a patient with a low-integrated psychic structure, according to the OPD-2. He was a 24-year-old student. In his therapy, Fabio's main goal was to cope with severe anxious symptomatology that included social anxiety, claustrophobia, and panic attacks characterized by tunnel vision and temporary loss of reality perception. He reported having very low functioning in social relationships, with feelings of discomfort and freezing in social situations, conditions that fomented strong internal judgment and feelings of guilt that were the object of disturbing and continuous rumination. In the face of these difficulties, he wanted to become more spontaneous in social interactions. Fabio saturated the DSM-5 criteria for panic disorder in axis I and schizoid personality disorder in axis II. Although Fabio reported severe symptomatology and the therapists evaluated his personality as being low structured, Fabio's total scores compared with Italian normative data were within the nonclinical range at the beginning of the therapy (see Table 1 ).

The same 32-year-old male therapist treated the patients. He is one of the founders of the ITAP approach, an expert in transactional analysis and brief dynamic therapy. He had a formal 4-year clinical training as a psychotherapist and had 3 years of experience in doing psychotherapy after training. The therapist discussed each clinical case in regular group supervision with the research team.

Research Team

In addition to the therapist, the research team was composed of three experienced researchers with both scientific (doctor of philosophy) and clinical training as psychotherapists and three advanced students. Two of the experienced researchers also had specific training as psychotherapy supervisors. The students participated in research team/clinical supervision groups, and they were also involved in data collection and analyses.

Recruitment and Ethical Issues

Patients were recruited from a waiting list of students who had psychological or relational difficulties and were voluntarily referred to therapy as part of a larger clinical study. The patients were voluntary students attending the same university as the research team, but they had no direct connection with the research team. The Ethical Committee of the University of Padua approved the research protocol. Before entering treatment, all patients received detailed descriptions of the research protocol, and they were informed that they were free to leave the research protocol at any moment without consequences for the continuation of their therapy. In the informed consent, a specific section for the use of video-recorded sessions was included, and it was specified that patients would not be identifiable on the basis of the material presented in scientific publications.

Data Collection

For the evaluation of psychotherapy outcome time series, longitudinal data were collected in three different phases: (a) Baseline included 5 weekly evaluations in 5 consecutive weeks before the beginning of the therapy (with the last evaluation immediately before the first session); (b) treatment included weekly evaluations realized immediately before each session (with the first evaluation immediately before the second session); (c) follow-up included evaluations realized at 1, 3, and 6 months after the end of the therapy. For each assessment, patients filled out the CORE-OM in the clinical psychology laboratory and in the presence of an external research assistant. During the first follow-up, a researcher carried out the Change Interview to collect qualitative data concerning patients' subjective perception of changes. Patients were informed that the therapist had no access to any research data provided.

The treatment followed the procedures described in the ITAP manual (Sambin and Scottà, 2018 ). Sixteen sessions of ITAP therapy were planned as part of the research protocol. Maria had the planned number of sessions, whereas four additional sessions were provided to Fabio due to the clinical evolution throughout his therapy (see Results). The sessions were 50 min, with weekly frequency, with a total time of 4 months of treatment for Maria and 5 months for Fabio. The therapy was provided free of charge, and the patients were informed that they could withdraw from the study at any point, without any negative impact on their therapy.

Process Data

Impulse emersion.

Here, we present two excerpts of the therapy of Maria and Fabio to illustrate how ITAP works. Each excerpt is introduced by a brief description of the context of what was occurring in the session and is followed by a brief conceptualization of the event in line with the ITAP model. The excerpts are verbatim transcripts with ellipses to show where words were deleted to shorten the presentation, and minimal encouragers (e.g., “Mm-hmm”) were dropped unless they had specific communication value. In brackets, we reported the position in the intrapsychic triangle (A = Anxiety, D = Defenses, or I = Impulse) and interpersonal triangle (P = Past, C = Current, or T = here-and-now in psychotherapy). Regarding the therapist's interventions, the positions to which the therapist moves are preceded by the symbol → (e.g., if the therapist explores or emphasizes an I/C, we use the symbol “ → I/C”). In few cases, interventions escape from triangle classifications. Thus, we provided few additional categories. “Aw” refers to therapists' interventions aimed at stimulating aspects of awareness in the patients (→Aw) and the patient's responses indicating the acquisition of aspects of awareness (Aw); “E” refers to empathic interventions; “Al” refers to therapists' interventions aimed at the alliance. According to the consensual qualitative research method (Hill et al., 2005 ), research team members discussed to reach a consensus for the assignment of a category to each intervention.

Excerpt From Maria

This excerpt is taken from the eighth session. In this excerpt, the patient talks about an episode in her current life (C): she recently encountered a dog similar to the one she had to leave with her ex-boyfriend and became sad. The therapist aims to bring out the impulses activated in this episode by comparing the patient's defensive modes (D) in the here-and-now of therapy (T) to the emotions related to the loss of the dog (I). The patient is able to achieve a greater awareness regarding her tendency not to face conflict situations by giving in to the will of others (such as leaving her beloved dog to her ex-boyfriend).

