CHAPTER 6

Piscussioi^
 CHAPTER 6

DISCUSSION

This specific research was conducted to ascertain the effectiveness of

the Bioenergetic treatment method as a psychotherapeutic tool for clients
suffering from personality disorders. The four different parameters under
observation were the clients:-

I) psychiatric health status

ii) psycho-physical health status
iii) self-esteem level and
iv) bioenergetic condition

In addition, the factors Involved In positive therapeutic outcome were

also investigated. A series of scales, questionnaires and inventories were
used on a sample of forty-four clients suffering from nine different types of
personality disorders. The research study was based on certain theoretical
assumptions fonnulating six sets of hypotheses, which were statistically
analysed. In this section a comprehensive discussion is being made of
findings of the results. The following format pattern was adopted for this
purpose.

1. The nature of personality dysfunction.

2. The effect of the Bioenergetic psychotherapeutic programme on four

different features of personality disorder, such as psychiatric status,

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 psycho-physical health status, self-esteem level and bioenergetic
condition.

3. Differential effects of Bioenergetic treatment on psychiatric status of

various types of personality disorders.

4. Other factors contributing significantly to therapeutic outcome, such as

education, occupation, socio-economic status and family support;
empathy and motivation; chronicity of illness and medication
prescribed, and the effects of defence mechanisms and re-
inforcement styles.

5. Discriminant Functional Analysis of key variables.

5. The holistic nature of personality dysfunction and the three different

components of bionergetic assessment and treatment (energetic,
physical and psychological processes) will be highlighted with the
presentation of a detailed case study.

1. Nature of Personality Dysfunctions:

With the publication of the third edition of the diagnostic and statistical
manual of mental disorders (DSM III) in 1980, and the introduction of the
multi-axial diagnostic system, personality disorders were distinguished as
clinical syndromes in their own right on Axis I. which were clearly different
from Axis II dysfunctions like disorders of mood, depression and psychotic
disturbances. However, the recognition and treatment of personality
disorders continued to be neglected by psychiatrists and psychotherapists

189
 alike. As Clarkin (1996) pointed out "personality disorders are among the
most difficult and least understood problems facing the psychiatric profession
today". Firstly, dysfunctional personalities were difficult to conceptualize
clearly and secondly, clients with disturbed personalities presented a wide
range of diverse symptoms which did not easily respond to the specific
treatment mode of a particular therapist like cognitive therapy, behaviour
therapy," humanistic approach or psycho-analysis.

The principal empiricalbase of this research was the recognition of

the diverse and multidimensional nature of the different personality groups,
both in terms of classification into diagnostic categories as well as symptom
presentation. Hence, the study proceeded with the careful and meticulous
classification of the nine different personality disorders under observation into
diagnostic categories as laid down in Millon and Everly's (1985) Diagnostic
Evaluation of Personality Disorder Inventory (Appendix II). The
homogeneity of each group was tested by Classification of Results (Table
5:7.g) and a 100% hit rate in accurate prediction was observed.Hence, any
generalizations drawn on this sample could be validated by any other
measures.

While classifying these groups it became apparent that the diagnostic

categories themselves presented an integrated selection of diverse psycho-
somatic components, namely, personality characteristics, inter-personal
conduct, physical behaviour, affective expression, and self-perception. The
pyramidical structure of personality dysfunction as illustrated by Lowen
(1979) was evidenced in the classification system (Fig 6:1).

It was also realized that an effective treatment programme for a

psychiatric condition as diverse, complex and multi-faceted as personality

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 ego
self-
'perception^

cognitive
processes
inter-personal
processes

affective processes
emotions and feelings

physical and somatic

processes

Fig 6:1 Pyramidical structure of personality dysfunction (Lowen,1979)

disorder must essentially aim to alleviate all the different dysfunctional

elements in a holistic manner. Hence, it was considered efficacious to apply
the bioenergetic mode of psychotherapy which was an essential combination
of psychological and physical techniques and methods of understanding
aimed at relieving all the different aspects of personality dysfunction
(physical, affective, interpersonal, cognitive and inter-psychic functioning).

2. Effect of Bioenerqtic psychotherapy on holistic (mind-body)

functioning;

In keeping with bioenergetic principles, the nine different personality

disorders were correlated to five bionergetic personality patterns (Table 4:3)
and the therapist commenced a six months treatment programme. At the

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 termination of the therapeutic process, clients were assessed on the levels of
change in:-

i) psychiatric status
ii) psychophysical heath status
iii) self esteem level and
iv) bioenergetic condition
which occurred as a result of the psychotherapeutic treatment.

Psychiatric Status:

The statistical results recorded in Table 5: l a indicated that the

majority of clients experienced highly significant decreases in psychiatric
symptoms as a consequence of the bioenergetic treatment. At the start of
the treatment programme the mean score on psychiatric status was 34.16
compared to the significantly lower mean score of 10.43 after the termination
of the treatment process. The obtained 't' value between the means (t: 39.33;
d.f. 43, p: 0.001) shows that the majority of clients, suffering from
disturbances in personality dysfunctions benefited significantly from the
therapeutic course in terms of psychiatric status.

It was also observed that prior to treatment S. D showed little

variability (S.D 0.99 with S.E.m. 0.15) which indicated homogeneity in the
whole group prior to treatment in terms of their psychiatric status. In contrast
there was considerable post-treatment variability (S.D. 4.17 with S.E.m 0.63)
suggesting differential prognostic impact as a result of Bioenergetic Therapy.

During the course of this study the following trends were observed in
the psychiatric status of the different personality disorders:

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 i) Clients with paranoid personalities appeared much less
suspicious of others including the therapist, less hypersensitive
to presumed insults and attacks, more confiding and more self
- confident

ii) Clients with schizoid disorders were found to be less

emotionally detached. They began to experiment v/\\h sexual
relationships, were more willing to enjoy leisure pursuits and
started to express feelings and emotions in an overt manner;

iii) Clients with anti-social personalities became more appreciative

of social norms and rules. They were more considerate of
others, less deceitful, impulsive, aggressive and irritable.

iv) Clients with borderline problems felt less abandoned, and less
uncertain about their sexual identity. At the termination of the
therapeutic course, they were more realistic in their judgement
and expectation of others and started to show signs of
emotional stability.

v) The histrionic client's pervasive pattern of excessive

emotionality and attention seeking; sexually provocative
behaviour; theatrical shows of self-dramatisation; all decreased
as a result of the Bioenergetic treatment programme.

vi) The narcissistic client's grandiose sense of self importance; his

inter personal exploitativeness; his preoccupation with fantasies
of unwarranted success; his lack of empathy and constant
displays of arrogance decreased significantly towards the end
of the psychotherapeutic process.

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 vii) Clients suffering from avoidant personality disorders were much
more willing to take personal risks and engage in new activities
without feeling embarrassed; they were less socially inhibited;
less hyper sensitive to negative evaluation; and began to feel
less inferior to their peers.

viii) The clinging, submissive, excessively passive behaviour of the

dependent personalities showed remarkable changes. They
started to make everyday decisions without continual
reassurance from others; began to initiate projects
independently; felt much more confident about taking care of
themselves, and gradually showed overt signs of
assertiveness.

ix) Clients with obsessive-compulsive disorders demonstrated

significant positive changes in their preoccupation with
orderliness and perfectionism; their over conscientious,
scrupulous, inflexible attitudes; their excessive devotion to work
and productivity; their inability to delegate tasks and their
refusal to discard worn out and worthless objects.

Similar changes in psychiatric symptoms of borderline personality

disorder were found by Runeson and Beskow (1991) during their work with
young Swedish patients following a cognitive therapy programme; and, a
marked decrease of paranoid symptomology was noted by Weston and
Siever (1993) as a consequence of intensive psychotherapeutic treatment
based on Gestalt methods.

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 Psychophysical health status:

The results noted in table 5: 1b demonstrate that most of the clients

showed considerable decrease in psychophysical disturbances at the end of
the six months therapeutic process. Prior to treatment the mean score (m;
43) was substantially higher than the post- treatment score (m: 16.52). The
obtained 't' value between the means (t: 39.25, d.f. 43, p: 0.001) indicates a
highly significant difference in pre and post treatment condition in terms of
psychophysical health status and it was concluded that bioenergetic
techniques effectively reduced the level of psycho-physical distress in clients
suffering from personality disorders.

Another feature was the low level of variability in the client group prior
to treatment (S.D. 1.89 with S. E.m 0.29) suggesting the existence of a
homogenous group compared to high level variability after treatment (S.D.
4.34 with S.E.m 0.66) indicating that the Bioenergetic treatment process
impacted psycho-physical health status of clients at different levels.

At the termination of the six month therapeutic programme the

following general trends were observed in the psycho-physical condition of
clients:-

i) Increases in appetite and less discomfort in digestive and

urinary systems,
ii) Improvement in cardiovascular and pulmonary functioning,
iii) Less insomnia and fewer panic attacks,
iv) Decreases in migraine attacks and back aches,
v) Memory appeared shaper and concentration improved.

