Katathym Imaginative Psychotherapy: Textbook of Working with Imaginations in Psychodynamic Psychotherapies [1st ed. 2023] 9783662678046, 9783662678053, 3662678047

Table of contents :
Foreword to the 2nd Edition
The Gate to the Book—A Foreword
Contents
About the Authors
1 Introduction
Excursus 1: katathym
Excursus 2: Hanscarl Leuner
References
2 The Stuff that Imaginations are Made of
Excursion 3: Kinesthetic
References
3 Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination
3.1  The Beginning Before the Beginning—How Therapy Gets Started
3.2  Basic Principles of Indication Setting and Treatment Planning
3.3  Indication for the Inclusion of Imaginations in the Psychodynamic Therapy Process—Their Three Therapeutic Functions
Excursus 4: Primary Process
3.4  Basic Principles of Treatment Agreements in Psychodynamic Therapies
3.5  Imagination Announcements as Part of Treatment Agreements
Excursus 5: Daydream and Imagination
3.6  Specifics of the Initial Imagination and Practical Handling Tips
Excursus 6: Initial Dream
3.7  Debriefing of the Initial Imagination
References
4 A Short-Term Therapy With Imaginations: The Case of Musat
4.1  Establishing Contact and First Impressions of the Therapist
4.2  Therapy Planning
4.3  The Initial Imagination
4.4  First Treatment Phase
4.5  Second Treatment Phase
References
5 A Psychodynamic Psychotherapy with Imaginations: The Case of Grün
5.1  Initial Contact, First Impressions, Symptoms
5.2  Therapy Planning
5.3  Initial Imagination
5.4  The Therapeutic Process
Reference
6 An Analytical Psychotherapy with Imaginations: The Case of Eichel
6.1  The beginning before the beginning
6.2  Therapy Planning
6.3  Initial Imagination
6.4  Three central scenes of the analytical process
6.5  The Analytical Process: At the Foot of the Mountain—Uphill—Reaching the Summit Plateau—Downhill
Reference
7 Systematic Presentation of Working with Therapeutic Imaginations
7.1  Therapeutic Attitude in KIP
7.2  Dealing with Stimulus Motifs in the Initiation of Imaginations
Excurse 7: Symbol
7.3  Intervention Techniques in Imagination Accompaniment
Excursus 8: The Acoustic Dimension of Imaginations
7.4  Embedding Imagination in the Therapeutic Session and the Therapeutic Process
Excursus 9: Subject-level/Object-level Dream Interpretation
7.5  On the Post-Imagination Adaptations
7.6  Termination of a Therapy with Imaginations
7.7  Dealing with Transference, Countertransference, and Resistance in KIP
7.7.1  Introductory Theses
7.7.2  The Concept of Transference in Kip
7.7.3  Resistance in and Outside of Imaginations
7.7.4  Transference Phenomena in KIP
7.7.5  Perception and Handling of Countertransference
7.7.6  Practical Tips for Resistance Management and Transference Analysis in KIP
Excursus 10: Projection Neurosis
Excursus 11: Scene
References
8 Application Spectrum and Training Organization
Excursus 12: Precursors of KIP and terms used for KIP in other countries; references to related methods
References
9 Imagination in Art and Intellectual Life
References
Directory of Excursions
References

Citation preview

Ulrich Bahrke Karin Nohr

Katathym Imaginative Psychotherapy Textbook of Working with Imaginations in Psychodynamic Psychotherapies

Katathym Imaginative Psychotherapy

Ulrich Bahrke · Karin Nohr

Katathym Imaginative Psychotherapy Textbook of Working with Imaginations in Psychodynamic Psychotherapies

Ulrich Bahrke Zürich, Switzerland

Karin Nohr Berlin, Germany

ISBN 978-3-662-67804-6 ISBN 978-3-662-67805-3  (eBook) https://doi.org/10.1007/978-3-662-67805-3 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer-Verlag GmbH, DE, part of Springer Nature. The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany

V

to our children

Foreword to the 2nd Edition Four years of working with our textbook in various training and further education groups, many appreciative collegial feedbacks, and the growing interest in KIP have shown us that the elaborate attempt to fundamentally rethink the work with imaginations in psychodynamic therapy processes has more than paid off. Furthermore, we are pleased that with the translation of our textbook into Russian, this psychodynamic guide to working with imaginations is now also available in Russia, where the “symbol drama” enjoys great appeal. In particular, our conceptualizations of the character of imaginations in their kinesthetic, enlivening potency and the basic functions of imagination use, as well as the largely newly systematized intervention inventory of imagination stimulation, accompaniment, and discharge, have proven themselves along with the illustration in the three case presentations and the differentiations in the in-depth chapters. That they are very conducive to learning or rethinking the sometimes seemingly simple, but actually requiring much knowledge, experience, and tact handling of therapeutically guided imaginations—this pleasing impression is suggested by feedback from the training and further education institutes, which coincides with our own teaching impression. For the new edition, we have made a few changes: In 7 Chap. 2 and 3 we have more precisely defined the formerly four functions of imaginations and now describe their three: clarification and expression function, stabilization function, and structure-promoting function. In the characteristics of imaginations, we have included their enlivening and aesthetic potency— thus eliminating conceptual ambiguities between characteristics and functions of imaginations. For professional reasons and for international comprehensibility, we have replaced the expression “depth psychologically based,” which is only used in Germany, with the adjective “psychodynamic” and have only left it where it is derived from the statutory provisions. We would like to thank the staff of Springer Publishing for their professional support of the book, especially Monika Radecki, Claudia Bauer, and the editor Sonja Hinte. Ulrich Bahrke Karin Nohr

Zurich and Berlin in spring 2018

VII

The Gate to the Book—A Foreword Before you read this book, we invite you to a short imagination exercise: Please close your eyes, go inward with your attention, and imagine a gate. Any gate. Take your time … When a gate appears before your inner eye, look at it from all sides, let it have an effect on you. What do you notice about it? How does it feel? Do you know it? How do you like it? Can you make out the surroundings in which it stands? What is in front of, what is behind the gate? And is there something you would like to do, something you feel like doing with or at this gate? Perhaps you would like to implement your impulses in your imagination as well … And now emerge again. You are just beginning to read a book about the use of guided imaginations in therapeutic processes. Let the impression of your gate accompany you during your reading. Perhaps questions will come to you like: Why this gate and not another? What does it remind me of ? What does it tell me? Would a different gate come to my mind tomorrow than just now? Why “gate” at all? For Freud, the dream, and for Jung, the imagination was the gate on the via regia to the unconscious, and the two men disagreed over this as well as other differences in opinion. We, as members of a later generation of analysts, have learned to use such polarizations for an ever more precise understanding of what makes therapies work. Therapeutic processes are longer or shorter accompanied paths in a special form of relationship design that enables growth and differentiation of internal and external, psychic and real living spaces. On these paths, there are many “gates”: dreams, understanding, empathy, scenes, enactments – and also therapeutic imaginations. They all contribute to leading the patient from his psychologically conditioned suffering and the initially experienced dead end to the freer field of his human possibilities. Our book aims to show you how imaginations can help open or close something on this path.

IX

Contents 1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2

The Stuff that Imaginations are Made of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3

Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

The Beginning Before the Beginning—How Therapy Gets Started. . . . . . . . . . . . . . . . . . Basic Principles of Indication Setting and Treatment Planning . . . . . . . . . . . . . . . . . . . . . Indication for the Inclusion of Imaginations in the Psychodynamic Therapy Process—Their Three Therapeutic Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Basic Principles of Treatment Agreements in Psychodynamic Therapies. . . . . . . . . . . . 3.5 Imagination Announcements as Part of Treatment Agreements. . . . . . . . . . . . . . . . . . . . 3.6 Specifics of the Initial Imagination and Practical Handling Tips. . . . . . . . . . . . . . . . . . . . . 3.7 Debriefing of the Initial Imagination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.1 3.2 3.3

14 15 17 21 22 24 31 33

4 4.1 4.2 4.3 4.4 4.5

A Short-Term Therapy With Imaginations: The Case of Musat. . . . . . . . . . . . . 35

5

A Psychodynamic Psychotherapy with Imaginations: The Case of Grün. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Establishing Contact and First Impressions of the Therapist. . . . . . . . . . . . . . . . . . . . . . . . Therapy Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Initial Imagination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . First Treatment Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Treatment Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Initial Contact, First Impressions, Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapy Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Initial Imagination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Therapeutic Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5.1 5.2 5.3 5.4

6

70 71 75 79 95

An Analytical Psychotherapy with Imaginations: The Case of Eichel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

The beginning before the beginning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapy Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Initial Imagination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Three central scenes of the analytical process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Analytical Process: At the Foot of the Mountain—Uphill— Reaching the Summit Plateau—Downhill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.1 6.2 6.3 6.4 6.5

36 36 41 44 56 68

98 99 104 107 111 140

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Contents

7

Systematic Presentation of Working with Therapeutic Imaginations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Therapeutic Attitude in KIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dealing with Stimulus Motifs in the Initiation of Imaginations . . . . . . . . . . . . . . . . . . . . . Intervention Techniques in Imagination Accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . Embedding Imagination in the Therapeutic Session and the Therapeutic Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 On the Post-Imagination Adaptations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 Termination of a Therapy with Imaginations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dealing with Transference, Countertransference, and Resistance in KIP. . . . . . . . . . . . 7.7 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.1 7.2 7.3 7.4

8

142 144 163 181 187 191 194 216

Application Spectrum and Training Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . 219

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 9

Imagination in Art and Intellectual Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228



Supplementary Information Directory of Excursions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

XI

About the Authors Priv.-Doz. Dr. med. Ulrich Bahrke 5 Psychoanalyst (DPV/IPA) and training analyst (DGPT) 5 Specialist in Psychiatry and Psychotherapy (FMH) in private practice in Zurich and lecturer at the Freud Institute Zurich (FIZ) 5 Specialist in Psychosomatic Medicine and Psychotherapy, Specialist in Neurology/Psychiatry, 1991–2007 Senior Physician at the Clinic and Polyclinic for Psychotherapy and Psychosomatics at Martin Luther University Halle-Wittenberg, 2001-2009 Chairman of the Central German Institute for Psychoanalysis Halle (MIP) 5 since 2007 at the Sigmund Freud Institute Frankfurt, from 2010– 2015 as Head of the Institute's Outpatient Clinic and Clinical Director of the LAC Depression Study, 2009/2010 Substitute Professor at the Institute for Psychoanalysis of the Department of Educational Science/Human Sciences at the University of Kassel 5 Lecturer and former board member of the Central German Society for Katathymic Imagery (MGKB) and lecturer of the Working Group for Katathymic Imagery (AGKB), teaching the method, among other things, as a former co-organizer of the Berlin Continuing Education Seminar of the German Society for Katathym Imaginative Psychotherapy (DGKIP) and at the Lindau Psychotherapy Weeks 5 Board member of the German Society for Psychoanalysis and Music (DGPM) since 2012. PD Dr. med Ulrich Bahrke Psychoanalytic-psychotherapeutic practice Neptunstr. 4 8032 Zurich [email protected] 7 www.ulrichbahrke.ch

Dr. phil. Karin Nohr 5 Study of literature, didactic-methodical training of student teachers 5 Study of psychology, graduate psychologist, psychological psychotherapist and psychoanalyst in private practice 5 From 2007–2016 board member of the German Society for Psychoanalysis and Music (DGPM), which she co-founded in 2007 5 Since 1988 lecturer of the Working Group for Katathymic Imagery and Imaginative Methods in Psychotherapy (AGKB), teaching the method, among other things, since 2006 as co-organizer of the Berlin Continuing Education Seminar of the German Society for Katathym Imaginative Psychotherapy (DGKIP)

XII

About the Authors

5 Since 2012 freelance writer. Karin Nohr has published five novels: “Herr Merse sets off” (2012), “Four Couples and a Ring” (2013) Eastern Sittichs” (2017), “Silent Change” (2018), and “Kieloben” (2020). Dr. phil. Karin Nohr Crellestr. 36 10827 Berlin [email protected]

1

Introduction Contents References – 5

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_1

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1

Chapter 1 · Introduction

We have written a textbook on Catathym Imaginative Psychotherapy (KIP) because the only basic textbook on this subject (Leuner 1985) is outdated in some respects and can be misleading due to ambiguous formulations, although it still offers a wealth of valuable suggestions for dealing with imaginations today. Although there are numerous newer publications that reflect the current state of working with imaginations, their focus on individual aspects or pragmatic orientation does not provide a systematic guide and comprehensive reflection on the possibilities and limitations of using imaginations in psychodynamic therapies (e.g., Dieter 2001; Hennig et al. 2007; Hennig and Rosendahl 1999; Kottje-Birnbacher et al. 2005; Kottje-Birnbacher et al. 2010; Salvisberg et al. 2000, Ullmann and Wilke 2012; Ullmann et al. 2016; Ullmann 2017). Leuner’s conception, which goes beyond Jungian symbol work, was the therapeutically active imagination process stimulated by so-called motifs (7 Sect. 7.2), which was maintained and dialogically designed between patient and therapist as part of the therapeutic process through special intervention techniques developed by him (7 Excursus 2: Hanscarl Leuner). From

this, he developed the “Catathym Imagery” (Leuner 1955), which has been included in the psychotherapy guidelines in Germany as a special treatment method of depth psychology-based psychotherapy (Dieckmann et al. 2017). Leuner’s textbook is no longer up to date with the current understanding of psychodynamic self-conception, especially where he sees the primacy of therapeutic effect in the imaginative power of symbolic processes themselves, rather than in the therapeutic relationship that uses imagination at certain points with certain patients for specific purposes, despite his frequent reflection on the transfer process. Leuner’s conceptual assumption of an autonomous power of imaginations, while at the same time emphasizing their rootedness in the psychodynamic conflict ­process (Leuner 1985), appealed to therapists of very different therapeutic approaches, so that the self-understanding of today’s KIP therapists generally follows the psychoanalytic-psychodynamic approach, but occasionally also has a proximity to therapy methods that use imaginations with other conceptualizations, e.g., behavior therapy, hypnosis, systemic therapy, or psychodrama.

Excursus 1: katathym

The unusually sounding word “katathym” comes from Greek (kata = according to, dependent on; thymos = soul, emotionality) and means “according to the feelings” or “coming from the soul, the feeling, the mind.” The term was introduced into German psychiatry by Hans Maier in 1912 and later taken up by Ernst Kretschmer (1956, p. 156): “By katathymy we understand … the transformation of mental contents under the effect of affect.” Leuner adopted the term and defined the “katathymic image” by “plasticity,

c­ olorfulness, and emotionality, in contrast to the simple ideas of everyday life. The katathymic images hardly obey the will anymore … ”, admitting “intermediate stages” between “simple ideas” and “fully developed” imaginations (Leuner 1985, p. 42). The word thus emphasizes the kinesthetic character (7 Chap. 2) of the imaginations. Katathymic imaginations are mostly emotionally saturated, they can express the current emotional state vividly and, therapeutically equally important, thereby stimulate other emotional and emotional states.

3 1 Introduction

In this textbook, in line with modern therapy research (e.g., Luborsky 1995), we not only represent the view of the primacy of the therapeutic relationship as the most powerful factor of therapeutically induced change, but also that of a relationship determined by complex transference processes, which requires reflected understanding (7 Sect. 7.7). Accordingly, we present the work with imaginations as a specific enrichment of different psychodynamic therapy processes: in short- and long-term therapies as well as in analytical psychotherapy. We do not see the imaginations developed in the therapeutic process as “relatively autonomous and individually adapted … release of conflict material” (Leuner 1985, p. 433), but rather we consider what the patient develops on his imaginative stage as a specific product of the therapeutic relationship dynamics. Leuner was also aware of the significance and ubiquity of transference dynamics and considered their knowledge to be “indispensable” for a KIP therapist at the “intermediate and advanced level”; however, he also held the view that in many cases “these sublime relationships do not necessarily have to be taken into account therapeutically” (Leuner 1985, p. 413). This favored the development of views that see KIP as a supposedly “spared” method from transference problems, since particularly negative transference takes place on the “canvas of imaginations” and can be largely or even completely kept out of the therapeutic process (7 Sect. 7.7, 7 Excursus 10: Projection Neurosis). We explain in detail, using three case presentations, how unconscious motivations, conflicts, and their defenses symbolically illustrate themselves under the transference relationship in the imaginations, and show how imaginations can be effectively used in different therapy situations and have proven themselves as an access

1

route for working on many disorders in short- and long-term therapies. We assume that our textbook is of interest to very different readers, both ­because of the described reception situation and because of the further development of psychodynamic theory formations, who will bring their specific reading needs to the book: We imagine readers as interested psychoanalysts of Freudian and Jungian provenance, as well as participants in psychodynamic and analytically oriented training institutions; both experienced practicing therapists of various directions and young clinic doctors who are encouraged to “work with imaginations”; both trainers and lecturers at various training institutes who want to deepen their overview of the therapeutic spectrum, as well as students at newly founded psychoanalytic universities or in master’s programs who just want to “get a taste” of something. Accordingly, we have designed our book as a practical guide on the one hand, from which it can be concretely deduced how to introduce imaginations into the therapeutic process, how to work with them, how and for what purpose they are used (7 Chaps. 3 to 6). For this, we do not expect any prior knowledge or prerequisites. On the other hand, we present the work with imaginations within the framework of a psychodynamic-analytical process understanding and therefore deepen these illustrations through conceptually fundamental reflections (7 Chap. 7). Where this would expand the ongoing train of thought too much, we refer to further excursions (overview in the appendix). The entire spectrum of application forms of KIP and further training opportunities are presented in 7 Chap. 8; more general thoughts on the interplay between imagination and art or philosophy can be found in 7 Chap. 9. In order to demonstrate the practical handling of imaginations in the different

4

1

Chapter 1 · Introduction

therapeutic framework conditions and their embedding in the relationship dynamics in a fundamental and comprehensible way, we have decided not for a multitude of case vignettes, but for the continuous presentation of three very different treatment courses. Since these three case presentations are referred to repeatedly, they are briefly introduced here: The Manager at a Crossroads. 35-yearold Dr. Musat seeks therapy as a compact “crash course” within a specially taken “time-out.” The explosive power of love has thrown her “clocked” life off balance and thus herself. She senses where she wants to go but feels inhibited by her difficult-to-understand inner limitations on her path. She is treated within the framework of a 21-hour short-term therapy. The Tortured Back.  30-year-old saleswoman

Ms. Grün has already undergone surgery five times for herniated discs. Pain conditions, fear of failure, compulsions, and her high inner tension lead her to therapy, as she fears she will not be able to cope with her retraining measure and fail in life otherwise. She is treated in 50 sessions within the framework of a psychodynamic psychotherapy. The unlived life.  59-year-old Ms. Eichel in-

itially seeks a place in a Balint group for teachers, but then it turns into an analytical psychotherapy with 620 sessions. Ms. Eichel works tirelessly in an almost unimaginable intensity professionally and privately for others and has lost the only beloved person through death. Her health is acutely endangered by a high blood pressure disease she trivializes. Thus, through practical treatment and reflective explanations as well as outlooks on “rewarding detours,” we have presented a “travel guide” to the land of therapeutic

imaginations and hope that through this mode of presentation, not everyone has to squeeze through the same gate while reading, but that the reader can “skip” unnecessary sections and linger in other places, and pass through some gates with profit. Our thanks go first and foremost to the three patients who gave us their consent to publish their treatment history in the anonymized form in this textbook, but also to all our patients who entrusted themselves to us in their distress over the decades and through whose treatments we were able to mature personally and acquire the professional competence that we make available to a subsequent generation of psychotherapists with this book. We would also like to thank those who once introduced us to KIP: Erdmuthe Fikentscher, Heinz Hennig, and Walburg Weiske (Ulrich Bahrke) as well as the sadly deceased Marianne Rintel-Lieck and Jürgen Pahl (Karin Nohr), but also all the lecturers with whom we have been involved in a discussion process about the theoretical foundations, self-understanding, and the associated specific terminology since 2000; W. Dieter, L. Kottje-Birnbacher, W. Rosendahl, H. Salvisberg, M. Schnell †, B. Steiner, H. Ullmann, and E. Wilke are mentioned as representatives. A “position paper” emerged from this discussion (Bahrke and Nohr 2005), which formed the first basis for the joint textbook now presented. We would also like to thank Barbara Hauler, Heinz Hennig, Manfred Rust, and Barbara Bahrke for suggestions and critical comments on the manuscript. Finally, our thanks go to the encouraging, patiently helpful employees of Springer-Verlag Monika Radecki and Sigrid Janke and for the second edition to our attentive-helpful editor Sonja Hinte. We also thank each other: In our “tandem project” we sat in front or behind at different stages—and could not have written all sections without the support of the other.

5 References

1

Excursus 2: Hanscarl Leuner

Hanscarl Leuner (1919–1996) is the founder of Catathym Imaginative Psychotherapy. After a medical study interrupted by military service (1939–1946), he underwent a training analysis with Jung’s student Schmaltz in Frankfurt and began working at the Psychiatric Clinic in Marburg in 1947. Supported by Professor Klaus Conrad, he moved from Marburg to Göttingen in 1959, habilitated there with a thesis on experimental psychoses, and began to establish the field of “Psychosomatics and Psychotherapy” within the Psychiatric Clinic Göttingen. In 1975, this became an independent “Department of Psychosomatics and Psychotherapy,” which Leuner headed until his retirement in 1985. Early on, Leuner became interested in the therapeutic effects of imaginations, studied precursors of his method, and began to practically test working with imaginations. In the mid-1950s, he described this method in initial publications under the term “catathymic image experience” (Leuner 1955). His interest in the inner world of imagination extended far: he also began to use various hallucinogens to support imaginative psychotherapy (psycholytic psychotherapy); work that was discontinued due to the risk of drug abuse and the ban on various psychotropic substances in the late 1960s. However, Leuner remained interested in questions of possible consciousness expansion and founded the “European Collegium for Consciousness Studies” (ECBS) in 1985, together with other researchers, and assumed its presidency.

References Bahrke U, Nohr K (2005) Katathym Imaginative Psychotherapie: eine Positionsbestimmung. Imagination 27/4: 73–92

In 1974, at Leuner’s initiative, the “Working Group for Catathymic Image­Experience” (AGKB) was founded (7 Chap. 8). The later affiliated “Institute for Catathymic Image Experience and Imaginative Methods in Psychotherapy” trains medical and psychological psychotherapists in the therapeutic handling of imaginations in decentralized seminars and psychodynamically oriented training centers. In this work, the “Textbook of Catathymic Image Experience” by Leuner (1985) played a fundamental role in the content conception of the further education seminars. With its broad experience-based diversity and countless case vignettes, the textbook remains a valuable and extremely stimulating “treasure trove” for interested parties to this day. Hanscarl Leuner combined theoretical-scientific interest with great practical-constructive commitment in his personally appreciative, unobtrusive, and passionate manner. He also gladly responded to the contact search by Heinz Hennig from the GDR, under whose direction a working group on catathymic image experience had been established in Halle in the 1970s. Leuner first lectured and discussed at the local university in 1985. After reunification, he visited the Central Training Seminar of the Central German Society for Catathymic Image Experience (MGKB) in Reinhardsbrunn. In June 1995, an interview film was created during a visit (Media Center of the Martin Luther University Halle-Wittenberg, 99-03), in which the founder of KIP impressively presents the method and his positions on it for posterity.

Dieckmann M, Dahm A, Neher M (Eds) (2017) Faber/ Haarstrick. Kommentar Psychotherapie-­Richtlinien. 11, überarbeitete ed. Elsevier Urban & Fischer, München

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Chapter 1 · Introduction

Dieter W (2001) Die Katathym Imaginative Psychotherapie—eine tiefenpsychologische Behandlungsmethode. Imagination 23: 5–41 Hennig H, Rosendahl W (Eds) (1999) Katathym-imaginative Psychotherapie als analytischer Prozeß. Pabst, Lengerich Hennig H, Fikentscher E, Bahrke U, Rosendahl W (2007) Beziehung und therapeutische Imagination. Katathym Imaginative Psychotherapie als psychodynamischer Prozess. Pabst, Lengerich Kottje-Birnbacher L, Wilke E, Krippner K, Dieter W (Eds) (2005) Mit Imaginationen therapieren. Neue Erkenntnisse zur Katathym-Imaginativen Psychotherapie. Pabst, Lengerich Kottje-Birnbacher L, Sachsse U, Wilke E (2010) Psychotherapie mit Imaginationen. Huber, Bern Kretschmer E (1956) Medizinische Psychologie. Thieme, Stuttgart

Leuner H (1955) Experimentelles katathymes Bilderleben als ein klinisches Verfahren der Psychotherapie. Zeitsch Psychoth Med Psychol 5: 185–196 Leuner H (1985) Lehrbuch des Katathymen Bilderlebens. Huber, Bern Luborsky L (1995) Einführung in die analytische Psychotherapie. Vandenhoeck & Ruprecht, Göttingen Salvisberg H, Stigler M, Maxeiner V (Eds) (2000) Erfahrung träumend zur Sprache bringen. Huber, Bern Ullmann H (2017) Einführung in die Katathym Imaginative Psychotherapie (KIP). Carl-Auer, Heidelberg Ullmann H, Wilke E (Eds) (2012) Handbuch Katathym Imaginative Psychotherapie. Huber, Bern Ullmann H, Friedrichs-Dachale A, Bauer-Neustädter W, Linke-Stillger U (2016) Katathym Imaginative Psychotherapie (KIP). Kohlhammer, Stuttgart

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The Stuff that Imaginations are Made of Contents References – 11

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_2

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Chapter 2 · The Stuff that Imaginations are Made of

Imaginations are universally occurring, kinesthetically structured inner perceptions that mobilize early, holistic states of experience and can be symbolically charged. The universality of imaginations is based on the human ability to represent conscious and unconscious inner psychic states in symbolic-imagery form (Chap. 9). Imaginations occur spontaneously, can be limited to a single pictorial impression, but can also be extensively elaborated. The affective events can be experienced intensely, but also casually. A relaxed state can promote the occurrence of imaginations—leisure as the gateway to fantasies! –, but imaginations can also enhance or prevent relaxation. They can help process moving experiences, but also lead to withdrawal from stressful life situations. They can facilitate remembering, but also take on the overwhelming character of flashbacks. The therapeutically used, so-called “katathym” imaginations by Leuner (7 Chap. 1, 7 Excursus 1: katathym) are kinesthetically structured. This term, introduced by Leikert (2008, 2012), refers to developmental psychological findings on human perception and expression possibilities. Infant research (Stern 1985, 1992) has shown that in the early pre-linguistic developmental stages, sensory perception is organized holistically and amodally. Seeing, hearing, smelling, moving, and tasting are not separated from each other; one permeates the other. Analogous to the doctrine of word meanings in verbal exchange, Leikert describes a semantics of this early, amodally-changing functioning communication, which unfolds physically-sensually in the biographically typical scenes of parent-child interaction. Here, in short, the voice dominates; only later does human communication come under the rule of the word (7 Excursus 3: kinesthetic). However, the physically experienced expressive power of the early life phase is retained even when words extend the sensual mode of expression in later life stages, i.e., when the lexical

level is added to the kinesthetic expression level. The kinesthetic form of expression and perception thus remains familiar to us and can be mobilized, even if it recedes behind language-dominated communication with increasing age. Leikert’s thoughts are of fundamental importance for understanding the special communicative achievement of imagination work. In kinesthetic experiences, the perceptual object is experienced as if fused with the respective current subjective sensory impression. Thus, although the mother is a contoured, delimited object facing the infant, she is not perceived as such: she “is” what the holistic sensory impressions absorb in the respective scenes: a transmodal experience figure newly synthesized in the respective moment. Such experience figures are also the spontaneously synthesized, imaginative scenic impressions of the patient: For example, a tree is perceived tactilely, its bark is felt, at the same time the patient also sees it with the inner eye and hears the rustling of the leaves, especially when supported therapeutically. We often need support for this form of holistic experiencing, as the accompanying sensory perceptions and affects are often abandoned in favor of other expression desires or inhibitions within verbal communication. However, if they can be experienced, the imaginations lead to the early, fusionary state of relatedness, as occasionally experienced when listening to music, and thus to a vitalizing, enriching form of experiencing. Thus, the predominant mode of expression of imaginations is, as in dreams, the mental image that arises in front of the patient’s—closed or open—eye, develops, changes, fluctuates, fades, breaks off, and reappears spontaneously or guided. Nevertheless, imaginations are by no means purely optical phenomena due to their kinesthetic structure. The resulting “images” rather represent holistically experienced scenes: A visualized flower can be touched, smelled, watered, handed over, or broken

9 2  The Stuff that Imaginations are Made of

Excursion 3: Kinesthetic

With the term “kinesthetic,” Leikert (2008) initially explained from a psychoanalytic perspective special states of experience when listening to music. He has since developed his considerations into a general “psychoanalytic aesthetics.” In this, he investigates the question of “how perception can be organized in such a way that a specific perceptual element—an apple, for example—is not understood as a pure indication of the presence of a concrete thing that can be bought or eaten, but as an aesthetically elevated object of art that knows how to fascinate” (Leikert 2012, p. 7 4). In his view, in a kinesthetic experience, the perceptual object is experienced as fused with one’s own body self—a transmodal unity arises from the perception of the body self (the subject side) and the various perceptions of the sensual object (the object side). This fusion corresponds to the way infants perceive their mother: not as a delimited counterpart, but merged with the changing sensory impressions. More than Stern (2005), Leikert emphasizes on the one hand the physical foundation of the sensual-perceptive attribution of meaning, especially of listening experiences, and on the other hand the temporally fleeting, transient nature of a kinesthetic perception: “Only for moments do we immerse ourselves in zones where the experience is really regulated by the kinesthetic reference” (Leikert 2012, p. 82). Through “sudden turning points,” one enters an intensely experienced state of increased significance of the perceptual object, which is thereby intensified into a lasting inner impression. There is a “more-or-less” of kinesthetic experience, but no permanently retainable states. Leikert’s considerations help to better understand the special therapeutic suitability of imaginations—as a sensual inner perceptual field. They explain why patients can enter a special affective state when dealing

imaginatively with their imagined flower, for example, and experience individual imaginations with an elevated horizon of meaning. For even in imaginative experience, such an early, fusionary state of relatedness to the imagined content can arise. We often experience with patients that they initially hesitantly attune to their inner imaginative objects, but then during the imagination, triggered by the experienced dynamics in the relationship with the therapist, move in and out of a deepening in the sense of a kinesthetic “more-or-less” through “sudden turning points.” For Leikert’s conceptualizations of “kinesthetic semantics” as the doctrine of early, pre-verbal sensual meaning production, the terms semantics, kinetic, and aesthetic are central. Semantics as the study of word meaning investigates how the words we use contribute to generating the meaning that corresponds to the expression desire. Leikert adopts the term semantics for the elements and structures of perception and asks: Which non-verbal meaning carriers play together in sensual perception to generate meaning? Kinetics refers to sequences of tension and relaxation and thus the body-related side of emotion and sensual perception: “The subject of sensual cognition is not given by an abstracted element, but by the experienced corporeality that connects with the sensual stimulus … The meaning of the sun—pleasantly warm or too hot—is realized from the connection with the body self ” (Leikert 2012, p. 7 5). Aesthetics refers to the object side of sensual cognition. An aesthetic object—be it an image, music, dance, or theater—requires certain conditions to unfold its specific effect, with the frame (the “stage,” temporal structure), transmodality (the stimulation of early, perception shifting from one

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Chapter 2 · The Stuff that Imaginations are Made of

sensory channel to another), ritualization in the sense of inner rhythmic organization, co-creation (the inner co-creation), and fu-

off “as in real life”; patients hear water splashing and trees rustling, lie and relax on meadows, fly on carpets, taste food or the water of a mountain river, etc. Imaginations thus capture the entire range of sensory perception if we do not hinder patients from imaginative immersion but rather promote it through appropriate interventions (Sects. 3.6. and 7.3), so that intense, affect-saturated experiences can develop. In this respect, the kinesthetically organized vitalization potential represents a central characteristic of imaginations, which can become therapeutically significant in various ways, particularly with regard to stabilization and structure promotion (7 Sect. 3.3). In addition to the affective intensity of the inner mental images, their symbolic charge is therapeutically significant. The imaginatively perceived impressions become a “symbol” (7 Sect. 7.2, 7 Excursus 7: Symbol) through the human tendency to personally charge perceived things with meaning, intertwined and permeated with pre-existing supra-individual symbols. For example, if a grave with a cross appears in an imagination, a collective symbol is used, regardless of one’s own religious attitude, to enrich a scene with individual meaning, which can be better understood in therapeutic conversation. Due to their symbolic quality (7 Sect. 7.2, 7 Excursus 7: Symbol), imaginations, similar to artworks, gain an excess of meaning. Also, in their product character with a beginning, an end, and certain stylistic features, e.g., striking breaks or a clear narration, they resemble an artwork in the process of creation; imagining partially exhibits characteristics of a creative creation process. With its moments of emotional

sion, which interlocks the kinetic inner perception with the aesthetic outer perception, being central to this.

density, the primary process-like (7 Excursus 4: Primary Process), kinesthetic-sensual experience, and the associated altered time perception of the patient, the process-like imagining is related to the “flow” processes known from creativity research (­ Csikszentmihaly and Charpentier 2007). The “journey of images into the interior” can also be scenically understood by the patient as “playing,” in which they distance themselves from the therapeutic conversation as “the seriousness of life” (7 Chap. 9, Schiller). This aesthetic potency of imagination with the aspects of excess of meaning, product character, flow, and play similarity can be used therapeutically in different ways, just like its vitalizing potency: Depending on the disorder and therapy situation, the imagination and especially its subsequent design, the painted image, can become a transitional object (Case Eichel); it can facilitate detachment from the therapist during therapy termination or therapy breaks (Case Green), it can, due to its memorable experiential product shape in total or in individual symbols, facilitate reconnection in therapies with low frequency (Case Musat). In patients with structural disorders who suffer from fragmentation fears, the experience of wholeness can be promoted; in patients dominated by the defense form of altruistic surrender, the self-occupation can be strengthened through the joy of their own actions. There are also patients who experience imaginations—similar to a picture or a piece of music—as a promise, a “foreshadowing” (Bloch 1980, 7 Chap. 9) of a life not yet lived for them, often due to guilt conflicts or consequences of traumatization. For these patients restricted by a rigid

11 References

s­uperego, imagining allows the mobilization of strengthening early kinesthetic experiences, the trying out of previously unexplored ego possibilities, and thus the processing of constricting superego impulses. Such promising, future-oriented aspects experienced in imaginations promote therapeutic motivation and have been particularly emphasized by C. G. Jung as an expression of tension between (conscious) ego and (unconscious) self in the individuation process. However, today all psychodynamic therapy directions assume that “the unconscious” “knows more” than our conscious ego and that its manifestations can be interpreted as prospective tendencies. Thus, due to their aesthetic potency, imaginations, similar to art or dreams, as highly condensed and ultimately never fully fathomable structures “full of infinite interpretation” (7 Chap. 9, Hölderlin), provide an incentive for self-exploration as well

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as self-experience, which is fundamentally conducive to introspection and therapeutically promoted self-contact.

References Bloch E (1980) Das Prinzip Hoffnung, Edn I. Suhrkamp, Frankfurt Csikszentmihalyi M, Charpentier A (2007) Flow: das Geheimnis des Glücks. Klett, Stuttgart Leikert S (2008) Den Spiegel durchqueren: die kinetische Semantik in Musik und Psychoanalyse. Psychosozial-Verlag, Gießen Leikert S (2012) Schönheit und Konflikt. Psychosozial-Verlag, Gießen Stern D (1985) The interpersonal world of the infant: a view from psychoanalysis and developmental psychology. Basic Books, New York; dt. (1992) Die Lebenserfahrung des Säuglings. Klett-Cotta, Stuttgart Stern D (2005) Der Gegenwartsmoment. Verände­ rung­ sprozesse in Psychoanalyse, Psychotherapie und Alltag. Brandes und Apsel, Frankfurt

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Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination Contents 3.1 The Beginning Before the Beginning—How Therapy Gets Started – 14 3.2 Basic Principles of Indication Setting and Treatment Planning – 15 3.3 Indication for the Inclusion of Imaginations in the Psychodynamic Therapy Process—Their Three Therapeutic Functions – 17 3.4 Basic Principles of Treatment Agreements in Psychodynamic Therapies – 21 3.5 Imagination Announcements as Part of Treatment Agreements – 22 3.6 Specifics of the Initial Imagination and Practical Handling Tips – 24 3.7 Debriefing of the Initial Imagination – 31 References – 33

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_3

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

3.1  The Beginning Before

the Beginning—How Therapy Gets Started

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“You are connected to the psychotherapeutic practice of …” These are very special moments when a patient picks up the phone to contact an unknown therapist, perhaps recommended or found on a list. Such a moment can be preceded by years of indecision, or it can also be the result of a spontaneous impulse arising from a current crisis. The first thing the patient encounters after making this decision is the therapist’s voice, usually from the answering machine. Signals that the patient reads from the voice, such as “warmth” or “coolness”, determination or empathy, as well as signals that he or she derives from the way of speaking, are immediately understood according to the transference desires developed from previous relationship experiences and lead to initial vague ideas of whether the patients want to entrust themselves to this unknown person or not. From this transference situation and the therapist’s “response”, an unconscious “scene” (7 Excursus 11: Scene; 7 Sect. 7.7.4) is created during the initialconversation, alongside or beneath the patient’s consciously expressed concerns, which often contains psychodynamically relevant patterns in condensed form. Due to the complexity of this event, the first encounter has become the subject of numerous publications (e.g., Argelander 1992, Eckstaedt 1991). From these impressions and observations, preliminary images of the other person emerge for both the therapist and the patient. The therapist formulates initial hypotheses: What relationship difficulties underlie the patient’s complaints? How long will the therapeutic process last, given the presumed severity? These are questions of external and internal “fit”. Through the continuous perceptive observation of his

or her inner emotional reaction to the patient, the therapist will further pursue, supplement, or even discard these hypotheses during the course of the initial conversation and replace them with others. The psychoanalytically or psychodynamically trained therapist will therefore pay close attention not only to the symptoms the patient describes and how they report them, but also to how this affects them and what the described situation triggers in them, i.e., how their countertransference reaction (7 Sect. 7.7.5) is shaped. And they will only offer the patient another appointment at the end of the initial conversation if they believe they can help this patient with their possibilities and also want to do so. For the patient, the first conversations confirm, differentiate, or disappoint the spontaneous impression. The patient will be satisfied if they have experienced that this therapist has understood them, and perhaps, through their inquiries and observations, has already conveyed insights in the first conversation that they had not yet gained themselves, so that a certain trust has arisen in being able to find a way out of their difficulties together with the therapist. If the initial contact has been satisfactory for both parties, the first course has been set for the joint therapeutic work. The psychotherapy guidelines and health insurance regulations (cf. Dieckmann et al. 2017, information letters from the KBV at 7 https://www.kbv.de/html/psychotherapie.php) take into account this important process of coordination, the developmental psychological backgrounds of which have been increasingly well researched (Stern 1992), by providing preliminary consultation hours and trial sessions, at the end of which the actual therapy agreement is made. The therapist also needs these sessions for the in-depth biographical anamnesis, which helps him to relate the patient’s current or long-standing complaints to a hypothetical internal context with the life-history shaped

15 3.2 · Basic Principles of Indication Setting and Treatment Planning

internalized conflicts as an expression of relationship desires and their defense. The scenic impressions, the identification of a triggering situation, and the anamnestic information help the therapist to formulate the psychodynamics and thus to be able to submit the application for justified cost coverage by the health insurance company. If the therapist realizes early on that imaginations could be useful in the upcoming therapy, he will already carry out an imagination sequence during the probatory preliminary talks (7 Sect. 3.6), use the experience for the elaboration of the psychodynamic connections, and possibly add it to the report to the expert (as shown in 7 Chaps. 4 to 6). The decision to work with imaginations depends on the indication and influences the treatment planning. To illustrate the various aspects that lead the therapist to modify the often-described usual course of therapy initiation (Hohage 1996; Wöller and Kruse 2010) by including imaginations at this early stage, the process of indication setting and the close interweaving of treatment planning and therapeutic relationship design will now be considered separately. 3.2  Basic Principles of Indication

Setting and Treatment Planning

From the psychodynamic hypotheses and diagnostics laid down in the therapy application, the therapist derives treatment indication and planning. Both lead to the treatment agreements with the patient (7 Sect. 3.4) after the approval of the psychotherapy application. The psychodynamic diagnosis is based on the scenic information and its internal evaluation by the therapist as well as the results of the anamnestic interview (7 Sect. 3.1). In addition, the symptomatology is recorded in its development and its effects on the patient’s self-experience as well as on

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his private and professional relationships through detailed questioning. Furthermore, the intensity of the suffering, the subjective explanatory theory for the complaints, the “healthy” areas of the patient’s life, and the treatment expectations are also important factors regarding the motivation to seek psychotherapy and thus the estimated prognosis. For a comprehensive understanding of the psychodynamics, it is important to explore symptom-triggering situations and have the development of complaints described. In the anamnestic interview, the focus is on conflicts and possible traumas that have occurred in various stages of life, as well as on the way they were dealt with and the design of typical life-historical threshold situations. The presentation of recurring relationship patterns can provide further clues to the structural level, the basic conflicts, central relationship configurations, and the organization of defense, which become the starting point for the formulation of psychodynamics (see also Rudolf 2010). With regard to psychodynamic hypotheses, essentially three working models are distinguished: the conflict model, the model of developmental pathology, and the trauma model. The decision on the primary assignment leads to important different treatment-technical consequences. The diagnostic core question for the later treatment technique is the structure. The assessment of the structural level, as described by OPD diagnostics (OPD-2, Arbeitskreis OPD 2014), is of great importance for the indication and treatment planning because it allows conclusions about defense stability, type of defense, and introspection ability, as can be derived, for example, from the ability of self-object differentiation. It should be noted that these initial assessments have a hypothetical character and should generally be linked to the therapist’s willingness to change them in the further course of therapy. From the patient’s

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reactions to therapeutic interventions, it can be deduced whether they confirm the psychodynamic assumptions or whether these need to be modified. For example, a superficial conflict dynamic may initially conceal ego-structural disorder components, just as trauma sequelae or a conflict theme may only become recognizable later in the course. Of course, the development of the transference-countertransference dynamic must also be taken into account, as, for example, a negative transference may distort the assessment of the structural level and provoke an overly defense-sparing approach. The complexity and provisionality of hypothesis formation are taken into account by guideline psychotherapy in that extension applications for psychotherapy provide space for additions to psychodynamics. Despite this important hypothetical-waiting attitude, it is necessary for treatment planning in a psychotherapy working with imaginations, as in any other psychodynamic therapy, to assess the patient’s disorder and, at least provisionally, commit to the relative importance of the conflict-pathological-neurotic components, the developmentally structural components, and the understanding of the background of insufficient processing of traumatizations in the therapy application. Of course, this division is a schematic simplification. In order to do justice to the individual patient, it makes sense to assume a continuum between so-called mature and immature structural levels as well as between more or less differentiated object relations. For example, the following questions have proven helpful in treatment planning: 5 Is it necessary to primarily gain insight into unconscious conflicts for successful therapy? That is, do the progressive defense analysis and the acquisition of affectively supported insights into internal conflicts, as they also appear in the

transference process, focus on the therapy? And is this primarily indicated due to the external and internal conditions of the patient? 5 Or is initial support in coping with external conflicts required? Are auxiliary ego functions to be provided? And is support for affect regulation indicated in order to first promote an intrapsychic situation on the basis of which the processing of psychodynamic conflicts can take place in a later treatment step? 5 Should developmental deficits be primarily or even exclusively addressed by working on ego functions with the aim of building a more integrated self ? Is a new—initially particularly holding and containing—relational experience at the therapeutic center? 5 Does the patient need primary supportive relief and should resources for coping with the consequences of trauma be strengthened? That is, for example, is it opportune to use defense mechanisms of denial and externalization or/ and techniques of positive resonance for psychological stabilization in the first treatment step? Based on the preliminary answers to these questions, the therapeutic objectives can be formulated more realistically and the choice of treatment form can be clarified. It can now be estimated which goals can be achieved with which session frequency at which hourly volume (7 Chaps. 4 to 6). The complexity of therapy goal finding with its versatile implications has been excellently presented by Hohage (1996), which is why a further presentation will be omitted here. This also applies to further details of the internal clarifications that the psychoanalyst or psychodynamically working therapist negotiates with him or herself before the definitive treatment agreement with the patient (e.g., Wöller and Kruse 2010): What

17 3.3 · Indication for the Inclusion of Imaginations in the …

suits this patient best—acute crisis talks, short-term therapy, depth psychology-based psychotherapy, or psychoanalytic therapy? In addition, there is the important question: Should imaginations be used or not? 3.3  Indication for the Inclusion

of Imaginations in the Psychodynamic Therapy Process—Their Three Therapeutic Functions

Due to the specific characteristics of imaginations: their universality, their affective enlivening potential, and their aesthetic dimension (7 Chap. 2), it is fundamentally close to a KIP psychotherapist to use imaginations therapeutically; and in the disorders and therapeutic situations listed below, this seems particularly useful to him. In this context, three different therapeutic functions of imagination work are distinguished: z Expression and Clarification Function.

Since imaginations are associated with the ability to represent conscious and unconscious inner psychic states and conflicts in symbolic-figurative form (7 Chap. 2), they can serve in therapeutic work to vividly or symbolically veiled “bring to the eyes” revived relationship desires, typical defense mechanisms, but also special ego strengths and regulatory abilities. We refer to this as the Expression and Clarification Function. Through the process of transforming previously unconscious or preconscious material into the inner image, an intermediate step towards linguistic appropriation is made possible and important additional material for further clarification and reflection is provided. Imaginations often show conflicts and self-states in a surprising and vivid way due to their symbolic clothing, which facilitates spontaneous insight and new perspectives for the person imagining, who often

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stands amazed at their own imaginations (see initial imagination of all three case presentations). The symbolically-figuratively represented can become a further starting point for self-confrontations at the imaginative level, open up an additional possibility for creative problem-solving, e.g., in the form of imagined trial actions, or also allow the trying out of previously un-lived self-aspects and thus the processing of restrictive superego impulses (see especially the case of Musat). z Stabilization Function.

Furthermore, by accessing the imaginative level, psychological processes such as anxiety binding, relaxation, and alleviation of restlessness, as well as many forms of resource activation, can be supported. Therapeutic interventions with imaginations that aim at such regression in the service of the ego (Kris 1952) are summarized under the term Stabilization Function (see all three case examples, especially the case of Grün). Stabilizing are primarily the psychophysical relaxation states often associated with the kinesthetic mode (Excursus 3). Leuner described this as a “circular process”: if the beginning imagination evokes relaxation, which in turn increases the “plasticity of the mental images,” which can then cause a deepening of relaxation (Leuner 1985, p. 44). It should be noted that such “circular processes” do not develop automatically, but depend on both the structural level and, in particular, the transfer relationship and are susceptible to disturbances. The change from the conversational to the imaginative dimension can also be stabilizing, as it expands the possibilities for proximity-distance regulation (7 Sect. 7.4.) and thus for affect dosing (case Eichel) in the therapeutic process. Finally, targeted alternation between confrontational-revealing work and stabilization sequences can prepare processes of conflict and anxiety management (7 Sect. 7.3).

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

z Structure-Promoting Function.

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Distinguished from the first two functions, although overlapping in some aspects, is the structure-promoting function of imaginative work. It is initially evident in the stimulation of detailed descriptions during the act of imagining. The therapeutic functions of holding and containing, with the aim of increasing self- and affect regulation, are combined with the promotion of more reality-based perception and orientation— also in imagination. Building on this, trustand support-giving self- and object representations (e.g., helpful figures, positively charged places) can be activated in the imaginative experience space through the initiation of benign projective processes, which helps to strengthen the self-system, or specific intervention techniques (7 Sect. 7.3.) can be used to overcome divisions at certain points. Finally, by stimulating the imagination of positively supportive symbolic figures, the attention to a previously suppressed, needy self-part and thus self-care can be initiated. Depending on the disorder and therapy situation, the imagination and especially its subsequent representation, the painted image, can be used as a transitional object (Case Eichel) and thus promote object constancy, especially during therapy breaks, and facilitate detachment from the therapist during therapy termination (Case Grün). In patients with structural disorders and fragmentation fears, the experience of wholeness is promoted; in patients who are dominated by the defense mechanism of altruistic surrender up to the development of a “false self ” (Case Eichel), the self-occupation can be strengthened through the imaginative enjoyment of one’s own actions and the targeted stimulation of self-activity. Therapeutic imaginations can be fruitfully used in many treatments due to these three functions; in this respect, the indication spectrum of KIP does not differ from that of psychodynamic or analytical

­ sychotherapy. The same concepts of genp eral and psychodynamically justified effective factors also apply. The additional therapeutic effectiveness of imaginations associated with the dominance of primary process-kinesthetic experiences has been fundamentally distinguished and discussed elsewhere (Bahrke 2010). The reasons that suggest the specific inclusion of imaginations in the therapeutic process concern, on the one hand, the fact that patients with certain disorders benefit particularly from this (Leuner 1990). On the other hand, regardless of the patient’s disorder, there are phases and situations in many psychodynamically based or analytical therapies in which imagining can be particularly process-promoting. For example, working in the symbolic-imaginative area is particularly beneficial for patients who, due to their schizoid structural components, have a strong intellectualizing defense, with which they unconsciously anticipate feared evaluations or “labeling”—interpreting themselves. They already “know” “everything”, have read a lot, and can experience little. The emotional part within them has been so injured that they need to protect it especially. They are greatly helped if they can allow more emotional closeness in an imaginative space, protected from the feared proximity of the “all-knowing” therapist, and thus experience that more is possible in a relationship than they assumed (see the case of Musat). Just as eloquence can become a defense strategy, so can speech and expression inhibition, which arises from class-specific, shame- or other transference reasons. Patients with such inhibition avoid feared humiliations or criticism through restrained speech behavior and are anxiously focused on “doing everything right”. For them, the inclusion of imagination can be anxiety-relieving and enable a gain in affect-driven expression (see the cases of Grün and Eichel).

19 3.3 · Indication for the Inclusion of Imaginations in the …

In patients with a psychosomatic main symptomatology and in those with somatoform pain disorders, imaginative work is often the only way to promote the insight that there are body-mind connections and to encourage them to pursue the question of why they have to express emotional pain physically: Imaginative designs can become a “translation aid” for their physical experience into linguistic expression using certain treatment techniques (7 Sect. 7.3) and thus build a bridge between symptom, affect, conflict, and transference. Traumatized patients also benefit in a special way from imaginations, as they can be guided to protective imaginative introject-splitting (Steiner and Krippner 2006). Such introject-externalization can also serve in some other cases to protect the therapeutic relationship from possible destruction due to an overpowering negative transference that cannot be stopped and represent an important intermediate step in the treatment of patients with pronounced destructive potentials (see the cases Grün and Eichel). In depressive patients, imaginations help to facilitate proximity-distance regulation, which is particularly difficult for them due to internal boundary problems. Thus, imaginations in the therapeutic relationship can help bridge separation situations such as a therapist’s vacation as a transitional phenomenon and generally illustrate boundary and separation difficulties. Depressive patients can be confronted so impressively with their typical self-sacrificing tendency in the imaginations that from here, through the devotion to a needy self-part, as it can be represented in the form of symbolic figures, the neglected self-care can be initiated and strengthened. The confrontation with the warded-off aggressiveness can be just as impressive (see the case Eichel). Patients with adjustment disorders benefit from the stabilizing, ego-strengthening function of imaginations. For example,

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these patients can be encouraged to imagine pleasant landscapes or soothing places to regressively recharge their ego narcissistically in the service of their self and recover, so that they do not automatically “continue working” in the therapeutic conversation, but the pressure to “function” noticeably loosens. Patients with personality disorders and borderline pathology or generally those with structural disorders can also benefit in a special way from working with therapeutic imaginations; however, they, like traumatized patients, require differentiated treatment techniques (7 Sect. 7.3). Regardless of the disorder, there are numerous therapy situations in which it can be fruitful, either from the beginning of therapy or during its course, to initiate a change from the level of conversation to that of inner mental images. Such therapy situations include, for example, repetitive descriptions, beating around the bush, increasing periods of silence, or tendencies to trivialize—in short: therapy situations with obvious transference resistance. However, as a therapist in such resistance phases, one does not always have an interpretable hypothesis, and may then feel at a loss and “groping in the dark.” Enlightening dreams are not brought up, one notices that interventions “do not help,” and direct questions yield no information. In such cases, imagination can be used to try to clarify the current transference dynamics and to derive a new perspective for processing—since imaginative processes can often reveal something in a coded form that must still be avoided in direct contact. In the conflict field between unconscious desires mobilized and pressing in the therapeutic relationship and the equally unconscious inner balancing and protective work of resistance, the use of imagination is helpful in a different way than transference interpretations are—it can prepare or supplement them (7 Sect. 7.4). Interpretations are intended to lead to insights that dissolve

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

resistances. However, for various reasons, they can also reinforce resistance (7 Sect. 7.7.6). If an imagination is stimulated in such a situation, there is a chance that it will contribute to the patient’s acceptance or self-development of a corresponding interpretation later on, through ego-strengthening and symbolic conflict illustration of the transference process. 7 Excursus 4: Primary Process Independent of resistance treatment, there are therapy phases in which patients with different disorders are under acute additional stress: exams, moving, job applications, impending birth, death, illness, or caregiving in the family. And there are patients who, due to their depressive or traumatized structure, are constantly burdened because they cannot set boundaries and constantly create

new stressors. In these cases, imaginations can be used for stabilization, as described for patients with adjustment disorders. The variety of therapeutic possibilities for using imaginations can thus be bundled into the three basic functions described: The work on inner conflicts and their defense using imagination represents the expression and clarification function of the imaginative process; the ego-strengthening, enlivening regression promotion in stressful situations represents its stabilization function, and all work that strengthens the self-system, encourages maturation, and overcomes divisions represents the structure-promoting function. With these three general, overlapping functions: clarification, stabilization and structure promotion, the process-serving possibilities of imagination work have been briefly outlined here;

Excursus 4: Primary Process

With the terms primary and secondary process, Freud described two mental modes of functioning since 1900, the explanatory schemes of which he adapted to his changing theoretical approaches (Mertens and Waldvogel 2000). Secondary process thinking follows the rules of logic and syntax and is predominantly verbal. In contrast, primary process thinking does not follow the rules of rational logic and is more image-based and symbolically pronounced. Freud considered the latter to be the typical thinking mode of the childlike “immature” ego and assumed a regression to primary process thinking in adults during dream work, in faulty actions and symptom formations, as well as in artistic expressions; he also dealt with the affinity of poets and artists for primary process thinking. This conception is considered outdated. It was inappropriately devaluing; in particular, the intertwining of primary process and regression by Freud was revised (Noy 1969). Current views assume that representa-

tions of experiences are stored in both systems and that primary and secondary process thinking moves along a continuum. Apparently, there are also various systems of prelogical thinking (Holt 1989), and the question of regression is differentiated between a more adaptive process—regression in the service of the ego in the sense of Kris (1952)—and maladaptive regression processes. Developmental psychological findings also contributed to this correction, which describe thinking and perceptual performance from infancy onwards in a much more differentiated way (Geißler and Heisterkamp 2007; Posth 2009; Stern 1985). Overall, this reorientation contributes to the understanding of the therapeutic effectiveness of guided imaginations within a psychodynamic process presented here: The primary process event means more than regression; it can also be an expression of scenic memory, serve defense, or prepare progressive solutions (7 Chap. 2, 7 Excursus 3: kinesthetic).

21 3.4 · Basic Principles of Treatment Agreements in Psychodynamic Therapies

their differentiations and limitations will be discussed later (7 Chap. 7). Concrete ­examples can be found in the three detailed treatment examples (7 Chaps. 4 to 6). 3.4  Basic Principles

of Treatment Agreements in Psychodynamic Therapies

After the indicator considerations, which the therapist weighs up alone and the results of which lead to the application for health insurance, the treatment agreement is made jointly with the patient. Treatment agreements are all arrangements that need to be made with the patient or that need to be communicated to him. They relate partly to the working framework and partly to the peculiarities of therapeutic communication and mark the transition from the initial interview and the collection of anamnesis to the actual therapeutic situation after. In this respect, they represent a significant relationship design. For the way in which the therapist makes these agreements with the patient—what, when, and how he informs, what and how he determines together with the patient—paves or hinders the patient’s familiarization with the therapeutic relationship form and its possibilities and limitations. In principle, we work with the same therapeutic framework in short-term therapy, psychodynamic, and analytical psychotherapy. Differences exist only in the emphasis of certain framework elements. In detail, the patient is taught what the therapeutic framework looks like (duration of sessions, frequency, responsibility for cancellations, payment, etc.) and what this framework contains in terms of content as an offer to them. They are informed about the basic rule of free association, aspects of abstinence and their backgrounds, as well as other significances of therapeu-

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tic communication; possibly, the jointly determined or extrapolated goals and focal points (KZT) are also confirmed, or the patient is advised to bring important life decisions into therapy beforehand (psychodynamic and analytical psychotherapy). In the way we communicate these framework conditions, be it all at once, step by step, more strictly or more flexibly, be it explanatory and waiting for consent or simply setting them, be it based on forms or without them: With all this, we show ourselves in our professional identity. We indirectly tell the patient: In this proven and well-chosen framework, I can help you—not otherwise. (However, if we feel insecure or are beginners, we certainly also tell them: I am very clear at this one point because I am convinced of it, and at this other point somewhat vague because I am less convinced of it. This applies especially to cancellation rules and the missed appointment fee.) In this respect, patients react to us by reacting to the framework or elements of the framework. Any change in the framework involves a change in the relationship structure. Through the framework agreements communicated in the first sessions, the patient’s spectrum of internal reassurance (Tuning; 7 Sect. 3.1)—Is this therapist the right one for me?—extends beyond the personal to the professional contour. Our handling of the framework also conveys to the patient initial “verifiable indications of (our) conscious and unconscious intentions and of (our) reliability” (Trimborn 1994, p. 94). Therefore, these clarifying conversations before the actual start of therapy are extremely important, as they contribute to the establishment of a stable therapeutic relationship. They should be conducted in detail and without time pressure. Insofar as it involves “negotiating” certain rules, these often already meet central conflict constellations and are therefore by no means therapeutically unused time.

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

Equally important are the explanations of the therapeutic type of communication. It is completely new, unfamiliar, and in some respects strange to the patient. Therefore, like everything new and especially the strange, it can cause fear. Orientation supports the feeling of security, as in other uncertain situations, but cannot and should not eliminate the therapeutically necessary insecurity—after all, dysfunctional old thought, feeling, and behavior patterns are to be questioned. However, if a therapist is too silent at this point, they promote the experience of the necessarily given asymmetry in the therapy situation and possibly induce feelings of fear, powerlessness, or insecurity. This would be detrimental to the establishment of the therapeutic relationship, can even intensify symptoms, and in any case leads to avoidable defensive movements in the patient. By being all these “clarifications” relationship designs, one will experience that the therapist’s communications experienced by the patient in them, especially about his personality, perhaps and especially his insecurities, will “return” scenically or in content and mostly conflict-laden during the course of therapy. This is not “bad”, but indispensable and valuable. For example, a therapist who, for reasons of his own altruistic defense, shows insecurities when communicating his cancellation fee will experience how his patient, depending on the transference dynamics, will “hook in” at this very point through corresponding scenic action (7 Sect. 7.7, 7 Excursus 11: Scene). However, we therapists should be aware that a completeness of treatment agreements in these probatory hours is not achievable, nor even necessary, because the specific transference constellations acting between the patients and us cannot be eliminated by “clarifications”, but become a fruitful part of future therapeutic work.

