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Case Study on Z not as Impossible as we had Thought

Lloyd, J., 2007. Case Study on Z not as Impossible as we had Thought. Reformulation, Summer, pp.31-39.

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CAT and severe PLD

Nowadays offering therapy to a person with learning disabilities is far more accepted than when Bender wrote his original 1993 article called the ‘Unoffered Chair’ on the therapeutic disdain for people with learning disabilities. However, with an IQ of 51 and a language level measured at 5 years 4 months, talking could never be the main focus of a therapy for 25-year-old Z. Obviously, work could not be just at an individual, direct level; it would involve indirect working with the staff team and wider agencies involved in her care. Nevertheless, I wanted to find out if Z could develop more helpful procedures, even when reflecting verbally with her about reciprocal roles (RRs) was going to be difficult or impossible. I wanted to see if a person with learning disability (PLD) could have sufficient relational intelligence to make working in a CAT-informed way possible.

Getting CAT supervision

It is difficult to get a CAT psychotherapist / supervisor willing to supervise in learning disabilities. This may not be abhorrence of the client group, although it sometimes is. Some supervisors feel stumped; they may have had no experience of PLD. CAT often has a highly paradigmatic approach involving developing reflective ability by casting an observing eye over internal maps. If this level of meta cognition were outside a client’s cognitive abilities, how could it be done?

As a learning disability clinical psychologist, I approached a CAT psychotherapist / supervisor and asked if we could work together. Although she was reluctant because she had conducted only one 32-session CAT therapy with a person with severe learning disability, she did finally agree to help. I would deal with the learning disability bit, whilst she could deal with the CAT bit, as I had not been trained in CAT. Interestingly, in the end we both learned about the other’s approach and combined these skills to help the client, who changed and strengthened more than we ever thought possible when we began.

Initial referral and contact

Because of her frequent crying, the community nurse who was visiting Z asked me along to see if I thought anything could be done. Staff described how they tried hard to help Z to be happy, but she would not engage in the nice things they offered and did the bulk of the housework, relieving her housemates of these duties.

At first when we arrived at her supported living home, she sat there, face very flaccid with a vacant look and then burst into tears. Once recovered enough to speak, Z tearfully said she wanted to be happier and agreed to work with me.

History

Z is the youngest of four children. The oldest is her 40-year-old sister, who has a dual diagnosis of schizophrenia and learning disability. Next is her brother, who has serious substance abuse problems. Her second sister, who is a couple of years older than Z, has a learning disability that is even worse than Z’s. Both her parents have a history of in-patient psychiatric treatment, and the family has a local reputation as ‘a social problem’. Social Services described Z as a Cinderella at home, to the extent that she was not allowed to go to college and was required to do most of the housework.

A year ago, before her referral to psychology, Z was living with her parents in the family caravan. Her parents contacted social services demanding they remove Z, as they could not stand her crying any longer. Z was then placed with two other tenants in a supported living arrangement provided by a national charity.

Initial sessions (assessment, therapeutic alliance, relationship)

Although most community learning disability work takes place in the person’s home or where they attend daytime activities, in order to offer her the safe, separate type of place that most people can access when having therapy, her support workers agreed to bring her to the local community learning disability team. Unfortunately, the team does not have a ‘therapy’ room, and all rooms have multiple occupants, perhaps reflecting the idea that people with learning disabilities would not need a therapy space. However, two chairs could fit in the storeroom, which has an adequate window, and despite much competition to get access to this space, most sessions could take place there.

At first Z seemed so bewildered. When she wasn’t crying, her face was flaccid and blank. She could not tell her story directly, so we used CAT adapted tools, including the 6-part story (Kim Dent-Brown), Blob Tree (Pip Wilson), and Inner Voice Check, a pictorial device created by my supervisor (see Elia’s article in this issue). The 6-part story allowed Z to draw 6 pictures to tell a story with a central fantasy character who had to accomplish a task. She was asked to show that a problem arises, then to show how something helps solve the problem, and then what happens in the end. Typical of many people with learning disabilities, Z’s story about wanting to fix something broken (in her case, a broken swing) was perhaps describing how she saw herself as broken and incomplete. In addition, the van in her story broke down, while carrying new equipment to fix the swing.

