Transactional Analysis Psychotherapy for a Case of Mixed Anxiety & Depression : A Pragmatic Adjudicated Case Study

Using an original method of case evaluation which involved an analysis panel of over 80 Italian psychologists and included a lay case evaluation, the author has investigated the effectiveness of transactional analysis psychotherapy for a case of mixed anxiety and depression with a 39 year old white British male who attended 14 weekly sessions. CORE-OM (Evans, Mellor-Clark , Margison, Barkham, Audin, Connell and McGrath, 2000), PHQ-9 (Kroenke, Spitzer & Williams, 2001), GAD-7) Spitzer, Kroenke, Williams & Löwe, 2006, Hamilton Rating Scale for Depression (Hamilton, 1980) were used for screening and also for outcome measurement, along with Session Rating Scale (SRS v.3.0) (Duncan, Miller, Sparks, Claud, Reynolds, Brown and Johnson, 2003) and Comparative Psychotherapy Process Scale (CPPS) (Hilsenroth, Blagys, Ackerman, Bonge and Blais, 2005), within an overall adjudicational case study method. The conclusion of the analysis panel and the lay judge was unanimously that this was a good outcome case and that the client’s changes had been as a direct result of therapy. Previous case study research has demonstrated that TA is effective for depression, and this present case provides foundation evidence for the effectiveness of TA for depression with comorbid anxiety.


Introduction
The evidence base for the effectiveness of transactional analysis (TA) psychotherapy is rapidly gaining ground.Two large scale studies have demonstrated the effectiveness of short-term TA psychotherapy for reducing overall distress, depression and anxiety symptoms (van Rijn, Wild and Moran, 2011;van Rijn and Wild, 2013) and have demonstrated that TA, gestalt, person centred and integrative counselling psychology have comparable outcomes (van Rijn and Wild, 2013).Three previous case studies have demonstrated the effectiveness of transactional analysis psychotherapy for the treatment of depression (Widdowson, 2012a(Widdowson, , 2012b(Widdowson, , 2012c)).In one of those cases (Widdowson, 2012c), the client appeared to have considerable anxiety; however this was not measured in the study and therefore conclusions regarding the effectiveness of TA for comorbid depression and anxiety could not be drawn.This present case study examines the process and outcome of brief, 14-session therapy with 'Alastair'a white British man presenting with mixed depression and anxiety.
This case study draws on several research designs; firstly, the case is presented using pragmatic design.Pragmatic case studies focus on the clinical process in an attempt to elicit aspects of best practice (Fishman, 1999;McLeod, 2010).The case study was evaluated using an adjudicational method.Adjudicational case studies rely on a quasi-legal framework drawing on a panel of judges for forming conclusions regarding the outcome of the case and possible factors which have influenced the outcome (Bohart, Berry and Wicks, 2011;Elliott, 2002;McLeod, 2010).This present case has utilised a novel approach for evaluating the case by drawing on a large group of psychologists and also by the use of a lay judge.Although several published adjudicated cases have suggested that there may be value in recruiting lay judges in the adjudication process (see Stephen and Elliott, 2011), the author is not aware of any previous studies which have actually done so.
The aim of this present case study was to investigate the process and outcome of short-term TA psychotherapy for the treatment of mixed depression and anxiety.The author, who was the therapist in this case, had developed a manual for the treatment of depression (Widdowson, in press) and a further aim of this case study was to provide a pilot evaluation of the treatment manual for comorbid anxiety and depression.

Client and Case Formulation
Case Context Alastair had weekly individual psychotherapy with a therapist in private practice.He independently sought out his therapist, who was the author was the therapist in this case.At the time of conducting the therapy, the therapist was a 39 year old white British male with 16 years of clinical experience.The therapist is a teaching and supervising transactional analyst and a post-doctoral psychotherapy researcher.