3.5  Imagination Announcements

as Part of Treatment Agreements

If one wants to work with imaginations as a therapist, this belongs to the treatment agreements that concern both the framework and its content. In addition to the clarifications mentioned in 7 Sect. 3.4, one would embed the announcement that one not only offers conversations to the patient, i.e., listening, asking, understanding clarification and interpretation, but also, beyond the conversation, will encourage him or her to devote themselves to the inner world of their own imaginations in the form of guided imaginations and to include these in the therapeutic work. With this announcement, the patient is informed that a KIP therapy consists of two things: conversation and imagination work. It makes sense to immediately follow this with the implementation of a first imagination sequence so that the patient can vividly understand what is meant, how therapeutically guided imagining “feels”, and thus gain a basis for their consent or rejection (7 Sect. 3.6). Finding an understandable, appropriate justification is important and necessary because imagining is something “different” from what patients usually expect from a therapeutic course. “Including imaginations” initially remains something unusual, under which patients can imagine little. The ideas about it can seem as strange as the basic rule with its “strange” request to “say everything” or the “strangely” experienced “refusal” of the therapist to answer questions about personal matters, e.g., marital status, children, vacation destination, etc. As a framework element, all these communication forms have the character of the “other” because they deviate strongly from everyday communication; they emphasize the experience of asymmetry since they in-

23 3.5 · Imagination Announcements as Part of Treatment Agreements

itially come from the therapist. Since the patient does not know “how it works”, the imagination announcement can also be unsettling and arouse slight fears alongside curiosity—and thus resistance. Expressed “skepticism” towards imagining does not have to (only) apply to this, but can apply to therapy in general, and therefore requires clarifying resistance processing, to whom and why it applies (7 Sect. 7.7.3). For the therapist who is still unfamiliar with imagination work, the announcement can also be associated with uncertainties that interact with the patient’s feelings and thus have an impact on the transference process. In order to build a bridge for the patient out of the possible initial uncertainty, several points of connection are given: If the patient is open to the idea that dreams contain psychological messages that can expand their own self-understanding, they will probably also be open to the suggestion of enriching the therapy with “therapeutic daydreams.” For patients who have little access to their dreams for defensive reasons or devalue them, this is not the case in this way. Here, the reference to metaphors can provide a plausible transition: One could explain, for example, that hardly any conversation and certainly no therapeutic process takes place without metaphorical comparisons because we are used to describing our condition in a pictorial way. We feel, for example, “like a tiger in a cage,” “like a hamster in a wheel,” “like a stranger in our own house,” etc. Ideally, we pick up on such metaphors that the patient used on their own in the initial conversation or later. The knowledge of the fact that these metaphors represent a pictorial level can open up the patient for the implementation of “image journeys.” A third possibility lies in the comparison with “fantasizing” or “daydreaming” (7 Excursus 5: Daydream and Imagination). Even if the imaginations

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stimulated by the therapist in KIP are not identical to the daydreams that everyone knows or has had, they can still be linked to such experiences, especially for anxious, shy, or simply expressive patients. The therapist could then say:

“You are certainly familiar with the situation where you drive home from a first love encounter or an important interview and let everything run through your mind’s eye again. This seeing with the inner eye can be very valuable for our work here, and that’s why I suggest that we incorporate it from time to time (now once).”

For intellectual patients, one could point out the ubiquitous ability of humans to express feelings and thoughts in a symbolic way. In this context, one could draw attention to scientists for whom the solution to their problem appeared in a visionary-pictorial way (discovery of the benzene ring). Or one could continue with the formulation:

“People think not only in thoughts but also in images. When you open up to your own inner ideas, you sometimes come to views that you would never have thought of before. Therefore, I would like to suggest that we also deal with this in your therapy.”

In any case, it is necessary for the announcement of imagination to understand the patient’s attitude or fears together with them precisely, as this brings important relationship problems into the conversation, such as those of biographically founded performance anxieties (“I can’t do that”) or

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

devaluation habits (“That doesn’t help anyway”). This also applies to patients who unquestioningly accept or enthusiastically agree to such an announcement. The type of justification in each case depends not only on the individual patient but also on the pursued objective, i.e., the therapist’s assessment of whether the imaginations should be part of the therapeutic framework from the outset or integrated into an ongoing therapeutic process for special reasons later on. If imagining is announced from the outset as part of therapeutic action and framework, the justification can be incorporated into the treatment agreements. This could be formulated specifically as follows:

“In some sessions, I would like to suggest expanding and deepening the therapeutic conversation by working with inner images.” Another formulation could be similar to the one described above: “Our inner world knows not only words and thoughts but also ideas, inner images. They often express something that we were not even aware of or put something familiar in a new light. Therefore, they are of great benefit to our work. I would like to stimulate such ideas in your therapy from time to time, but you can also suggest yourself whether and when we want to take such an ‘imagination journey’ (image journey into the interior).”

If imaginations are only used in the course of therapy at the suggestion of the therapist, the justifications look somewhat different, depending on the therapeutic process assessment. The general announcements above can also be used in these cases, but first, for example, precede:

“Today I suggest something different because I feel it could be helpful (clarifying, advancing) … ”

In these cases, however, the associated transmission messages (7 Sect. 7.7) must be taken into account even more than usual and— especially in the analytical therapy framework—be problematized in an understanding way, because unquestioned, the patient could perceive the announcement of imagination as criticism of themselves (“I don’t bring enough, too much, not the right thing” etc.) or suspect the therapist’s helplessness (“Well, with me it just doesn’t go any further, now he/she has to try it differently”). The described possible uncertainties are part of the necessary relationship adjustments that characterize the therapeutic process and are also a source of ongoing understanding opportunities. This applies in principle to every therapy session and also to imagining: Even if several imaginations have already been carried out, the patient never knows what awaits them on their “inner stage”, what is “just happening”, so that a certain tension remains and should remain. 3.6  Specifics of the Initial

Imagination and Practical Handling Tips

How and when does the therapist perform the first imagination? Regardless of whether short-term therapy, psychodynamic or analytical psychotherapy has been agreed upon with the patient, it has proven useful to carry out the first imagination during the probatory sessions: This promotes familiarization with the imaginative and the initial imagination can provide diagnostic clues (7 Chaps. 4 to 6). To

25 3.6 · Specifics of the Initial Imagination and Practical Handling Tips

facilitate the patient’s “entry” into their inner world of images, we suggest a thematic starting point in the form of a stimulus ­motif (for a problematization of this therapist activity, see 7 Sect. 7.2). The “flower” has proven to be a successful initial stimulus motif, as it has a pleasant meaning horizon and is often spontaneously perceived by patients as a “snapshot” of a desired or currently experienced self-state: “This is exactly like me! A bit shaky at the top, but quite well-rooted.” 7 Excursus 5: Daydream and Imagination Leuner called this first imagination “flower test” (Leuner 1985). This term has become obsolete, as it does not adequately reflect the complex scenic events of this “initial imagination.” Moreover, it is misleading because “test” implies a performance aspect. However, there can be no “better” or “worse” in this first imaginative exploration, and the evaluative aspect ­

c­ontained in the word obstructs understanding. Furthermore, we now assume, unlike Leuner could, that the basic ability to imagine, like all kinesthetic perception forms (7 Chap. 2, 7 Excursus 3: kinesthetic), is available to everyone and therefore does not need to be “tested,” even if it is used with varying intensity (7 Chap. 2). Thus, even for this reason, the term “test” is misplaced. If one wants to speak of a “test” at all—then it is most likely a “relationship test”: How and what can this patient communicate to this therapist at this point in time from their inner world, beyond the verbally communicated, pre-arranged, censored or affect-isolating hinted at, in a more symbolically uncontrollable, emotionally closer way, and thus “share” with them? These important questions with their transfer implications are indeed “tested” (7 Sect. 7.7.2, intersubjective paradigm). It crucially depends on the patient’s relationship experiences and expectations

Excursus 5: Daydream and Imagination

Daydreams are often intensely and mostly pleasantly experienced inner representations, in which scenes or situations, as well as memories or future events, such as the encounter with a loved one, desires or upcoming significant life events are spun out; sometimes this happens realistically, sometimes fantasized, as in erotic daydreams or revenge fantasies. Attention is withdrawn from the environment during daydreaming but can be turned back to it at any time; the daydreamer is focused entirely on the inner world of representation but can, despite maintaining wakefulness, “startle” out of this inner immersion. Daydreaming is widespread; it is perceived as very “private” and intimate and is usually not shared; it often occurs when one is alone, has leisure time, or before falling asleep. Daydreaming has a

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stabilizing function but can also take on an addictive character and destabilize the daydreamer. Dieter (2005) emphasizes that daydreaming cannot help the individual to really get rid of, for example, “unbearable” things; they can only “expel” it temporarily (Dieter 2005, p. 93) and remain alone in this. Therapeutic imaginations, on the other hand, are developed in the awareness of the participation of the significant other and are therefore, unlike daydreams, dialogically oriented. Imaginations are made of the same “representational material” as daydreams, but they belong to the “context of a triangular psychological structure” and in this respect to a shared “imaginative space” (Schnell 2005), indeed they receive their shape and character from the “relationship state” between patient and therapist (Pahl 1982).

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

Excursus 6: Initial Dream

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In psychodynamic therapies, the initial dream is the first dream that the patient reports to their therapist. Since they reveal something about themselves that they do not fully understand and thus release from their control, the initial dream has not only a content-related but above all a transference meaning (see the time of communication in the case of Grün in the 9th therapy session) and is usually experienced by the therapist as very significant. The initial dream can occur even before the actual first contact or only after many sessions. Freud (1911) characterizes this first dream reported by the patient: It stands out from all later ones in that it is, so to speak, “naively” dreamt, for the dreamer does not yet know how the dream material will be dealt with. Therefore, as Freud writes, the first dreams reveal a lot, they often build up “over the entire pathogenic material of a case”. He therefore also calls them “program dreams” or “biographical dreams”. They are a symbolic translation of the entire neurosis content into the language of dreams and are therefore basically only interpretable at the end of a therapeutic process.

how they want and can turn to such ideas in the presence of another person and report about them, especially in the presence and with the participation of a “psychologically powerful” other person to whom they have turned for help. Those who have been shamed, “belittled”, not mirrored, over-, under-challenged, or neglected—to name just a few common relationship experiences—unconsciously expect something similar from the therapeutic transference person and protect themselves accordingly (7 Sect. 7.7.4). Therefore, if—as occasionally happens—a patient sees “nothing” or only “fog” in the initial imagination, this does not mean that they cannot imagine, but that they cannot (yet) allow imagining in the current transference situation.

These four basic features of Freud’s conception of the initial dream: naivety, programmatic nature, diagnostic richness, limited interpretability, continue to be considered noteworthy, although today the first dream is closely related to the transference process: “They (the first dreams) often contain in nuce a great deal about the desired relationship with the analyst and about the patient’s fantasy of the analytical relationship” (König 1991, p. 130). Jung expresses different views on initial dreams. He describes the contents of initial dreams as “infinitely diverse” (Jung 1929) and emphasizes, similar to Freud, their diagnostic richness: “Very often, a dream occurs at the beginning of treatment, which reveals the entire program of the unconscious to the doctor in a far-reaching perspective” (Jung 1931, p. 168); on the other hand, Jung considers many initial dreams, in contrast to later dreams, to be “astonishingly transparent and clearly shaped” (p. 154) and speaks in this context of “luminous initial dreams”.

The first imagination in psychotherapy always has a special significance. It is comparable to the first dream reported by the patient in therapy (7 Excursus 6: Initial Dream). As described in 7 Sect. 3.5, it represents a certain risk for the patient; once they have gone through this imagination experience with the therapist, all subsequent ones build on it. It can be assumed that all patients consciously or unconsciously feel: “The way he (she) deals with my imaginations is the way he deals with my soul, the way he deals with me.” In the implementation of imagination, (a) setting, (b) introduction, (c) accompaniment, and (d) conclusion of the imagination, as well as the conduct of the follow-up conversation (7 Sect. 3.7) are important.

27 3.6 · Specifics of the Initial Imagination and Practical Handling Tips

z a) Setting

To emphasize that imagination represents something detached from the conversation, one can suggest a spatial change by offering the patient to lie down on the couch for imagining, in order to achieve a relaxed physical state. Due to its novelty and the patient’s limited familiarity with the therapeutic situation, one can convey to the patient during the initial imagination that imagining can also take place while sitting. Of course, now and in the future, the patient should be given the choice of the most comfortable spatial situation for them. (Most patients initially imagine while sitting, and once they are familiar enough, they like to switch to the couch and the therapist to a chair next to it or, as in analytical therapy, behind it.) If the patient already adopts this spatial setting change during the initial imagination, it can be assumed that they are either fundamentally inclined to implement the therapist’s suggestions for internal reasons, or a good relationship has already been established in its beginnings (7 Sect. 3.5). After all, the patient initially has to “believe” many things from the therapist: That their imaginations actually have therapeutic effectiveness, that the spatial change can contribute to it, and that they can even imagine in the above-mentioned “relationship sense.” Confirming this through an imagination experience is therefore an important first partial goal—having achieved it means a significant further stabilization of the therapeutic relationship. At this point, occasional inhibitions must also be overcome, which are associated with the suggestion of a spatial setting change. Some patients, for example, have been so shamed in their lives that they would be reluctant to walk freely through the practice room to the couch. At this point, it is advisable to simply register this and by no means, for example, to interpret

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the patient’s preferred sitting or the (too) willing lying down in terms of the patient’s psychodynamics, as this could increase the level of anxiety and provoke resistance. If an analytical therapy is carried out lying down, the suggestion of a spatial setting change is omitted. Whether, when, and how imaginations are included is part of the permanent reflection exchange. Ritualizations such as introductory instructions are also helpful here but are repeatedly problematized with regard to the relationship messages that the analysands derive from them (further details 7 Chap. 6). The main treatment-technical tasks of imagination guidance now consist of first initiating the imaginative process, then keeping the patient “in the picture” and not being obstructive in the emotional enrichment of the image, and finally leading the imagination out at a meaningful point in time. z b) Introduction of the first imagination

You can start with a short relaxation instruction and ask the patient to assume a comfortable, cozy physical position in their chair (on the couch)—this is important for patients who, for example, sit only at the very front of the chair due to tension—and, if they like, close their eyes. You can say:

“Only what is inside you is important now, all thoughts can come and go as they please.” or similar.

The design of the relaxation instruction is intertwined with the transference-countertransference dynamics (7 Sect. 7.7). Thus, a too detailed relaxation phase can serve the therapist’s anxiety defense contrary to conscious intentions. The relaxation instruction should be omitted if you feel that focusing on one’s own body self is not

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

­ ossible for the patient in the presence of p the therapist and only creates more tension. Next comes the introduction instruction:

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“Let an image of a flower (a tree, a landscape) appear before your inner eye, and if something comes up, please describe it so that I can imagine it too.” (or similar). To express to the patient that this is just a suggestion that they can follow but do not have to, you can add something like: “And if you have something completely different in mind, just describe that.”

It has proven useful in the introduction instruction to speak of “imaginations” instead of “images”, as some patients associate something so plastic with “image” that it easily evokes the feeling that they cannot evoke something as colorful, plastically painted as an “image” within themselves. The word “imaginations” avoids this unnecessary possible irritation. Still part of the introduction are the very first interventions aimed at establishing the imaginative image in the patient at all. So, if several imaginations appear, you say:

“Take your time.” Or: “Describe them one after the other.” (Once that has happened:) “Which one is closer to you at the moment/in front of your eyes/stands out most clearly? Do you like better? Appeals to you particularly?” or similar. If “nothing” appears: “Take your time.” Or one of the following questions: “What do you have in front of you instead?” “How do you feel?” “What is inside you right now?” “Do you want to try again to imagine any flower?” “Is there a flower you like? Then just describe it as it comes to your inner eye.” You can always weave in or add: “But any other imaginative image is also possible/right/welcome.” to soften

the expectation pressure. If many flowers or trees (e.g., a sunflower field, a forest) appear or infinitely wide landscapes: “Is there a flower/a tree/a spot in the landscape that stands out to you for some reason?” If only a partial image (e.g., only the blossom, only the trunk) or something nebulous, diffuse appears: “It doesn’t matter. Just describe what you have in front of your eyes, even if it’s a bit unclear.” Usually, the image becomes more plastic afterward, and details can be described.

If, as may exceptionally occur, no imaginations appear despite these interventions or they are perceived by the patient but not reported, this is “not bad” but an expression of a need for clarification based on the relationship. z c) Accompanying the imagination

Now the mental image has become somewhat established. The patient has seen, for example, a sunflower field and upon your inquiry, notices that one flower stands out to him: “Yes, it’s standing a bit apart, right next to a path.” He pauses. At this point, further engagement with the flower can be encouraged through descriptive questions (7 Sect. 7.3) like this:

“What do you notice about the flower? Try to describe everything as it appears in your mind’s eye.”

When the patient does this, the imagination becomes more vivid and emotionally closer for them. It is helpful to ask about all sensory qualities in order to reinforce this process. For example, if the patient talks about a bumblebee flying around the blossom, it makes sense to ask if they can hear it; if the patient approaches the flower, to ask if it has a scent, if they can touch it, etc.

29 3.6 · Specifics of the Initial Imagination and Practical Handling Tips

A special function among the descriptive questions is the “touch intervention” (7 Sect. 7.3), as tactile experiences are among the earliest, already intrauterine object perceptions, followed by hearing (7 Sect. 7.3, 7 Excursus 8: The acoustic dimension of imaginations). Stimulating tactile and auditory experiences is therefore particularly conducive to the kinesthetic design of imaginative experiences (Nohr 2006). Depending on what the patient is focusing on, you can ask:

“Could you try to touch the stem/the leaves/the blossom/the petals? How does that feel? (Is it a pleasant feeling?)” If you notice that the patient cannot approach their flower so quickly and remains in a diffuse overall imagination: “What does it look like right where you are?—Can you make out the immediate surroundings?” Or: “Where do you see the flower in front of you? How does the ground feel right where you are standing? Do you smell/hear anything?”

Once the initial exploration of the imaginative design is completed—this can happen quickly, taking less than a minute, but also taking several minutes—it is important to follow up with an effect question (7 Sect. 7.3): “How does (the flower, landscape, tree …) affect you?” This intervention differs from questions about individual sensory qualities by aiming for wholeness and affectivity. The focus is on the patient’s current emotional state, which is fused with the internally perceived in the imaginative mode (7 Chap. 2 and 7 Sect. 3.3). This can be deepened or clarified by directly asking: “How are you feeling right now with the flower?” With the question of effect, a new field opens up, a new inner space. For at the latest now, the patient shares emotional impressions with you, for example: “Well, it

3

stands there quite alone.” Or: “It seems a bit withered.” Or: “The stem is twisted strangely from the middle.” Or: “It seems somehow lost.” Or: “It’s beautiful. It towers above all the others. It radiates…” You can already sense at this point whether the patient idealizes their flower or tree, creates a desired image from it, or whether they see in the flower an image of their current self-feeling or state of being. Now that the affective involvement has become more noticeable, action impulses emerge in the patient. This happens spontaneously for some, while for others it is necessary to initiate this side with impulse questions (7 Sect. 7.3) such as:

“What would you like to do now?”, “What do you feel like doing right now?”, “What would be nice now?”. If patients can pick up on this by saying, for example, that they would like to take the flower home or water it or support the stem or simply continue to look at it, it can be therapeutically fruitful to connect an encouragement intervention (7 Sect. 7.3), for example: “Try to do/ implement what would be good for you/ the flower.” (If that “doesn’t work”): “What would be helpful now?”, “What could help?”, “What possibilities come to your mind to implement this anyway?”

This can, for example, situationally alleviate inhibitions and restrictions caused by the superego, helping the patient to move more naturally in their imaginative space. In summary, it can be said that all interventions that promote contact with the objects (flower, meadow, animals, etc.) through descriptive questions or help to clarify and strengthen the emotional experience through effect questions are useful. The less suggestively asked, the more the patient has the strengthening experience of their own design. The goal is to

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

achieve an experiential form (7 Chap. 2). This is achieved when the sensual contact with the objects is primarily established and maintained (questions about individual sensory qualities) and, building on this, the accompanying feeling is explored (effect questions). If the feeling is addressed too early, defense mechanisms can cause the image to “blur,” and the imaginative immersion is disturbed. In these situations, the renewed question about sensory impressions and suggestions for detailed descriptions such as “In what environment is the flower standing?”, “What is the nature of the ground?” leads back into the imagination. It is important to develop a sense of balance between these interventions and the inner spaces they each initiate. In short: The descriptive questions open up the imaginative space, the effect questions help with affective enrichment and differentiation—and only then can impulse questions complement and round off the experiential form (Further 7 Sect. 7.3). z d) Ending the Imagination

The first imagination is usually quite short, rarely longer than five minutes. For patients who readily and easily embrace the imaginative offer (7 Sect. 3.3), it can also last a little longer, as one would not want to abruptly pull the patient out of an intense emotional state, such as when presenting a flower to a loved one or simply when deeply contemplating a pleasant or burdensome mental image. However, if the therapist delays the termination because they feel that “it is not enough” or “it has not been worked on enough” or, in their opinion, the patient has not yet reached a “good place” or “conclusion,” this represents a countertransference resistance. If they recognize their tendency to delay within themselves, it protects them (and the patient!) from acting out their own performance or altruistic issues. Because their procrastination of the conclusion can evoke various, even difficult feelings in the

patient, such as a sense of deficiency. Therapist and patient can quickly and directly enter into a collusive transference scene, in which the patient, for example, proves to themselves and the therapist that they “cannot do anything” or “are not good” or “destructive” or “deficient”—or that “even this method” and “even this therapist” “are not sufficient.” Countertransference reflection is helpful in supervision (7 Sect. 7.7.5). The conclusion instruction can initially be announced in one of the following ways:

“The imagination will fade away soon.”, “We need to slowly come to an end.”, “Is there anything else that is important to you right now?”, “Would you like to change anything?”, “Would you like to return to the starting point once more and describe how it affects you now?”. This is followed by the actual conclusion instruction in a formulation similar to: “Take everything in and let the images slowly fade away. Open your eyes when you are ready (and stretch yourself vigorously.)” Or: “Come back to this reality, to this room.”

In conclusion, the therapist’s behavior during the first, but also subsequent imaginations, should be characterized as follows: It is generally recommended to structure the imagination framework well, i.e., to clearly express the introduction and conclusion instructions in words—while at the same time giving the patient “all freedoms” regarding pace, content design, and pauses for silence during the imagination, and supporting this through the type of interventions, e.g., through the quite ritualized opening phrases: “Take your time”, “Any other mental image is possible.” Thus, the therapist has a “securing dominance” at the beginning and end of the imagination but hands over control of the course and design of the imagination to the patient as soon

31 3.7 · Debriefing of the Initial Imagination

as they have “arrived in the picture.” Our main task is not to disturb or hinder the patient, but to accompany them spaciously and benevolently. This can also include a change in the language level: Many patients express themselves more concretely, colloquially, incompletely, or lapse into their dialect. The therapist should adapt to this changed speaking behavior of the patient. Interventions are like a hand that we extend to the patient, which they can grasp in their own possible way or not. They provide orientation, but in a different way than questions and conversation interventions. Because in conversation, the therapist is focused on a “response” in the sense of understanding or clarifying differentiation. Imagination interventions, on the other hand, are like small energetic encouragements to completely focus on one’s own inner world and momentarily distance oneself from the receptive or “responding” orientation towards the therapeutic counterpart. Thus, for the first time during the initial imagination, this specific “space within space” is created as an experiential space detached from the conversation situation. Later, it can become a familiar framework element of therapy used by the patient in their specific way. With unobtrusive, merely suggesting the motif (7 Sect. 7.2), interventions that prompt description and sensual perception, we have led the patient to the threshold of unknown inner spaces. Some patients enter their rooms freely, without visible inhibitions, others remain cautiously at the threshold for a longer time, some close the door again, through the gap of which they may have peeked. And mostly not because this form of self-exploration frightens them, but because, as explained above, they can or want to open up to the inner world in the presence of another only in a very controlled form due to various fears and negative experiences.

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3.7  Debriefing of the Initial

Imagination

Through the initial imagination, the therapist has initiated something new. The patient has communicated with the therapist during the imagination from a special state of being. When the patient opens their eyes after imagining and sees their therapist face-to-face, both are in a sensitive phase: The patient has to emerge from their experiential space and adjust to the direct conversation encounter with the therapist. This can also be accompanied by astonishment and slight feelings of shame. The therapist, on the other hand, also has to adjust to the conversation level again and only knows about the imagination from what the patient reported during the sequence. The follow-up conversation does not simply continue the dialogue that was conducted before the imagination. At this point, a communicative transition is needed, in which empathic resonance and echoing are initially beneficial for the patient. This can be expressed by asking how the patient felt during their inner journey of images and how they feel now:

“How are you feeling now?” or “How did you feel during the imagination?” or “How do you feel right now?”, and later also “What touched you the most/particularly?”

Patients differ greatly in how quickly and seamlessly—i.e., unempathically with themselves—they demand to switch from the brief, experience-rich state of being back to that of a conversation partner. They also differ in terms of the insecurity that the experience stirs up in them. Some want to know exactly: “And what does that mean now?” or: “What do you make of it now?”. Others have to trivialize their experience, while others immediately engage in interpre-

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Chapter 3 · Katathym Imaginative Psychotherapy—From First Contact to Initial Imagination

tive self-exploration. Many, however, linger a little and express how surprised, delighted, or even alienated and irritated they are. So first, we let ourselves be informed by what has just been experienced and try to alleviate the uncertainties in patients who are very eager for interpretations by pointing out, for example, that there are no 1:1 interpretations, just as in dreams, that there is also a wider range of meanings here, but we can use the imaginations to better understand emotional states. Patients often strive for interpretations on their own because they think, for defensive reasons, that they have to anticipate the therapist doing it. This urge for interpretation, if it appears spontaneously in the patients during the follow-up conversation, should therefore be carefully problematized by the therapist; under no circumstances should he himself pursue it. This also applies to dealing with the painted images (see below and 7 Sect. 7.5). Comparable to the dream discussion, the patient should gradually be introduced to the subtle self-exploration that the imaginations allow. The processing technique of encouraging free association with details is similar to the psychodynamic approach to dreams. In the further course of the follow-up conversation, transfer implications should also be addressed in an exploratory manner, for example:

“How did you feel with me during the imagination?” You can explain, for example: “Some people feel disturbed by the questions, some wish for more inquiries—how did you just experience that with me?”

The issue of closeness and distance between patient and therapist should not be discussed in depth after the initial imagina-

tion; being asked how he experienced the interaction with the therapist is helpful for many patients, however, as it indicates that “this too” plays a role: That the therapist is willing to adjust, and that as a patient, he has an influence on future imaginations and his wishes are important. All these aspects of the follow-up conversation can, of course, also be picked up in the following session. As in the rest of the therapy process, the impressions of the imagination and the follow-up conversation have an effect and lead to further reflections, through which the therapy sessions are connected to each other. The initial imagination is, even more decisively than the initial dream (7 Sect. 3.6, 7 Excursus 6: Initial Dream), a first joint therapy product. Therefore, an approach that avoids interpretations but encourages self-exploration is appropriate: The first catathymic flower should be cared for very carefully and with all the protection that a young plant needs: viewed together, watered with interest, fertilized with exploratory questions. In this sense, we encourage many patients to paint the imagined scene until the next session and bring the picture with them (7 Sect. 7.5). This suggestion also aims to focus the patients on their own experiences and promote the lingering, non-binding engagement with the inner world and the “world of therapy.” From a relational perspective, the painting instruction expresses our interest in the patients’ self-explorations. In addition to the relationship-promoting aspect of the initial imagination, there is a pragmatic-diagnostic one: The therapist can derive important symbolically veiled indications of the patient’s unfulfilled relationship wishes and their defense, as well as their ego strengths and so-called “resources” (Rosenberg 1998) from it. The first imagination thus represents an important addition, sometimes even a relativization of the previously formulated h ­ ypotheses on

33 References

psychodynamics and also offers an opportunity to illustrate central conflicts in the insurance application.

References Arbeitskreis OPD (2014) Operationalisierte Psychodynamische Diagnostik OPD-2: Manual für Diagnostik und Therapieplanung. Huber, Bern Argelander H (1992) Das Erstinterview in der Psychotherapie. Wissenschaftliche Buchgesellschaft, Darmstadt Bahrke U (2010) Wirkfaktoren der Psychotherapien: Wodurch hilft die Katathym-imaginative Psychotherapie? In: Kottje-Birnbacher L, Sachsse U, Wilke E (eds) Psychotherapie mit Imaginationen. Huber, Bern, p 213–231 Dieckmann M, Dahm A, Neher M (eds.) (2017) Faber/ Haarstrick. Kommentar Psychotherapie-Richtlinien. 11., überarbeitete Aufl. Elsevier Urban & Fischer, München Dieter W (2005) Warum sind Imaginationen therapeutisch hilfreich? Überlegungen zu einigen Wirkfaktoren der KIP aus tiefenpsychologischer Sicht. In: Kottje-Birnbacher L, Wilke E, Krippner K, Dieter W (eds) Mit Imaginationen therapieren. Pabst, Lengerich, p 90–97 Eckstaedt A (1991) Die Kunst des Anfangs: psychoanalytische Erstgespräche. Suhrkamp, Frankfurt Freud S (1911) Die Handhabung der Traumdeutung in der Psychoanalyse. GW 8:350–357 Geißler P, Heisterkamp G (eds) (2007) Psychoanalyse der Lebensbewegungen. Springer, Wien, New York Hohage R (1996) Analytisch orientierte Psychotherapie in der Praxis. Schattauer, Stuttgart Holt R (1989) The present status of Freuds theory of the primary process. In: Holt R (Ed) Freud reappraised. A fresh look at psychoanalysic theory. Guilford, New York, p 280–301 Jung CG (1929) Ziele der Psychotherapie. GW 16 (1985), p 38–56 Jung CG (1931) Die praktische Verwendbarkeit der Traumanalyse. GW 16 (1985), p 148–171 König K (1991) Praxis der analytischen Therapie. Vandenhoeck & Ruprecht, Göttingen

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Kris E (1952) Psychoanalytic Explorations in Art. International Universities Press, New York Leuner H (1985) Lehrbuch des Katathymen Bilderlebens. Huber, Bern, Stuttgart, Toronto Leuner H (1990) Katathymes Bilderleben. Ergebnisse in Theorie und Praxis. Huber, Bern, Stuttgart, Toronto Mertens W, Waldvogel B (eds) (2000) Handbuch psychoanalytischer Grundbegriffe. Kohlhammer, Stuttgart, Berlin, Köln Nohr K (2006) »Meine Seele hört im Sehen«—Zum szenischen Charakter des therapeutischen Umgangs mit katathymen Imaginationen. Imagination 28/4 : 5–29 Noy P (1969) A Revision of the Psychoanalytic Theory of the Primary Process. Int J Psychoanal 50:155–178 Pahl J (1982) Über einige abgrenzbare Formen der Übertragungs- und Gegenübertragungsprozesse während der Arbeit mit dem Katathymen Bilderleben. In: Leuner H, Lang O (eds) Psychotherapie mit dem Tagtraum. Ergebnisse II. Huber, Bern, p 73–91 Posth R (2009) Vom Urvertrauen zum Selbstvertrauen. Waxmann, Münster Rosenberg L (1998) Kraftquellen und Ressourcen in der KBTherapie. Imagination 20:5–36 Rudolf G (2010) Psychodynamische Psychotherapie: die Arbeit am Konflikt, Struktur und Trauma. Schattauer, Stuttgart Schnell M (2005) Imaginationen im Dialog. Zur Dynamik der Übertragungs- und Gegenübertragungsprozesse in der KIP. In: Kottje-Birnbacher L, Wilke E, Krippner K, Dieter W (eds) Mit Imaginationen therapieren. Pabst, Lengerich, p 69–78 Steiner B, Krippner K (2006) Psychotraumatherapie. Schattauer, Stuttgart Stern D (1985) The interpersonal world of the infant: a view from psychoanalysis and developmental psychology. New York: Basic Books, dt. (1992) Die Lebenserfahrung des Säuglings. Klett-Cotta, Stuttgart Trimborn W (1994) Analytiker und Rahmen als Garanten des therapeutischen Prozesses. Psychotherapeut 39:94–103 Wöller W, Kruse J (2010) Tiefenpsychologisch fundierte Psychotherapie. Schattauer, Stuttgart

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A Short-Term Therapy With Imaginations: The Case of Musat Contents 4.1 Establishing Contact and First Impressions of the Therapist – 36 4.2 Therapy Planning – 36 4.3 The Initial Imagination – 41 4.4 First Treatment Phase – 44 4.5 Second Treatment Phase – 56 References – 68

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_4

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

4.1  Establishing Contact and First

Impressions of the Therapist

4

A colleague asked me if I could therapeutically support a relative working abroad in finding a way out of a life crisis. The relative works in a high position and has taken a two-month professional break, which she wants to use for self-exploration. Out of collegiality, but also curious due to the special circumstances of this therapy search, I gave a conditional commitment. I made it dependent on a two-hour preliminary talk in which I wanted to assess whether an intensive KZT offer could be helpful to the relative at all and not, on the contrary, possibly harm her. A few days later, Mrs. Musat calls me. I recognize her name, which my colleague had already mentioned, but due to her voice, I have the impression of having a man on the phone. The voice sounds warm and quite deep. This confuses me: Wasn’t a woman announced to me? Or did I remember it wrong? We arrange an appointment, to which the patient travels from a distant major city. At the agreed time, a tall, slim, strongsporty, “upright” and age-appropriate 35-year-old woman in a well-groomed, discreet pantsuit with soft, feminine facial features and a friendly smile appears; her open attentiveness is spontaneously pleasant to me. Her descriptions are clear, she responds precisely, almost accurately to my questions and answers them with a differentiated, but not exaggerated detail, creating an atmosphere of coolness and rationality. She still seems to me to be capable of resonance and emotionally involved, but also repeatedly escapes into an intellectual protection zone. 4.2  Therapy Planning z Current Issues

Mrs. Musat takes a seat in the armchair opposite me, crosses her legs and reports: For two years, she has been working in a de-

manding “firefighting job” as a managing business economist for a large car company in Italy. Together with four engineering colleagues, she had come from Frankfurt to Milan a few years ago, where a kind of “school camp atmosphere” had developed among them. This was a good thing, as they had to stick together at their level, constantly monitored by their bosses, who had to meet their delivery deadlines. Everyone was under pressure, also due to media publicity. She is satisfied with the “job”—as she downplays her high position—but has problems distancing herself from work, colleagues, and bosses: “The pressure to complete tasks is consuming me.” It is difficult to live anything of her own at all. She only sees her husband (an 11-year relationship, married for 6 years) on weekends. However, this has always been the case. Meanwhile, she has developed a love relationship with a woman, an Italian. She had occasionally felt attracted to women before, but this is her first intimate relationship with a woman. With her, a richer leisure life and more distance from work have developed. But her marriage? And the family’s reaction? That’s where the problem lies. She feels trapped, at a loss, and sometimes desperate, and is looking for a perspective: Something has to change professionally and privately. In terms of her job, she has already initiated something: Soon she will take a two-month break and then return to Frankfurt; she already has a good offer. During this break, she wants to gain clarity about her further private steps with therapeutic support. After hesitating for a long time, she told her husband about the girlfriend and also took a “break” from the marriage. Her husband definitely wants to continue the marriage, but there are no ideas for change from him in the many conversations she has initiated. The question of children is also intertwined and completely open. She feels pressured by his passivity: “He waits and suffers.”

4.2 · Therapy Planning

z Biographical Information

Mrs. Musat is the middle of three children (brother +3, dentist, married, three children; sister, –12, studying pharmacy). Her mother (+29) is said to be a teaching nurse, her father (+29) a doctor of business administration. Originally, he had started studying Catholic theology but had “suffered too much under the associated boarding school-like conditions. He wanted to go out at night.” Both parents came from a strict Catholic-Westphalian milieu. She was a wanted child but had been “in the wrong position,” so her birth was more difficult than her brother’s. The mother weaned early, “she had no more milk” and went back to work soon. In her second year of life, she suffered a facial laceration from a fall, which was stitched under general anesthesia, “because I screamed so much.” She was afraid of having the stitches removed, so the mother wanted another general anesthesia—but the father was able to “calm her down in his arms,” so it was done without. The patient recalls in this context that as a child, she occasionally wished to be injured or sick to receive attention. However, she was a healthy child. She has fond memories of her time in the Montessori kindergarten, especially of a quiet, loving educator. As a child, she was already serious and conscientious and dealt early with questions like: “Am I calm or wild, shy or impulsive, thoughtful or spontaneous?” Often, she would wake up at night from nightmares. A recurring dream was about a “war of two colors, yellow and black,” in which she felt helplessly exposed, “everything pushed through a tunnel, it was very threatening, then I landed in a meadow and sat there alone.” The patient experienced a break when her father initiated a job-related move in her 7th year of life to a North German “culturally barren environment.” Her musically interested and active mother did not want this but—as a teaching nurse professionally flexible—reluctantly agreed.

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The children were encouraged and challenged: sports and piano lessons. Excellent performance in school and independence were top priorities. There were clear rules, and the parents were “very consistent.” They were not punished; it was more likely that the rules were so emphatically stated that they were naturally followed. She describes her mother at this time as a cheerful, open-minded, active-sporty, conscientious woman, but also one with a very anxious side and easily overwhelmed. For example, when she came home from work, the children were not allowed to disturb her afternoon rest under any circumstances. Basically, she was more of a “father’s daughter,” spending a lot of time with him on weekends. She has fond memories of joint mountain tours and skiing with the whole family. Her brother was her role model, and she emulated him. He liked to play with dolls and envied girls who could dress up. She, on the other hand, would have preferred to be a boy and rejected doll games. During her elementary school years, she played soccer instead, even in a club. Due to the mother’s dissatisfaction with the rural situation, there were repeated disputes between the parents. She suffered greatly from this. She remembers wishing for a sibling at that time. The little sister, born to her delight in her 12th year of life, was intensely “mothered” by her; she was “strict and caring” with her. In her 14th year of life, there was another job-related move to a larger city further west. She “took a good friend with her” from each place of residence, maintaining intense pen friendships with them. In these friendships, she experienced more closeness and intensity than in the newly developing friendships at each location. She was aware that she was writing against her feelings of uprooting and being an outsider with these pen friendships. She reports that during this second move—this was a onetime occurrence—she broke down in tears

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

in front of her parents, which relieved her. In general, however, she dealt with her grief alone, being a “Robin-son.” During puberty, she remained reserved towards boys, but always had athletic and sociable contacts with them. Her first intimate relationship was with her now-husband Jürgen, whom she met during her studies. “Trust and freedom” were the basis of their quickly intensifying relationship. He was generous, indulgent, and supportive. Both were very “modest people” who worked too much and could fit well into any given structures. After their studies, they lived “from weekend to weekend.” She had a very good job in West Germany, he in South Germany, and they alternated meeting here and there. Both were “well organized” and did many beautiful things on weekends. When she started thinking about having children, Jürgen could not find a job in her location despite several applications. Perhaps he had acted in such a way that it could not work out, she suspects. They could not clarify this together. Gradually, also due to the intensifying work pressure in Italy, their relationship lost its balance, she became estranged from her husband, and a lack of “feeling at home” emerged. At the beginning of their marriage, she had felt attracted to a woman during a group hiking vacation but did not open up to her. Francesca, the slightly younger Italian woman with whom Ms. Musat is now in a relationship, actively sought contact with her. At first, it was a friendship, then also an erotic-sexual deep experience. With her, she felt as alive as never before. z Countertransference

While I was confused by the masculine charisma of her voice during our very first phone contact, I experienced Ms. Musat as a strong, beautiful woman in our first direct encounter, who, however, downplays her feminine charisma and “masculinely” covers up possible insecurities. Inciden-

tally, I wonder if this is only the case with me as a woman, in order not to provoke rivalries. This impression is based not only on body language signals but also on the nature of her report, in which a longing, soft moment is clearly palpable behind her clearly structured words and a partly tomboyish way of expression. This discrepancy arouses my interest, her inner involvement and open-mindedness my sympathy—and so I was happy to meet her again. z Psychodynamic Hypotheses

In the now important assessment of whether I can assume that I can help Ms. Musat as a patient during her two-month break and then also say goodbye to her in a sufficiently stable state, I made the following considerations: She is a very performance- and egostrong woman who, however, fends off strong regressive needs with this side capable of top performance and autonomy: Her basic motherly longing remained “unfulfilled,” and the disappointment about it should be “narcotized” (like her fears when taking care of the laceration). Unconsciously, she may still blame herself for having caused her mother pain by her existence “the wrong way around.” Her early childhood needs for attention and security found a way out “in her father’s arms” and later with the loving kindergarten teacher. Her older brother may also have been a support that partially compensated for her mother’s deficits—but on the condition that she hid her feminine side, which he envied so much. The brother’s idealization and her early childhood fatherly devotion and identification with the father in the sense of an early, “strategic” Oedipus complex (Rohde-Dachser 1987)—she had to search for the “good mother” in him in a certain way—may have made her insecure in her own gender identity: Showing herself as a girl was not opportune in several respects with regard to her childhood needs. Against

4.2 · Therapy Planning

this background, the actual Oedipal and pubertal situation could not be used for correction: An “Oedipal triumph” over the mother did not succeed as the “better wife of the father,” but in a masculinity-oriented way. Identification with the mother’s femininity aspects was blocked. In the relationship with Francesca, these two basic conflicts find their current compromise solution. Neither the sexual orientation and its complex backgrounds nor the disappointment pain associated with it about her too cool, demanding mother and her unfulfilled basic, maternal security wishes—so it is clear to me—can be changed within the treatment framework available to us. Likewise, it will not be possible to shed light on the topic of “desire for children” in all its diverse backgrounds, as I internally associate it with a fundamental unfulfilledness that would need to be processed and mourned. (For if the assumption of a lack of maternal-emotional care should be confirmed, far-reaching questions arise that cannot be solved in short-term therapy, such as: How should she give a child what she herself has not experienced without envy? Would there be a risk of altruistic overburdening for reasons of envy defense? Has she accepted her husband’s rejection of parenthood for so long because it suited her internally, as these questions are too destabilizing for her? Or did she projectively “accommodate” them in him, to which he offered himself in his passivity? Could turning to a woman represent a step in the internal processing of these questions? A step that brings her closer to the solution, but perhaps also further away from it?) That her successful performance orientation had long repressed her security wishes was already recognized by herself as “missing the point of life” and dysfunctional when she developed the relationship with Francesca. Understanding the biographical backgrounds of this defensive attitude and developing better-fitting de-

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signs, on the other hand, is a therapeutic endeavor suitable for short-term therapy. I would have to work with the patient to understand how she found parental recognition through performance in her childhood and further development, which she expanded in the academic and athletic fields. Stabilization through emotional support in her peer group was repeatedly disappointingly interrupted by the family’s moves, so the patient began to mistrust engaging intensively in close relationships. Again, for protective reasons against disappointment experiences, she cultivated familiarity through more distant pen pals and eventually chose a man with whom she could design a relationship “from weekend to weekend” while continuing her professional career. Another point caught my attention: It is unusual for the patient to state that she wished for a sibling during her prepubescent years. Possibly, this wish played a role in the fact that she experienced her parents in a lot of conflict at that time. (Consider also the recurring dream of the “arguing colors yellow-black,” at the end of which she “sat alone.”) Thus, it is conceivable that, out of fear of parental discord and concern about losing her beloved father, she took on the role of the “peacemaker” but also felt the burden on herself. A new joint child of the parents would have relieved her—and probably did so. Assuming the role of peacemaker in the work area and her difficulty in distancing herself from the demands and conflicts of others were among Ms. Musat’s professional problems. This aspect also seemed addressable on a current conflict level, although it would certainly not be “rollable” in its biographical complexity. z Treatment Planning and Indication

From the psychodynamic considerations, the following priorities and goals of the upcoming short-term therapy emerged: With the relationship to Francesca, Ms. Musat

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

has discovered a lively, performance-free side in herself and joyfully experienced it as belonging to her. Supporting her better compromise between performance and pleasure sides found with this relationship is possible in short-term therapy. However, she had not yet managed to live this relationship and commit to it. That is why she is “at a dead end.” Helping her out of this seemed possible in short-term therapy if it would succeed in sufficiently separating the associated conflicts from the deeper conflict layers. In the more psychologically superficial “dead-end conflict,” it seemed to me that the decision was not about whether Ms. Musat wanted to live with her husband or Francesca—in my impression, she had already made this decision internally—but rather about both self-permission, i.e., a superego problem, and a loyalty problem towards her parents. Despite her independent lifestyle and distance from her home country, I experienced the patient as still being very attached to her family of origin and their approval of her decisions, as well as their goodwill. In particular, she had an excessive “sense of responsibility” towards her mother, wanting her to be well. This is fueled by the multi-layered neurotic guilt described, which demands punishment: As a “lifelong mediator,” she must atone for a combined basal-oedipal mother “betrayal” (as a “father’s daughter”). And since the mother reacts negatively to a same-sex love relationship of her daughter, Ms. Musat unconsciously accuses herself of burdening her with such “misbehavior.” She had already begun to correct her general and professional altruism, which derived from this. In this process, it would be important to continue to support her. However, it would also have to address a guilt and superego problem “superimposed” on the deeper conflicts concerning the mother and family of origin, so that a step of detachment could be achieved through internal permission. The basis of

a supportive process taking place within a tight timeframe would be an attitude of positive resonance, especially towards what Ms. Musat had discovered as belonging to her and as liberatingly alive. With these considerations, I felt more confident about the treatment approach I eventually suggested to Ms. Musat. All three treatment focuses: clarification, focusing, and defense loosening through impulse promotion can be well addressed by including imaginations (7 Sect. 3.3). Precisely because of the patient’s intellectualizing defense, her not affect-isolated but inhibited affect expression, it would be expected that her emotional side and thus her desires would be more easily and clearly revealed with the help of imaginations. Giving space to these desires has brought her here. In this respect, it would be helpful in a first step to support her in an exploratory process that fits her “time-out” therapeutic framework, discovering her own desires and needs, and balancing her overemphasized performance side. Especially in the short time available to us, the inclusion of imaginative experiences offers a great opportunity to promote self-investment. New, I thought, for Ms. Musat will be to turn to her needs and herself in the presence of a woman, as she has been used to empathizing with maternal objects and encountering them as a “mediator” or “caretaker.” Our gendered therapeutic constellation means for the transference dynamics that a patient initially taking care of me, sparing me, can be expected, and the “externalization” of the negative mother transference: First, she will have to “care” for me as a therapist, and working through a negative mother transference with the associated disappointment anger will not be possible. The risk of a process development with a negative mother transference should be considered in a short-term therapy. Fortunately, a “mild good mother transference” could be linked to helpful substitute mother figures, such as the kindergarten teacher or

4.3 · The Initial Imagination

the positively connotated relative who recommended therapy with me. Her fear of closeness would also only be touched upon later, as it is related to her described basal problem of dependency fears, and these, as well as her identity problems, can only be satisfactorily and fruitfully treated for the patient within the framework of continuous analytical work. Encouraging such work could also be a result of this short-term therapy. z Treatment Agreement

After completing my indicative considerations, I agreed to the KZT for the patient within the following framework: Within her two-month break, we could carry out two therapy sections, interrupted by the fourweek vacation I had planned during this time. In these two phases, I suggested to her, she would come to me for a daily treatment session for one and a half weeks each. She immediately agreed with this session density and also with the fact that I could usually only offer her late or early fringe hours, which again confirmed the suspected transference line (that she feels she has to fulfill the expectations and settings of the close other rather unquestioningly while holding back). In order to give Mrs. Musat—as a completely therapy-inexperienced person—some orientation and not to encourage exaggerated expectations, I also told her something like the following: “During this treatment time, we will not achieve far-reaching internal changes in you. However, it will be possible for us to better understand your crisis and the nature of your dead-end situation and to support you in making a decision. Above all, our main concern should be that we better understand together what prevents you from feeling freer in your life design, what inhibitions and concerns may play a role, where they come from, and how they could be overcome.”

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In the manner described in 7 Sect. 3.5, I combined these statements with the announcement that I would also like to work with her, including imaginative sequences. In response to this, she was—again fitting the outlined transference dynamics—immediately open, so that I already suggested a first imagination to her in this, the fourth probatory session and the last before our first treatment section—which would only begin in six weeks. 4.3  The Initial Imagination

After the imagination announcement (7 Sect. 3.5) and a brief relaxation instruction (Sect. 3.6), I suggest: 5 Imagine a flower for a moment. 5 It’s an iris, the blossom is white—no, violet. It’s a single flower and also a blossom on a straight stem. Yes, it’s a very straight stem, a clear shape, and a very intense color. 5 Can you describe the blossom in more detail? 5 Yes, the blossom is open in a funnel shape and facing openly. The blossom is very stable at the bottom of the stem, it is well guided by the stem. 5 Would you like to touch it? 5 The stem feels strong, not soft like the blossom. The blossom is very soft, velvety. The stem is almost a bit angular. Straight cut off, even the leaves are angular and straight. 5 Can you describe the surroundings of the flower? 5 At first, I only had the flower in mind, without any surroundings. Now I see it most likely in a garden, in the garden at my parents’ house in N. It is in a flower bed. The garden is quite wild, there are individual flower beds, in one bed stands the iris. 5 And how does the flower affect you there?

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

5 Outstanding, as it stands alone and is special. It catches the eye. Like a colorful dot in a lot of green foliage. It stands out for its beauty, colorfulness, and strength—it is also somewhat alone there. 5 What do you feel like doing with or near the flower? 5 I would like to look at it extensively. Spend time with it. Not cut it off at all. Let it be. Leave it as it is, not pamper it, enjoy it.—I would often go to it, but not be able to stay long.—When I leave, I could dig it up, but I’m not sure about that. I’m undecided. I don’t know if that would be good. 5 Maybe you would like to ask the flower if it would be okay if you came more often, but didn’t stay long. 5 Well, the flower lets me know that it would indeed change its location. It would come along. It doesn’t want to remain in expectation. At this point, I suggest ending the imagination, which has lasted six minutes. From the brief follow-up conversation (7 Sect. 3.7), it becomes clear: For Ms. Musat, this first imagination has a striking, vivid “evidence.” Her flower, as if rising from her inner self, evokes both joy in its beauty and astonishment, especially how vividly she sensed an ambivalence towards the flower. When she wanted to “turn to it extensively,” she was “disturbed by an inner restlessness.”—Spontaneously, she can understand the flower as a self-symbol: What has been imagined here has a central connection to her! Ms. Musat leaves my practice stimulated and thoughtful. How can we understand this first imagination? What could it have caused in the patient during this last probatory preliminary talk before a longer period in which we will not see each other? What impulses might possibly emanate from it? What does it tell me as a therapist, who had been intensively dealing with the patient’s biography and psychodynamic considerations in

the previous sessions? What does the imagination also say about our emerging relationship? For my diagnostic understanding, the imagination is helpful. One immediately striking peculiarity in this imagination is the contrast: The softness of the opened blossom forms a contrast to the angular clarity of the stem. The blossom is turned towards, thus in a movement towards the viewer, the stem stands upright and straight. White or violet? A color contrast appears in the hesitation. The flower is called Iris by the patient; she could also have said sword lily, but decides on the female name. The designation sword lily would have contained another contrast: a weapon of war and a symbol of innocence. The motif of contrast is continued when the initially single flower is imagined in an environment. The flower stands out due to its strong size and bright colorfulness from the rather uniform green herb. It stands alone in the parents’ garden with several beds, which in turn appear juxtaposed to the wild growth. Finally, contrasting aspirations of the flower are expressed: The patient wants to look at it extensively but cannot stay long. She does not want to cut it off and leave it as it is, but on the other hand also take it with her (for example, dig it out). There are further, albeit less striking peculiarities in this imagination, such as certain linguistic formulations: stably grown, well guided by the stem. The word clear is used several times. In terms of content, the themes of the special (the flower is particularly beautiful, surpassing simple herb) and “aloneness/autonomy” versus “relatedness/ remaining in the ancestral place” stand out. The flower would come along, but should also be left, left as it is. It is first seen individually, then together with other plants. Through such “peculiarities,” this imagination acquires a special, unmistakable face, it “shows” something. Its content orientation and formal design allow

4.3 · The Initial Imagination

­ypothetical assumptions about the pah tient, which expand my therapeutic understanding of her personality and inner conflict world. Thus, I try to relate the imagination to the previously collected anamnestic data and scenic communications of the patient and check how the picture fits here and what it possibly accentuates differently. My diagnostic view focuses in detail on the perceived personality structure (a), the inner and outer conflict world (b) with the conscious and unconscious relationship desires (c) and their defense (d), on the patient’s possibilities to deal with it (“resources,” “ego strengths”) (e) as well as on signs of the transference process (f). The flower image imagined by the patient initially reflects certain aspects of her personality structure (a): the clear, direct, and straightforward manner of behavior in the straight, angular stem, her orientation towards the needs of others in the velvety, funnel-shaped, as if “listening” to the expectations of others, blossom. The extraordinary performance of the doctorate, working in a very high responsible position, is reflected in the theme of the outstanding; and: The flower is as beautiful and intense as the highly motivated, good-looking, albeit rather understating her feminine charisma, patient is. But also internal conflicts (b) become apparent: By having the soft blossom well guided on the stem and this being stably grown, an intrapsychic conflict between the soft, colorfully expressing, emotionally charged “female” self-parts turning towards the “passion color” and the orienting, goal-directed, clear, also angular-contoured, closed, traditionally “male” self-parts becomes noticeable. The symbol of the flower combines emotional life and vitality in blossom and stem. Both form a complementary whole. How does this fit with the patient’s life? There, moments of wholeness are rare, gender identity is uncertain, and utility and performance thoughts

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dominate. Everything is subordinated to professional activity and success: marriage, desire for children, leisure needs, joy of life and enjoyment—until her life forces rebelled against it. As mentioned: The patient fell in love and is in a life crisis, as she does not know how to reconcile this powerful feeling of love with loyalty to her much-appreciated husband. Less consciously, but clearly expressed in the imagination, is her more far-reaching loyalty problem towards her parents. By having the imagination play in the parental garden, where she has her “roots,” this initial imagination precisely “chooses” the focus that can and should be addressed in a first therapy section of this KZT: The question of the inner “leaving” from the parental garden, whether she will allow herself to dig up:the flower tells me that it would indeed change its place, … I could dig it up, but I am unsure. I am indecisive. From a psychodynamic perspective, based on the anamnestic knowledge and what the patient has communicated about her problems, a central wish (c) can also be derived from the flower image: In relation to the patient’s self, it is the wish for a better conflict resolution: Since her desire for achievement dominates and she strives to fulfill internalized demands, she suppresses her longing for the expression of emotional desires and falls into a stressed deficiency. Without overlooking that this wards off a basic depressive core conflict, there is primarily a classical ego-superego conflict, which also serves to ward off feelings of guilt. In relation to a partner, her wish would be conflictual, to be able to live both with him and not—as with her husband, who also puts work first—to be hindered by either of them. When wishes are mobilized—and starting therapy is synonymous with wanting to give in to her wishes, but not being able to do so alone—a defense movement is always to be expected, which ensures that the wishes do not become too intense.

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

For  when long-suppressed wishes press forward, they destabilize the self, making it susceptible to fears, disappointment anger, mourning for the unlived, guilt and shame conflicts (7 Sect. 7.7.3). The defense (d) of the wish for affection and closeness becomes particularly noticeable in this imagination in the second part. The experienced accepting affection (leaving the flower as it is, enjoying it, looking at it extensively) cannot simply remain and be enjoyed; worries arise that the flower might be coddled, and the counter-impulse of turning away or dosed self-affection (the patient would often go to it, but not stay long) comes into the picture. Here, the ambivalence tension between desire and fear or defense becomes particularly clear and dominates the events. Since intrapsychic conflicts always become interpsychic transference dynamics (f) in the course of therapeutic processes (7 Sect. 7.7.2) and these then act as a motor for change, I can also understand certain aspects of the imagination prognostically: The patient wants me to pay attention to her entire personality, she does not want to be seen only in her enormous performance capabilities—which she rather downplays. At the same time, she fears being destabilized by such a form of attention and possibly also sought me out in a distant city for this reason, thus only considering short-term therapy. Perhaps she wants to be shown the reasons for her life crisis, but then to cope with them autonomously in her proven performance capabilities, without having to rely on help—and above all, without having to enter into an emotional dependency experienced as threatening due to her life history. I would often go to her, but not be able to stay long can therefore also be related quite directly to me in the sense of a transference allusion (7 Sect. 7.7.4)—as regret, but also as chosen protection against an eventually pending disappointing separation: the flower does not want to remain in expectation.