With the Blob Tree, which has people in various places up a tree, Z placed herself right at the top, where she longed to be. She also described in a very perceptive manner where other people she knew were to be placed. Using the Inner Voice Check, she described parents picking on children. She showed overall that she could reflect and have a sense of selfdirection. Her relational ability would facilitate our therapeutic aim of helping Z help herself to be happier and not exploited. To do this we would need to find the right tools to aid our communication and form a working alliance.

Z and I tried hard to build a relationship. It was very difficult at first. She had an idea of parental and support worker relationships, but the collaboratively reflective therapeutic interaction was completely different. Support workers have a range of roles, often like parents guiding children-- teaching and advising, as well as doing for or helping with some things whilst putting a stop to other things. I struggled, as the normal therapeutic approach of conversational inquiry quickly proved futile. Z could not initiate conversation and had such difficulty remembering events and describing her feelings that she replied “I don’t know” to nearly all questions asked. We felt so far apart, and nothing seemed to work.

My supervisor and I discussed connecting via touch, but touch isn’t generally allowed in LD work owing to abuse. My supervisor suggested we hold a scarf between us and tug on it to indicate how we felt. I tried the scarf once, but there still seemed to be no contact between us. Then I tried a more sensitive material, a wide stretch band like the ones used in physiotherapy or Pilates. This allowed us to feel movement better, although, at first, Z simply hung on to it. Things moved forward, in an early session, when I accidentally dropped the elastic band and Z picked it up, handing my end to me. My supervisor and I considered this showed how keen Z was to be in contact.

I wondered how Z was feeling and my supervisor suggested getting a happy and sad mask to find out which one Z looked at the most. Z preferred the happy one. As this worked, my supervisor suggested we could try some dolls, and I found two old wooden dolls, one of whom had a broken off foot. Z and I could role play, with her as the Z-doll and me as the Julie-doll. Our first game involved me demonstrating a blockage in our relationship. My supervisor suggested I play out how the Z-doll needs a new foot but everything the Julie-doll tries fails, which makes the Julie-doll cry. We hypothesised that Z, who feels broken and has been treated like rubbish at home, might rubbish ‘poor’ Julie. But this did not happen.

As the Julie-doll started to cry, I passed her to Z and asked, ‘What now?’

‘She needs to cheer up,’ replied Z, and she suggested the two dolls could dance. I praised her enthusiastically for having such a good idea, as she made them dance. I then drew the story in our respective folders, where we could keep our work to help us remember it. Praising Z for having good ideas astonished her at first, as she had no notion that she had any ideas. Sinason (1992) discusses the concept of Secondary Handicapping as a defence against the trauma that having a learning disability usually produces. Showing intelligence was a frightening risk for Z, as it meant her peeking out from her handicapped shell. She was totally unused to her views being respected.

The staff team and I then discussed how they could praise her, not just when she had done or suggested something, but just anyway. This led us to think about her vacant expression. We speculated that children with a learning disability might miss out on the many smiles that normal children are spontaneously given. Also, as the deficiency becomes more obvious when, as a small child, the developmental gap between the PLD and other children grows, she would become less attractive to others and less cheerfully responded to, more neglected. This leads to a ‘no smiles trap’. We wondered if practising with a mirror could teach her to smile more instead of simply looking vacant. Although she became far more expressive including smiling more, it is unlikely that this was because of practising with a mirror as although she liked looking in it she did not take to the task, perhaps as it was too artificial.

Reformulation

Z said the main reason she was unhappy was daily intrusive, bullying phone calls from her parents, often in the evening after support staff had gone home. Her father would tease her, but worst of all her parents would take it in turns to slag each other off. Her mother would also keep demanding that Z tell her that she had been good (which therefore implied she was bad). She repeatedly said that she only wanted a weekly call and for her parents just to talk about nice things. But since Z was unable to leave the phone ringing or put it down when upset, she would end up in tears both during calls and when she thought about them later.

In supervision, I learned about Trap, Dilemma, and Snag and discussed with my supervisor how to communicate some of this to Z, using words and the gesture and drawn sign language Makaton. In the reformulation I wrote to Z

You have told me you get sad because: you don’t have the love you need from your Mum and Dad; Mum and Dad get cross with you, tease you and tell you about their problems.

I wonder if you are also sad and cross because having a learning disability means you feel broken and wish someone could mend you.