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 vi) The clients gradually became more sociable, more optimistic
and less depressed. They also showed a marked increase in
their thresholds of tolerance,
vii) Decreases in lethargy and increases in goal-directed
behaviour,
viii) Attitudes of helplessness and passive dependency on others
became less habitual.

Similar findings had been reported by Ornish (1995) who found that an
effective psychotherapeutic programme could reverse the condition of
arteriosclerosis.

In their observation of patients suffering from clinical depression

Nityanand and Satyavati (1989) recorded significant changes in
psychosomatic condition including increases in mental alertness and self-
confidence and considerable decrease in asthmatic attacks and bowel
irritability following a six weeks course in pranic healing.

Self-esteem Level:

The statistical results of table 5:1. b demonstrated that the majority of

the client group showed a noticeable increase in self-esteem levels in post-
treatment condition (m: 32.79) compared to the pre-treatment mean score of
26.43. The T value obtained between means (t: 5.15. d. f: 43. p: 0.001)
indicated that the Bioenergetic treatment was significantly effective in terms
of raising their levels of self-esteem.

During the course of the six month Bioenergetic psychotherapeutic

programme specific changes in the various components of self-esteem
became apparent in the following manner:-

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 i) Clients who were self-critical, self-doubting, displeased with the past
and expectant of future failures prior to the commencement of the
therapeutic programme, started to feel self-confident, and more aware
of the positive sides of their personality. They also showed a more
realistic acceptance of past failings and became more hopeful of
future successes.

ii) Clients who initially lacked self discipline, were easily distracted,
unable to finish tasks and v/ere prone to alcohol and substance abuse
began to show more self-dicipline, perseverance, and determination
In achieving goals They also showed considerable restraint in
drinking, smoking and the use of drugs.

iii) Clients who had previously considered themselves physically

unattractive, who were displeased with their appearance and doubted
their sexuality started to take pride in their physical appearance,
noticed that members of the opposite sex were sexually attracted to
them and were determined to enhance their feelings of mental and
physical well-being.

iv) Towards the end of the therapeutic process, several clients, showed a
clearer sense of their own identify, their behaviour became markedly
more purposive, they started to establish long-term goals and
experienced a sense of inner cohesion and integration.

In their work with adolescents Steinberg and Silverberg (1996) had

found similar changes in the young peoples' self-concept. Children who had
previously felt unlikeable. unpopular, unwanted and excluded, started to feel

197
 needed, popular, accepted and included by their peers as a result of co-
operating in a family therapy progamme.

Bioenerqetic condition:

The results shown in tables 5:1.d-e indicated that most of the clients
experienced a considerable reduction in bioenergetic discomfort in terms of
energetic, physical and psychological processes at both diagnostic and
functional levels, due to the psychotherapeutic treatment in the following
manner-

i) pre-treatment mean score of 6.48 for energetic processes

(diagnostic) was dropped to post-treatment mean score of 3.05.
ii) pre-treatment mean for physical processes (diagnostic) (m: 8.95)
dropped to post-treatment mean (m: 6.41)
iii) pre-treatment mean for psychological processes (diagnostic) (m: 6.75)
dropped to post-treatment mean of 3.14. All these mean differences in
scores were significant at p: 0.001 level,
iv) pre-treatment mean score of 8.82 for energetic processes (functional)
was dropped to post-treatment mean of 6.41.
v) pre-treatment mean score of 6.61 for physical processes (functional)
was dropped to post-treatment mean of 3.52, all of which were also
significant at p: 0.001 level,
vi) pre-treatment mean score of 8.86 for psychological processes
(funtional) decreased to a post-treatment mean of 6.32, all of which
were significant at p:0.001.level.

The results shown in the above tables appear to be a clear indication

of noticeable and comprehensive changes in all three components of

198
 bioenergetic condition which occurred as a consequence of the Bioenergetic
treatment. The discernible changes between pre and post treatment
bioenergetic condition of the five personality patterns {schizoid, oral, psycho
pathic, masochistic and rigid patterns) occurred in the following manner:-

1) The majority of clients experienced a significant increase in energetic

charge towards the periphery of the body including hands, feet, face
and genitals; and considerable reductions in energetic blockages. For
example, clients displaying the oral energetic structure found a
noticeable reduction of energetic weakness in the chest, abdomen
and eyes; clients manifesting the masochistic pattem noticed
resumption of energetic flow to the back of the neck, spine and calves,
and clients with psychopathic disorders observed reduction of
energetic constrictions in the waist and diaphragm.

ii) At the physical level, many clients demonstrated decreases in chronic

patterns of muscular tension and alleviation of dysfunctional
physiological patterns. Thus, the contracted neck, immobile jaw,
hunched shoulders and stiff mechanical movements of clients
suffering from schizoid disorders were noticeably lessened and eased.
Similarly, muscular tensions in flexor and extensor muscles of the
arms and legs, proneness to lower back pain, tight inflated chest and
constricted deliberate movements of the rigid pattern also showed
signs of positive change.

iii) At the psychological level the clients were apt to show characteristic
changes in their reduction of psychological discomfort. The typical
schizoid pattern of dissociating thinking from feeling, tendency to
polarise, hallucinatory ideation, constant night mares and avoidance of
intimacy were considerably reduced towards the end of the

199
 psychotherapeutic process. Similarly the strong feelings of spite,
negativism, hostility, impassivity and self-deprecating, self-doubting
behaviour of the masochistic pattern were much less apparent by the
end of the six-month bioenergetic treatment.

Other research studies on the evaluation of Bioenergetic treatment include;-

i) Halsen's (1992) work at a child psychiatric clinic with children

diagnosed as suffering from narcissistic and avoidant personality
disorders. Halsen found considerable changes in his patient's
energetic, physical and psychological bioenergetic patterns following a
six month treatment programme.

ii) Bandini's (1990) recording of a case of acute schizoid disorder, which

responded positively after a period of long-term Bioenergetic
psychotherapy.

iii) Helfaer's (1990) experiments with a group of psychopathic patients

who achieved a series of holistic, psycho-somatic changes including
marked improvements in respiratory and cardiac functioning and
significant increase in satisfaction levels in intra and inter-psychic
functioning, which was due to the effectiveness of the Bioenergetic
psychotherapeutic method.

The effectiveness of the Bioenergetic process in alleviating personality

dysfunction of forty-four clients studied here have been attributed to the
following reasons:-

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 a) A psychotherapeutic programme is genuinely effective only when it
focuses equally, simultaneously, and comprehensively on all four
inter-reiated parameters of personality dsyfunction including:-

i) psychiatric status
ii) psycho-physical health status
iii) self-esteem level and
iv) bioenergetic condition.

Other researchers like Pierrakos (1969) and HIadky (1993) had also
found that therapeutic changes tend to occur either at a holistic integrated
level in all components of disordered personality, or there tends to be no
significant therapeutic impact at any level. For example, in this study the
success rate of 100% in Discriminant Analysis classification (Table 5:7.f)
occurred because all four psychosomatic aspects of personality disorders
were significantly affected at the same time by the Bioenergetic Therapy
treatment programme. Thus, Bioenergetics represents a multifaceted
treatment method for a multi dimensional breakdown in the client's
psychosomatic system. The focus is equally on psychological and
physiological factors responsible for personality dysfunction and no one
factor is considered of primary or exclusive importance. As this study
demonstrates, psychological factors do not cause physical problems, nor do
physical factors cause mental problems, and neither is the result of the other.
As observed by Lowen (1993) all human problems and illnesses are
systemic in origin with synchronous and simultaneous mind-body (psycho-
somatic) causes.

b) The Bioenergetic method of treatment demonstrated a shift away from

presenting symptoms of personality disorders, towards the seeking of
the origins and causation of abnormal personality development.

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 According to the Bioenergetic framework, personality dysfunction's are
crucial disorders underlying a vast majority of human disturbances
and illnesses. During the course of this study, it was also noticed that
problems of personality development are not only qualitatively
different from other psychiatric illnesses and therefore have to be
treated differently, but that disturbances of personality may well be an
all-pervasive factor underlying the development of other more serious
psychiatric conditions like manic depression and psychotic states such
as schizophrenia.

c) Bioenergetic psychotherapy is an integrated amalgamation of several

significant psychiatric principles and methods of treatment like:

i) Gestalt therapy which emphasised the concept of holistic

functioning (Perls, 1973)
ii) Bio-psycho-social paradigm initiated by Engel (1977)
iii) Primal therapy which focused on the neuro-physiological
re-living of childhood traumas (Janov, 1996)
iv) Principles of holistic healing as advocated by Venkat (1996)
v) Behavioural Kinesiology as practiced by Diamond (1989) which
concentrated on the energetic processes of the body,
vi) Neurophysiological approaches of Joseph (1992), Miller (1990)
and Pert (1997) who studied the biochemical composition of
emotions.