And finally: Her imagination also provides information about which “resources”, i.e., ego strengths (e), the patient has to deal with her conflicts. In the case of Ms. Musat, it is noticeable: She can focus on her goal (a vivid flower appears immediately; in other internal conflict or transference situations, sometimes “nothing” comes at first or several flowers appear or only certain parts become visible), she can fully concentrate on the inner object, touch it and perceive it sensually. And she can enter into an emotional contact with the flower, interact with it, and also empathize with it in the role reversal suggested by me at the end of the imagination.—All of this is, of course, at the same time an expression of her positive transference relationship to me that has developed in these four hours. For now, I also remain in expectation of how she will encounter me again. 4.4  First Treatment Phase

Six weeks later (5), Ms. Musat comes to her first of eight treatment sessions taking place within one and a half weeks, making it her fifth session overall. (In the therapy presentation, the number of the therapy session is indicated in parentheses.) She reports that she has only been in Berlin since the morning, having flown from Milan to Frankfurt yesterday and from there to Berlin this morning. And she is now on leave for seven weeks. She has trained her successor, but the other employees assume that she will return and know nothing about her decision against her previous workplace, so it was like a “secret farewell”. For the future, she is aiming for a “Frankfurt-Milan combination”. This would allow her to decide where her base should be at any given time… I notice the haste of her report, but I initially refer to the content by addressing whether she may have missed the appreci-

4.4 · First Treatment Phase

ation of her work. She confirms this, but a feeling of liberation is more decisive for her. “And actually more” she is preoccupied with the upcoming meeting with her husband at some point. He wants to keep her, but she feels good with Francesca now and sees her future with her. She is “actually decided”, but he is waiting for her. And that puts her under pressure.—I ask how her communication with her husband is at the moment.—Occasionally there are phone calls about practical matters. Feelings are not discussed. He keeps saying that he is waiting for her decision and “doing nothing”. In my countertransference (7 Sect. 7.7.5) I experience myself as searching and striving during this report, which already represents an inner counter-movement to the experience of not yet being able to be emotionally involved with Ms. Musat. I perceive the patient as still “far away,” rushed to her therapy project under time pressure, the feelings are “still outside,” and she also seems to be waiting somehow. Then a small pause arises, into which I ask after a while: “Where are you right now, internally?”—She continues to talk about external things at first, but gradually gives more space to the internal: How this departure stressed her, that she had brought her bicycle, how she is reminded of the decision-making time after her studies “with the whole thing”… I notice that the patient needs more time to arrive back with me and cannot yet speak directly about what is occupying her internally. Therefore, I first ask how she wants to spend her time here in Berlin.—She has a few friends here, has rented a place nearby. She wants to explore neighborhoods, visit exhibitions, read, and also has some unfinished business with her. Then I try to connect to the flower imagination with an open questioning impulse and ask her how all this now described fits in—and whether she has brought a self-designed picture. (Also to support that she

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can maintain the inner contact with me more easily over the six-week break, I had suggested to her after the initial imagination to create a picture, 7 Sect. 7.5)—Yes. She had often thought about it, but only painted it the night before. “Was it a bit like homework?” She smiles: “Maybe a little.” She had had a clear idea of the picture for a long time and then enjoyed painting. We look at her picture together: a symmetrical blossom, a stem with asymmetrical, irregular, naturally appearing leaves. The “well-behaved” cultivated round flower bed, the “wild” blurred background. The patient associates ambivalences and then lingers on the thought that she wanted to give the iris in the imagination the freedom to stay or come along, but maybe it is she herself who needs the freedom. Now she spontaneously remembers a night dream: “I was traveling with my Italian work colleagues to a small unknown ski resort towards Slovenia, which suddenly turned out to be the in-place where ”everyone“ is. I met many friends from my high school graduation time there. We wanted to perform a play. It was a hearty peasant play, the content of the play and the real environment mixed somewhat. There was chaos, turmoil, nothing was rehearsed. I didn’t know how my lines went, when it was my turn. I had a scene to play with Francesca. Then a break: I am at work. There was cake. The boss said: There are 13 pieces, but we are 15. He insisted that it be shared. It was stressful. Then another break: An evening with the suppliers. We listen to a performance. I sat between a supplier and a colleague. One made advances, I rejected him. With the colleague, I then had a trusting, fitting body contact.” Spontaneously, I think that the current focus here is also on finding a suitable contact and approaching it, but I do not express this thought. (Such a transference interpretation at this early stage could be understood as an inappropriate “approach attempt” even in psychoanalytic ­ therapy

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

and provoke resistance; 7 Sect. 7.7.6) Therefore, I initially ask her in the usual way about her own ideas. Her associations reveal that she felt “at her limit” shortly before the farewell and did not know what was really affecting her internally. She also could not say goodbye to everyone as she wanted. She is always the one who pays attention to fairness when sharing, not wanting to “owe anyone anything.” It becomes clear to her: She is extremely eager to bring everything together, to take care of everything, and to be fair to everyone—it is like in her childhood, especially in her relationship with her mother. But in reality, she sits alone and registers her exhaustion and sadness—where does she remain? The hour is over. Taking into account my countertransference mentioned above and thus the cautious limitation to orienting approaches in my interventions, as well as the actively encouraged connection to the imagination six weeks ago through the painted picture, have made Ms. Musat open to telling me her night dream, her initial dream of our therapeutic process (7 Sect. 3.6, 7 Excursus 6: Initial Dream); the thoughtfulness contained therein (e.g., Is this all just theater? What is my role?) and the vibrant liveliness contrasting with the cautious probing in the conversation, as well as her reference to adolescence, bring her closer to me again: I can feel her and her distress that brings her here—and her potential as well. After the session, I wonder how the first imagination, which took place several weeks ago, may have continued to affect Ms. Musat. She said she had often thought about it but had postponed painting. Perhaps because performance pressure came into play? This would be expected based on the transference hypothesis. In the expression “homework,” both aspects can be found: performance and adaptation. Ms. Musat will probably use her flower picture for both narcissistic strengthening

(e.g., “My flower is strong, intense, beautiful—am I perhaps also? Or can I be like that?”) and for the hinted entry into her ambivalence theme and self-exploration (e.g., “Where do the ambivalences come from; where do I know them from in my previous relationship experiences?”). Thus, I expect that Ms. Musat, stimulated by such thoughts, will soon start talking about her biography, especially the high-performance demands of her parental home. I hope that the imagination will serve as an incentive for her to achieve the briefly experienced, pleasantly balanced kinesthetic state while looking at the flower (beginning of the imagination) again, to give more space to such states in her life in general, and to think about what prevents her from entering such states. As a “joint therapy product” (Sects. 3.7 and 7.5) imagination and picture have helped to strengthen the relationship with me as a therapist and to maintain motivation and hope. The next day, (6) Ms. Musat seems quite different: Rested and open, she begins the hour with another dream report: “I was with a colleague in the mountains. It was spring. I had two fresh avocados with me. We were at her home, she was expecting a child, everything was already prepared. There was a spiral staircase. I had the feeling she could take her time.” She says she also has this spring feeling right now in Berlin. Yesterday, she rode her bike around, felt alive, and intensely took in the birds and their songs.—As she bubbles so lively, it crosses my mind that her spring feeling will be fed from several sources: the decrease in stress, the pride in realizing her “time-out,” but also already from the narcissistic strengthening experienced with me. But she cannot yet introspectively dwell on these “sources.” She continues: The colleague in the dream is a woman who shapes her life as it suits her. She has “found her center” and is, by the way, really pregnant at the moment. She couldn’t say goodbye

4.4 · First Treatment Phase

to her, but she has the desire to talk to her about her relationship with Francesca.— It crosses my mind (7 Sect. 7.7.4), that the friend represents the desire for the found center, as she also brings it to her therapy project and thus to me. Possibly, with the positive occupation of the colleague, she also installs a side-transference, because too great and exclusive closeness to me would still frighten her too much. On the other hand, she is “in good hope” for her “therapeutic child,” if one “reads” the dream subjectively (7 Sect. 7.4, 7 Excursus 9: subjective/objective dream interpretation). Ms. Musat recalls the avocados, that during her one-week vacation alone in Madeira, she enjoyed avocados and had planted the brought-back seeds in a pot after her return. That’s not usually her style. She gave such a pot with the seed buried in the soil to Francesca as a farewell gift. “As a symbol of hope that something develops.” And that Francesca has to take care of.—I ask if Francesca was happy. “Yes, a bit restrained maybe. She was surprised.” And apologetically: “You only see soil.” “How were the fruits in the dream?” “As big as mangoes, cracked open, as if fallen from the tree, not yet ripe.” The patient then talks about Francesca wanting children. I notice how I slightly flinch (is the relationship with Francesca “ripe” for that?) and even feel a bit overwhelmed because this big topic seems to me like “unripe fallen from the tree.” In the anamnesis, it had only briefly appeared in the context of marital problems. In my further reflections, I then experience these “child thoughts” as something symbolically pointing to the beginning of our therapy: her hope that something new and lively will grow within her here. Ms. Musat unfolds many fantasies and questions about the children’s topic. Even with her husband, the thought had not been easy for her. She is good with children, can take responsibility, but carrying a child? And: Is it good for a child to

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grow up with two mothers instead of a father and mother? Will there be conflicts if Francesca also has a child because each mother then sees her child more? Moreover, with Francesca and her, there cannot be the special gene mixing as between a man and a woman. That’s a pity. After all, both parents give their children a lot genetically. Mrs. Musat has now increasingly entered an affect-avoiding, monologizing level of discussion. Unlike in psychoanalysis, where I could imagine addressing this form of a “forward-fleeing” resistance as a topic (7 Sect. 7.7.6) or relating the child theme further to the transference (What does she want to “carry out” with me here? What fears does she have about how our “genes mix,” whether we will raise our therapeutic child amicably, etc.), I suggest an imagination as another form of dosed resistance processing at this point, especially since we had already come close to the imaginative level with her dream report and there is enough time left in the session. In the usual way for initial imaginations, I choose a broad stimulus motif (7 Sect. 7.2), the motif of the “meadow”. 5 I see a mountain meadow where I used to go with my family in the spring. The snow has not been gone for long, the grass is starting to stand up, some of it is already lush green. It is afternoon and the sun is already warm. There is forest all around, a few small stables can be seen, and there is a view over the valley. The mountains in the background are covered with snow. No one else is there, which is pleasant. 5 Can you describe the spot right where you are? 5 Yes—I’m sitting, no lying now, feeling the warm sunrays, sleeping, dozing a little, taking in everything intensely, the fresh air, the birds … 5 Can you hear the birds? … Yes … How does all this affect you? 5 There is a harmonious whole around me. I am part of it. I am also an intruder, but I do not disturb. Everything is right. I can

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

perceive myself as part of the whole, I am receptive, not giving. 5 Is that a pleasant feeling? 5 Yes, I really soak it up. I breathe deeply, bloom in the process. I perceive the air, the scent, the warmth. 5 What is the scent like? 5 It is such a fresh mountain air. It smells mixed of forest and dry meadow. Almost like straw. 5 Does the scent envelop you pleasantly? 5 Yes. It is life- and energy-giving. The sun is very important. 5 Where do you feel it? 5 On my face, on my head. Also on my stomach. But mostly on my head … There are mountain flowers growing all around: crocuses, primroses, they all sprout, open up in the sun. I sleep, like in a light sleep, half dream, half sleep, pleasant, even if I don’t know what the dream content is. Beautiful state, sleeping and dreaming. This imagination initially ties in with her current “spring-like” break and departure situation here in Berlin and with me (The snow – which was still noticeable in places during yesterday’s hour – hasn’t been gone for long, but everything is starting to grow vigorously), to then again address the topic of parental attachment (vacation stay with parents), but without dealing with a conflictual moment. On the contrary, Mrs. Musat “recharges,” and I notice that for the purpose of distance regulation (7 Sect. 7.7.3) she emphasizes being alone: No one is there but me, which is pleasant. She wants to experience herself as self-sufficient—but can take from nature, the sun, thus accept the atmosphere of the therapy session and oppose it to her usual accelerated life. Only at the end does she have to slightly take back her self-abandonment in a controlling manner: half dream, half sleep, pleasant, even if I don’t know what the dream content is and thereby signals how much she expects that “one” generally has to know what one dreams.

This imagination is guided exclusively by the technique of leading accompaniments (7 Sect. 7.3). It is an intervention style that aims to lead into the imagining and intensify it as much as possible. This is done through interested descriptive questions that orient the patient towards sensory perception, especially hearing and smelling (7 Sect. 7.3, 7 Excursus 8: The acoustic dimension of imaginations). This is important for many patients who, like Mrs. Musat at the beginning of their therapy, are “only in their head” and far from a holistic self-state. The tactile experience, hearing, and smelling should then be specifically addressed. This serves both to orient oneself towards the self and to provide a “permission” to the patient’s superego to feel and let the regressive state unfold. This intervention style can therefore also be called “regression-promoting.” The “regression in the service of the ego” (Kris 1952) is extremely ego-strengthening but necessarily also triggers defense movements in the self-system (7 Sect. 7.3). In the “dose” practiced here, this is only the case in the last sequence of this imagination mentioned. This state—the vacation and “timeout” feeling –, intensified by the emotionally and sensually stimulating imagination, spreads further towards the next session (7): “Enjoyed the morning! So rare!” Yesterday she had been out and about a lot and met a friend. In the evening, she had actually wanted to go to the theater but felt tired and stayed at home. She had made pending phone calls that she hadn’t gotten around to for a long time. She had wanted to tell her parents that everything was beautiful here. “But there was trouble in the phone call with my mother.” As before, a few times in writing, the mother had expressed reservations about her relationship with a woman in Milan. She should try to get back together with Jürgen. The patient is irritated as to why the anger at her mother occupies her so strongly.

4.4 · First Treatment Phase

This report pleases me: She has refrained from a distracting theater performance and focused on her “inner theater”: With the support of our sessions and strengthened by the self-centering imagination, she has faced her conflict, as it had already “announced” itself directly in her flower and meadow imagination: Iris and mountain meadow are connected to the parents. She exposes herself to the mother confrontation in the phone call, but now also addresses her inner conflict. (By the way, the metaphor of the mountain is often associated with the theme of a challenge, Sect. 7.2; in this case, the challenge lies in the conflict conversation with the parents.) In order to enable her to pursue her emotional experience more in our therapeutic togetherness, I suggest giving space to the anger feeling first, sensing what all plays into the anger, and only later pursuing the why.—The patient thus develops what constituted her anger: that she had lost her clear position again. After the session with me, she had clarity all day with a “good spring feeling”: I want to live with Francesca in Milan. This clarity was shaken by her mother’s remarks. And that was her anger. It had weighed on her that she had “lost harmony with her mother.” She even had the fear that she might have to hurt her if she stuck to her decision. This puts her in conflict with the well-known urge to please her mother. I first ask her how she dealt with the touched conflict with her mother in the conversation.—She says she registered her mother’s reproaches but did not address them, nor her inner reaction, and did not respond. She just realized that she had to face the conflict. After the phone call, she sat there burdened and alone. Since I think that the upcoming inner detachment conflict should be addressed in the second step, but first of all, she should address and carry outward any external discrepancies as such, instead of just moving them within herself and thus “sitting

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there burdened and alone” (as in her childhood dream with the two colors), I initially stay with this and ask her if she knows this about herself, that she first absorbs conflictual things, moves them back and forth within herself, and only later or not at all confronts others with her feelings. Yes, she knows this well. As a result, she appears cooler on the outside than she really is, more controlled. She deals with many things on her own. She hides her unwillingness towards her mother and older brother the most. Ms. Musat appears very thoughtful and internally involved. She is silent. I suggest looking at the meadow picture she painted and brought with her to see if any of the topics just touched upon can be found in it. With this intervention, I also aim to bring Ms. Musat a little closer to a joint conversation with me, as I feel in my countertransference that she is also “dealing with something on her own” in her thoughtful silence right now. The meadow was familiar to her from the previous Easter tours with her parents. During puberty, she liked to be there, experiencing a “contented solitude.” The patient hesitates again, as if she shouldn’t question the contented solitude.—I suggest looking at the picture as if someone else had painted it: She opens a book and comes across the picture. What does she notice? (With such self-distancing, reflection sometimes succeeds, which is less obscured by defense mechanisms; Sect. 7.5)—Mrs. Musat agrees: The meadow is “surrounded by the forest like a fortress,” she now realizes. “An inner circle. There is an inside and outside, a distant expanse, clearly separated.” She painted the stable as a not-so-cozy house. The path stops abruptly at the forest. The person—her—is “not really on the path.” It is also unclear whether the path leads to the house. The house could symbolize her longing for a home. However, it appears more like a frame, a norm. Mrs. Musat is now very preoccupied with the

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conflictual aspects of her childhood on a symbolic level. I therefore point out to her that the house has a “face.”—“Yes. It looks in a different direction. It doesn’t fit so well, isn’t so inviting.”—I ask if it could also represent her conflict with “her home,” where the mother was present but often not very “inviting.”—Yes, and her path leads away from it, she says determinedly. At least the painted one. In that respect, she must first search for her path. It ends here in the picture at the forest. She experiences the forest like a wall: “Shady, uncertain, cool, overgrown, wildly proliferating.” (The forest—I don’t mention this at this point—often symbolizes an unconscious area; Sect. 7.2) About the “person”—as she speaks distancing herself from herself for quite a while—she says it remains unclear whether he is just resting or wants to continue on the path. His feet are strikingly small. He appears like a boy around the age of 15. With the end of the hour, some things must remain unclear for me as well. What I believe I have understood, however, is that Mrs. Musat is regressed back in time with this imagination to a period of identity and detachment issues typical of puberty and adolescence: Having to become clear about the traditional and one’s own “home” as well as one’s own path in self-reflection— questions she is now picking up again here. She has (8) decided yesterday, Mrs. Musat states determinedly at the beginning of the session, to stay in Germany for the weekend and only drive to Francesca after our talks are finished on Wednesday. It has become a priority for her to clearly tell her parents where she stands. She then expresses many thoughts about why the relationship with her husband “ran aground.” “We didn’t discuss our conflicts clearly. Also because I didn’t feel them clearly enough myself.” The vision of togetherness, especially living in one place with children, was always brought up by her to him. Something held him back. It becomes clearer to her how much it hurt her that

he left everything to her, didn’t go house hunting with her, wanted to stay in the familiar: “Only live on weekends, wait in between.” The patient then talks about the issue of having children again. Here too, he left everything to her: “Tell me when you’re pregnant.” She always considered his needs and assumed he couldn’t be different. But she probably didn’t express her wishes urgently enough. While listening (7 Sect. 7.7.6) I notice the anger towards her husband, which is presented for the first time. A pressure to understand arises within me: How can the urgency of the “parental confrontation” be classified? What does the anger towards Jürgen, which is now becoming noticeable for the first time, mean in this context? Is something being shifted onto him that might actually apply to the parents, perhaps even to Francesca, whom she is not visiting for now? Does Mrs. Musat feel the need to accomplish something with me, perhaps due to transference, by having to clarify the parental conflict now? Is Francesca idealized, Jürgen devalued? What does the topic of having children mean? I am aware that she needs to “arm” herself for the conversation with her parents over the weekend and requires “separation energy.” Thus, I keep these potentially confrontational considerations to myself at this point: In short-term therapy, it is important to focus and provide stabilizing support at this sensitive point, especially since I am aware that she is setting up “justification defenses” because she finds it so difficult to represent a deviating position towards her parents without feeling guilty. Therefore, I decide to use the therapy time until the weekend to prepare for the confrontation with her parents and ask her, referring to her critical portrayal of her marital relationship and the last session: “Are you familiar with the restraint, being cautious when presenting your own wishes?” Yes, she knows this well from the past. She often felt misunderstood but did

4.4 · First Treatment Phase

not express what she wanted. She probably didn’t know it often either. For example, she often had to look after her younger sister because everyone else wanted to go away, so they knew what they wanted, but she didn’t, and so the task was left to her. “What made it difficult for you to express wishes, to stand up for yourself ?” It was probably fear of criticism and evaluation. “Maybe it was the same with Jürgen. He often seemed uninvolved. If he ever said something I found absurd, he backed down as soon as I addressed it.”— “There was probably something that connected you and was so valuable that you thought you had to protect it through mutual conflict avoidance.” She confirms this and adds that it also fits that he blames everything on her work stress and prefers to ignore their relationship entanglement. “The valuable thing was the feeling of a common basis from which each one did their own thing. That had to be preserved. By avoiding confrontations.”—I want to broaden her perspective and ask: “How was it with confrontations in your family?” Mrs. Musat recalls that all conflicts revolved around the mother. Because she was the one who clearly showed herself with her expectations and her latent or openly expressed tendency to be overwhelmed. “If she was disturbed during her midday rest, there were outbursts of anger.” Her brother had clashed more with her, while she had been considerate and wanted to support the mother. She knows states of intense, powerless anger towards this brother because he often “put her down.” When he heard about her then still vague intention to separate in an earlier phone call, he called her “as the embodiment of social conscience” and, as her former best man, made her feel guilty. Since then, she has kept her distance from him. In the next session (9), she continues the topic with the main question: “How do I manage this with my parents? They

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have known for some time that I want to separate, but they always say I should try again.”—“And do you then find yourself in a position of justification? Wouldn’t there also be the possibility to ask back what the parents’ assumption is based on, that it would be better to try again?” Yes, she justifies herself, says Mrs. Musat very thoughtfully. She hadn’t really been aware of that before. Yes, she wants to take up this suggestion to ask back. Maybe there would be a possibility for the conversation to continue. “What made you decide to go to your parents instead of flying to Francesca as originally planned for the weekend?” With this question, I try to clarify the “unclear” topic of the last session. It is so important to her to create clarity with her parents. But she feels “queasy.”— Apparently, she is experiencing a physical anxiety correlate and cannot initially describe the affect clearly, which is why I ask: “What does feeling queasy feel like?”— She thinks aloud: It is “unclear whether it is physical or emotional.” Maybe both? She feels queasy in her stomach. Was she perhaps in the sun too much with her bike? She also wants to stop by her brother’s place. But why? What does she want there? The patient herself is surprised at how important it is to her to seek agreement there as well. She actually wants to go where she feels safe and secure, but senses a great pressure to justify herself. “For you, your feeling of security is connected with your parents and brother— and in order not to endanger this, you think you have to meet expectations? That would be an important inner pattern.” She agrees with this interpretation. At this point, I interrupt our conversation and suggest to her that we continue exploring the topic on an imaginative level, and choose the stimulating motif “animal family” for this third imagination. I expect the imagination to provide stabilization in this tense situation for Ms. Musat and the

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motif suggestion to offer stimulating conflict illustrations. 5 There is a vast North Frisian landscape, lots of grass, ditches from the sea; cows grazing. No, the image of a sheep family comes to the fore. Standing close together. Licking each other. The mother sheep, a ram close by, a lamb. The mother radiates calm. The little one drinks nearby, not interested in anything else. Ram and mother are busy with each other. The little one now claims the mother, the father is around the mother like that. 5 What is he doing? 5 He encloses and pats the woman from head to head. He has a protective function. Shows strength to the outside. Is vigilant against the surroundings. However, there is nothing else around. 5 Yes, what is the environment like? 5 There are the three of them and the green expanse. The whole thing is in front of a stable, an enclosure, there are more sheep there. The mother shields the little one from the others. The father too. But it doesn’t create a close family picture. 5 What do you feel towards the sheep? 5 I feel most connected to the mother—she is protective, shielding. The ram seems a bit helpless, almost superfluous. The child is safe. Discovers the environment a bit wobbly. Needs protection. Is sometimes nudged by the other lambs. 5 How do you feel when you perceive everything like this? 5 Queasy stomach. The queasy feeling has to do with the lamb when it comes together with the others, comes out of the protection. It’s such a contrast: strong family relationship—setting out into the world… The queasy feeling increases when the lamb is near the mother. The father doesn’t appear. It has no connection to him. 5 Would you like to ask the lamb what would be good for it now? 5 It wants to take its first wobbly steps. Discover the environment. It is now to-

gether in the pack, the lambs perceive each other’s bodies, are wobbly. They fall down, get up again. Stumble over stones. Rub their heads tenderly against each other, also frolic a bit. One falls down again… It keeps going like this. The lamb has no urge to return to the mother. Everyone is close together, it’s a small group. 5 How does the lamb feel? 5 It feels accepted, good. 5 Would it be possible for you to go back to the beginning? You had cows in mind then. What happened to them? 5 Yes, the picture changes. I now see a cow and her calf. The calf stands very close to the mother. It is an image of seeking and giving protection. Instinctively drinking, standing under the belly and snuggling. The mother turns her head towards the calf. 5 Yes, a very intimate togetherness? 5 Yes. Very natural. Both are very focused on each other, without any questioning. Since the hour is over, there is only time for a brief debriefing, in which Ms. Musat highlights the final moment of intimate relatedness as “very beautiful.” I experienced the imagination as very complex: On the one hand, Mrs. Musat expressed her regressive wishful thinking in it: finding the ideal, supportive family and security with her mother without any questioning. On the other hand, her fear of the upcoming confrontation on the weekend becomes clear: The queasy feeling—with which Mrs. Musat already enters the session – increases when the lamb is near the mother. Also included are the support from the peer group and the recourse to a time when she with shaky legs made her first attempts at venturing into the world. Something aggressive also mixed in here through the striking choice of words, because a pack only exists among the enemies of the lambs, the wolves. It is noticeable how much more space the mother-relationship takes up compared to the father-relationship.

4.4 · First Treatment Phase

I understood the immediate change at the beginning from cows to sheep as a defensive movement, possibly moving from the mother conflict hinted at directly in the cows into the more regressive wishful world of an undivided, difference-leveling flock of sheep. Even though conflictual elements already mixed into this world of sheep, I tried to make the warded off more clearly recognizable with the help of the treatment-technical intervention, returning to the initial image at the end of the imagination (7 Sect. 7.3). This did not become obvious; instead, the patient imagines in the form of cow and calf quite differentiated and sensuous the wishful image of a devoted, intimate mother-child scene. Now I am curious about Mrs. Musat’s painted pictures, whether the warded off appears more clearly there (7 Sect. 7.5). On Monday (10) the patient comes to me beaming: “I am back in Berlin, this is not an arrival, but a return!” She reports on her “communication tour” to her parents. She felt like back then when she announced the wedding at home and introduced Jürgen as her future husband. The meeting with the older brother did not work out, he could not make it. Yesterday she wanted to call Jürgen, but could not reach him. “I should, want him …”, “Want or should?” She should out of fairness, but also wants to: Tell him before a monastery week planned by him that she sees her perspective with Francesca, at least not with him: “So that he can already deal with it there.”—I first ask how she experienced the conversations with her parents.—The parents picked her up from the train station. “They started with very direct questions, it was like an interrogation.” At first, she only answered, did not ask back. Father had evaded the professional topic. Later, on a walk, the mother asked more pressing questions: “So you have crossed out the topic of family for yourself ? Don’t want children?” When she objected that there were indeed possibil-

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ities for two women to fulfill a desire for children, the mother stayed behind and cried for a long time. Unlike before, she endured it and did not take care of her. Only later did she approach the mother and ask her what was the hardest part for her in the whole thing. This led to a better conversation. The mother—according to Mrs. Musat’s impression—mourned the impending loss of the “smooth”, the “normal” and argued that the daughter had the “duty to make it right again.” She herself had always followed her duty, even in earlier marital difficulties. In doing so, she had appeared “very forceful.” Mrs. Musat had again slipped into her old role and had dealt with her mother understandingly, justifying herself, thus avoiding the argument. I say: “I experience it like ‘Topsy-Turvy World’: You are in a crisis, but instead of your mother dealing with you and your problems, you deal with your mother.”—Yes. It was strange. But she still felt strengthened after the trip. The fact that her parents hoped so much for her to continue the marriage had weighed heavily on her. I ask about Father’s attitude.—Father was more open, he said, “That’s your business.” He also finds it difficult because of his attachment to Jürgen and his family. And he worries that she might take steps too quickly that she might regret later. By the way, she told him about the marriage crisis months ago. He then told her about his own crisis during her second to fifth year of life: Both parents had had an extramarital relationship and had given it up again at Mother’s suggestion. She hadn’t noticed anything about it at the time. (“Oh yes,” I think, and remember her recurring dream with the “war of two colors.”) However, during her puberty, she found it “terrible” that the chief physician of her hospital courted Mother at parties at home and flirted with her, while her father had to put up with “his bourgeois wife” for social reasons. She had confronted her parents at the time, but had not received a satisfactory answer.

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Unfortunately, only after talking to her father did she wonder why he had agreed to Mother’s suggestion at the time. Whether he really wanted it himself. I ask her about her fantasies about it: Her father was probably fascinated by Mother’s creative and lively nature, but had to take a lot off her hands and deal with her fears, e.g. her fear of flying. Then another vacation would be booked. He would like to downsize, move to the city and prepare for old age, but Mother wouldn’t. He accepts many restrictions. She only really noticed that now. How much he is moved by Mother, how much he does not live for himself.—I point out parallels between her and her father. “Yes, to stand up for others and not even notice it.”—“How do you feel about these considerations?” Thoughtfully, she says that she is probably more like her mother on the outside, but more like her father on the inside. She naturally takes responsibility and always makes sure to give the other person space, even priority. She also takes care of Francesca. With Jürgen, she had felt safe. “But I just couldn’t get close to him.” She feels bitterness there. I ask her: “Where else do you know the feeling of not being able to get close?” “From the past. From my wife, uh, mother probably. You can’t really get close to her.” Mrs. Musat reports (11) that she was in a “relaxed mood” yesterday after the session. The slip of the tongue deepened the previously worked out parallel to the father like an aha experience. Like an exclamation mark! For her, it is becoming increasingly clear: The conflicts with the family are central. The pressure to make a decision regarding the relationship is fading into the background. The phone call with Jürgen was very fruitful. He is now starting to work on himself, but probably too late for her. She has the pictures from the imagination on Friday with her, painted them only after the parents’ visit, a sheep and a cow picture. On the cow picture, we notice the absent father. Despite the togetherness of

the cows, both seem lonely. The house of a former schoolmate, to which she often cycled during primary school, has become the stable on the sheep picture. She had first painted the calf, which was actually supposed to become the cow, but it turned out too small for her.—We recognize her mother entanglement in this, again her “upside-down world”; as in the imagination: I feel most into the mother she also starts painting not with herself, but with the mother. The difference to the warm and intimate passages of the imaginations is particularly noticeable in the cow picture. The sheep picture, on the other hand, has warmer colors. I offer the interpretation that the cow picture shows conflictual aspects, while the sheep picture shows more wishful aspects. Mrs. Musat follows this and is touched by the “empty gazes of calf and cow.” She cannot remember any “cuddling” with her mother as a child. She was her first girl, but was raised “like her brother.” The little sister, by the way, too. If you could call that upbringing, she adds somewhat bitterly. She had been responsible for the little one herself a lot. She had always felt her physicality to be insignificant. With her father, there had been a good intellectual exchange; during puberty, she went for coffee with him, discussed her problems with him, not with her mother. He had been her central reference person, now she saw his limits. As the hour comes to an end, I spontaneously ask in the context of maternal deficiency and physicality how she perceives the painted udder of the cow. She looks at the picture and says that it is actually “only hinted at. Very unclear. Blurred.” After the patient has left, I feel uneasy (7 Sect. 7.7.5). I admit to myself that I have allowed myself to be seduced by her thoughts and my image associations to address a conflict area that I had deliberately decided not to make the subject: the deeper mother issue—both her “unquenched” state and the question of the background of her own de-

4.4 · First Treatment Phase

sire for children. And that in the last hour before my vacation! Is there perhaps also my wish to continue working with the patient beyond the KZT? At least to open her up for it? In any case, I feel the need to reflect on my countertransferences once again. Indeed, Ms. Musat begins this last hour (12) of our first treatment phase hesitantly, with doubting questions: What is really in the pictures? What can be read out? What is unconscious? In these indirectly critical questions, I recognize a negative transfer moment or resistance (7 Sect. 7.7.3) to my intervention and the difficult conflict area it triggered. I want to address our transfer conflict openly and ask: “Which statements during the last hours have your doubts and questions attached themselves to?” “To the topic of female identity. To the missing udder.” But since she initially painted the calf as a cow, it could also be a “technical problem” of painting! A random product! Basically, images and dreams always have an excess of meanings (Chap. 2 and Sect. 7.2, 7 Excursus 7: Symbol), so I can fully agree with Ms. Musat that there is no certainty in their interpretation. I also emphasize that the images primarily serve as a means of self-exploration, that they stimulate further questioning rather than providing answers (7 Sect. 7.5). We can agree that this has been the case between us so far: That there is a common search for what “fits,” and that I do not have the authority to interpret. Then I add the question (7 Sect. 7.7.6), whether her doubt, especially now before our break, could also be an expression of wanting to withdraw, of her need for protection, which she initially directed at the method with her question.—Yes, there might be something to that. She notices that she is reaching limits as to which questions she wants to allow. Also with regard to her parents.—I tell her that I experience it as an expression of the growing trust between us when she can talk about doubts that come to her here. And

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that I experience it as progress on her part that she is able to bring a conflict with me into the conversation between us and not just deal with her doubts alone. After acknowledging her openness and a mutual silence, I share my impression with her that she has already allowed herself to be very involved, given that we have such a short time available, and that today it might be more difficult because I will now leave her alone with her questions for four weeks. It is important to dose, to sense which questions are helpful to her right now and help her move forward, and to put others aside for the time being. In response, she says, “When I scratch the surface of the parent image, I stand outside. That gives me a feeling of injustice.” She found all my questions important, but she is afraid of losing her footing if she questions too much. I summarize this understanding once again and suggest for the rest of the hour to look at the pictures painted so far from a different perspective, namely only as an expression of self-states. What she would then notice. (This technique of a summarizing picture review is particularly suitable for threshold situations, i.e., breaks or termination situations; Sect. 7.5). She spreads the pictures in front of her and spontaneously says, “There is a lot of loneliness.” She feels “a search for safe spaces, something melancholic, longing.” She knows this, melancholy and loneliness are intertwined in her sense of life. She then talks about the house and the memory of her schoolmate. He drew comics and was creative, his family was “chaotic” in contrast to hers. She built tree houses with him and found it great. She considered herself uncreative. Once she wrote an invented story that the teacher read out with praise, which encouraged her. But she always had problems showing herself with impulsive or creative things. In her family, this was almost impossible for her. When she invited friends, ironic-evaluative remarks from her

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brother came. In contrast, everything in the school friend’s house was a counterweight. She is surprised at how significant this has pushed itself into her childhood family image. But perhaps not coincidentally: Here, the evaluations of the parents and the brother fell away, just as they do now in therapy, I think; 7 Sect. 7.7.4) and she is currently chewing on this topic! With this view of herself, but above all with the addressing of the autonomy-promoting areas of the peer group and the creative, I do not find it difficult to say goodbye to the four-week break. 4.5  Second Treatment Phase

At the reunion (13), Ms. Musat says that she has “put Berlin aside for now,” by which she of course primarily means me and our sessions. It is understandable to me that this was the only way she could cope with the long separation after the intense, daily sessions. She gives a “break report”: She met Jürgen, who would only agree to couples therapy if it brought them back together. She couldn’t promise him that. They then discussed separation modalities amicably. Over the holidays, she followed her parents on their vacation. She felt how much she was waiting for a signal that her parents would accept her new relationship. But it didn’t come. In a few weeks, her little sister would get married. She wondered whether she should go to the celebration alone or with Francesca. And she visited friends. It was good for her to feel that she was accepted there with her new path, even if it was difficult for some friends. Professionally, she had brought about a clarification: She would take on a new job in the same company, management in the research area. Mostly in Milan, but this would also involve commuting to Frankfurt. She wanted to find an apartment in Milan and establish her center of life there.

Her father had recently sought a conversation with her again. He had visited her specifically for this reason. The night before his arrival, she had dreamt of him. He “appeared—mixed with the new boss—like a legal decision-making authority. Inquisitorial.” In fact, however, he had merely appealed to her once more to take her time: “Do nothing that you will regret later.” She then addresses the open questions that she now wants to pursue with me in the second treatment phase: She is concerned about why she is so loyal to her family. Why she clings so much to their evaluations, especially those of her mother and brother. Furthermore, her gender identity has occupied her. “When and where do I feel most like myself ?” I experience Ms. Musat with these questions expressed as work projects tense, a bit as if she wants to have the “matters of her psyche” settled as quickly as possible after the job matter. I try not to take on this pressure. I find it pleasant to mention her friends, that she has actually actively sought and found the peer group support, as discussed in connection with her last imagination. Since the last set of questions she addressed has no place in our treatment framework, I focus after a while on the first problem, which ties in exactly with the previous therapy process. Thus, the rest of the session is about the question of why it is so important for the patient to receive acceptance from her parents regarding her separation and living together with Francesca. Her brief dreamreport is helpful in this regard, as it had clearly shown from a subject-level perspective (7 Sect. 7.4, 7 Excursus 9: subject-/object-level dream interpretation) that she herself is much more inquisitorial towards herself than her external world could ever be—so it will have to be about the mitigation of her superego, where the actual “inquisition” takes place. With these considerations, I also manage to achieve a certain “mitigation of the

4.5 · Second Treatment Phase

c­ ountertransference pressure” as I had initially felt it (7 Sect. 7.7.5). The patient remembers that as a child she had sought agreement with her mother, while her brother occasionally rebelled against her. Upon specific inquiries, it becomes clear that the mother “freaked out” at the provocations of the older brother. Ms. Musat had suffered from these outbursts, withdrawn, and taken over household chores. In order not to “burden her mother as well,” she had taken care of many things for herself, secretly, or had given up on them. Everything had first gone through a filter of questions for her: Is it reasonable? Does it correspond to what is desired? There is a deep insecurity within her about what is good for her, what actually suits her.—I sense that in her mentioned question about gender identity, there is a more comprehensive identity question—and I wish her inwardly again that she might follow up our CAT with a psychoanalysis at her place of residence. The next day (14) the patient picks up directly: “It has been fermenting in me— what is it with the ‘filter’?” In general, she probably lets too little through this filter, which makes everything “well-tempered.” I wonder what she might have to “filter out” right now and here with me, but I initially leave this hint of transference (7 Sect. 7.7.4) untouched and say: “I think of you in this regard in two directions: Your filter originally protected your mother and at the same time served as self-protection for you.” The patient then recalls a cruciate ligament tear while skiing, where she had to be carefully transported down the mountain. Her mother scolded her: “How can you do this to us? Ruining the whole vacation!” And her brother chimed in: “How can one fall so stupidly!” She herself blamed herself for driving too fast and impulsively. The impulsive must therefore get caught in the filter so that she is protected from reproaches and humiliations. The pa-

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tient then talks about attempts to appear more humorous, spontaneous, to surprise herself—but she couldn’t really let go of her controlling “planning”. She seems affected.—Furthermore, it is also about dealing with emotions in her parents, how her father protects himself through reasonable self-control and her mother expresses fear and anger in such a way that others have to take care of her soothingly. Finally, I suggest a change to the imagination level (7 Sect. 7.4): The “insight channel” seems to me to be “saturated”, the patient has for the moment sufficiently approached the understanding of the biographical backgrounds for her fear of showing herself. For the focus of the impulsive, especially aggressive impulses in a broader sense, the motif of the “lion” is suitable from the motives (7 Sect. 7.2) in KIP: 5 There is a male lion in a steppe. Nothing else. He stands there, makes lion sounds, moves a little, is preoccupied with himself, with the form a lion should have… 5 How does the lion appear? 5 He wants to pose, looks around: ‘How was the effect?’ He plays lion games with his head… Gets a little bored. But doesn’t lie down… Yes, he poses. 5 Can you describe his appearance? 5 The head with the mane forms the main part, from what I’ve seen so far. When I imagine him from the side, he is slim, even a bit unkempt, but stands straight, has high muscle tension. The tail hangs down. He focuses on his lion pose. Whether he sits or stands—the important thing is the pose. He lives from the front with a full head. A bit like an old church: a huge facade and nothing behind it. 5 What about his eyes? 5 Everything is a bit puffed up—the eyes appear rigid. They convey strength, concentration, he knows how he has to appear. It’s a bit funny because there’s no one there for him to impress. He does it for himself. Should I maintain that? He

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

behaves concentratedly as he thinks a lion should be. 5 Would it be possible for you to bring yourself into the picture and perhaps make contact with the lion? 5 Hm. I could easily slip into him. But contact? Hm. 5 Follow your impulse and slip into him. How does it feel as a lion? 5 I feel insecurity. What do I want as a lion? To stretch? To maintain the pose when no one is there? Ridiculous, actually! But what would I do? I have impulses to lie in the sun, but that’s calculated, it’s not real letting go… 5 You’re looking around with lion eyes now: Where does your gaze linger? 5 Well, there’s nothing nearby. I look into the distance… at the horizon… 5 Is there something there? 5 … Well, yes, something is approaching… 5 And what does the approaching thing look like? 5 Maybe a person, on foot. Oh, that takes too long, it’s so far away. Maybe a Jeep. It’s very far away… But it keeps moving steadily. 5 How is that for you? 5 Interesting. I can really feel my heartbeat. The person is coming in my direction… There is someone in this emptiness! I’m happy! I have my pose because I correspond to the image of a lion. The pose is my protection. But behind it, I feel my curiosity. The facade is like a shield, like a shell. I only feel the inside—but others see the pose first. 5 If you just pay attention to the inside: Are there impulses for how you would like to meet the person? 5 Authentic. Funny. It’s really tingling with joy! I’m moved. Like when you vibrate with joy. I’m almost overflowing. There was so much loneliness and formality— and now I’m bursting with anticipation! But I know I will hold back so as not to overwhelm or monopolize the other person. Let them arrive first…

Since Ms. Musat is now familiar with imagining and has a vivid image of the “posing lion” in the introductory picture, which represents an aspect of her problem that has just been discussed (clarifying function of imaginations; 7 Sect. 3.3), I chose a slightly more confrontational intervention style here. The effect intervention can therefore precede the description interventions, unlike in an initial imagination (7 Sect. 3.6). After establishing the imagination using the technique of guiding accompaniment, the lion is focused on with the eye test intervention (Sect. 7.3) and thus on the rigid, tense-concentrated, controlled (living from the full head) in her. With the formulation huge facade and nothing behind it, Ms. Musat also includes her transgenerational imprint (“old church”). The contact encouragement here as a prompt question is an even further introduction into her inner conflict world. The patient hesitates, but only needs a slightly intensive encouragement intervention to follow her impulse to be a lion—which means to feel him and what he represents much more strongly (role exchange; 7 Sect. 7.3). This confronts her more strongly with the feeling of the fake, her pose-like-strained side, which represents something strong outwardly but is insecure regarding her own inner impulses. Even if she enjoyed the sun, she would not know if it would be calculated: no real letting go. Her “filter”, as becomes clear through the imagination in addition to the conversation, has not only prevented something impulsive from coming out, but the patient has “tamed” her lively-creative-instinctual side in such a way that she is not even sure of her very own impulses! In her indecision, which I do not want to let spread further in the imagination at this stage of treatment, I help her with the focusing question (7 Sect. 7.3), what the lion is actually looking at. This intervention is directed towards a sensual outward orientation and at the same time a necessary relief of the superego: “You can calmly con-

4.5 · Second Treatment Phase

tinue and intensify your engagement with yourself and your experiences.” At first, it remains with the “emptiness”, and one could consider my question “Is there something?” as suggestive. However, it is primarily intended as an encouragement intervention for relationship search—the agent that can really and solely help!—in the sense of: Please check your inner world, the internalized positive object experiences: “Is everything really empty?” That this probing does not have to be unsuccessful: There is someone in this emptiness! the patient had already hinted at several times before, emphasizing how “boring” the lonely lion is with his posing in the empty desert, meaning she is able to feel loneliness and longing for relationships and share this feeling with me. A step that is difficult for Ms. Musat, as worked out in previous sessions, due to her inner mother conflict dynamics (see also “intersubjective paradigm of transference” in 7 Sect. 7.7.2). In a long-term therapy, one might have refrained from these encouraging interventions in order to bring the patient into even closer emotional contact with the topic of loneliness. In our treatment framework, a more active approach seemed appropriate. Her shift in imagination from empty posing to the feeling of overflowing anticipation of a relationship contact impressed me— as well as the patient herself, as she emphasized in the follow-up conversation and again later when ending the therapy. In this imagination, her insecure identity, her associated self-control, and the longing for a lively, authentic, “unfiltered” relationship with herself and others found expression. The focus on making contact with “unfiltered” aggressive impulses, which I also intended with the lion motif, was not “on” from the unconscious that guided her (“the tail hangs down”)—which I naturally respected. Ms. Musat picks up on the invigorating aspect of this imagination in the next session (15): She felt “so good afterwards:

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Something was set in motion. Even into the physical experience. This exuberance behind the pose!” Physically, it was as if she had “turned in one plane. That was surprising. That I couldn’t influence it. The feelings were stronger than I usually perceive them in life.” She also felt the pose extremely strongly (7 Chap. 2, 7 Excursion 3: kinesthetic). “Tempered on the outside—lively life inside!”, I agree.—Yes. She appears cool. Unapproachable at first glance: “I regulate myself down.” She wouldn’t show if she was interested in someone. As a teenager, she only had secret crushes. No one knew about it. She always protected herself. She also left breakups to the others. Except last summer with Francesca, when she decided she wanted to save her marriage. They had decided not to see each other anymore. After this summer break, however, Francesca had contacted her again, and she was so happy about it! I am surprised; she had not told me about this breakup and her inner struggle almost a year ago. Why had this been stuck in her transfer-“filter” (7 Sect. 7.7.4)? I tell her that I am surprised that she has been struggling with this conflict for so long— and that I wonder if she had not withheld this information from me not only out of “forgetfulness” or embarrassment, but also because she might not have wanted to burden me with the weight of her conflict: that she wanted to protect not only herself but also me by keeping the duration and depth of her relationship conflicts somewhat concealed. So, whether the pattern she learned in contact with her mother, of not really imposing herself completely, could also play a role between us (7 Sect. 7.7.6). The patient reacts with concern and says that this could be the case. I consider the clarification of this central relationship conflict to be a significant step, but I do not want to further deepen its transfer dimension due to the chosen work focus and steer the conversation back to

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

the painted imagination by asking what she thinks about her picture. The patient emphasizes the lion’s alert eyes. The figure on the horizon turned out larger than it had been in the imagination. Yes, then she had painted a few branches in all four corners, perhaps so it wouldn’t look so empty. As she speaks, I am reminded once again of her holding back, even in the transfer towards me—and that emptiness is relationship emptiness and arises where one thinks one cannot “impose” oneself… I ask for ideas about the four gnarled branches. Mrs. Musat thinks one branch looks “like a stick insect.” The other “like a divining rod.” She says this somewhat uncertainly, and I encourage her to let her thoughts run free, instead of discussing her uncertainty in terms of resistance work. She picks up on this: “Yes, the stick insect could establish contact with the lion. Like in the fable ‘The Lion and the Grasshopper.’ The lion asks, ‘What do you want?’ And the grasshopper says, ‘Move a little!’ The lion has the big head, but is slow, the grasshopper agile and mobile. There is already some relationship between them.” The patient has already started fantasizing on her own, so I suggest at this point to continue this in imagination: 5 I have the interested lion’s face in mind, but this time I am not inside the lion. I could be inside the harmoniously agile lines of the grasshopper. The two talk casually with each other. It’s like a nice diversion on the way. Where they notice each other: “What are you doing here? You stand here so rigidly alone, nothing holds you here, you can come along!” says the grasshopper. The lion: “Yes, you are interesting, but I feel comfortable here. You can come by again sometime.” The lion is benevolent. But he stays where he is. The grasshopper is at one with itself: “I discover the world! The lion encourages me on my way.” 5 Maybe he goes a little way with her? In his big territory?

5 Yes, he goes a little way with her, but not for long, because it would be too burdensome for the lion … 5 Where are you right now? 5 Towards the left branches. The lion seems fatherly … he can bear it well where he is. 5 And what is the grasshopper doing? 5 The grasshopper trots over to the lion. It has so many impressions it wants to share: energy, a new day, not so hot and oppressive. It tells the lion: I saw a forest, it’s very fresh there, I found water. Today the steppe, tomorrow something different! … The point in the distance, that person from yesterday, suddenly seems like an intruder. The lion is satisfied, happy to hear that there is more than just the steppe. He can now sit down like this. Feels good. You can tell there is an exchange between the two … In the next session (16), the patient comes in feeling insecure. The two of them had a pretty good conversation. But she is confused, can’t find a common thread. She wondered while painting: What kind of relationships do I build? “My ‘facade’—how does it play into my relationships? Yesterday I was more the stick insect—the lion was static.” The grasshopper-lion relationship is not how she usually conducts her relationships. But the one in the imagination was rather superficial—not much remained. I also found this imagination “more fleeting,” not as emotionally moving as the others before. Her sentence: The two talk casually with each other also made me wonder if I should relate it to our relationship and the patient’s proximity-distance regulation with me. This could be attributed to the often-observed phenomenon that after an intense “close” session, more distance must be sought again for defensive reasons. Now I find it particularly therapeutically positive that the patient not only notices the questionable aspect of “non-commitment” herself but also addresses it (Sect. 7.7.4).

4.5 · Second Treatment Phase

Building on this, various aspects of their theme of relationship design can be discussed: It is striking that feelings they experience intensely from a distance can scare them when they are close: This person from yesterday suddenly seems like an intruder and they then become more “tempered.” On the other hand, they seek approval and goodwill from the other person—just as they wonder why the acceptance of their new relationship by their parents is so important to them.—Ms. Musat follows up on this and connects the lion with their father. She thinks that the benevolent eye of the lion has done them good. I formulate a third aspect by saying: “I noticed that the grasshopper was afraid of burdening the lion.” They think about it and cannot remember this. I quote their sentence from the imagination: “a little bit he goes along, but not for long, because it would be too burdensome for the lion … ” Yes, they know that about themselves. They think for the other person and hold themselves back. They seem affected. When looking at their picture, they continue these considerations: They wonder if the grasshopper is not “selfish” when it goes its own way? “Whoever lives their will is selfish.” That is their parents’ view. I ask: “What do you find selfish about the stick insect’s intention to go its own way?” “Well … it is strong. Maybe too strong and therefore has to be considerate.”—“Isn’t that a ‘reversed world’ when you look at the two animals like this, the small stick insect should be considerate of the big lion?”— The patient agrees thoughtfully, but something tells them that the grasshopper is responsible if the lion is not doing well. This is a “huge topic” for them, maybe they take on too much responsibility. So far, they have always seen everything positively that was demanded of them and what they demanded of themselves. Thus, after the initially fleeting-evasive impression, much significant content becomes accessible again: Their fear of close-

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ness and search for acceptance, their altruistic relinquishment, and their “filter” that also applies to me in the transference. The imagination with grasshopper and lion is an example of trial action in imagination (7 Sect. 7.3), which immediately also makes the “filter” of evaluations and questioning clear. At the beginning of the Friday hour (17), that is, the last weekend break before the end of therapy and our farewell, she continues this topic of the agile “selfish” locust in a way I did not immediately understand and reflects on her current life situation, which she describes as a “vacation of a special kind.” She notices how much she is “otherwise stuck in working life, and thus missed balancing work and private life.” Actually, she never has time to look for clothes with pleasure and to “stroll,” as she sometimes does now.—I ask how this came about.—She remembers the year after school. She never had such leisure again. That was great. “Or also the time when I had the cruciate ligament tear.” That’s when she researched for her “dissertation.”—I recall: “You were also quite happy when you were sick before.”—“Yes, I have always lived a tightly scheduled life and was then glad when something was canceled. With illnesses, I also had the desire for more attention, but it was not fulfilled: ‚Don’t let yourself go!‘ was the motto.”—Only now, as I listen, does it occur to me that the last imagination, in addition to the external, probably addressed above all an inner relationship issue (7 Sect. 7.4, 7 Excursus 9: subject-/ object-level dream interpretation): That the agile locust and the leisurely lion thus stand for two self-parts to be integrated. That it is therefore the rigid lion’s share focused on the outside and the agile-jumpy locust impulse part that are so far in a state of “non-commitment”! And that these should enter into a binding exchange in order to further develop both sides—so that the impulses can be better sensed and less

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“­filtered” and the shaping of external relationships can become more flexible. I ask Mrs. Musat: “How do you feel about having stepped out of your tightly scheduled life for once?”—“At first it was easier not to have anything to do. Now it’s getting harder.” In the earlier “program mode,” she hadn’t even felt that being alone was somehow exhausting. Sometimes now she doesn’t even get out of the apartment easily, not knowing what she might be up to. It feels a bit like boredom. And like loneliness. She then gets “such twilight states of thought.” She feels better when she goes to a café, thinks there or reads the newspaper … For me, it becomes noticeable that Mrs. Musat, by addressing her performance-related “posing” side and her insecurely experienced autonomous “agile locust impulses” on the one hand, and her altruistic defense on the other hand, has come more clearly into contact with her underlying depressive basic conflict. Thus, I understand the description of her states of inner emptiness, which the “locust” cannot yet fill uninhibitedly. Here I would like to relieve her within the framework of our setting and explain to her that this is a stage belonging to the therapeutic process: While she knows and can do well to work off what comes to her as an external demand or even only seemingly from the outside, she is less familiar with sensing the impulses that come from herself, from within. The states she described and somehow experienced as exhausting when alone could have to do with her now sensing more of this: moving from fulfilling external impulses to perceiving inner ones … In the further conversation, I ask her about her “agile” sides, about passions, and whether there is actually something she passionately enjoys doing. Indeed, it was not easy for her to say. She also sometimes did not know what to do that would suit her. For example, when she told herself it was okay to do nothing and “just” clean the bike, there was “inner

objection”: Then you miss out on something in Berlin. On Monday, she had a long, “perhaps too long” bike ride. Actually, she had the need to sit in the sun. She did not allow herself that.—“Sitting like on a mountain meadow,” I remind her. “Yes. Yesterday it worked.” She rode her bike and then took a long break. During her break, the phone rang, so she stayed seated. This way, the decision—to continue or stay— was taken away from her. “I find it so difficult to make such small decisions on my own. I always need encouragement. Or I have the desire to keep everything open.” So we are once again working through her conflict: wanting to meet the expectations of others, the learned internalized demands, and now also her own needs (which corresponds to the transference to me). And we talk about how making a decision also exposes oneself, making oneself vulnerable to criticism. She can understand that and thinks it would be better for her to show herself more. She also tries not to perceive and hide her own needs as “selfish,” not to let them get stuck in the “filter.” But then she thinks again that she might be taking something away from the other person. At this point, she has an idea that shows that she sometimes already feels lighter, shedding “emotional baggage”: Yesterday she bought a scarf and couldn’t get the tag off. She didn’t know how to best remove it. She dreamt about it. The dream was: The tag was no longer attached. We don’t get to discuss the relieving dream in more detail, as the end of the hour is approaching. As she leaves, the patient mentions that it is uncertain whether Francesca will be able to come as planned for the weekend. She had been in an outpatient clinic for thrombosis risk, and it was unclear whether she would be allowed to fly. I am left concerned: Why had she not talked about this important topic for her throughout the entire hour? Why did it get stuck in her “filter”? Did she want to spare me the participation in her uncertainty

4.5 · Second Treatment Phase

and worry, possibly disappointment—and through the expected therapeutic mirroring, spare herself the associated feelings? Did she not expect any compassion from me in the line of a mother-transference? Or is she already anticipating the upcoming end of therapy with the weekend separation, the feeling of having to cope alone and without my empathetic understanding soon anyway? The short-term therapy we agreed upon is nearing its end. That’s why on Monday I start the session (18) and suggest to Ms. Musat that we continue working as before for two more days and then use the last two sessions for review, reflection, and perspective.—Ms. Musat agrees. She had already tried to summarize a lot for herself on Friday. And she tells me: Francesca did come after all. For the first time, they had been together outside of familiar contexts. “It was differently beautiful.” She had initially been worried about the thrombosis and had therefore called her parents. Her mother had at least said: “Now you have a nice weekend with Francesca ahead of you.” That had done her good … I experience the patient as not very focused on me, and I also wonder if I might already be distancing myself (7 Sect. 7.7.5). But as if sensing this question and wanting to “bring me back,” Ms. Musat continues to report dreams, the first of which has a clear reference to the transference relationship. Last night she dreamt: “There was a personality-building training measure from the company. I was very close to the organizer. The trainer came from outside. The organizer was surprised that the trainer came on foot, had everything in her backpack, not so boss-like with a car and leather briefcase. Ines, the pregnant woman from the avocado dream, also appeared and helped with the preparation of the training.” She recalls another dream from the time between our two treatment phases: “I stayed overnight with Francesca at her parents’ house. The parents came into our

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room. That bothered me. I went out into the city, was threatened by a gang there, then returned to the house, which had turned into a hotel. I was the only one who felt the threat. And I wanted to hide all our things from the gang. Mother showed me and Francesca clothes she wanted to get rid of. The gang came, I was worried about the money, but the others not at all.” From around this time, she also remembers a semi-conscious dream when she said goodbye to Francesca: “Both of us had a little separation pain. I said: Sometimes you have to take a step back from the picture to perceive the whole. Francesca said: I would rather paint myself. I later doubted whether it was right to say that. After her call on Friday, saying she would come after all, I felt a huge anticipation. But when she was there, really close, I experienced myself as so matter-of-fact-neutral.” I feel somewhat overwhelmed by the abundance of the reported dream material and briefly consider how I should understand this: Whether the feelings about our therapeutic path and our relationship, which are hinted at in a multifaceted way— including the separation pain, which will also affect us this week –, should not be made discussable for defensive reasons, or whether, on the contrary, they can only find expression in this condensed form due to their complexity. Still busy with it, I refrain from hasty interpretations and think it might be more appropriate to return to the dreams later. So I first pick up on the last reported experience, her inner distance towards Francesca in their actual interaction, as she also experienced it so impressively in the lion imagination, and ask: “What could have caused that?” Mrs. Musat ponders. She probably was unsure how she could “share all this with her” and then “made a program.” I say: “It seems to be an important and difficult scene, what happens in the approach. How do your dreams fit in?”—In the training dream, Mrs. Musat says, she was actu-

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Chapter 4 · A Short-Term Therapy With Imaginations: The Case of Musat

ally the organizer. She was dissatisfied with this role. She was not the mother of the nation! But she always had to organize the celebrations in the company. I remind her: “The organizer in the dream is very surprised?” “Yes, by the coach’s naturalness.” She also lives very naturally here, with her bicycle. But more than that, she is preoccupied with her mediating position, her boss has impossible manners, she mediates between him and the employees.—“You know that, mediating between the explosive mother and the brother or father, and not wanting to be so explosive yourself.”—She confirms this and then says that it is completely new to her that her mother admires her. She had never noticed that before. She had already thought about whether her mother might even like that she was different, that she was going her own way.— “That’s a completely new thought. How does the dream relate to that?” “It was strange. Francesca and I were staying in the parents’ bedroom, and Francesca and my mother were very harmoniously busy with the clothes. Francesca seemed happy to belong. She wasn’t annoyed at all that they just came in.” She stood there all alone with her irritation. “It’s a kind of boundary violation that the parents invade their intimate sphere and find nothing wrong with it. That causes justified anger,” I say, but also consider that a dream can always be understood from several levels. The “trainer” represents a different, “natural,” respectful interaction. She had given the trainer—as she had given me in therapy (7 Sect. 7.7.6)—access to her intimate sphere of her own accord, so the assumption is obvious that she had accommodated me and her experience with me in the “trainer of the personality-building training measure” and perhaps also in the parent figure, to whom she allowed access to her intimate sphere. On the other hand, it is striking that after the boundary violation in the dream by her mother alone, she was the one who perceived the threat from the gang, it might be

a gang not outside, but inside herself, something she was unpleasantly “bound” to, as we had already discussed with the “inner inquisition”—she herself being the gang that spoils something (7 Sect. 7.4, 7 Excursus 9: subject/object-level dream interpretation).—She agrees thoughtfully: That may be true, she feels that she “keeps bumping into the value system within myself.” I consider that in the dreamt Francesca, she shows a desire for self-evident female intimacy with her mother. However, addressing this would be too confrontational for the framework of the KZT, even if the session had not already come to an end. Yesterday (19) after the hour, Mrs. Musat continues, she had just “let it run”. Her clearly felt anticipation “and then this departure of emotions in the vicinity” had occupied her further, “the lion theme”.—With the question: “Can you just let it run here as well? Not ‘work’?” I invite her to continue her free association from yesterday, which is connected to sensing her impulses and relating her self-parts.—Just now she had thought about her mother’s dominance. And that she wanted to be different. How things were in her family, about the “factually down-regulating” of her father, that mother makes the actual decisions, “by not being able to do this, it is too much for her, she emphasizes this emotionally … ”—“You wonder how autonomous your father really is? You had already expressed doubts.” Yes, she has new questions. He had always advocated not to become dependent on the company. But towards the end of his working life, young bosses were put above him and he was sick for a long time: “It became an exit through illness … But why do I need his feedback? He has actually always only confirmed me … ”—“Where would you have wished that he would also oppose you, represent a different opinion?” She thinks and then says: “Milan. I would have wished that he had said ‘No’, that I would have received support from him to say no.”—

4.5 · Second Treatment Phase

We are in a thoughtful conversation. I suggest: “Perhaps he does not sense that you need this, he cannot show his concern for you, as it looks to him as if you are managing everything well for yourself ?”—Mrs. Musat follows this and sees a parallel to her mother: She too appears as a strong, self-confident woman on the outside. But in fact, she always needs “such a female complicity”. The sister had asked the mother to help choose her wedding dress. She immediately declined when she realized that several women, including the mother of her future brother-in-law, would be there. She feels insecure then. She only feels safe within the family. Not only for her is probably “the family the source of security”! With her thoughts, the patient works on differentiating her parent images, individualizing the “homogeneous flock of sheep”, but also on making the mutual dependencies more clearly visible. In doing so, she is working on her inner detachment process. We must continue such a conversation together, so I suggest a final imagination, the theme of which I formulate openly (7 Sect. 7.2) according to such a concluding therapy: 5 Try to imagine a landscape that matches your current mood. 5 There is a vast meadow landscape, green, North Frisian. With wind, warm. It has something free, is a free meadow landscape … 5 Where are you looking right now? 5 I have a clear view to the horizon … I see pastures, fields, ditches … maybe the sea is far back. I have a clear view … 5 And how do you feel about that? 5 Liberating, the fresh air, wind, can let myself be blown through … let my gaze wander … You can almost look, walk, move infinitely far. 5 What do you feel like doing? 5 I want to walk against the wind, run, jump, feel myself. I notice my strength from the headwind. The jacket puffs up … I have to work against it a bit …

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5 How is that? 5 Pleasant, making my way like this. My head is free, my hair is blowing, I am now walking on a small dike, the wind is even more noticeable there … 5 Yes, how is it on the dike? 5 I have a clear view in both directions. On the left is the sea, on the right the green landscape. Now I feel the salty air. The sea, the sea wind. With the dike, the path is now predetermined. But you can also ride a bike in zigzag lines up and down … 5 How is that for you? 5 It’s a nice drifting with tailwind on the bike. It’s great, I could do that endlessly, let myself drift, then up again, then down again … 5 That sounds really nice, full of joy. 5 Yes!! … I’m going to sit down here on the dike and look at the sea … 5 Yes, how does it lie there? 5 It’s far away, I see a few ships. It’s difficult to perceive it up close … Now it’s changing, hitting the quay wall. The spray splashes in my face, I look into the raging waves … Now there’s a real beach here, where the waves roll in. What a force they have! How they change! What natural forces! There’s the pull, then they come back. 5 Can you hear that too? 5 Yes, I hear the surf. Everything is intoxicated by it. It’s so penetrating, space-consuming. Nothing else has room … I also hear a few seagull cries … 5 We have to slowly come to an end now. Is there anything else that would be important to you there? 5 It would be nice to be there together. With Francesca. We sit there together on the beach. Each for themselves, but sharing the feelings. That would be an even stronger feeling than being alone. In the penultimate session (20), the first of the two “balance and perspective sessions,” we spread out all the painted pictures in front of us, and Mrs. Musat also adds her

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new one from the day before: She had again experienced a particularly vivid physical vitality yesterday (Chap. 2, 7 Excursus 3: kinesthetic). This had been as pleasant as the conclusion on the beach, where she was not alone for the first time in these imaginations. Especially in comparison, she realizes that she often had to deal with loneliness in the other pictures. Now she has painted herself red, with the color of emotion and the sunset—that’s almost too romantic, she says with slight distance. The gesture—that she puts her arm around Francesca’s shoulders—should express the wordless agreement she had felt. Which is difficult to paint.—To me, the sun seems like a triangulation, so I ask about it.—It embodies warmth and intensity. “If it were gone, it would be more dreary, lonelier.”—I cover the sun in the picture to let her check the difference, and she says: “The sun is like an opposite for the two.”—“Maybe even an accepting opposite?”—“Yes.” Some of what was shown in this last imagination can still be discussed together: the clear view and the liberating experience, noticing one’s own strength, with which one can pleasantly make one’s way. And that one’s own strength against the wind becomes noticeable, thus experienced in tackling conflicts. Also, that she was in a pleasurable way in contact with her “elemental natural forces” with wind and sea. It touches us both to have come this far, to such an intense experience and this confidence, to which Mrs. Musat will be able to connect.—At this point, it should be considered that the last imagination also represents a “thank you” to me, filled with ambivalences—and as a “gesture of wordless agreement” has a transfer dimension (7 Sect. 7.7.2). It is important to me to also reflect on the path to this point with her: That she had started the session with “letting go,” with the openness to associatively surrender to her inner impulses. That her head was ex-

perienced as free and no longer full in this way. And I was impressed by the image she had found for this in the imagination: a beautiful drifting with tailwind. The tailwind of therapeutic “backing”—we are both aware of this; but also the tailwind of positive introjects of one’s own unconscious, I add in thought: I could do this endlessly, let myself drift, then up again, then down again. This “letting go” associating in conversation with me had led her to her parent images and to taking another step in de-idealization and differentiation, detaching herself a little further from them. The sea, the emotional-passionate, which she then initially perceives far away in the imagination, she can finally let it come very close, very close—until a couple situation succeeds, feelings can be shared, closeness succeeds even in closeness. But as the final image of the imagination—although now more integrated—cannot be held on to, we too must move apart again; and so I ask Mrs. Musat in the last part of the session, turning back to the painted pictures, which kind of review and balance she prefers in the future: In addition to the chronological viewing of the pictures, I suggest the “dowsing rod technique,” in which she lets herself be guided by the feelings that the pictures evoke in her, associatively. Mrs. Musat chooses the “divining rod” and lets all the images initially have an overall impact on her, then selects four that are currently significant to her and begins with the curiously open face of the lion: She has become curious about herself. She will continue to deal with her criteria and evaluation standards. She is, of course, also curious about Milan, how it will be when she moves her center of life there. She sees herself walking through the market, shopping… Also curious about the relationship with Francesca. And how things will develop with her parents: “How they will find their way.”