The main unhelpful RR was ‘bully—victim’, with Z mostly in the victim role. Under headings that I wrote, Z drew this expressive picture (figure 1) describing the RR. Other RRs included ‘blaming—blamed’, ‘abandoning—abandoned’, and ‘perfectly caring—perfectly cared for’.

The target problem procedures were:

Sometimes when you are sad you stop yourself doing things you like doing. That makes you feel even sadder.

Sometimes you think that either you have to put up with other people dumping on you and being bossy, or they won’t like you any more and you will lose them.

Figure 1

Sometimes other people try to cheer you up, but it’s not enough, so you throw them in the dustbin.

As Z wanted to learn how to be happier, the aim was for her to learn how to be kind and caring towards herself, and how to stand up for herself.

Z and I used to look at the letter often, as she was thrilled to have received her own letter. We tended just to look at one or two sentences at a time because her concentration was limited. She said she wanted her support staff to read it to her. I think this was a way of bringing them in, as she did have a taped version that she could have listened to without them.

Developing a Sequential Diagrammatic Reformulation

Several different Sequential Diagrammatic Reformulations (SDRs) did not seem to connect with her. For example figure 2. However, after we discussed what she understood to be her predicament, she could identify more with the following diagram shown in figure 3.

She recognised at once what it was about and the trap in which ‘trying to please’ would not alter mother’s unpredictability, always leading Z back to her powerless and depressed victim role. Coming round in a circle every time it left her not knowing whether or not her mother would be nice or nasty, so Z would constantly try to please. The SDR also included an Aim: to give up both the bully and the victim roles and still somehow find a way to be happy.

Z identified with the diagram and when I asked her what each of the people in it were doing and feeling, she decided to call them Mum and Dad and her name. Initially she nodded at both possibilities about whether she liked to be nasty or nice, but over time she began to express the wish that she wanted to be nice. She liked the diagram so we often referred to it, but only as therapy finished did she become able to recognise how trying to please other people who were being nasty towards her did not work, including incidents with other tenants. At first, she did not even recognise what was happening as bullying—the other tenant never cleaning up after herself and expecting Z to do it. This was just as it had been at home for Z. Since she wanted the other tenant to like her, as she had wanted her parents to love her, she cleaned. However, towards the end of therapy, staff told me that they had witnessed Z refusing the request the tenant’s request to pick something up that she had just dropped, replying, ‘Why don’t you do it yourself.’

New procedures, such as putting the phone down, could be written via Carol Gray’s Social Story methodology. In this way we were able to work together to find an exit from ‘bully— victim’.

Although Z could recognise this TPP in sessions, her dramatic revision of it had to wait until after therapy sessions had finished, when she had become stronger.

Creative approaches

We developed a Happy List full of pictures of things Z liked to do as suggestions about how to cheer up. She liked this and arrived at one session with many more ideas that she had developed with her support workers. She wanted a copy of the Happy List on her wall as well as in her folder.

When she arrived for therapy, Z would come bounding up the stairs to the storeroom looking cheerful. Staff began to talk about her smiling and being responsive. Over the months, her crying reduced, and in our sessions she became alive and started to fiddle around with the dolls before putting them down and waiting for me to direct the games.

Our games played out the 3 TPPs described above. However, she was still accepting the emotionally abusive phone calls, and staff were unable to protect her as these calls came after they left. Although she now occasionally considered she was being bullied by one of the other tenants, she would hastily reassure herself and me that really the tenant was nice and they liked each other.

Z started to lead the doll play sometimes. On one occasion, she had the Z-doll beg the Julie-doll to give the Z-doll her foot (as the Z doll had a missing foot). The Julie-doll (played by me) kept saying she couldn’t; she couldn’t cut off her wooden foot, as it wouldn’t fix onto Z’s so it wouldn’t be any good. The Z-doll (played by Z), kept on and on begging, moving from an initial coy request to getting very insistent and upset. I stopped the doll play at this point, put the dolls down and told Z how sorry I was that her life with her parents was so difficult and that she had a learning disability, but that I could not make it all better. She cried and tears welled up in my eyes too.

She had been starting each session by saying “Not those dolls again!” in a gruff, endearing voice, at the sight of them sitting in their usual place on top of a table. It was clear to me from this ironic greeting, how much she enjoyed the dolls and our work with them. I wanted her to lead the games, but she rarely did this, and doll enactments of the TPPs were not apparently changing her behaviour.