3. Differential effects of Bioenergetic Treatment on psychiatric status:

As discussed earlier, the nine different types of personality disorders

were grouped into five sets of bioenergetic personality patterns, each
representing characteristic styles of thinking, feeling and behaving which

202
 were manifested simultaneously at three levels of functioning (emotional,
physical and psychological) (Table 1:4) In this way each group presented a
significant level of homogeneity within itself prior to the commencement of
the Bioenergetic treatment programme which was considered essential for
successful treatment outcome.

The psychiatric status of clients in each group was assessed prior to

treatment commencement (pre-treatment condition) on the DSM IV
personality Dysfunction Scale (Appendix III) and again at the termination of
treatment (post - treatment condition). The difference between pre and post
treatment scores were statistically analysed. It was found that the different
types of personality disorders and correlated bioenergetic personality
patterns showed differential levels of changes in psychiatric status as a result
of the psychotherapeutic treatment.

Table 5:2. d indicated that;-

i) the maximum level of decrease in psychiatric symptoms was

experienced by 12 clients with Rigid personality pattern (histrionic and
obsessive compulsive disorders) who recorded a mean difference in
pre and post psychiatric scores of m: 28.17.

ii) 8 clients with Masochistic personality pattern (dependent personality

disorder) also showed considerable improvement in psychiatric status,
with a mean difference of 25.62 between pre and post-treatment
scores on the psychiatric evaluation scale.

ill) Moderate changes were recorded by 17 clients who suffered from

Psychopathic (anti-social and narcissistic personalities) and Oral
(avoidant and borderline personalities) patterns.

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 iv) 7 clients who exhibited schizoid patterns (paranoid and schizoid
personality disorder) showed the lowest level of psychiatric changes.

Table 5:2.e recorded that the mean of all the five groups differed significantly
at p: 0.001.

The results clearly demonstrated a hierarchical pattern of psychiatric

change as advocated by Lowen (1979). At the bottom end of the hierarchy
was the Schizoid personality pattern (paranoid and schizoid disorders) and at
the top end of the spectrum was the Rigid pattern (histrionic and obsessive -
compulsive disorders). The various personality patterns and disorders
appeared to fit into the hierarchical order according to the type of mind -
body patterns they exhibited and the severity and chronicity of their energetic
blockages, physiological and muscular tensions, and the strength of their ego
defences. [Lowen Bioenergetic Scale, Appendix VI]

The typical hierarchical pattern demonstrated in this study could be

summarised thus:-

i) The Schizoid personality pattern demonstrated the lowest level of

change due to severe energetic blockages, restricting flow of energy
to periphery of body, chronic muscular tensions at head, shoulders,
pelvis and hip joint and psychological split of personality into polarising
attitudes.

ii) Compared to the Schizoid position, the oral structure is a less

dysfunctional condition e.g. oral energy flows weakly to the periphery
but is not frozen like schizoid energy. Similarly, the Oral personality

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 experiences depressive attitudes in early youth, but is not autistic like
the Schizoid.

iii) The Psychopathic structure combines oral as well as masochistic

traits but at a less dysfunctional level. For example, there tends to be
energetic weakness in the lower extremities and a characteristic
dependence on others (oral traits); needs are often suppressed at an
overt level but there is a covert submission to parental manipulation
(masochistic trait)

iv) The Masochistic structure typically experiences energetic blockages at

the neck and waist which are related to the tendency towards
manipulative and provocative behaviour and difficulties in self-
assertion. The structure represents a lower level of severity compared
to the psychopathic structure.

v) At the physical and psychological level the Rigid structure represents

the minimum level of pathology and the most optimistic prognosis. At
the physical level, the body is relatively integrated and well charged
energetically. Psychologically, the client with a rigid personality
pattern copes effectively with others and usually gets his needs met in
a constructive manner.

The discriminatory power of the THP variable (change in psychiatric

status) for the five different groups of personality pattern are graphically
illustrated in Figure 5: 7a.

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 Group 3 which comprises of Rigid personality pattern (obssessive-
compulsive and histrionic personality disorders) has the highest THP value
and demonstrates the maximum level of change in pshychiatric status which
occurred as a result of the Bioenergetic treatment.

Group 1 which consists of Masochistic personality pattern (dependent

personality disorder) has the next highest THP value.

Group 4 which represents the Psychopathic personality pattern (anti-

social and narcissistic personality disorders) demonstrates a moderate THP
value.

Group 5 which contains the Oral personality pattern (avoidant and

borderline personality disorders) indicates a relatively low THP value.

Group 2 which consists of the Schizoid personality pattern (paranoid

and schizoid personality disorders) has the lowest THP value indicating its
place at the lowest position of the therapeutic change hierarchy.

4. Other factors contributing significantly to therapeutic outcome:

The following factors were considered for analyses:-

i) Socio demographic variables like education, occupational status,

socio-economic level and family support,
ii) Motivational level of the client and the degree of empathy achieved
between the client and the therapist,
iii) Chornicity of illness and level of medication prescribed.

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 iv) The client's characteristic defence mechanism and the particular
reinforcement style used to maintain personality dysfunction.

Impact of Education:

The group of forty-four clients was divided into three educational

categories:-

i) post graduate
ii) graduate
iii) non-graduate.

Table 5:4.a indicated that the above educational groups showed different
levels of changes in psychiatric status as a result of the Bioenergetic
treatment course:-

i) 20 clients wi-io had post-graduation degrees showed the highest level

of decrease in psychiatric symptoms (m: 26.55)
ii) 13 graduates showed moderate changes (m: 23.15)
iii) non-graduates experienced relatively lower levels of positive
psychiatric change (m: 19.27)

Table 5:4.b showed that the means of the three educational categories
varied significantly at p: 0.001 level.

It was concluded that a client's educational status significantly affected

therapeutic outcome.

During the course of this study it was observed that in the Indian
milieu psychotherapy is affordable and acceptable only to a minority of the

207
 psychiatric population. The type of client who selects the psychotherapeutic
method of relieving personality distress Is inevitably from the more educated
sectors. Even within this selective group the level of education seemed to
have made a significant impact on the degree of therapeutic success
achieved.

Clients with higher educational qualifications like post-graduate

degrees appeared to have the following characteristics;-

Confidence in themselves and their therapist, determination to

succeed and in possessed of the tools/skills of success.They were totally
involved in the therapeutic process, accepted responsibility for their 'cure,'
had optimistic attitudes and were expectant of positive therapeutic
outcomes.ln comparison, the relatively less educated clients typically
displayed attitudes of greater helplessness, passivity, pessimism and
fatalism.

It was concluded that education was one of the key factors impacting
the level of therapeutic success achieved.

The positive effects of higher levels of education on therapeutic outcome

were also noticed by Kilzieh and Cloninger (1993) in their work with a group
of patients suffering from obsessive-compulsive personality disorders. The
researchers found that following a course in Systemic Family Therapy,
patients who were professionally qualified showed significantly higher level of
changes in symptom manifestations such as indecisiveness, over-
conscientiousness and perfectionism than patients who were relatively less
educated. The highly educated group was also more willing to discard worn-
out worthless objects and were ready to express emotions openly compared
to the less educated group. Kilzeh and Cloninger concluded that educational

208
 status was a significant factor in determining the level of success achieved
by patients in Family Therapy programmes.

Impact of Occupational Status:

The client group was divided into four occupational categories:-

i) professional and private business

ii) skilled and semi-skilled

iii) unskilled
iv) unemployed

Table 5:4.d recorded that the different occupational categories

affected the level of positive change achieved in psychiatric status at the
termination of the Bioenergetic treatment:-

i) 19 clients who were private businessmen or professional showed

maximum levels of changes (m:26.21)
ii) 13 clients who were skilled or semi-skilled workers also showed good
levels of positive changes (m:24.00)
iii) 7 unemployed clients and 5 unskilled workers achieved relatively
lower levels of therapeutic success in terms of decrease in psychiatric
symptoms (m: 19.43 and m: 19.60 respectively).

Table 5:4.e demonstrated that the means of the various occupational

categories varied significantly at the p: 0.001 level, indicating that
occupational status had a significant effect on the psychotherapeutic
process.

209
 It was noticeable that clients occupied in family business and
professionals like doctors, teachers and lawyers possessed high levels of
self-esteem, positive self-perception and self worth. They saw themselves
as role models for their subordinates and were unwilling to lose status in the
eyes of their colleagues. Hence, they were thoroughly committed to
overcoming what they considered a temporary personality dysfunction and
return to their fulfilling responsible jobs. Skilled and semi-skilled workers like
hairdressers and bank clerks also possessed some of the above qualities but
to a relatively lesser degree. In contrast unskilled workers and unemployed
clients were apt to be significantly less inspired, or motivated to change.
They appeared less detemiined to fight their psychological and physical
problems and more willing to accept their dysfunctions. They also
demonstrated the tendency to blame others or fate for their unfortunate
condition.

Impact of Socio-economic status:

Clients were divided into two socio-economic groups:-

i) upper middle class
ii) lover middle class

Table 5 4.g recorded mean differences in psychiatric status for group (I)
(m: 25.07) and for group (ii) (m: 23.03), but the differences between means
was not at a significant level and it was concluded that in this study the factor
of socio-economic status did not make sufficient impact on the level of
therapeutic success achieved.