Client
To preserve the client's anonymity, some details have been changed: however the client description and description of the therapy process are still 'close enough' to give the reader a clear sense of the client and the therapy.Any changes made do not adversely affect the validity of the case study or change crucial variables.
Alastair was a 42 year old senior executive who initially presented for therapy for "problems with self-confidence and self-esteem".He was well-dressed in a stylish suit and well-groomed, suntanned, and had a warm, friendly manner about him and the therapist found him to be instantly likeable.Alastair grew up in a small town in rural Scotland and was the eldest of three children.His parents had divorced when he was ten years old, and to some extent he had blamed himself for this.He had not enjoyed school and after the divorce felt different to the other children.He also became aware of his parents not having very much money when compared to families in the area who were largely middle-class and relatively affluent.He reported having a "decent" relationship with his parents and siblings but said that they were not very close or warm or affectionate with each other.He had left school at 16 and gained an apprenticeship in a local engineering firm where he had done exceedingly well.He completed day-release degree education whilst working, gradually gaining promotions and seniority in the company.Six months prior to attending therapy he had been given a substantial promotion onto the board of directors.Although his work performance was excellent, he was personally struggling with this and in particular with feelings of inferiority, of "not being good enough" and was concerned that he would eventually get demoted or fired.He was particularly struggling with his feelings relating to and stirred up by frequent board meetings and presentations he had to make.It was these concerns which had prompted him to seek out therapy.He was married, with two boys aged 9 and 7.He reported a good relationship with his wife, but felt that he did not quite know how to relate to his children and was afraid that they would grow distant over time.Socially, he was quite isolated, seeing a small group of friends fairly infrequently.He said that he had never spoken to anyone about how he felt before and was a little apprehensive about therapy.
The purpose of the initial meeting was to clarify his presenting problems, form a working alliance, conduct induction into the tasks of therapy and clarify process expectations, and for the therapist to conduct a mini diagnostic interview.His therapist identified a persistent, chronic low-grade depression and some anxiety using DSM-IV criteria (American Psychiatric Association, 1994)..There was no indication of any other disorder.He was screened using CORE-OM (Evans, Mellor-Clark, Margison, Barkham, Audin, Connell and McGrath, 2000) PHQ-9 (Kroenke, Spitzer & Williams, 2001) and GAD-7 (Spitzer, Kroenke, Williams & Löwe, 2006).His initial CORE score was 15 indicating mild levels of global distress and functional impairment.His PHQ-9 score indicated mild depression and his GAD-7 score indicated severe anxiety.Therapist scored Hamilton Rating Scale for Depression (Hamilton, 1980) score was 15, also indicating mild depression.Alastair completed CORE-OM, PHQ-9 and GAD-7 every fourth session and also at his final session and at follow-up intervals of one month, three months and six months.
Strengths: Alastair was warm, friendly and energetic (in spite of his anxiety and depression).He was an intelligent and articulate man who appeared to be very open and receptive to new experiences and had a curiosity about the world.Although he initially struggled with identifying and expressing his feelings, he engaged well with this aspect of the therapy.His initial apprehension about therapy soon disappeared and he enthusiastically participated in the process.He was very active and committed to the therapy process and consistently performed all negotiated homework tasks with considerable care, attention and effort.Prior to attending therapy, Alastair had read a number of self-help books, which he had found interesting, but which had not resulted in any change in how he felt.Nevertheless, his reading had given him some insight into what he might get out of therapy and in identifying issues he could address in sessions.
It was considered that for therapy to be effective this introjective process would need to be dismantled and replaced.The self-critical introjective process was influenced by his script beliefs (Stewart and Joines, 1987) which were formed from implicit learning during childhood, and then subsequently reinforced through distortions and negative interpretation of events which was replayed via his script system (Erskine, 2010).This had negative interpersonal consequences which repeatedly reinforced his core script belief of "not being good enough".Furthermore, positive feelings such as joy and pride were disallowed.These factors combined meant that Alastair had developed a self-perpetuating system which he was unable to challenge alone.This case formulation is consistent with the framework presented in the TA treatment manual (Widdowson, in press) on which this therapy was based.The author had previously conducted a case series which investigated the use of TA psychotherapy for depression.This case was used as 'proof of concept' pilot study to test out whether the principles of the manual would work in practice and specifically if they would be suitable for mixed anxiety and depression.The treatment manual places great emphasis on the intake procedure and client role induction.