• T: What did you feel in that moment? [→ I/C]
• M: I don't know how to express it, I mean it was really a strange thing…a lump in my throat… [A/C]
• T: How was this lump in the throat for you? [→ A/C]
• M: Nice and bad…Nice because it was nice, I mean, ah, it took my back to another world in a moment … And bad because once it's finished you think in any case “Who knows what will happen to my dog…” [D/C]
• T: As if you'd realized that that scene isn't there anymore?… How did you feel in that moment? [→ I/C]
• M: Ah, the darkness takes you [I/C]
• T: You mean, this scene was sad? [→ I/C]
• M: Yes, yes, also. Even now that I'm talking about I feel the darkness returning, yes … [I/T]
• T: Yes, but you're laughing a lot [→ D/T]
• M: Ah I know, well, unfortunately it's a bad habit of mine, laughing [D/T]
• T: No, I have the impression that there's a part of you that's sad, and another part that says “No, no, come on, everything is ok, laugh about it” [→ D/T]. But a part of you is sad [→ I/T]
• M: Ah yes, I can't get rid of it, I mean I can't get rid of a piece of my life, get rid of some memories. No? [Aw/C]
• T: But the memories are sad… [→ I/T]
• M: Ah yes, but, but you've got to deal with them [D/T]
• T: And how do you deal with them? IF you deal with them by laughing and then they come back [→ D/T].
• M: Ah… I don't know another way… I mean the time, I've always said “In time things will pass”, sure enough time has passed a lot, ah, I mean that … [D/T]
• T: Yes of course. I was concerned about the part, actually, that is worried …that then becomes darkness … [→ A/T]
• M: I hope not. I mean, I hope that… this doesn't happen, I hope so. I mean every day of my life … to do things that make me so satisfied that I don't think of anything else, no? [D/T]
• T:… I have the impression that not thinking about it creates a, sort of, barrier for a bit [→ D] , then something bigger comes along … [→ I/T]
• M: Yes, yes, I've thought about this … [Aw/T]
• T: … the barrier collapses and everything that wasn't there before comes along … [→ D/T]
• M: Yes, yes, it's true … [Aw/T]
• T: And I'm worried about this, because the barrier of doing stuff so as not to feel what there is over here [mimes a barrier with the hand], it holds up a little, a little and then by dint of doing this you get all of the manifestations [he points to her arm, on which the patient had a cutaneous eruption], and then, as is natural, it collapses. And when it collapses it's a month and a half, two, of darkness . [→ D/T]
• T: What are you in contact with? [→ I/T]
• M: I don't know what, I don't know what this thing inside of me is, I'm trying to bring out something that's inside me that I don't know . [D/T]
• T: On a cognitive level yes, I have the impression that you don't know. On an emotional level how are you, when you think of these things? Actually, when do you feel this thing?…Let's try to remain there, to listen to what's there, behind that barrier that I was talking about before … [→ I/T]
• M: [Silence] I don't know, because I was different, I was like other people, as if I was talking about other people, a lot of things have changed, so I can no longer reflect myself in what I was. I have really changed personality so I can't remember anything at all . [D/T]
• T: What is it that's coming back then…? [→ I/T]
• M: The sensations come back, of nostalgia. I mean, it's the emotions that come back up, nostalgia, anger, it's not the memory… The emotions, I mean the impotence .[I/T]
• T: What are you feeling now, the impotence? [→ I/T]
• M: Yes . [I/T]
• T: Is that what you couldn't get a handle on? [→ I/C]
• M: Yes, exactly maybe the impotence of not having - I as I do generally - I mean that I let things go rather than assert myself on things, I don't assert myself on things … Because I don't want to get to a discussion… [I/C] Like when S. says to me “Oh, the dog's staying with me, because I can provide it with more things”… [Aw/C]
• T: And you want that dog? [→ I/C]
• M: … Yes, I want it [I/C] , but I can't, I made this choice [D/C]…
• T: Yes, yes… on a cognitive level it seems very clear: “I chose this” .
• M: Ok, on an emotional level. Ah no, because clearly it wasn't good for me .
• T: And that thing there comes and returns, cyclically [→ I/C].
• M: [the patient talks about how recently she is feeling the necessity to assert herself in various contexts] … now I am starting to reason in a much more selfish way [Aw/C]
• T: Ah there you are, if you could think in a selfish way when you're with L? [→ I/C]
• M: Ah I'd like to give him a slap it's different [I/C]… but there as well, what's the point of it…? [D/C]
• T: There's the sense of listening to what you feel. That's it, what you feel. As a fantasy, if you could what would you do to this L? [→ I/C]
• M: Ah, I'd gladly give him a few slaps [I/C]
• …[the patient stimulated by the therapist expresses her anger through the use of fantasies]
• T: You knocked it down, and you knocked it down, and you knocked it down… and now, luckily, it's coming up, it's coming up, it's coming up…
• M: I had enough…That strength I… I've always had it inside .[Aw/P]
• T: Very good, meanwhile let's try to understand what there is underneath it, that reservoir that stayed there and let's start to knock it out, and to process it…Have you seen that we've caught our fish: you are very angry with him still … Can you accept it?
• M: Yes! [Aw/T]

In the therapy extract, we can observe some elements that indicate a good level of ego strength in the case of Maria. First of all, it can be observed that anxiety is present at manageable levels and is mainly discharged at the level of the striated muscles (e.g., a lump in the throat). As typically happens with this type of manifestation of anxiety, the defenses are of an evolved type and concern the recognition of emotional aspects on a cognitive level with an avoidance of the actual emotion (the patient smiles while telling a sad episode so as not to come into contact completely with the sadness) or the repression (“I have really changed personality so I can't remember anything at all.”). Finally, we see that Maria manages to understand the therapist's interventions without getting too anxious and easily acquires aspects of awareness.

Example From Fabio

This excerpt is taken from the third session. The patient starts with an episode from his own past (P) in which he recounts a situation where he had been very frightened, and his fear had not been accepted sufficiently. The patient easily links the terror he felt in P with the terror he currently feels during his anxiety crisis (C). The therapist encourages Fabio to focus on his emotions in recalling that episode in the here-and-now of the session (T), helping the patient to recognize some defensive tendencies and to get in touch with his own impulses of sadness (I).

• F: I was on my way home and there was someone there, I met someone who was like, “Hey there, who are you?” Ah I got scared for a moment no, pretty scared for a child…Then this person I saw - then maybe I imagined - that he was following me from behind, so I had a moment and started running . [I/P]
• T: How scary![→ I/P]
• F: Oh yes quite so… there was nothing there, it was in the middle of nowhere, to get home, that is there are only fields and so I was alone there… And then I was like this [indicates a child's height] , the other guy was like this [indicates an adult's height]… [I/P]
• T: And so you were very scared [→ I/P]
• F: Yes, exactly [I]
• T: And so every time you went that way, you relived that fear? [→ I/P]
• F: Yes pretty much [I]
• T: Have you ever had a chance to talk to anyone about that moment?… was your fear somehow acknowledged? [→ I/P]
• F: Yes, it was acknowledged, but I couldn't find a solution. So… .
• F: My dad told me, he said, “Look, don't worry about it…” I mean, a reassurance that's a little too rational, that's all .
• T: He didn't listen to you. (he hugs his belly)
• F: Exactly .
• T: That kid was still worried [I/T].
• F: Yes, terrified [I/T]
• T: Terrified. By others? [→ I/C]
• F: Well, in this case yes, well now that you mention it this terror maybe with the panic attack comes back a bit when… for example in a deserted street like I told you… [I/C].
• T: Is this memory useful to you? I mean, this connection that you're making? [→ Aw]
• F: … Well, it's useful because I see a similarity between the terror felt in both cases . [I]
• T: The terror of the child being left alone with maybe someone following him in the fields… … [I/P]
• F: Yes. (I/P)
• T: And terror of the adult who, on the other hand, how can I put it, connects, links up… …[→ Aw of the link between I/P and I/C]
• T: with the terror of the child . [Aw of the link between I/P and I/C]
• F: Because it is the same terror in those moments when the panic attack… in fact I feel like a child… I feel in the middle of the fields, lost, small… helpless even . [Aw]
• T: Small, helpless, scared .
• F: Scared .
• T: Where are we now, out of these things? [→ I/T]
• F: in this moment, sadness [I/T]
• T: … as if we had also evoked the sadness of when you were a child… That child was feeling so many things [→ I/T]
• F: Yes, quite… I've always made things complicated . [D/T]
• T: You're judging yourself [→ D/T]
• F: Yeah, my parents told me I was complicating things [D/P]. And now I just remembered that around elementary school - these episodes are all around elementary school - I had to go… [D/T]
• T: Can I stop you for a moment? [→ Al]
• F: Yes . [Al]
• T: I think it's useful to stop, otherwise we'll move on to more cognitive aspects… [→ Al]. Remember that it' s all right, it's all right . [→ E]… But it's like we're jumping a little bit away from these emotions [→ D/T]
• F: Ah ok [Al]
• T: It's not a judgment, no one is to blame, it's okay . [→ E]. But I think it's useful for you to stay on these emotional issues that have emerged very clearly and very strongly [→ Al] , otherwise there's a chance we'll do it the way we did it [moves his hand, as if to move, to pass over] [→ D/T]
• F: Oh, okay, I get it, yeah, you mean, just distance yourself right away… [Aw/T]
• T: Distance yourself immediately. Instead we found out that that child was angry, scared, feeling helpless [→ I/P]… Now you're feeling these emotions here [→ I/T]
• F: Ah [sigh] [A/T]
• T: Ah [sigh] [E/T]
• F: Ah, it's not simple… [A/T]
• T: It's not simple [E/T]. As far as I can stand them, how can I say this, I'm there, I'm with them, it's a way to be with that child too…we here maybe have the chance to be with that child. If
• not, we'll leave him alone one more time . [→ Al].
• F: Ah ah, ok. Yes that's ok . [Al]
• T: Mm? Do you have it, are you seeing it?
• T: And what's it like?
• F: I don't know, I'm picturing him locked in a corner with some bars… crying . [I/T]
• T: Ah, ok. Mm. And as you see him, what can you do? Now, that you're older . [→ I/T]
• … [the therapist explores a possible Impulse]
• F: Well, I'd give him a hand and caress him, let's say… [I/T]
• T: Does he feel it? [→ I/T]
• F: Yes . [I/T]
• T: And how is he? [→ I/T]
• F: Ah, warmer, more relaxed [I/T]
• T: Listen to yourself for a second. Don't use words, there's no need to explain [→ I].
• F: Ok . [Silenzio] [I]
• T: Listen to yourself. How's your breathing, how's your body, how is this sensation of warmth? [→ I]
• F: Calmer, more relaxed. With fewer things running through my mind [I/T]
• T: Calmer, more relaxed. The warmth calms . [→ I/T]
• F: Yes. Ah yes, the thoughts as well . [Connects I and D]
• T: It calms your thoughts as well .
• T: So even the thought of that child with the hand calms you down .
• F: Ah yes. Pretty much, yes. But my ears are ringing [A/T]
• T: Yeah. Okay. All right. It's okay, it's okay. We're working on some important stuff… [E/T]
• F: Ah ok [E]
• T: So there is a realignment of your structure right now [→ Aw]. Do you follow me? [→ Al]
• F: Ah ok. Yes yes yes yes yes. Yes yes yes yes … .[A/T] [the patient motions, indicating that he can hear the ringing in his ears…]
• T: Have your ears started ringing? [→ A/T]
• F: My ears have started ringing [A/T]
• T: Was there also a feeling of movement a little bit inside? I mean 'oops'! [→ A/T]
• F: Yes, exactly yes [Aw].
• T: … You' re becoming aware of yourself in a different way from the way you were before, you're in contact with a part of yourself, emotionally and physically, as you weren't before… [→ Aw].