210
 However it is possible that the division of forty-four clients into only
two categories which have been somewhat incidentally selected was not the
best method for determining the effect of socio-economic status on
psychological well being. On the other hand it is also probable that personal
characteristics like determination, self-confidence, positive self-perception,
commitment, responsibility and optimism which tend to have significant
impact on positive therapeutic outcome, may not necessarily be dependent
on the client's socio-economic background. As such, the whole group
represented a section of middle class socio-economic status.

Impact of Family Support:

The client group was rated on the Family Support Check List
(Appendix VIM) and four levels of support were recorded

i) very good
ii) good
iii) average
iv) below average

Table 5:4.h demonstrated that the four levels of family support affected
psychiatric status in different ways: -

i) The mean difference of change in psychiatric status for the first level
was m; 27.87
ii) The mean difference of change in psychiatric status for the second
level was m: 25: 61
iii) The mean difference of change in psychiatric status for the third level
was m: 23.64

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 iv) The mean difference of change in psychiatric status for the fourth level
wasm: 19.00

Table 5:4.h indicated that all the above means were significant at the
p: 0.001 level.

It was concluded that the level of support a client enjoyed with his
family members significantly affected therapeutic outcome, since clients with
highly supportive families were able to achieve higher levels of positive
change in psychiatric status whereas, clients with unsupportive families
obtained relatively lower levels of therapeutic success.

The discriminatory power of the Family support factor (F.supp.

variable) on the degree of change in psychiatric status as achieved by the
five different personality groups is graphically illustrated in Figure 5:7. d

i) The highest impact of family support level was made on Group 3

(Rigid personality pattern as seen in obsessive-compulsive and
histrionic personality disorders) (group mean: 3.58).

ii) The factor of family support also impacted Group 1 (Masochistic

personality pattern as demonstrated by dependent personality
disorder) at a high level (group mean: 2.62)

iii) Group 4, Psychopathic personality pattern of anti-social and

narcissistic personality disorders, was moderately impacted by the
type of family support received by clients (group mean : 2.55)

212
 iv) Group 5, Oral personality pattern as seen in avoidant and border line
personality disorders, was impacted at a relatively low level by the
family support variable (group mean: 1.25)

v) The factor of family support level impacted Group 2, Schizoid

personality pattern as demonstrated in paranoid and schizoid
personality disorders, at the lowest level. Hence, changes in
psychiatric status for this client group was not impacted by the factor
of family support to the same extent as the other four groups.

In this study family support appeared to be a highly significant factor

facilitating high levels of therapeutic success as a consequence of the
Bioenergetic treatment. Several other researchers have found family support
to be a factor of great magnitude impacting the degree and speed of
recovery from traumatic episodes lil<e earthquake damage and volcanic
disasters (Hanna and Puhakka, 1991) Similarly, Chopra (1992) noticed that
patients suffering from cervical cancer and acute cardiac arrest appeared to
recover considerably faster and much more comprehensively when they
enjoyed high levels of support and understanding from family members. In
this study it was noticed that the 'type' of family support received was a
crucial factor. For example, it appeared much more constructive to have a
family who not only cared deeply for the patient's welfare, but who also
encouraged the patient to use his own natural healing potential instead of
making him helpless and dependent, or pitying him or, blaming themselves
for his personality problems.

Impact of Empathy Level:

An accurate and authentic measurement of 'empathy' initially proved

a problem in this study. To start with, the therapist invited the clients to fill in

213
 a self-designed chek list to assess their empathy level. Almost 96% of
clients professed to be engaged in an empathic relationship but this was
considered to be an unrealistic result. The therapist subsequently invited a
colleague to observe the therapeutic sessions in order to evaluate the
therapeutic relationship. However, several clients were either unwilling to co-
operate or showed obvious signs of discomfort and embarrassment due to
the presence of an outsider. At the end of the seventh session, the therapist
attempted to gauge in an objective manner, whether or not the client
experienced a genuine feeling of being in an empathic relationship and the
results were recorded.

Table 5:5.a showed that the mean difference in psychiatric status for
clients in an empathic relationship (m: 24.68) was considerably higher than
the mean difference for clients who were unable to experience empathy with
the therapist (m: 20.00). The significance level between the two means was
recorded at p: 0.001 level and it was concluded that the factor of empathy
made a strong impact on the level of successful therapeutic outcome
achieved at the termination of the six month treatment programme.

The discriminatory power of the factor of empathy level (EMPL

variable) on the degree of change in psychiatric status as achieved by the
five different personality disordered groups was demonstrated graphically in
Figure 5:7.g

i) The highest impact of the presence of an empathic relationship was

made on Group 3 (Rigid personality pattern of obsessive-compulsive
and histrionic personality disorders), with the group mean of 1.00.
ii) The factor of empathy also impacted Group 1 (Masochistic personality
pattern of dependent personality disorder) at a high level (group
mean: 0.87).

214
 iii) Group 4 (psychopathic personality pattern of anti-social and
narcissistic personality disorders) was moderately impacted by the
presence of an empathic relationship (group mean: 0.77)

iv) Group 5 (Oral personality pattern of avoidant and borderline

personality disorders) was impacted at a relatively low level by the
empathy variable (group mean: 0.75)

v) The factor of empathy level impacted Group 2 (Schizoid personality

pattern of paranoid and schizoid personality disorders) at the lowest
level (group mean: 0.43)

The factor of empathy has been universally accepted as a highly

significant feature of successful therapeutic relationships. Traditionally,
empathy is defined as "the capacity to respond to and understand other
peoples feelings" (Evans, 1988). Empathy does not mean being kind,
sympathetic.consoling or gratifying. According to Krueger (1989), the crucial
feature involved in empathy Is the therapist's ability to adopt an "internal
listening" perspective. In an empathic listening attitude the therapist does not
impose her own preconcieved values, perceptions or notions of reality on the
patient. It is only through dynamic understanding and internalization over the
entire process, that the patient is able to develop "self empathy and self-
structure" which is the ultimate therapeutic goal (Racker, 1996)

Impact of Motivation Level:

The degree of motivation invested by the clients in the therapeutic

programme was assessed on the Motivation Level Check List (Appendix VII)
and four categories were recorded.

!15
 i) very good
ii) good
jji) average
iv) below average

Table 5:5.b indicated that:

i) 11 clients With very good levels of motivation showed the highest

levels of decrease in psychiatric symptoms at the termination of the
Bioenergetic treatment course (mean of change 27.54)

ii) 11 clients with good motivation were also successful in relieving

psychiatric discomfort (mean of change 25.09)

iii) 13 clients with an average degree of motivation were moderately

successful (mean of change 23.08)

iv) 9 clients with below average motivation (mean of change 18.33)

showed relatively low therapeutic progress.

Table 5:5.c recorded that the above data were significantly different at the
p.0.001 level

The discriminatory power of the factor of motivation level (MLVL

variable) on the degree of psychiatric change achieved by the five different
personality pattern disordered groups was shown graphically in Figure 5:7.h

216
 i) The highest impact of the factor of motivation was made on Group 3
(Rigid personality pattern as shown by obsessive compulsive and
histrionic disorders) and the mean of change was 3.66.

ii) Group 1 (Masochistic personality pattern as seen in dependendent

disorders) was also considerably impacted by the motivation factor
(mean of change 3.00)

iii) The factor of motivation level influenced group 4 (Psychopathic

personality pattern of anti-social and narcissistic personality disorders)
to a moderate level (mean of change 2. 22)

iv) Group 5 (Oral personality pattern of avoidant and borderline disorders)

was relatively less influenced by the motivation level factor (mean of
change 2.00)

v) The motivation factor impacted Group 2 (Schizoid personality pattern

as seen in paranoid and schizoid disorders) at the lowest level (mean
of change 1.14)

It was concluded that the factor of motivation was critically important

for the effectiveness of the psychotherapeutic encounter. However, during
the course of this study the therapist realized the importance of differentiating
between a genuinely motivated client and one who only paid iip-service to
the idea of being motivated, thereby concealing an underlying fear of positive
changes. The therapist was also required to distinguish between the
collective motivation of family members and the deep-seated, sustained
motivated attitude originating from the client himself.

217
 Impact of Chronicity of illness and level of medication prescribed:

The chronicity level or duration of the clients illness was categorized as

follows:-

i) first episode
ii) less than one year onset
iii) one to three years onset
iv) more than three years onset.

Table 5:5.e indicated:-

i) The highest level of improvement in psychiatric condition v\/as

shown by the first group (mean of change 28.17)
ii) The second group also showed a good level of decrease in
psychiatric symptoms (mean of change 25.73)
iii) The third group showed relatively lower levels of relief from
psychiatric distress (mean of change 23.67)
iv) The fourth group showed the lowest level of psychiatric change
(mean of change 18.64)

Table 5:5.f recorded that the means of the different levels of chronicity varied
significantly at p: 0.001 level.