Therapy Process
Alastair attended a preliminary mutual assessment session.The therapist engaged Alastair in some initial exploration regarding the problems he was seeking help for in therapy, a mini diagnostic interview and some discussion about the tasks and process of therapy as part of the role induction procedure.The therapist also raised the potential for Alastair to engage in research in this meeting.
The first therapy session was spent on some further history-taking, problem formulation, goal setting and the therapist explaining how the therapy would work, and clarifying expectations.Part of the problem formulation process involved the generation of a basic case formulation, which the therapist checked with Alastair for purposes of verification and consensus agreement.
In the second session, Alastair described his chronic feelings of inferiority which he had felt since childhood.The therapist gave Alastair several positive strokes (Steiner, 1974) during the session and noticed how Alastair deftly discounted them (Schiff et al., 1975).This was explained by the therapist as a strategy which maintained Alastair's sense of inferiority, and he invited Alastair to practice simply and graciously accepting positive strokes which came his way.This was framed by the therapist to Alastair as accepting a gift which was freely given, and that just as he enjoyed doing things which made other people feel good, his acceptance of strokes would likely enable others to enjoy the good feelings they produced in him.It was also suggested that if he found any adverse consequences to practicing stroke acceptance he could quickly reverse his behaviour.
Session 3 began with more detailed exploration of the origin of Alastair's feelings of inadequacy in childhood, and his script decision to remain "closed" to other people.Alastair felt that if he opened up to others, they would think less of him, and thus confirm his inferiority.The therapist proceeded with deconfusion (Berne, 1961(Berne, , 1966;;Hargaden & Sills, 2002, Widdowson, 2010) and assisted Alastair in expressing his sense of shame, and his historic sadness and fear.To support this, the therapist explained the interpersonal nature of feelings and how attuned responses from others can change emotions.The session concluded with some behavioural contracting around "letting other people in", in particular, his wife.
Alastair started session 4 by reporting that he had started experimenting with opening up more to his wife, and had been surprised by her positive response to this.The remainder of this session and session 5 continued with more exploration of his self-limiting narrative and script beliefs around not being good enough.Alastair was invited to pay attention to when this belief was influencing him, and to actively question whether or not the belief was valid.The therapist conceptualised this as decontamination (Berne, 1961;Woollams & Brown, 1979), which would weaken the influence of the script belief and start to interrupt Alastair's self-critical ego state dialogue.Alastair was also invited to experiment with wondering what it might be like if he did see himself as good enough, and what the negative consequence of this would be, if any.This was seen by the therapist as a strategy which would challenge the limiting narrative of his script, and also continue the process of deconfusion by encouraging a surfacing of Alastair's anxieties and Child fantasies around issues of worth.
Session 6 focused on deconfusion, and in particular how Alastair prevented himself from feeling joy, pride and self-confidence.The therapist engaged Alastair in some discussion of these 'forbidden feelings', and Alastair explained how he was afraid that if he experienced joy that "things would go wrong", and that pride would automatically lead to being arrogant and narcissistic.The therapist considered this to be a key dynamic in Alastair's depression.The therapist's approach was not to challenge or confront this directly, but to invite Alastair to spend the week noticing whether stopping oneself from feeling joy would actually prevent anything bad from happening, and also whether people who felt a sense of pride were always arrogant, narcissistic and selfish.This would generate experiences which would cause cognitive dissonance (Festinger, 1957) and thus facilitate the change process.The therapist's stance here was of empathic enquiry (Erskine, Moursund and Trautmann, 1999;Hargaden and Sills, 2002), and inviting Alastair to develop a more self-compassionate stance and understand how these beliefs were born out of positive intentions.
Alastair arrived for session 7 clearly excited and bursting to tell his therapist "some good news".He had been out with his friends a few evenings previously and decided to tell them that he had struggled with feelings of depression and anxiety for many years, and also that he was in therapy.Their reactions astounded him.Instead of judging him, as he expected, they were warm and accepting.Two of his friends disclosed that they too had similar feelings, and one was also in therapy.The terrible rejection he feared did not happen, and instead he found his relationships were strengthened.The session went on to explore how he had often felt responsible for the happiness or unhappiness of others, and the origin of this in his fantasies of blame around the time of his parents' divorce.Following on from the previous session, he described how he had realised that bad things would happen, regardless of whether he felt happy or depressed, and that worrying about them only had the effect of making him anxious.Furthermore, he had also noticed how someone who reported directly to him at work had been proud of an achievement and Alastair noticed that pride did not necessarily mean arrogance or narcissism.He noticed one of his children feeling pride and seeming to "grow" from this positive feeling.He realised it was possible to feel pride "quietly" and "healthily".The therapist considered this a breakthrough session, as Alastair was starting to re-evaluate his script narrative and find disconfirming evidence in his day to day life.