Z told me that the dolls kept fighting, so not knowing what to do with them next, she agreed when I suggested we could put them under the table. She then asked for them to come out again. In supervision we reflected how learning disability is catching. I wanted her to have ideas, which she rarely had and often I ran out of ideas too.

My supervisor said it would be all right just to be there together and be patient, instead of always trying to have ‘good’ ideas or judging that change was too slow. Before the start of the next session, I placed the dolls under the table, and Z commented “They’re so naughty”. She reached for the dolls and after playing for a bit, noticed that she was wearing nail varnish the same colour as mine. We then talked about what was similar and different about the clothes we were wearing. When I asked her about being grown-up now that she was 25, she told me about having menstrual periods. She even knew the brand names of the different sanitary towels, and we discussed their relative merits. This was my first access to Z as one woman to another, and in supervision we wondered whether this personto- person maturity would extend to thinking about babies and to asking Z if she had ever wanted to have one.

Over time, the staff and I could see how Z had developed a rush on one of the male support workers. This is so often a problem for people with learning disabilities who are almost always disappointed in this area. Being repeatedly rejected as a loved partner is difficult to bear and makes people like Z more vulnerable to abuse and grooming by predators. In addition to legal safeguards, there are strict policies in place. While we did not believe the support worker was consciously leading Z on, the home manager and I met to discuss how to best protect Z’s feelings. His role was changed from being her key worker, and a female support worker replaced him. I also met several times with him to help him put in firm boundaries. As he later decided to leave the job, Z and I spent time processing this loss. After he left, she quickly transferred her crush onto a new male support worker, and so I worked with the staff team again on helping the new support worker to have the same absolute boundaries in place.

We continued with doll play during our sessions, and I found a tiny doll to add to the other two. Z disliked this doll intensely, wanting to chuck it away, which she did gleefully. She was clearly jealous – there was no place for a baby doll getting in the way of the Julie-doll and the Z-doll! During this session she picked up my end of the stretch band, which I had accidentally dropped again, and when we started to pull it, I asked her if we should sing a song to the chucked away baby doll. I taught her ‘Rockabye Baby’, as we could chuck it away during the last line, “Down will come cradle, baby and all’. This lead to one of the two main games we played over and over during therapy.

She would place the two wooden dolls (having discarded baby doll permanently) on the stretch band, and we would sing the nursery rhyme. At the point in the song when the baby falls down, we would tug the band to throw them up into the air. Z loved this game and played it over and over, but I felt really uncomfortable as she chucked the dolls around the place, particularly aiming at getting them in an old dirty plant pot stored in the room. I worried at her joy at seeing them being hurt. When I asked the dolls if this would hurt them, Z would laugh sadistically. She sensed how I felt and would keep reassuring me that the dolls were ‘cute’ or ‘sweet’, whilst carrying on enjoying hurting them. I used to model how to be caring and sympathetic towards them.

I wondered and discussed with my supervisor the dilemma: allow her to express her shadow side and possibly reinforce unacceptable sadism or stop the free expression of hurtful behaviour and teach good enough behaviour. Although Z didn’t feel uncomfortable, I really did, so deciding to make a moral stand, I found a foam ‘cabbage patch’ style doll that was dressed like a teenager and sat this new doll on the table along with the wooden ones. It might sound strange that I felt the foam doll would not get hurt by being chucked, unlike the wooden ones. I suppose this is owing to the greater resilience of foam compared to wood. The bigger foam doll did not clatter like the wooden dolls when she hit the floor. Z was absolutely delighted by the new doll, which we called ‘Big Doll’. (I can’t remember who named her). Now chucking Big Doll around at the end of the rhyme became fun for me too as we both laughed.

‘Big Doll’ soon became everything Z wanted to be, and Z would get her to do things she wanted to do. For instance, she wanted us to be able to pull the stretch band and chuck Big Doll right up high so that she would land on the top shelf fixed high on the wall. At a non-verbal level, this was a step towards revising her sadness by beginning to believe it was possible to be in a top place, as in the Blob Tree assessment. The game was about empowerment.

‘Not a chance of getting her up on that shelf,’ I explained to her, happy to play the game but thinking how this was an expression of what it is to have a learning disability but never reach your goals. I discussed in supervision how tragic this was, as Z’s aim seemed to re-capitulate her failure to achieve in other areas. Gently, I used to point out to her that I didn’t think we could get Big Doll up there. I wanted to protect her from repeated failures, but my supervisor advised me just to stay with it.