The client group was also subdivided into two categories according to:-

i) psychotropic drugs prescribed

ii) no psychotropic drugs prescribed.

218
 Table 5:5.h demonstrated that clients who had been prescribed psychiatric
medication experienced lower levels of therapeutic progress (mean of
change 22.31) compared to clients who were not imbibing psychotropic
drugs (mean of change 25.78)

Table 5:5.h showed that the two groups were significantly different at the
p: 0.001 level.

It was concluded that In this study chronicity of illness and medication

level strongly impacted the level of psychiatric relief experienced by the
majority of the clients suffering from personality dysfunctions.

It was noticed that in the predominantly bio-medical system adopted in

India, a vast majority of psychiatric patients are frequently encouraged to
consider their affliction as a chemical disturbance to be treated bio-medically
with psychotropic drugs. Hence the type of patients who voluntarily choose
psychotherapeutic methods of relieving personal distress represent
individuals who are critical of, or uncomfortable with the typical bio-chemical
methods of treatment. Within this selective sample, clients who have
suffered from dysfunctional personality problems for a period of one to there
years or more and who are dependent on daily doses of psychiatric
medication are more likely to be indoctrinated into believing that they are
suffering from a hereditary, genetic or constitutional illness over which they
have little or no control. These clients also tend to have feelings of dis-
empowerment and are apt to rely passively on the opinions of the bio-
medical experts or blame fate and others for their psychiatric predicament.

219
 The effect of defence mechanism:

The temi 'defence mechanism' was defined by Evans (1988) as "the

various strategies employed by the ego or conscious self to protect itself from
threatening or repressed ideas lying in the unconscious." According to
Millon and Everly's personality development theory (1985) individuals who
developed dysfunctional personalities typically used specific and
characteristic ways of defending themselves. Millon and Everly demonstrated
that a patient's therapeutic progress was invariably affected by the specific
type of defence mechanism employed. In this study, the nine types of
defence mechanisms typically employed were identified as:-

i) dissociation
ii) reaction formation
iii) introjection
iv) rationalization
V) acting out
vi) fantasy
vii) regression
viii) intellectualization
ix) projection

The client's characteristic style of defence was expected to affect

psychiatric status achieved at the termination of the Bioenergetic treatment.
The anticipated hierarchy of change was noted in Table 5:6.a. which
indicated:-

i) Clients who employed the defence mechanisms of dissociation and

reaction formation showed the highest level of decrease in psychiatric

220
 symptoms (Dissociation, mean of change 28.33 and Reaction
formation, mean of change 28.00)

ii) Clients who used the mechanisms of Introjection also showed high
levels of positive therapeutic outcome (mean of change 25.62)

iii) The defences of Rationalization, Acting out and Fantasy appeared to

produce moderate levels of therapeutic success (Acting out mean of
change 23.75) (Fantasy, mean of change 23.000 ) and
(Rationalization, mean of change 22.60)

iv) The mechanisms of Regression, Intellectualization and Projection

produced the lowest level of effects on psychotherapeutic outcome.
(Regression, mean of change 18.67), (Intellectualization, mean of
change 17.67) and (Projection, mean of change 17.25).

Table 5:6.b recorded that the above mean differences were highly significant
(F: 46.49; d.f. 8.35; p: 0.001)

The hierarchical effect of the various defence mechanisms on the

level of positive change in psychiatric status at the termination of the
bioenergetic treatment was graphically illustrated in figure 5:6.a

The following conclusions were made regarding the nine different

types of defence mechanisms observed in this study:-

a) The most successful patients employed the mechanism of Reaction

formation or Dissociation. Reaction fonnation represents processes in
which individuals repress their undesirable impulses and form
diametrically opposed conscious attitudes whereas, Dissociation

221
 refers to the tendency of individuals to separate their 'real' selves from
their 'public' selves. Both these types of maladaptive processes
originate in dysfunctional family patterns, which encourage a split
between the 'psyche' and the 'soma' and often respond to therapeutic
methods which combine cognitive-rational techniques with an
awareness of bodily processes. Hence, Bioenergetic psychotherapy
was an ideal therapeutic style for these types of personality
dysfunctions as It focused on expressive release through somatic
bodily movements, especially in terms of early childhood traumas.

b) Introjection was the tendency of dependent personalities to

'internalize' others with the hope of creating an inseparable personal
bond. When these clients established an empathic bond with the
therapist, they invariably transformed their dependence into assertion
and autonomy. Hence, the therapeutic prognosis for clients suffering
from introjective defensive styles was usually good.

c) In the case of the defence mechanisms of Acting out (that is, the
tendency to impulsively display socially offensive thoughts, emotions,
and overt actions like temper tantrums) and 'Rationalization (that is
the unconscious process of self-deception in which the individual
tends to create a justification for disappointments and failures) there
tends to be a moderate to strong resistance against the therapist's
attempts to facilitate the acceptance of reality. If such resistance is
gradually revoked, personality dysfunction is likely to decrease. On
the other hand, if resistance continues to prevail, the personality
disorder is apt to persist. Hence, clients, displaying these styles of
defences have a moderate chance of succeeding in the
psychotherapeutic process.

222
d) Millon and Everly (1985) observed that with the defence mechanisms
of Fantasy (which is the semi-conscious process of imagination that
appears to gratify needs and wishes that cannot be fulfilled in reality)
and Regression (which is the retreat under stress to earlier
developmental stages), unless the client's 'reality' begins to assume
meaning and significance in here-and-now situations, he finds it
difficult to relinquish his mechanism of defence and continues to
remain dysfunctional in Intra and inter-psychic-functioning. Therefore,
these mechanisms are relatively resistant to change and therapeutic
prognosis is usually poor.

e) The defence mechanisms of Intellectualization (the tendency to think

of and describe affective and inter-personal experiences in a
mechanical, over-rational, matter-of-fact manner) and Projection (the
process of attributing undesirable traits and motives to others)
appears to be even more resistant to change. Millon's (1981)
research studies had recorded that individuals who chronically used
these mechanisms of avoidance, were usually intensely distrustful of
others, (especially people who wanted to help them) and frequently
refused to enter into a warm relationship with the therapist. Moreover,
these clients tend to have a great deal of positive reinforcement from
remaining in a dysfunctional state. Hence, schizoid and paranoid
personalities who displayed defence mechanisms of projection and
intellectualization were apt to remain unaffected by the process of
psycotherapy.

223
The effect of reinforcement style:

Millon and Everly (1985) regarded the concept of 'reinforcement' as

synonymous with reward, satisfaction or pleasure. They analysed the
processes by which an individual seeks reinforcement in terms of a) the
manner in which the individual seeks reinforcement — actively or passively
and b) from whom be seeks reinforcement — independently from himself,
dependently from others, ambivalently, or in a detached manner.

The five types of reinforcement styles utilised in this study included:- -

i) active
ii) dependent
iii) passive
iv) ambivalanent and
v) detached styles

It was hypothesized that some reinforcement styles were more

conducive to therapeutic success than others. The level of
therapeutic change anticipated on the basis of the client's specific
style of reinforcement was recorded in Table 5:6.d which showed :-

i) The maximum level of decrease in psychiatric symptoms was

experienced by clients in the active reinforcement style group
(mean of change 28.17)
ii) Clients who typically used a dependent style of reinforcement
also showed a good degree of decrease in personality •
dysfunction (mean of change 25.62)

224
 iii) Moderate changes in psychiatric status were recorded by
clients with passive and ambivalent reinforcement styles (mean
of change 23.11 for passive and mean of change 21.37 for
ambivalent)
iv) Minimum levels of positive therapeutic change was noted by
clients using a detached style of reinforcement (mean of
change 17.43)

Table 5:6.a indicated that the means of all the various reinforcement
styles differed significantly. (F: 58.75; d.f.: 4,49; p: 0.001)

Figure 5:6.b graphically demonstrated the differential affect of the five

different reinforcement styles on the level of therapeutic success achieved
as a result of the Bioenergetic therapeutic process.

During the course of this study it was observed that clients who seek
reinforcement In a pro-active (as opposed to re-active) self-contained
fashion tend to be more highly motivated to change and accept therapeutic
insights more readily than clients whose method of seeking reinforcement is
based on a passive dependence on others. Hence, these clients achieve
relatively high levels of therapeutic changes.

Lower levels of therapeutic success are attained by clients with an

ambivalent style because these clients are unsure where to seek
reinforcement for their needs and frequently experience a high level of
frustration as a result of unresolved personal problems.

The minimum level of positive therapeutic outcome is experienced by

clients using detached styles of reinforcement, since these clients invariably

225
 end up seeking no reinforcement at all, or deceive themselves into believing
that there was no necessity to satisfy, please or reward themselves.