Session 8 focused on Alastair's beliefs about "how he should be", and his sense of guilt and shame over his emotional responses.This exploration began when he described the previous week's events.He had been on a family holiday with his wife, children, his mother and stepfather and his sister and her husband and children.The holiday had not been a positive experience for him, as he realised that he was continually preoccupied with ensuring "everyone was having a good time".As the holiday progressed, his awareness of his sense of responsibility for everyone's happiness had grown, and he had started to question whether this position was appropriate or helpful.As the week wore on, he gradually stopped trying to keep everyone happy and he noticed that there were no negative consequences of this.He was however still struggling with some guilt, which was related to his feelings of anger towards his sister and his step-father, who had both behaved quite badly on occasions during the holiday.He believed that his anger was somehow 'wrong, and wondered if this was evidence that he was 'a bad person'.The therapist used decontamination to facilitate change in Alastair's view of feelings and invited Alastair into various in vivo experiments about feelings and in particular, anger.This helped to normalise these emotions.After this exploration, Alastair made a throw-away remark which revealed he had been experiencing some anxiety prior to the session about 'being boring'-a fear which often preoccupied him.With this, his sense of responsibility for the happiness of others had been transferentially replayed in the therapy.The therapist invited Alastair to describe what it was like for him to be in relation to another when he did not know whether they found him boring or not.In doing this, Alastair spontaneously identified that there had not been any indications that his therapist was bored during any of their sessions.The therapist concluded the session then and invited Alastair to continue to reflect on this after the session.
Alastair was noticeably different when he arrived for session 9.He triumphantly stated that he had come to the conclusion that it was 'ok to feel his feelings'.The therapist considered this to indicate that Alastair had made a spontaneous redecision (Goulding & Goulding, 1979).There was evidence to support this, including him reporting that he had felt angry during the previous week and had not felt guilty about this.On further discussion, it appeared that he had also reached a point of self-acceptance.He stated that he had realised that he was not a bad person, and that actually he believed that he was a good person, even though he had flaws.He described how he had been "enjoying being himself", had been feeling optimistic about his future and had not felt wracked with guilt even once.
In session 10, Alastair explored the origins of his sense that he "should be different to who he was".The therapist understood this to represent Alastair's continuing reevaluation of his 'don't be you' injunction (Goulding & Goulding, 1979).He described occasions during his childhood where he had felt "second best" and "not good enough" and how he no longer believed these to be the case.He did however describe a lingering concern that people might not like him.The therapist brought this into the therapeutic relationship and invited Alastair to reflect upon what it was like for him to be in therapy with someone who he felt disliked him.It appeared that this generated some cognitive dissonance and did not square with Alastair's experience of the therapist.He stated "I've no reason to think you dislike me, and lots of reasons to think the opposite.Come to think about it, I don't know why I've been worrying about things like this.I get really nice feedback from people, and there is no reason for them to lie.Besides, it's not possible to be liked by everyone, so I'm being unrealistic there.As long as I like myself and that the people I care about like me then it really doesn't matter that much."The therapist considered that this was evidence of further redecision.
Session 11 focused mostly on Alastair's strong sense of social justice and fairness.This was framed as a positive attribute, although in the past had led him to overcompensate in situations where he felt people were being treated unfairly by others.He also explored his strong sense that people "should feel good about what they are doing.I don't want my workplace to be somewhere that grinds people down.I think we have a responsibility to care for our employees and pay attention to their well-being, above and beyond simple health and safety."The therapist inquired about the aspects of Alastair's job which had brought him the most satisfaction.He described that aspects which involved coaching, mentoring and so on were the most satisfying tasks.The therapist suggested that perhaps he might explore whether it was possible for him to adjust his workload so that he could do more of this.Alastair was excited by this prospect and felt that this was all within his existing portfolio.The therapist also checked whether Alastair still felt happy with himself and that he had a right to feel all his feelings and this was confirmed.
Alastair's new, positive and relaxed attitude was evident from the beginning of session 12.He reported how his colleagues and his wife had all commented on how he was more relaxed and seemed happier.He described feeling happy and engaged in life and was enjoying a greater sense of connection to others, and in particular, his children.He also reported that his performance at tennis had considerably improved and had been commented on by the friends he played with.He attributed this to "being more present and more confident in general".Conscious of the planned ending in a few weeks, the therapist shifted the focus of the session to relapse prevention.They explored potential prodromal symptoms or processes that Alastair would need to look out for.These were; comparing himself negatively to others, being overly concerned about what others think of him, over-preparing and loss of ability to be in the moment.To support this, the therapist taught Alastair some simple mindfulness techniques in the session and invited him to get a guided mindfulness CD and buy a book on mindfulness.
Alastair started session 13 by describing how he had successfully adjusted his work calendar to enable him to do more of the tasks he enjoyed.He described how he had been practicing mindfulness daily and was finding this incredibly useful.He was also pleasantly surprised to find how enthusiastic his fellow board members had been about this.He spoke about how he had really started to value the uniqueness of himself and others and had let go of negatively comparing himself to others.Instead he realised that he had some weaknesses, but that these were balanced with strengths and that this made him "no better but no worse than anyone else."The therapist picked up a card from his bookcase which had the UN declaration of human rights (United Nations, 1948) on it, and asked Alastair to read out articles one and two; "All human beings are born free and equal in dignity and rights" and "Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind".The therapist asked Alastair if he agreed with these statements, and then asked Alastair if there was any reason that these might not apply to him.Alastair said he could think of no reason, and then smiled as he recognised the point the therapist had been making.
The final session was devoted to the ending process.During the session, Alastair and his therapist reviewed the entire therapy, discussing and celebrating key changes Alastair had made, specific life events and how he had handled them differently, and the changes in his outcome measure scores (which included the final scores from the beginning of this session).The therapist also reviewed and reinforced Alastair's contingency planning and relapse prevention skills.The informed consent procedure for participating in the research was repeated.Overall, the session was positive and upbeat in nature.