One day, to my astonishment we did it; we got Big Doll up there! After that we got her up there lots of times. My supervisor commented that all along Z had known we could do it, whilst I had insisted we couldn’t. It was as though I had blocked her aspiration by buying into the apparent hopelessness of LD. Z and patience taught me that you can be learning disabled and still have special experiences and sense of achievement. Learning disability and determination are not incompatible. I was reminded that people with learning disabilities could enjoy perfect moments that go beyond the limits others have in mind for them.

Z was still having problems with accepting her mother’s phone calls. She seemed to have no concept that she had a right to refuse to take these unwanted calls. My supervisor and I wondered if we could try looking at this through doll play by teaching Z how to hide. We got Big Doll to hide tiny Easter Eggs amongst the books and boxes in the storeroom. We enjoyed eating the eggs Big Doll found and chuckled knowing that some of the eggs were still there, as Big Doll couldn’t find them all. Then one day whilst telling me about receiving another phone call, Z suddenly said that next time it rang she could hide in the bathroom. Despite this brilliant idea, however, she was still unable to ignore the phone.

Use of staff

Liaison with the staff team took place before and after each session with Z. Staff would discuss with Z how she had been the previous week and remind her of any events they thought I should know. After the session, Z could tell them anything she wanted help with, such as putting her Happy List up on the wall. Much of our conversations centred on what to do about these phone calls from her Mother; staff were reminding her that she could put the phone down or fetch them if they were on shift. We also regularly talked about how they were praising her, not just for things she had done, but for anything. I had several staff training sessions, going through her main SDR. These meetings were very productive, as we explored together more helpful procedures for her and how not to be pulled into her previous ones.

Finally, the care manager and I decided to visit her parents to ask them to phone only once a week and to talk just about ‘nice things’, which Z defined as asking her about college or nail varnish. We gave them a letter to this effect from Z, which she had been supported to write. Agreeing to allow us to make this visit required great courage from Z, as she was scared she would lose her parents’ love. Unsurprisingly, her parents appeared sullen during our visit, but they did not challenge the authority they perceived us to have. Phone calls reduced. Although her parents then gave Z a mobile so they could ring her without us knowing, this did not work, as Z could not use it.

Ending

Staff and Z reported how happy she was, and as our yearlong work seemed to have gone as far as it could, it was time to slowly end. Z filled in the Inner Voice Check again. There were substantial changes. At assessment, she had said in response to the first drawing, which shows a child being happy and dancing: “I didn’t dance at home – I would have liked to – might be more nicer for me. Parent says not to dance and the child says it would be nice for me to dance”. At the close of therapy, her response to the same item was: “She might be enjoying dancing on her own. She (the parent) might let her do colouring. (The parent knows the child) likes going to the cinema. She likes doing singing; it makes her happy.” On the drawing showing ‘The child is sad’, Z had said in an upset voice at assessment, “About my Mum, when she argued she argued on Friday with Dad – often. He picks on her, I don’t like it.” By the end of therapy, Z had developed a way of separating herself from her parents’ arguments: “aaaagh. (a very sympathetic noise) Her Mum might have an argument with her Dad and she gets upset. She (the child) might like to go up in her room.”

We both felt that it was okay now to move on. She said that she felt a lot happier and was able to do things from her Happy List. Using an outcome measure, The Assimilation of Problematic Experience Scale (APES) Newman and Beail version for PLD (2002), I established that she had reached a vague awareness of the Bully/Victim RR, although I considered she was at risk of not being able to recognise it without prompting. She made clear statements about what she wanted and was far more able to improve her mood by using her Happy List as a strategy. And she had become more assertive.

When we celebrated the work we had done and exchanged Goodbye letters, (in prose, with the photo of Big Doll on the top shelf from me to Z and a drawing from Z to me), she said she wanted to tell the staff team about her therapy herself. She wanted to use her folder and wanted me to help her. We had such a joyful meeting as she took charge of it, turning the pages over and pointing to the bits she wanted me to describe, and adding her own comments including asking staff if they had anything they wished to ask her about our work. We also talked about further games with Big Doll, who now lives on the top shelf in Z’s room, this time involving the staff team to explore whether Big Doll might learn to live on a middle shelf sometimes. We were worried that Big Doll cannot always be on top because in that position, all Big Doll could do is to fall down. But she’s on the top shelf at the moment, as we didn’t want to deny her the joy of being on the top shelf sometimes.