In this second therapy extract, we can observe certain elements that are indicative of a low level of ego strength in Fabio's case. It can be noted that the anxious manifestations also involve cognitive-perceptive aspects (ringing in the ears), as well as those concerning the striated muscles (being stuck to the chair) (Abbass, 2015 ). To deal with these high levels of anxiety, the therapist uses many interventions of empathic validation and alliance verification, an attitude that highlights the holding attitude. Despite the low level of ego strength, the therapist, through his constant holding, allows Fabio to contact different aspects of impulse and to acquire some elements of awareness.

Outcome Data

Quantitative outcome.

To quantify change, we calculated Hedge's g value for a corrected effect size (ES) of change in CORE-OM scores (global score, well-being, psychological problems, functioning, and risk) from baseline vs . treatment phases, baseline vs . follow-up phases, and treatment vs . follow-up phases (Rosenthal, 1994 ). The calculation of Hedge's g is based on the subtraction of the mean of one group from the other (M1–M2) and the division of the result by pooled the standard deviation. Both comparisons, “baseline vs. treatment” and “baseline vs. follow-up,” provided data concerning pre- vs. post-therapy; however, the former was influenced by fluctuations in the score during the therapy, whereas the latter was not. The additional “treatment vs. follow-up” comparison was useful in evaluating the maintenance of improvements obtained in the treatment phase.

High-Functioning Patient

Maria's CORE-OM scores at baseline were in the clinical range, except for the functioning score that was in the normal range (see Table 1 for scores). The total CORE-OM score was situated in the mild range of distress. As shown in Figure 1 , a rapid improvement was observed in Maria's scores during the early sessions, with scores that decreased from the clinical to the nonclinical range for all CORE-OM subscales and with a global decrease from the mild range to the healthy range of distress. Thus, CORE-OM scores show a complete recovery for Maria.

Fabio's CORE-OM subscales scores in Baseline, (B) Treatment (T) and Follow-up (F) evaluations.

This description was confirmed in statistical analysis. In “baseline vs . treatment” comparisons, we found very large ES in CORE-OM total scores (ES = 3.76), as well as in subscales well-being (ES = 2.44) and psychological problems (ES = 2.99). A large ES was found for the functioning subscale (ES = 1.28), and a medium ES was also observed for the risk subscale (ES = 0.75).

Similarly, in “baseline vs. follow-up” comparisons, very large ESs were observed in CORE-OM total scores (ES = 2.88), in the well-being (ES = 4.03) and psychological problems subscales (ES = 1.01), and a large ES was observed in the functioning subscales (ES = 1.01). Only a small ES was found in the risk subscale (ES = 0.75) for the “baseline vs . follow-up” comparison.

The described improvements were maintained in follow-up evaluations, except for the risk subscale score that increased slightly in the last follow-up (6 months), influencing the global score of distress that moved from the healthy to the low-level range of distress in the follow-up phase (in the nonclinical range nonetheless). In line with this description, non-relevant changes were observed in the “treatment vs. follow-up” comparisons, indicating the maintenance of achieved CORE-OM scores.

Low-Functioning Patient

Although Fabio reported severe symptomatology and the therapists evaluated his personality as being low structured, Fabio's total scores compared with Italian normative data were within the nonclinical range at the beginning of the therapy. As shown in Figure 2 , in this therapy, we can observe a progressive deterioration of the patient's CORE-OM score starting from the 11th session, with scores that increase from the non-clinical to the clinical range for almost all CORE-OM subscales, and with a global increase from the low-level to the mild range of distress. A partial recovery of previous scores was achieved after the 18th session, but it remained in the mild range of distress.

Maria's CORE-OM subscales scores in Baseline, (B) Treatment (T) and Follow-up (F) evaluations.

The peculiar evolution of this case was also reflected in the statistical evaluations (see Table 1 ). In “baseline vs. treatment” comparisons, we found a medium effect size indicating the deterioration of the CORE-OM global score (ES = −0.68) and the psychological problems subscale (ES = −0.58). A large ES of deterioration was observed for the functioning subscale (ES = 1.01), whereas non-relevant changes were observed for the well-being and risk subscales.

In “baseline vs. follow-up” comparisons—which is less influenced by fluctuations in the score during the therapy—a large ES indicating improvement was observed for the well-being subscale (ES = 1.08). However, very large and large deteriorations in ES were observed, respectively, for the functioning (ES = −1.62) and risk subscales (ES = 1.23), whereas non-relevant changes were observed in the psychological problems subscale and in the CORE-OM global score.