Three month follow-up feedback
At the three month follow-up interval, Alastair completed the CORE-OM, PHQ-9 and GAD-7.The therapist invited Alastair to pass on any information about how he was doing.Alastair responded by saying that "things are going really well, at home and at work and I'm experiencing so many day to day activities in a completely different way than ever before!I'm much less stressed, less self-critical and much more at ease with life and myself.I still have some times when I find myself making negative comparisons with others, being overly concerned with what others are thinking or procrastinating but these are very rare and I seem able to move on quite quickly."

Six month follow-up feedback
At the six month follow-up, Alastair repeated the outcome measures and provided the following statement regarding how he was doing; "I'm doing really well and have been able to maintain a much more positive outlook on life and seem to have kept going and made progress with all of the positive changes that you helped me make.I still have slightly self-critical tendencies and find myself drifting towards making negative comparisons with others but I am now getting quite good at recognising what's happening and having a quiet word with myself so that I don't dwell on it for too long.I've also been working on mindfulness techniques and getting quite good at relaxing and enjoying the moment much more than ever before.Can't thank you enough for your help -it really has been life changing for me but more importantly for my family and especially my kids who now have access to a much more attentive, more focused and less stressed dad!"

Session Rating Scale
The Session Rating Scale (SRS v.3.0)(Duncan, Miller, Sparks, Claud, Reynolds, Brown and Johnson, 2003) is a four-item client self-report measure.The client is asked to provide feedback on ten-point scales relating to their experience of the session.The four items relate to the therapeutic relationship (feeling understood and accepted), focus on client-directed goals for the session, the client's perception of the suitability of the therapist's approach, and an overall rating.As part of the regular and on-going review of the therapy, the therapist invited Alastair to rate his experience of therapy using the SRS at regular intervals.Alastair gave a mean score on all scales of 9.5 throughout the therapy, indicating high levels of satisfaction with the therapy and a strong working alliance.