4.5 · Second Treatment Phase

I direct her reflection back to herself by asking her if she can also draw conclusions about her strengths and what is helpful to her from the images and the experiences here.—The images, the painting, and the calmness have helped her to feel herself more. She wants to listen more to herself in the future before doing something. And she thinks she can experience more feelings in close proximity. She also wants to show these! “Like the grasshopper: It shows itself outwardly. I want to be able to show myself in relation to my inner self.” Our last hour (21) is the one of our farewell. Mrs. Musat first talks about another separation by drawing the arc to our beginning and saying that she has become aware that it was not about the decision to separate from Jürgen, which had already been made, but about its acceptance. She has noticed how much she is influenced by her family, how significant they intervene in her entire inner being. But that this inner being is the real problem, she cannot base her path on the goodwill of her parents, but on the sensing and trusting of her still-to-be-discovered impulses and sensations, as she has often been able to experience here. Building on these, it is initially about self-acceptance—the parents cannot precede her in acceptance, but can only follow their own. She wonders how what she has experienced here will affect her new life. She has learned a new way of dealing with her own feelings. And she feels more need for contact, “I feel like leaving my biotope.” She has engaged here, noticed how through the stimulation to let things run freely “some things go in circles and thus certain things keep coming back.” This and the intensity of the feelings in the imaginations were an impressive new experience for her, especially the accompanying body sensations. And that she could no longer control these. She remembers most vividly the feeling of anticipation in the lion imagina-

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tion and the real anticipation of Francesca in the last week. The experience of being able to let it run was impressive. She had not known anything like this before, otherwise everything had always been planned and “worked through” by her. I have little to add to this. I appreciate the intensity of her opening to her own inner self. As a result, her dead end has also opened up. However, I also emphasize that it is a challenge to preserve and further develop these experiences and insights on her own. Thus, we jointly acknowledge the achievements and discuss what is still necessary for her: That the attitude of wanting to please others first is deeply ingrained and cannot simply be “switched off ” like a reflex, but that it takes psychological work to trace one’s own impulses and feelings. That sensing and “living from the inside out” has been able to find an experiential approach in this short-term therapy, but this process requires further development. Especially since resistances will repeatedly arise that label the self with doubts and evaluations (e.g., “selfish”)—and then there is the danger of projecting these again onto others, i.e., making parents or other people responsible, as she had mentioned at the beginning of the session. Despite all this, I also notice (7 Sect. 7.7.5), that I myself have an acceptance problem: To acknowledge that Ms. Musat, regarding her therapeutic path—for reasons that had already become clear to me before our treatment—could not find a real conclusion with me. And that this is the psychological work that I have to do: To acknowledge that this last session does not change that, and I cannot compensate for it with advice, but that this session is precisely for that purpose: To rejoice in what has been achieved and to accept the limited. And that I too must let go, but can also do so, trusting in the process initiated together here and the forces continuing to work within her.

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References Kris E (1952) Psychoanalytic Explorations in Art. International Universities Press, New York

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Rohde-Dachser C (1987) Ausformungen der ödipalen Dreieckskonstellation bei narzißtischen und bei Borderline-Störungen. Psyche 41: 773–799

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A Psychodynamic Psychotherapy with Imaginations: The Case of Grün Contents 5.1 Initial Contact, First Impressions, Symptoms – 70 5.2 Therapy Planning – 71 5.3 Initial Imagination – 75 5.4 The Therapeutic Process – 79 Reference – 95

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_5

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The 30-year-old saleswoman, Mrs. Grün, has already undergone surgery for herniated discs five times. Her pain, along with fears of failure, compulsions, and high inner tension, lead her to seek psychotherapy on the advice of a doctor. She gladly accepts the suggestion, as she assumes that her fears of failure and exams are emotionally based, and fears that without help, she will not be able to complete her retraining as an office specialist and thus achieve her urgently needed professional consolidation: “I don’t want to be a failure like all my siblings.” 5.1  Initial Contact, First

Impressions, Symptoms

Mrs. Grün is made aware of the possibility of psychotherapy by her trainer after she faints for the umpteenth time during an exam as part of her retraining program. She immediately registers with the referral center at my analytical institute, which was recommended to her by her health insurance. She has to wait almost a year and renews her urgent therapy request in writing twice. The clinic director recommends her to me, saying she is so “touchingly committed.” I accept the suggestion because I am impressed by Mrs. Grün’s perseverance in the face of her difficult life circumstances, which I have gleaned from her file. I want to find out what has kept her from resigning and help her further. For the initial consultation, Mrs. Grün arrives a little early. She greets me with a firm handshake, her hand is sweaty. She is a small, sturdy-compact, sportily dressed woman who seems to me to be masking her insecurity with tomboyish behavior. She sits down at the very front of the armchair and looks at me tensely. I notice that she is trembling. When I ask her what brings her to therapy and as she senses my interest in her through further questions, the tension gradually subsides. She tells me how important the retraining is to her, how she abso-

lutely wants to succeed: “It’s my ticket, you know. Out of the life as an underdog.” She repeatedly addresses me directly, speaking more and more candidly (trustingly? with reduced distance?) in the course of the hour with a “Berlin snout” and impresses me with her approaches to psychogenic insight in statements like “The fainting spells are definitely psychological, right? Because I want it too badly!” and through her vitality: but “it doesn’t always work out the way I want, and then I freak out; the soul goes its own way, you understand?” In terms of symptoms, a lot comes together upon my inquiries: sleep disorders, loss of appetite, feelings of loneliness and sadness, listlessness to apathy, while she “functions outside” but “collapses at home.” She focuses on her great fear of failing at school. She then experiences strong inner restlessness, cannot sit still, her pain increases, she “picks” her lips and nails bloody, and has suicidal fantasies again and again. A suicide attempt (with tablets) is a bit in the past, her husband found her. In addition, she mentions multiple phobias, which probably protect her from this self-destructiveness: Since childhood, she has experienced panic attacks with dizziness on bridges, ships: “I’m afraid, it pulls me into the water.” Added to this are compulsions (she has to check several times whether the apartment is locked, the stove is turned off, her husband has brushed his teeth). Everything must proceed in fixed rituals, otherwise her level of restlessness increases. She has had pain since the age of 20; the four surgeries—one with the use of a titanium block—have helped little, she experiences restrictions in movement and walking ability, is not allowed to dance. Since the age of 25, she has been 50% disabled and occasionally takes strong painkillers. She has been advised against pregnancy for medical reasons; but if it were to happen, she would have to lie down for the duration of the pregnancy: “But I actually do want to have a child.”

5.2 · Therapy Planning

5.2  Therapy Planning Current issues  Mrs. Grün has been participating in a retraining program for office professionals for a year after her back surgeries. She is the only “back patient” there, the others are recovering alcoholics and former drug addicts. Although she used to get poor grades in school, she has done surprisingly well in the first exams, but the longer the program goes on and the closer the exams get, the harder it becomes. Her pain has increased before the exams, and she can only manage with medication. Her classmates are kind and empathetic during her fainting spells and have taken care of her. At home, she is often so tense and stressed that she becomes either apathetic and withdrawn or hurtful towards her husband and friends: “I just stubbornly stay silent and can’t get out of it, or I yell and would like to smash everything to pieces.” Her husband may be a “little egoist,” but she loves him and doesn’t want to lose him. She feels drained, nothing fulfills her, and she can no longer be the “always strong” one. It’s a constant struggle: “I want to succeed in school. I just don’t want to lose.”

z Biographical information

Mrs. Grün is born as the first child of 20-year-old parents. The mother is an unwanted, illegitimate child from a children’s home without vocational training; the father (now a master craftsman with his own business) comes from a socially better-off family (parents and brothers are academics). When the mother became pregnant, the father wanted to marry her, but she declined “out of pride” (“She didn’t want to befriend the father’s social class”). The father then broke off contact with the mother, denied paternity, paid child support only after a lawsuit, and first made contact with the patient when she was ten years old. Mrs. Grün has few memories of her first eight years of life. “I only grew up with

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criminals and alcoholics.” The mother received welfare, drank, “had many men,” and “always lied.” She “dropped her off ” at her grandmother’s, who was the most important person in her childhood. At the age of six, the patient’s mother marries a butcher. That’s when the beatings began: when she ate with her left hand, when she stuttered out of fear, when she defended her also abused mother. The patient began wetting herself when she came home from school (ages 8–14). For this, she was beaten again. The mother always took the stepfather’s side, but the grandmother took even more care of the patient after the mother’s marriage and the birth of her sister (−7, temporarily homeless, now an unskilled saleswoman, living with the mother again): “She was my dearest person.” However, from the age of nine, the grandmother increasingly suffered from dementia. The patient remembers “mean scenes where the mother cruelly mocked the grandmother.” When the grandmother died (at the age of 10), the patient was not allowed to cry or go to the grave, and the mother has not told her to this day where she is buried. Thus, she had no place to mourn. The mother had two more children, a brother (−8, now drug-addicted, dropped out of bricklayer apprenticeship, divorced) and a second sister (−11; no secondary school diploma due to “truancy,” now in a job creation measure for nursing assistant training). The patient remembers the time after the grandmother’s death with the three younger siblings as the “worst time” with beatings and fights, which led to a turbulent separation and divorce (at the age of 14), and the stepfather temporarily kidnapped the brother. The mother was “always drunk,” the patient ran the “whole show,” took care of the younger siblings, and tried to protect them from the men the mother “brought home.” One of them gave himself the “golden shot” in the toilet, the emergency doctor performed a tracheotomy in front of the children’s eyes, she

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screamed so much that she was given a sedative injection. Meanwhile, the mother listened to music. In her 10th year of life, her biological father contacted her and wished for her to move in with him, which she would have gladly done, but she did not want to leave her mother and siblings alone. Throughout her adolescence until her 21st year of life, the patient had loose contact with her father, whom she admired, loved, and emulated. He had always been with much younger girlfriends and married a woman her age in the patient’s 21st year, who soon gave birth to a son. Since then, the father has rejected any contact with her, allegedly because his wife wanted it that way. She suffered greatly from the rejection and still wishes for a reconciliation today. In kindergarten and school, she was initially quiet and shy, always seeking a close relationship with her teachers; she was mocked and beaten by other children for her stuttering and being a “tattletale.” Later, however, she became the strongest in the class and sometimes hit others senselessly; she was still often protected by the teacher. She completed secondary school and wanted to become a hairdresser, but had to quit her apprenticeship due to allergy susceptibility and then decided on a three-year apprenticeship as a specialist salesperson for meat and sausage products. After completing this, she worked for three years in a supermarket under a “brutal” master, had to carry heavy loads, and took on even more tasks to gain recognition; then the pain occurred (two initial back surgeries). She attempted retraining as an accountant but felt harassed by a “terrible boss,” leading to more back pain and surgeries. Afterward, the patient fought for her current retraining from the employment office. The patient describes herself as a loner with only loose friendships. Her development into a woman is marked by experiences of abuse, one of which she remem-

bers: “I’m sitting on the couch in my nightgown, next to my mother, and on the other side a man who is fumbling with my vagina.” Due to her mother’s asocial behavior, she gained early insights into her mother’s sex life and developed a disgust for sexuality. After menarche at 13, cohabitation began with a “jailbird type” of her mother, who mocked her: “Looking for a father, huh?” From the age of 16 to 19, she had her first relationship with a drug-addicted ex-boyfriend of her mother. She did “everything” for him until she “woke up” and “kicked him out.” A similar situation occurred in her next relationship until she met a “nice young man” at the swimming club at 21. She became pregnant and wanted the child, but the man insisted on an abortion, which she has “horrific memories” of. At 22, she met her current husband, who is eight years older and was a coach at the swimming club: “That’s him. You’ll have your peace.” Her husband, a trained electrician and later IT specialist, earns well, and “we live in a small apartment without debt, leading an outwardly secure life.” She describes him as not very affectionate but attentive and supportive. He works a lot. Three years ago, she temporarily developed a tender, non-sexual relationship with an acquaintance, with whom she went to museums and exchanged a lot. Since she did not want to tie him, who had been single, to herself and did not want to endanger her marriage, she gave up the relationship. The patient enjoys reading and painting, and before the increase in pain, she often went for walks or did light fitness and swimming training. z Countertransference

I feel respect for this woman, who has not resigned despite all the suffering she has endured, and I am impressed by her vitality, which is expressed in her forcefully presented speech and her insatiable ambition to rise; what particularly touches me

5.2 · Therapy Planning

is how sensitive strings resonate behind her “rough shell.” However, this respect also includes distance: She comes from a completely different social world than I do. This makes me somewhat insecure: I feel privileged in comparison to her due to the manifold traumas and limitations related to her background, and I fear that I might want to be “especially good” for her out of an irrational sense of guilt, which could make it more difficult for me to establish closeness and understanding, as well as necessary confrontations, and could cause unnecessary pressure for me—and indirectly for her as well. In particular, I am concerned that, due to my strong desire to support her, I might unquestioningly adopt her “drive for advancement” and not accompany it with sufficient understanding in places where it would be important. z Psychodynamic Hypotheses

The patient has been neglected from an early stage in her development due to her fundamental lack of maternal security experiences and paternal orientation, and has been traumatized multiple times through physical abuse, devaluation, and sexual assaults. Due to the early disturbance components, there are mentalization deficits and significant affective tensions in the face of insufficient mirroring; libidinal and aggressive impulses could thus only be inadequately integrated and must still be kept under control with compulsions, phobically warded off, or dissociated due to their intensity. In the impulse breakthroughs that nevertheless occur when the patient “loses control,” an unconscious identification with the aggressor, the hated stepfather, is also expressed—as well as in her first vocational training as a meat seller. Possibly, this identification also allows her to discharge disappointment anger over the lack of mothering. Her affect intolerance, especially towards aggressive impulses, threatens the cohesion of the self and must be controlled by compulsions or turned against the self

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(phobias, back pain, surgeries that make pregnancy difficult and thus question her own motherhood). The phobic symptomatology originates from several sources: protective impulses due to the massive external intimidations, assaults, and experiences of violence as a child, the defense of inner impulse breakthroughs, and the reliance on a controlling object. The patient’s inner object world is as fragile as her self-representations, so Mrs. Grün uses divisions such as “good father”—“evil stepfather,” “good retrainee”—“bad daughter” to stabilize herself. This also serves the idealization of the distant biological father and the defense of disappointment over his rejection, just as the early parentification warded off disappointment over the lack of mothering: she takes care of the mother, even stays with her when a better life with the father is offered, and takes care of the younger siblings to this day. The willingness to idealize—she idealizes her teachers and her retraining supervisor—is at the same time her most important help in the attempt at social advancement and thus her autonomy development, which would bring her into the paternal sphere. On a psychodynamic level, the struggle for professional qualification can be understood as a struggle for the father. What currently leads the patient to therapy is a loyalty conflict: a successful completion of the retraining measure and first steps into an employment relationship would take the patient even further, as she has already succeeded through marriage, beyond the social sphere of the mother and closer to the one rejected by the mother, the father. The ascent is therefore associated with the idea of complete mother loss and, due to deep ambivalences towards the mother, with unconscious guilt conflicts. Just as the mother did not accept the father out of “pride,” i.e., to regulate her self-esteem conflicts, the patient fears that the mother will break off contact with her, the

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daughter, as punishment for moving too far away from the maternal world. Since the patient is internally bound to the consciously rejected, disappointing mother, she is caught in a burdensome inner conflict between autonomy and individuation desires on the one hand and loss and guilt fears on the other. The physical symptoms such as fainting and pain symptoms occurred with the beginning of her departure and ascent from the maternal world. Her ambivalence regarding the desire for children is also an expression of this unconscious loyalty conflict. z Diagnosis

Somatoform, dissociative, phobic, and depressive symptoms in the context of developmental and trauma-related structural deficits (personality disorder). Status post nucleotomy and four-time renucleotomy with fixation of a segment by titanium block. z Indication and Treatment Planning

The psychodynamic psychotherapy is indicated insofar as the patient seeks help with a specific, currently effective conflict: Although there would be more extensive therapy goals in view of significant structural deficits and various developmental limitations, including the area of female identity formation, the processing of which would suggest a structure-building longterm therapy. However, this would be a very time-consuming, lengthy process, which both parties involved in the therapy should initially examine before engaging in this severe pathology. The patient does this intuitively by emphasizing in the preliminary talks that she is seeking help in her current situation and clearly expressing that she knows what stabilizes her and that her partnership must not become an issue here because she does not want to “shake” her marital situation. She is “completely satisfied” with her life so far, “if only the exam were passed.” This puts a limited desire for

change in the foreground, which in therapeutic agreement means that her existing defense formations should only be modified and specific partial goals should be pursued. Specifically, it will be about working with Mrs. Grün on affect regulation, uncovering the unconscious desires, fears, and irrational feelings of guilt behind the work disorder, and supportively and encouragingly accompanying her in overcoming them. The therapy goal would therefore be to work with Mrs. Grün on her self-regulation and object-related limitations caused by structural deficits, as they are symptomatically expressed, for example, in her somatization, lack of concentration, and lack of confidence, to such an extent that she can achieve exam success and subsequently search for a suitable job, thus enabling a transition to a new life world and demarcation from the world of origin. This could, in the sense of spiraling success experiences, allow further loosening of defenses and thus significantly improve the patient’s quality of life. In addition, she could be motivated for a later therapy project, an analytical psychotrauma therapy (Steiner and Krippner 2006) would be conceivable. In this therapeutic process, the expected transfer dynamics should be observed and used, but only if they disturb the process in the sense of a transfer resistance, should be addressed (7 Sect. 7.7.6). In view of the special position of the long-distant, highly idealized father, I assume that the patient’s readiness for idealization (which would be expressed in an idealization of the therapy and probably also of my person) can bring about a temporarily important narcissistic strengthening. This could be made therapeutically fruitful, while the defensive function of idealization—against disappointment rage and depressive lostness from the experienced lack of mothering—cannot be analyzed, as would be the case in a high-frequency analytical therapy. Overall, in addition to limiting the frequency and number of sessions (50 or 80),

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an active therapeutic process design and focusing on partial goals must counteract a destabilizing regression to which the traumatized patient with a history of deficiency might tend. From the transmission constellation, dangers also arise: first, not being able to permanently separate the described subgoals from the overall dynamics stably enough because unconscious desires of the patient push forward, concerning the development of femininity and a more stable identity. Therefore, I intend not to question her ritualizations and the mentioned control compulsions, as they are part of the defense she needs against destructive-aggressive introjects that have emerged from the traumatizations, trusting that the self-esteem stabilization associated with the therapeutic process will already make a less rigid defense form possible. Another danger arises from the motherly transference, which is also not to be addressed but has an underground effect, with its deep mistrust and longing for regression. Mrs. Grün could want to ally herself with me as with her distant ideal father in order to ward off these feelings. Finding a good balance between accepting such an idealizing transference on the one hand and disappointing unrealistic narcissistic desires in a development-promoting way on the other hand will be important. If this fails, a temporary retreat, perhaps even impulses to terminate, can be expected. From the paternal countertransferencedimension, finally (I belong to a higher social class like the father), the third danger also results, either underestimating the patient, for example, because she speaks a different language due to her lower-class socialization, or overestimating her in the sense of a countertransference idealization. The therapy can be well conducted as KIP for several reasons (7 Sect. 3.3): first, to facilitate the understanding of the focal conflict through the vividness of the imaginations (clarification function). Second, to encourage and emotionally relieve the pa-

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tient, who is under high suffering and tension pressure, through the experiences in her inner world of images (stabilization function). Furthermore, it could be helpful to provide her with a painting prompt (7 Sect. 7.5) as a means of self-calming between sessions. Experiencing self-efficacy in expressing her own inner worlds of imagination could serve her affect regulation and self-esteem stabilization. In addition, a biographical connection emerged that suggested that Mrs. Grün would be able to use therapeutic imagining well for herself: She had enjoyed going to museums with her boyfriend and immersing herself in pictures with him. Here, I could start with the reasoning and hope for a positive response (aesthetic potency of the imaginations). z Treatment Agreement

Mrs. Grün and I agreed that she would come to see me once a week after the approval of the application, and she was familiarized with the basics of the special therapeutic communication form (abstinence, free association, framework elements). She spontaneously welcomed the inclusion of imaginations, even before I had mentioned the painting suggestion: “Then I’ll have something to paint!” 5.3  Initial Imagination

In the last anamnestic, our fourth probatory session, I say towards the end of the hour: 5 I had told you that we also want to look at your inner images together here. As if visiting your inner museum! (Laughter.) Would you like to engage in that now? 5 Yes, what do I have to do? 5 Just sit comfortably in the armchair, now you are sitting so far forward, so really settle in comfortably and if you want, close your eyes too… (Relaxation instruction; 7 Sect. 7.3). And then

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please imagine a flower. And when you have something in your mind’s eye, tell me what it is so I can imagine it too. Even if something else should appear. 5 I see a sunflower (laughs delightedly). 5 Can you describe it as you see it? 5 It has a long, tall stem… two leaves. There’s a little ladybug. It has four spots… 5 Oh! Is it sitting on the blossom? What is it like? 5 The petals are radiant yellow. The center is brown, brownish, yes, I can already feel small holes in the brown… yes, and the stem too. 5 What does the long stem feel like? 5 The stem feels quite rough, I notice now, it’s stuck in the soil, the soil is very loose, dry, brown. It’s like a small hill, the flower seems buried, like buried in a molehill, that’s how loose the soil is. I could just pull it out… yes. I pull it out… It should always stay like this… Now the molehill is alone. 5 Hm. What do you feel like? Is there something you want? 5 I’d love to take it home, paint it, photograph it. The ladybug is nibbling on the leaf… But it should stay like this! Not wither! Best to freeze it. But then it will become stiff… 5 Yes, what would be good for it? 5 So painting it would also work. I put it by the window at my place. The sun should shine on it. I see that now. That’s pleasant. The cat shouldn’t go near it… The initial imagination is closely related to the previous scenic experiences between Ms. Grün and me, as well as the anamnestic details remembered and shared in our contact. In its symbolic condensation, it provides a valuable addition to diagnostic hypothesis formation and treatment planning and also has an immediate therapeutic value, insofar as it positively surprises the patient, lets her feel her self-efficacy, and offers her a motivating incentive for

self-exploration (“Then I have something to paint!”). Diagnostically, the imagination says something in detail about the patient’s personality structure (a), her inner and outer conflict world (b), the relationship desires mobilized by the therapeutic situation (c) and their necessary defense at this point in time (d), about the patient’s possibilities to deal with her conflict-defense dynamics (“resources”, “ego strengths”) (e), and about the transference process (f). a) Primarily, a structural disturbance is indicated by the missing contact with the “maternal” earth, which surrounds the flower very loosely, dry, thus not nourishing and holding it. The visible flower appears intact with its large long stem, but proves to be only buried, not grown, and thus de facto uprooted in its invisible part located under the earth, a drastic image of missing supportive security. The structural pathology is also evident in the “pulling out”: Both in this self-destructive act, which has something concrete, little symbolized, but even more in the absence of the corresponding affect of fright, which reaches me projectively, typical for splitting phenomena (7 Sect. 7.7.5). The radiant sunflower appears in this respect as an arbitrarily manipulable “object”: I pull it out. b) If one nevertheless understands the act of pulling out scenically-symbolically, the loyalty conflict could be expressed: If the patient withdraws from her disappointing relationships of origin, which could be derogatorily represented in the molehill, she fears an elementary threat: But it should stay like this! Not wither! c) Different currently effective wishes and fears can be identified: The narcissistic desire for warmth, mirroring, and security is central in the choice of the flower. The fact that the patient imagines a sunflower, which in reality turns its “face” towards the great warming ­ celestial

5.3 · Initial Imagination

body throughout the day, could suggest that Mrs. Grün had to direct her mirroring and warmth desires towards a distant, fatherly, idealized object compensating for the lack of mother. The search for a suitable “form of existence” for the pulled-out sunflower in the second part of the imagination leads back to the central mirroring scene and longing for warmth when the patient places the flower in the sun in her apartment: The sun should shine on it. With the idea of freezing the flower, it is hinted at how the patient had to “hibernate” in her lack of mirroring. The longing for protection can be inferred from its lack and in the reaction-forming effort for the flower. It is about protection from a beetle—which is already there before the patient has even described the blossom—and from a cat that would “nibble” the flower if she took it home. Beetles and cats could be both negative object and self-representations. Mrs. Grün, as is often the case, first brings the object attachment into the conversation in the following session and associates the four-spotted beetle with her four siblings. Thirdly, the desire for maturation is delicately indicated. The patient’s sunflower is ripe (think of the desire for children), indeed, some seeds have already fallen out (one can think of the forced abortion, but also of the already completed, ultimately fruitless first training). She has something to give, wants to be generative, but the patient is also afraid of “withering” and passing away “infertile” (without a child, without suitable work): The center is brown, brownish, yes there are already small holes in the brown … d) As forms of defense, on the one hand, there is the inversion into the opposite, in which the desire for rootedness must remain unrecognizable to the patient’s consciousness through “pulling out.” In addition, the identification with the ag-

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gressor becomes visible in the abrupt manner of the uprooting carried out by the patient herself: What she does herself does not have to be experienced again as painful and powerless—and in the lack of emotional involvement, the dissociation. The defense form of dissociation appears once again when the freezing of the flower is referred to as “protection.” Similarly, the turning against the body-self becomes noticeable in the active uprooting, in another form, possibly in unconscious abuse representation, this defense form plays a role in the fantasy of being “nibbled” by the ladybug. e) Resources of the patient are evident in the progression-supporting-sublimatory possibilities (photographing, painting) that the patient develops in dealing with her flower. This can be used as a starting point to therapeutically promote the urgent desire for vitality and further development. Another resource lies in the patient’s ability to productively pick up on her therapist’s encouragement intervention (finding something that is good for her). f) Important aspects of the transference dynamics are conveyed by the imagination both atmospherically and with regard to individual peculiarities. The fact that Ms. Green responds well to the therapeutic offer is immediately noticeable in the atmosphere and affect. She laughs in surprise during the imagination and says in the follow-up conversation how delighted she was that there was such a “beautiful image” inside her. She may also have been relieved, due to a performance tension caused by transference, to have already passed her “exam” here, so to speak. Her positive therapy motivation was palpable from the first sessions, and this shared experience with me gives her further drive. In detail, the idealizing transference desires dominate, seeing the therapist

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as a sun, a warming, reflecting, large, life-sustaining, distant object sought through one’s own efforts. In the unconscious choice of a sunflower, I see the narcissistic longing of the patient (see b.) symbolized as a transference image: She shows herself to me with her desire for encouraging mirroring, indeed she wants to be able to “root” herself in the interest of the other and thus find her own place. She shows me the urgency of her desires when she demonstrates to me how little grounding she has and lets me be frightened by taking away even the last one. These desires will, of course, only be imperfectly fulfilled and only partially understood in our process, and therefore the therapy will also provoke frustration in her, so the significance of the above-mentioned balancing between accepting and frustrating the transference desires, between partial confrontation and stabilization through imagination, becomes even more vivid to me. For if this does not succeed—the patient may “pull” herself out of the therapeutic relationship. The transmission dynamics becomes clear “in the picture” not only through the symbolic expression, but through a striking imaginative design of their imagination, which could be seen as an enactment in the imagination: Because Mrs. Green very quickly presents a ladybug, an interesting “object” with four points, on her flower, it makes me pause immediately. What in her has demanded expression? Why does she enrich her flower image in this way at this early stage? Although I do not understand this immediately, I use this inner “pause” in me as a countertransference hint, which leads me to intervene in a certain way: I assume that the patient imagines the ladybug because she is not convinced that her flower (and thus herself) is interesting enough for

me “just like that”. If I were to immediately engage with the bug, my interest would “leave” the flower, which has not yet been able to unfold in my inner perception, just as the patient could not biographically unfold in either mother or father back then. So, I primarily experience the fundamental insecurity of the patient in the ladybug image, who has to make something else interesting and thus tragically threatens to prevent her own narcissistic wish fulfillment—simply being found good “just like that” as a “flower”. With this small transference action, a scenic sequence (7 Sect. 7.7, Excursus 11: Scene), the patient unconsciously puts the relationship “to the test”, she checks to what extent I “fall for” her negative transference, finding something else more important than her. Since I want to show Mrs. Green my interest in her, I do express a surprising recognition of the bug with the resonance intervention “Oh” (7 Sect. 7.3)—which of course also represents a self-aspect—but otherwise initially stay with descriptive questions focusing on the flower. My “staying with her” in connection with the touch intervention (stem) is crucial for an affective intensification of the experience and for the conflicting desires and fears around the theme of seeking support and being seen versus uprooting and disinterest to become clearer. Due to the patient’s structural weakness, there is—as in her everyday reality—rapid, impulsive action with destructive aspects (pulling out, freezing), so I have a stabilizing and affect-stimulating effect on her with the two encouragement interventions (7 Sect. 7.3). Thus, this first joint imagination experience complements the presented treatment planning particularly in the aspect that it will be important to convey to Mrs. Green in an active-supportive way the legitimacy

5.4 · The Therapeutic Process

of her desires through interest, empathy, and encouragement in image and conversation. This also includes questioning impulsive-quick and possibly destructive “solutions” (as they are imaginatively represented in the “pulling out”), not through criticism, but by picking up on positive approaches, slowing down action in the form of persistent stimulation to sense associated affects. Furthermore, it will be about clarifying irrational feelings of guilt and her forms of self-destructiveness in conversation with the patient using imaginative conflict illustrations (her idea of freezing the flower so that it becomes stiff reminds me of her submitting to invasive medical procedures that stiffen her spine with titanium), and overall accompanying her in accepting her autonomy desires and implementing them in a suitable way in partial steps. 5.4  The Therapeutic Process

The process of a total of 50 h extends over a frequency of one session per week for almost three years, interrupted by a longer trip to the USA by the patient with her husband. We conduct nine imaginations, and Mrs. Grün brings thirteen dreams, which she often paints like the imagination experiences on her own initiative (7 Sect. 7.5). Mrs. Grün always comes reliably to her sessions and cancels in good time if it becomes necessary due to illness. Due to resistance, the patient cancels several sessions in a row in the middle phase, and before her written exam, there is an agreed four-week therapy interruption. The sessions are resumed after the exams. z The Beginning of Therapy

In the fourth approved session (a total of 9), Mrs. Grün tells that she had fainted again after an exam, “briefly slumped.” She then quickly changes the subject and deals with the details of the exam preparation,

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how she coped, how restless she had been beforehand, and then reports in detail how “stupid” she found it that everyone had left so quickly after the exam and did not want to talk to her about the individual tasks or relax together. She says, almost threateningly, that she will prove to them and the teachers that she is “not stupid.” She asks, without transition, if we could not do another “picture journey” like the one with the flower. Again, the breaks in her report are striking whenever an affect could become too intense and slip out of her control. I think that in the “fainting” this emergency strategy manifests itself before an affect breakthrough, but also that both longing for attention and resignative tendencies condense in it. In complementary countertransference (7 Sect. 7.7.5) I feel concern and protective impulses, want to promote her understanding and self-care. Therefore, I slow down the pace at this point and try to bring her a little more in contact with herself and her split-off feelings in the protection of our relationship. I ask her to describe “first of all all the fainting circumstances” to me so that I can “better understand everything” and because I am worried about her: “What could have happened if you had fallen hard!” Mrs. Grün is very willing to do so, and I have the impression that my questioning relaxes her. It turns out in her narration that the fainting was preceded by a disappointment. She had made a great effort, filled out the exam sheets neatly, and then drawn a “small funny picture” of a bird on an extra sheet for the teacher, which she had placed on top of the stack of papers. However, he had been distracted while collecting them and had not seen it. “How was that for you?” “Well, he has a lot to do…” “Nevertheless, one can still feel something! Even if one realizes that he had no time,” I insist. She says thoughtfully that she was actually sad. And when the classmates “just left” afterward, all the tension “suddenly

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fell off ” her, and she “slumped.” But she also noticed how she had clenched her fists (demonstrates it). She says, contritely, it almost seems as if she wanted to force attention with the fainting. Her neediness and the desires to be seen become palpable here, and I notice how Mrs. Grün breathes heavily and becomes restless. Obviously, such self-understanding is more acceptable to the patient than allowing a hint of the dissociatively warded off massive disappointment anger. Therefore, I give an interpretation in the sense that one should not blame oneself for unconscious processes, and besides, her desire for attention is very justified, as she had far too little of it in the past. I now suggest to her the imagination she had previously desired in the sense of a continuation of conflict resolution at a symbolic level, once, to let her feel that her wish is not forgotten here with me, even if I did not immediately respond to it. Equally important to me, however, is to offer her the possibility of an affective channeling of the addressed, especially since I hope to be able to influence her self-criticism and self-destructiveness “in the picture” further and in a different way. I choose the motif “Little bird on a meadow” to signal to her with this transfer offer that she is in the right place here—unlike in school—to pursue her neediness and to be seen by me in it. (I choose the addition “on a meadow” as a help for her to be able to abstract more easily from the drawn bird and thus the concrete scene and develop a new experiential shape.) Mrs. Grün smiles when she hears the motif and begins immediately: 5 I see a little bird. It sits on a bush, right on top of it … 5 Can you describe it? 5 Yes, it’s so inconspicuous brownish-greenish, almost like a sparrow, but not so fluffy, somehow narrower. It doesn’t chirp, just sits there and looks.

5 How does it affect you, how it sits there and looks? 5 Serious. Lost. There is the huge meadow, its bush and nothing else. Also suspicious. Like me, it is. (She takes a deep breath.) 5 What’s up? You’re breathing deeply? How does that feel? 5 Yes, I feel such a tightness between my stomach and head. I am a total stomach person, want more connection between top and bottom. 5 Has the bird noticed that you are there? 5 If it notices, it flies away. 5 How could you make contact with it so that it would be good for both of you? 5 … I don’t know … 5 You just kept silent and thought about it. What spontaneously came to your mind? 5 Well, something silly; if I were invisible there and stretched out my hand and there were a few grains on it or an earthworm and only the hand was visible—that would be good for both of us. 5 Oh, wonderful idea, then imagine that! 5 Yes, it becomes curious, looks at the worm, which wriggles in my hand. Yes, now it wants to snatch it, but can’t get it. Now it sits on my fingertips and takes it carefully. 5 How does it feel? 5 Very light, a little ticklish. I’m happy that it worked. After the imagination, she smiles again. She is glad about how it turned out, because in between, when she had to breathe so heavily, something terrible had occurred to her: that as a child she often crushed small birds and fish to death in her hand and was beaten for it. She is so glad that she could now handle the little bird differently. When I ask her what she associates with a little bird, she says “soul,” “soul bird.” She brings up again how terrible she finds what she did as a child. When I say that I imagine she let the little animals

5.4 · The Therapeutic Process

feel the h ­ elpless anger and disappointment that she herself had to experience from her stepfather in terms of brutality and fear of death, and that she was actually looking for a hand to hold and comfort her, she looks at me silently and surprisingly for a moment and then spontaneously remembers the dream she had when she heard she had a therapy place, even before our first contact (7 Sect. 3.6, Excursus 6: Initial dream): “I saw a black figure in another black figure. Like those Russian wooden dolls that fit inside each other. I am the inner one myself and want to get out. But I can’t get out. It was a shock: I died inside myself.” At my suggestion, she associates that she would like to get out of her body, but that is not possible, and we talk about how she can hardly accept her body as maltreated and abused due to the abortion and the surgeries—she does not mention the sexual abuse experiences. Only in the swimming club, which is an important additional world for her besides school, family of origin, and the couple relationship, in the water, when she is not seen, she feels “as comfortable as a fish in water.” She remembers the frightening memory of the crushed birds again. I ask her what the soul bird could and would do if it had received affection instead of brutality. She thinks: bathe, chatter, fly, and SING! She herself would also like to be able to sing, can actually sing beautifully, but it doesn’t work in front of others. I explain to her that dreams express fears and desires and that the dark dream, as well as her imagination, clearly express the desire for vitality. If she can feel alive in the water, then that is a good sign, and therapy can help her feel alive in other situations as well. In this session, I combine the focused confrontational-revealing understanding work in the two interpretations from my complementary countertransference (7 Sect. 7.7.5) with a supportive intervention style (7 Sect. 7.3), especially in the imagination and dream discussion. I am im-

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pressed by how vividly the patient addresses the lostness of the bird in the imagination in response to the effect question, which she immediately recognizes as her own: Like me, he is, and how she also gets close to the feeling of mistrust and longing for attachment. This is a piece of conflict illustration, mobilized by the disappointment experience with the teacher and the earlier one with the father contained therein: “If he (me) (no)tices, he flies away.” I see these emotional communications as an expression of growing trust in our relationship, i.e., a positive transference, as well as the fact that she can tell me about her intense aggression (which she had only reported in the form of her school fights) after the imagination. The moment when she confides in me and the aggressiveness becomes so palpable in the room marks one of the numerous, shocking experiences for me (my countertransference reaction to her traumatization and its dissociative defense) during this initial period (similar to the moment of pulling out the sunflower or when she tells me about beating and rejection scenes in the following sessions). I then experience myself in a demanding container function, as a counterpart that senses her terrible experiences with their powerful affective content, absorbs them, keeps them within itself, and returns them to the patient “transformed” through an empathetic understanding offer in a bearable form. Just like in this session with the bird interpretation (7 Sect. 7.7.5). The confrontational intervention, connected with a punctual role reversal (7 Sect. 7.3), “Did the bird even notice that you are there?” reaches the patient when she is occupied with her memory of crushing the bird: She knows that he should be suspicious of her, breathes deeply in her excitement, and says: “I feel such a tightness between my stomach and head. I am a total gut person, want more connection between top and bottom,” with which she picks up

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a central therapy concern, learning to control her overwhelming “gut affects” more by the ego. In the imagination, she momentarily succeeds in making this connection: In the statement that the bird would then fly away, there is a piece of empathy for the “bird” who suspects the tormentor in her. The patient is not overwhelmed by feelings of shame and violence, as she senses that I trust her to have a positive contact ability for both sides; and she can communicate her self-found “invisibility solution” in the protection of our relationship and through my active encouragement, further supported by a resonance intervention “Wonderful!” This leads to a positive relationship experience and thus directly to a relieving affect experience in her (she describes very subtly how she feels the little bird in her hand). And like the “doll in the doll” (an apt image also for her aggressive impulses “imprisoned” by compulsions and restrictions, she speaks of a “black figure”), the memory of crushing, not yet reported, is embedded in the imagination-triggered, spontaneously shared memory of the dream that the patient can share with me in the now created transference situation after overcoming her shame and showing herself with the past aggression. This, in turn, succeeds after she has come into a suitable, resonant contact with the “soul-bird” that initially seemed impossible to her. This example demonstrates the spiraling therapeutic mutual fertilization of imagination and conversation (7 Sect. 7.4): It was important not to simply accept the patient’s silence at the most difficult point of the imagination but to help her overcome the speech inhibition erected by self-devaluation (“silly”). This had an ego-strengthening, trust-building effect and prepared the understanding of the interpretation given in the subsequent conversation. The “invisibility solution” found in the imagination through therapeutic encour-

agement, by the way, very creatively linked to one of her defense strategies and allowed the emergence of the memory of her liveliness in the water, hidden from the eyes of others and thus also from her own critical-destructive gaze projected into others. That the initial dream (7 Sect. 3.6, Excursus 6: Initial Dream) contains much more as a condensed structure as indicated, is beyond question, but the positive effect of this session on Mrs. Grün, which becomes clear in the following hours, shows that the chosen focus of treatment has been helpful for her current path. Because after this session, Mrs. Grün approaches her further school matters with much buoyancy, shares more with her husband and friends, reports more zest for life and decreasing pain—and she no longer faints: “’The therapy is doing you good,’ everyone says,” she reports. With this still cautiously hiding behind others “invisibility statement” she draws a first positive balance in the 11th session and then asks: “And you? Do you think so too?” “Yes.” z Summary of the First Therapy Phase

The therapy had started intensively. Soon, a kind of “session shape” emerged, which largely remained similar throughout the process—with few exceptions: Mrs. Grün usually comes full of emotional pressure and quickly presents thoughts and connections. She reports vividly about her experiences, successes, and failures, and does so in the (transference) gesture of “wanting to ally with me”: Almost with a desire for fusion, she expresses through her way of speaking (tone, question dynamics, direct address): “You surely see it exactly the same way, don’t you?” After this “reporting phase,” Mrs. Grün then likes to imagine or discuss her painted picture, or she brings a dream with her. Usually, I slow down the pace at this point by asking how she feels right now, what of the just reported particularly lin-

5.4 · The Therapeutic Process

gers with her, or by putting a processing point in the center myself. This begins a more thoughtful, introspective phase in which Mrs. Grün becomes more aware of her emotions and often speaks of very memorable, traumatic, or sad memory images or impressions, e.g., “When grandma became demented, mother mimicked her and threw stuffed animals at her as she sat on the sofa and laughed at her.” When I notice that she is approaching the threshold of her emotional tolerance— she then says that it becomes “too much” for her, she wants to “pull herself together”—I move on to the imagination or picture discussion or other deepening phase. I keep the imaginations rather short, once to maintain the emotional boundaries she can tolerate, and secondly, to leave enough time for “surfacing” and resonance and exchange. In the debriefing phase, Mrs. Grün initially searches strenuously for “recipes,” “application aids,” but after I convey to her that the therapy “works like that” too, she doesn’t have to take anything “black on white” home, but that the important things for her will stick by themselves, she can trust me with that (as she used to trust teachers and grandma), she relaxes, and often very touching, insightful debriefings ensue. Thus, the sessions usually have this four-part shape (whose individual phases can, of course, interplay or overlap). The topics addressed by Mrs. Grün in the deepening phase are very diverse; traumatic memories of beatings, abortions, sexual assaults, and terrible experiences with her drunken mother also repeatedly come up in her, for example, the mentioned cruel devaluation of the demented grandma. Stimulated by her imaginative experiences and dream discussions, Mrs. Green also reports during this time about scattered “inner images,” as she calls them, which accompany her for weeks at a time and to which she cannot assign any biographical event and cannot connect to a

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narrative, e.g., she and her mother stand with a suitcase by the roadside. Or: the castle ruins in Heidelberg. Or: a tree stump in the forest. When these dissociative, affectively unconnected or sad images oppress her at night, she deliberately turns to “beautiful spots” from her imaginations and “chases away” the others. In doing so, she uses the transitional object characteristics of the aesthetic potential of therapeutic imaginations (7 Sect. 3.3). I encourage her to paint these “inner images” as well, to support her self-regulation ability and, for example, to prevent flooding by flashbacks. Mrs. Green takes up this suggestion and creates a “picture book of terrible images” that she can “open” but also “close” (for more on psychotrauma therapy, see Steiner and Krippner 2006). As the therapy progresses, I cautiously try to focus on three areas of processing: control of aggressive impulses towards oneself and others; demarcation from her family of origin; approaching her father and social success. The first topic deals with her defense structure and affect regulation, the second includes her guilt tolerance, and the third allows her narcissistic supply and ego strengthening. These inner topics are worked on in relation to her external relationships: using important people from her retraining program with a father and mother figure, her siblings and mother, and her circle of friends. Since a disturbing transference resistance does not occur, addressing the transference is not necessary at this stage (7 Sect. 7.7.6). She rarely brings up her marriage on her own; she views and needs her husband as a “rock in the surf ” and does not want to delve deeper into it, even if something in their relationship is not optimal, so as not to jeopardize this support. This is not only respected by me but actively supported in light of her traumatic history, structural pathology, chosen therapy goal, and treatment framework.

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z Excerpts from the Middle Phase of Therapy

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Mrs. Green reports (23) in her effusive manner that she is alone this week because her husband is on a business trip. Her younger brother visited her. He wanted money from her, “as always,” and told her about his plan to take their mother in and care for her—but with what? Mother “wanders around drunk and steals.” But he himself has no money. Maybe he lied to her, it wouldn’t be the first time, to “soften her up.” “He always just wants the money for his drugs.” He has already begged from the others, her sister told her, but she is the only one where there is “something to get.” Memories of the time with her stepfather after her grandmother’s death, when her mother was beaten so badly by the stepfather that she fled with the children to a women’s shelter, surfaced during and after his visit. She tells me about her fear for her mother, her strangeness in the women’s shelter. Upon request, she says she gave her brother some money, but feels bad about it, didn’t really want to. She is annoyed. I think she is ashamed of her family and her “softness” in front of me, and I ask how she is feeling right now. She replies that she feels somehow under pressure, it is a pressure that she feels all around her body and that does not stop at night because she cannot cuddle up to her husband. Yes, and she had a dream: I won a lot of money and bought a large estate with two wings. In one lives Mother. I got doctors for her and bought her nice things. And gave her money for furnishing. In the other wing live my siblings. And I was at the stock exchange, speaking fluent English with a stockbroker in the USA. U. and J. (friends from the swimming club) are very surprised. “You’re doing stock trading? What do you do with all that money?” “I put it in a savings account.” I ask for dream details. She remembers the wealthy father in connection with the

stockbroker. But he doesn’t speak to her, “not even in German.” I say, “You would like to learn English even better” (this is her plan for the time after retraining as preparation for the trip to the USA with her husband). She then associates English with the world language, with which one can achieve something like her father. The dream is actually a wishful dream, she says. It would be great if she could give such gifts to the family. I say, to connect her with her detachment debt: “What strikes me: You take care of Mother and siblings, but in the big estate there is not a single room for yourself.” She hadn’t even noticed that. But it’s true. And it actually fits her tension. It’s not really a wish, but a pressure. First, she has to take care of this terrible family, and only then does she come to herself. This sense of responsibility: “It’s like the pressure armor! I’d love to shake it off. But I keep falling for it.” She seems agitated and resigned. I think of her loyalty conflict, her strictrigid superego, her trauma-introjects, but decide from the many deepening possibilities, as often before, for an understanding-supportive intervention that allies with her defense. I tell her that there is a lot of love for Mother and siblings expressed in the dream, love “despite everything,” and also a lot of strength, and besides, she has at least set up a savings account for herself. What does she think of the savings account? She laughs and says she sees therapy as an “investment”; she may not yet be able to set boundaries and use her money more for herself, but she is learning here and collecting until she can. For the first time, she talks about her plans to move to a slightly larger apartment after hopefully completing her retraining, where she would have a room of her own. “And even more space,” she adds somewhat mysteriously. Since the hour is over, I don’t ask what she means by that. In the following 24th session, Mrs. Grün reports in a good mood that she has

5.4 · The Therapeutic Process

made sketches of a possible apartment layout for the larger apartment at home. She also received praise from Mr. S., her favorite teacher, whom she also finds “macho-like,” though. The move could happen faster than expected, even before her exam, which she doesn’t like because of the stress, but they have a great offer to move within the same building to a larger apartment with a balcony. Then she complains vividly that 10 of the 25 students were absent today, who don’t care about anything, and that she plans to take the next exam without a cheat sheet, because it would be too dangerous to cheat in the actual exam and she wants to learn to trust herself. The fact that she could speak English in the dream gave her a boost. And that I wouldn’t find it “stupid” that she loves her family despite everything. She tells all this in the style of her typical transference expression, her co-opting, “trustingly” seeming conviction that I would agree with her, e.g., share her critical attitude towards her classmates. Since I have the impression that Mrs. Grün has been strengthened by the last session for a conflict-focused processing of her detachment and loyalty issues, I choose the demarcation theme from her heterogeneous communications for deepening and share my impression with her that she has just spoken about the missing students in the same tone as she often does about her siblings: full of frustration that they simply do not want or cannot improve. She agrees and asks, “That’s frustrating too, isn’t it?” I remain silent on this, as I assume that I can attack her desire for inseparability between us and promote her autonomy and her own emotional experience. She remembers that she is also angry with a friend who, despite her aunt being sick, went on a skiing vacation. She would like to “give her a piece of her mind.” When I ask what she finds so outrageous about it—instead of sharing her indignation—the patient can initially feel that she identifies with the sick person, and she expresses fear that no one

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would care for her if she were lying sick in a clinic. I think that she has to stabilize herself with her superego, which is normatively placed above everything, and still struggles a lot with allowing her wish to “go on vacation” like this friend, i.e., to travel to the USA or something similar, when someone in the family might need her presence or her money. Picking up on her rationalization, I therefore first explain to her that this is a completely irrational fear (I make a brief explanation about appropriate and irrational fears); because in fact, her husband and friends would certainly take care of her. At the same time, however, I acknowledge her great fear, which is almost an “inner certainty” and is “caused by old disappointments from the past” where she “really remained alone and nobody cared.” She agrees and says, “I want to get away from that old stuff!”, thus decidedly withdrawing from her contemplation. That’s why she is also looking forward to the new apartment. This sounds like a “cue” that I pick up on because I don’t want to further destabilize their defense at this point. So I suggest an imagination on the theme of “house” (continuing the dream theme from the last session and the apartment theme from the beginning of today’s session): 5 I only see the front side. It has a pointed roof, with round windows at the top. Covered with wavy tiles. There are also two square windows at the bottom, I see the curtains, they are drawn, you can’t look inside. There are flower boxes in front of both windows. There’s a bench in front of one. It’s a red brick house, the flowers in the boxes are yellow, the curtains too. 5 How does it affect you? 5 The windows look like eyes, they are downcast. I don’t know, I don’t like it that much. The flowers are drooping their heads. So, mhm … 5 So it gives a downcast impression. Mhm. What would you actually like now? 5 I would like to go inside out of curiosity. I’ll take a look at the door first. It’s

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made of wood and has a curved handle, very pleasant. The hallway looks clean and tidy, to the right is the kitchen. Everything is made of wood, a counter to sit at, very nice, but it seems uninhabited. There are no plants in the living room at all, there’s dust. I see a cabinet, a wall clock, a TV, a small table, everything matches—but no pictures on the wall. Now I’m going up the stairs. Upstairs is a brightly tiled bathroom and a bedroom with a wardrobe and stripped beds. As if everyone had moved out very quickly. Now I’m outside again. From the outside, it’s actually nice because of the colors. There’s no nameplate on the door. Should I water the flowers? 5 Do you feel like it? Feel carefully what you would like to do. 5 I realize: This is not my house. It’s actually a witch’s house. The windows make me feel uneasy. 5 If it were to become yours—what would you change? 5 Put pictures on the wall. Cook something. I would plant roses in the garden. Water the yellow ones. Paint the bench. Invite friends. 5 Imagine that, the green bench, the smell of food coming from the kitchen, friends arriving—how does that feel for you? 5 Nice! I’m sitting on the bench and they’re coming towards me. They bring flowers. I sit there comfortably and I’m happy. In the follow-up conversation, Ms. Grün immediately says that she had difficulties with the “house” motif, as she considers owning a house to be beyond her reach. “Apartment—yes, house—no,” she says. I am somewhat irritated by this concrete explanation because I feel that she has to distance herself from the emotional content of the imagination, as well as from what I suggested, for reasons that are not yet clear, and wraps it in an explanation that reminds me of her mother, who self-destructively dismissed the “noble” layer of the

potential husband as “too good for her.” I don’t quite understand the reasons behind the distancing yet and therefore initially draw her attention to the contrast that she dreams of a multi-winged house for her family of origin, but for herself, she only considers an apartment at most. She remains silent about this. This silence and her “house criticism” now slowly make it clear to me that a transfer resistance (7 Sect. 7.7.3) has been mobilized. It will be important to understand this, i.e., what caused the withdrawal from the relationship with me, which fears were triggered by me in an overwhelming way for the patient. I ask into the silence (active-supportive approach, instead of addressing the silence) about the color yellow: “Why yellow flowers and curtains?” She says: The others (mother, siblings) would be “yellow with envy” if she had a house. She assumes that they would not be able to grant her that at all. I pick up on this previously unexpressed, highly conflict-laden answer through questions. In the further conversation, it becomes clear that her entire previous rather modest lifestyle also served the purpose of hiding from her family of origin that her husband earns well. “If they knew, I wouldn’t have a moment’s peace!” I think of her “invisibility strategy” and emphasize the importance of this realization, giving her a positive response to the connection she has worked out herself. Then I try a cautious questioning of the “invisibility strategy” by pointing out that with this kind of self-restriction she has not yet found any really helpful protection against envy and the feared borrowing. She agrees. I add that it would be just as little help to her siblings if she restricted herself because of them without them even knowing that she was doing it. But if she could develop an inner conviction that she deservedly, since she and her husband worked and made an effort for it, had a larger apartment or a house, then she could also ­better set boundaries with the help of this ­inner

5.4 · The Therapeutic Process

conviction. Such a conviction gives one more stability than hiding. And maybe in this way she could even be an inspiration for her siblings. A role model. She reacts hesitantly, but expresses that she wants to think about it. In the course and nature of the session and the imagination, I also recognize our current transference dynamics, which I do not address (7 Sect. 7.7.6). Thus, I assume that Mrs. Grün indirectly expresses to me what she can currently “make visible” and experience in our relationship and what not. The house motif causes irritation in her because it mobilizes the topic of the self and thus the showing of oneself. This touches on a central disappointed desire. For protective reasons, she initially “keeps her distance” and quickly shows me a house only from the outside, only the “front side”, i.e., she “fulfills a task”. The “well-behaved facade” is a self-restriction (which we can talk about later) and an effective protection against what she partly consciously, partly unconsciously fears from the other and which only becomes clear towards the end “in the picture” as well as in the conversation about the color yellow: against envy, greed, and being functionalized—and thus an expression of her lack of self-assertion and boundary-setting ability. It can be assumed that she has also come into contact with her own envy of me, but this must be kept unconscious by her—dependent on our relationship—and may have further promoted the transference resistance. On my first effect question (7 Sect. 7.3) in the imagination, her feelings of dejection can become clear, which brings us closer together again after the resistance-related distancing. I assume that Mrs. Grün experienced the motif “house” (instead of “apartment” or “room”) differently from the motifs before, not as stabilizing, but as conflictual. With “house” I had referred to her dream of the last session, but not to her more conscious preoccupation with the motif “apartment” which she had brought up

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several times in conversation. Thus, she experienced a kind of performance demand in it, perhaps even the demand to approach me and the paternal sphere, which led to an overload of her guilt tolerance towards her maternal family. In the imagination situation, she could neither resolve the mobilized inner conflict nor openly show the anger—or even envy—towards the therapist and retreated into “dejection”. My subsequent impulse question (7 Sect. 7.3) allows her to ward off the feeling of disappointment because she can use it to quickly immerse herself in a facade-like, affect-isolated “inspection activity.” On the other hand, the message contained in the intervention, “I am interested in what you want right now,” does allow her to enter the house and thus approach her own imagined self. In the following imagination, a peculiar ambivalence arises because she finds the furnishings “actually” beautiful, but experiences them as not belonging to her and foreign, only lifeless (no pictures, beds stripped). It is also possible that she is expressing to me how unfamiliar she feels in her identity (no nameplate on the door) and in her body self. I therefore see her spontaneous impulse to water the flowers less as an expression of selfcare—since she cannot accept the house as hers up to this point—but as an altruistic defense. Therefore, I intervene very actively with the following impulse question by asking her to sense whether watering flowers is really what she wants. This calls into question the defense “in the image,” which is later explicitly questioned in the conversation as an “invisibility” defense. Only through this supportive-encouraging impulse question is she able to clearly articulate her feelings of unfamiliarity and her projective fears (eerie witch house) and to sense for herself what reminds her of the black figures in her initial dream. While in the previous sessions my balancing between stabilization and uncovering questioning has tended to favor

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s­ tabilization, in this session my rejection of her desire for confirmation (“That’s right, isn’t it?”) and the punctual weakening of defenses leads to greater insecurity. In the metaphor eerie witch house, not only her self-image is contained, but also the “eerie” aspect of the transfer process: “How do you see me? What do you see?” The house metaphor (7 Sect. 7.2) touches on the highly problematic issue of identity for her; and so, following our preliminary conversation and the previous session and in the sense of a progressive, self-disclosing level with therapeutic support, I naturally assume that the “house” is indeed “her” house, unlike the patient herself. However, she cannot stand up for herself—even in the transfer relationship—and can hardly explore her “house.” Similarly, she is not allowed to show her modest prosperity to her family. Therefore, at the end, I dare to make the encouragement intervention for the “taking possession” of the house in the sense of a trial action in the imagination (7 Sect. 7.3). Ms. Grün can pick up on this with relief, and it is touching to witness how she can imaginatively make the house “hers” in these moments— as an outer and inner dwelling place—probably due to the message sensed in the intervention: “You have the right to have your own beautiful house and to make your life pleasant.” How much the session is permeated by the conflict of standing up for oneself and the “invisibility strategy” mistrust, and how much it has also fostered trust, becomes clear in the following session when the patient can describe that she had “concealed” from me that she had been to the gynecologist. She was quite sure she was pregnant, but the test did not confirm this. We can jointly understand that she initially showed me “only the facade” because she feared that otherwise “too much emotion” would come. In retrospect, I understand what her formulation from the end of the previous

session had meant: “more space”—for a nursery! This resistance, expressed in the mentioned different phenomena, is not addressed in this case but is accepted by me, as my goal is also not to fundamentally question the patient’s defense configuration and to achieve the common partial goal. I experience these sessions as Mrs. Grün creating a scene of parental involvement (comparable to parental homework help), which she never experienced as a child. Nevertheless, in my countertransference, I fear that under her inner tension, which occasionally brings her back into dissociative defense states, she may completely “withdraw” from the therapeutic process like her sunflower. I try to suggest to her to use the sessions and imaginations as “energy-giving relaxation” from the preparatory work, but I fail in this situation driven by her fear, as well as in trying to bring this to understanding. At the current state of our relationship and under the exam pressure, which intensifies her loyalty conflict, Mrs. Grün cannot imagine a relaxing preparation break that would give her strength. So I take another step back and accept her temporary distancing as the best “fit” for her right now. With this attitude, I manage to “believe” in what has been worked out so far on my part. In the further course, during the peak of her exam stress—which extends over a quarter of a year—there are relapses of symptoms; not fainting, but Mrs. Grün suffers from tension pain and severe inner restlessness. Mrs. Grün had initially responded very positively to the therapeutic offer to imagine and paint. Her tendency to idealize certainly played a role in this. On the other hand, she may also have been open to her own inner world of imagination because she wants to differentiate herself from her family of origin through her efforts at introspection and thus perceives therapy as identity-strengthening in her desired differ-

5.4 · The Therapeutic Process

ence. During the height of the exam, other needs come to the fore. In our sessions, she relieves herself of her pressure, and the content revolves around the exams and her fears. Deepening, as shown in the sessions, occurs less frequently. However, she still uses “beautiful spots” from previous imaginations for self-relaxation, as well as those from dreams (“I can speak English—then I can do other things too!”). As the exam approaches, she declines new imaginations for fear of destabilization (7 Sect. 7.7.3). Instead, she asks me to listen to her exam material and even requests a short therapy break just before the exams. z The Therapy Comes to an End

Mrs. Grün did not make use of the offer to come in between but wrote me a letter in which she outlines her ambivalent feelings about the therapy interruption. In it, she reports that she was very much looking forward to the post-exam period but is now not relaxed at all as she had thought. It seems to her that the oral exam is already threatening, although there is really still time until then. Last week, she had the very certain feeling of being pregnant again and was very disappointed when she heard that she was not. She writes about her plans to become pregnant as soon as possible after the exam and before starting a new job, as it must be a lying pregnancy due to the titanium block. She is a little afraid of this and wants to prepare for it with books, audiobooks, and the beautifully furnished apartment by then. When she comes back, she seems strained and restless. In the 40th session, the second after resuming talks following a one-month therapy break, she speaks of her feeling of alienation in response to my question about her current well-being. She is so different from everyone in her family—except her father; smarter and simply different. But she also feels like an outcast. For example, when her brother, whom

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she practically raised, now glorifies his drug life and tells her that she and her husband are conformist and bourgeois. Or when she hears about her sister taking advantage of their mother. Her husband is also an outsider in his family, she says for the first time. He comes from a “noble” but “cold intellectual family” and struggles for recognition there. She desperately asks herself: “Where did I find the strength to become different?” In my countertransference, I feel again the appeal-like desire for me to take her side, to say something “uplifting” to her. This would also bypass the “alienation” between us caused by the break. On the other hand, I feel that addressing our current transfer relationship would overwhelm the patient’s defense and think that it can be used more productively later. However, expressing feelings of alienation instead of having to show me a facade, I register as a step towards our reconciliation. Therefore, I emphasize her question as central and significant for her and stress that we should find out exactly that. Does she have a suspicion for herself about what has strengthened her in the past and still strengthens her? She says she feels too tense to “think” right now and agrees relieved when I suggest that we could continue working on the topic at the level of imagination. She missed imagining with me, she says. Does she have a wish for a starting image? “No, suggest a topic, it’s always so exciting to see what comes,” she says. I decide on the motif “animal family”, taking up their theme on a symbolic-natural level. 5 There is a beautiful small lake with water lilies and a duck family. There is the fat mother duck and six little yellow ducklings chattering around the mother. 5 How does the mother appear to you? 5 Well, she always looks so excited at the little ones, who flutter around her. There is also a frog, sitting on a water lily leaf and watching the ducklings.