The partial recovery achieved after the 18th session was maintained in follow-up evaluations. This recovery can be statistically observed in the “treatment vs . follow-up” comparisons where a medium ES was obtained for the CORE-OM global score (ES = 0.57), the well-being subscale (ES = 0.84), and the psychological problems subscale (ES = 0.54), whereas a medium ES of deterioration was maintained for the risk subscale (ES = −0.54), and non-relevant changes were observed for the functioning subscale.

Qualitative Outcome

Although quantitative data indicated a positive outcome for Maria and a negative outcome for Fabio, the qualitative evaluation of the psychotherapy outcome realized using the Change Interview method accounts for a very positive outcome for both patients. They reported several changes classified as very important and extremely important, and they considered many such changes as being unlikely without the therapy. Interestingly, most of the reported changes are in line with the declared aims of ITAP. They concern interpersonal relationships (analyzed with the interpersonal triangle), emotion regulation (analyzed with the intra-psychic triangle), and the improvement of self-representations achieved through contact with self-relevant impulses. Detailed results of the Change Interview are reported in Tables 2 , ​ ,3 3 .

Summary change interview of Maria.

Summary change interview of Fabio.

In the present study, we contrasted two clinical cases of patients with different levels of ego strength (or different levels of psychic structure integration) treated with ITAP, a new psychotherapy approach that aims toward the intensification of therapist intervention through the integration between transactional analysis and brief psychodynamic approaches. Following the what works for whom approach, our final aim was to reflect on the possibility that intensive interventions may be differently efficacious in helping patients with different levels of psychic structure integration.

If we consider ITAP outcomes evaluated using quantitative measure, CORE-OM data account for clearly different outcomes in the clinical cases analyzed in the present study. Maria—the patient with a well-integrated psychic structure—obtained a complete recovery, with a rapid improvement in early sessions and the maintenance of these results in follow-up evaluations. This pattern of change corresponds to a typical trajectory of change previously described in the literature (Duckworth et al., 2010 ; Vittengl et al., 2016 ). Moreover, these data are consistent with extremely and very important changes associated with the therapy as reported by Maria in qualitative evaluation, as obtained through the Change Interview. Thus, the efficacy of ITAP seems incontrovertible in the case of Maria.

Fabio, the patient with a low-integrated psychic structure, showed more fluctuations in CORE-OM scores during the therapy, and deterioration or non-relevant changes in outcome scores were observed in the “baseline vs . treatment” or “baseline vs . follow-up” comparisons. At first sight, these results support the hypothesis that ITAP may be more effective for patients with high ego strength compared with patients with more impaired psychic structure. This conclusion would be in line with previous studies showing that psychotherapy outcome is influenced by patients' ego strength (Barron, 1953 ; Conte et al., 1991 ; Laaksonen et al., 2013 ). However, an in-depth reflection is required to define a more realistic picture of Fabio's case. First, studies concerning the psychometric characteristics of CORE-OM have largely demonstrated that initial levels of distress are predictive of subsequent improvement after therapy (CORE Partnership, 2007 ). Namely, the chance of improvement is negligible for patients with CORE-OM global scores classified as healthy or low level (they cannot recover because they are already “healthy”), whereas it is more likely for patients in the clinical range. Despite the severe symptomatology reported by Fabio and the personality impairment observed by the therapist, the patient was situated in the non-clinical range in the initial assessment. Thus, statistically relevant changes were not expected for this patient. Second, qualitative data are not consistent with the hypothesis of a negative outcome. Indeed, Fabio reported several moderately to extremely important changes attributed to the therapy in the Change Interview. Furthermore, in the group supervision, the therapist reported important changes that defy standard evaluations. For example, we know that Fabio was overweight and lost weight during his therapy. Thus, an alternative hypothesis is that standard outcome measures are less suitable to capture therapeutic change in patients with psychic structure impairment.

Nevertheless, the deterioration observed in Fabio's CORE-OM scores requires reflection. Apparent deteriorations are expected in the early phases of some psychotherapy approaches. If the cognitive approach uses cognitive strategies to downregulate emotion, psychodynamic approaches—and more in general “expressive therapies”—are focused on affect recognition and expression (Greenberg and Pascual-Leone, 2006 ; Frederickson et al., 2018 ; Grecucci et al., 2018 ; Messina et al., 2020 ). As an example of expressive therapy, in ITAP sessions, the therapist is active in encouraging the patients' expression of their full experience of emotions and the associated impulses physically present in the body. This might be experienced as emotionally challenging by patients. Indeed, in previous studies, an initial trend to deterioration followed by a recovery toward positive outcomes has been noted as an effect of experiential and expressive techniques, such as imagery and chair work (van Asselt et al., 2008 ; Malogiannis et al., 2014 ). We consider that this temporary deterioration can be attributable to the progressive awareness of the patient's emotional difficulties in expressive therapies. For instance, it has been previously reported that some forms of deterioration in self-report questionnaires could reflect a less defensive attitude in the patients throughout therapy sessions (Mohr, 1995 ). In line with this interpretation, Fabio expressed the desire to continue his therapy after the end of this experience, suggesting an improved awareness concerning his psychological difficulties.

Finally, process examples reported in the present article may also help in reflecting the real efficacy of ITAP in the considered cases. As showed in the illustrative excerpts, despite the differences in available psychic resources in Maria's and Fabio's cases, both subjects were able to follow the therapist's analyses of intrapsychic and interpersonal triangles reaching the expression of their repressed impulses. The main difference between Maria and Fabio was that fewer psychic resources in Fabio required longer therapy and more caution in confrontations during the intervention, with the adoption of a supportive approach. In this regard, we consider that the observation of verbatim interactions of the therapeutic dyad is an irreplaceable element for the judgment of therapy effectiveness.

The results of the present study should be considered in light of the limitation of single-case methodology. Although patients involved in the study are representative of patients seen in clinical practice, any generalization of our results must be avoided due to the small number of patients considered. At the same time, exactly due to the specificity of single-case methodology, this study extended previous knowledge regarding the influence of ego strength on psychotherapy outcome by documenting the efficacy of ITAP therapy for patients with different ego strengths. Thus, we conclude that ego strength is not a limitation for the use of expressive therapy such as ITAP, but rather it is an important variable that should be considered to dose confrontations and support during psychotherapy sessions, with more support (and probably longer therapy) for patients with less ego strength.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Ethical Committee Psychology University of Padua (number 1703). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

IM: study planning, data analysis, and manuscript writing. AM: process material preparation. FS and MS: therapy provision, study planning, and ITAP conceptualization. EB: study planning and realization of change interview. AG: manuscript revision and supervision. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