Comparative Psychotherapy Process Scale Data
The Comparative Psychotherapy Process Scale (CPPS) (Hilsenroth, Blagys, Ackerman, Bonge and Blais, 2005) was administered on two occasions during treatment.
Alastair was asked to comment on his experiences of all the sessions so far (or since last measurement point in the case of the second administration).This was used to evaluate whether the TA therapy he received was more similar to CBT or Psychodynamic therapy.The CPPS is a 20-item measure with 10 items each relating to procedures which are characteristically cognitivebehavioural or psychodynamic in nature.Each sub-scale yields a mean score between 0 (uncharacteristic) and 6 (extremely characteristic).Interestingly, Alastair's scores on both sub-scales were a mean of 5.4, indicating that the therapy was equally very characteristic of both CBT and psychodynamic therapy.

Case Analysis
The rich case record (McLeod, 2010) was constructed by the author.This included all the collected data from the case, which included quantitative data from outcome and process measures and qualitative data from client interview.

Adjudication
The rich case record was examined, analysed and adjudicated by 83 psychologists who attended a two-day case study research training workshop which was organised by the Centre for Dynamic Psychology, Padua, Italy.Participants in this workshop read the case and discussed it in small groups.All participants then engaged in a group discussion to see if a consensus could be agreed regarding the outcome of the case.The 56 criteria as developed by Bohart, Berry and Wicks (2011) were used to evaluate the case.Bohart et al (2011) developed these criteria as a method of examining psychotherapy case study evidence to enable adjudicators to form clear conclusions regarding the outcome of the case and to identify factors which are likely to have been significant to the outcome of the case.These criteria fall into three broad groupings; the first of which examines the evidence as to whether the client has changed or not.The second group examines evidence for specific changes the client may have made.The third group explores whether there is sufficiently plausible evidence to conclude that the client's changes are due to therapy.Elliott's (2002) eight non-therapy, alternative arguments were also used as a means of examining if there was evidence in the case that the therapy was not effective or if therapy was not the primary causal agent in the client's change process.
Although the use of teams of judges is standard practice in adjudicated case studies, the author is not aware of any previous studies which have drawn on such a large group of professionals for this purpose.
Previous adjudicated case studies have tended to rely on the verdicts of other psychotherapy researchers.As such, it is possible that some inadvertent bias may creep into the adjudication process as it could be argued that as therapists they would be predisposed to having a positive view of psychotherapy.In order to mitigate against this potential bias, the author recruited a lay person to act as a judge in this case and to balance the views of the psychologists who evaluated the case.The lay judge was Paul Pinder, a lawyer who had a degree in chemistry and a post-graduate qualification in secondary education.This judge was known to the author prior to this study, and was approached to participate on the basis of having this dual background in science and law.It was considered that this combination would predispose him towards objective and scientific evaluation of evidence in forming his conclusions on the case.
Although it has been suggested in a number of previous papers, the introduction of a lay judge into a case adjudication process is a novel approach in case study research method.Both the panel of psychologists and the lay judge were instructed to examine the rich case record and evaluate it using the 56 criteria proposed by Bohart et al (2011) and the eight non-therapy explanations proposed by Elliott (2002).The panel and the lay judge were also instructed to evaluate each criterion individually and to form their judgement based on whether there was 'clear and convincing evidence' (Stephen and Elliott, 2011) in the case materials that each criterion had been met.

Concluding Evaluation of the process and outcome of therapy
Overall, the analysis team and the lay judge unanimously concluded that the case was a clearly good outcome case, that the client had made many positive changes and that these were clearly as a result of therapy.

Evidence that the client changed
The first 39 criteria examine the case to identify evidence that the client changed.10 were not applicable to Alastair's case.In the case record, there was clear evidence for each of the remaining 29 criteria that Alastair had changed.This was considered to be clear and unambiguous evidence for positive change and outcome.
These criteria included: that the client stated that he had changed and provided specific information about the changes he had experienced since starting therapy and was able to provide supporting detail and examples.The changes seemed plausible and clearly related to the client's presenting problems and intended direction of change and growth.Alastair's changes included a reduction in symptoms and an increase in subjective well-being, and was confirmed by comments and observations made from his family and associates.
The analysis team noted that Alastair's quantitative outcome measures demonstrated clinically significant change on all four measures, and that this provided evidence of symptomatic change.However, the view of the analysis team and the lay judge was that the qualitative evidence from Alastair's Change Interview was considered to provide an argument which was more compelling and detailed than the quantitative measures.
In this Alastair described how he was more relaxed in general and had a greater ability to "be in the moment".The description of the therapy process reported changes in Alastair in sessions 7, 9, 10, 12, 13.These changes were considered to be plausible and clearly related to the type of work that was taking place in the therapy.The analysis team felt that although it was constructed from the therapist's notes, there was sufficient evidence in the case narrative to conclude that the therapy work was critical in stimulating these changes.

