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Case Study - Page 3

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CASE COMMENTARY

By Steve Andreas

The first three aspects of the Universal Growth Process (UGP) David Daniels mentions are Awareness, Acceptance, and Appreciation, all wonderful qualities that have been advocated by spiritual paths for millennia. But for the therapist, these broad concepts must be made concrete and clinically operational. The key question for awareness is “Awareness of what?” and the key question in regard to acceptance and appreciation is, “How do I do that?” Undirected awareness, like free association, seldom leads to a solution. And if you ask a client to accept and appreciate their experience, most will have no idea whatsoever how to do that—even if they accept that as a useful goal!

In this case, Daniels doesn’t go enough beyond broad labels to show us the actual processes of change with a client like Marie. He tells us that she presented as someone who denies her own needs in deference to others’ out of fear of rejection. This pattern used to be labeled “codependent,” or, in some circles, “enmeshed” or “blurred ego boundaries.” A Jungian would describe this as a “lack of individuation,” and the Enneagram apparently calls this a Type 9, “The Mediator.” But none of those labels in themselves really tells us how to resolve the problems clients present.

From my viewpoint Marie’s main difficulty is simply an overuse of a very important human skill, namely compassion: the ability to step into other people’s experience and be sensitive to their needs. Periodically, out of frustration and in recognition of her own needs, Marie erupts into disruptive and unproductive anger. She’s stuck in an either/or polarity between submerging herself and asserting herself that severely limits her choices in relationship. The therapeutic question for me is, “What action does Marie need to take in order to change this pattern?” Understanding and insight into core beliefs aren’t enough to initiate change.

There are any number of methods I might use with a client like Marie to help her integrate her extreme polarities. One is the old Gestalt Therapy method of a dialogue in which the client role-plays each of the two opposites. In this process, unconscious thoughts and motives can be expressed as the client gradually becomes more and more aware of each opposing “part” as a valid component of his/her identity.

Another way to integrate is to ask the client to place an image of one part in one hand, and an image of the other in the other hand. Once these two images have been elaborated and developed and put into dialogue with each other, each is asked to identify and express their “meta-outcome” (the result of the more immediate behavioral outcome). Typically this is quite positive and often identical for each part. Here, for instance, both involve personal survival. Finally the client is told to gradually bring her hands together, observing as the two parts spontaneously change and blend into a single integrated image that’s taken back into her body.

Still another approach would be for a client like Marie to close her eyes and visualize her relationship with her mother or other significant early caretaker. Often clients discover that their body is physically connected with that other person, like a Siamese twin. This image embodies an unconscious belief that maintaining connection is so vital that if either one were to be cut off from the other, both would die. This internalized belief image elicits the life-or-death intensity of response to any threat of rejection. One can then lead the client through processes to separate the two images, enabling each to become a self-sustaining individual.

Whatever method the therapist chooses, the important point is that broad typologies, however interesting and seemingly explanatory they may be for both therapists and clients, have limited clinical value. To bring about change, we need ways to help clients take action to experiment with new experiences of themselves and their relationships, not just new explanations of why they are the way they are.

AUTHOR’S RESPONSE

It’s true that Marie’s behavior could readily be labeled “codependent,” “enmeshed,” or “lack of individuation,” as Steve Andreas points out. As a clinical tool, the contribution that the Enneagram system made in this case was focusing on her core belief that she must not make a big deal of herself if she wanted to be loved and secure, rather than dismissed and rejected. For Marie, this meant focusing her attention on others and finding her importance through others, which resulted in her lack of individuation. I find the Enneagram so useful in my work because it gets right to each individual client’s fundamental beliefs and organization of attention and energy.

But Enneagram work isn’t only a system for helping us understand overall personality functioning. A key element is the use of practical strategies to enact change (the Action dimension). The Enneagram approach trains clients to notice, pause, and breathe back down to collect their energy when they get reactive. It regularly directs them to experience the felt sense in their bodies as a means of determining whether some core belief about the way the world should be is being violated. This gets followed with inquiry about the underlying belief that’s the cause of this upsetting reactivity.

In the Action dimension, I worked with Marie to use this breath practice—breathing down and in to get grounded and self-observant (the Awareness dimension), opening her heart to herself in kindness, without judgment (the Acceptance dimension), and experiencing gratitude for her own good qualities and what she cherished (the Appreciation

dimension).

An ongoing practice in Enneagram work is having clients assess whether an old core belief is guiding their behavior, and then determining whether some alternative actions might be taken that would be more respectful to them and others. In Marie’s case, I said, “Sense that anger in your body and really welcome it. When you get angry, get yourself grounded, open your heart and speak up for what you want.” We worked with her to befriend her upset, not simply act it out. And we worked with her to recognize that in speaking up for and manifesting herself, she could still be present for another person, even as she transformed her own self-concept.

I fully concur with Steve Andreas’s statement, “To bring about change, we need ways to help clients take actions . . . , not just new explanations of why they are the way they are.” I feel, however, that we need to grasp both the content that explains the behavior—in Enneagram terms, the core beliefs and associated adaptive strategies of the type—and the process or action practices, based upon this understanding, required to bring about lasting change.

David Daniels, M.D., clinical professor in the Department of Psychiatry and Behavioral Sciences at Stanford Medical School, was a developer of the Enneagram. He established the Enneagram Professional Training Program with Helen Palmer in 1988 and is the coauthor of The Essential Enneagram.

Steve Andreas, M.A., has been learning, teaching, and developing methods in Neuro-Linguistic Programming for three decades. His books include Virginia Satir: The Patterns of Her Magic; Six Blind Elephants: Understanding Ourselves and Each Other; and the forthcoming Transforming Negative Self-Talk: Practical, Effective Exercises.

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