• Abbass A. (2015). Reaching Through Resistance: Advanced Psychotherapy Techniques . Kansas City: Seven Leaves Press. [ Google Scholar ]
• American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders . 5th Edn . Washington, DC: Author. 10.1176/appi.books.9780890425596 [ CrossRef ] [ Google Scholar ]
• Barkham M., Margison F., Leach C., Lucock M., Mellor-Clark J., Evans C., et al.. (2001). Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies . J. Consult. Clin. Psychol. 69 :184. 10.1037/0022-006X.69.2.184 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barron F. (1953). An ego-strength scale which predicts response to psychotherapy . J. Consult. Psychol. 17 :327. 10.1037/h0061962 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Berne E. (1961). Transactional Analysis in Psychotherapy . New York, NY: Grove Press. [ Google Scholar ]
• Conte H. R., Plutchik R., Buck L., Picard S., Karasu T. B. (1991). Interrelations between ego functions and personality traits: Their relation to psychotherapy outcome . Am. J. Psychother. 45 , 69–77. 10.1176/appi.psychotherapy.1991.45.1.69 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• CORE Partnership (2007). Is initial overall CORE-OM score an indicator of likely outcome? CORE Partnership Occasional Paper, No 1. CORE IMS: Rugby. [ Google Scholar ]
• Davanloo H. (1994). Basic Principles and Techniques in Short-Term Dynamic Psychotherapy . New York, NY: Jason Aronson. [ Google Scholar ]
• Duckworth A. L., Tsukayama E., May H. (2010). Establishing causality using longitudinal hierarchical linear modeling: an illustration predicting achievement from self-control . Soc. Psychol. Person. Sci . 1 , 311–317. 10.1177/1948550609359707 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Elliott R., Slatick E., Urman M. (2001). “Qualitative change process research on psychotherapy: alternative strategies,” in Qualitative Psychotherapy Research: Methods and Methodology , eds J. Frommer and D. L. Rennie (Lengerich: Pabst Science; ), 69–111. [ Google Scholar ]
• Evans C., Connell J., Barkham M., Margison F., McGrath G., Mellor-Clark J., et al.. (2002). Towards a standardised brief outcome measure: psychometric properties and utility of the CORE—OM . Br. J. Psychiatry 180 , 51–60. 10.1192/bjp.180.1.51 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fosha D. (2000). The Transforming Power of Affect: A Model of Accelerated Change . New York, NY: Basic Books. [ Google Scholar ]
• Frederickson J. J., Messina I., Grecucci A. (2018). Dysregulated Anxiety and Dysregulating Defenses: toward an emotion regulation informed dynamic psychotherapy . Front. Psychol. 9 :2054. 10.3389/fpsyg.2018.02054 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Freud S. (1923). The Ego and the Id . The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth Press. [ Google Scholar ]
• Getter H., Sundland D. M. (1962). The Barron Ego Strength scale and psychotherapeutic outcome . J. Consult. Psychol. 26 :195. 10.1037/h0047960 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Goulding M., Goulding R. (1979). Changing Lives Through Redecision Therapy . California: Grove Press. [ Google Scholar ]
• Grecucci A., Messina I., Amodeo L., Lapomarda G., Crescentini C., Dadomo H., et al.. (2020a). A dual route model for regulating emotions: comparing models, techniques and biological mechanisms . Front. Psychol . 11 :357. 10.3389/fpsyg.2020.00930 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Grecucci A., Messina I., Dadomo H. (2018). Decoupling internalized dysfunctional attachments: a combined ACT and schema therapy approach . Front. Psychol . 9 :2332. 10.3389/fpsyg.2018.02332 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Grecucci A., Sigirci H., Lapomarda G., Amodeo L., Messina I., Frederickson J. (2020b). Anxiety regulation: from affective neuroscience to clinical practice . Brain Sci . 10 :846. 10.3390/brainsci10110846 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Greenberg L. S., Pascual-Leone A. (2006). Emotion in psychotherapy: a practice-friendly research review . J. Clin. Psychol. 62 , 611–630. 10.1002/jclp.20252 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hersoug A. G., Høglend P., Gabbard G. O., Lorentzen S. (2013). The combined predictive effect of patient characteristics and alliance on long-term dynamic and interpersonal functioning after dynamic psychotherapy . Clin. Psychol. Psychotherapy 20 , 297–307. 10.1002/cpp.1770 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hill C. E., Knox S., Thompson B. J., Williams E. N., Hese S., Ladany N. (2005). Consensual qualitative research: An update . J. Couns. Psychol . 52 , 196–205. [ Google Scholar ]
• Laaksonen M. A., Knekt P., Sares-Jäske L., Lindfors O. (2013). Psychological predictors on the outcome of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of mood and anxiety disorder . Eur. Psychiatry 28 , 117–124. 10.1016/j.eurpsy.2011.12.002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lake B. (1985). Concept of ego strength in psychotherapy . Br. J. Psychiatry 147 , 471–478. 10.1192/bjp.147.5.471 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lindfors O., Knekt P., Heinonen E., Virtala E. (2014). Self-concept and quality of object relations as predictors of outcome in short-and long-term psychotherapy . J. Affect. Disord. 152 , 202–211. 10.1016/j.jad.2013.09.011 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malan D. H. (1976). The Frontier of Brief Psychotherapy . New York, NY: Plenum. 10.1007/978-1-4684-2220-7 [ CrossRef ] [ Google Scholar ]
• Malogiannis I. A., Arntz A., Spyropoulou A., Tsartsara E., Aggeli A., Karveli S., et al.. (2014). Schema therapy for patients with chronic depression: a single case series study . J. Behav. Ther. Exp. Psychiatry 45 , 319–329. 10.1016/j.jbtep.2014.02.003 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Menninger K. (1958). Theory of Psychoanalytic Technique . New York, NY: Basic Books. 10.1037/10843-000 [ CrossRef ] [ Google Scholar ]
• Messina I., Grecucci A., Marogna C., Calvo V. (2020). Relational exposure and semantic processes as mechanisms of change in psychodynamic psychotherapy: convergences between psychotherapy research and affective neuroscience . Testing Psychometr. Methodol. Appl. Psychol . 27 , 43–56. 10.4473/TPM27.1.3 [ CrossRef ] [ Google Scholar ]
• Messina I., Scottà F., Benelli E., Bianco F., Sambin M. (2018). Intensive transactional analysis psychotherapy (ITAP): a single-case time series study . J. Psychol. Psychotherapy Res. 5 , 46–52. 10.12974/2313-1047.2018.05.5 [ CrossRef ] [ Google Scholar ]
• Messina I., Scottà F., Benelli E., Marchi A., Sambin M. (2019). Intensive transactional analysis psychotherapy (ITAP): a case series study . Counsell. Psychother. Res . 20 , 222–232. 10.1002/capr.12277 [ CrossRef ] [ Google Scholar ]
• Mohr D. C. (1995). Negative outcome in psychotherapy: a critical review . Clin. Psychol. 2 , 1–27. 10.1111/j.1468-2850.1995.tb00022.x [ CrossRef ] [ Google Scholar ]
• Norcross J. C., Wampold B. E. (2011). What works for whom: tailoring psychotherapy to the person . J. Clin. Psychol. 67 , 127–132. 10.1002/jclp.20764 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• OPD Task Force (2008). (ed.). Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning . Cambridge MA: Hogrefe Publishing. [ Google Scholar ]
• Palmieri G., Evans C., Hansen V., Brancaleoni G., Ferrari S., Porcelli P., et al.. (2009). Validation of the Italian version of the clinical outcomes in routine evaluation outcome measure (CORE-OM) . Clin. Psychol. Psychotherapy 16 , 444–449. 10.1002/cpp.646 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rosenthal R. (1994). “Parametric measures of effect size,” in The Handbook of Research Synthesis , eds H. Cooper and L. V. Hedges (New York, NY: Russell Sage Foundation; ), 231–244. [ Google Scholar ]
• Roth A., Fonagy P. (2006). What Works for Whom?: A Critical Review of Psychotherapy Research . New York, NY: Guilford Press. [ Google Scholar ]
• Sambin M. (2018a). “ITAP: the theoretical model,” in Intensive Transactional Analysis Psychotherapy: An Integrated Model (ITAP) , eds M. Sambin and F. Scottà (New York, NY: Routledge; ), 8. [ Google Scholar ]
• Sambin M. (2018b). “Modulation of the intervention,” in Intensive Transactional Analysis Psychotherapy: An Integrated Model (ITAP) , eds M. Sambin and F. Scottà (New York, NY: Routledge; ), 6. [ Google Scholar ]
• Sambin M., Scottà F. (2018). Intensive Transactional Analysis Psychotherapy: An Integrated Model (ITAP) . New York, NY: Routledge. 10.4324/9780203730850 [ CrossRef ] [ Google Scholar ]
• Schiff J. L. (1975). The Cathexis Reader: Transactional Analysis Treatment of Psychosis . New York, NY: Harper and Row. [ Google Scholar ]
• Scottà F. (2018). “Our idea of relational holding,” in Intensive Transactional Analysis Psychotherapy: An Integrated Model (ITAP) , eds M. Sambin and F. Scottà (New York, NY: Routledge; ), 5. [ Google Scholar ]
• Vaillant G. E. (1992). Ego M echanisms of Defense: A Guide for Clinicans and Researchers . Washington, DC: American Psychiatric Pub. [ Google Scholar ]
• van Asselt A. D., Dirksen C. D., Arntz A., Giesen-Bloo J. H., van Dyck R., Spinhoven P., et al.. (2008). Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy V. Transference focused psychotherapy . Br. J. Psychiatry 192 , 450–457. 10.1192/bjp.bp.106.033597 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vittengl J. R., Clark L. A., Thase M. E., Jarrett R. B. (2016). Defined symptom-change trajectories during acute-phase cognitive therapy for depression predict better longitudinal outcomes . Behav. Res. Ther. 87 , 48–57. 10.1016/j.brat.2016.08.008 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Transactional Analysis