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5 Can you describe him in more detail? 5 It is a small green frog, it has big protruding eyes and looks angry. He wants to have his peace, feels disturbed. The mother seems hectic, she notices the staring and that he feels disturbed and can’t get a grip on it. Now the frog croaks very loudly. The ducklings get frightened and are quiet and look at him. One duckling wants to go to the frog, but the mother whistles it back. 5 How does this one duckling appear to you? 5 The children are now swimming next to the mother, very quietly. The fright is in their limbs. The frog is happy, dozing. 5 And the little one? What is it doing? 5 The little duckling is more persistent. It has an orange beak, always looking over at the frog. It still wants to go to the frog. Yes, and now the mother is busy with something else, and the little one swims very quietly to the frog. The frog looks at it … 5 How does he look? Can you make that out? 5 The little one swims closer and croaks very softly to the frog, but doesn’t dare to come any closer. Now the frog croaks again suddenly very loudly, the little one flutters, the mother shoos it back. Then they all go ashore. 5 What would be good for the little one now? 5 Oh, it won’t work with the frog. It wants to play now. It nudges a pink water lily, the sun is shining, everything smells good. 5 Can you hear anything? 5 Yes, it splashes and the crickets chirp. The mother sleeps and the little ones too. The little one tiptoes to the cricket and listens and likes it. The cricket chirps and chirps, it’s cozy … Mrs. Green says immediately after the imagination that she felt relaxed by the final image, that she often thought of her sunflower or the little bird happily flying in the

meadow during the therapy break, and here at the end—this is now also such a peaceful image. She wants to paint the final scene. She then starts talking about the little one, in which she recognizes herself, and the frog, which she associates with her stepfather and the first boss in the supermarket. When I ask about her biological father, whether his rejection after his marriage might not also be in the frog scene, she hesitates and says, leading away from this painful point: “But I myself can also croak quite loudly sometimes!” We laugh and briefly talk about her “show of strength”, which we, like the “invisibility”, have understood as one of her “emergency strategies”. At this moment, I feel from my countertransference that the patient has overcome her “feelings of strangeness” towards me. I say, aiming at a conflicting point, as he addresses her in her otherness: “Actually, you want to sing and not croak, so the crickets are more suitable, right?” She agrees. She remembers the fable of the cricket and the ant: “But sometimes I feel weak like a little ant.” I return to the topic of being an outsider. An ant alone is weak, but not the whole colony. Is she sad about the lack of support from her “family-people”? With this, I return to her previously defended pain and say: “The little duckling set off for the father all alone. The mother did not support her in this.” In my countertransference, I feel regret at this point that this constellation has unconsciously also manifested itself in our process by her canceling the sessions before the exam. When I show her this connection, the patient cries for the first time in therapy, and there is a longer exchange about how her unconscious mother identifications hinder her, and then considerations about how she could now reestablish contact with her father. Then she comes to the realization that she is looking for a new “people” and has actually already found it in her husband

5.4 · The Therapeutic Process

and the club, but it is not yet firmly anchored in her, the feeling of new belonging. Maybe it would be different if she and her husband had a real family with children. I ask her about the significance of the fable of the cricket and ant for her personally. Mrs. Green sees herself in the ant, her siblings in the cricket, and reproaches herself for not being able to set boundaries as well as the ant in the story, who reads the riot act to the cricket in winter and gives her nothing. But she herself cannot be so cruel. I remember that there are also other conclusions to the story, and I tell her about them. That the ant in other fable variants also criticizes the cricket asking for help, but then says: “Well, if you make music for me now, I’ll give you something.” Maybe it’s about her finding her very personal, suitable attitude towards her siblings. And towards the cricket-like lightness “in her” itself. That she may also sing and be carefree as a “cricket”, not always having to be an “ant”. Mrs. Green is happy that there are such other solutions to the story and suddenly says: “No, the frog is already my stepfather, but the cricket and the little one, how the cricket chirps so cozily to the little one, that would have been nice with my real father.” In the imagination, Mrs. Green vividly shows me her wish and fear: the desire for appropriate, guiding, and encouraging mothering—different from what the fearful duck mother can give, in which I also (7 Sect. 7.4, Excursus 9: subject-/object-level dream interpretation) see the completely overwhelmed, young patient in her parentified mother replacement role towards her younger siblings (with the “frog” then having a mother aspect). And her desire for an affirming, caring, and confirming father— who is symbolized here in the biographically experienced negative variant in the frightening and rejecting frog, but is recognized positively in the cricket at the end. Of course, the splitting-like polarity between the “croaking frog” and the “singing

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cricket” also contains a transferential dimension. Mrs. Green, by wanting to interrupt the therapy, probably also had to ward off a regression temptation and, although unconsciously desired, could not consciously imagine leaning on me during the sessions. With my response to her request, there may also have been disappointment that I did not fight even harder for her to stay with me—even though this was not indicated from the above-mentioned dynamics. Considering her current desire for children, the patient may also express her concern in the imagination about how she will be able to fulfill her own mother role and how she will be able to accept her husband’s fatherly support, as she has hardly experienced support and triangulation. Principally, there would have been an opportunity for an “eye test” and an “associative loop” in this imagination (7 Sect. 7.3), which I did not apply due to the associated conflict focus and possible trauma reactivation. The sudden quacking of the frog was already an indication to me that further anxiety mobilization would not have been appropriate. However, unlike in the initial imagination, where it would not have been appropriate for me to engage with the ladybug leading away from her (Sunflower) (see above), it was now helpful and progressive to ask the patient about the frog as a therapist: The patient was able to further engage with him and the associated conflict aspects. 45th session  (In the 44th session, Mrs. Grün told me joyfully about her pregnancy. She decided not to apply for a therapy extension due to the upcoming bed rest pregnancy—starting from the 10th week of pregnancy; she would rather come back to therapy with me later if necessary. I can easily agree to this. Mrs. Grün has also passed the last oral exam by now.) The session begins with Mrs. Grün regretting that, although she has achieved her

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big goal, the exam, a “total feeling of happiness” has not yet set in, but perhaps that is also unrealistic. I think that the “feeling of happiness” might not be able to set in because, due to her loyalty conflict, she cannot allow herself to give it more space and because the upcoming end of her time with me destabilizes her. Mrs. Grün then reports enthusiastically about the visit of her mother and a sister to her new apartment. She invited them to a small extra exam celebration because she did not want them to be present at the actual celebration with her husband and friends. She did not invite her brother because he mocks her, and she did not invite her younger sister because she always makes fun of their mother and is ashamed of her. I am impressed by her differentiated ability to set boundaries and express this. Mrs. Grün is pleased and continues: It was nice. The mother has made progress with the withdrawal, was very quiet and impressed by the apartment and furnishings, and to Mrs. Grün’s great surprise even praised her: “That you managed to do this.” When Mrs. Grün told her that her husband had recently seen her father in a restaurant, well-dressed, charming, with a wife and child, the mother just remained silent and did not say anything derogatory, as she had feared. “And for next Sunday, I’m inviting friends to the new apartment for an election party with lasagna … ” I ask what she feels now, as she tells me about her mother’s statements and behavior. Mrs. Grün evades by first adding that the other sister has two fighting dogs and a criminal boyfriend, but recently got a job— she delivers mail. The fighting dogs are not allowed in her house. I ask if she is worried about the baby? Mrs. Grün says, actually about the cat, but probably also about the baby. But that is still a bit unreal. I ask again about her feelings regarding her mother’s remark. Mrs. Grün says she doesn’t want to have feelings about it, otherwise she would become too sad. But

it is a step forward. I say I understand that she doesn’t want to let the deep pain “from the past” come up, but I also see it as recognition from her mother. Mrs. Grün nods. I notice that she is struggling with her feelings. She wants to imagine: “My first picture journey with a baby in my belly!” I respect that she wants to get away from thoughts of past disappointments and traumas. Since I am aware that due to possible pregnancy complications, each session could be the last, and I want to give Mrs. Grün a sense of “rounding off ” her process (7 Sect. 7.6), I suggest the stimulus motif “flower” as at the beginning of therapy: 5 First, I only see something green, again with a little ladybug on it. Like grass or something. Now a big sunflower, standing in a brightly yellow field full of other sunflowers… 5 Can you describe this big sunflower? 5 Yes, when I look at it, looking into the corona of petals, it seems to me as if it has a face and is looking at me too. 5 And how does the facial expression of the flower affect you? 5 Pleasant. Calm. Loving. It wobbles a bit. 5 Wobbles? 5 Well, it could also be a baby’s face (smiles), but no, it’s just a calm, friendly facial expression. And at the bottom of a leaf, uh, on a leaf, there’s the ladybug again. 5 What do you think the sunflower wants to tell you with its facial expression? 5 That I should be a bit more positive. Not always so skeptical and assuming the worst. But that also makes me angry. I tell her to her face: “You can’t always be happy!” I say. 5 And? How does she react? 5 Well, she’s a bit startled, but says, yes, sometimes angry, but then positive again. Changing, that is. That’s life. Or something like that. 5 And how is this answer for you? 5 Yes, okay. Actually, she’s right. My yelling woke up the bug. It looks at me

5.4 · The Therapeutic Process

d­azed, flies to my ear, and whispers: “Don’t take her seriously, she’s the most arrogant one in the whole field! Be who you are!” 5 How do you feel about that? 5 I see, the sunflower now has a hole in the leaf where the bug was sitting. It makes me a little sad. My anger has vanished. I think both are right, and I find it stupid that he badmouths her. She’s not arrogant. Just big. Being big doesn’t mean being arrogant. The whole field is full of sunflowers. Only this one is different. I like her. Just the way she is. 5 What would you like to do now? 5 Fly away. But it’s not possible. And why, actually? It’s beautiful here. The sunflower is shaking a bit now, and a kind of yellow powder falls out. 5 Aha?! 5 Yes, it smells good, I’ll take it with me, she gives it to me. Who knows what it’s good for! I see a tree stump with moss on it now, comfortable to sit on. I’ve put the yellow powder in a handkerchief. It smells good through the handkerchief! Somehow it gives me confidence that everything will continue. Nothing is lost. In the follow-up conversation, Ms. Grün immediately brings up that with the first sunflower, she had noticed that “the brown seeds had partly already fallen out. Simply pecked away by birds or something.” I think of the traumas and the envy theme that we have touched upon. She finds it nice that this flower has given her something. Her mother had also brought her flowers for the visit. By the way, she hasn’t told her mother about the baby yet. Only her husband and I know. I think that in this case, she uses her “invisibility strategy” well for her own protection. As the hour comes to an end, I do not address the ambivalence expressed regarding the sunflower. During the discussion of the brought picture in the next session, the beetle ap-

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pears quite large compared to the sunflower. Ms. Grün has decided to see it as a “lucky beetle” and thinks of her baby in this context. She now brings up the ambivalence herself: The beetle may have “put down” the sunflower in the imagination and damaged the leaf, but it said to her: “Be as you are.” Like her father in the good times before the rejection, during her puberty. She has decided to contact him after all. She has good reasons now: she can tell him about her exam, her new job, the baby, and her marriage: “to brag a little!” “That’s not bragging!”, I step in—supporting her—on her side. She eventually brings up that “actually everyone was right” in the imagination. The sunflower with its message, but also herself with her anger that the sunflower was “different”—yes, that’s how she was, she was different from her siblings. The beetle may have put down the sunflower like her mother did to her father, but it also said something good to her, like her mother did at the celebration. She wants to learn to “take along”, not to “blurt out” immediately, but to listen more, to take her time. I encourage her. The patient associates her experiences in therapy with the “yellow”, but good-smelling powder. I have “stayed with her”, which has made a lot happen, and that now continues to work like the powder. Fittingly, I notice that she has integrated a pleasantly sitting tree stump into this imagination, which had appeared at the end of the first therapy phase in her “picture book of terrible images”. From the perspective of transference dynamics, this “balance imagination” already marked by farewells shows the central narcissistic desire to be seen in the sunflower’s gaze. In the friendly facial expression of the flower, more positive self- and object representations find their expression, which allow a dialogue determined by more mature ambivalences, which ultimately also includes a critical appreciation of the experi-

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enced accompaniment. Unlike in the first imagination, this sunflower is well-rooted; the beetle is not a troublemaker, but a symbolic expression of both triangulation attempts and self- and superego aspects. Although it becomes the mouthpiece of her inner self-degradation and also her anger at me—who will leave her: from “friendly” to “arrogant” –, it verbally conveys to her the same central message that the sunflower conveys: Be as you are! This leads to an important moment of greater affect tolerance, which contains many moments of lack, losses, and pain (symbolized in the “hole in the leaf ”). This moment is unstable, as shown in the response to my impulse question: flying away or staying here, in this question of the right place, the question of ending or continuing therapy certainly resonates. In the flying away motif, I also hear the “pulling out” from the initial imagination. What had to be done impulsively back then can now be sensed as an impulse that does not imperatively push for implementation. The patient has become more introspective and can, according to her wish, take her time. The patient does not end her imagination there, but shows her gained therapeutic progress in the form of a positive internalization that continues to accompany her and her ability to be grateful for it: The sunflower shakes itself a little now, and a kind of yellow powder falls out… Yes, it smells good, I’ll take it with me, it gives it to me… It smells good through the handkerchief! Somehow it gives me confidence that everything will continue. Nothing is lost. z Comment on the last therapy phase

Supported or initiated by our process, a number of significant changes have occurred in Ms. Grün’s life—the defined therapy goal has been achieved: She gains self-confidence and passes both the written and the even more dreaded oral examina-

tion with satisfactory and good results. After some time, she finds a suitable job in a trade union office, where she settles in well. She approaches her father internally and makes contact with him. And she begins to stand by her desire to have children and becomes pregnant. In this respect, the therapy process has clearly strengthened her narcissistically. Ms. Grün learns to better protect herself against the constant “pumping attacks” of her younger siblings and moves into the desired larger apartment with her husband, which includes a separate room. In this respect, the associated process goal has also been sufficiently addressed: Achieving a greater tolerance for feelings of guilt, through which she was able to reduce her irrational feelings of guilt towards her mother and siblings. Finally, she succeeds in mitigating her rigid defensestructure, especially the impulses directed against herself: Ms. Grün can relax better, her fainting spells have completely stopped, and the pain has decreased; she also no longer reproaches herself for occasional failures with the former severity. At the end of the therapy, she is expecting her first child. In total, as a follow-up contact revealed, she has three children: For eight years after the end of therapy, she comes back to me with a request for therapy. The reason is depressive symptoms such as restlessness, insomnia, and feelings of being overwhelmed: “I want to be the best mother and I can’t do it,” she says. It turns out in the conversation that the other symptoms, such as the compulsions, the phobic fears, and the back pain, hardly play a role anymore. I am pleased to see how clearly she recognizes that she can use help well and can understand this well; after all, we had focused our process strongly on partial goals, and it does not surprise me that she is now approaching the aspect of female identity that is so central to her.

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Since I have since returned my health insurance approval, I refer her to a colleague. Ms. Grün writes to me that she feels well accepted and understood there.

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Reference Steiner B, Krippner K (2006) Psychotraumatherapie. Schattauer, Stuttgart

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An Analytical Psychotherapy with Imaginations: The Case of Eichel Contents 6.1 The beginning before the beginning – 98 6.2 Therapy Planning – 99 6.3 Initial Imagination – 104 6.4 Three central scenes of the analytical process – 107 6.5 The Analytical Process: At the Foot of the Mountain— Uphill—Reaching the Summit Plateau—Downhill – 111 Reference – 140

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_6

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Chapter 6 · An Analytical Psychotherapy with Imaginations: The Case of Eichel

The 59-year-old woman Eichel initially only seeks a place in a Balint group for teachers, but then it turns into a 620-hour analytical psychotherapy. Mrs. Eichel exhausts herself in an almost unimaginable intensity professionally and privately for others and has lost the only beloved person through death. Her health is acutely endangered by a high blood pressure disease she trivializes.

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6.1  The beginning before the

beginning

z Two answers to the question: How did the therapeutic process get started?

Mrs. Eichel’s answer, as the analyst later imagines it, based on statements from the patient from later stages of the analytical process: A long-time colleague of mine, Clara, occasionally told me about her Balint group, where she presents her school problems to an analyst alternately with other colleagues: “Why don’t you join too? It’s nice, you learn something about yourself, it helps, and you can also deduct it from your taxes.” My problem was: I had absolutely no time for such a thing. My days were already filled to the brim with work! But then the problems with Helga got bigger and bigger. Helga is a former student of mine who had children early, was not up to it, and whom I practically “adopted”: took out savings contracts for her children, cared for them, and supported them in every possible way. But when she wanted more and more money, more and more attention, Clara scolded me for letting myself be exploited. Then she said, “That would really be a good reason to join the group.” But I still didn’t want to. I didn’t want to show myself to complete strangers with problems. I wanted to find out on my own how I could do good for Helga. She had grown so close to my heart. But then Helga lied to me and there were more problems

with a very aggressive student. I don’t need much sleep, but now I could hardly sleep at all, couldn’t switch off anymore. That’s when I decided to try attending a session in Clara’s Balint group. For example, I wanted tips on how to get the student into child and adolescent therapy. I called the leader. She wanted to get to know me personally before I came to the group session. And then everything turned out differently. She suggested I do therapy! She had gotten the impression that I needed it. I could have sunk into the ground with shame! Did she think I was trying to sneak in with her in this way? Had I “whined” without realizing it? What did she see in me at all? I was completely confused and at first absolutely against it. I was also angry with myself for showing something I didn’t want to. I couldn’t sleep again because of self-reproach, I was so upset. My first analysis came back to me, and it had ended so terribly badly. … Everything spoke against accepting the suggestion. And yet I decided to do it. Very quickly even. I think I just couldn’t say “no”. Maybe it touched me that someone was thinking about me at all. But I kept blaming myself inwardly: What did you stage there, that she makes you such an offer? I was quite glad that it couldn’t start right away and I had to wait a year for the place. The analyst’s answer, written from memory after the therapy was completed: Mrs. Eichel expressed by phone that she was interested in a place in my Balint group for teachers because she wanted to “deepen her psychological understanding” as a trainer. Since a group member had just quit, I invited her for a preliminary talk. Mrs. Eichel had sounded open, very interested, and not “burned out” on the phone. Also, the fact that she was a trainer, not a struggling teacher, and appeared committed and passionate about her profession, pleased me. “She will enrich my group,” was my confident feeling before our first encounter.

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6.2 · Therapy Planning

Mrs. Eichel, whom I estimated to be in her mid-50s, entered my practice punctually. I noticed how thoroughly she cleaned her shoes on the doormat. She seemed shy, and it crossed my mind: “She doesn’t want to bother me with her gaze.” Dressed modestly, her smooth hair styled simply and “neatly,” speaking with a rather quiet, almost “neutral” sounding voice, she appeared “inconspicuous”; yet her lively and intelligent-looking eyes impressed me, as did occasional vitalizations in her voice, which suddenly made her sound energetic and no longer “pale.” She was very attentive, paid attention to everything, did not talk too much or too little, gratefully picked up on every conversational impulse, asked nothing and questioned nothing. I thought: “So inconspicuous that it stands out!” I tried to better understand this paradox through some questions, and as Mrs. Eichel spoke very cautiously about herself, her motivation for the teaching profession, and her life situation, I gained the distinct impression that this capable woman was concealing a need for therapy with her desire for a Balint group. Mrs. Eichel’s condition now seemed so alarming to me that I cautiously asked towards the end of the hour whether she would like to have her own analytical therapy instead of a Balint group, in which she would probably, as always in her life, support others, where she could understand the meaning of her overwork and change herself, which would then also have a positive professional impact. I suggested that she think about my probably surprising proposal for her and that we could meet for a second conversation. She silently accepted my words, only asking at the farewell whether I would have an analysis spot available. I denied, but offered her a waiting spot with occasional irregular meetings and the start of analytical conversations after about a year. The introductory session had gone quite differently than expected. I was surprised at myself for having so quickly accepted Mrs.

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Eichel internally as a potential patient. My therapeutic interest was composed of detective impulses (What’s behind it? What looks out of her eyes? What is she “really” like?) and empathy (What terrible thing must have happened to her that she adjusts herself so “perfectly” and “correctly”?). So, in my countertransference from the patient, projective-identificatory helper impulses mixed with my own narcissistic motives. Since Mrs. Eichel accepted my proposal, the second encounter already moved on to the anamnestic conversations. 6.2  Therapy Planning z Life Situation

Mrs. Eichel works as a secondary school teacher in a socially disadvantaged area. In addition to her teaching, she is responsible for the training of young teachers, for whom she holds seminars and visits them at their respective schools to provide didactic advice. She administers state examinations and has to supervise final theses for this purpose. At her school, she is the class teacher responsible for groups of adolescent students, sits on various committees, is elected as a trusted teacher year after year, and tries to mediate in school conflicts. As a moderator, she trains students to become so-called “conflict mediators” who are supposed to intervene helpfully in not infrequent physical violence situations. She also leads a theater group, with which she performs a play once a year. All these activities often keep Mrs. Eichel at school until late in the evening. In addition, there are time-consuming lesson preparations and corrections in her subjects German and English. Mrs. Eichel is married to a prematurely retired teacher due to illness. His attitude, which she calls “crown prince attitude,” had led to severe conflicts, as a result of which Mrs. Eichel had conducted an initial analysis, but little has changed in the marital

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dynamics: Mrs. Eichel does the housework and lives in constant tension in anticipation of his demands, against which she can only delimit herself through her work and further education. One result of this first analysis was that she rented a small apartment near the school. Here, after having dinner together in the marital home, she often works late into the night, sometimes through the nights. Mrs. Eichel has a larger circle of acquaintances but no close friend and takes care of sick people in her church community. She has a concert subscription with her husband and adapts to his taste in music. The elaborate care of a mentally unstable and socially weak former student, Helga, and her two children form part of her weekend routine. z Symptomatology

The symptomatology, which is only partly reported, partly deduced, and then confirmed by her, consists firstly of a trivialized sleep deficit: “I don’t need that much.” By rushing from appointment to appointment without feeling her fatigue due to an excess of assumed obligations, Mrs. Eichel often suffers injuries such as bruises, arm or toe fractures, which she does not recover from, and continues to “function” in pain. She tends to reproach herself for any impulse towards relaxation or relief and trivializes her high blood pressure despite a family history of heart attack risk. She has “respect” for sporadically occurring, severe pain conditions (trigeminal neuralgia and neuralgic pain in the legs) and fights them with medication. A cure, as is common among teachers of her age, does not occur to her. Because of her various pain conditions, Mrs. Eichel despises herself, as she also disqualifies any expression of overload in herself as “whining.” The lack of self-care is not only evident in dealing with her body but also in the always postponed “self-administration,” which sometimes

leads to financial losses due to the late submission of tax returns. There is no room for hobbies except for the joint concert visits. In her experience, her marriage only takes energy from her instead of giving her something. The only person she feels lovingly connected to, a fatherly friend, she lost to death two years ago. Thus, Mrs. Eichel appears to me like a biblical “Martha”—the embodiment of the altruistic person par excellence: attentive, well-organized, extremely disciplined, compassionate, and selfless outwardly; her own self with its needs and desires seems non-existent. z Biography

Mrs. Eichel’s biography is characterized by traumatizations and experiences of deprivation: Shortly after the end of the war, she is born as the second child (her always exemplary brother is already ten years old) in the home village of her maternal grandmother, to which her mother had to flee from the bombed-out Berlin apartment. Mrs. Eichel’s parents (housekeeper, carpenter) meet in Pomerania. For the early orphaned father (14 years older than the mother), whose first, beloved wife dies of mumps shortly after their marriage, the second marriage is more of a rational decision, according to Mrs. Eichel’s assumptions. After the wedding, the parents move to Berlin, where the mother runs the household in a wealthy house. She is said to have idealized her “masters” so much that she even adopted their names for her own children. The father is drafted. From statements by the mother about how difficult it is to have an abortion, Mrs. Eichel later concludes that, in contrast to her older brother, she was unwanted and already a burden to her mother while still unborn—heavily pregnant and on the run. The mother, described as energetic, rigid, and dominating, often sick and “complaining,” is said to have longed to return to the city after the war, as she despised the forced “rural”

6.2 · Therapy Planning

lifestyle with her own parents as too “low.” She missed the “refined lifestyle” of her former “masters” and the urban educational opportunities for her son. The father, with a war-damaged hand, joins the family after captivity and, like the patient who loves her grandmother and enjoys playing in the garden, would have preferred to live in the village. Mrs. Eichel remembers never being “right” for her mother, as she was constantly—even physically—reprimanded and never praised. On the other hand, the mother boasted about her daughter’s early “baking skills” to the neighbors. She was an “eager child,” “liked to help,” but her playing and talking with flowers were dismissed by her mother as “crazy,” her reading later suspiciously commented on, and “dreaming and idleness” not tolerated. Mrs. Eichel recalls a relocation at the age of five, where she “came to life” and, unlike at home, enjoyed eating, “chattering,” and even singing. The patient feels intensely drawn to her father, who is also strict but perceived as fairer by her. She prayed with him and for him, sought his closeness, but she was also always worried about him, who was portrayed by the mother as “weak.” The father impressed upon her: Being a guardian angel to others is her destiny. This alone brings happiness. She adopted this early on. She remembers praying when she was sick that God would let her die so she wouldn’t be such a burden to her mother. She experiences a severe turning point when, in her 6th year of life, her father gives in to her mother’s insistence to return to the city. She was lied to about the intentions and left alone with her grandparents by her parents and brother. When her parents picked her up a year later, she was harshly scolded by her mother for her tears at the farewell from her grandmother, who dies shortly after. In the new environment, she feels “foreign” and “insecure.” She sensed her mother’s shame about the simple living condi-

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tions in the dark Berlin rear building and developed an “unbridled” zeal to please her in order to comfort her, but “no matter how hard I tried, it was worth nothing.” The living kitchen is the space for everything, and when the doorbell rings, everyone, according to a previously discussed choreography, stuffs everything personal behind sofa cushions and sits up straight, Mrs. Eichel describes. During the course of the analysis, she reports with shame about a first suicide attempt: At the age of eight, she wanted to jump out of the kitchen window after a maternal reprimand. The mother pulled her back from the windowsill. Around this time, her distant, withdrawn and rejecting older brother leaves the house. The patient recalls that she tries even harder to cheer up her mother. While her mother always criticized her actions and her “miserable” appearance, she was praised in school, music lessons, and church for her achievements. Mrs. Eichel would have liked to study medicine like her brother (now has his own internal medicine practice, divorced, one child; little contact from her side, as he has become an “image of the mother” according to Mrs. Eichel’s perception), but her mother considers this “too ambitious”; therefore, she leaves high school after 10th grade and becomes a nurse. Her father stays out of the career decisions. After a first platonic love affair at the age of 18 with a married man 20 years her senior, Mrs. Eichel develops a sexual relationship with a doctor six years older, who encourages her to take evening classes and study for a teaching degree, but then takes a job in a distant city and leaves Mrs. Eichel shortly before her state examination. She blames herself for the separation—he had often urged her to move in with him—but she could not leave her parents’ house because she wanted to take care of her now heart-diseased father. When her father dies in her 28th year of life, she stays with the “clinging” mother at the dying man’s

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r­ equest, trying to distance herself from her mother’s care demands through training in psychagogics. A teaching therapy helps her overcome her scruples and move into her own apartment. Already at a young age, she becomes a trainer and writes a dissertation on subject didactics, which she postpones due to the intensive care of her now cancer-stricken mother and does not submit despite the urging of her doctoral supervisor. After her mother’s death in her 37th year of life, Mrs. Eichel marries a “boyish” high school teacher (+10) she recently met in a church circle, who, having grown up as the only son in an all-female household, behaves demandingly, while Mrs. Eichel adapts to his wishes. For example, he did not want a child and she gave up on it: “I have enough school children.” Sexuality quickly receded. She often feels the impulse to separate due to the devaluations she experienced through his ridicule but could not give in to them for fear that he would not survive it. When he is retired after his second stroke, she sees it as a “sign from above” to stay with him and take care of him if necessary. She feared that if she asserted herself more, he would die from a third attack. She felt “trapped.” Because of her marital conflicts, she undergoes a long-term analysis in her late 40s, which she believes ends with her being “sent away”: “She couldn’t stand me anymore because I simply couldn’t separate from my husband.” The “expulsion” by the analyst triggers a suicidal impulse: She stood on a high-rise building and wanted to jump. Her impulse turns into murderous rage: She develops the fantasy, only confided to me late in the analysis, of a suicide attack, first killing the analyst and then herself. Mrs. Eichel then takes sedative medication, develops a painful gait disorder, and goes to a psychosomatic clinic. Afterwards, she immerses herself more than before in her work.

An intense platonic love affair with a disabled, older married man (“soul friend”), which Mrs. Eichel began during the time of her first analysis, stabilizes her for years. They travel a lot together, which she justified to herself and her husband by saying that she went as “his support.” Mrs. Eichel desires physical contact, but the lover refuses in order not to “burden himself with guilt.” He dies of cancer two years ago after a short illness. Mrs. Eichel tries to contain her despair over his loss by taking on additional school functions; she believes that the symptoms develop due to taking on too much. z Psychodynamics

The loss of the “soul friend” who had stabilized her as a self-object mobilizes in Mrs. Eichel childhood experiences of deep loneliness and abandonment, which until then had been sufficiently warded off primarily through her altruism, especially towards the “adoptive daughter” and the increased “manic” work. At the same time, the compromise formation of being able to temporarily remove herself from the marriage and her everyday life as the “support” of the beloved and temporarily live regressive needs is now also eliminated. The lifelong warded off, previously already several times clearly emerged depression in the suicidal impulse as a child, after being abandoned by the first partner and by the termination of the first analysis breaks through and shows itself in feelings of abandonment, worthlessness, and psychosomatic symptoms. The causes of the depression are a supply-autarky-conflict, reinforced by unaccompanied childhood loss experiences, a self-esteem conflict, and related and superimposed guilt conflicts: the basic guilt feeling of the unwanted child, vitality guilt feelings of the child set back by the mother behind the brother and emotionally abused, who turns the rejection against itself; and finally the Oedipal guilt feeling due to the

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6.2 · Therapy Planning

“silent agreements” with the father. (The patient has probably placed herself in her unconscious fantasy in the position of his first, beloved wife and at the same time “mothered” him as a “guardian angel”, competing with the mother in this, which increased the Oedipal guilt feeling.) In addition, there are feelings of guilt related to social ascent and superiority. Mrs. Eichel, for example, renounces the doctoral title in order not to make the social ascent too visible. In choosing her partners, she follows a repetition of rejecting or patronizing men corresponding to the maternal introject or the Oedipal fantasy of unattainability. In renouncing children, she avoids confrontation with her own desires for security, as well as competing with her mother. In this respect, she shows in several ways a psychological non-separation from the primary objects with a self-damaging loyalty. The defense of lacking experiences of empathy, affection, and mirroring in the form of early parentification, the massive restrictions on autonomous developmental steps, and the development of the altruistic defense with almost masochistic tendencies allow us to speak of the formation of a “false self ” in the sense of Winnicott with considerable narcissistic vulnerability. z Diagnosis

Chronic depression with somatic syndrome and somatoform disorder, particularly sleep and pain disorders. Altruistic and performance-related defense, self-harming tendencies through accident proneness, and latent suicidality. z Indication

The complexity, severity, and chronicity of the internalized conflicts described in the psychodynamics, the rigidity of the superego structure, and defense mechanisms can only be expected to achieve lasting structural changes through long-term psychoanalytic therapy.

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z Treatment Planning

For treatment planning, the patient’s various self-destructive defenseforms are particularly significant. It will therefore be crucial to control the analytical process in such a way that the awareness of repressed relationship desires and the associated tendency to regress occurs in a measured manner, so that it does not derail self-destructively through the defense forms directed against oneself: through psychosomatic illnesses with hospital admission, accidents, or even suicidality. The reflection of the transference relationship is of decisive importance, firstly, because the interpretation and understanding of the transference and a self-destructive transference acting out are expected to provide the necessary emotionally supported insight for real changes in the patient (7 Sect. 7.7), and secondly, because only with the help of reflecting on the transference-countertransference process can such a process be therapeutically held (and endured!). Otherwise, a resignation in the face of resistance and thus a retraumatizing, countertransference-acting out rejection process would be feared (7 Sect. 7.7.5). The process is, of course, not predictable in detail. However, the primary transference process appears to me in such a way that the “true self ” of Mrs. Eichel, silently looking out of her eyes in the first encounter, surrounded by an impenetrable protective wall, longingly “adopted” me in the sense of a projective identification with her deep desire to “be” (cf. initial imagination). Because presumably, the offer of analysis mobilized her disappointed narcissistic-regressive desires to be seen, cared for, and accepted. But these are hidden behind her ego-syntonic defense of altruistic surrender and affect-avoiding performance orientation. The destruction of this “false self ” will bring the patient into contact with inner emptiness and lostness. Only when such painful feelings are endured in the protection of a supportive, understanding rela-

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tionship can the structures of an authentic autonomous self develop. But until then, she will fight—against me and against herself with her “tried and tested” self-destructive means. Working with imaginations seemed useful to me for several reasons: Due to the expected strong resistances, imaginations with their expressive and clarifying function (7 Chap. 3.3) should help to illustrate and weaken processes of defense formation. For example, it should be easy to show in the imaginative process how Mrs. Eichel suppresses or “removes” her impulses, how comprehensively and self-sacrificingly she has to adapt to the other person, etc. This could be particularly helpful at the beginning of the process when a transference analysis would still overwhelm her defense regulation (7 Sect. 7.7.6). In the further process, it is expected that in addition to changes in the transfer relationship, conversation content, dreams, and scenic behavior, imaginations will also indicate and promote aspects of the “true self ” or “germs of autonomy” (structure-promoting function of imagining). Symbolizations can express such “germs of autonomy” more vividly and often more enduringly than is usually the case with conversation content. They can thus contribute accentuatingly to opening and helping to use a transitional space in the patient’s self-structure in the expected tough transfer struggle. Imaginative ideas can also be helpful as a stably accessible transitional phenomenon for the separation-damaged woman Eichel in bridging breaks (7 Chap. 3.3). For me as an analyst, I also expected the imagination work to provide effective help in dealing with my countertransference feelings. Just as Freud considered it useful to sit behind the couch to relieve the strain of constant eye contact, it seemed advisable to me to offer the imaginations—as if cushioning the transfer-countertransfer dynamics—as an “intermediate space” for the patient and myself. As the work progressed, it

would then become necessary and helpful to understand together why this space was entered and used, what it promoted, and what it helped to avoid. The imagination sequences in our sessions and the discussions of the image material would thus also expand the possibilities of my proximity-distance regulation. (At this point, it should be noted that the inclusion of re-enactments in psychodynamic therapies with imaginations, especially in an analytical treatment framework, is by no means necessary or even obligatory, 7 Sect. 7.5). The inclusion of imaginations was communicated to Mrs. Eichel from the beginning as a constitutive part of the therapeutic framework alongside the basic rule and was accepted by her without question like everything else. Only in the last part of her analytical process could she express the desire for an imagination on her own, while she followed her own impulses much earlier and unsolicited when painting imaginations or dreams. She often painted during breaks and brought the pictures to the sessions, but needed encouragement from the transfer fear for a long time to show them, fearing possible rejection (see below). 6.3  Initial Imagination

The first imagination initiated by the stimulating motif “flower” (7 Sect. 7.2) took place towards the end of the fourth probatory session after the completion of the anamnesis collection. I said to Mrs. Eichel: “We have now dealt intensively with questions about your development. I now suggest that we turn to your inner world of imagination.” This was followed by a brief relaxation instruction (7 Chap. 3.6 and 7 Sect. 7.3) and the request: “Please imagine a flower, and if something appears before your inner eye, please describe it so that I can follow. Even if something completely different appears.” In a soft voice, Mrs. Eichel begins:

6.3 · Initial Imagination

5 I see a wild mallow. With pink, rather small flowers. It grows in our garden, back then in the countryside at my grandmother’s. It is a slender, straight, upright stem with several buds, uh flowers. Some have already withered. 5 How does the mallow affect you? 5 Well, it stands rather alone. On the left are many other mallows, but this one stands by itself, on the edge, as if it needs space … 5 Yes, what is straight? 5 I am amazed at how delicate the petals are. You only notice that when you get closer. I didn’t see it at first. The green leaves are yellow and hang like that. 5 Is that the case with all of them? 5 No, there are two green ones at the top, they are well cared for. 5 What does the stem feel like? 5 It is a cool, slightly hairy stem. It is also quite delicate. There is a risk that it will break. But the main stem is woody and strong. It withstands the wind … This flower just wants to be, not to sit in the center. It is just there. 5 And is there something you would like to do there with or by the flower? 5 … Maybe pick a bouquet? No, then it goes under. But maybe loosen the soil around it, draw a furrow so that water can get to it, so that it is well cared for. I only now realize how dry the ground was! After the imagination, the patient says with shame effects that throughout the imagination she has always plucked withered parts from the flower. Which is “actually not a real flower, but a weed.” At first glance, one could be quite optimistic after this imagination: The patient shows hopeful self-aspects in the “buds” alongside “withered” ones, fragile as well as “strong” self-aspects (brittle vs. woody stem); she can express care wishes (so that water can get to it) and the desire to be seen at least in the negated form: not to sit in the center, not to “disappear” in the bouquet;

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self-strengths become apparent in terms of self-care (loosen the soil around it) as well as motivation and self-activity in the impulse to loosen the soil oneself and not to “wait” for it to “rain”. This first impression could suggest that the main therapeutic task is to further encourage the patient on an already self-discovered path and to accompany her with understanding resonance. Considering the raised psychodynamics, it can be assumed that the patient might not benefit much from such a non-psychoanalytic therapeutic orientation. Since her defense strategies include those of altruistic orientation and adaptation, it can also be expected in therapy due to transference, as is already evident in this initial imagination (see below). It can be assumed that she would eagerly search for “instructions for action” in the therapeutic understanding efforts, but would not be able to “implement” them due to internal resistance. A transference-countertransference dynamic would be expected, in which the patient demonstrates her frustrating efforts (“I try, but I can’t succeed.”) and blames herself for this “failure.” The therapist would “encourage against it.” The process would either be quickly terminated by one side, as “too little changes,” or it would lead to a long, but frustrating process for both sides, in which the patient repeatedly confirms her negative self-assessment, not being able to develop— it would end in the dead end of her masochistic triumph. Looking at the initial imagination from the psychoanalytic perspectives presented above, a different assessment is reached: The wild mallow is seen as a currently expressive identity symbol, in which the annihilating mother’s gaze on the child as “weed” is combined with the patient’s longing for an original self-expression, wild and pink-colored—corresponding to the girl’s color. The stem is in danger of breaking and the flowers … have already withered. The patient has to take care of herself (“wa-

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ter”), as the nurturing soil is dry. The flower, viewed in this way, appears unstable and endangered in many ways by relationship experiences that will feed the transference dynamics: By degrading her beautiful mallow to a “weed,” she identifies herself with the negative maternal attribution (weeds are pulled out, she should have been aborted). The identification with the maternal aggressor determines her stabilizing defense configuration, which is, however, threatened by tentative desires for vitality: She senses that she needs space … I’m amazed at how delicate the petals are. I didn’t see that at first. More than her only hinted conscious and unconscious desires, the imaginer shows their defense through inner withdrawal and external distancing: The mallow stands rather alone, space is only available at the edge, she fears to disappear in relationships with others, in the bouquet … she is lost. This is also evident in the transference: Mrs. Eichel must also keep her analyst at a distance: She presents herself as self-sufficient, modest, and free of care desires: This flower just wants to be, not to be in the center. It is just there. With more consistent reflection on the transference relationship (7 Sect. 7.7.4) the following becomes clear: Mrs. Eichel responds to the initially only orienting question of whether all leaves are yellow and “hanging”: No, there are two green ones at the top, they are well cared for. Due to her transference, she hears the question in such a way that I do not want too much “withering”; and she fends off her care desire by supposedly “caring” for me in this way or adapting to my supposed wish. Similarly, she takes back the topic of the “fragility” of the stem by—because she probably thinks she has to “calm” me down—imagining that the woody main stem is very stable and can withstand the wind… In the way she supposedly satisfies the analyst, it becomes apparent how directly her parentifying defense is presented in the transference. Therapeutically helpful, however, may be that she now identifies with

more supportive self-aspects, fulfills “more positive” expectations than the previous parental ones, and thus there is a chance that she will accept more positive self-aspects in the transference relationship compared to her negative ones. It is important, however, to initially characterize this identification with the analyst’s supposed expectations as an adaptation performance of the “false self ” and not to confuse it with developed autonomous self-parts. Only the transference-focused reading of the imagination reveals the complexity of the therapeutic imagination process: Mrs. Eichel is identified with old attributions (weed), shows her defense against unsettling new things (the flower “needs nothing”) and, due to transference, picks up on expectations she assumes (Nothing green? Yes, a little green). The parentified and dutifully driven self, as well as initial approaches to identification with me as a new transference object, are particularly evident in the initially concealed, but imaginatively lived out and— prognostically favorable—subsequently entrusted impulse to pluck out the yellow withering. Mrs. Eichel approaches the “plucking” of her flower in the same way her mother approached her. It was always important to the mother—as Mrs. Eichel recalls in many examples during the analysis—that her daughter was “presentable”, that, for example, her “meager” hair had to be combed at all costs: “What do you look like again.” Identified with her mother’s view of her as a child, Mrs. Eichel experiences herself as a being that she has to “pluck at” in order to look and become halfway “acceptable”. The rigidity of this self-perception was scenically expressed in the transference by Mrs. Eichel checking her appearance in the mirror in the hallway outside the practice for years (hidden from my eyes) and combing her hair. She always had an umbrella in her purse. Later, she could say that she would not have come to

6.4 · Three central scenes of the analytical process

the session with wet hair because she would have experienced herself as “unacceptable” (7 Sect. 7.7, 7 Excursus 11: Scene). Of course, plucking out the withered is also a gardening care action in the service of plant growth. The patient thus also expresses that she desires development in the analysis and imagines it in such a way that she has to detach herself from the past— and that she has to do this herself and cannot make use of any help in doing so. The concealment of the plucking impulse and the shame in confiding continue to suggest the emerging transfer of superego aspects. Mrs. Eichel suspects that I might reject her for both this “arbitrary” impulse and the fact that it happens “secretly”—possibly also because of the aggressive-instinctual moment in it, which embarrasses her. For in the “plucking” there is also an auto-aggressive childish symptomatology, which she only confides to me much later: that she inflicted injuries on her skin and bit holes into her clothes and tore them with her teeth. The imagination, along with the subsequently communicated information, thus provides further assistance in the treatment planning and the development of process goals: I prepare myself—as already explained above—for an analysis in which dealing with the strong regressive-fusionary desires for care and closeness and the resistances against them will be in the foreground for a long time. Mrs. Eichel will have to try in many ways to sabotage the progress she so desperately desires, she will have to keep me at a distance through idealization and self-devaluation and in many other ways, and her unconscious tendency will aim to evoke rejection, frustration, and powerlessness in my countertransference. Overall, it becomes clear that a reading of the imaginations that includes the transfer conflicts protects the therapist from unrealistic assessments of therapeutic possi-

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bilities. Here, it also confirms the indication of an analytical treatment framework and allows a vivid “preview” of the expected process dynamics. 6.4  Three central scenes of the

analytical process

In the last third of her analysis, Mrs. Eichel reports the following dream: I was on a mountain that had a wide plateau as its peak, and now began the descent. But there was no serpentine path, it went quite steeply down over larger bumps, everything was crumbly and somehow dangerous. But I noticed that although there was no path, one could make one. And so it went downhill, laboriously. I practically dug my way into the crumbly earth and thus had a hold. Mrs. Eichel relates the dream in her associations to her analytical process, which first went long, “serpentine loop”-like, uphill in ever-varied transfer-fed scenes (7 Sect. 7.7, 7 Excursus 11: Scene), then led over a summit “plateau” with suicide and termination risk, and finally arrived downhill in advances and setbacks on a “dangerous” path characterized by working through her previously warded off relationship desires. The particular difficulty of our “mountain climbing” and also the reason for its long duration was that every therapeutic progress, as feared, led to self-punishments in the form of psychosomatic symptoms, self-injuries, and suicidal-resignative fantasies and impulses. Metaphorically speaking: “Uphill” the old externally oriented “false self ” including its defense was weakened, the suicidal crisis represented part of the collapse of this defense and the subsequent new beginning, and the “downhill” path served the development of a “true self ” that recognizes, asserts, and balances its own needs with the concerns of others.

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During the first stages, there was little movement in Mrs. Eichel’s external life design, in accordance with her inner clinging to her defense configuration, apart from the detachment from Helga and the initiation of an extramarital love relationship; all the more impressive and tangible were the changes in her professional situation, marriage, and friendships in the last section. Viewed from the end, I experienced in my countertransference an often extremely strenuous and challenging “mountain climb”—which also enriched me greatly and deepened my respect for the possibilities and limits of psychoanalytic change. z The Ceiling Scene

Mrs. Eichel often froze from exhaustion because she worked through the night. When I noticed this and had also clarified that it was not due to the temperature in my room (the other patients did not freeze, nor did I, the room had a temperature of 22 °C), I began to point out a warming blanket that was lying on the side of the couch, in parallel to the ongoing processing of self-overload. I repeatedly encouraged her to take it and tried to understand with her why she always refused. The following reasons could be successively worked out: First, Mrs. Eichel could not admit her exhaustion to me or herself at all, as she would have been too exposed to the criticism of her super-ego, which she had projected onto me (she would have expected to “get scolded” like “Can’t you manage your time better?”). When I addressed the exhaustion directly through the “blanket encouragement,” she became annoyed that it had become noticeable and rejected my offer with self-reproach: “If I were faster, I would get more sleep. Why am I so slow!” She did not deserve a blanket. As her self-reproach and destructiveness became better thematized, she could rationally grant herself a “right to exhaustion,” but she was still ashamed to show it, as she would become “a burden” to

me, as it would show her “failure” in therapy: She “learned” self-care here but could not “implement” anything (presented in the speaking style of a teacher). The shame also hid her masochistic triumph insofar as her defense against my “attack” on her self-neglect prevailed. At the same time, this “victory” over me unconsciously caused her feelings of guilt, which in turn promoted self-punishment tendencies in the sense of a circulus vitiosus. Another dimension of understanding opened up when Mrs. Eichel told me that she could not take the blanket because her former analyst had interpreted it as “hiding” and “inhibition of showing” and she had been afraid of a repetition of such an interpretation experienced as criticism. These reasons for rejecting the blanket are therefore resistance-related. This resistance transformed—similar to the initial imagination when she “discovered” two green leaves “for my sake”—into a transfer resistance, as Mrs. Eichel now “for my sake,” i.e., in an adaptation process, slowly pulled the blanket towards her. Only in a further step could we approach her regressive wishes, which are actually connected with the blanket and which she could initially only allow and express in a devaluing form: “How does that look! Snuggling up and not working here!”, she said when she just put the blanket over her legs. Or: “… as if I want to wrap myself in your care.” Or: “… as if I want to be covered like a child by you.” In these anticipatory self-interpretations, it was clearly noticeable how she tried to keep her need for security under control and to keep me as an empathetic, caring object at a distance. And yet, her wishes for closeness, care, and security shone through the self-reproachful formulations and could finally be made more visible and allowed by her. This was associated with giving up the devaluation that this was about “childish stuff,” i.e., recognizing that these were developmentally appropriate and not con-

6.4 · Three central scenes of the analytical process

demnable wishes, and learning to trust that the analyst’s persistent “sticking to it” stemmed from genuine care. It was not until the “descent from the mountain” that Mrs. Eichel no longer condemned her wishes for being cared for and maternal warmth and also took this on for herself by naturally taking the blanket when she was cold. She commented on this with laughter, saying, “I couldn’t have done that before!” In the end, she rarely needed the blanket because she slept at night instead of working. z The Gift Scene

Giving was closer to Mrs. Eichel than taking: She liked to bring bouquets of flowers, sometimes in vases, later also chocolates or homemade cakes, initially for common celebrations, increasingly also outside of normative occasions. Since I knew that giving was associated with painful rejection experiences—for example, she gave her mother a small bouquet of strawberry blossoms as a little girl and received strict rejection and punishment for it (because the child had unknowingly reduced the strawberry harvest)—it was important to me not to repeat this, although various thoughts about the gifts came to me in the reflection of my countertransference discomfort: Did she want to appease me because she could not accept my therapeutic attention? Conceal her feelings of guilt about it? Leave me something to be able to feel connected to me after the sessions? I initially accepted the flowers in particular without or with little thematization, but invited Mrs. Eichel to understand the reason for it—and on the other hand, I expressed my joy about it, which was not difficult for me, as they were beautiful bouquets. For a long time, her always consistent statement that she “simply” wanted to share her joy with me could not be further questioned.

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However, I noticed that Mrs. Eichel increasingly developed fear of my questioning—and thus also of giving itself. It became a kind of “test of courage” for her, as she said: Whether I would accept or reject it, how I would thematize it, how I would “reprimand” her by interpreting it. (Later, she could confide in me that the previous analyst had interpreted her giving as “aggressiveness”, at least that’s how it had arrived with Mrs. Eichel, and she feared a repetition similar to the “blanket interpretation”.) Through persistent thematization, however, giving more and more provided the opportunity to uncover and understand transference fantasies. It became apparent that giving “uphill” fed the fantasy of connectedness with me; she left something with me and could thus gain access to me and remain permanently present. A second important issue was her selfdoubt shifted to the content of the gifts: She had no measure, felt completely insecure about too much or too little, good enough or not. She was convinced that her gift was never “right” or “appropriate” and therefore had to produce rejection— just like herself. And indeed: The more perfect it was, the more exaggerated it seemed to me—and the more obvious it was to me that it was never just about accepting a gift! If I was happy, Mrs. Eichel was momentarily relieved and happy, but could not “believe” my surprise or joy for long and soon mistrusted herself and me again. For example, after the session, she thought that one of the flowers in the bouquet might show signs of wilting or not match the color. In a twist against herself, she made a martyrdom of self-torment, not having put the bouquet together “well enough”, having disappointed or hurt me. With this seemingly completely inappropriate torment without deeper understanding, she also “annoyed” and tormented me in my coun-

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tertransference: I, who was “the reason for it”, got to feel her emotional state in a concordant way (7 Sect. 7.7.5). Through persistent thematization of giving as a scene in need of understanding, by including dreams and the unheard-of excitement that Mrs. Eichel got into when giving, it was finally possible to uncover layer by layer that the act of giving represented an action dialogue (7 Sect. 7.7.4) that contained even more unconscious or tabooed affects: In a fantasized fusion movement, she “gave herself away” to me. For this regressive defense movement, to merge symbiotically with me and to avoid the conflictual confrontation of two separate people, as we are, she found the expression “to dissolve oneself in love”. After the collapse of this defense and the recognition of separation between us, Mrs. Eichel was able to “go downhill” less often, without affective arousal and without subsequent self-accusation. The gifts were now more personally related to me, their meaning could be discussed together with regard to the situational transference dynamics, and at some point they were no longer necessary in any other sense than simply being a gift. z Hiding the Body

Mrs. Eichel was not allowed to be “physically present” when going “uphill”. She sat or lay stiff and motionless, quickly got the greeting and farewell over with, and did not look around at me. She always left the practice hastily and only put on her coat outside, as if she did not want to “bother” me for a second too long. In winter, she changed her shoes in front of my door and put on clean ones she had brought with her. In many ways, she scenically demonstrated that she was not allowed to “contaminate” “my territory” with her physicality. For years, she did not use my toilet, but got up earlier to use the restroom in a corner pub after an hour’s journey before the 8 o’clock

session. When the analysis took place lying down, Mrs. Eichel lay stiffly: “Like on an examination couch”—she said later when she could express the desire to lie on her side or even “embryonically”, which she did even later. In all of this, her need for control was palpable as a protective movement; if she were to “show” herself more spontaneously, she would be “helplessly” exposed to my gaze and my evaluations, which she could only assume to be “devastating” as the negative-critical mother’s eye. Later, she expressed the desire for an “invisibility cloak”, but was not allowed to use my blanket (see above) as such. This would also have created the paradox that she would have shown herself to me in a defensive desire, namely to physically disappear. But even showing defensive desires, she tried to avoid “uphill”, as she expected rejections. With her self-sufficient defense of not needing or even wishing for anything, she wanted to counter the “danger” of being “exposed” as a “dirty”, “annoying”, “unreasonable” counterpart. Particularly “hidden” were injuries, illnesses, and wounds that could have triggered my immediate attention and mobilized her warded-off care-seeking desire. Identified with the maternal voice “my daughter has nothing”, physical weaknesses were a “blemish” for her. She sought the blame for illnesses in herself, doctor visits were not mentioned, surgical interventions only after they had occurred. It was particularly annoying for her to have a cold, as she could not hide it from me. A therapeutic change in this regard was only evident in the last treatment phase in the growing physical freedom of movement and display. Because in relation to her physicality, her self-sufficiency defense was particularly persistent. Now and then, I had probably lost patience in the analytical processing of these and other scenes and had slipped into countertransference acting. For

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example, I once said that I simply could not stand to watch her freeze any longer, and if she did not take the blanket soon, I would spread it over her. This was a situational boundary violation in relation to her resistance, which nevertheless promoted the analytical process through understanding this transference-countertransference dynamic. Because with the help of the scenic acting, Mrs. Eichel, like many traumatized patients, had constellated a situation that led to a direct authentic reaction, in which she really reached and subsequently integrated the “human” therapeutic empathy. Her relationship to her body eventually became more natural. Sentences like “I am exhausted”, “my stomach hurts”, which I had to guess or suggest again and again, Mrs. Eichel could now pronounce. “Everything is so much easier this way!”, she sometimes said in astonishment. When she can move more freely in the room and even sit on the floor once, as she has “wanted to for years” (522), I think of Freud’s sentence: “The ego is primarily a bodily one.” The success of the analysis is most visible at this point in the literal sense.

6.5  The Analytical Process: At

the Foot of the Mountain— Uphill—Reaching the Summit Plateau—Downhill

z At the Foot of the Mountain

Representation of the first treatment year (hour 6-49, twice a week in face-to-face sessions): The waiting year has passed quickly, begins Mrs. Eichel. The “plucking” of withered parts from the mallow has occupied her for a long time. She sees it as the “dead” in her life, which she does only for others, without having anything from it herself. How can she get away from it? She can never say “no” to either Helga or her husband when they demand something from her. And actually not to anyone

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else either. My questioning of her great loyalty and self-restraint is gratefully and diligently taken up by her, but it has no effect. I quickly experience myself in a massive complementary countertransference, as I inwardly rebel for her. For me, the extent of her seemingly masochistic endurance, the lack of any outrage in the face of multiple exploitation, is difficult to bear. And I experience myself as powerless and therapeutically de-potentiated, because Mrs. Eichel only takes criticism from everything I mean understandingly or sympathetically encouraging, and if I cautiously interpret that, she also experiences it as criticism—a vicious circle. Her auto-aggression is not only evident in her boundary issues, intertwined with it is the second main theme of the beginning of the analysis, her work overload. She never addresses it directly, but in such a way that it “shines through”, so that I, for example, question why she works through the night. Although Mrs. Eichel feels generally criticized by this (she then reproaches herself for not being well enough organized), she sometimes also reacts with joyful astonishment that I stand up for her. Through this, an idealization process begins to establish itself, which, through her projectively transferred self-care to me, initiates a transference dilemma: She agrees to want to burden herself less, but this involves adapting to my attitude in the sense of adopting a likewise foreign superego. Thus, she begins to put pressure on herself to do less, but cannot do so due to her own powerful superego impulses and then reproaches herself for not “getting it right”. Through this resistance problem interwoven with the superego conflict (which demand do I follow?), the desperate scene familiar to her from childhood is recreated: “No matter how hard I try—it’s always wrong.” But she also lets me feel this, because with the reproach contained therein towards me: “You also overwhelm me.” I notice in concordant countertransference (7 Sect. 7.7.5), what

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it is like to make an effort and experience “always only being able to do everything wrong”. In my countertransference, I thus experience quite directly the inner world in which Mrs. Eichel lives. In fact, she is so under the inner dictate of “doing everything right” that sometimes it seems to me as if she is not in contact with me at all, but a trained, externally controlled—introject-controlled—being, “the perfect patient”—always punctual to the minute, always seemingly grateful and receptive. Spontaneity is suppressed, real closeness to me is not allowed, Mrs. Eichel “toils” in her analysis as in the rest of her life and must keep me at a distance through these forms of unconscious control and undermine my interventions. In this difficult transference situation, I hope that after a few hours, I will be able to use the enlivening potential (7 Chap. 3.3) of the imaginations in addition to the subterranean therapeutic effectiveness of the reliable framework and my understanding efforts specifically for loosening the defense structure. During the imagining, which she carries out with her eyes closed, Mrs. Eichel must at least give up the securing eye contact control of my reactions to her—the analysis has so far been carried out in a face-to-face manner—while at the same time she is oriented “inward” towards the spontaneously developing pictorial events from within her. This does not mean, of course, that she could give up her need for control or that the complicated transference situation would be otherwise resolved. Mrs. Eichel “senses” my possible intentions differently in the imagining than in the conversation, but has a somewhat larger behavioral spectrum through the symbolic veiling. The special defense-weakening potency of the imaginations becomes apparent in that Mrs. Eichel’s inner tension often increases after the imagining, as she reproaches herself for the “surprising” things that have “slipped out” of her. Brief, ego-strengthen-

ing moments are followed by self-punishments—the inevitable negative transference dynamics (7 Sect. 6.2) take their course. Seven imaginations were carried out in this section at my suggestion, initially with stimulus motifs (Sect. 7.2) such as flower, meadow, stream, path, then increasingly with those that originated from Mrs. Eichel’s own pictorial expressions: “labyrinth”, “scene of pleasant lightness”, “a pleasant voice”. Mrs. Eichel imagined very willingly, on the one hand she adapted to my expectations, on the other hand she was situationally open to the new states of experience associated with it. However, she always waited for my suggestion and did not express her own desire to imagine, although I had suggested this possibility as part of our therapeutic communication. She took up the suggestion to paint in the sense of a homework assignment to be completed as a matter of course and always brought a painted picture with her to the next session. In the 6th post-probationary session, I suggest an imagination of a “meadow” to her, chosen as an open stimulus motif in the beginning process, but also as a targeted regression-promoting “relationship message”, meant in the sense of “Take a break for once.”: 5 I see a hilly beautiful meadow, which glistens steamy in the sun like after a rain shower, it shines and shimmers… 5 (after a pause) What’s happening now? 5 It has now changed into a trampled meadow, through which a sandy path leads. To the right, there is a cornfield just before harvest. It smells of summer and warmth, the stalks move flickering… The trampled meadow disappears now too, I walk across a potato field. 5 Can you look for your first meadow again? 5 Yes. It is now somewhat different. A North German meadow with dandelions and plantains appears. Everything is lush and strong. In the back, there is a forest

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edge, in front of it, tree trunks are piled up. Far in the back, a few grazing cows. 5 Yes—what do you feel like right now? 5 Oh, I would like to sit on those tree trunks… 5 And how is it for you there now? 5 I see much more delicate grasses here, also sorrel, which bends in the wind. The sun is pleasantly shining. It’s such a peaceful atmosphere here! So beautiful! 5 Where is your gaze resting right now? 5 I’m looking back, there’s a fenced-in meadow with cows, they’re standing at the trough and drinking. Oh, it’s so beautiful here. I actually have a guilty conscience: I shouldn’t linger here so much. 5 How do the tree trunks feel, on which you are sitting? 5 Good. Rough. Grippy. Also a bit sticky. They smell pleasantly of resin. I think there are five, six felled pines. Under the leafy bark, a smooth trunk appears, in some places branches have been broken off, the spots look like wounds. 5 How old might the trees be? 5 Probably 40, 50 years. 5 Why were they cut down? Do you have a fantasy about that? 5 Actually, they look healthy. Maybe they were cut down for the care of the forest? Maybe it’s just utility wood. The interventions—largely those of accompanying guidance (7 Sect. 7.3)—aim to encourage the patient to reveal her inner formations at all. However, since the desires mobilized by this must be immediately fended off (recognizable by the fact that the beautiful meadow, which … sparkles, shines, and shimmers quickly becomes a trampled one, then even a potato field), I intervene with targeted encouragement intervention (7 Sect. 7.3), by actively advocating for the emerging narcissistic desire for relaxation and shining with the question about the initial meadow, which probably arrives as a punctual superego mitigation for Mrs. Eichel: “Sparkling is allowed.”