Follow-up

Before our third and final follow up, Z made a serious accusation of sexual abuse by a man living nearby. The abuse happened to her and another vulnerable tenant. The ensuing Vulnerable Adults Investigation involved my supporting the police to interview Z on video and providing the protocol for and contributing to a series of risk meetings between care management, the community team, and the provider charity. Z coped extremely well and appears to have recovered from this trauma much better than the other tenant, whose mental health deteriorated to such a point that she had to be moved out of supported living into adult placement. Although her therapy may have given Z the strength to recover, this incident does point to the extreme vulnerability of adults with learning disabilities to sexual predators. At the time of writing, a decision by the Crown Prosecution Service is still awaited, but as for most accusations by people with learning disabilities, it is highly unlikely that it will proceed to trial.

Shortly after this incident, Z’s mother unexpectedly turned up to visit her (only the second visit since her mother had thrown her out), but was caught attempting to steal several bags of Z’s clothes. Further vulnerable adults procedures were looked at and Z asked for help to write to her mother, insisting that her mother only be allowed to visit if she gave prior warning, was accompanied by staff, and remained in the lounge. Z was far more confident about having such a letter written this time. A few weeks later, her mother turned up one evening when staff were absent and according to Z said that unless Z gave her some money she would kill herself. Z described how she replied, “If you don’t go away, I will kill you.” and closed the door. Z then went through the back door to access the next-door house, which is also a supported living home and has staff present. Clearly, she was now able to decide not to be exploited and to summon help. Staff told me how proud they are of her and that our therapy had clearly helped her become not just happier but to be more appropriately assertive.

Summary

My work with Z was very complex owing to her degree of learning disability, the risks she encountered in her supportedliving house when staff were unavailable, and the therapy process, which had been challenging for her. She had chronic difficulties arising from the ‘bully—victim’ RR, learnt in childhood, which led to ‘trying to please’, lack of assertiveness, frustration, and depression. Therapy offered her the opportunity to address these issues directly, although it had been environmentally addressed when she moved from into supported living.

I felt that I had little control regarding the situations she encountered, particularly with her family and the sexual abuse incident, but close work with the staff team helped me obtain a realistic description of the risks and an acknowledgement of how the system could not keep Z as safe as we wanted. Z had seemed powerless to apply understandings from knowing her TPPs for a long time, but she surprised all of us as she found her strength and her voice. She became assertive with her exploitative fellowtenant and her upsetting, selfish mother, learned to change her mood using the Happy List of things to do, presented her case with her therapist to the community team, and recovered from a scary assault. She made Big Doll fly through the air and land on the top shelf.

The CAT model helped me work with Z in a one-to-one, creative manner and to get far closer to her than I would have thought possible. I struggled at the beginning, as I wanted her to take the lead more but found her passive. Then, as our relationship deepened, I felt uncomfortable alongside her sadism. Maybe she first needed to feel at ease expressing this through the dolls, in order to be able to decide what her boundaries would be in relation to others, especially her mother.

There were several learning points for me. The first was in thinking about what to do, when I feared the uncomfortable nature of the RRs being played out between us when the doll play was sadistic. The second came when I saw for myself how Z exceeded all my expectations about what she could do. Here was a clear example of how intelligence is made up of multiple parts, as she was clearly relationally intelligent whilst struggling verbally. After verbal/pictorial work around teaching her alternatives to her TPPs seemed to have failed, I was pessimistic. But Z taught me that she had the capacity to move forward productively in her own creative way and at her own pace.

Julie Lloyd

References

Bender, M. (1993). The Unoffered Chair: the history of therapeutic disdain towards people with a learning difficulty. Clinical Psychology Forum 54: 7-12. Gray, C. (2003). My social stories. London: Speechmark Pub Ltd. Sinason, V. (1992). Mental Handicap and the Human Condition: New Approaches, Tavistock Free Association Books Ltd.

Full Reference

Lloyd, J., 2007. Case Study on Z not as Impossible as we had Thought. Reformulation, Summer, pp.31-39.

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