Transactional analysis basic concepts.

Transactional analysis is a type of psychotherapy developed by Canadian psychiatrist Eric Berne in the 1940s.

Berne believed that communication with others comes from three distinct parts of self which he called ego states.

The ego states are:

Berne wanted to develop a therapy which was easier for the general public to understand.

Using ‘layman’s terms’,  he went on to write a number of influential books. One of these books is ‘The Games People Play’  which is still popular today, 25 years after it was first published.

The theory of TA is (on the surface) is quite simple: Berne believed that people have difficulty in their lives due to how they communicate and interact with others.

He believed that human beings have three distinct attitudes or states of mind which he called  ego states.

The 3 Ego States

• Parent  (behaving in ways which we learn and react out our parent’s behaviour as adults)
• Adult  (using logic and evidence to guide our behaviour, not becoming emotional)
• Child  (replaying childish behaviours as adults)

The goal of TA is to help clients strengthen their  Adult Ego State  and enhance their communications with other people.

The Key Concepts and Principles of Transactional Analysis

• Transference and Counter-transference .  How memories from past relationships can impact on your current relationships.
• Phenomenology . How our individual perception can impact on how we conduct relationships (this idea is also the basis of  Gestalt  &  PCT
• Ego States -Structural and Functional Models in TA . Structural – The basic idea of ego states Functional – How the theory of ego states is applied
• Life Scripts .  How messages we receive as children help us build a view of ourselves and others which through therapy we can change.
• Games . How a series of interactions between two or more people follow predicable patterns and outcomes.
• Racket feelings . Feelings that the child learns are acceptable and/or desired, which are used to replace the real feelings which a parent may find unacceptable.

Clients are encouraged to undertake homework  to assess how the therapy is working for them.

The therapist analyses your past and how it affects the here and now, which is why it is known as an Active Directive form of therapy .

TA therapists believe that past life events (things that happened maybe in childhood) hold the key to understanding what our present difficulties are. This is known in TA therapy as the  presenting past .

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Structural and Functional Models of Ego States

Types of Transactional Analysis

Since the death of Eric Berne in 1970, Transactional Analysis has developed along differing theoretical paths, sometimes referred to as 'Schools'.

• The Classical School - sometimes referred to as transactional analysis proper, includes ego state analysis, life scripts and game analysis, is the original concept based on the work of Eric Berne, Claude Steiner and several close associates.
• The   Redecision School - developed by Bob and Mary Goulding who integrated TA with  Gestalt  to make a powerful, vibrant means of personal change.
• The Cathexis School - developed initially by Jacquie Schiff who worked with clients who had been diagnosed with severe mental health problems. Her approach was very controversial and was based on the theory of  radical reparenting.

Modern Schools of TA are referred to as 'second wave' and have significantly influenced TA practice in recent years. Practitioners combine these new ideas with the Classical School to produce a contemporary, research-based approach to client work.

• Relational school - outlined by Charlotte Sills and Helena Hargaden in their book “Transactional Analysis a Relational Perspective”. This school draws strongly on the humanistic idea that the therapeutic relationship and empathy are central to the healing process.
• Integrative psychotherapy - developed by Richard Erskin . Like the relational school, this approach emphasises the empathic nature of the relationship in helping clients regain the parts of self, which become lost or fragmented due to traumatic experiences.

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Transactional analysis psychotherapy with a woman suffering from multiple sclerosis: a systematic case study

Research output : Contribution to journal › Article › peer-review

• Hermeneutic analysis
• Multiple sclerosis
• Psychotherapy

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• 10.1177/0362153713509954

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T1 - Transactional analysis psychotherapy with a woman suffering from multiple sclerosis

T2 - a systematic case study

AU - McLeod, Julia

PY - 2013/7

Y1 - 2013/7

N2 - Living with a long-term health condition can lead to anxiety, depression, posttraumatic stress disorder, and relationship difficulties. This article uses a systematic case study approach to examine the process and outcome of transactional analysis psychotherapy with a woman suffering from multiple sclerosis. Hermeneutic analysis of a rich case record was used to evaluate the outcome of the intervention. A set of factors contributing to change were identified and are discussed in relation to previous research into psychotherapy for long-term health conditions. It is concluded that transactional analysis psychotherapy may represent an effective means of allowing different facets of the experience of illness to be explored and resolved. The implications of this study for practice and future research are discussed.

AB - Living with a long-term health condition can lead to anxiety, depression, posttraumatic stress disorder, and relationship difficulties. This article uses a systematic case study approach to examine the process and outcome of transactional analysis psychotherapy with a woman suffering from multiple sclerosis. Hermeneutic analysis of a rich case record was used to evaluate the outcome of the intervention. A set of factors contributing to change were identified and are discussed in relation to previous research into psychotherapy for long-term health conditions. It is concluded that transactional analysis psychotherapy may represent an effective means of allowing different facets of the experience of illness to be explored and resolved. The implications of this study for practice and future research are discussed.