5. Discriminant Functional Analysis of key variables

The research data was statistically tested on Discriminant Functional

Analysis, (a) to delineate the key variables which impacted the five main
personality groups, (b) to identify the important discriminants which impacted
the Bioenergetic treatment programme and (c) to detennine the accuracy of
prediction by way of classification with each group of clients. -

The discriminant impact of the eight primary variables studied is

shown in Figs 5:7.a-h, which indicate that the highest discriminant power in
all five personality groups is manifested by the THP variable (psychiatric
status) and the PGI variable (psychophysical health status). Hence, the
client's range of holistic (mind-body) personality characteristics and his
physical and psychological sense of well-being, appear to be the two most
significant discriminant factors which have impacted the Bioenergetic
treatment.

Table 5:7.d records the Eigen value, percentage of variance,

accumulation of percentage and Canonical correction of the four major
discriminant functions. Function 1 explains 62.55 % of total variance,
followed by Function 2 which explains 17.92 % of total variance, followed by
Function 3 which explains 1.57 % of total variance and Function 4 which
explains the lowest level of total variance, namely, 0.15 %.

226
 This result substantiates that the highest discriminant factors in this
study are (a) the client's psychiatric symptoms like disturbances inter-
personal conduct and self-perception and (b) his psycho-physical health
symptoms such as dysfunctions in physiological and psychological
functioning.

In Table 5:7.g the Classification Matrix indicated a 100 % hit rate in

terms of accuracy of classification. Therefore, it was concluded that whatever
generalizations have been drawn from the classification results reflect
accurate prediction.

6. Presentation of Case-Study to illustrate-therapeutic impact:

The major premise of this study was that the mind and the body are
inextricably connected within the human organism. Whatever happens in the
mind is automatically registered in the body and what occurs in the body
necessarily leaves an imprint on the mind. Hence, there is no mental illness
that does not have a physical overlay. However, it is difficult to test these
principles quantitatively. Therefore, it was considered essential to present
certain important clinical and therapeutic data in the form of a detailed
diagnostic case history.

The case illustrated here will be discussed in the following manner:-

(A) PESENTATION OF:-

i) Socio-demographic and diagnostic data
ii) Pre-treatment psychiatric status
iii) Pre-treatment bioenergetic condition

227
(B) FAMILY AND DEVELOPMENTAL HISTORY:-
i) birth history
ii) early childhood
iii) precipitating factors leading to personality dysfunction

C) PROCESS OF BIOENERGETIC PSYCHOTHERAPY: -

i) bioenergetic analysis of presenting symptomatology
ii) stages of therapeutic process
iii) evaluation of psychiatric status and bioenergetic condition at
tennination of treatment programme.

228
 5.A i) SOCIO—DEMOGRAPHIC AND DIAGNOSTIC DATA

NAME All Akbar (assumed name)

AGE 21 years
SEX Male
SOCIO-ECONOMIC STATUS Upper Middle class

EDUCATION School drop-out

FAMILY SUPPORT LEVEL Below Average
MOTIVATION LEVEL Below Average
EMPATHY LEVEL Absent

DIAGNOSIS Schizoid Personality Disorder

PSYCHIATRIC HISTORY: -Personality dysfunction diagnosed
at 13 years at Child Guidance Clinic
following academic failure and self-
mutilating behaviour.
-Succession of psychiatrists but total
non-co-operation.
-Referred for Bioenergetic treatment
following suicidal attempt in
February 1998

CHRONICITY OF ILLNESS 8 years

MEDICATION Prescribed but refused.

PROGNOSIS Very poor.

229
 5.A II) PSYCHIATRIC STATUS (PRE-TREATMENT CONDITION)

Ali, psychiatric status was assessed on the DSM IV personality

Dysfunction Scale. (Appendix III) The severity level of pre-treatment
condition was recorded.

Score
1. Neither desires nor enjoys close relationships including 4
being part of the family

2. Almost always chooses solitary activities 5

3. Rarely, if ever, claims or appears to experience strong 5

emotions such as anger or joy

4. Indicates little if any desire to have sexual experiences with 5

another person

5. Is indifferent to praise or criticism from others 4

1. Has no close friends or confidants (or only one) apart from 5

first degree relatives

7. Displays constricted affect e.g is aloof, rarely responds with 4

facial expressions such as smiles or nods.
Total=32
(Maximum Score for each rating: 5)

230
5.A III) BIOENERGETIC CONDITION (PRE-TREATMENT)

All's bloenergetic condition was assessed on the Lower Bioenergetic

Scale (Appendix VI)

Diagnostic and Functional Analyses were recorded on energetic, physical

and psychological scales as follows:-

SCHIZOID BIOENERGETIC STRUCTURE

(Paranoid and Schizoid Personality Disorders)

Energetic Scale Diagnostic Analysis

Therapist rating 1-10

10 = most typical 1 = least typical

231
Energetic Scale - Functional Analysis
Yes No

1. energetic block at base of skull

2. energetic block at base of shoulders

3. energetic block at base of pelvis

4. energetic block at base of hip joint

5. energetic block at base of diaphragm

6. energy deflected through eyes

7. energy deflected through ears

8. occasional explosive energetic charge

9. top-bottom energetically split (see diagram)

10. left-right energetically split (see diagram)

Total

232
 MAJOR BODY
SPLITS

Right/Left Split Top/Bottom Split

Physical scale -Diagnostic Analysis

Yes No

1. mask like face

2. little or no eye contact
3. fixed smile
4. contracted neck
5. arms hang like appendanges
6. feet everted
7. body weight carried on outside of feet
8. stiff mechanical movement
9. immobile jaw
10. shoulders hunched forward
Total 10 0

Physical scale -Functional Analysis

1. inflexibility of elbow
2. inflexibility of wrist
3. inflexibility of hip joint
4. inflexibility of knees
5. inflexibility of ankles
6. poor body concept
7. permanently cold hands
8. permanently cold feet
9. depersonalisation
10. disassociated from sexuality
Total 8 2
 Psychological Scale-Diagnostic Analysis

Yes No

1. split in psychological functioning

e.g. tendency to polarise
2. thinking dis-associated from feeling
3. mood swings
4. frequent nightmares
5. hyper-sensitive
6. out of touch with reality
7. hallucinating ideation
8. unable to express anger
9. highly secretive and private
10. socially unskilled
Total 10 0

Psychological Scale-Functional Analysis

1. low self-esteem
2. tendency to withdraw from difficult situations
3. sensitive to rejection
4. actions contrary to needs/wants
5. avoids intimacy
6. feelings of rejection
7. tendency to intellectualise feelings
8. inability to trust or confide in others
9. intense fantasy life
10. difficulty in making decisions
Total 10

235
 5.B FAMILY AND DEVELOPMENTAL HISTORY

Birth history

much wanted only son in orthodox Muslim family with four

daughters.
family tradition of first cousin marriages.
conceived when parents middle aged (mother 52 years father
51 years)
mother constanWy unweW <iuriv^g pregnancy - nearly aborted
twice.
traumatic and premature birth: umbilical cord around neck.
placed in incubator for six months.

(ii) Early childhood

neuromuscular development poor

delayed milestones e.g.. walking, talking, cutting teeth
mother too nervous and unwell to look after child who became
labelled "the Zenana baby"
Over-protected, pampered and smothered by elderly female
relatives
Father an infrequent visitor who was embarrassed and
ashamed of All's fragility.
All was taunted for "being a sissy' and constantly compared to
"the young man of the house" (the youngest daughter).

236
 iii) Precipitating factors leading to personality dysfunction

When Ali was seven years old his parents were involved in a serious
car accident as a result of which his father was paralyzed from the waist
downwards. They had been returning home from a late night party and All's
father had forced his wife to drive, as he was thoroughly intoxicated. Ali
reported that his father had always been a hot-tempered and chauvinistic
person. He was now house-bound, impotent and was becoming an
alcoholic. As a "punishment for her careless driving " he started to abuse his
wife physically and verbally. In sharp contrast to the domestic violence, he
was " a paragon of virtue" in public. Ali had vivid memories of being woken
up by his father in the middle of the night and being ordered to watch while
he "bashed my mother's face and head against the wall' accusing her of
making him "into a zombie." All's mother accepted this treatment
uncomplainingly as her 'legitimate punishment" and continued to feel guilty
about her "negligence."

Twice a year All's mother was "banished" to her native village in

Punjab escorted by young Ali. Gradually, she developed a 'liason' with her
maternal uncle. Ali become their confidant, their "big strong man", "the only
one who could be trusted to keep the family secret.' Under these
circumstances Ali felt isolated, confused and overwrought;

he was forced to accept "the unbearable responsibility" of his

mother's extra-marital relationship.
No parental figures were available to confide in or be protected
by
He had no safe place to express his confused and polarized
thoughts, feelings and emotions.

237
 He was trapped between his father's overt rage and his
mother's implicit pleas for secrecy.

As a consequence, Ali began to develop the typical Schizoid

Personality Pattern of:-

dis-associating from intra and inter-psychic reality,

separating his psyche (mental and emotional self) from his
soma (physical and sensory self)
rationalizing and intellectualizing his feelings.