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The resulting fourth, the North German meadow, represents a compromise image with a transfer-related adaptation character: it is now powerful, no longer “shining,” but also not “trampled.” The motif of “weeds” from the initial imagination is picked up (plantain, sorrel) and positively occupied again. A regressive wish: Oh, I would like to sit on the tree trunks there … can show itself in response to the impulse question (What do you feel like right now? 7 Sect. 7.3). Through the tactile exploration of the “bark” (touch intervention; 7 Sect. 7.3) as a boundary organ of the “other,” she simultaneously comes into contact with something within herself (under the “rough” hides “smooth,” something “sticky” appears—later we understand that one of her transfer fears is to appear clingy or that I would recognize her in her excessive neediness and therefore reject her). Conflictual aspects are vividly symbolically veiled in the sense of a catathymic experience shape (branches have been broken off, the spots look like wounds). The question about the age of the trees is intended to suggest to the patient—but leave it up to her—to relate the chopped trees to herself. My (unshared) association was: They are as old as the patient was when she postponed her desire for children and resigned herself to being utility wood for life. Already Pahl (1982) points out that the wish-defense configuration is usually condensed in the entrance scene of an imagination. So also here: The urgent desire to confide in the analyst like a downpour must be fended off; the downpour evaporates “under” into a beautiful, harmonizing, and idealizing landscape. This experience delights and strengthens the patient, so that despite its defensive character, it also becomes a mosaic piece of the trust-building process that prepares her to be able to confide her needs. Soon after the meadow imagination (9), as she thinks about the topic of “­ utility wood,” Mrs. Eichel spontaneously tells a

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first dream (7 Chap. 3.6, 7 Excursus 6: Initial dream): I was in a room, a kitchen with a wooden bench and table. There were snakes everywhere. I found it repulsive and strange. A thick snake looked up menacingly, a small one I can take off my arm. It was like a snake pit. Day residue: book of a snake researcher who died from a snake bite. Mrs. Eichel’s associations see the thick snake as a “positive symbol of transformation.” She thinks of the healing Aesculapian snake, which does not appear in the dream and which she associates with therapy. She also talks about the rescue of Daniel from the lion’s den, which she compares to the snake pit. She speaks of her desires to shed her skin, to renew, to “get to the core.” She wants to learn to shed shells, like she picked out the wilted mallow leaves and like the dead branches were cut off. I realize how Mrs. Eichel at this point— far from her own experience, which she fills with educational knowledge—must eliminate everything threatening and frightening from her dream: She idealizes the analysis and declares it to be a natural process of shedding, not a painful process that threatens her “false self ” with death. In this sense, she points to the rescue of Daniel instead of the threat of annihilation. She also does not address the deadly danger of the snake researcher and the biblical symbolism of punishment, and I also remain silent about it, in order not to prevent the narcissistic strengthening of the idealizing bond to me that is required in this treatment section. For me, the dream connects a terrible childhood scene (living kitchen) with the new analytical space with me, in which not only “beautiful” but extremely painful experiences await her. The dream shows me her fear, which her conscious desire for change and my struggle against her defense trigger in her, the fear of losing her grip on her old strategies, since she cannot yet imagine new supportive strategies from an au-

tonomous self that is yet to be developed. The negative mother transference is expressed in the symbol of the thick snake. It is still “too thick” for therapeutic processing: From the day residue association with the ill-fated snake researcher, I infer that the patient unconsciously experiences herself and our relationship as being threatened with destruction by the “mother poison.” Therefore, in our process, there can initially only be “small” progress, such as Mrs. Eichel can achieve herself, just as she takes a small snake off her arm. Only at her pace, with which she learns to help herself, can she bear her dependency fear of me and the fear of her “deadly” oral greed, which explains why she keeps me at a controlling distance. The dream in connection with the meadow imagination strengthens me in persistently and gradually promoting her understanding, which I try to prepare through ego-strengthening. A third imagination (12) for the stimulation motif “Bach” (7 Sect. 7.2) is based on a metaphor self-critically used by Ms. Eichel in conversation: “I’m talking here like a torrent!”—I also think of the “downpour”—and continues the initiated process (abbreviated reproduction): 5 I hear it before I see it, it roars from the top right down. It seems lively, the sun is shining. It widens downwards … I see many stones, it is a mountain stream, at the forest, in front of a meadow. Such a pace! It roars along. There is a thick stone, worn down, the water bubbles around it, good for sitting, but too wet. Up towards the source there are even more stones. It looks cheerful! 5 How is it right where you are? 5 I’m standing on a soft meadow, slightly damp, want to take off my shoes. It’s pleasant on the feet, delicate grass, moss, not too warm, not too cold. 5 Do you feel like doing anything there? 5 I’m looking in. Clear, sandy, small stones, bubbles from the current, the sun is reflecting, it seems softer and warmer than it is

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when I now hold my hand in it. It is very cold, but clear, fresh. Everything sparkles. It reminds me of the sea. It’s not deep … 5 Would you like to go in or is it too cool? 5 Well, I splash a little in (takes a deep breath), get boisterous! The edge has sunk a bit, I’m already standing up to my thighs in it! It’s fun, I feel like a 5-year-old child splashing. As a child, I would have fetched boards and branches to balance. Oh no, it’s too wide there. I’ll just fall in. (She then discovers “bridge building material” after encouragement from me to look around and builds.) It’s a bit silly, but fun. But it’s quite shaky. The other bank is higher. I go through the stream because the bridge is too shaky. The other bank is much too high, though. It always crumbles when I want to go up there, and it’s quite cold and tearing there … 5 What could help you? 5 Oh, now I’ve made it. I’ll wash the dirt off my hands. There. There’s a beautiful view up here! Mrs. Eichel’s initially cheerful stream is increasingly robbed of its pleasant character by a crumbling bank with a sagging edge and very cold water, which corresponds to the transformation of the meadow into a potato field (6). My impulse questions lead her into “cheerful”, childishly experienced activities, which she immediately has to “scold” (boisterous, silly). She can pick up on my encouragements, which psychodynamically can be understood as an adaptation to what is supposedly desired by the analyst and unconsciously represents a breach of loyalty to internalized, play-despising norms. This makes it understandable that impulses for self-punishment are directly translated into images: The water now becomes cold and tearing, the bank is crumbling and much too high, and she “slips off ”. My indirect encouragement intervention (7 Sect. 7.3) “What could help you there?” leads to an immediate (!) success ex-

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perience, which she presents to me. Thus, the imagination ends with a parentifying appeasement of the analyst—an attempt to seduce me not to see her further in her neediness and conflict and to keep my distance, which only became conscious to me through the reflection of my countertransference, having experienced the promptness of her “good solution” as inappropriate (7 Sect. 7.7.5). 13th session (session protocol): Mrs. Eichel appears short of breath, exhausted, and speaks quickly in a soft voice. Everything is a bit hectic because the twoweek autumn break is coming up and she is preparing to leave for Mallorca, where her husband is already waiting for her in the holiday apartment. Mrs. Eichel takes out the picture she painted at home about the “stream” imagination from the last session while talking and wants to immediately start commenting on it. I address her breathing, which I notice, and ask what is going on. She reports that she worked through the night to get everything ready for the departure. Upon further questioning, it becomes clear that at her husband’s request, she had to get many things to bring with her, including his favorite liverwurst. She explains that she wants to leave the house in a certain, perfect way, so she quickly cleaned everything, and her husband called three times to give her more errands. She also picked up something from the pharmacy for a sick relative and sat with her for a while because she was feeling so bad, and only got to pack her own things very late; she has to correct three class assignments and review an exam paper during the holidays… She had to prepare a lesson for this morning… she had promised something special for this last hour and it had been quite elaborate to prepare… Mrs. Eichel rattles off these things as if apologizing and turns back to the picture. I ask when she had even painted the picture under these circumstances. She says,

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ashamed, that she only got to it just before our session. I try to convey to her that she should take the appropriate space for painting the imaginations, not put herself under pressure, and ask if it hadn’t occurred to her to paint calmly during the holidays. Mrs. Eichel denies; it had been self-evident to her to create the picture so that the process here could continue correctly. She just has to learn to manage her time better. I mirror to her that I perceive the high pressure she puts on herself and how self-reproachful she reacts to my concern, and in my countertransference, I feel guilty: I could not express myself in such a way that she does not experience my intervention as directed against her. She looks back at the picture. “What is attracting your attention right now?” (cf. technique of image debriefing, 7 Sect. 7.5) “The stone.” (The picture shows a stream with a large and several small stones, a narrow strip of meadow, and a dense forest with stacked tree trunks in front of it.) She experiences the stone as a “big chunk,” much larger than in her imagination, where everything had been more beautiful and radiant (see 7 Sect. 7.7.3: Imaginations sometimes “lose” the “beautiful” outside of the therapeutic situation or only the “beautiful” is remembered). In general, there are “many chunks” there. “What comes to your mind when you think of ‘big chunk’? “Helga.” She has a “massive” problem with her. She couldn’t reach her, eventually gave the precooked food to a neighbor because of the upcoming departure, and didn’t get her own key back, which Helga should have given her for a long time. Now she’s leaving with the uneasy feeling that Helga has the key. And probably not reliable enough to remember that the craftsman needs to get into the house, for whom she wanted to leave the key with the neighbor. Then the renovation would drag on, and her husband would blame her, and she would be bothered by it all vacation long… (listening to this, it’s hard for me to wit-

ness how she has moved herself into a victim role towards Helga and thus increased the likelihood of ruining her vacation). She looks back at the picture and emphasizes that she finds the meadow beautiful, it’s so colorful, especially on the far left. But the forest has turned out so dense! The trees stand in rows and files. I ask how she feels about it, whether it could also represent protection for the meadow. She hesitates and says maybe, but she experiences it more like closing off. Just like she closes off from the problem with Helga. She simply can’t manage to be consistent, to set boundaries, as she can do in class. I ask her if she has any idea why that might be. She denies it. I suggest that setting boundaries might be easy for her when she does it for others, like reining in individual students when they disturb the well-being of the whole learning group. But that it’s difficult for her to do it for herself. Mrs. Eichel agrees. She then immediately starts talking about Helga again. The key is like a trump card that Helga holds. When she tried to address it, Helga screamed “hysterically” that she probably didn’t trust her. Helga always manages to make her feel like she’s to blame or has done something wrong. I say, “Yes, she just turns the tables.” That’s how she’s always known it, says Mrs. Eichel desperately. With her mother, it was the same. She elaborates and tells again in detail how long it has been going on with Helga… In this hour of complaining about Helga, it becomes particularly clear to me how much Mrs. Eichel has externalized a tyrannizing self-aspect in this relationship, which, however, usually pursues her internally, as in her actions in this hour. The end of the session is approaching. Mrs. Eichel looks at the clock and starts packing up the picture, even though there is still some time left. Since the break is coming up, I don’t want to address the scene of the early and self-determined session closure—in which I experience that she doesn’t want to burden me at all, but also that she

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has to maintain control and can’t get out of the “processing” mode—and instead ask her about the bridge in her picture, which crosses the stream far in the back. Mrs. Eichel thinks for a moment and then says that if she could cross the bridge, she would feel like she was leaving Helga behind and entering something new. I say, “How nice that the bridge exists,” and we say goodbye. For the next session after the holidays, Mrs. Eichel brings me a small basket of fresh fruit from Mallorca. I thank her without further elaboration (see 7 Sect. 6.4). Mrs. Eichel appears extremely exhausted and fragile to me. She reports that she fell ill at the beginning of the holidays “as so often.” She had developed a swollen eye, painful, along with an irritating cough, and had to take antibiotics, and on top of that, endure her husband’s ridicule: “You look like a boxer with a mashed eye.” “Oh, what am I complaining to you about?” In the second week, she began to recover, but then there were the exams, and her husband insisted that she join him on hikes, so she worked again at night. She wonders: “Why do I always stage something like this? Sick during the holidays?” “Why do you have to blame yourself for getting sick?”, is my typical problematization. Because she blames herself for it. Her mother always said: “You’re just staging it.” She organizes herself poorly and cannot set boundaries. At this point, I decide to withhold the transference interpretation that she is self-reproachful in order to preempt my unconsciously feared criticism. Instead, I tell her a little story I experienced myself about a flutist who once couldn’t produce a sound and immediately condemned herself for it; but it wasn’t her fault, it was the broken flute. Could it be that with her assumption of guilt, she prevents understanding with me what might have weakened her defense against illness? Mrs. Eichel seems touched. She then tells with a soft voice how beautiful she found it in Mallorca at the end, describes an evening atmosphere

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there, and wonders: “How can I change it so that I rarely come to myself ? That I don’t always put myself under a whip and then only notice: I don’t want to live anymore.” I am startled, as one is startled when instead of the expected stair step, there is a deeper recess, and I have the impression that she too is startled by how the admission of weariness of life slipped out in that “soft moment.” She abruptly returns to the old haste and reports, again identified with her defensive side, that upon her return she found a critical email. She blamed herself for not having written the exam report well enough… But then she remembers a dream from the second half of the holiday: I was at an event, sitting in a row. You came and sat next to me. I didn’t know if I liked it or how I felt about it. But then I found it quite terrible because suddenly my brother appeared, noisy, loud, along with his wife. They immediately started taking pictures of everything, including you. I was terribly ashamed, but you took it all very lightly. Then you and I helped serve soup to children. The children spilled it on themselves. Then you asked me what I took away from the therapeutic encounters. You said I only talked about others in my sessions. Then I saw an image like a landscape from above. It lay beneath me like a puzzle. I looked down. You said: “All of this takes a lot of time.” After Mrs. Eichel, typical for this phase, initially says that she can’t think of anything about the dream, she associates at my encouragement: She felt her brother and sister-in-law with their snapping photos as an imposition. Actually, like in real life. The school meal as touching. Soup from England. She remembers care packages. Hard times after the war. She was so glad that I said in the dream that everything takes time. I say: “Care means care. You take care of others, and here we think about how you can take better care of yourself. In the dream, the children represent your needy side (7 Sect. 7.4, 7 Excursus 9: subject-object stage dream interpretation),

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which longs to be cared for.” I ask her what she thinks herself, why self-care is so difficult for her while she takes care of others so considerately and lovingly? With this question, I am trying to follow up on the thread from the last session. Other aspects are not considered, e.g. the possibly displaced desire for a photo of me and thus a tangible form of my constant presence on her brother. The dream helps me to better perceive our transference situation: How much she begins to seek my closeness and that she can entrust me with fearing my criticism—and that she reserves the right to “look down on” our relationship from above due to this ambivalence. The session passes with Mrs. Eichel reflecting on her lack of self-care, without us visibly getting closer to the masochistic core of this problem, but she remembers her father’s mandate to be there for others. In the 4th imagination (15) on the stimulus motif “path”, Mrs. Eichel makes her wish for more peace and quiet clear, for a retreat from me as well. She encounters a house on the path, the first in a series of various later imagined or dreamed houses (7 Sect. 7.2), which she spontaneously associates with self-aspects (excerpt): … a North German farmhouse. Willow trees around it. Cozy, peaceful. A few flowers in the garden, vine leaves on the walls, red bricks. The door is small, hunched. A rustic wooden door, without frills … The door is open, I can go in. No one else wants to go in. Inside it’s dim, warm smell, something familiar, natural. This is where peace is. Worn stone floor in red tones. Genuine … This is where I can find peace. In a 5th imagination (18) on the motif “labyrinth” (Mrs. Eichel had talked about feeling like being in a labyrinth), the defense against and the desire for closeness is further negotiated and receives a new emphasis: 5 I walk along a path. Like a forest path with an embankment. Can’t see far. It’s impressive that there’s no room for a second person next to me.

5 How do you feel about that? 5 Sad, but I have myself to blame. I chose the narrow path myself. 5 Does a scene from your life come to mind where you were so sad? 5 When the soul friend died (suppressed crying). If he were here, it would be nice at the labyrinth. Exciting. Spirited. Now it’s tedious to walk there. I miss the momentum. I can’t move forward and don’t know where to go. 5 What would be good for you? 5 A hand from above. 5 Can you imagine it? 5 Yes, but I can’t reach it. I’m too small. 5 What could help? 5 I have to grow. Or ask the hand to come down … (after hesitating) I’m actually doing it now. It’s hard for me to accept. It seems so … it’s embarrassing. Like in a fairy tale. What’s the point. But now the hand comes down further, lays itself around my shoulder. I feel gifted … I still have a long stretch of path ahead of me … around me the ruins of Pompeii, I sit on a hill and look at the ruins field, where everything has collapsed on top of each other. The onset of sadness can initially be experienced more intensely after the intervention of the associative loop (7 Sect. 7.3). The fusionary longing movement towards a dyadic merging, however, immediately wards off the experience of sadness and feeling lost. Alone, it lacks any “momentum” and, with a shame-laden regressive movement, it grasps the “hand from above.” It represents a significant step of trust that she can show herself to me in her—in everyday life so perfectly warded off under the capable self-sufficiency—deficient self-perception and with her idealizing defense: In the “hand from above” may be father, soul friend, and “God,” but above all, a rescue fantasy directed at the analyst, merged with her at a place where no second … has room, to escape the labyrinth of her inner

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conflicts. The ruins of Pompeii suddenly appearing towards the end of the imagination raise questions in me: Do they stand for a fear of sudden (self-)destruction due to an explosion of anger or (self-)hatred? For a punishment impulse for grasping the hand? Or for something hopeful, the preservation of a grandiose site beyond destruction? The backgrounds of the massive affects hinted at here remain ununderstood at this point. This imagination, with the illustration of her supposed “union” with me, a perceived closeness of self and self-ideal, actually brings Ms. Eichel vigorously into a narcissistic elation at first: In unconscious fusion with me, she asserts herself against Helga for the first time and signs up for further training (conflict mediation training). She begins to call the imaginations of nature motifs “refueling spots” and experiences them similarly to her concert visits: There, she feels protected, calm, and with herself. This can be understood in such a way that she feels secure in my “hand” when my real presence does not “disturb” her idealization. In the real conversation situation with me, however, great tension is noticeable: She prepares for the sessions, has to “work through” her topics, and can hardly integrate interventions. This splitting defense intensifies the above-described transference dilemma and her tendencies towards self-punishment. Not only in the imaginations do images suddenly “deteriorate”; particularly pleasant imaginations and sessions in which Ms. Eichel can give more space to the expression of exhaustion or resignation are followed by “inexplicable” psychosomatic reactions. Thus, the blood pressure rises to 240:120 mm Hg after Ms. Eichel experiences in the 6th imagination (20): “Scene of pleasant lightness” (the motif choice was based on Ms. Eichel’s regret about how much she misses lightness in her life) a light, lively evening in an Italian city together with a sympathetic man. She takes medica-

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tion and develops feelings of guilt about the further training. She can’t even manage her everyday work, and then go away! She expresses for the first time, wrapped in humor, a kind of anger at me: I had given her a seductive topic with the imagination stimulus and lured her into “coquetry”! The elation is gone. She is now afraid that at the mediation weekend, it would come out how “disturbed” she is. This is a clear transference allusion (7 Sect. 7.7.4), I could notice her idealizing fusion with me. Therefore, she steers towards more conscious fields: A friend had been horrified at how she let her husband treat her. She had already recognized in the first analysis that he was just like her mother, but had not been able to change anything about it. She wished he would have an affair so she could finally distance herself. However, her dreams reveal deeper fears (23): I was in a house where a wall was crumbling. Outside, marauding Nazi troops. Feeling: I have to protect myself, hide, save myself. The dream could show: Should the wall of idealizing defense and, furthermore, that of the false self crumble, Ms. Eichel fears coming into contact with a destructive hatred, which will be directed particularly at me as the one “penetrating” reality with the Other. Aggressive impulses cannot yet be processed in the transference relationship. Ms. Eichel turns them against herself, concretely breaking her toe because she hurried to the phone too hastily—she cannot allow herself not to answer a call. And despite severe pain, she only goes for an X-ray after a few days. Mother always said: “Don’t make such a fuss!” Witnessing the masochistic turn along with the physical injuries repeatedly fills me with concern and feelings of helplessness, the indications of massive aggressive affects behind her defense (Pompeii, Nazi troops) unsettle me. Therefore, I suggest an increase in frequency combined with a change in setting, continuing the analysis lying down.

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Ms. Eichel agrees. With the change in setting, I also aim to relieve both her and myself from focusing on my “critical” expression and to refer her even more strongly to herself and her inner experience, thus being able to more effectively unfold and address the transference dynamics. z Uphill

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Presentation of the second to fourth year of treatment (hour 50–380, three times a week lying down): On this “mountain stretch,” there are a total of 29 imaginations, starting from stimulating motifs (which are still developed by me from the conversations and associations) such as “fairytale landscape,” “object,” “I take something for myself,” as well as aspects or locations from night dreams (7 Sect. 7.2). Since Ms. Eichel now lies on the couch, the imagination is not connected to a spatial change as before. I ask—making sure it suits her—if she would like to imagine; a relaxation instruction is omitted, everything else happens as in 7 Chap. 3.5 described, with her changing affective state during imagining increasingly being addressed and related to the transference process. Ms. Eichel describes her more frequent coming and looking out the window while lying down initially as pleasant, which again triggers the thought of at least partial adaptation in me. In an imagination of a “fairytale landscape” (51), she sees … a clearing with a villa. Stately … Next to the large columned entrance … a completely normal house. Next to it another extension … like a Hundertwasser building. It doesn’t fit. She associates this with the discrepancy between the “maternal ideals” and parental reality—for me, it is clear how insecure Ms. Eichel is in her identity, how uncertain about where she “belongs” and wants to be, even the extension … doesn’t fit (to “house” 7 Sect. 7.2). Being an “extension” to the parental home seems to me a vivid expression of her lack of detachment. Denying

this and delighting in the colorful Hundertwasser building, Ms. Eichel feels strengthened but soon suffers a sudden hearing loss, accompanied by dizziness and very high blood pressure. Possibly, she had also perceived her critical thoughts about her parents as a breach of loyalty, which put her under (psychological) high pressure. She projects the fear triggered by this process dynamic onto me and expresses that I could lose patience with her after this psychosomatic “setback.” When I accidentally meet her in my street during this time, she reacts shocked and turns away abruptly. In the hours afterwards, she expresses concern about having been intrusive and the certainty of being a nuisance to me. Her affect escalates into self-disgust. Since I have never before experienced her so intensely, I tell her out of my own concern that I find the discrepancy between her experience of worthlessness and how I perceive her—I enjoy working with her—to be startling (for the communication of countertransference feelings 7 Sect. 7.7.5). After this expression of active resonance, Ms. Eichel feels better and thinks that her anger at herself is not only related to the psychosomatic “collapse” after the imagination she “enjoyed,” but also to the increased frequency: She does not feel entitled to “so much,” has experienced herself as “voracious” and fears that she would destroy everything here with her “greedy clinging.” This is an approach to her warded-off neediness. What she is not aware of at this point—and I do not interpret it to her yet—is that the increased frequency primarily increases her fear of no longer being able to control her defense and that she could “devour” me with her shamefully experienced “oral greed.” Furthermore, it becomes clear to me that this moving sequence contains a more extensive defense dynamics: The real encounter with me in everyday life had been experienced by Ms. Eichel as a threatening

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attack on her idealization of me. I do not address this transference at this point, but ask her at the end of the session if an “object” spontaneously comes to her inner eye that reflects her emotional state after our conversation (59): … a terracotta amphora. Rustic, rough… But there is a silver edge—as if there is a second vase inside. Yes, a finely decorated second vase is inside, the rough one is like a protection.—She wants to take out the inner one and in doing so breaks the outer one into a pile of shards. In the following sessions, she deals with this surprising “discovery,” which she experiences as a hopeful expansion. Then she finds the inner vase “too beautiful” and wonders: Which is the real vase? The one inside? Or outside? What is this strange double vase anyway? In the countertransference, I am particularly disturbed by the pile of shards she does not address, which reminds me again of the ruins of Pompeii and which I associate with a possibly “sudden breaking” of her defense. What is closer to Ms. Eichel’s consciousness is something else: As she ponders the “double vase,” she begins to suspect that with her altruism she wards off the frightening search for her own self. As an irritating change, she reports: Helga called recently and she noticed: “I’m bored!” She agrees when I say: “You have forbidden yourself such feelings so far.” She feels confused. Increasingly, our conversations shake her perspectives, her confusion causes “cracks” in her world of functioning. After this understanding approach to her altruistic defense, Ms. Eichel has another hypertensive crisis associated with a severe dizziness attack. However, she attributes it to an excess of external demands, her “stress.” “That means, I stage it myself.” My problematization of her self-blame, in which I feel again that she wants to preempt interpretations she fears from me, is difficult for her to bear. “That you take me so seriously!” Her brother—thus she stabilizes

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her altruistic defense again—once wrote in her poetry album that she should “be like a light that consumes itself for others.” Increasingly, she reports that her current “only peace” is in concerts, “where no one can talk to me.” In doing so, she lets me know (see external projection; 7 Sect. 7.7.4) how exhausting the analytical sessions with me have become, how much her regressive desires press in during these sessions, and how her multilayered defense, including the concealment of the idealization of my person, is called into question. She cannot speak of this effort, consciously experiencing something entirely different when she reports that sometimes at night she lights a candle and, “thinking about the therapy,” sinks into feelings like “heavy sweetness.” I understand this as an expression of how much she struggles outside of the hours to maintain her idealizing fusion with me, which she can maintain less and less during the analytical sessions. As the summer holidays are approaching, I do not want to destabilize the idealizing defense by interpretations at the moment. She shamefully attributes her bladder complaints back to her overwork, which probably keeps the impending separation pain at bay. In my countertransference, I feel—thinking of the broken outer vase— the desire to stabilize her using the kinesthetic dimension of imagination (7 Chap. 2, 7 Excursus 3: kinesthetic). Building on the fact that she is currently dramatizing a saga with her students (79), I suggest the motif “figure from the world of legends.” After Kriemhild as the first idea, Antigone appears as the second. 5 How do you see her in front of you? 5 A slender, rather delicate medium-sized figure, dark-haired, in a long robe. 5 How does her facial expression affect you? 5 It is a gentle and also energetic gaze into the distance. Clear. Mild … a line of poetry comes to my mind: “Lovely anemone … Nausicaa.” Beautiful light.

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5 Can you try to bring yourself into the landscape and make contact with Antigone? 5 That’s not so easy. She seems unapproachable. 5 Has she noticed that you are there? 5 I squat there, knees bent. She stands straight, motionless. I feel so clumsy in front of her. She is so clear, noble. I feel out of place. This feeling is so familiar to me … 5 Does a scene from your life come up with this feeling? 5 I am too tall, too rough, too clumsy. My mother always said: How can one have two such different children, one so beautiful, the other so ugly … (cries). 5 What would be good for you so that you could make contact with Antigone after all? 5 If I imagine that I am wearing something neat or even noble. Yes, that’s better. I am standing now too, not as straight as Antigone, but slimmer than before. Maybe everything would be better if I could hear Antigone’s voice. 5 Yes, how could you manage that? 5 Approach her. She looks at me now with a warm, friendly gaze. She seems so completely with herself. Harmonious. Now she smiles. Friendly, familiar, as if she knows me. She points to the sea. She wants to show me something. I don’t feel inferior anymore. Everything looks beautiful: the waves run from left to right … 5 And what does her voice sound like? 5 Soft, dark, melodic. In this imagination, I actively promote the contact between her and Antigone, in which she illustrates her ego ideal in the transference to me. The approach of her imagined real self to Antigone is intended to help both perceive this ideal and my person idealized by her more realistically and thus strengthen Ms. Eichel narcissistically. At first, however, the narcissistic gradient is almost insurmountable: I squat there … She stands straight … I feel clumsy … She is so

clear, noble. In the end, she has something decent or even noble about her … She stands now too, although not as straight as Antigone, … smiles … is friendly … as if she knows me. And: I no longer feel inferior. Of course, the idealization has not suddenly given way to a relationship on an equal footing to be developed during the analysis, as the sentence also shows: She points to the sea. She wants to show me something. But an approach succeeds, and here with the help of the associative loop (7 Sect. 7.3). Through the question: “Does a scene from your life emerge with this feeling?” the imagination can be enriched with biographical associations, and the pain of devaluations and humiliations can come into feeling: The impulses directed against the self (I am too tall, too coarse, too clumsy) turn in the “Kriemhild” idea in this imagination for the first time briefly as a revenge impulse against the failing mother. (In the saga, Kriemhild causes a bloodbath due to her rejection.) The defense of this revenge impulse by turning it into the opposite, into the “victim,” is present when she chooses Antigone instead of Kriemhild. (Antigone’s rebellion is fueled by loyalty to her brother, is punished with death, and represents self-sacrifice.) During the holidays, Ms. Eichel deals intensively with recreations of the Antigone imagination, which also promotes the processing of her brother relationship. How pronounced Ms. Eichel’s altruistic sacrificial attitude also feeds the transference dynamics is shown by a scene (7 Sect. 7.7, 7 Excursus 11: Scene) that occurred twice (!) during this time: I forgot to bill an hour. In the sense of a countertransference error (probably I had to “make up for” unacknowledged aggressive impulses), I had miscounted in her favor. Ms. Eichel pointed this out to me. I asked her if she would have mentioned it if I had accidentally billed too much. She said she was sure she would have silently paid the money. (At the end of the analysis, I actually billed her

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one hour too much, which she addresses and makes both of us smile, thinking of this earlier scene.) In the 86th session, there is another vividly pictorial communication of her exaggerated closeness wishes towards me, as Ms. Eichel sees a serious, then smiling angel in the motif “Something from a Chagall painting” (which she visited on a trip) who wraps her protectively and tells her that she doesn’t have to climb the narrow Jacob’s ladder. Mrs. Eichel associates the angel with shame in herself. Unlike in Antigone, who represents an idealized self-sacrificing self-aspect on the subject level and an ideal figure on the object level, her regressive needs for maternal security are more clearly expressed in the protective “angel” on the object level. On the subject level, the “angel” symbolizes self-centeredness (7 Sect. 7.4, 7 Excursus 9: subject-/object-level dream interpretation). Mrs. Eichel openly speaks of her great longing to be seen by me during the discussion of her painting made at home and brought to the next session, but immediately adds: “… even though I have no right to it.” During therapy breaks, physical symptoms now almost regularly occur, which restrict, hurt, or disfigure her (chalazion on the eye, fractures, bruises, slow-healing infections, pain when walking). Only slowly can Mrs. Eichel understand this as an expression of separation pain and old disappointments; superficially, she blames herself for these injuries to protect me from her disappointment rage. With the increasingly noticeable feelings of affection for her, which I have to protect against her devaluation and explain as a necessary part of her self-search, Mrs. Eichel’s dependency fears become increasingly unbearable. She therefore expresses doubts about my authenticity (“It’s just a professional contact for you”) and reveals her fears indirectly when she talks about her new love relationship with a distant man: “If he doesn’t get in touch, I

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feel annihilated.” How much she means the transference relationship by this, she herself says shortly afterwards: “When the therapy is over, I won’t be able to cope.” Her love relationship is thus not only a side-transference that should alleviate her dependency fears from me but also one with which she can indirectly address the transference. Mrs. Eichel dreams of a horse. We discuss her desires to be carried, and I try to help her become more aware of such shamefully warded off affects in a continuation of this night dream (7 Sect. 7.2) with an imagination (clarification function) (105): She sees a white horse, it runs at full gallop, powerful, stormy. I touch it, very smooth, strong, silky, not too soft. Giveit a carrot. It paws impatiently. Eyes full of fire and trust … I ride now without a saddle, beautiful movement feeling, slow rocking … indescribably beautiful … If I had the courage, I would gallop … I am not afraid that it will throw me off. Safe feeling. Warm body. The need for closeness becomes more physically noticeable to her in this imagination. Mrs. Eichel connects the distant lover with the horse and feels so safe with me in this session that she allows herself to experience such feelings in my presence in the imagination, not just reporting about them. When her lover rejects her Christmas gift as “too big,” she reports to me (!) how she had been beside herself with crying for days: “As if I am worth nothing.” I pick up on this transference allusion: “Is that also the danger between us when you give me something? If I reject, would that be a confirmation of your inner certainty of being worthless?” “Yes.” I accept her artfully self-made Christmas star and hang it on the therapy window (for a detailed description, see above “gift scene”). Mrs. Eichel repeatedly expresses doubts about the “right path.” Should she break up with her lover? Separate from her husband? (How conscious are her tendencies to break away here? I think.) Picking up

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on her metaphor, I suggest an imagination about the “path” (115): Blue chicory lines the path, walking is springy, pleasant. It used to be paved—is it Pompeii? Two hands are in front of me, protecting, sheltering. To the right and left of the path, bushes become clearer, trees, tall ferns. Safe. As if the path has a canopy of leaves. The hands point forward: There is your path. I see a tiny house, like children draw. With a large fieldstone well. I lower a squeaky bucket. Mrs. Eichel associates the “hands” with me, like the “angel,” and the chicory as symbols of longing that line her analytical path. My interventions can now be more appropriately used as “protective hands,” no longer as a “hand from above” (18) originating from a nebulous beyond as a “signpost.” At the same time, the image of the hands shows how much Mrs. Eichel needs to adapt to my presumed ideas of where “it goes along.” She lets her path be shown. The tiny children’s house could be considered an “autonomy germ,” a house, not an annex. By lowering the bucket into the well, the hopeful outlook could show that the “soul element” can be drawn from the “unconscious” of our process, from which her authentic path can emerge. She also expresses that it will still squeak quite a bit beforehand. It is often difficult to decide when an interpretation or an imagination better promotes the process. Some of my interpretations are still processed extremely self-critically, which provokes further resistance. Since I know Mrs. Eichel better now, I let myself be guided more by my intuition and try in conversation and imagination to accept the often agonizing stuckness in the “I-just-can’t-manage-to-set-boundaries” on the one hand as despair, and on the other hand to understand it as an expression of masochistic self-torture arising from unconscious needs for punishment. Imaginations help me occasionally to distance myself better from this burdensome trans-

ference-countertransference dynamic and support my concern to introduce Mrs. Eichel to her impulses and desires. In this sense, I also suggest an imagination on the motif “A source of strength” (before a short wellness vacation, which we consider a small therapy success). This leads to a playful encounter between a bull made of swamp mud and a flamenco dancer dancing around him, but afterwards Mrs. Eichel feels “seduced” by me to “such fiery desires” and then “caught” with shameful feelings. More important than interpreting this projection is to appreciate that she opens this thought to me, and I take her transference fantasy as an occasion to discuss the imagination work under the transference aspect (7 Sect. 7.7.6). Unlike before, she can entrust me with her fantasies about my choice of motifs. They oscillate between negative transference fantasies (I want to “catch” her with feelings and scold her for them or envy her like the mother who used to complain to her as a child about the “disgusting sexuality” with the father) and more realistic perceptions (I want to encourage her to more sensual self-care). Mrs. Eichel can accept my goodwill after this problematization around the “source of strength imagination,” but I am aware that this will again alternate with negative transference fantasies. At the moment, she brings the discrepancy between what she habitually expects and what she actually experiences in contact with me into a thoughtful astonishment. To start an imagination on her own initiative and with her own inner image, Mrs. Eichel still cannot imagine. It does not occur to her, although she reports that she sometimes came to the session with the desire for an imagination. We also understand from this analytical sequence how much she “sniffs” towards me with her entire sensory system in the real encounter and puts her own needs aside to orient herself towards me and my supposed wishes. With this, we can lift the

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previous denial of her adaptation to me a little further. By using splitting defense (bad mother, good analyst), that is, a previously unconscious negative transference to me, Mrs. Eichel can allow more childlike experiences, especially in the imaginations. Here, for example, she appears in the form of a girl (socalled age regression; 7 Sect. 7.3). A motif chosen according to the season and her mood is “spring landscape” (145): 5 Hilly green expanse, carpets of wood anemones, stream with yellow marsh marigolds. Pick a bouquet of cowslips. Under white flowering trees. See myself there as a child with a white ribbon under an apple tree. But why do I look so serious, so pale? So joyless? 5 Would you like to ask the child? 5 It says: I left the party. I did something wrong. 5 Do you have an idea of what might be good for the child? 5 Playing ball… The child plays as if transformed. It gets a friendly woman to play with. It’s fun—we’re doing well, colorful ball, flowers. Long playing by the stream. The girl is worried that someone will call her. She has to go back. Her teddy is there. We make wreaths for him. We are now plotting against the others. In these imaginations, Mrs. Eichel learns to turn to her childlike self more lovingly, supported by me, who, as here, increasingly appears in a more realistic form as a “friendly woman.” At the same time, the negative transference to me becomes clearer: She expresses fear that she is banal and exhausting for me because little changes in her life and she is so “slow.” She can even confide in me the fantasy that I take long vacations because I need to recover from “someone like her.” And she notices, probably also because she senses that I appreciate imaginations and wants to appease me: As soon as she enters my room, her feelings are “as if flown away.” In therapeutic conversations,

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she thinks exclusively—only in the imaginations is this different at times. Of course, this is not true, but it shows how much she wants to maintain control over her emotions in my presence. When I interpret this to her, she can admit: She would expose herself defenselessly to feelings of feared rejection, envious resentment, and contempt. Mrs. Eichel can now more productively pick up interpretations like these because she increasingly feels that she is beginning to bear them together with me. And she can also allow them more when they contain the empathy and care she missed in her childhood: For example, when I address her that it is a kind of self-destructiveness when she continues to work tired instead of going to bed, or when she sends text messages while driving to do friends a favor. Despite these successes, I experience the ever-new complementary “transference struggle” (7 Sect. 7.7.5) against her self-destructiveness—the patient feels this quite accurately—as burdensome and choose (168) from the strain of my countertransference the motif “mountain hike” (see specific motif “mountain“; 7 Sect. 7.2). In doing so, the significant image of the “abyss” appears for the first time. With this expression, Mrs. Eichel later characterizes her fear of the feeling of a helpless dependency on me: It is a mountain path, rocky, narrow, craggy. Deceptive. On the left, a rugged rock face; on the right, a deep abyss. (after a touch intervention) I am now sitting on the path, looking into the distance. A bird, rustling. An lizard emerges. From a hole in the rock, bushes grow, even an alpine violet… Bright clouds alternate with dark ones. I want to lean against the warm rock. And hope that no one comes. But it is very narrow. I find a stick that supports me, protects me from the abyss, and also helps with climbing. Far below, I see a river, houses, meadows. But the abyss yawns deeply in between. And behind it, a dark fir forest. I feel

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unease. I want to find another way back. Now just linger and rest for a while. The path will go along steep rock faces, but there is also a wooden railing. Mrs. Eichel is far from enjoying herself in her own house on a meadow by the river of her life, but at least such a vision appears in the far distance imaginatively. Closeness—also between us—is characterized by the space-filling, dominating rock of the other in her experience and the fear of the abyss, losing hold in her defensive configuration and plunging into a loss of self and object. Mrs. Eichel spontaneously relates this imagination in a beautifying way to our analytical process: After all, she has already come a little way! She sees me in the helpful stick and in the supportive warm rock. Against which she can even lean! She no longer puts me on the high pedestal like Antigone! My question: “Do you have to appease me that it is progressing because you fear my impatience?” she can affirm and, upon my inquiry: “And what does the abyss mean to you?” admit: “Annihilation. If you can’t bear me anymore.” Many other aspects contained in the “abyss” only become clear to me in the course of the process; at the moment, I contradict her formulation “bear” and say: “We can only stop here when you can feel that our common path is also an enrichment for me.” In the next session (175), Mrs. Eichel can say that the idea that she could mean something to me had relieved and cheered her for a while, but she had to quickly “chase away” this feeling, could only “secretly” bring it out, “at night, when everything is done.” As for her feelings for me, she will only open the door a crack, she announces. So that I don’t shake her off as “annoying.” To further pursue this often-expressed transference fear and to use this justopened crack in her defense, I pick up on

her metaphor and suggest imagining the motif “door that is ajar”: 5 Dark door with wrought iron handle, in the gap something bright, wide. I am so small, do not reach the handle. I am 3, 4 years old, want to open the door, but am too small. 5 What would be helpful? 5 That someone comes and helps me, but now I hear demanding, angry voices from the next room. Someone scolds. If I keep quiet, no one will find me. Now I see a cat, it is a black and white spotted loving house cat. She sees that the door is open and quickly slips in. I also carefully squeeze through. It is an empty, light-filled room, shimmering in warm colors. You are also there in the form of the friendly woman from the apple tree imagination. I have now grown taller, in my current form, and stand in the middle of the light, completely penetrated by it, it is caressing, enveloping, healing, and surrounds me in spirals. Gold, yellow, white, also red. Each color corresponds to a different sound. The sounds envelop and penetrate me (excerpt). In this imagination, her early longing for security becomes apparent again, as well as the attempt to keep the negative mother transference out of our relationship through splitting (evil voices outside, me as a good figure inside). However, already the communication about her regressive needs in the follow-up conversation calls the persecuting superego back into action: Mrs. Eichel gets a gastrointestinal infection. Weakened, she comes to the next session and brings her painted door picture with her. She has glued a tiny photo of my practice door right in the middle, which I don’t even see, it’s so small. Therefore, I cannot initially classify why she comments on her picture with intense self-hatred as “ugly” and “stupid.” Affected, I wait silently for a while before I ask confusedly what is ­going

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on. The processing of this scene reveals that Mrs. Eichel has experienced my silence about the small photo as an expression of my contempt, as confirmation of her inner certainty of being intrusive and annoying with her “childish needs.” She cries when the misunderstanding is cleared up. She can finally accept that I didn’t see the photo at all and is then affected by what she has “made” of it. Now her “childish dependency” has come out. She is very ashamed, of course also about her reactive self-hatred, and we work through this scene again and again. After this and before the Christmas therapy break, Mrs. Eichel bumps her head against an iron pillar and suffers a laceration. “I’m always in a hurry”—she means her emotion-suppressing, efficient haste. During the Christmas break, after a sexually fulfilling meeting with her lover, she experiences a dramatic increase in blood pressure. I register with concern the self-destructive acting out, the interpretation of which Mrs. Eichel only turns against herself, and I have to represent her delegated self-care against her own interests. The doctor she visits at my intervention diagnoses angina pectoris and declares her unfit for work for a while. I understand these very stressful, extremely self-reproachful events as part of an escalating transference dynamic: In complementary countertransference I clearly care for her in the way she usually cares for others in altruistic defense. However, our relationship dynamic contains an even more extensive action dialogue: Mrs. Eichel virtually forces me to experience my concern for her. In order to trust that I am genuinely interested in her well-being, she must unconsciously create situations that cause concern. She can now better accept interpretations in this direction, and when she can understand such a scene, Mrs. Eichel relaxes in the “aha experience” of recognized evidence. She can then cry, increas-

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ingly stand by her needs, experience this as an “inner expansion” that corresponds to the external expansion she experiences primarily through the cessation of caring for Helga (who has meanwhile “found a partner suitable for her”); and sometimes she can take some of this into her other relationships for a short time. So we continue to make progress “uphill.” At the next “transference serpentine,” she develops a painful granuloma. A torturous dental treatment takes place, and the pain worsens. Mrs. Eichel only mentions this in passing. Since I now know her self-neglect and the still necessary takeover of her delegated self-care to me, I problematize why she doesn’t let a second doctor take a look. With doubts (“So much fuss about me?!”), Mrs. Eichel changes the practitioner. The new doctor finds that the first one left a piece of his instrument in the tooth. In projection of her superego, she tells him how terrible it must be for that doctor “if this comes out.” The new doctor says, astonished, “Well, why do you feel sorry for him? These are your teeth and pain!” I am glad that she tells the remark of the second doctor and can also productively pick up on it, which would not have been the case earlier, and problematize why she is not allowed to feel anger, not even when the first dentist does not apologize and sends the bill without comment (she thus continues to side with the superego of the “attacker” instead of her ego). Mrs. Eichel recalls that at the age of eight, she wanted to jump out of the window in anger at her mother. The story with the second dentist as a “side therapist” helps her understand the extent of the turn against herself: how much she is identified with her mother, who could not bear illness or weakness and therefore denied them in her children or accused them of pretending to be sick just to burden her. And how little she was allowed to burden her father, whose ideals of self-sacrifice had become “ingrained” in her.

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After this, Mrs. Eichel can trust me more spontaneously. When she hears piano music from the background of the practice, which is part of my apartment, she mentions for the first time that she used to play the piano and accordion. She fantasizes that I play the piano brilliantly, while she stopped because she was too bad. I modify my usual analytical restraint, as this situation is well suited to weaken the defense-related divisions, and say: “How you must idealize me. I can’t play the piano at all.” Mrs. Eichel laughs in surprise, and it makes her happy that she has heard something “personally genuine” from me. This incident allows her to use her own keys: She now practices the accordion again, takes it on vacation—and comes back with a bandaged hand. She had caught herself in a hurry in a door. She appears vulnerable and tells a dream (208): A giant tomcat, who hugged me like a human, was plucked. I clean his fur. He purrs, is trusting, stands on his hind legs. He is quite disheveled. I discover a broken piece of metal in his fur. The dream tomcat as a self-symbol brings her the tooth story back into consciousness with the metal in its fur, the fur cleaning the scene of leaf plucking; as a counterpart, it appears not idealized, but seeking contact, trusting. Possibly a longing for the father is expressed in it. I suggest further imagining this dream figure containing new transfer dimensions at a suitable opportunity (210): The tomcat stands on injured paws at the feeding bowl. He licks his fur, has a beautiful mane, he is tired. What do you feel like? I stroke his fur and feel something sharp, pull a piece of metal out of his paw. It’s a tin fork, as if someone wanted to stab him. The imaginative experience leads Mrs. Eichel through a subject-level consideration (7 Sect. 7.4, 7 Excursus 9: subject-/ object-level dream interpretation) initially closer to her aggression turned against herself. With the tin fork (a cake fork), she associates motherly things and recalls im-

pulses to stab or cut herself when her mother was not satisfied with her. The “fork” as a murder weapon then reminds her of her murder impulses towards her first analyst; and for the first time, she now reports in detail, with shame, about the traumatic experience of the “expulsion” back then. The analyst had repeatedly “confronted” her with why she didn’t change, didn’t separate from her husband, and one day received her with the words: “This is our last hour. I don’t feel like doing therapy with you anymore.” Almost “petrified”—in dissociative defense—she could not protest. In this exceptional state, she went up to the roof of a high-rise building after the session and wanted to throw herself down. Standing on the edge of the roof “like on an abyss (!)” she developed the fantasy of breaking into the analyst’s place, killing her with a knife, and then herself. “How exaggerated! I also received so much good there!” That Mrs. Eichel reports to me about the frightening fantasy at this time, I consider significant in several ways: Above all, I understand her communication as progress in terms of recognizing and integrating her own aggressive impulses. It makes me confident insofar as she is on her way to alleviate divisions, to represent me and herself more holistically within herself. Also, her description already contains some transferred anger, because she basically reproaches me for “nothing changing,” and her long analysis so far only brings her a change of progress and regression. Possibly, she has also come into contact with a more extensive disappointment rage (fork in the paw) about the fact that there can be no “embrace,” i.e., truly lived closeness between us, as the cat in the dream strives for. These are assumptions that can be deduced from the transfer relationship, which cannot be clarified with Mrs. Eichel at this point because her anger towards me must remain unconscious: She feels too dependent on me and could not yet trust that our

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relationship would withstand and not be destroyed by anger expressed against me. Indeed, it is now more often about her aggressive impulses and her anger. As in a dream (231): Many guests, including deceased ones. Had no time to set the table. Others did it. I folded napkins. Cold and loveless zucchini soup was served. Everything messy, bread crumbled. An old slice of cheese. I say angrily: “Impossible!” Then she expresses anger about an “impudent student” who provokes her. In the class, she can contain him well, as she feels the anger on behalf of the others. But alone, she is helpless against him, “weak as a straw.” And she is ready to confront aggressively: She contacts the former analyst to understand what happened back then. But she refuses a conversation: “I don’t work anymore.” She initially turns this evasion against herself in the form of resignation. Then again, she experiences a “liberating feeling” when her husband is in the hospital for heart surgery and no longer “bothers” her, but she has to punish herself for this thought with a laryngitis. For the first time, she uses the secondary gain from illness: Since she cannot speak, she cannot go to school. In this work break, she feels herself more and can allow depressive feelings: Grief that she has no children of her own, that she has adapted so much to her husband. And indignation that he “treats her like a servant, but is charming to the nurse.” In these hours, I now experience Mrs. Eichel as noticeably more vital and attentive to her needs. She expresses the desire to travel alone with a friend. She buys herself a beautiful “chicory blue” dress. She takes accordion lessons and experiences there “speechless with joy” that something beautiful comes out of her, but mistrusts the praise of her teacher. I use this to interpret her negative transfer, that she also mistrusts me and the authenticity of my empathy. Thus, self-punishment alternates with more self-oriented behavior. She tells me that she bought a beautiful carpet that re-

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minds her of mine in the practice room. When she meets me on the street for the second time, she is startled at first: “How do I look again!”, but she doesn’t have to run away. In the following session, she can even communicate how she experienced me in contrast: younger, more natural, more self-evident; and she adds convincingly: If I had not met her in the therapeutic context, I would not be interested in her. Only my “therapeutic interest”—that could be genuine. After this comparison, which negotiates her self-worth, she expresses anger that she “processes” her vacation with corrections: “I’m missing out on life!” Probably, she processes her mainly unconscious envy and anger towards me, I think, who leave her stuck in her old life and in her fantasy embark on the most wonderful vacations. When her emotional detachment, which is typical after separations, loosens up again, she can express needs such as “wanting to curl up,” “rolling up like a child.” She feels so exhausted. She feels so cold. “But I have such inhibitions about taking your blanket!” Now she can confide in me that covering up in the first analysis was interpreted as “exhibition inhibition” (7 Sect. 6.4). She experiences herself as “one step further” in confiding her feelings. Flower gifts accumulate (7 Sect. 6.4). At the next hairpin bend, she can face the processing of her husband’s infidelity, which has come out unexpectedly. Now she would have a “reason for separation,” says Mrs. Eichel, upset and hurt. In everything, she tries to please him—and now this. But when she tries to feel how she would cope with the separation, she is seized by a desperate fear, above all that I would now drop her like the first analyst, who, in her experience, would have lost patience at this point. After we resolve this transfer fear, she can admit how much she needs her husband, whom she is so upset about, for “self-assurance”; however, she cannot perceive how dependent she feels on me: She decides to have a conversation with her h ­ usband

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about his affair and expresses contempt for him when he “plays everything down,” that he does not separate from her. With this reaction formation, she wards off her self-contempt for not being able to separate, and I respect that it will take further hairpin bends for Mrs. Eichel to face the processing of such a projection and her dependency issues. z Reaching the Summit Plateau

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Presentation from the fourth treatment year (hour 381–419, alternating between sitting and lying down three times a week): After the holidays (381), Mrs. Eichel brings me two bottles of wine. She wants to hand them over to me and is highly excited. I problematize: “As long as you feel you have to give me something so urgently, there is something in it, a must, that we have not yet understood. What can it be?” Mrs. Eichel fends off as usual: “No must, but an expression of joy and gratitude.” I confront that by having to give me something, she cements her inner certainty that she alone is not enough. I don’t want to allow that.—The bottles are in a double pack, a white and a red wine. Mrs. Eichel tries to counteract the feared rejection of her gift and makes me the “offer” to accept at least one bottle. I feel how she involves me with the worry of hurting her too massively (in a way, “throwing her out” in the form of the rejected bottle), but I still want to use this scene (7 Sect. 7.7, 7 Excursus 11: Scene) and ask: “Which one?” She then wants to keep the, as she says, perhaps somewhat “worse” white wine for herself and thinks of giving me the “better” red wine. I reply: “But I can’t accept it like that! The wine wouldn’t taste good to me if I had to think about your attributions while drinking it: The good for me, the bad for you.” A distant silence ensues. I understand this “double pack” gift of the two closely standing bottles as a plastic expression of their unconscious desire

to merge with the “good red wine mother” in order to experience their “white wine self ” as “upgrading” and justified in existence, to better endure feelings of inferiority and envy in the transfer relationship. In concordant countertransference, I feel the sad-helpless dilemma of the child not loved for its own sake, who so urgently seeks closeness and affection and whose communication efforts end in distant silence: I neither reject the gift nor can I accept it with the implications it contains. And I have tried to make Mrs. Eichel aware of her self-deprecating way of relating in this scene. She agrees with me “obediently,” as I perceive it, but I feel the force with which she is struck by the rejection. When she leaves, she leaves the bottles on the floor. Helplessly affected, I put them in a corner of the treatment room— they will have to be brought out again later, as the language contained in this scene between us has not yet been sufficiently found (7 Sect. 7.7, 7 Excursus 11: Scene; Action dialogue, 7 Sect. 7.7.4). Mrs. Eichel comes to the next session as if petrified and says tonelessly that she wants to break off the therapy. It is only with great difficulty that we manage to get back into a conversation. She speaks self-reproachfully and contemptuously, saying that she is “incapable of living”; reports of “devastating feelings” up to a finally expressed suicidal fantasy: “I’ll get rid of myself.” She cannot express her aggressive feelings towards me; such feelings are dissociatively split off. She had processed my explanations in such a way that I accuse her of “sticky clinging” and annoying desires for closeness. Finally, what she had always feared has now happened. In order not to be “shaken off like a piece of dirt” by me like the first analyst, she wants to preempt the eviction. We work through the scene with the contained self-esteem and dependency anxiety issues for hours, and in doing so, we

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also come back to her self-contempt projection (see above) before the holidays; it finally becomes a painful process of insight, in which Mrs. Eichel also gains an understanding of the then murder-suicide fantasy. The experience that I “survive” her threat to break off, even resist it, and seek her out in her terrible despair, promotes her security and trust. In order to further work through her splitting defense, her identification with the rejecting mother imago on the one hand and her idealizing merging desires with the “good” on the other—and I embody both for her, although she repeatedly wants to accommodate only the good in me—I suggest an imagination that starts with “… as a child in the kitchen with mother” (392): 5 I make dough in a children’s baking mold. Mother makes sheet cake, checks if I’m doing it right. I’m proud that I was allowed to make yeast dough. I hear Mother: “Don’t knead so much!” “Put them in rows and files!” “Don’t lick your finger!” 5 What would be good? 5 Throw the mold against the wall, stamp my feet. I won’t participate anymore! Neighbor comes and asks, she praises me, then Mother becomes insecure. In this imagination, Mrs. Eichel can allow a rage effect directly towards the mother— narcissistically supported by the analyst in the form of the “neighbor“. The split mother images move closer together—here symbolically spatially in one room. She then associates merging moments of closeness when she thinks of me and no longer needs to hide this for fear of my condemnation. She experienced something similar with her soulmate, and earlier with her father. Through such further processing of the “bottle scene”, the patient gradually becomes more aware of how retreating into a fusionary relationship fantasy with an idealized person or a transitional phenomenon like music represents her central “survival

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strategy”; and that she has to defend this illusion of non-separation with me against my analytical interpretations so massively. This insight leads to a more authentic relationship with me and with herself. However, it also leads to feelings of weakness, which cause her to stay home from school and enjoy the free space. At the same time, the regressive longing for fusion must be worked through again and again. At night, she occasionally has erotic dreams with me or the deceased soulmate—but she reports about it in the analysis and seems emotionally as accessible as never before. She expresses a longing for togetherness and acts it out again: she wants to give me a concert ticket because she cannot go due to time constraints. I can connect to the elaborations in the context of the “twin bottles” and do not accept the ticket. She is disappointed, but this time she can better “cope” with the feeling of rejection, i.e., bear the associated feeling. How deeply her experience of rejection goes becomes clear to me when she reports that she has separated from her lover, who had no time for her after an elaborate meeting arranged by her. By giving up this side-transference as the last protection against her dependency fears towards me, we move towards the summit plateau of the analytical hike, where Mrs. Eichel feels completely at the mercy of the feelings in the relationship with me. Dream (401): I walked down a staircase, had my hands full and carried a lot on my arm. Suddenly the staircase split in the middle. Gaping abyss. Dizzy, no hold. On the other half of the staircase, a nouveau riche, unsympathetic neighbor. I asked her for help. I am not entirely clear why I mutate into a nouveau riche neighbor; but the fact that she expresses unsympathetic things shows me how she descends from her idealizing staircase and makes room for a more holistic view of the important object relationships—a progress that also scares her considerably during this transition period: in

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dependence on an imperfect object, one has no hold, so that she becomes dizzy. Mrs. Eichel develops heart problems (!) when she realizes and expresses “how massive the love” for me is. Eye irritations accumulate. In a renewed attempt to gain support through the idealizing transference, she primarily experiences herself as an imposition for me, whom I have to look at when greeting. Once she blurts out: “Blind with love.” It does her good to repeatedly paint the gaping abyss from the dream, which we visit together imaginatively several times during this period, in its small changes: grass has grown high on one side, there is more space for the little yellow flower … Connected with this are autonomous steps: She demands borrowed money back from the ex-lover and goes on Christmas break an hour earlier than me to show me that she doesn’t need me completely. Of course, this also includes the attempt not to be helplessly exposed to the painful separation, a turn from passive to active. Indeed, her feelings of dependency on me are very strong, and after the break, she feels bad for a long time. She comes to the sessions sick and weak. However, she sees an infection right after the beginning of the vacation in Mallorca as the trigger for this escalation. Her husband did not “believe” that she was sick, and so she continued everything as usual. She did not hold it against him, as he had only become the mouthpiece of her own self-reproach: “During the holidays, one is supposed to feel good, what kind of drama are you making!” She describes herself as “tired of life”; but she wants to continue living for my sake, as I have already invested so much work in her. Her internist did not perform a stress echo and stress EKG because she is “too frail” for it and wants to admit her to a clinic, which Mrs. Eichel refuses. I am alarmed, deeply concerned, and struggle with feelings of hopelessness,

as well as doubts about whether therapeutic change can be achieved at all—identifying with Mrs. Eichel’s condition in concordant countertransference, suffering through it (7 Sect. 7.7.5). My peer consultation group helps me to endure this: The deterioration of her condition can no longer be explained solely by the previous transfer dynamics of punishing herself for regressive, longing desires directed at me. Mrs. Eichel has lost the illusion of being held by me as an omnipotent object, but has not yet been able to find sufficient support in realistic self- and object relations. In this situation, where it is necessary to further strengthen the already existing seeds of her autonomous development, I try to connect to shared experiential forms of our previous path: “Which of your inner images, which moments of our work play a role for you at the moment?” “Abyss, dead branch, vase, donkey, angel,” she lists tonelessly and very softly. “And your patience,” she adds. We search together, so to speak, for what she has experienced as “valid” from what has happened so far and what “carries” her. She then lingers a little on the apple tree and the friendly woman (145). In the next session, however, she speaks again of her “tiredness of life” and feels “unbearable” because of it. At the same time, she doubts the suicidality that can only be expressed with me, as when a student or her husband is “weak,” she is overcome with “boundless pity” and can give, no matter how she feels. She tries to rebuild her altruistic defense—and generates in me with this double message on the one hand concern and impulses to support, which she fends off on the other hand. But she can’t go back either. She “hangs in between.” And she loses weight. At a birthday party, she cries from weakness but is amazed at how nice everyone is to her: “Despite everything!” She tells me all this tonelessly, as if against my attempts to understand