U2 - 10.1177/0362153713509954

DO - 10.1177/0362153713509954

M3 - Article

SN - 2329-5244

JO - Transactional Analysis Journal

JF - Transactional Analysis Journal

Transactional Analysis Examples - Get Practical Exercises to each Concept

You have a presentation to hold at university? You want to know how to use Transactional Analysis (TA) in practice? In this article you will find Transactional Analysis for everyday situations. I asked in the Transactional Analysis Facebook group for examples of Transactional Analysis application in day-to-day life. I compiled the results in this article. You will get a brief explanation of the concept followed by the concrete example. To make it even easier, I created a menu that allows you to jump directly to the corresponding example. Of course you can also scroll through the page step by step. If you want to know more about Transactional Analysis, you can click here . Have fun!

1. Ego States

Ego states are a concept that helps you analyze in which state you and other people are in. It consists of:

• Parent ego state (divided into nurturing and critical parent)
• Adult ego state
• Child ego state (divided into adapted, rebellious and free child)

Kathrin posted this example: There is a bad working atmosphere in the team because one member of the team constantly goes into devaluation and speaks from the critical parent ego state to colleagues. Each team member reacts differently to this behavior: Some adapt and bottle up their frustration (adapted child ego state) and some are even stubbornly like a child. Others, for their part, react from the critical parent ego state and like this provoke a lot of arguments. In any case, it helps to make the team's communication structures transparent and to communicate from the adult ego state. When coaching of the affected individual(s), it helps to find out what causes lay behind this and to practice a different behavior. The mood in the team should become better.

Kathrin has another example: In a relationship, one partner permanently goes into adaptation (child-ego). He wants peace and relaxation in his free time, the other wants action and new experiences. When enough trading stamps (suppressed frustration) are collected, the "adjusted one" bu rsts and accuses the other one of always getting his will. With the help of the TA, both can hopefully be able to discuss their needs from the adult ego state. 

Thank you for this contribution, Marion: I take other people serious (adult ego state). The frightened colleague says after a  storm, "I thought the roof is falling on my head." (adapted child). When I ask, "So, did it fall?" (adult ego state), she begins to think, and we're both in here and now (adult ego state).

You want more examples of this concept? ​ Click here and get to the main article about ego states.

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2. What is a Transaction?

A friend enters the rooms and asks: “What time is it?”

You answer: “It's just after seven.”

In this very moment, you have completed a transaction. A transaction takes place when one person offers to get in contact with another person - the so-called stimulus - and the other person also reacts to it - the so-called reaction. You could say transactions rely on the back and forth of communication.

A game is a set process with a hidden motive that may not be accessible to the consciousness of the other person and that is revealed only when the participants change their behavior (role change in the drama triangle). The outcome is a feeling of misunderstanding and confusion of everyone involved.

He wants the attention of his partner. But maybe he is not even aware of that. It just becomes obvious through how he begins to taunt and tease her. She actually doesn't like this kind of rapprochement, but laughs at the beginning. This is ok for a little while. After some time though, it is enough. She changes from being the victim to the persecutor and shouts out: "That's enough!" He is quite perplexed and feels hurt. She's mad.

Someone who often fails to perform tasks assigned to him plays "kick me." The corresponding complaining part plays "Now I got you, you bastard".

“Yes, but” plays somebody, who complains about a personal problem and then blocks his argument and seemingly justifies his complaint with the statement "Yes, but ...". With this behavior, the player shows his advisors that they are not superior to him. 

"Turmoil" is the name of another game. A fight is provoked to avoid intimacy. The denomination of a game is nowadays not the focus anymore. It is rather the recognition of the process, i.e. the structure of the game, that is crucial.

Click here for the main article about psychological games ( Click here! ). You want more transaction examples? Let's take a look at the drama triangle.

4. The Drama Triangle

The drama triangle consists of the following positions:

You start in one position and switch to a different one after a certain time. This can create tension as shown in the following.

Maximilian has this example: We have to give a group lecture. I play the rescuer in the group, offer my help and do the work of others. In doing so, I diligently collect trading stamps (a hidden frustration that is not lived out). In the end, I accuse everyone that I always have to do everything.

If you like to know more about the drama triangle, click here !

5. Inner Drivers

Does one of the following statements maybe provoke a "yes" inside you?

• I always have so much to do
• I am addicted to harmony
• My life lacks lightness
• I am a perfectionist
• I always stand my ground

If any of the statements resonate with you, you're likely to exploit yourself in certain situations. You use more energy than you should.

Behind this lies the transactional concept of inner drivers. There are five essential drivers:

• “Hurry up!“
• “Do it right!“
• “Give your best!“
• “Be perfect!“
• “Be strong!“

In my online basic course you will learn more about the inner drivers and the other main concepts of Transactional Analysis. Plenty of lovely animated and knowledge-intensive videos. No blah blah. Exercises and overviews. Everything you  need.

Examples Transactional Analysis: Let's have a look at the passivity concept.

6. Passivity

The concept of passivity describes how people manage to not solve certain problems. An employee cannot concentrate at work because the blaring radio of the colleague distacts him. Instead of paying attention to his own needs and, for example, asking the colleague to turn off the radio, he stays silent and accepts the constant disruption. Only to not provoke conflict. The passivity concept could help him to do more for himself.

7. Life Script in Transactional Analysis

I had a date with a woman last week. While eating she says to me: "Surely you are one of those guys who walk around Berlin wearing a Hugo Boss suit and thinking they can have any woman they want. Just because you have money." I had to smile a bit. I thought, "I actually had a Boss suit once. I bought it for the funeral of my grandfather and then sold it again. And really? I could have any girl? I did not know that. Oh, and I have money? Good to know."

Then I showed her my cat purse and asked her, if I had this in my Boss suit. She had to laugh. I'm sitting in a brightly colored shirt wearing flip flops.

Where do I want to get with this? I'm certainly not the man she described. I studied social sciences and status symbols like Hugo Boss suits do not interest me. At home I ride a ladies' bike, because getting on and off is so easy. She projected a picture on me that I could not identify with. She painted me with the same brush she probably did with all men. This works like a filter. It scares off certain men and attracts certain other men. With such a filter, she probably conjures a prophecy. We can also say: her life script is active.

The life script in Transactional Analysis describes an unconciously designed life plan of ours. It includes a view of us, others and the environment.

Inspired by the experience with the woman, I start watching my thoughts when I meet new people. Last week I gave a workshop on the drama triangle. I look at one of the participants and I think, "He looks pretty soft." I watch my feelings on this thought about him and notice how I have no desire to deal with him. His facial features are very soft. This leads me to believe that he is also soft in character. Whatever this could mean.

A few days later he approaches me. I immediately remember the soft-looking face. I decide to set aside my rating on him for now. We engage in a conversation. He is also a coach. We arrange an exchange and I have to say: He is not at all soft in his personality.

At his point, I had been tricked by my hasty assessment. Had I followed my first thoughts about him, I would have missed a great opportunity to exchange. In this case, I would have conjured up a fate - I would have avoided a profitable exchange.

G et to the article about life script here. ( Click here! )

These were the examples of the many concepts of Transactional Analysis . I hope they have been helpful.