5.C:1 PROCESS OF BIOENERGETIC PSYCHOTHERAPY

i) Bioenergetic analysis of presenting symptomatology

A detailed bioenergetic analysis of Ali's psychosomatic (mind-body)

dysfunctioning was made in order to provide an accurate and effective
framework for formulating a therapeutic plan and achieving therapeutic goals.

Bioenergetic assessment of presenting symptoms was made

from three simultaneous perspectives (psychological, physiological and
constitutional)

-Psychological perspective which attempts to explain behaviour in

terms of conscious and unconscious mental attitudes.
-Physiological point of view seeks to understand disturbed attitudes in
terms of derangements of bodily functions and
-Constitutional perspective relates personality to bodily structure.

238
 From the psychological perspective Ali's schizoid distrubance was
manifested by.-

-Lack of identify: Ali frequently maintained "I don't know who or what I am. I
have no idea where I'm heading or what I want.. At times, I am even
confused about my sexuality."

-Lack of normal intimate relationships: Ali constantly avoided close contact

with others, including family members. He was excessively shy and timid
and invariably felt inferior to others. He was over-sensitive to criticism and
unduly suspicious. He remarked that "I feel hollow and empty inside... it's a
very lonely place... I can't get involved, so I make up fantasies instead."

-Inability to express emotions: Especially hostile or aggressive feelings.

Ali often turned negative affects like anger inwards towards himself, as seen
in his frequent attempts at self-mutilation.

-Rapid swings and polarisation of thoughts, feelings, attitudes and

behaviours: Periods of hectic activity would be rapidly followed by
prolonged withdrawal; feelings of grandeur by long bouts of depression;
unprovoked temper-tantrams by docility and guilt.On one hand Ali
experienced feelings of sexual inadequacy, on the other hand he proclaimed
"I am God's gift to women." Ali's personality appeared to be split into
opposing attitudes.

From the physiological view point the following tendencies were exhibited:-

-Distorted awareness of bodily self: Ali portrayed an alarming disturbance of

self-perception by completely dis-associating from the sensory and physical
aspects of his personality. His over-perceptive mind regarded his body as an

239
 "alien object." Ati "disowned" hiii body and continuously declared "it's not
mine, it doesn't belong to me."All's body concept was very poor. He hated
his "revoltingly ugly face", his chin because "it refuses to grow a beard" and
his lack of masculinity. He considered himself "a wimp" and moaned that" I'll
never become a real man no matter how hard I try."

-Lack of physical co-ordination and disintegration: Ali was unable to catch a

ball, he had difficulty learning to swim, he had a series of accidents on his
motor bike.Under strong emotional stress his hands and feet trembled. On
social occasions his fingers shook when holding a knife and fork. Ali reported
feelings of "disintegration" within his body - "my left side is always trying to
dominate the right side" "my head is not on speaking terms with the rest of
the body." All's feelings of fragmentation and dissociation were portrayed in
Figure 6:2.

-Inability to experience pleasure or satisfaction: Ali had an inadequate

supply of energy, reduced mobility, he suffered from permanent fatigue, he
could not engage in any purposive social or sexual activity. He showed
occasional outbursts of irrational violence and anger.

He had an eating disorder associated with frequent bouts of nausea and

serious respiratory problems. Ali complained that " most of the time I feel
lethargic... my energy seems to be stuck in a frozen ball here (pointing to his
chest)... "But somehow this icy snowball sometimes becomes an active
volcano... I feel eruptions and explosions all over.

From the constitutional perspective All's body belonged to the aesthenic

type — elongated, thin and with under developed musculature.

240
 9 §

t I t

\ ^
u
Fig 6:2 Graphic expression ^ragmertadon" and "disintegration"

241
 -The central problem of Ali's disordered personality was represented by the
relationship between the head ana the rest of the body. Ali felt that his head
was hanging slightly to one side as if its connection with the rest of the body
was broken. At the same time he noticed severe and chronic muscular
tension at the base of the skull. Ali described these sensations as a "noose
drawn round my neck and pulled tight." This description seemed identical to
the "noose hang-up" which Lowen attributed as being typical of the Schizoid
constitution (Fig 3:6.d).

-Ali displayed some features usually associated with the opposite sex, like a
hairless chest and a rounded pelvis. As Boadella (1990) had mentioned
these bodily features are typical of the schizoid personality and are known as
'dysplasia.'

-One of the most strking features about Ali's appearance were his eyes
which seemed to assume three types of expressions—a cold, glassy," fish-
like" look, an intense, burning, piercing stare with a quality of desperation in
it; and an unfocussed, remote, "spaced-out switching-off."

-Ali showed a marked lack of facial expression which could be described in

bioenergetic terms as "The Schizoid Mask." (Lowen, 1979). The
characteristic features were a fixed smile in which the eyes did not
participate; a "cadaverous" look in the face; and excessive rigidity and
inflexibility in the jaw. These typical expressions also appeared in Ali's figure
drawing of himself as shown in Figure 6.3.

242
Rg 6:3 Illustration of the Schizoid mask

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 5.C 2 STAGES OF THERAPEUTIC PROCESS

The bioenergetic treatment process between Ali and the therapist

underwent the following stages.

1) Resistance and escalation of dysfunctional behaviour

2) Process of transference
3) Awareness and acceptance of psychosomatic dysfunctions.
4) Expression of repressed material physically and experientially.
5) Resolution.

1"'-4'*'session:
Combination of passive-aggressive behaviour, bouts of intense
negativity, unexpressed hostility and anger towards the therapist.Over a
period of two weeks, Ali slashed his wrists, took an overdose and attempted
to drown himself.

5^^ - 8"^ session:

Expression of open hostility and attempts to demean, insult, humilate
and ridicule the therapist. Ali did not believe he could be helped and went all
out to prove it. The therapist did not measure up to him and would not be
"strong enough or clever enough to cure me."

9"^-13*''session:
Transference to therapist of feelings and attitudes developed in
relationships with his parents. The therapist became a substitute mother
figure.The first overt emotion transferred was distrust, and the therapist was
accused of being "cold and unemotional." At the covert level, Ali was seeking
warmth, comfort and acceptance for being himself which he was deprived of
from his parents.

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 14*^-17'^ session:
The therapist allowed Ali to focus his anger directly towards her rather than
dissipating his feelings amorphously in his usual fashion, or converting his
negative energies into violent fantasies.Gradually Ali became aware of his
repressed emotions and eventually realized that "the actual focus of my rage"
was "that bastard, my father, who I worshiped and idolized."

-,gth_2oth Session:
Acceptance of the above awareness was a much more difficult task for Ali,
because with acceptance came the realization that there was no 'magic cure'
for his predicament, that 'understanding' the problem and 'blaming' his
parents was not going to change the past, present or future.Reluctantly, Ali
began to realize that if he really wanted to "get out of this mess" the therapist
was probably "the best of the bad lot." and he considered "giving this
'therapy-thing' a shot.... at least for a while."

21** session:
At the start of this session Ali announced "I am ready!". This
statement marked the beginning of establishing an empathic bond with the
therapist; accepting responsibility for his psychiatric symptoms; and the hope
that "I think it's going to work."

22nd _ 26th session:

Phase of active bioenergetic treatment commenced with a series of
relatively passive movements to increase All's identification with his
kinesthetic body sensations. The first step was to assist Ali to become aware
-of his somatic self. Ali began to experience his bodily inadequacies and
weaknesses only when he was put in a position of stress. He was asked to
stand with his feet thirty inches apart, toes turned inward, knees bent as

245
 much as possible, the back arched and hands on the hips. This position is
known as The Bow and is illustrated in Fig 6:4. In All's schizoid body
structure the tension was unequal on the two sides and the trunk was twisted
one way, while the head was twisted the other way. His heels turned
inwards and his legs trembled violently. The Bow position served to increase
All's feeling of his legs and the perception of their tension.

Another posture, which is the reversal of the Bow, was used to bring
All closer to the ground and develop feelings in his diaphragm and abdomen.
As Figure 6.5 demonstrates the body's full weight is upon the feet, which are
approximately fifteen inches apart with the toes turns slightly inwards.In this
position All's diaphragmatic block was gradually released and his breathing
became abdominal, deeper and more relaxed.

Another particularly helpful posture was to have Ali arch his back over
a stool as shown in Figure 6.6.The Arch Position stretched the muscles in
All's back and promoted deeper breathing. Following this Ali went into a
position of hyper extension as indicated in Figure 6:7.The position of
hyperextension was particularly effective in stretching muscles in front of the
thighs, which were quite spastic in All's schizoid body structure.

These movements appeared to give Ali a sense of "aliveness" in his body. As

sensations began to flow through into the legs and feet, when breathing
became spontaneous and rhythmic, All's feelings of fragmentation and
dissociation gradually decreased. Ali remarked "I am beginning to feel in one
piece not torn apart" and "for the first time in my life my head seems to
belong to me".