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and accompany her. She talks about her inner image of the “abyss,” and I suggest (415), continuing to imagine based on that: 5 Stand at the edge, look into a battle turmoil of soldiers. Threatening. I have to go in, but I will perish there. 5 Do you want to go in? 5 No, I have to. 5 Who says that? 5 There is a quieter spot. Like a cave. I go in and retreat. A pleasant rest. The angel is also there. Also a staircase, stable, but without a railing. Next to it, a steel door with a bolt. It keeps the soldiers away. It’s brighter below. The angel comes and points there: “It gets better in the back. Slowly. But it does.” The imagination illustrates where we stand in the analysis: She experiences my offers of understanding not as access to something hopeful, and psychoanalysis as a threatening battle turmoil, in which she … perishes, and from which she believes she can only save herself by retreating again into a cave. I am no longer the angel, but an analytical soldier, against whom she needs a steel door. Only with confrontational questions (“Who says that?”) do I penetrate her and can stop the resigned crash. While Mrs. Eichel leaves the session situationally strengthened after the imagination through my containing, she shows her picture painted in “night shift” as if crouching in a grave. It deeply frightens me, I address her about it and her further weight loss, which I notice. Beyond perceiving my complementary countertransference and taking on a helper ego function, I push more strongly than before for medical help. This time she can accept it. Pathological laboratory values are found, toothaches are added: “My body screams.” It feels “empty” and “hollow.” Yet she has so much “luxury” compared to her mother: concerts, three times a week here, her friend! She is too weak to make music, cancels hours there and with me, accompanied by self-re-

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proaches: “Mother knitted so she could afford music lessons for the children.” Mrs. Eichel describes how she feels at the mercy of the introject voices with every self-care impulse: “Do this, don’t do that, don’t make such a fuss, don’t be ridiculous, don’t make a scene … ” and is flooded with memories. She then dialogues with me internally to brace herself against the maternal voice. In the sessions, I perceive her as depressed, exhausted, and partially petrified. In view of this development, I suggest increasing her session frequency, alternatively a clinic stay. I convey to her that I see her condition as a severe, but process-related crisis and that her body, in its weakness, helps her to take her neediness seriously in a broader sense. But that she needs more support for that. Mrs. Eichel is relieved at the end of the session after this intervention, which she initially received without visible reaction, and dissolves from her dissociative petrification. Later she says that my suggestion was the turning point of the analysis. Just as she could not express her desire for therapy at the first encounter, she would never have asked for another increase in session frequency. I also experience it that way. The peak—or the valley floor—has been reached. z Downhill

Presentation of the fifth and sixth treatment years (420th session to termination after 620 sessions three times, temporarily four times a week lying down, from the 560th session twice and from the 612th session once a week sitting): Mrs. Eichel begins the session (452) talking about a lively feeling, “as if a constricting crust” had crumbled away from her. In the last session, she had expressed her impression that I wanted to force the termination of the now temporarily four-hour analysis, thinking she “must finally stand on her own two feet.” The thought of an imminent separation had frightened her, and she had been able to recognize the reason for her projec-

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tion of superego aspects, but had initially reproached herself for this as a “relapse.” The insight into how and why she herself “creates” such thoughts had finally relieved her. Under the “crust,” she says now, she feels a new skin and with it a growing sense of security. “It helps that I now really feel that I can shape the end here in a way that suits me. I could never believe you when you said that we would determine the frequency and termination together.” She smiles. I smile back, I rejoice with her and now often feel in my countertransference how relieved I am that the “encrusted” transference dynamics between us have also dissolved—through the withdrawal of projections onto me, clearer self-object boundaries, recognition of separateness, and an increase in thoughtfulness in the hours, as it corresponds to the grown triangular inner space of Mrs. Eichel. So also now: Mrs. Eichel relativizes once again what she said in the last session under the arisen separation anxiety and the anticipatory fear of being a nuisance. She is embarrassed to have ever associated our process with the “expulsion disaster” of her first analysis. I point out the self-reproach contained therein. Mrs. Eichel is silent for a longer time. I ask after a little while: “Where are you right now?” She answers, picking up on an earlier imagination: I am lying curled up like a cat in a hollow. I can come to rest, I don’t have to achieve anything, not even here, I can just be. But I still need you to remind me of it again and again! She smiles again. I think of how she used to have to turn my clarifications against herself (“I am still self-reproachful.”) and me (“You confirm that it is futile with me.”) but can now simply accept them and instead immerse herself in a symbolic expression of being accepted—like a cat curled up in a hollow -. After a little more silence, she says her altruism is diminishing. In the past, she used to write cards to “everyone” during

the Christmas season, bring many gifts, but not this time. She bought winter shoes: beautiful, warm, with a good profile. She feels good in them. I know, she always used to walk around in ancient winter shoes and when she thinks about it now, her idea was: I always take off these shoes at the door when I go to others, so others hardly see them and that’s why they are “irrelevant“. It becomes clear to her how much she bought clothes to look suitable for others. It had little to do with herself. “How did I treat myself …” She then reports vividly about the weekend visit of a friend who helped her with the preparations for the planned Christmas performance of her class. “In the past, I wouldn’t have even said that I needed help. I would have stayed up at night, worked, and during the day only made sure to make it nice for the friend.” She now notices how much more lively the togetherness is when she also shows her weaknesses and limits. She cries. There is a swing of sadness about so much effort in such inauthentic relationships, her unlived life. I give space to that, then I add: “Yes, you could only ever show yourself with good performances. Only the polished crust. We know how long it took here, too, until you were allowed to be weak, for example, cry.” “Yes, and if so, self-punishment followed immediately.” Mrs. Eichel then tells that her friend discovered her entries for her analytical sessions on the calendar and asked about them. It had been uncomfortable for her, she had felt “caught,” but then answered openly. To her surprise, the friend had not reacted with raised eyebrows, but admiringly: “That you take this upon yourself. Such an intense process. How do you manage it all!” She hadn’t been able to see it that way herself! She had actually only experienced that I give her my time, the whole analysis was like a huge gift from me to her. “But you have been paying for it hour by hour by now,” I interject. She nods. Yes, she had downplayed that to herself. The

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friend’s reaction also made her realize once again that the workload, which was “normal” for her, was not normal at all. She realizes how she “constellates this drudgery,” how she always arranges it with too much so that she can’t manage the work, and then creates the feeling of worthlessness … It was especially tricky just before Christmas, even though she was doing so much less. After the friend’s reaction, however, my often-expressed words about self-punishment came back to her mind. Yes, she had finally understood. Currently, she was working “like a slave” again precisely because she was punishing herself for the holidays in the sunny area in the middle of winter. “I’m actually still showing my parents that I’ve completed all my tasks before the holidays so they can’t accuse me of selfishly enjoying my free time. It’s terrible to be so trapped.” I say, “Even here, with the termination issue, you have always been under pressure to prove yourself. Having to show me that you still need me. To preempt me saying, ‘It’s over now.’ It’s a good turning point that you are now considering the possibility that you yourself could sense from within when you will want to come less.” With this transference interpretation, I try to help Mrs. Eichel in working through the internalization of her important insights from the last session as well. Mrs. Eichel agrees and now remembers a dream she had after the last session: I am in a tall house, like a hotel or conference center. Up in the attic. A corner of the roof is gone, broken off. It looks like a ruin, plants have settled in, it is not at all comfortable. I want to get out. It goes down very steeply. Abyssal. When I look, I get dizzy, I’m afraid of falling. But I manage to get out by hanging onto a rope. I am very happy to have made it. Then a scene with an unsympathetic house owner, by whom I feel cheated. It had to do with vouchers that were devalued, always rounded down. Regarding the house, she associates a previous imagination of a tall, dark, ru-

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inous house, but with a small beautiful balcony full of blooming plants. She had painted a picture of this imagination, and she had also “destroyed” the house in another picture with wild crossing-outs when I had addressed her denial that she only looked at the “balcony” as the little “beautiful” in her life and could hardly acknowledge how threatening the condition of the “entire house” was. Just as she had thought back then that she could get by with the “beautiful balcony of analysis” in an otherwise gray and hard everyday life. Or to escape into “paradisiacal” imaginations or concerts. The relief that she now wanted and could leave the house recognized as uncomfortable in this dream, Mrs. Eichel says, corresponds to her new, more secure feeling; with the rope, she associates me and with the house owner her (internalized) mother. I understand their associative associations as a further virulent splitting defense (“saving rope” vs. “unsympathetic homeowner”) and express the thought that I too could be stuck in the homeowner and be contained in the fear of “rounding down” their “Bons” (sessions)—as an allusion to their “eviction” fantasy. We further understand the “rope” as a connection to their own self, which is still very dependent on the analytical relationship, “in order not to become dizzy”—and that there is no longer any alternative to leaving the ruinous, self-exploitative self-system across all abysses, even if there is no paradise waiting “abseiled” from the illusion ideals of the attic, but a conflictual world. In this last third of the psychoanalytic process, Ms. Eichel’s conflict themes are further worked through based on her external and our transfer relationship. This involves the increasingly differentiated and spontaneous perception of the neediness of her self, the dismantling of her altruistic defense, the mourning for the unlived and no longer livable (especially her own child), the perception and processing of

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the reasons for situational dissociative retreats, the acceptance and appreciation of her own life’s work, the accompanying mitigation of self-condemning superego rigidity and self-contemptuous ego-ideal instances “from the attic”, the development of adequate self-care, which was previously also blocked by the dynamics of the negative therapeutic reaction with physical self-punishments, and finally the detachment from the analytical relationship. This separation work is carried out in many steps and connected with the dissolution of the transfer. The understanding of the transfer relationship had repeatedly led to an immediate affective insight into self-images and conflicts in the various serpentines and had proven to be particularly effective in bringing about change (7 Sect. 7.7.6). Thus, during this process, the earlier idealization movements aimed at fusion as a defense against lostness, the neediness experienced as “greedy” at that time and therefore warded off, her adaptation-related identifications with me, the painful processes in recognizing our separateness, but also the internalization of various positive relationship experiences were worked through. All of this radiates into the everyday life of Mrs. Eichel. There, she shows herself as a counterpart who communicates her desires and dislikes more often and more clearly, and she says, often surprised herself: “I don’t know myself like this,” so in contact with her own emotions, sad, angry, and demanding something for herself: A “quite gruff ” gynecologist discovers “something unclear” in Mrs. Eichel’s uterus, suspects a polyp “or something else” and suggests a curettage with tissue examination. She presents everything as a small routine matter, and Mrs. Eichel initially adapts to the doctor’s trivialization. In session (480), however, Mrs. Eichel can then feel fear and also sadness: “Others have an ultrasound image of their child, and I

have one of a possibly malignant tumor.” She cries. She shares her feelings with me, which she could only report on in the past, as she was not allowed to “impose” herself in them. It touches me very much that she, who has fought so hard for her self, now has to experience it acutely threatened, and she senses my empathy. After another visit to the barely advising gynecologist, Mrs. Eichel comes to the session (482) full of anger but tries to distract from this emotion. “Do you have to distract from it because you feel less bearable with anger than with sadness?” Mrs. Eichel confirms this and recalls how she always directed anger against herself, even as a child. With this, she recognizes how mother-like she experienced the doctor’s routine disinterest. However, she has already made inquiries about another gynecologist. She compares her current behavior—as she often does now—with the past: “Do you remember how I defended the dentist who left a piece of metal in my gums?” She feels how much her self-esteem is strengthened by standing up for herself: “In the past, you did that for me!” Towards the end of the session, she can show her anger at the doctor more clearly: “When I compare that to what I do for my school children!” I ask: “How do you experience the anger? Do you have an inner image for it?” Mrs. Eichel slips into an imagination: 5 I see earth, earth, in which bumps always form. Like in Naples. As if everything wanted to be thrown out at once. Funny, now a few bumps have burst, and the individual craters where something came out look like big flowers… 5 What does the stuff that comes out look like? 5 Black, unpleasant. It is thrown up so high, then the next one comes. You have to be careful where you stand, the whole earth is hollow, just a thin crust. I feel the heat under my feet, an enormous energy and violence. I have the feeling I really have to be careful, I got away with

6.5 · The Analytical Process: At the Foot of the Mountain—Uphill—Reaching …

it again. When the craters are open, the black stuff is out, the edges look fluttery, like big flowers. Then it’s good. Like redeemed. I’m actually amazed… This vivid image full of aggression picks up on her earlier Pompeii associations and her metaphor of the “crust” as a symbol of a hardened boundary between herself and others. In terms of transference dynamics, I am all too familiar with the “energies” threatening her boundaries that are projected into me. The imagination illustrates how much aggressive impulses are still fused with auto-aggression in her, but she has escaped again. The violent dynamics that unfolded between us during the suicidal crisis come to mind. The word redeemed fits here; for more than the word “relieved”—a description that usually follows an emotional outburst—it contains an elevated component, traditionally derived from religious language. With the big flowers, Mrs. Eichel seems to want to appease the aggression, probably also to reassure me. Such imaginative “emotion pictures” in the middle of or at the end of sessions now often find their place (7 Sect. 7.4); they increasingly come from Ms. Eichel herself (see above “cat picture” (452)), and she only brings re-creations when she feels the desire to do so—the defense of her own impulses by focusing on supposed performance expectations decreases—a significant change as well. Fortunately, her concern for her physical integrity was soon resolved due to reassuring medical findings, but she can allow further engagement with the associated feelings: “The limits of my strength and the vulnerability of my body have become clearer to me.” We work through the earlier projective delegations of her self-care to me, and in addition to the increasingly noticeable changes in our relationship with more

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self-confidence and self-determination possibilities, there are also decisions and changes in her everyday life; Ms. Eichel— previously unthinkable!—is eagerly looking forward to her upcoming retirement. She discusses the distribution of housework with her husband and reports a “tearful breakdown” when he devalued her “beautiful fruit arrangement” during one of their joint vacations in Mallorca. In the past, she would always withdraw and hide her emotions behind cool rejection; now, to her surprise, he apologizes and, when she has a cold and lies down—unlike before—takes care of her. She sadly realizes what she has also prevented in her marriage: how much her pressure for perfection, which she had to exert on herself, contributed to the drying up of emotional life between them. In the 515th session, Ms. Eichel tells that a neighbor in Mallorca wanted to take her on a small excursion with his family while she was still recovering from a “relapse into the old marital dynamics.” She didn’t really want to go, but he had so charmingly campaigned for her participation. It turned out to be such a beautiful trip! She didn’t have to do anything, take any responsibility, just tag along and enjoy nature. She cries when I say, “Yes, that’s how it would have been nice for her as a child: to be wanted as a child in the familiar family environment and simply experience togetherness without pressure.” “Doing nothing” becomes a catchphrase that plays a big role in the sessions. “Today I would like to do nothing,” she “dares” to say, still a little on guard whether she gets “a slap on the wrist” for it. “I would love to sit like a child on the floor in front of the couch, at your feet, and just be. I’ve actually wanted that for years.” The fact that Ms. Eichel can not only allow such regressive wishes but also express them to me, I find significant; I tell her about Balint’s patient with the somersault, and Ms. Eichel soon afterwards (522) sits down at the end

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of the ­session, first a little shyly, then smiling on the floor, leans her head against the couch and lets herself slide into an imagination: I feel like I’m lying in a small boat and drifting on a calm water. My hand hangs over the edge of the boat, touching water lilies. White clouds slowly pass by in the sky above me… Oh, now I feel a current… (She sits up anxiously in the boat), I can’t see anything, but the beautiful mood is over, I’m somehow excited. On my intervention: “What would be good now?” she sees me from afar standing at the edge of the lake and waving. (She lies down again and listens to the gentle wind and seagulls). I ask: “What was going on with the turbulence?” Ms. Eichel states that she suddenly became afraid as she let herself drift, “becoming blind to dangers.” In such a surrendering state, the controlling “mother’s voice” had “crashed in.” But when she heard my voice and question, she came back “to herself.” I seem to be present in her differently now than before, when she could never have imagined that I would wave to her on my own. In one of the next hours, Ms. Eichel brings a painted picture that shows the Mallorca trip with the “family”—and me, as I stand in the distance and wave to the group. With the frequency reduction and setting change (sitting opposite each other) desired by Ms. Eichel from the 560th hour, she initially associates frightening fantasies of not yet being “that far” and thus destabilizing herself in a self-damaging way or also damaging me through lower bills. Through our conversation, it becomes clear that she wants to let me closer as a “real person” and is “curious.” In the countertransference, I feel relief and notice again how much the tension of containing Ms. Eichel’s projective identifications and maintaining the analytical position at the same time had weighed on me. Thus, something also dissolves in me concerning a greater naturalness of my behavior.

Indeed, Ms. Eichel has detached herself from idealizing and adaptive identifications with me and can perceive me as a separate counterpart. She had developed fantasies about my interests through knowledge of my publications and took singing lessons. She now stops this but intensifies her accordion playing, often together with a new friend. She starts a painting course and dares to talk about “light” literature instead of the “heavy” literature she thought would interest me. In place of her old fears of becoming a nuisance by revealing her “boundless desires” to me, cheerful, self-confident descriptions of her new orientations emerge: “I’m buying an iPhone, an iPad, and a lightweight laptop now!” she says, beaming. “Everything old is thrown out.” The analysis of her statement that I could be financially harmed by her coming less often leads us to Ms. Eichel’s previously self-denying handling of money. One reason for the frequency reduction was her desire to renovate. Related to the “house” dreams and imaginations, she realizes how significant this decision is for her process. Appropriately, during this time, my overcalculation of an hour due to a slip occurs, which Ms. Eichel—unlike before—can address, and which I “book” in the countertransference analysis as an expression of my sometimes denied effort in this process. With the change of framework, the farewell is even more obviously approaching, which is now directly or indirectly contained in every hour and in all dreams and imaginations: By Ms. Eichel crying a lot about what she has not been able to live so far, in life and also in our relationship: Longing to lean on, “do nothing,” feel herself. She expresses sadness and disappointment that I cannot be her lifelong companion, sometimes blaming herself again: “I’m whining again” and humorously—thus with mature defense—adding: “I’m not allowed to say that.” (I had once pointed out the self-deprecating nature of the word “whin-

6.5 · The Analytical Process: At the Foot of the Mountain—Uphill—Reaching …

ing” to her.) Occasionally, she requests additional hours, e.g., when “psychosomatic self-punishments” appear in the manifold changes, the current reason for which she wants to understand with me. Many dreams and imaginations also explicitly deal with the farewell (7 Sect. 7.6): Thus, Ms. Eichel repeatedly associates the mental image of positive object internalization, me waving to her from afar, with our farewell: “When I feel that this image in me is not lost, I can always find it, then I can go” (571). In the 582nd hour, she reports a dream: “You had introduced me to a sailing club. I was grateful and looked for something meaningful to do there. You were sanding a boat and trying to fix the cracks in the hull. I helped you. It was a beautiful, equal coexistence. A trip was to be made. I was afraid: Now it will come out that I can’t sail at all. I suddenly discovered a small, unnoticed enclosure with a few animals in it. They were somewhat foolishly humanized: The dog lay in a deck chair, three rabbits crouched next to each other, and a cat dozed in the sun. I panicked that you had introduced me to the club, but I didn’t participate in sailing and instead stayed with the animals. I see you sailing away. I feel bad.” The dream discussion helps Mrs. Eichel to accept that she is “different” from me, that we have worked together on her “selfship” and now each can immerse herself in “her” life (Mrs. Eichel had concluded from a sailing picture in the hallway to my sailing hobby). The “animals” as different self-aspects (cat: femininity, rabbits: fears, dog: loyalty) occupy Mrs. Eichel and become symbolic companions in the sense of helpful figures (7 Sect. 7.3), which join the inner scene of “waving from afar” and stabilize it. Mrs. Eichel chooses the first summer after her retirement for the end of her analysis and our separation. She has settled into her new “animal lazy life” and feels the ability for self-creation (in fact, she has

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not “lazed” for a year, but renovated, rearranged, sorted out accumulated school materials, taken accordion lessons, intensified painting at an academy, and set up a studio). In the last weeks, she often talks about earlier imaginations, some from a long time ago. For example: “Do you remember? Back then I saw a donkey loaded with far too much burden, driven by a farmer. You prompted me to negotiate with the farmer whether the burden could be lightened. And to make contact with the donkey. But that was hardly possible! The farmer didn’t want to listen. And later the donkey appeared again, I was able to take the burden off him with your help and saw the wounds he had suffered. I stroked him and took care of his wounds. Recently I thought of him again and looked for the picture I had painted back then. I was shocked at how he looked. I now imagine him trotting happily and have painted him like that.” She brings a picture of a happy donkey in a flower meadow. The farmer sits on the edge and has a picnic. We laugh. For the penultimate session (619), Mrs. Eichel brings all the pictures she has painted in relation to the analysis. It is a full folder; she leafs through it and selects the most important pictures for her (7 Sect. 7.6). There are three: The picture with the mallow from the initial imagination; the picture of the “destroyed” house and the picture of her “lazy animals”; she has painted her animals by the sea and me in a sailboat; I wave to her. She herself stands next to the dog, both waving to me as well. In the last session, we experience a farewell with laughter and tears. Mrs. Eichel surprises me: She comes with her accordion and sings a song to me that she knows from her mother. It is one of the rare occasions when her mother, in her positive “shape”, music as a universal expression of early positive kinesthetic relationship experience (7 Chap. 2, 7 Excursus 3: kinesthetic) spreads out in Mrs. Eichel’s

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a­ nalytical space. That after all the negative and missed aspects of her mother relationship, which she has often painfully, rarely angrily mourned with me in her years-long analytical process, she presents a positive aspect of this mother, who has given her the life she now appreciates, in this last session, I consider a highly significant integration achievement that deeply touches me. Then I surprise Mrs. Eichel by taking the “twin bottle” from the 381st session out of the corner of the room, where it had stood the whole time, forgotten by Mrs. Eichel. She chooses the “better” one, the red wine, and I am not sure if it is not a refined adaptation performance because

she thinks I expect her to demonstrate “mature, delimited” action to me now. I ask her. She thinks and says: “It’s both. I prefer red wine. But I also assume that you prefer red wine too. That’s right, I wanted to prove to you that I can take something. But not only! I just like it better.” We laugh.

Reference Pahl J (1982) Über einige abgrenzbare Formen der Übertragungs- und Gegenübertragungsprozesse während der Arbeit mit dem Katathymen Bilderleben. In: Leuner H, Lang O (Eds) Psychotherapie mit dem Tagtraum. Ergebnisse II. Huber, Bern, pp 73–91

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Systematic Presentation of Working with Therapeutic Imaginations Contents 7.1 Therapeutic Attitude in KIP – 142 7.2 Dealing with Stimulus Motifs in the Initiation of Imaginations – 144 7.3 Intervention Techniques in Imagination Accompaniment – 163 7.4 Embedding Imagination in the Therapeutic Session and the Therapeutic Process – 181 7.5 On the Post-Imagination Adaptations – 187 7.6  Termination of a Therapy with Imaginations – 191 7.7 Dealing with Transference, Countertransference, and Resistance in KIP – 194 References – 216

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3_7

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7.1  Therapeutic Attitude in KIP

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Like every form of psychotherapy derived from psychoanalysis, Katathym Imaginative Psychotherapy also adopts an understanding approach that forms the basis of its fundamental therapeutic attitude: The primary focus is not on the elimination of a defined disorder, but on enabling understanding—including of the symptoms— as a process of healing, integrating the absorption of emotions, and as a key to promoting beneficial relationship formations. In this respect, the basic therapeutic attitude does not differ from that in other psychodynamic therapies and can be characterized as empathetic-supportive-approachable as well as clarifying-understanding-interpreting, but not evaluative. A manipulative-suggestive approach to the patient’s problems and conflicts is not only consciously avoided, but also attempted to be excluded through the continuous reflection of conscious and unconscious countertransference (7 Sect. 7.7.5). The individual therapeutic behaviors and interventions related to the patient are based on this basic attitude and are not to be understood as a normative set of rules. They are guided by the question: How can I, as a therapist with my possibilities and those of my method, do justice to this specific patient? This already begins with the initial encounter. With respect for the patient’s wishes and boundaries, the therapist should ask what the patient is seeking from them and whether they can offer a treatment proposal. For example, does the patient come with a request for support in a crisis? Does he suffer from his symptoms so severely that his primary goal is their rapid elimination, which he would prefer to achieve through medication? Is he open or can he be opened to better understanding himself and his problems, and do I want to therapeutically accompany this particular patient? In the trial sessions, the fundamen-

tally empathetic-understanding therapeutic attitude is thus primarily combined with diagnostic competence and one’s own professional clarity. Even if a therapy agreement is not reached, the understanding approach is helpful in strengthening a basic respect for the patient: The way he encounters us has fateful and development-related reasons. His maladaptive behaviors were once adaptive and deserve respect because they were part of his required conflict management. Even a referral made in this non-evaluative attitude can be an important helpful experience for the patient. If therapeutic work is agreed upon, the fundamentally understanding, respectful, and tactful attitude towards the patient will always be maintained, regardless of how the concrete intervention behavior must be modified in relation to his structural level. For example, I can do justice to a patient with a stronger structure by holding back and not hindering his autonomy steps, while I usually do justice to a patient with a weaker structure by encountering him more actively in order to let him experience the notion of a change in his self-perception and his possibilities for shaping relationships in the first place. In this respect, therapeutic behaviors such as empathy, containing, perceiving the patient’s viable ego functions as well as providing auxiliary ego functions, expressing concern, resonance, holding, mirroring, confrontation, interpretation, etc. (7 Sect. 7.3) will be oriented towards the respective patient and process events and thus vary, but always from a respectful-understanding basic attitude. Working with imaginations also pursues the fundamental therapeutic goal of promoting the patient’s self-empathy and self-understanding in order to be able to perceive the significant others more appropriately and to behave more adequately in relation to them based on this foundation. During the imaginations themselves, the therapist does justice to the patient by adapting to the patient’s controlled-re-

7.1 · Therapeutic Attitude in KIP

gressive state. This means that the therapist modifies their behavior when accompanying the imagination—according to the modified experiential state during imagining: On the one hand, the patient is usually more willing to lean on the therapist, on the other hand, their defense is less controlled. In this respect, they would be accessible to suggestive, steering-manipulative, or even intrusive therapist statements, which would be untherapeutic and possibly unethical. The basic attitude of respecting the patient’s autonomy prohibits “using” the possibly mobilized kinesthetic self-state of the patient for any other purpose than promoting understanding—unless this was previously agreed upon in a transparent manner (e.g., conducting an imagination with the aim of psychological stabilization). On the contrary, it is important for the therapist to endure the openness of the imaginative space and let it be shaped by the patient’s impulses (7 Sect. 3.6). Tendency-wise, the therapist is less “opposite” the patient during the imagination, but actively accompanying “by their side,” which corresponds to the usual spatial setting during the imagination. The therapist’s behavior during the imagination accompaniment is also more active, although not necessarily more wordy than in the dialogue situation, according to the affective intensity of the events. The therapists should be very present, follow the imagination attentively and interestedly, and be as excited about possible scenic surprises as the patient themselves. If they are not, if they feel tired, distracted, or uninvolved, this can be an important countertransference reaction that needs to be understood—possibly in supervision (7 Sect. 7.7.5). During the imagination, the therapist remains both the observing outsider who can provide support with their interventions if necessary, and the process-promoting, variably resonant, non-directive companion of the imagination events. Stimulating or curiosity-arousing questions are best

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formulated in the subjunctive (Sects. 3.6 and 7.3), so that the patient is left with the creative space. The modified therapist behavior during the imaginative sequences is often also evident in the therapist involuntarily adapting more clearly to the patient’s language style, behaving much more identificatory-reinforcing with their choice of words than they would in a dialogue. Sometimes it even happens that they adopt the patient’s dialect. The therapist is therefore predominantly more resonant than in the usual therapeutic conversation, going much more “along with them”: In a thoughtful mood of the patient, they may imperceptibly pick up on it with a “Yeah” or “Hmm.” In a spontaneous discovery situation, they might pick up on the patient’s surprise with an amazed “Oh!” in the sense of a basic presence and resonance intervention (7 Sect. 7.3). In situations that the patient experiences as challenging, they will also more clearly “stand behind them”; i.e., supportive statements or encouragement interventions (7 Sect. 7.3) may be more direct (“Yes, why not!?”), possibly also suggesting something new, but usually in the form of suggestions (“Maybe it could go like this …?”, “What if you …?”). Likewise, the “inner going along” can also lead to a more directly formulated and adopting the style of counter-speech, for example, when the patient calls something “stupid” and the therapist spontaneously replies: “What’s stupid about it?” Also, the case examples (7 Chaps. 4 to 6) show that the therapist behaves somewhat more “familiar” and casual during the imagination than in the dialogue. Thus, it can be said overall that the therapist should be experienced by the patient as empathically resonating, tending to be more resonant, more “on my side” and more “behind me” during the imagination, so that the patient can develop the feeling of being understood and accompanied and not being alone. Despite all the scenic co-design of the imagination by the therapist due to the

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transfer relationship (7 Sect. 7.7), the design dominance and freedom of choice— within the scope of his transfer-related possibilities—always remain with the patient. As already mentioned, the therapist’s basic attitude is, however, determined by respect, abstinence, and openness both within and outside the imaginations and is oriented towards understanding. Abstinence means the controlled renunciation of the therapist to make the therapeutic relationship subservient to his own (proximity, sexual, narcissistic) needs, as well as the renunciation of wanting to “accommodate” his own values and convictions in the patient. Openness means, in accordance with the psychoanalytic basic rule, to internally allow every utterance of the patient without taboo, to experience it as strange, irritating or inappropriate if necessary, but to fundamentally consider it worthy of reflection and to examine it with interest for which psychic emotion it stands. Conversely, this also means not to evade any question to the patient, i.e., to be able to ask it with the necessary “tact”, as Freud (1898, p. 493) called it, even if the resistance-related reasonableness of the question has to be checked due to the patient’s limits of humiliation, anxiety level, and processing capacity (7 Sect. 7.7.3). What has been described here as openness is ultimately based on the appreciation of the unconscious as part of the human being itself: In the recognition of the incompleteness of every psychic insight, which can only be realized in the form of a spiral reflection. In this always consistent basic attitude, even if it is expressed differently in the dialogical and imagination situation, supported by adherence to the psychoanalytic basic rule and empathic understanding of the patient’s expressions, a relationship atmosphere is generated in catathymic imaginative psychotherapy, in which the patient—according to his possibilities within the transfer relationship—can open up to his own inner space, regardless of whether

short-term therapy or analytical long-term therapy is carried out. 7.2  Dealing with Stimulus

Motifs in the Initiation of Imaginations

Under a stimulus motif is understood a pictorial-thematic suggestion proposed by the therapist or developed together with the patient. Its purpose is to initiate an imagination and to lead into the imaginative experience. It is also possible to start an imagination without a stimulus motif. In any case, the stimulation of imagination is a therapeutic activity carried out from the countertransference, the implications of which are further presented in this chapter. The decision whether to suggest the patient to imagine with a stimulus motif or without one depends on various factors (see below), not least on what the therapist feels more confident with based on his experience. Under Sects. 3.5 and 3.6 as well as in the case descriptions (Sects. 4.3, 5.3 and 6.3) it was shown how the initial imagination—often already within the probatory sessions—is announced and therapeutically initiated, accompanied, and terminated by the stimulus motif “flower” (see below). The intention is to provide the patient with an initial experience in this specific, detached-from-conversation experiential space through the initial imagination. It was also discussed how to try to keep the fears and insecurities possibly associated with this change to a minimum. This is also served by the choice of the first stimulus motif. The “flower” has proven particularly effective for this purpose, as it has a pleasant meaning horizon and is often spontaneously perceived by patients as a “snapshot” of a desired or currently experienced self-state. Other first motifs or those that can follow the “flower” are also taken from the natural realm, which easily stimulates

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

our inner ideas, such as the “meadow”, the “landscape”, or the “tree”. Such stimulus motifs originating from the natural realm are proposed in this phase of the introductory accompaniment (7 Sect. 7.3) mainly because they connect to the patient’s familiar and close-to-hand imaginative content, because they keep the confrontation moment low, and often lead to an experience of evidence: “That’s me!”, “That corresponds to me!”. Of course, even these first imaginations can contain a lot of conflictual content, which would have to be countered with interventions other than those of the introductory accompaniment (Sects. 7.3 and 5.4 (4)). However, this conflictual content usually appears in a symbolically bound and therefore more or less encrypted form due to the chosen nature-related stimulus motifs and is therefore not immediately experienced as an anxiety-laden imposition or as tense (compare in the case of Green, 7 Sect. 5.3, the “pulling out” of the flower). For example, a thunderstorm may gather over a meadow or a combine harvester may appear in the distance; both do not have to immediately become clear to the imaginer as an expression of an inner conflict. Entering the imagination is also possible without a motif. If, for example, the patient has talked about a feeling whose backgrounds and connections should become even more conscious to him, one can suggest to him to associate a suitable imaginative image with this feeling, which is then taken as the starting point for an imagination. (7 Sect. 7.4; examples especially in the last analysis 7 Sect. 6.5): “I would like to suggest that you let a scene – any scene from your life or as it now arises in your imagination – emerge in connection with this feeling.”

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This suggestion can also be given within an imagination (7 Sect. 7.3, intervention of the associative loop), so that an “imagination within an imagination” is created. This can be helpful in dealing with resistance. Another, non-motif-related formulation for initiating an imagination can be:

“Try to imagine something that matches your mood” (Case Musat, 7 Sect. 4.5, (19)).

If imagining becomes a natural part of therapy, it can occur spontaneously: For example, if a patient says they currently see their youngest son in front of them, or constantly hear a melody, or cannot detach themselves from a movie scene—then this imaginative or auditory impression can be transformed into an imagination simply by suggesting a more detailed description. Depending on how soon the patient has opened up their imaginative space in relation to the therapist and how extensive the therapeutic framework has been chosen, motives can also be offered several times; details from previous imaginations, such as a specific garden piece, meadow field, a group of trees, etc., can be picked up and suggested as the next stimulus motive. However, this is rarely necessary; much more often, the motif suggestions can soon follow the individual process, just as the transitions from conversation to imagining generally arise from the therapy process itself (7 Sect. 7.4). The presented treatment cases show how this can be done concretely. In many examples, situations arise from the course of the conversation, from which a concrete “motif ” develops as an entry point into a further imagination (e.g., Case Eichel, 6.5 (175): The patient talks about opening the door “just a crack” for her feelings; the

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therapist picks up on this metaphor and suggests imagining a “door that is slightly ajar”). Especially when patients spontaneously express pictorial phrases such as “I feel like a leaf in the wind,” these can be used to individualize the imagination suggestions by making these phrases the stimulus motif, with the relationship message resonating that the patients are perceived in what they express (Case Eichel, 7 Sect. 6.5 (18)). Another approach is useful when the therapist interrupts the conversation at a specific, emotionally charged point and suggests an imagination related to the content just discussed—not to avoid this emotional situation and the transference problem, but to initially enrich the problem emotionally or to strengthen the patient narcissistically so that they can subsequently address the conflictual topic (7 Sect. 7.4). Such a stimulus motif can then either be suggested by the therapist or developed in a joint conversation between the patient and therapist:

“Would you like to deepen/re-experience/ follow up on this situation you just described in an imagination?” (Case Musat, 7 Sect. 4.5 (15), further development of the lion imagination from the conversation) or: “I would like to suggest that you imagine this. What do you think—and at which point would you like to start?” or, if you have already agreed on an imagination: “Where would you like to meet this person in your imagination?” or: “What kind of situation could be suitable for starting the imagination?”

Also, the night dream can be used as an entry point for an imagination exercise. Perhaps the patient has reported a dream that ended unclearly or was “abruptly” interrupted for them, or the discussion of which initially remains unproductive for inter-

nal protective reasons. The patient can then be suggested to continue the dream imaginatively and discuss the moment of entering the dream together beforehand (Case Eichel, 7 Sect. 6.5 (210), imagination work with the night dream of the tomcat). The understanding of the trauma statement or the necessity of resistance usually deepens from the development of the imaginative events. However, it is essential to note: Regardless of whether the therapist chooses a specific stimulus motif familiar to them from their own experience, a patient-specific individual motif developed from the therapy process, or merely suggests the act of imagining itself in a particular situation, they are following an internal hypothesis or intuitive fantasy about what they consider process-promoting in the current therapeutic situation. The suggestion to imagine, with or without a motif, is always an offer of understanding from the therapist for the patient’s situation and is also based on the symbolization of their countertransference. Therefore, the motif suggestion is embedded in the transfer dynamics. This also means that the choice of a specific motif on the therapist’s side can serve resistance purposes just as much as the way the patient receives the therapeutic motif suggestion on the patient’s side (7 Sect. 7.7.5). It also applies that at the beginning of a therapeutic process, the somewhat ritualistic initiation of imaginations using stimulus motifs and repetitive instructions (7 Sect. 7.3) helps the patient to view and use imagining as a natural element of the therapeutic discourse. An imagination suggestion in the first few hours without any motif suggestion can represent uncertainty in an already unfamiliar situation, just as one with a motif suggestion can be perceived as directive-constricting. Therefore, if a motif is chosen for the imagination suggestion, as explained in 7 Sect. 3.6, the addition “If something else appears before your inner eye (than the flower or meadow,

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

etc.), that is just as right” should be included at the beginning of each session to explicitly emphasize the freedom, spontaneity, and autonomy of the person imagining. The addition can be omitted when the relationship is characterized by grown trust and shared experience. Leuner (1985) has described numerous so-called “standard motifs” that primarily address specific experience and conflict themes, such as the “mountain” motif addressing performance and challenge issues (see below). The KIP therapist can also draw on this repertoire of tried-andtested specific stimulation motifs, which will be discussed below, in the treatment process to initiate the imaginative events. However, we replace Leuner’s previous term “standard motif ” with the term “stimulation motif ”, as each therapeutic process is highly individual and eludes any “standardization”. Nevertheless, we know from clinical experience, general knowledge from symbol theory and archetype theory (Jung 1934) as well as individual research studies (Nohr 1985; Otremba 1982; Zepf 1973) that certain imaginative contents are generally associatively linked with certain experience and conflict themes. Clinical experience also shows that the imaginative events, because the psychic dynamics want to bring something more urgent to the surface for transference reasons, can develop thematically quite differently (Case Musat, 7 Sect. 4.5 (14), Lion Motif) than corresponds to the general expectation horizon of the chosen specific motive. These specific, compiled by Leuner stimulation motifs include “flower”, “meadow”, “stream”, “mountain”, “house”, “forest edge” and “lion”. The motif of the “meadow” is particularly suitable as a stimulation motif:

“Please try to imagine a meadow, any meadow.”

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The landscape panorama associated with a meadow generally opens up an “imaginative field” of great and therefore little anxiety-inducing openness, and almost always corresponds to the current mood in the therapeutic relationship moment. When the meadow “appears,” one can ask about the type, height, and color of the grass (tall, short, green, wilted), about its “estimated” extent (wide, narrow), about the presumed season and time of day, one may possibly inquire about “what else is there” and explore the affective charm of the meadow with the question of effect (7 Sect. 7.3). Depending on whether flowers, trees, fences, as well as insects, butterflies, or cows, horses, sheep, or other animals are imagined, one will vary one’s exploratory questions or, for example, focus on a conflict-illustrating detail through the touch intervention (7 Sect. 7.3) (see Case Eichel, 7 Sect. 6.5 (6), touching the tree bark). Also interesting is the demarcation and embedding of the meadow in the landscape: whether it is enclosed by forests, reveals dwellings, allows a view into the distance, or not. Sometimes a familiar meadow is imagined first, perhaps the one from the grandparents’ garden, or one known from vacation with the corresponding surroundings. The person imagining themselves can also appear, standing on a path, walking, looking into the distance, sitting in the grass, or crouching bent over in the tall grass. All of this can provide numerous clues to upcoming topics and current states of mind, and always to the transfer (7 Sect. 7.4). This is to suggest that the “meadow” is not only suitable for becoming familiar with imagining in general, but it can also serve as a stage, so to speak, on which the most diverse figures can spontaneously appear. An active introduction of figures on the imaginative stage of the meadow by the therapist represents an intervention frequently used, especially in the later course of therapy (7 Sect. 7.3).

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Basically, the “meadow,” like any imagination, should always be understood as overly complex and therefore not hastily interpreted from a single level of meaning: As with the day’s residue of the dream, the statement of the imagination can also be about a less lasting impression of external reality, situational states of mind, as well as important clues to the transfer or life-accompanying conflict manifestations that are symbolically expressed. One-dimensional or exclusive interpretations do not do justice to the complexity of the symbolically condensed statements (7 Sect. 7.1), however, background knowledge of the general symbolism of the respective motif will fruitfully deepen the understanding work of a KIP therapist (7 Excursus 7: Symbol). The symbolism of the meadow often stands for the supply theme: A well-supplied meadow “blooms,” a dried-up one “withers”. If the person imagining encounters cows there, they usually represent maternal figures. Sometimes the imagined meadow provokes age regression (7 Sect. 7.3). The person imagining then develops a childlike experience, which the therapist can promote by asking about the current age and the clothing being worn “right now”. A meadow experienced as barren or desolate can represent (childlike) desolation and abandonment issues, but also the currently experienced “barrenness” in the therapeutic relationship. In this respect, formulations like the following (Leuner 1985, p. 67) do not do justice to the complex situation: “Indications of acute emotional or neurotic

problems manifest themselves in an impairment of this fertility-giving and restorative character: The meadow is, for example, grazed, dried up by the sun, particularly small or strongly delimited by a barbed wire fence (pasture) or forest. Rarely, the patient (as a sign of a severe neurosis) is trapped behind a fence”. Our objection applies not only to the apodictic manner of this formulation but primarily to its detachment from the current transference relationship: “dried up,” “restrictive”, etc., the patient can also experience the relationship with the therapist or express their transference wishes with these statements; and fences can also be understood as necessary and important boundary symbolizations (7 Sect. 7.7.4). In the later course of the process, the motif of the “meadow” can, as mentioned above, serve as a starting point and setting for indefinite-symbolic or concrete object relationship encounters and confrontations:

“Please try to imagine a meadow. Perhaps you perceive a figure there, approaching you from a distance.” Or, following a corresponding preliminary conversation: “Imagine your partner coming towards you there.” Or it is agreed to visit a meadow scene from an earlier imagination to meet a specific person (e.g., a deceased grandmother) and engage in a dialogue with them.

7 Excursus 7: Symbol

Excurse 7: Symbol

Symbol is derived from the Greek word symbolon and means “the joined together”. In ancient Greece, when two friends parted, they broke a ring or a clay tablet. Whoever returned with the matching half identified themselves as a friend of the friend and thus gained a right to hospitality. This

etymological origin of the term makes it clear that a symbol establishes a reference context and indirectly points to something not directly appearing: here to friendship, which goes beyond a concrete friend to hospitality for all who are included in the friendship.

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

In contrast to allegory, code, or emblem, a symbol cannot be determined unequivocally in content, as it correlates as a fundamentally infinitely interpretable variable depending on the respective context with its possible contents and its possible interpreters, and can thus always receive new meanings, always having a surplus of meaning. Early psychoanalytic approaches deviated from this understanding of symbols and are now considered outdated. For example, Freud postulated relatively fixed, “typical” dream symbols independent of the individual dreamer. He also understood symbolic representations in the sense of a neurotic symptom as ideas not admitted by consciousness, which led Ernest Jones (1918, p. 244) to the categorical statement: “Only what is repressed is represented symbolically.” Consequently, this early psychoanalytic symbol theory had to consistently associate mental health with the absence of symbols, which for a time led to the erroneous view that art and cultural achievements stood for historical repressions of humanity, and were thus symptoms of the “humanity neurosis”. Jung (1928) did not follow this and instead declared the formation of symbols as a prerequisite for the process of the psychological development path, which he called individuation: The symbol formulates an “essential unconscious piece” on the path of “wholeness.” It is neither of a rational nor irrational nature and is composed of all psychic functions. Thus, the symbol’s mysterious and meaningful nature appeals to both thinking and feeling, and its peculiar imagery arouses sensation as well as intuition. In analytical psychology, the symbol thus became a central therapeutic concept. However, the Freudian psychoanalytic symbol theory was also fundamentally revised, especially by Alfred Lorenzer (1970), who, in his “Critique of the Psychoanalytic Concept of the Symbol,” incorporated newer

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views of philosophical authors Ernst Cassirer and Susanne Langer into a new symbol theory. According to this, symbols do not represent the result of repression, but the act of repression causes desymbolization. A distinction is made between discursive symbols, in which there is a clear relationship between sign and object, and a presentative symbolism, which is capable of representing and provoking a multitude of different, not fully verbalizable ideas. This view corresponds both to the etymological content of the word symbol and to Goethe’s so-called “surplus of meaning,” as well as to the distinction between sign and symbol by C.G. Jung. While psychoanalysis has left behind the debate on the evaluation of symbols, there is still an ongoing discourse on the development of symbolization ability, which was initially stimulated by Kleinian psychoanalysis. Hanna Segal (1957) showed how disturbances in object relations are reflected in disturbances in symbol formation. She introduced the concept of “symbolic equation,” which refers to the non-differentiation of symbol and symbolized. Today, there is consensus that the symbolization function develops as a psychological reflection of a child’s experiences with primary caregivers and serves to process desires, fears, and conflicts. The results of infant research also suggest that the condensation of holistically experienced event sequences in the symbol is possible from about the 18th month of life. This describes a process towards an increasingly advanced ability for symbol formation and distancing from the respective immediate situational pressure. The highly complex discourse on mentalization, symbolization, and symbol use ability associated with these questions occupies a prominent place in today’s psychoanalysis and cannot be explored in depth here (see Bahrke 2005; Dieter 2000; Fonagy et al. 2004).

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The motif “stream” can either be stimulated from the already imagined meadow or directly without a landscape context. Sometimes the patient discovers a stream on their imagined meadow or hears its rushing, whereupon the therapist can ask if they would like to “follow this noise.” If this is not the case, but the patient is on an imagined meadow, they can be asked more directly:

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“Would you like to look around and see if you can find a stream nearby?” Or you can express it in another, slightly suggestive way: “It is to be assumed that there is also a stream nearby.” or similar. You can also stimulate the motif very directly: “Please try to imagine a stream— but any other image is also welcome. Please wait and see what appears, and then report it to me.”

The stream can appear in very different ways, and a more complete impression will gradually develop through exploratory description questions (7 Sect. 7.3): It can be, for example, a fast-flowing, more or less wide mountain stream, a narrow trickle, or a smaller river. The bank can have vegetation, be easily accessible, “crumbly”— as with Mrs. Eichel, 7 Sect. 6.5 (12)—or be delimited by walls. The water can be perceived as more or less “clear” and “fresh” or also “murky,” and the whole can be embedded in different landscapes, from “lush” valleys to desert regions. Symbolically, the stream often represents the “flowing” emotional development—meaning an unhindered psychological unfolding or one characterized by inhibitions—which can then manifest in the form of weirs, dams, or canalizations. Quite directly, the libidinous energy can be more or less “in flow,” “dammed up,” or “seeping away” in places. Water is the fundamen-

tal prerequisite for all life and thus the invigorating, refreshing, fertility-enabling “element” par excellence. As a current, however, it can also possess tearing force, cause floods, and thus cross supportive (bank) boundaries—which could suggest structural deficits and impulsive impulsivity, but could just as well be an expression of a momentary overburdening or desire situation. A river can also contain a dangerous whirlpool into which someone has become crisis-ridden. If the patient has described the place where they perceived the stream in more detail, so that the therapist also gets a picture of it, and if its affective appearance has become noticeable either directly through the impact question or indirectly through the description, and if they have also characterized the water, it can—if appropriate— be asked whether they would like to moisten themselves with the water, perhaps drink from the stream or bathe in it. With these questions, (transference) issues of “healthy curiosity,” making contact, trust, or mistrust up to “poisoning” fears can emerge. In any case, the impulse question: “What do you feel like doing at the stream right now?” in the sense of a regression invitation or also a “permission” for self-initiative as in the case of Eichel, 7 Sect. 6.5 (12), is useful. If patients build small dams, harbors, or bridges here or splash around in the water, this can mean a punctual, important narcissistic strengthening, which increases the future scope for dealing with conflictual issues (see below).

Furthermore, we can encourage the patient from this point and ask if they would like to follow the course of the stream, and if so, “whether they prefer to go upstream towards the source or downstream with the flowing water towards the mouth/to the sea.”

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

If the patient chooses the path towards the source, it is likely that they are moving towards their origins and into the time of their childhood. The source can directly represent the internalized primary mother experiences, as well as the currently experienced or desired motherliness of the therapist. The handling of the spring water, the desire to “quench” one’s thirst here—or not—can express early oral and intentional aspects and resulting transference messages: The water can emerge shallowly from the ground, it can “bubble” with varying intensity from a rock or come from an artificial pipe, it can be “refreshing” but also “ice-cold,” it can look “dirty,” taste bad, or be suspected of being “full of bacteria.” If the source is experienced only positively, the patient’s affective involvement, countertransference perceptions, and anamnestic knowledge provide important clues as to whether this is a psychological reality or a defense-determined wishful illusion. If the patient follows the course of the stream towards its mouth, a course corresponding to nature may emerge: from the widening stream to the river, to the current, up to the mouth into the sea. However, the water can also seep away and reappear elsewhere, flow into a pond or end at a dam. In such cases, one might encourage the patient in their imagination to look for a drain or a place “where the water flows again”. In the follow-up discussion, one can try to understand which life situations the patient associates with the imaginative content or what they mean for the transfer process (7 Sect. 7.7.6). There may also be bridges to cross or obstacles to overcome—possibly showing current or future projected conflicts or fantasized (transfer) fears or desires, the imaginative design of which should be described as detailed as possible for the joint understanding process. “The perception of the accompanying emotional tone and the mood of the landscape as well as the ­desires

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and tendencies of the patient should be fully exploited in the area of this motif with the diverse and therapeutically fruitful handling of water” (Leuner 1985, p. 81). Imaginations of water as a “life element” can also be used in a different form in a therapy that aims less at conflict resolution and more at supportive ego-strengthening (7 Sect. 7.3): Comparable to a psychosomatic hydrotherapy, patients can be offered to “drift” or “bathe” in a body of water of their choice—the sea, a lake, a river, from an island, etc. One will then discuss with them beforehand where they may have already had such experiences that “did them good.” This form of experiential design of an intimate touch with the water supporting one’s own body is a striking example of the stabilization function of imaginations (7 Sect. 3.3). This, of course, is not independent of the transfer: trusting the water, surrendering oneself to the flow while swimming, requires a transfer relationship that allows for the relinquishment of control. Using water imaginatively in the sense of the stabilization function can also be a very valuable aid in preparing for conflict resolution. Therefore, it is often appropriate to perform the “stream” motif either twice and only encourage the walk along the stream, which almost always leads to conflictual topics, the second time or only if it fits. While the stream motif is suitable for addressing both situational and biographically expanded areas, the motif“path” often focuses less on the “path of life” and more on the well-being and conflicts in the current life or therapy section (see case Eichel, 7 Sect. 6.5 (115), Wegwarte): “Please try to imagine a path—but any other image is also welcome. Please wait and see what appears and then report it to me.”

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After describing the nature of the path itself and its surroundings, decision-making problems can often be illustrated here, such as “which path to choose.” This can involve forward and backward movements, a sudden dead end, or the relieving discovery of a larger, “passable” path. Crossroads, signposts, etc. can appear and stimulate the illustration of alternatives, ambivalences, desires, and inhibitions regarding a specific topic or even a stage of autonomy development. In uncertain situations, the therapist can encourage the search for a helpful figure or a “knowing animal” (sometimes an owl) in the sense of externalizing a good inner object or an ego-ideal part, in the hope—perhaps through a small dialogue— of receiving helpful advice (7 Sect. 7.3). It can also be fruitful to ask the patient to look at what is lying on the side of the path; this can initiate the engagement with a perhaps neglected ego strength; the request to look back or forward can encourage a review of what has been achieved so far or encourage perspectives. The understanding of the transference-countertransference dynamics is always crucial for the type of intervention: What does the patient trigger in me? What does he want to move me to do for what reasons? etc. (7 Sect. 7.7). In the context of the autonomy theme, the stimulating motif “A piece of land of one’s own” can also be placed, on which various aspects of self-definition or the transfer-related currently possible self-definition and associated boundary problems can be imaginatively illustrated and worked through. An imagination based on the motif“Mountain” can be stimulated in various ways: Leuner (1985, p. 83) suggests asking, starting from the imagined meadow, whether there is a path or trail leading away from it, and then “predicting” that this “leads through a forest to a mountain.” However, he himself has also proposed a “simplified version” (ibid., p. 90), which, in our experience, is more suitable because it is less suggestive:

“Can you imagine a mountain in the distance?” Or: “Please try to imagine a mountain that you are looking at from a distance.” If initially various mountains appear, “wait until one stands out more clearly,” or: “Which one are you drawn to?”

The phrase “in the distance” is given to facilitate the description of the mountain, its shape, its height, the estimated distance to it. It can be a snow-covered giant mountain, a wooded medium-high one, or a grassy hill that only slightly stands out from the surroundings. The mountains can be made of different materials: a granite massif has a completely different effect than a clay hill. Following the descriptive exploration, it is important to capture the patient’s emotional impression with the effect question (“How does the mountain affect you?”). Later, one can add: “What do you think about climbing this mountain?”—or connect with the open impulse question: “What do you feel like doing now?” These questions can trigger ambivalences that are worth clarifying further in the imagination: “What are the pros and cons?” “What could support you?” “Under what conditions would you like to try it anyway?” etc. (7 Sect. 7.3). If the ambivalences are very strong, one can focus on them: “How do you feel in this indecision/in this back and forth?” A clear refusal without ambivalence is rarer. Most often, one experiences a more or less joyful to hesitant agreement to the suggestion. One can also leave the way of dealing with the challenge of “mountain climbing” entirely to the patient by simply asking what they feel like doing “there at the mountain.” It is by no means appropriate to always suggest a climb when a mountain appears in an imagination. Whether it makes sense to understand it as a challenge and whether a

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

c­ onfrontation with this topic is even pending is solely determined by the process dynamics. Furthermore, if the patient is aiming for an ascent, they are guided through the path to the mountain, its surroundings, the respective view of the mountain, the remaining distance to the summit, always combined with inquiries about their current experience. The imagination can end with the summit being reached and a more or less complete “panoramic view” serving as a “reward” to conclude the “ascent,” with the descent occurring within this imagination, or with the ascent being “completed for today” at a point, perhaps “halfway up” with the prospect of “continuing the ascent another time.” If the patient has decided not to climb the mountain or has laid down on a mountain meadow after a short exploration or perhaps started to explore a cave appearing there, the subsequent conversation should attempt to clarify together whether or why avoidance is present. For example, due to transference, it could be important for the patient not to do exactly what they suspect the therapist wants—or vice versa. The symbolism of the mountain is primarily associated with the themes of achievement, level of aspiration, and challenge, i.e., the issues of the superego and ego ideal. The view of the distant mountain corresponds primarily to the narcissistic theme of the “distant” ego ideals, while the path and the manner of ascent can express something about the willingness to perform, the approach to challenges, and the associated coping possibilities. The mountain imagination can also vividly illuminate the nature of self-care, such as how “breaks” are thought of, experienced, and designed “on the way”; and it can contain something about whether and how mastered challenges can be “enjoyed.” If, for example, the mountain top is so “full of undergrowth” that the view is not possible, this could be an indication that the patient must ward off pleasure or joy in their own

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performance. Or at the summit, it could “turn out” that this “is not the summit at all” and impulses to continue climbing immediately arise, as if tirelessly toiling on an endless mountain range. Summits are also areas of insecurity, and there may be a desire to meet other people at the latest on the mountain top or to find a guesthouse or something similar. It should be remembered once again that all these actions and statements made in the imagination fundamentally also always contain a transference message (7 Sect. 7.7). The metaphor of the “mountain standing in front of you” in the sense of an impending conflict or stress situation is generally familiar. “Ascent” can describe a professional career as well as “descent” its social opposite. When someone has “arrived at the summit,” it usually means the highest social position achievable in their life, or perhaps a fulfilling moment of happiness. More often, however, concrete current challenges are depicted in the mountain imagination, e.g., exams or job applications—or the motif is chosen precisely for the imagination in order to explore how to deal with an upcoming performance requirement and to make the associated affects more conscious: “Mountains” can be “circumnavigated”, one can approach them step by step, be held back from actually climbing them by numerous detailed observations. Ambitious, “always ready” patients may already be busy with their climbing equipment or on their way to the summit as soon as the mountain appears. Patients with histrionic traits, on the other hand, may “promenade” to the mountain in a wishful fantasy manner, light-footed and with appropriate (non-mountain-suitable) footwear, possibly skipping long distances and experiencing this denial of reality as “effortless” and not at all as a sweat-inducing effort. Patients with a narcissistic (defense) structure may immediately discover a helicopter and be “already at the top an-

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yway”. Or they have climbed to dizzying heights and project their fear of “not coming down safely” onto the therapist, who experiences feelings of worry and tension. Depressed patients, on the other hand, often imagine either small hills, the “climbing” of which does not mean success, or mountains so high that they resign at the beginning of the ascent. Compromises suggested—“only halfway today”—may be rejected, possibly also to make the therapist feel the aggression turned against themselves in their helplessness in his countertransference (7 Sect. 7.7.5). Others, on the other hand, will want to “keep panting” “until exhaustion becomes debilitating” without any prospect of success, etc. All these reactions should, of course, not be acted out in the imagination, but should be helpfully worked through, taking into account the countertransference and the accompanying affects, and better understood in the follow-up discussions. In the hypothesis (Zepf 1973) that the initially described height of the mountain correlates with the individual level of aspiration, the age of the patient should be taken into account. If an adolescent patient imagines an ice-covered distant peak, this can be classified differently in the context of the still fragile ego-ideal formation typical of this age than if a patient describes this imagination who has had many years to adjust the demands on themselves to the reality requirements to be mastered. In any case, this correlation should always be considered with caution; a very high or low mountain may also appear simply because of a specific occasion, such as a partner problem currently occupying the patient, which became virulent during a mountain vacation, or as a defense-related reversal into the opposite. It goes without saying that this imagination, like any other, also has a transferential dimension: The act of imagining itself and the therapy can be experienced as

a “mountain” to be overcome, and the therapist can activate the patient’s superego and ego-ideal problems. And this, in turn, can refer back to a genetic transferential dimension: If the mountain is described as “jagged”, “unapproachable”, “broad and sluggishly lying there”, “sublime and dominating”, etc., these descriptions may refer to people who were crucial for the formation of the psychic structure in the biography. Thus, unresolved authority, competition, and rivalry conflicts can be revealed in the imaginative confrontation with the “mountain” as well as successful identifications with high-performing parental parts—and all this can become an incentive to further work on these conflict contexts in the course of therapy (7 Sect. 7.4, 7 Excursus 9: subject/object-level dream interpretation). The imagination for the stimulus motif“House” is usually introduced with the open formulation:

“Please try to imagine a house (any house).”

In the context of motifs such as “meadow” or “path,” patients often spontaneously encounter “houses” as in the case of Eichel, 7 Sect. 6.5 (15), and the house motif can also be picked up more frequently from reported night dreams, as in the case of Grün, 7 Sect. 5.4 (23). As always, it may take some time for an imaginative idea to emerge or be expressed; there may be several houses (or huts, towers, castles, garden houses, fortresses) visible due to ambivalences, or a house or (initially or later in the course of imagination) something else may appear promptly.

As always, when several imaginative contents appear, the current priority can be asked in the following way: “Where are

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

you most drawn to?”, “Which of the houses are you particularly interested in?”