You have more examples? Share your expertise with others and post a comment!

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What is Transactional Analysis?

Analysis was founded by Dr. Eric Berne – an innovative and creative thinker who brought together some of the most effective ideas in psychotherapy (analytic, cognitive behavioural, phenomenological) into a powerful body of theory and practice.

Although psychoanalytically trained, he espoused the values of the humanistic movement believing that change is possible and that human beings have a natural aspiration to live in harmony with themselves and others.

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Perhaps his most significant contribution was that he sought to demystify psychotherapy and use oncepts, language and methods, which were understandable to all. He developed theories, that have both simple immediacy and subtle depth. One of his most revolutionary innovations was the treatment contract, by which he invited his clients to choose their own goals and agree with him a plan for their psychotherapy. In recent years many new trends in transactional analysis have emerged producing exciting and effective approaches to working with individuals, couples and groups.

The Institute’s programmes seek to build upon Berne’s work, incorporating new evelopments in Transactional Analysis and integrating new ideas from other approaches to psychotherapy and counselling while retaining the original theoretical framework, values and accessibility. The most significant of these developments has been termed Relational Transactional Analysis. For further details of this approach click on the heading What is Relational TA in the navigation panel.

Transactional Analysis: NOUN; A system of psychotherapy that analyzes personal relationships and interactions in terms of conflicting or complementary ego states that correspond to the roles of parent, child, and adult. Transactional Analysis is a therapy modality used to create growth and change.

A man by the name of Eric Berne from San Francisco in the 1950’s developed the concepts and tools of Transactional Analysis and introduced them to the public in his book “Games People Play. ” Berne referred to Transactional Analysis as social psychiatry, meaning a form of therapy or counseling used by every day people.

The concepts of Transactional Analysis are simple, straightforward, easy to use and understand, user-friendly, and not full of medical terminology or psychobabble like most other therapies. The tools and understanding provided by Transactional Analysis can create positive change to people, relationships, and the work environment when applied. Transactional Analysis is a theory of communications and interpersonal interaction. Sometimes the communications between two people have a hidden message, meaning, and agenda.

The result of this hidden message is a game.

The purpose of the game is to get a need met, without asking directly for what we need or want. People learn how to play these games to get our needs met as children, and they worked then. Now, as adults, they are the source of problems in ur every-day relationships with ourselves and those around us, because things get much more complicated as our age progresses. Transactional Analysis is also a theory on personality and psychological structure.

The concept ot the parent, adult, and child ego “states” also originated in Transactional Analysis.

These ideas help people to understand, explain and change their behavior and have better relationships with others. Through these ideas, people begin to understand ourselves and how we operate, as well as others. Relational TA Relational Transactional Analysis is a term that has evolved in recent years to escribe a paradigm shift in the theory and practice of transactional analysis, which mirrors similar shifts that have been occurring in the wider psychotherapy, counselling and psychological fields.

Over the past two decades within TA, there has been a move away from a focus on cognitive insight as the path to psychological change, towards an appreciation and emphasis on the working through of, the conscious and more significantly the unconscious relational dynamics that arise between the therapist and the client. Relational TA therefore is a framework or way f thinking about the work, about the role of the practitioner and about methodology.

Many of the original models of transactional analysis, which are still in existence today, are concerned with the process of strengthening the Adult ego state – the ability to function successfully in the here and now and take control of self-defeating behaviours. Naturally as part of our training we teach these models. These relate mainly to cognitive behavioural processes however – and therefore rely on a capacity to think consciously about things and take charge of the situation.

Although they are ften effective and supportive of increased levels of functioning, these kind of approaches are often not adequate when dealing with deeper injuries to the self, which tend instead to manifest through powerful unconscious transferential and countertransferential processes, which cannot be tamed, controlled or mastered in quite the same way. Relational TA therefore, is interested in those processes and methodologies that appreciate, contextualise and seek to understand and engage with the language and power of the unconscious.

These processes require quite different models and frameworks and within our training we teach and emphasise uch models, all of which have been developed within the relational TA community to support practitioners as they engage with clients at this more fundamental level of relating, uncovering and analysing as they do so, any unhelpful relational patterns that the client has developed as a way of defending themselves and in the process, offering new relational possibilities.

Relational TA practitioners therefore have a range of TA models to draw upon, those that work at the cognitive behavioural level and those that work at a more psychodynamic level and different relational TA ractitioners will and do, draw quite differently upon them, which is one of the things that makes relational TA so exciting and diverse, what they all have in common with each other however, and therefore what unifies them, is a set of concepts which are a central feature of their work, these include: The importance that is placed on relationship, in all its forms – with the self, with the other and with the inter- subjective (what happens when we get together).

The belief that the most profound change happens through experience (as opposed to cognitive insight), and most owertully through relational experiences that embody and enact ditterent meanings from those that relationships once did for the client. The central focus of bringing to light the unconscious relational patterns that shape all of our experiences of ourselves and of our selves with others. A recognition that providing different relational experiences from those that are expected and/or longed for by the client, can be extremely exacting for both parties, and within this the practitioner as well as the client will be called upon to extend, challenge, change and get to know them-self n some new way. The belief that the practitioner is an active participant in the work and is not and cannot be a neutral observer within this.

This suggests a two person rather than a one-person approach – the client is not there to be done to, nor the practitioner to be a benign provider of what was once missing for the client; both parties are actively involved in the process of finding new and more authentic ways of relating with each other. That central importance that is placed on the way that the practitioner uses the pushes and pulls of their own subjective experience (or ountertransference) with the client, to inform when and what intervention will best enhance the client’s knowledge of self and of the other. An appreciation for the fact that certainty is neither possible nor necessarily desirable in the search for meaning.

Recognising that the meanings that we have or will arrive at have been shaped and co-created and filtered through our individual social contexts, there is a belief that shifting from an individual perspective into a multiple perspective adds a depth and richness to the endeavour that enhances rather than detracts from it. n line with this ‘both/and’ thinking is valued over ‘either/or’. That the client is seen as and is treated very much as an adult, who is capable of a reciprocal, adult relationship with the practitioner.

Within this the maternal metaphor in which the practitioner acts as a temporary replacement for unsatisfactory parents, there to meet their client’s unmet relational needs, is made problematic. Instead, the “activity of relatedness” and a “love of truth”, (Cornell and Bonds-white 2001), where both parties are willing to acknowledge reality about themselves is emphasised.

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'Sitting in jail for everyone else'- a Hong Kong democrat's sacrifice

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• Visits with jailed democrat give window on cost of activism
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Reporting by Jessie Pang and James Pomfret; Editing by Lincoln Feast and William Mallard

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Jessie Pang joined Reuters in 2019 after an internship. She covers Hong Kong with a focus on politics and general news.

James Pomfret is a Special Correspondent for Reuters covering politics and policy in Asia, with a specialization on China, Hong Kong and Taiwan. A two-time Pulitzer finalist, his multimedia career has spanned print, radio, TV and photography. His reporting includes "The Revolt of Hong Kong" - an investigative series he helped lead that was a Pulitzer finalist for International Reporting in 2020, and a series on China's weaponization of the rule of law against its critics that won a 2023 SOPA award.

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