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Murase’s (2015) case study of Mr. R meticulously examined the process of psychotherapy with a severely disturbed male client who received a variety of diagnoses such as personality disorder, schizoaffective disorder, and nonspecific psychotic disorder. His condition was drastically improved through interaction with the therapist using the medium of drawing. The severity of his condition was shocking enough for me as a psychiatrist in private practice to carefully examine the differences and similarities with the assessment and intervention that I usually practice as a behavior therapist. This case study took the form of a "narrative case study," in which there were no quantitative outcome measurements used; however, there were more similarities than differences with single case experimental design in behavior therapy. Intervention in this case was carried out through communication enabled by drawing. It can be inferred that central to this process were emotional expression through drawing and the accurate verbal responsiveness of the therapist. As the intervention progressed, there emerged discontinuous change in the client without his making conscious efforts to do. I examine the mechanism behind this next. Murase’s intervention seems to be directed at the client’s living and its context itself, while setting the initial condition and constraining condition that determine the new emerging context. This is in sharp contrast to behavior therapy that directs its intervention to facilitate continuous change in a set of behaviors selected by the assessment using functional analysis. In this case study, the initial condition consists of the assessment expressed as "first take the pulse of the situation before you, then apply the method that best conforms to it (p.109)," which enabled two constraining conditions: the framework for self-expression in the form of drawing, and honest attitude and responsiveness with no evasiveness or shakiness. These are core facilitative determinants of this therapy. Finally, I conclude my commentary by discussing how case studies can provide models and guidance for future generations of therapists and therapy researchers.

Discontinuous Change Facilitated by Emotional Expression Through Drawing and the Accurate Verbal Responsiveness of the Therapist