246
Fig 6:4 iilustration of the Bow position

247
Fig 6:5 Illustration of the Forward Bend position

Fig 6:6 Illustration of the Arch position

Fig 6:7 illustration of the position of hyper - extension

Fig 6:8 A F^iysio-expressive movement

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 27^*^-43'^ session:
This phase of the bioenergetic treatment concentrated on the
simultaneous physical and experiential expression of repressed material from
the past. At this stage, more active bioenergetic movements were used to
help All to relive and express repressed emotions related to early traumatic
experiences and to allow feelings to become ego-directed.Figure 6.8 shows
a typical physio-expressive movement of a patient prepared to strike the bed
with a tennis racket. In All's case this movement served to release
aggression and develop coordination and control. Later, Ali struck the bed
with his bare fist. He also lay flat on his back on the bed and kicked
aggressively with his legs and feet.

These physically oriented movements spontaneously triggered off long

forgotten painful memories buried in the unconscious, and a combination of
emotive, analytic and physical bioenergetic activities allowed Ali to gradually
"evacuate the accumulated garbage of the past twenty one years" in the
safety of the therapist's clinic. It was noticed that memories were usually
triggered off in chronological sequences. For example, memories of birth
trauma preceeded reliving of the "Zenana Days".

Towards the end of this treatment stage, Ali said he felt "unburdened,
relieved from the burdens of the past" and wondered " why I waited so long
to free myself.The following psycho-somatic changes were noticeable:

At the psychological level, Ali was able to express anger more

readily, he had a clearer sense of identify, and his attitude and behaviour
were less polarized.

250
 At the physiological level, physical coordination had improved
considerably, Ali was not so embarrassed by his lack of overt masculinity,
and he felt much more energetic.

At the constitutional level. All's face and eyes had become markedly
more expressive, chronic muscular tensions at the base of the skull had
eased and Ali felt that "the right and left sides of my body are more
connected than before."

44th _ 52"'! session:

The last nine sessions of bioenergetic treatment focussed on applying
therapeutic insights gained to here-and-now situations. The therapist
encouraged Ali to assume primary responsibly in the therapeutic alliance.At
the termination of this stage Ali recorded that:-

he had started experimenting with and sometimes enjoyed

moments of intimacy with friends of both sexes.

He was involved in a series of social and intellectual activities.

He was much more interested in his personal appearance and

grooming

He had become less disturbed by criticism and was becoming

accustomed to praise from others.

He was much more at peace with his body.

251
 He experienced considerable reduction in muscular tensions
and significant increase in energy levels.

He was more relaxed and less excitable.

He was less secretive, and did not spend much time fantasying.

He noticed a significant decrease in his feelings of

helplessness and frustration.

He was much more ready to take an active role in getting what

he wanted, instead of suffering in silence.

53"^ session:
At the final session of the Bioenergetic treatment, All's psychiatric
status and bio-energetic condition were re-assessed on the DSM IV
personality Dysfunction scale and the Lowen Bioenergetic scale, with the
following results:-
Bioenerqetic Condition (Post treatment)

ENERGETIC SCALE PHYSICAL SCALE PSYCHOLOGICAL

SCALE
Diagnostic Functional Diagnostic Functional Diagnostic Functional
Rating Rating Rating Rating Rating Rating

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 Psychiatric Status (post-treatment condition)

1. Neither desires nor enjoys close relationships including being 2

part of the family.

2. Almost always chooses solitary activities

3. Rarely, if ever, claims or appears to experience strong emotions 2

such as anger or joy

4. Indicates little or any desire to have sexual experiences with another 3

person

5. Is indifferent to praise or criticism from others

6. Has no close friends or confidants (or only one) apart from first 1
degree relatives

7. Displays constricted affect e.g.is aloof, rarely responds with 1

facial expressions such as smiles or nods.

Total 13

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 All's case history was presented as a clinical demonstration of the
holistic mind-body dysfunction of the schizoid personality pattern. The two
most characteristic features which determine this illness are a) conflict which
splits the unity of the personality and b) the subsequent withdrawal and loss
of contact with reality.ln conclusion, All's schizoid personality is a classic
example of the "The Divided Body " and " The Disassociated Mind" as
illustrated by Lowen (1993) in Fig 6:9.

IHisloiuEgaLmd FeeUng of dflvamtiaai

BodyLsvd

-Spia
Dctpaix' > Distodation
bomAfaBody

Fig 6:9 Illustration of the divided body and disassociated mind (Lowen, 1993)

254
 In this chapter the major research findings have been dicussed in terms of
Millon and Everly's personality theory (1985) and the bioenergetic principles
laid down by Lowen and his colleagues (1970-1990). It was summarised
that:-

1.Bioenergetic psychotherapy was an effective treatment method for

alleviating psychiatric symptoms associated with the nine different types of
personality disorders studied here:

(a) Clients with Paranoid personality disorders were significantly less

suspicious of others.

(b) Clients with Schizoid disorders were less emotionally detached.

(c) Clients with Anti-social personalities became more law- abiding.

(d) Clients with Borderline disturbances became more emotionally stable.

(e) Histrionic clients became less theatrical and exhibitionistic.

(f) Narcissistic clients became less arrogant and self-opinionated.

(g) Avoidant clients became more purposive.

(h) Dependent clients became less submissive and passive, and

(i) Obssesive-compulsive personalities became less pre-occupied with

orderliness and perfectionism.

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 2.The psycho-physical well-being of the clients was also enhanced has a
result of Bioenergetic treatment programme. For instance, the clients'
cardiovascular, pulmonary and digestive functioning improved considerably;
they had fewer panic attacks; slept more soundly; were less tense; less
depressed; less dependent on others and more optimistic, sociable and
outgoing.

3.lt was noticed that in the majority of the clients, self-esteem levels were
considerably low prior to treatment and showed significant increases at the
termination of the therapeutic process. Thus:

(a) Clients who were self-critical, self-doubting and pessimistic gradually

became more assertive and self-assured.

(b) Clients who were easily distractable and lacked self-discipline became
more responsible and determined to succeed.

(c) Clients who had previously considered themselves physically

unattractive began to develop a positive self-concept.

(d) Most of the clients experienced a clearer sense of their own identity and
started to established purposive, realistic, long-term goals.

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 4. As explained in chapter 4 (Table 4:3), the group of forty four clients who
exhibited nine types of personality disorders were also classified into five
Bioenergetic groups in order to facilitate the implementation of the treatment
process.

The bioenergetic condition of the clients was assessed at three levels

(energetic, physical and psychological) with two types of analyses (diagnostic
and functional) as shown in Table 1:4. The majority of the clients
experienced considerable reductions in bioenergetic dysfunctions on all the
above paradigms, as a result of the forty eight sessions (approx.) of
Bioenergetic therapy they had undergone. For instance:

(a) At the energetic level, there were significant increases of energetic

charge towards the periphery of the body including hands, feet, face and
genitals.

(b) At the physical level, most of the clients demonstrated noticeable

decreases in chronic patterns of muscular tensions.

(c) At the psychological level, many clients experienced decreases in

hallucinatory ideation; their thoughts and behaviours became more
synchronised and there were considerable reductions in psycho-somatic
(mind-body) dissociations.

S.The nine different types of personality disorders and the five bioenergetic
groups show different level of changes in psychiatric condition, as a
consequence of the therapeutic treatment in terms of their behavioural
appearance, inter-personal behaviour, cognitive style, affective expression
and self-perception.

257
 As shown in Table 5:2.d;

(a) Rigid personalities (obssessive-compulsive and histrionic personality

disorders) showed maximum levels of psychiatric changes.

(b) Masochistic personalities (dependent personality disorder) showed the

next highest levels of changes.

(c) Psychopathic personalities (anti-social and narcissistic personality

disorders) were next in the hierarchy.

(d) Oral personalities (avoidant and borderline personality disorders) were

fourth in the hierarchy of therapeutic change, and

(e) Schizoid personalities (paranoid and schizoid personality disorders)

showed relatively the least level of changes compared to the other four
groups.

It was suggested, that some types of personality disordered patterns

indicated better prognostic outcomes and that some disorders were more
receptive to the psychotherapeutic mode of treatment than others.

S.The various factors which impacted therapeutic outcome were analysed by

Discriminant Functional Analysis and it was found that the primary variables
which accounted for the majority of therapeutic progress were education,
occupation, family support level, motivational level and empathy level.Hence,
clients who were well educated, in high status occupations enjoying good
levels of support from their families, who were motivated to change, and had
established an empathic therapeutic relationship were more likely to attain

258
 relief from their symptoms of personality disorder, than clients who did not
have these advantages.

7.A detailed diagnostic case-study of a client suffering from an acute

Schizoid personality disorder was presented to elucidate details of the
Bioenergetic psychotherapeutic process and to demonstrate the typical
psycho-somatic (mind-body) disturbances of the typical schizoid personality
patterns.

It was concluded that a) psychiatric disturbances involved in personality

disorders do not occur in isolation, but are part of an integrated complex of
holistic disturbance and b) Bioenergetic psychotherapy was an effective tool
in alleviating the holistic range of mind-body discomforts associated with the
various types of personality disorders.

259