Evidence that changes were due to therapy
The remaining 17 criteria examine the case for evidence that the client's changes were a result of therapy.Of these 16 the team could find no evidence for change due to therapy in one criterion, and inconclusive evidence for a further two criteria.The analysis concluded that there was clear and unequivocal evidence for changes being due to therapy in the remaining 13 criteria.This was considered to be clear and unambiguous evidence that the clients changes were due to the effects of therapy.
These included Alastair's clear statements that he believed that his changes were directly due to therapy, and that he was able to provide details of a plausible trajectory of change.Alastair freely discussed aspects of therapy which he found difficult, suggesting that his experiences were not subject to an overly-positive view.
There was evidence that descriptions provided Alastair's interview regarding the therapist's relational qualities and a sustained and focused therapeutic approach were consistent with the case formulation, treatment plan and the therapist's notes.Alastair provided specific information about the therapist's use of support and challenge and how an effective balance had been struck between these two aspects of therapy which he had appreciated and which had promoted his growth (see below).Finally, Alastair reported that there were no significant extra-therapy events which could account for his change, and provided evidence of changes which he strongly believed occurred as a direct result of his engagement in therapy.

Alternative explanations for change
The analysis team and the lay judge examined the case using Elliott's (2002) non-therapy explanations for change.The two arguments that the client's changes were due to attempts to please the therapist, or wishful thinking and self-correction, were considered to be explanations which may have been relevant in this case.
The conclusion of the analysis team and the lay judge was that there was no clear evidence to support any of these alternative explanations.Specifically, although Alastair had clearly had a positive experience with his therapist, his Change Interview was realistic and plausible.Furthermore, Alastair was able to provide a detailed and consistent but idiosyncratic description of his current circumstances and changes which suggested that his account of his changes was a good representation of his experiences.Despite this, the team did wonder if there was some possibility that Alastair might be down-playing his current difficulties.The argument relating to client expectation was ruled out as Alastair reported that he was surprised by most of his changes, and that the ones he was less surprised about had exceeded his expectations.His description of his life post therapy suggested that he had internalised the change process and integrated a range of positive resources.The argument that changes were due to selfcorrection was also rejected as although Alastair had used self-help materials, he had used these prior to therapy and reported that these had made no positive impact on his problems.Although he had used self-help methods since starting therapy, these were tools which were suggested to him by his therapist and therefore can be considered to be part of the treatment.Furthermore, Alastair's changes were already firmly in place before he started the self-help methods (namely, mindfulness) as recommended by his therapist, and his Change Interview suggested that the therapeutic relationship had been highly significant in facilitating change.

Analysis of key therapeutic strategies
The analysis team offered some perspectives on the key therapeutic strategies which could be identified in Alastair's qualitative data.The lay judge also provided some interesting insights on his perspectives regarding the key processes of change at work in the therapy which corresponded almost identically with the views of the analysis team.
The therapeutic relationship was highlighted as being highly significant to the outcome of this case.Alastair described quickly feeling at ease with his therapist, which

Discussion
This is the fourth case study which has demonstrated the effectiveness of TA psychotherapy for depression, and the second case study investigating the outcome of TA psychotherapy for a man with mixed depression and anxiety.Due to the fact that this case was of mixed anxiety and depression, this potentially acts as a limitation as it does not increase confidence in the specificity of TA for depression only, however it does highlight the clinical effectiveness of TA, when used in routine practice with a client with comorbid depression and anxiety.Although the research evidence is gathering, further replications are needed to firmly establish TA as an empirically supported therapy for depression as well as for mixed anxiety and depression.This present case also provides some support for the utility of the treatment manual which was used to guide the therapy.Further research is clearly needed to investigate and validate the treatment manual.
With regards to limitations of the case, it is possible that the multiple roles that the author took within the case (therapist, compiler of case record and facilitator of the panel of psychologists) may have inadvertently allowed researcher bias to influence the research process and overall conclusions drawn.Similarly, as the lay judge was an associate of the author, it is possible that the process may have been unconsciously influenced.Nevertheless, many of the psychologists did not have any allegiance to TA, and the lay judge was chosen for his objectivity and of him having no personal or professional allegiance to either TA or psychotherapy as a whole.Although consensus was reached in the meeting of the panel of psychologists regarding the conclusions of the case, it is impossible to tell if the power of the group acted to silence any dissenting voices.Despite this, it would appear that there is clear and convincing evidence that the client changed substantially and that these changes were due to the effects of TA therapy.
The finding which suggested that the therapy in this case was equally like both psychodynamic and cognitivebehavioural therapy is intriguing, and suggests that an examination of TA therapy which investigates its similarities in process to these types of therapy is warranted.

Comparison to previous cases
The case of Alastair most closely resembles that of 'Tom' (see Widdowson, 2012c).Both Alastair and Tom had depression with co-morbid anxiety, although Tom's depression was moderate and Alastair's depression was mild at point of entry into therapy.Although no measure of Tom's anxiety was taken during his therapy, a reanalysis of the case record suggests that his anxiety was not as as Alastair's.Nevertheless, both cases seem to provide foundation evidence of the effectiveness of TA psychotherapy for mixed anxiety and depression.
Both Tom and Alastair were around the same age, and both were white, British men.The therapists in the two cases were roughly matched in terms of level of experience, although Tom's therapist was white British female and Alastair's therapist was white British male.This would suggest that therapist gender is not likely to be a significant factor in determining outcome of the case.
There is considerable similarity in therapeutic factors between the present case and the cases of 'Peter' (Widdowson, 2012a), 'Denise' (Widdowson 2012b), 'Tom' (Widdowson, 2012c) and 'Linda' (Widdowson, 2013).In all of these cases the therapeutic relationship appears to be characterised by an atmosphere of permission, combined with emotional support with robust challenge.The most significant change appears to have taken place when the therapy was experiential.The therapeutic process appears in all of these cases to involve significant deconstruction of past events, examining and reframing these, finding new perspectives and creating new meaning.As part of this process of finding new meaning, all of these cases suggest that learning about TA theory was helpful for the client to understand and change their own process and the use of the shared language of TA created a collaborative and egalitarian framework for the therapy.

Conclusion
This case has provided initial evidence that TA therapy can be effective for the treatment of mixed depression and anxiety and also adds to the existing evidence regarding the effectiveness of TA therapy for depression.
The case also provides preliminary evidence that the TA treatment manual used in this case is a promising approach for the psychotherapy of depression.
The findings also suggest new directions in TA-based psychotherapy process research, which might include, for example, research which explores the similarities and differences between TA and other forms of therapy (specifically cognitive-behavioural therapy and TA) and research which investigates primary change mechanisms in TA therapy as well as particular therapeutic strategies (e.g.experiential focus) which might be most productive in maximising therapeutic change.

Mark Widdowson PhD, Teaching & Supervising
Transactional Analyst (Psychotherapy) is a lecturer in counselling and psychotherapy at the University of Salford and can be contacted on m.widdowson@salford.ac.uk The author would like to thank Dr Enrico Benelli, Serena Provazza and Francesco Scottà for their organisation, assistance and translation for the case analysis workshop.

Table 1 :
Quantitative Outcome Data Throughout the interview, Alastair provided consistent examples of how he had learnt to let go of worries and preoccupations and live in and enjoy his here-and-now experience.This appears to have had a considerable positive impact on his overall quality of life.This also seems to have taken place alongside a greater degree of self-acceptance and a letting go of expectations that other people would negatively evaluate him.
So, I've enjoyed things like that, going out for a meal, going to the shops, or watching a TV programme with the kids.Things I wouldn't have taken any pleasure whatsoever before, but actually it's like a new experience almost, it feels that different." got an impact on everyone and probably from a young age and actually You don't have to go back and play mind games to wipe it all out, just have to, you know . . .(pause) Come to terms with whatever it is and but it's part of who you are and . . .So that was really helpful." about your childhood and imprints and all that sort of stuff.And ah, it's been quite helpful to have touched on things some of those things without spending hours on, you know, my relationship with my parents and that sort of thing.Em, so it was really helpful just recognising that it's