Then, the house can be described in detail from the outside, and the distance of the viewer to the house, its surroundings, and embedding can be asked. A possibly existing (front) garden and its appearance should be included, as well as the entire view of the house with floors, windows, gables, plastering, roof, and other details, and of course the entrance. However, this does not mean that the therapist should follow a claim to completeness; rather, it is about their interested perception of peculiarities or omissions. Before suggesting entering the house, it is advisable to propose walking around the house, as this may reveal “a completely different side” or make it clear that “everything fits together well.” Perhaps another (rear) entrance or a (fenced) garden behind or next to the house will appear, and the patient will spontaneously want to enter the house from there. It is also therapeutically useful to round off the description of the house’s ambiance with the effect question, as patients often lose themselves in details for defensive reasons. With the effect question, we explore the overall emotional impact (7 Sect. 7.3); a house can be characterized as “lost,” “squeezed,” “shabby,” “ostentatious,” “stately,” and later provide an opportunity to understand self-aspects and identifications: “This is not my house. This is a witch’s house. It scares me with its staring windows,” says Mrs. Grün, 7 Sect. 5.4 (24). If the patient does not express the desire to enter the house on their own, the impulse question (7 Sect. 7.3) is asked, either in the open form: “What do you feel about the house?” or in the more targeted: “Would you like to enter the house?” The detailed description of the entrance area is often revealing due to the boundary and

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identity issues it contains, where bells, handles, nameplates, thresholds, etc., can be found, or “the door is open.” The act of entering itself also varies: shy, hesitant, or self-confident and assertive, expressing the patient’s general or currently mobilized contact behavior—or defensively its opposite. Occasionally, the house is opened from the inside, which can be done by a rejecting or inviting person, whom the therapist should have described in detail and perhaps suggest having a conversation with. More often, the person concerned soon finds themselves alone in the house, perhaps initially in a hallway with doors and/or stairs leading off from there; but they may also find themselves directly in a kitchen, a room, a ballroom, or wherever, and be more or less surprised about it. It should have become clear that the house motif offers an infinite variety of imaginative possibilities: basement, kitchen, bedroom, the “attic” and whatever else may be found, hold an inexhaustible metaphorical potential—not to mention the developments that can arise from possible detailed observations of a picture hanging on the wall or a doll lying in the corner. Of course, one must also resist the temptation to view these “areas” in a simplistic equation as intrapsychic “spaces” or even to hastily “equate” the patient with “his house” or to unquestioningly adopt such equations made by the patient (7 Sect. 7.7.1, 7 Excursus 10: Projection Neurosis). The order, intensity, and focus of the house exploration should be left to the patient, carefully registering the priorities, but especially which rooms and areas he avoids. Symbolically (e.g., “How are you, old house?”), the house is often spontaneously understood as a representation of one’s own person, its design associated with ideas of oneself (Case Eichel 7 Sect. 6.5 (15), Case Grün 7 Sect. 5.4 (24)). Different “sides” can represent different self-representations, one—in the sense of a selfideal—may “shine outwardly,” but on the

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back wall—corresponding to self-doubts— be “dilapidated.” Missing windows can be associated with schizoid or mistrustful issues, many, like Mrs. Grün’s “eerily staring” windows, with superego aspects; a high-rise or castle can express aspects of a grandiose-narcissistic problem, an office building can speak for the neglect of private life, a small hut can correspond to a corresponding self-confidence—all of this must, of course, always be interpreted contextually and together with the patient (see also Case Eichel, 7 Sect. 6.5 (51)). It is important to ask about the feelings when entering the house, not to overlook any hesitation before the “privacy,” but to let the associated ambivalences find expression. Most patients experience the house as “their house.” Oral references can be found in the corresponding areas such as kitchen, pantry, refrigerator, a noticeable “joy of cooking,” and in tendencies towards care, enjoyment or asceticism, or a securing “stockpiling economy”; sexual-erotic ones in the bedroom, e.g., the arrangement and condition of the beds or in a “secluded attic.” Biographical material can be found throughout the house, but especially in the form of toys, picture books, or “memorabilia” from childhood in chests, cabinets, or in the attic. There or in the basement, family albums can be discovered or transgenerationally important clues to overarching contexts can be established, and an examined detail, for example, can eventually be linked to the grandfather. The trip to the basement can, of course, also turn out “empty”; it will depend on the transferential events whether the person concerned can face his possible “corpses” in the current relationship with the therapist and wants to encounter them. It is generally important to proceed cautiously with the interpretation together with the patient and to counteract the possible tendency of a concretistic self-interpretation: “Now I know what it looks like inside me.” This also applies in connection with other motifs, for example, when a patient

believes he can make predictions about his future life based on the course of his stream or path. In addition to “house” or “flower,” other concepts can symbolize the self, such as “animal,” “musical instrument,” or “car.” However, since they also have numerous other implications and are less frequently related directly to one’s own personality by the patient, they are only suitable as specific stimulus motifs in special cases; especially when such a concept is introduced by the patient, self-references are possible. Then, the person concerned can find photos in an imagined car (Greek: the self) in the glove compartment, similar to the house imagination in a cupboard drawer, which they may work through in further imaginations, reconstructing part of their biography. Or desires can be derived from their car brand, and their driving style can provide clues to their current emotional state. Another stimulus motif that is specifically suitable for allowing preconscious or less repressed content to become more consciously “visible” is the “forest edge.” By actively attempting to initiate the “dialogue with the unconscious” (Seifert et.al. 2003), the introductory instructions are slightly suggestive. The introductory intervention could be:

“Try to imagine a meadow bordered by a forest edge.—Wait to see if something— an animal or a figure, perhaps even a fairy tale character—emerges from the forest.” It is also common to proceed in stages: “Try to imagine a meadow at a forest edge.” If this occurs, you can ask the patient how far away it is and suggest that they approach a distance suitable for them to view the forest edge. To strengthen the ego, you could add that they should find a pleasant spot in the scenery in front of the forest and settle

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

down there. “You can now linger here for a while, observe the darkness of the forest interior, and wait to see what happens.” Additionally, you can say that they should pay attention to animals or figures that might emerge from the darkness. Or you can add that they should wait patiently, perhaps initially perceiving something vague or shadowy.

Symbolically, the forest can represent the unconscious. In fairy tales and (midsummer night’s) dreams, it is inhabited by fairies, giants and dwarfs, wise figures, witches, and demons. The forest edge is then like a stage on which such symbolic figures can appear, acting as a boundary between a cultural and a natural world, the Apollonian and Dionysian principles, the ego and the id. In this respect, such an imagination can trigger fears, and it may then be important to encourage the patient to seek sufficient protection. For example, you can ask if there might be a tree, bush, or ground hollow available, behind or in which they could hide protectively. Some patients tend to want to go into the forest counterphobically. This impulse should be questioned by, for example, suggesting that they first pause and explore their current feelings. Or, using an intervention, ask them to first describe the place where they are currently in more detail. This could then reveal the need for protection that was initially overlooked. The figures that appear can be forest-dwelling animals such as deer, hare, mole, or fox, or even an imposing stag or bear, but also unknown or known people or mythical creatures. After a description, it is therapeutically fruitful to promote contact: Is it desired? Considered possible or impossible? What form of contact would be close to the patient? Which do they desire? How can they implement their wishes? Why is this not successful?

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A later interpretation in the subsequent conversation can be carried out at the object level and subject level (7 Sect. 7.4, 7 Excursus 9: subject-/object-level dream interpretation). On the object-level interpretation level, one will explore with the patient to whom the figure reminds him, perhaps a family member, a teacher; of course, it can also have attributes of the therapist. On the subject level, the figures are understood as parts of the patient’s self, can then represent his “shy” (deer) or “cunning” (fox) side or, complementary to his own insecurity, show the warded off “imposing” stag. Jung (1934) speaks of the “shadow” in this context. Other, usually unconscious areas symbolizing ideas such as “forest”, “sea” or “sea floor” touch on more repressed content due to their depth dimension—at the “edge of the forest” we are in a thematic field of boundary. Since therapy should work from the psychological surface and the patient should not be “overwhelmed” by urging to bypass the defense (which then rather has to be “raised”), the isolated suggestion of such ideas as a stimulus motif is generally questionable. It is quite different when they arise from the therapy process: For example, during a walk by the sea, the patient gets the idea to dive into this water to explore the sea floor. Or in an earlier imagination, cave entrances had appeared in a landscape, to which the patient wishes to return because he wants to explore them. Such exploration from the course of the process is then accompanied similarly “cautiously”, i.e., with a respective inquiry regarding the warded off ambivalent, anxiety-laden side, as the events at the edge of the forest or, for example, a walk into the basement during the house exploration (7 Sect. 7.3). Therefore, imagination experiences with such motifs should definitely occur in the self-experience process of a future KIP therapist, as only in this way can the necessary therapeutic safety in accompanying anxiety-laden conflict events be developed.

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This also applies to such motifs described by Leuner as “swamp hole” (approaching a swamp hole and observing from the edge “which symbolic figure emerges from the depths”) and “volcano”: An imagination emanating from this could help illustrate aggressive inhibition and, for example, be suggested when the therapist notices in his countertransference how he has to keep something “explosive” under control in himself—the patient has thus successfully “accommodated” pent-up aggression via projective identification in the therapist. Through the then proposed volcano imagination, this can reappear in a certain way where it “belongs” and be integrated into the process of self-confrontation through understanding the image and the transfer relationship. Often enough, extinct volcanoes or crater lakes appear in volcano imaginations, the discussion of which can help illustrate an affect shift, such as from anger to sadness or vice versa (multiple times in the case of Eichel, the “ruins of Pompeii”, 7 Sect. 6.5, among others (482)). From the broader spectrum of specific stimulation motives, which can help to focus on circumscribed inner conflicts and their defense using imagination, the “encounter with a reference person” should be mentioned. It can be stimulated in different imaginative settings such as meadow, forest edge, path, or it can also be a previously discussed, real or fantasized meeting place, for example the grandmother’s room, where she was visited before her death and where an imaginary farewell conversation is now sought. It could be a classroom where, decades ago, a possibly embarrassing or otherwise conflict-ridden situation took place, which is now being worked through again and possibly internalized in a corrective manner afterwards. It could be a couple conflict or a generational conflict with a parent or with one’s own children, a conflict in the neighborhood or work area (and intrapsychically, e.g., authority, submission, rivalry, Oedipal, or self-esteem conflicts).

The aim will always be to emotionally enrich the imagined situation with the imaginative experience and to achieve an emotionally expanded understanding of the overall situation in the sense of the expression and clarification function through the change between observing the scene, empathizing with oneself or with the help of the imaginative role exchange (7 Sect. 7.3) empathizing with the encounter person. In terms of treatment technique, one will ask in detail about the accompanying feelings when approaching the imagined person, have them describe the person in detail, perhaps encourage them to estimate the age (and then also the “own” age, sometimes surprising age regressions occur), to look into their eyes, to “read” in them and then possibly to enter into a dialogue with them, which can be a wordless or a conversational contact (7 Sect. 7.3, 7 Excursion 8: The acoustic dimension of imaginations). In the case of Eichel, such an encounter with the reference person is carried out in the living kitchen between the patient as a little girl and her mother (7 Sect. 6.5 (392)). Family constellations, one’s own place in them or also the parents’ relationship to each other can be metaphorically illustrated using the motif “animal family”—similar to child psychotherapy (Case Musat, 7 Sect. 4.4 (9); Case Grün, 7 Sect. 5.4 (40)). An imaginative approach to identity and identification problems is provided by the stimulation motif of the “ego ideal”. The patient is asked, after the usual imagination introduction:

“Please think of a female/male first name (depending on whether it is a male or female patient).” As soon as a first name comes to mind and is pronounced, the patient is asked to imagine this Katharina or Ines, this Andreas or Robert or another: “Imagine a person to whom the name Katharina (Andreas) could fit.”

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

The imagined person can correspond to idealizing self-conceptions and embody qualities that the patient desires for themselves, often revealing identifications with parental figures. However, it can also show an “alter ego,” an important personality aspect attributed to others by the patient and needing integration. For example, a patient who emphasizes her attractiveness imagines a woman dressed in wool skirts, “unadorned,” but appearing “very down-toearth,” and perceives a “natural self-confidence” in her character, which she herself more or less consciously longs for. Such an imagination can contain a strong confrontational element and provide approaches to reorientation; it can initiate or support a mourning process concerning the farewell of an exaggerated or otherwise distorted ego ideal, and it can promote an integration process towards a more complete identity. Therefore, an attempt should be made to establish contact between the ego ideal representation and the self-representation. If the discrepancy between the two is very high (as in the case of Eichel, 7 Sect. 6.5 (79): “I feel so clumsy in her presence. She is so clear, noble.”), the patient considers the contact impossible to establish; therapeutic encouragement interventions are needed at this point. A prerequisite for making contact and a successful dialogue is that the self-representation can be perceived more concretely “in the picture,” as the patient may be completely focused on the ideal figure and may not dare to approach her out of shame. For example, Ms. Eichel only manages to approach “Antigone” when she imagines herself in “appropriate” clothing, a vivid expression of accepting therapeutic self-esteem strengthening. For initiating contact, questions can be helpful such as:

“Has Katharina even noticed that you are there?” (cf. in another context, case

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Grün, 7 Sect. 5.4 (9)). Or: “How could you make yourself noticeable to Andreas?”

In this way, diverging personality aspects can come into contact with each other in the form of these persons, which should be further promoted in a subsequent therapy section through deepening conversations and further imaginative (self-)encounters. Sexual conflicts and themes are often more or less symbolically disguised in numerous imaginations. Leuner (1985, p. 176 ff) has suggested exploring attitudes, inhibitions, and conflicts regarding sexuality with a gender-specific motif for women and men, respectively, if this appears therapeutically beneficial. Even though these motifs have been critically discussed repeatedly concerning social changes in gender relations and additional motifs have been proposed (Hinnen 2009), they are still suitable in some cases as a “starting point to convey to the patient a message about the state of this problem and to encourage them to further deal with it” (Leuner 1985, p. 177)—even Leuner did not have an apodictic standpoint at this point. Of course, this topic should not be addressed in a simplified drive-theoretical manner but should be understood in a broader context of partnership conflict and identity search: in the sense that sexual-erotic problems are always linked to relationship problems and that the possibly inhibited drive side is always closely interrelated with the narcissistic one. The male patient is suggested to imagine a “rosebush”. Leuner correctly assumed that the scene from Goethe’s “Heidenröslein” has collectively anchored and the beautiful, attractive rose, which can also sting, is well suited for symbolizing both the male’s handling of his desire and his approaches as well as rejection-injury fears and, for example, the associated inhibitions or those “daredevil” behaviors of the man

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with which he habitually plays over the inhibitions, well illustrated. Visiting the rosebush is recommended— similar to the forest edge motif—“at the edge of a meadow”, but can also take place in other contexts such as a garden, own piece of land, etc. During the approach, one describes the color and shape of the bush and the rose petals, the number and shape of the shoots, the flowers themselves—which can be “still budding and closed” or “fragrant-inviting”, but also (projecting one’s own potency insecurities?) “long wilted”. The therapeutic suggestion to follow the impulses, desires, and associated ambivalences that now emerge and, if necessary, to pursue them imaginatively, then determine the further course of the imagination. The corresponding motif for the woman is the “wanting to be taken along”:

“Imagine you are walking along a country road, feeling tired and a little exhausted. At some point, a vehicle will come, stop, and the driver will ask you if you want to be taken along.”

If the topic is formulated in this way, it implies on the one hand a traditional role model: The woman receives an offer from the man and can accept or reject it (him)— and unlike in our social present, not actively choose. On the other hand, this formulation approaches the attitude required for fulfilled sexuality, to be able to surrender as a woman. Nevertheless, one can also approach the topic with the modified introduction of the “hitchhiking”, in which the woman actively stops a vehicle. The imagined vehicles can then be a sports car or pick-up, a motorcycle, a carriage or small car, and the driver inside can of course be of any age and appearance or of the same sex. The driver can then encounter the imaginer with the most charm-

ing to devaluing remarks—depending on the experienced and usually expected experiences or desired (and warded off) expectations. Here too, it is important to give space to the numerous ambivalences, to ask precisely about the vehicle and the expectations associated with it, as well as about the driver and his trustworthiness and the alternative in case of doubts: Continuing autonomously is also an option—with and without the expectation of another stopping vehicle—or waiting for a female driver. Often, after stopping and a short conversation, a joint ride takes place, during which both get to know each other better and which then ends in some way either at a common (resting) place or with a farewell—with or without a further appointment (see vignette under 7 Sect. 7.7.5). Another motif for this conflict area is the motif“celebration”. It lacks the symbolic veil, is therefore more “realistic”, but also more clearly allows the confrontation with the narcissistic experience dimension. The introductory intervention is:

“Imagine you are at a celebration. You are standing at a counter; the door opens and a man (a woman) enters, whom you find attractive.”

Often, from the somewhat safe overview-giving location of the counter, a desired partner can be imagined, and inhibitions or possibilities to draw attention to oneself or to make contact come into the experience, which can be more deeply understood or worked through in the imagination or in the subsequent conversation. Symbolically veiled again, like the “rosebush motif,” is the motif “fruit” or “fruit tree,” which alludes to the collectively anchored paradise experience of the “forbidden fruit” and enables an oral defense or brings the child theme to the foreground. Here, it is important to have the

7.2 · Dealing with Stimulus Motifs in the Initiation of Imaginations

fruit ­described and to encourage enjoyment in order to discuss any inhibitions or other problems. The motif “lion” is suitable for specifically focusing on the theme of one’s own aggressiveness in the sense of assertiveness in pursuing one’s own goals. “Symbolically as the ‘king of the desert,’ he presents himself as a sovereign being (lion as a heraldic animal). The lion is capable of attacking and being murderous when necessary, when he has to defend his life or his interests and secure his food. On the other hand, the lion is also lazy, sluggish, disinterested, and sleepy when not challenged” (Leuner 1985, p. 182). The imagination is initiated with the simple formulation:

“Please imagine a lion.”

The lion can then appear in the wild or in a cage, it can appear powerful or limp “with a hanging tail,” the distance to it can vary, and the approach and contact can be very different and more or less successful. Aggressively inhibited patients benefit from the intervention of “slipping into the lion” in the form of a role exchange and in this way feeling its power, potential, or even grandiose protective posture, as in the case of Musat, 7 Sect. 4.5 (14): Whether he sits or stands—the important thing is the pose. He lives from the front with a full head. A bit like an old church: a huge facade and nothing behind it. Alternatively to the stimulating motif “lion,” the more open “wild animal” can also be suggested. All the imagination introductions listed here with specific stimulation motifs can be assigned to the expression and clarification function of the imagination process. This also applies to the following motifs; however, with these, more than with other stimulation motifs, their vitalizing potential is particularly addressed, especially those that contain an invitation to give space to the

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childlike-playful side, for example, a flight through the air into fantasized (fairy tale) landscapes using a “flying carpet” or the childlike hide-and-seek and disguise games of the “masquerade ball.” Motifs such as “Garden of Eden” or “Paradise Garden” can be suitable for mitigating a rigid superego problem and excessive adaptation to external norms and illustrating the patient’s repressed wish and need side. The risk of self-punishing negative reactions to be considered here was discussed in detail in the case of Eichel. Nevertheless, it can be therapeutically fruitful if the patient imaginatively “remembers” creative-childlike self-aspects and how it feels (vitalizing) to be without the familiar normative pressure (see cases Grün, 7 Sect. 5, and Musat, 7 Sect. 4). The invigorating potential of imaginations simultaneously has a stabilizing effect through the special affective enrichment via the acoustic sensory access in the motif:

“Imagine a pleasant voice.”

In this case, one can ask more precisely what is perceived as pleasant in the vocal impression, and later also, from which person the heard voice originates, and one can promote contact with the “speaker” or the one who sings something. In this imaginative experience, the early positive relationship experiences represented in each case, usually with parents or parent substitutes, are mobilized (7 Sect. 7.3, 7 Excursus 8: The acoustic dimension of imaginations). In connection with the remarks on the Bach motif, the possibility was already mentioned of having a strengthening effect on the ego by suggesting being carried by the “element of life” water, and thus using the stabilizing function of imaginations. Motifs such as “source of strength”, “warm source” or “a place where I feel comfortable” or the entry via a previously agreed concrete place of ­ relaxation and

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s­trengthening are further possibilities to achieve ego-strengthening regression promotion in stressful situations with imaginations. However, one should not overestimate the therapeutic possibilities of promoting such strengthening and stabilization through the choice of motif. What is not available in positive introjects and what has not yet been developed in positive object internalizations in the therapy process so far cannot be cunningly produced by a motif that appears suitable in any way! On the contrary, the encouragement to seek a “source of strength” can lead the burdened, depressed patient on a painful journey—the pain of which will then also be found in the transference relationship (further information in 7 Sect. 7.7). Finally, special motifs should be mentioned, which apply to approaches in psychosomatic illnesses, for example, the attention to diseased body parts. Leuner (1985, p. 192 ff) has described various possibilities of an “introspection of the body’s interior”, for example, in the fairy-tale form of a “Tom Thumb” exploring the body through a body opening such as the ear or throat, especially the painful and diseased body area. Here is an example from the Eichel case (7 Sect. 6), which was not included in the continuous case presentation: Mrs. Eichel comes into the session very hoarse (410) and speaks in her usual haste, ignoring her illness. I mirror this to her, but she cannot pick it up. When I ask her how the hoarseness actually feels from the inside, she now describes more quietly and thoughtfully that she cannot breathe freely. It does not flow freely in and out. Everything is congested, the voice is compressed. I encourage her to follow these impressions; if she wants, also in an imagination: I am now literally ‘gone inside’ And I am very small at the back of the throat. I can now see the mucous membrane discolored by the cough drop and the thickened vocal cords that cannot vibrate freely. (Touch intervention) They feel inelastic, as if they

are being held from the inside. It is so rigid in the throat… Maybe I should massage something away… I suggest that she try ‘not doing anything’ but let herself drift further in the throat, where and for what purpose it would take her on its own. Yes, I am now sliding into the dark. I am already at the very bottom of the throat, below the larynx. I ask if she can feel or hear anything. Yes, I feel a rhythmic movement. I hear a rustling. A flow. I hear my heart beating. I am sitting very small in a fold. It is soothing, the rhythmic, muffled, perpetual pounding of the heart. It touches her. Her voice becomes soft and almost inaudible. My organs are trying so hard for me. She cries. It does her good to sit there small in the soft fold. She wants to thank her heart and lungs. I tell her we still have some time, she should “resurface” or stay at her own pace. Mrs. Eichel says, here in the fold I become free and calm. Her everyday life is once again filled without a break, she now realizes, how much I need to pause, but I find it so difficult on my own. In functional and somatoform disorders, such “body introspection fantasies” can occasionally imaginatively open up a coherent connection to conflicts and relationship problems (Wilke and Leuner 1990). Numerous approaches with imaginations have now been developed in the field of psychosomatics and psycho-oncology, to which reference can only be made here (Bahrke and Rosendahl 2001; Höring 2010; Steger 2010). Overall, it should have become clear that the introduction of an imagination through a stimulus motif has many advantages, but also poses problems: Motifs can stimulate imagination through their imagery, clarify specific conflict dynamics through their specificity, and productively advance the therapy process in an intensive way by picking up on metaphors from the therapy process. However, as mentioned at the beginning, it can be particularly useful in analytical processes or for patients who are very concerned about their auton-

7.3 · Intervention Techniques in Imagination Accompaniment

omy for various reasons to refrain from introducing motifs. Such an entry or transition into imagination without a motif can also be found in the last treatment section of the Eichel case, where in the psychoanalytic therapy framework, imagination was often used at the end of the session to explore the current emotional state. In conclusion, it can be said that the knowledge of these specific motifs experienced on one’s own person is necessary for a KIP therapist to get to know the particular mode of being of imagining in its complex variety. However, in the therapeutic process design, the therapist has an ultimately unlimited abundance of possibilities to initiate imagination sequences: through general and specific stimulus motifs of any kind, in connection with a previous imagination or a (to be continued dreaming) night dream or a metaphor or discussed situation found in the therapeutic conversation, and finally also completely without a motivic stimulus. In this context, it should be emphasized that all specific stimulation motifs are initially and primarily suitable for the method-specific self-experience process in the training of KIP therapists and are also helpful because the colleague usually does not start his imagination process like a patient with a personal concern. This imaginative self-experience allows his therapeutic confidence and competence to mature in general; the experiences with the various stimulation motivf are additionally important in order to learn as a therapist to have an internalized spectrum of possible approaches, from which motif suggestions can then arise in the therapy process, even if the variety of concrete imagination approaches is in principle infinite. In a therapeutic process, the “processing” of specific stimulation motifs is in no case opportune—not even for “diagnostic reasons”. Leuner’s earlier textbooks suggest this conclusion to some: certain “standard motifs” should be “pictured” in order to

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gain a more comprehensive idea of the patient’s inner situation. This is neither necessary nor common: the recording of psychodynamics does not require additional (diagnostic) confirmation through imaginations, for example, if a perfectionist performance problem described in the initial interview is also shown using the “mountain” motive. However, in a therapeutic sense—and thus at a suitable point in the course of therapy—the imaginatively experienced insight into this problem can gain higher evidence for the patient and in this respect the mountain motive can be very helpful here. The same applies to the interpretation and understanding of the symbolic dimensions in the motif suggestions. Of course, it is necessary to be sufficiently familiar with the area of symbols (7 Sect. 7.2, 7 Excurse 7: Symbol): literature, especially fairy tales, myths, (Wagner) operas, dream books, films, and paintings are a rich source for therapists to explore symbolic references (see also 7 Sect. 9). Of course, special books from Gestalt psychology or C.G. Jung’s theory of archetypes can also help to better understand the possible framework of meanings of imaginations. However, a general “symbol understanding” shaped in this way should by no means dominate or even normatively restrict the patient’s self-exploration! 7.3  Intervention Techniques

in Imagination Accompaniment

Intervention techniques are the therapeutic approaches that are intended to help achieve desired subgoals within the psychotherapeutic process and ultimately the therapy goal itself. As a form of depth-psychologically based and, in a broader sense, psychodynamic psychotherapy, the intervention techniques used in the therapeutic dialogue in

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KIP do not differ from those commonly used, as described in detail in the relevant textbooks and assumed to be known here (e.g., Cierpka and Buchheim 2001; Rudolf 2010; Wöller and Kruse 2010). However, specific interventions had to be developed or existing ones (Leuner 1985) modified for imagination accompaniment. Distinctions are made between the instructions that structure the framework of the imaginations (1) and the various groups of intervention techniques applied during the imagination: interventions of accompanying entry (2), conflict-processing (3) and supportive interventions (4), as well as intervention strategies and forms required by the expanded indication spectrum of KIP (5). z Instructions (1)

As instructions, interventions are referred to that structure the framework of imagination and therefore require clear, unambiguous formulations from the therapist. These include, in addition to the relaxation instruction, the introduction instruction and the conclusion instruction already listed under 7 Sect. 3.6. With them, the therapist takes on an actively structuring function at the beginning and end of the imagination. The irregularly occurring imaginations, usually taking place about every second to fourth session, but also more or less frequently, for about 5 to 25 minutes, usually begin—depending on the agreement after a spatial setting change (7 Sect. 3.6)—with a relaxation instruction. In the case of the relaxation instruction, its design can be discussed and modified according to the patient’s needs beforehand, for example, made shorter or longer, or even omitted entirely. The suggestion for relaxation is intended to help the patient transition into the imaginative space more easily. As with a threshold ritual, it is helpful to say goodbye to what has been and make room for something new. The therapist could initially express that the patient “may let what has just been discussed/said

pass by,” as well as the current thoughts, and “let the surroundings recede.” And continue: “Instead, feel your body, the contact surfaces, its heaviness on your back, in your arms, your legs…”, “Try to let peace and relaxation come in,” “You can notice your breathing, how it comes and goes, comes and goes by itself…” (The therapist can adapt their speaking rhythm to the rhythm of the patient’s breathing, recognizable by the rising and falling of the abdomen.) The design of the relaxation instruction depends on the patient’s ability to regress and their current relationship with the therapist. It is merely a means to the end of promoting regression that facilitates imagining and thus synchronizing physical and psychological events for a more holistic, kinesthetic (7 Sect. 2, 7 Excursus 3: kinesthetic) perception. The relaxation instruction then transitions into the introduction instruction:

“Now try to imagine a/an/one… with your inner eye, any/one… but any other mental image is also possible. Wait and see what appears, and please describe what you can recognize.” Possibly: “Take your time.” Another formulation emphasizing the patient’s autonomy would be: “… or whatever else comes to your mind.”

Further alternatives were listed in Sects. 3.6 and 7.2; it was also explained in 7 Sect. 3.6 why it is more favorable to initially speak of “ideas” rather than “images.” Furthermore, it was already discussed there what support options the therapist has if an idea does not spontaneously establish itself. If— which rarely occurs—no imagination sets in despite these interventions due to resistance, one can ask the patient what they “see instead” in their mind’s eye. They often report that it is “all blurred” or they recognize “indistinct patterns,” upon which one

7.3 · Intervention Techniques in Imagination Accompaniment

can inquire what they look like, what they consist of—this attentive inquiry alone provides so much security that the patient can often let an idea emerge. The same sometimes happens in response to the statement that everything appears “as if behind a veil.” The question can then be encouragingly asked if he/she might want to pull it away? One can also encourage not to be disturbed by it and to describe what is showing up contour-like behind the veil. If, nevertheless—initially—no imagination arises or is perceived but not reported, this can be relieved as “not bad” and understood by the therapist as an expression of a need for clarification based on the relationship. This clarification can be attempted in conversation; however, often the therapist should first bring it about with himself through reflection of the relationship using his countertransference (7 Sect. 7.7.5), just as the “working alliance” is one that the therapist can basically only agree with himself (Deserno 1994). This self-clarification helps to relieve and structure the conversation with the patient. Some of the numerous (transference) reasons for such initial difficulty in imagining were already mentioned in 7 Sect. 3.6, often a performed performance claim is the reason for the prevention. The termination of an imaginative sequence is done by an exit instruction such as:

“Our time is coming to an end; please let your images fade away.”

The exit instruction is of great importance because patients in the kinesthetic experience mode of imagining (7 Sect. 2) often develop a different sense of time: short seems long, long seems short. The exit should not coincide with the end of the session, so that there is enough time for a follow-up conversation (7 Sect. 3.6 and 7.5). It was already mentioned in 7 Sect. 3.6 that

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therapists who develop a caring countertransference towards the patient or act out their own altruistic defense structure occasionally have problems with the exit, as they also tend to extend sessions. A countertransference-related delay in endings may, however, represent a burdening relationship message to the patient (“I didn’t do it well enough, still haven’t achieved anything”). Accumulating delays in endings should therefore be addressed in supervision. z Interventions of Guided Accompaniment (2)

The intervention style of the first imaginations follows the principles of guided accompaniment. Its purpose is to promote familiarity with imagining, to introduce therapeutic imagining, to intensify it, and thus to open up the imaginative space as an additional place for therapeutic experiencing and acting. This is done in the form of anxiety-reducing, dosed, “accompanying” interventions that avoid confrontations and therefore also choose stimulating motives (7 Sect. 7.2) as a starting point, which can easily trigger inner representations and are almost exclusively taken from the realm of nature (7 Sect. 7.2). Distinguished are description, effect and impulse questions as well as touch and resonance interventions. Description questions are the guiding intervention of guided accompaniment. They are intended to help the patient perceive further aspects of the imagination in addition to those already mentioned by them. They take the form of an inquiring, interested questioning regarding the nature of the described, its shape, color, consistency, as well as accompanying circumstances such as the weather, time of day, atmosphere, etc. The questioning should not narrow or irritate the imaginative space, which is why no questions should be formulated that only allow a “yes” or “no”—the person imagining always has more alternatives than the therapist can imagine!

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Questions that serve the therapist’s orientation in the image also help the person imagining to make their inner representation clearer and more vivid, e.g.:

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“How far is it to there, approximately?” or: “What do you estimate, how long would it take you to get there?” If alternative questions seem necessary, they should be formulated openly: “Is it like this or like that or … completely different?”, “Does your path take you there or there or perhaps somewhere else entirely?” etc.

To further promote the plasticity of the imagination and thus its affective enrichment, it is helpful to relate the description questions to all sensory qualities (7 Excursus 8: The acoustic dimension of imaginations, see below), as it is offered by the image itself:

“Can you hear the bird too?”, “What does the flower smell like?” Spring water can (also) be touched and drunk (“What does the water taste like?”) etc. In this way, the perception process is intensified and differentiated. Particularly significant is the touch intervention: “Can you touch the trunk/the ground/the water once? How does … feel?”

These questions promote a holistic perception of form (7 Sect. 3.6 and 7.2; Case Eichel, 7 Sect. 6.5 (6)). Even if the patient unfolds his imagination with only restrained questioning support (which can express a specific transference constellation, 7 Sect. 7.7), it is important to make the therapist’s inner involvement tangible to him with basic presence and resonance interventions. This is therapeutically significant because, for example, parenti-

fied or performance-oriented patients often do everything quickly “by themselves” in their imagination and keep the therapist at a distance due to transference. If they remain without resonance, they easily scenically fall into states of old loneliness, i.e., they establish their inner situation in the transference. Anxiety neurotic patients, on the other hand, need the presence reassurance of their therapist. This can be a more neutral, presence-signaling “Hmm” as well as a resonance-giving, surprise and/or interest-signaling “Ah yes?!”, “Oh!” (compare the effect of this resonance expression in the case of Grün, 7 Sect. 5.4 (9), where the patient very insecurely expresses a contact wish to the imagined little bird, immediately fends off this wish as “silly”, but is encouraged by the therapist’s encouraging resonance intervention: “Oh, wonderful idea!” to pursue the wish anyway. What led to insecurity and defense is not eliminated, but is now better manageable.) Effect questions serve to promote affective experience: They ask how the created imaginative scene affects the person concerned and thus focus on the patient’s current emotional state, which corresponds to the inner perception:

“How does the flower/the house etc. affect you?”, “How do you feel right now when you look at …?”, “How do you experience the whole thing?”, “What do you feel?”, “How do you feel?”, “How are you here?”

Details can also be addressed and asked about the feelings they evoke. This also supports the process of affect enrichment. The feelings can be clearly named and experienced by the therapist, or they can remain diffuse or deviate more or less from the therapist’s experience. In this case, the therapist will ask:

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“How else would you describe your experience?” Or, with the aim of more authentic emotional perception and affect clarification, he will suggest an expansion of the scene: “What does this feeling remind you of ?”, “Can you think of something where you experienced something similar?”

Such questions can prepare the intervention of the associative loop (see below). This work on affective experience, affect communication, and affect differentiation is not limited to the imaginative process in KIP and also takes on the typically important role in therapeutic conversation for psychodynamic psychotherapy. If the therapist has the impression that the patient has “arrived” in his imagination with an intense experience, a change in his questioning behavior often occurs intuitively, instead of: “How is it for you there on the meadow?” the therapist will switch to: “How is it for you right here on the meadow?” and thus more appropriately correspond to the patient’s experience. Impulse questions usually follow the elicited affective experience, but can occasionally precede the effect question if the therapist has already understood the patient’s affective involvement based on the descriptions alone. They serve to raise awareness and clarify desires, needs, and impulses. They ask for what the person imagining currently desires based on their experience:

“What do you feel like right now?”, “What would you like to do most right now?” etc.

If the patient feels comfortable “here,” they may want to linger; if they feel uncom-

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fortable, they may want to change the location and have an idea in which direction and by which route this should happen; if they feel lonely, they may look for someone, etc. Such impulses can initially also arise from sensory well-being: From the sun experienced as too hot, the shade of a tree is sought; thirst gives rise to the idea of drinking from the nearby stream recognizable by its noise, etc. All these questions, which apply to the impulses currently in effect, round off the imaginative experience. The therapist should ensure that the imagining as a holistic experience unit is maintained while intervening in the form of impulse questions and does not turn into rationalizing deliberation. To support this, the focus of perception can be changed repeatedly and oscillated between the elements of imagination, the emotional tone, the current body sensation, and the impulses (see, for example, in the case of Musat, 7 Sect. 4.5 (14)). Impulse questions should also avoid restrictive answers that only allow two possibilities. If, for example, the person imagining gets up from a bench expressing the desire to continue walking but then hesitates, the emerging ambivalence should be explored first:

“What’s going on?”, “Do you want to continue walking or stay after all?”, “Or is something completely different happening right now?”, “Or what do you feel like right now?” And if they want to go but are undecided about the direction: “Do you want to take the path to the right or the left, or do you have a completely different idea?” Or also clarifying ambivalence: “What makes you hesitate?” Or: “Where do you know this hesitation from?” Or: “How do you feel right now?”

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These examples show that with impulse questions, we have entered the realm of the patient’s determining needs and their defense: With the desire comes the “but.” And the clearer the patient’s impulses and desires become through our therapeutic questioning, the more directly the defense side becomes present: For example, one could encourage the person imagining, who is lost in the forest and has just encountered a hiker (desire for support), to ask them for directions. If the person imagining then states that the hiker has already moved away (defense of the desire), this could be an expression of the patient’s embarrassment—due to transference also in front of the therapist—of having shown their need for help and thus their autonomy problem or need for attachment, and/or it could also indicate that they projectively fear being laughed at and shamed by the hiker—and therapist—as ignorant.

Impulse questions can thus lead to the rounding of an experiential gestalt, but also initiate conflict work. z Conflict Resolution (3) and Supportive Interventions (4) In Their Mutual Relationship to Each Other

Improving insight into the wish-defense process is central in any psychodynamic therapy and is predominantly achieved in KIP through therapeutic dialogue: The patient may hope for an improved work situation from their boss but fears being humiliated; they may be hurtfully rejected by the desired woman; they may be left alone by a friend seeking closeness, etc. We try to determine how realistic this is, which current and/or biographical experiences these fears are related to, and how far they restrict the patient’s scope of action. 7 Excursus 8: The acoustic dimension of imaginations

Excursus 8: The Acoustic Dimension of Imaginations

The therapeutic attention to hearing as an already intrauterine effective perception mode can contribute in a special way to deepening the kinesthetic character (7 Sect. 2) of imagination. Five different groups of auditory impressions occur: the natural soundscape (1); voice impressions and “wordless conversations” (2); dialogues with or between imaginative representations (3); calls (from humans, mythical and other beings, animals) (4); disturbing noises, mostly triggered by technical things or devices (5). (1) Natural sounds such as babbling brooks, forest rustling, gentle breeze, birdsong, insect buzzing, rustling in hay, crackling of fire, etc. are almost without exception experienced as pleasant, as well as emotionally condensing and intensifying, and often initiate a revival of harmoniously experienced states based on the model of the “intrauterine sound envelope” (Maiello 1999).

In this respect, description questions aimed at natural sounds (7 Sect. 7.3), while an imaginative landscape impression slowly builds up, are an invitation to a regression that serves narcissistic strengthening. The interventions are simply: 5 “Do you hear something?” 5 “Is there something to hear?” 5 “What does the stream/the babbling sound like?” (2) Similarly, the kinesthetic enhancement (7 Sect. 2, 7 Excursus 3: kinesthetic) works when focusing internally on a pleasant voice sound of the imagined conversation partner: This leads to “wordless conversations” in which the patients are in harmonious accord with the imagined other. They stroll with him through a beautiful environment or sit together on a bench and talk without exactly understanding what is being said, and do

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not find it important, because what is important for this situation is their deeply felt emotional connection to the other. This blending of voices without words ties back to primal scenes of vocal but preverbal communication, scenes of good fit and affective attunement (Nohr 2003). The revival of such scenes can be stimulated by simple questions like: 5 “What does the voice sound like?” 5 “How do you feel in the contact?” 5 “What is good for you and the other person right now?” In this case, leading questions that focus on content, such as: “What does the other person say?”, “What do you say?” would be less helpful. (3) Nevertheless, it can be useful to initiate literal dialogues between representations in imaginations to promote approaches to significant others on the inner stage, such as when working on polarizations and projections (7 Sect. 6.4 (79), dialogue with Antigone). When encouraged to pay attention not only to the content of what is said but also to the tone of voice of the counterpart, this often leads to genetic associations, and the patient realizes in the manner of an aha-experience from which previous relationship experiences he encounters others. The intervention for this is: 5 “How does the voice of … affect you?” 5 “What is the sound of …’s voice like?” (4) Calls of animals or humans cause special attention, in reality as well as in imagination. One feels addressed or emphatically pointed to another person and their emotional state. Often, calls in imaginations are related to important aspects of identity and are in the context of the “calling,” the “call” one follows or resists. Mythically, the significance of the “call” is expressed, for example, in the story of paradise: Through God’s call: “Where are you?” Adam and Eve become aware of their vulnerable uniqueness and ungodliness.

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If calls in imaginations occur spontaneously (e.g., a child’s call behind a fence, a dog barking, the call of a stranger, a striking bird’s cry, the roar of a lion), the therapist should intervene to ensure that these “calls” do not simply go unheard. Interventions such as 5 “How does the lion’s roar affect you?” 5 “What does the child’s call sound like?” 5 “Can you make out who is calling?” 5 “Who is being called?” and: “How does this call sound/affect you?” 5 “How does the dog bark?” and: “Who is it barking at?” 5 “What does the call remind you of ?” encourage a deeper exploration of the needs for being meant, being heard, and being seen, for example, with depressive or guilt feelings or with phallic-narcissistic desires. (5) Noises caused by things of all kinds, such as the screeching of saws in the forest, hammering, clock ticking, knocking on the wall, engine noise, gunshots, etc., generally represent “disturbances.” Occasionally, a soundscape caused by natural things can also take on a noise character, such as shrill bird screeching. To ascertain the character of these noises, ask the simple question: 5 “How does the noise affect you?” Whenever it is perceived as loud, annoying, or disturbing, it is regularly an expression of resistance-related “disruption maneuvers” of the person imagining, who thus prevents further emotional confrontation with the content of the imagination for defensive reasons. If the noises are perceived as pleasant, e.g., conveying constancy and security like clock ticking, they should be treated as described in (1). For unpleasant noises or noise, interventions such as 5 “What would be good now?” 5 “What possibilities are there to eliminate these disturbances?” 5 “What do these disturbances remind you of ?”

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A therapeutic laissez-faire is not appropriate at this point, as silently ignoring self-damaging behavior reinforces it. As a rule, encouraging resonance or the suggestion to eliminate or mitigate the sources of disturbance is necessary to enable corrective new emotional experiences. “Disturbances” of all kinds are therefore fundamentally to be seen as anxiety or inhibition signals in the current transference dynamics and have priority for processing solely for this reason. Case vignette. A patient working “under high pressure” wishes to imagine with the goal of “relaxing a bit” before a conference. She imagines a pleasant beach scene with the sound of waves, a light breeze, distant seagull cries, the voices of playing children,

Such a conflict-seeking dialogue can also take place in KIP at the level of imagination, prepared or continued there, or processed in different ways (7 Sect. 7.4). In the imaginative experience mode, such a conflict approach can sometimes be more gentle and yet closer to affect than in conversation, by symbolically veiling the possibly more distant consciousness in the imagination. Ambivalences can be felt in individual dimensions, steps of wish-approach can be tentatively ventured, and more distant possibilities can be “rehearsed” on the imaginative “stage.” This brings us to the core area of psychodynamic psychotherapy: To seek out the inner conflicts that hinder the patient in their life endeavors with understanding, to explore and gradually modify them so that their inner and outer spaces, their inner experience, and their external life design expand. The conflict resolution and supportive interventions described below are based on the fundamental insight that the process leading to understanding and change is therapeutically meaningful from two sides:

and the rustling of her husband’s newspaper. She felt completely comfortable, but only briefly, as a group of animators appears, equipped with “whispering cones,” through which they are called to all kinds of activities. After an animated reflection: “How do you feel about the animators?” (“bad, I’m annoyed”) and the encouragement intervention “What would be helpful now?” the patient reports that the animators disappear behind the dunes. The patient emerged strengthened from the session. In later sessions, she was able to understand that the “animators” represented personifications of her driving superego and in our transference relationship the fear that I might condemn her for her “laziness.”

The patient must be confronted with their dysfunctional relationship patterns and their restrictive defense; and this confrontation should be focused and lead to a work of understanding. At the same time, the patient should feel sufficiently supported to dare these (self-)confrontations. This can be summarized as follows: The therapeutic work should take place at an optimal level of anxiety—between as much confrontation as possible and as much (under-)support as necessary. For the sake of importance, let this be formulated once again from an attachment theory perspective: The feeling of security is fundamental for any exploratory behavior. In the therapeutic context, the patient’s feeling of security is derived from their relationship with the therapist and the positive object representations mobilized therein. When confronted with the danger of emotional pain, they must be able to assume that they can cope with it, if necessary, with the help of the therapist and their internalized positive experiences. Otherwise, they must avoid it. Fear signals that this danger

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is too great. In the protection of the therapeutic relationship, however, we expect the patient to expose themselves to the fear associated with this confrontation, because we assume that this fear is inappropriately large due to the patient’s prior experiences on the one hand, and that overcoming it will expand their life possibilities in a health-promoting way on the other hand. This general principle of psychodynamic psychotherapies, working in an area of optimal anxiety levels and controlling it using transference relationship, interpretation, and resistance analysis (7 Sect. 7.7), is served by the alternation between confronting and supporting interventions during the imagination process. In detail, with conflict-resolution interventions, a distinction is made between clarifying, focusing, and confronting interventions using the intervention techniques of the eye test, the power test, the associative loop, role reversal, and working with the so-called age regression. With supportive interventions, a distinction is made between resonance interventions as well as indirect and direct encouragement interventions, distancing requests, and working with ego-strengthening symbolic figures. The juxtaposition of clarifying and supportive interventions is primarily for didactic reasons and is artificial insofar as a clarifying inquiry can also be stabilizing and a resonance intervention can be conflict-resolving (. Table 7.1). With clarifying interventions, conflicts determining the patient can be brought into experience on the imaginative level, and in particular, wish-defense ambivalences can be explored. Just as in conversation, the basic goal of exploring ambivalence is to support the patient in their therapeutic concerns, helping them better understand their contradictions and possibilities. Therefore, general, open, non-committal interventions are usually the most appropriate, e.g.:

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“What options do you have there?”, “What speaks for and against it?”, “What else would you like to do?”, “Where would you be drawn to right now?” etc.

These open possibilities are definitely preferable to “solution suggestions” conceived by the therapist, such as: “Can you perhaps find a ladder?” or similar. Such solution suggestions often carry disadvantageous relationship messages for the patient, such as: “I am incapable.” “I would never think of such an idea!” etc. However, there are exceptions, e.g., in therapeutic work in the supportive area, when you want to express to the patient how much you care and wish for a solution for them (Case Green, 7 Sect. 5.4 (9)). As is generally customary in psychodynamic psychotherapy and due to the twosided process control described above, supportive intervention strategies are also used reflectively in the accompaniment of imaginations: The therapist is guided by the principle of supporting the patient on the one hand in dealing with their negative introjects and changing their maladaptive relationship and behavior patterns into more adaptive forms, and on the other hand, limiting this support to the necessary extent so as not to (possibly again) infantilize the patient and deprive them of their own autonomy steps that strengthen their self-esteem. For example, if a patient reports an upcoming confrontation with their boss that is causing them distress, the therapist will first try to understand, together with the patient, what specific fears exist, perhaps also what biographical backgrounds influence these fears, whether they are justified in this case, etc.—and then ask the patient what they think, how they will express themselves to the boss, what they can do, etc. (see in the case of Musat, 7 Sect. 4.4

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. Table 7.1  Overview of intervention techniques

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Desired process goal

Intervention techniques

Explanation

Securing the Imagination Framework

Instructions: – Relaxation instruction – Introduction instruction – Conclusion instruction

Interventions that structure the framework of imagination—require clear, unambiguous formulations from the therapist

Guiding Introduction

Description questions, Touch interventions, Effect questions, Impulse questions, basic presence and resonance interventions

Intervention style that aims to lead into and intensify the imagery experience in the form of anxiety-reducing, dosed accompaniment

Affect clarification, affect differentiation

Effect questions

Promotion of affect experience and affect differentiation

Clarification of desires and defense

Impulse questions Eye test interventions Work with role reversal

Support of self-confrontation

supportive intervention strategies: – Resonance interventions – direct and indirect encouragement interventions – Work with self-strengthening symbolic figures – Distancing requests

Activation of good inner objects and representations of the projected ego ideal, Strengthening of the self-system through temporary renunciation of conflict focusing and activation of positively toned early relationship experiences, Regression in the service of the ego

Awareness, processing, and working through central conflicts

Focusing Confronting associative loop Power struggle intervention Work with role reversal Dealing with age regressions associative imagining with minimally structured Intervention technique Return to the initial image

Integration of split self-parts, loosening of constricting impulse defense, work with negative introjects

Affect mitigation and promotion of symbolization ability

Resonance interventions Encouragement interventions distancing intervention strategies: – Slow-motion intervention, – Bird’s-eye view intervention

Affect-containing by the therapist, especially for structurally weak patients, promoting a triangular psychic thinking space

(8), (9) the discussion of the upcoming confrontation with the parents). If this clarifying form of accompaniment is not sufficient and the patient continues to feel anxious and helpless, the therapist could increase their “support dose” by asking, for exam-

ple: “Could you imagine behaving like this in this case?”—Of course, there can be various (transference) reasons why this is not experienced as helpful and sufficient. However, it is also possible that the patient continues to work with this idea and makes a

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positive, new experience that they can discuss and understand more deeply in one of the next therapy sessions—including reflecting on the reasons why this form of support was (still) necessary. Supportive interventions are applied in the imagination according to this principle: Already in the first imaginations, it can make sense to support the patient’s impulses regarding their handling of the flower, a path obstacle, etc., in different doses. Initially, one would usually start with indirect encouragement interventions to search for their own ideas:

“What would be helpful now?”, “What could help you?”, “What options come to mind?” If the patient has an idea but hesitates to implement it, this hesitation can be explored clarifyingly in their ambivalence (see above) and then the focus on a solution can be reconsidered with effect, impulse, and encouragement interventions: “How is it now?”, “What do you feel like now?”, “Then you can, if you want.”, “Maybe just give it a try.” or even with a suggestive accent: “You will find a way.”

With such an approach, for example, superego-related inhibitions and restrictions can be situationally mitigated, and the patient can be helped to move more naturally in their imaginative space—this can initially encourage them regarding their therapy project. As an example of an intervention style combining the supportive with the confrontational, the case of Eichel (7 Sect. 6.5 (79)) is referred to: Here, the motivation for the ego ideal (7 Sect. 7.2) is suggested and subsequently asked: 5 Can you try to bring yourself into the landscape and get in contact with Antigone?

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5 It’s not that easy. She seems unapproachable. 5 Has she noticed that you are there? (Clarification) 5 I’m squatting there, knees bent. She stands straight, motionless. I feel so clumsy in front of her. She is so clear, noble. I feel out of place. This feeling is so familiar to me… 5 Does a scene from your life come up with this feeling? (Technique of the associative loop, see below) 5 I am too tall, too rough, too clumsy. My mother always said: How can one have two such different children, one so beautiful, the other so ugly… (cries). 5 What would be good for you so that you could get in contact with Antigone? (Encouragement intervention, focusing intervention) 5 If I imagine I’m wearing something neat or even noble. Yes, that’s better. I’m standing now too, not as straight as Antigone, but slimmer than before. Maybe everything would be better if I could hear Antigone’s voice. 5 Yes, how could you manage that? (Indirect encouragement intervention) 5 Approach her. She’s looking at me now with a warm, friendly gaze… Maintaining the psychodynamic treatment concern, on the other hand, means repeatedly focusing, making conscious, and working through central inner conflicts. This is the other side of therapeutic work with the patient in the area of an optimal anxiety level: confronting them with their defense, their defended conflicts, and self-parts, for example, to enable the reintegration of projected parts into the self. This means imposing fear and other forms of emotional pain on them: Such confrontations with certain inner aspects and self-parts usually follow an unfolding process and are therefore not surprising or overwhelming. Once a specific inner

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conflict has been understood in the therapy process, desired confrontations with (inner and outer) objects in the imagination can be explicitly agreed upon together in a preliminary discussion. However, it can sometimes—and this can already happen during the accompanying guidance—very quickly lead to conflictual scenes under the pressure of emerging relationship desires. For example, the person imagining may encounter a frightening animal in their imagined meadow. How is this fear to be understood and what interventions are appropriate? If the patient encounters a frightening creature in their imagination, it is initially unclear whether it is a hostile experienced introject that has been split off, possibly a persecutory superego component, or a hostile experienced internalized overpowering object representation, associated with a transference implication—that the therapist is also experienced in this way (7 Sect. 7.7.4). Leuner has proposed the socalled intervention techniques “Nourishing and Enriching” as well as “Reconciling and Tenderly Embracing” for the phase of becoming familiar with imagining: The patient is asked in their imagination whether they have something with them to appease this creature or what they could feed the animal or whether they could stroke it for “pacification.” This way of dealing with the anxiety-laden hostile symbolic figure is intended to prevent the patient from either fleeing or wanting to “destroy” this figure according to the therapeutically unfruitful all-or-nothing principle. Instead, through the techniques described by Leuner (1985, p. 111 ff), something soothing—be it on the oral (nourishing) or on the intentional level of touch and emotional closeness (tenderly embracing)—is offered and brought to the threatening representations, which can have an anxiety-reducing effect and initiate a process of integration, for example, of split-off introjects. Both techniques can also be connected with each other in succession.

If this form of intervention is chosen, it is important in the psychodynamic context represented here to subsequently engage in a joint understanding work, a clarification regarding the questions of which representation or which self-part one has given away in this situation, which is to be understood in what way, in order to alleviate one’s own anxiety—and whether this is still necessary. This clarification, which can again take place exclusively in the therapist (7 Sect. 7.7.5), is important so that there is no countertransference acting out by the therapist reflexively letting the patient reach for the “imaginative food bag”! Instead, it is advisable to first explore the patient’s anxiety tolerance in this situation: The patient may find their own way to protect themselves (in a hollow, behind a tree, etc.) and observe the frightening object figure from this distanced position. If necessary, one can encourage this. As in psychodynamic psychotherapy, detailed observation often helps, i.e., clarifying to realize that the initial anxiety impulse overestimated the real danger. This often happens in imagination as well: If the therapist first has the frightening figure described in detail and, with resonance interventions, ensures that there is no longer pause in the patient’s reporting, i.e., that close contact is maintained, the anxiety often decreases without anything else being necessary. If necessary, the therapist can remind themselves by asking interested questions. Under the loss of contact with the therapist, the anxiety effect could become too powerful and the imagined image “disappear”—which would not be “bad,” but would have taken away the patient’s opportunity for confrontation. As a further, also anxiety-reducing, and at the same time conflict-processing-confronting intervention, the therapist can encourage the patient to look at the eyes of the imagined figure, “let the soulful expression of the gaze affect them” and have them describe it. With such an eye test intervention and the further association-­triggering

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question of whether the gaze reminds them of something, whether they have encountered this expression before, the assignment of anxiety sometimes succeeds: The specific gaze and then also the corresponding person are recognized—a teacher, an uncle, the mother—and the patient can, on the one hand, check whether the extent of their anxiety, justified from the past, is still appropriate today. In this way, there can be a sudden change in the imagination from, for example, a natural scene with a frightening animal in a landscape to a biographically significant memory or screen memory scene. The patient can then be prompted in the “new scene” to feel what impulse arises and how they want to actively shape the encounter from their own perspective—which, however, does not have to happen in the same imagination in every case. Not always does the fear subside through the “eye test.” And not always is the gaze immediately recognized and assignable. In this case, the therapist can try to prevent a possible situational defeat experienced by the patient (by fleeing in or out of the picture) by encouraging a stalemate situation, specifically with the intervention of “binding” the counterpart with one’s own gaze:

“Look X firmly in the eyes, try to persistently fixate on them and bind X with your gaze.”

This power struggle intervention can result in the figure changing, leaving the scene, or exiting the imaginative situation in an “undecided” but self-respecting and opponent-respecting, self-esteem-strengthening manner—and through clarifying follow-up discussions, a more favorable starting position for the patient for further imaginative encounters can be prepared or understood with them, what might have made

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the “other” so powerful or overpowering in their eyes. Such further contact, i.e., confrontation—usually, the imaginative symbolic figure represents a split-off part of the self— should be actively encouraged therapeutically. In a then often verbal exchange with the imaginative figure, both the self-experience and the perception of the counterpart can change over time, leading to clarifying, understanding insights. Supportive in such and other imaginative situations of danger, helplessness, or disorientation can be the work with occasionally spontaneously and then repeatedly appearing in the imagination self-strengthening symbolic figures as embodiments of positive introjects. They are, of course, also to be understood as expressions of the transference relationship or appear through it (7 Sect. 7.7.2). Usually, these are animals again, but in these cases—equipped with spontaneous instinctive knowledge—they can be helpful. For example, an owl sits there, knowing the way. Or a camel trots by, which can carry the weary one through the landscape. Helpful knowledge can also come from an “old wise man.” The therapist can also encourage looking out for such helpful figures in the respective situations:

“Maybe you can look around to see if there might be someone you can ask?” or more specifically: “Perhaps there is a resident of this area who knows their way around and can give you advice?”, “Who or what could be helpful now?”

One should not resort to such formulations reflexively, but decide countertransference-reflectively what is situationally reasonable for the patient (in terms of insecurity) and how far support may be necessary and helpful for the therapeutic process.

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With these positively charged symbolic representatives, which appear spontaneously or with therapeutic support in frightening or destabilizing imagined situations, depending on the psychoanalytic terminology, auxiliary ego functions or good internal objects are meant. They can represent representatives of the projected ego ideal, which “lead the way” for the patient in a fear-reducing and encouraging manner (Chasseguet-Smirgel 1987). In the therapeutically supported confrontation with such condensed, affectively charged symbolic material of the imagination (Leuner spoke of “symbol confrontation”), the technique involves a focusing on a central intrapsychic conflict (cf. above Antigone imagination). Combined with the stimulation of genetic associations, through which memory material can become accessible, this conflict can be specified with its desire or defense dimensions, and the confrontation with the associated affects can be facilitated, which helps initiate a gradual integration process. This is the goal of all these intervention techniques of initially distancing and then gradually “reconciling dealings” with negative introjects on the imaginative level: to serve the integration of split-off self-parts and thus the reduction of a constricting desire and impulse defense. As a result, intrapsychic damaging polarizations can be overcome, and interpersonal contact and relationship skills can be improved through the withdrawal of projections and delegations. Not always does this process take place in building spirals of understanding and experience loops, but often an increased defense can be observed. Nevertheless, in a psychodynamic KIP carried out with imaginations, explicit resistance analysis is rarely necessary (7 Sect. 7.7.6) and not always absolutely necessary even in analytical psychotherapy. Often it helps here to work with the technique of the associative loop (Antigone example, see above): The patient

is encouraged to unfold the psychodynamic focus in terms of its thematic complexity and its biographical time dimensions. By focusing the therapist on, for example, the eye expression or the emotional effect of a landscape detail or even on a currently prevailing body sensation, the imagination of “matching” genetic scenes is stimulated:

“Have you ever encountered this somewhere else?”, “What does this remind you of ?”, “Do you know this feeling from somewhere?”, “Can you think of a scene from your life where you also had this feeling/that would match your feeling?” And if the patient remembers something: “What do you see now?”, “Does a scene come to mind?”, “Can you imagine something that fits?”

In this way, often “pictures within the picture” develop, thematically associated imaginations enrich the focus and induce genetic associations in particular. At the end of such a multi-layered imagination, the intervention of encouraging the patient to return to the original image is often helpful. The changes in the initial image that are then noticed often lead to spontaneous insights and strengthen trust in the therapeutic change processes that are thus “visibly” taking place: After Mrs. Musat (7 Sect. 4.4 (9)) has dealt extensively with certain family-dynamically important experiences on a symbolic level (sheep family), the therapist suggests: 5 Would it be possible for you to go back to the beginning? You had cows in mind at first. What happened to them? 5 Yes, the picture changes. I now see a cow and her calf. The calf is very close to the mother. It is a picture of seeking and giving protection. Instinctively drinking, standing under the belly and snuggling. The mother turns her head towards the calf.

7.3 · Intervention Techniques in Imagination Accompaniment

The intervention technique of the associative loop, especially the induced redirection of the imaginative flow with regard to genetic associations, shows parallels to the concept of the Central Relationship Conflict (Luborsky 1995), even if the current transfer is weighted more heavily in KIP. As a psychodynamic concept, it is very compatible with KIP, as Hennig (2007) has pointed out and further elaborated on. Since the technique of the associative loop allows for a concise insight into the formation of defense configurations, it is also used in supervisions for states of collusive stagnation (Cottier 2005). Another intervention technique that intensively prepares integration processes and, in particular, makes affective splits tangible is the role reversal known from psychodrama. The patient is suggested to slip into the figure of, for example, the frightening counterpart: “Can you imagine perhaps being this lion yourself, slipping into it?” The role reversal is often spontaneously performed by the patient and radically changes the affective mood of the imagination (Case Musat, 7 Sect. 4.4 (14)). Of course, this does not overcome any split, but it enables an affective evidence experience that helps to work on their integration in the further course. Among the intensity-enhancing conflict-processing intervention strategies is the work with age regressions that often spontaneously occur in imaginations: The patient experiences himself in the mental image younger than he is, usually as a child. Often this is revealed from formulations and can be asked for orientation: “How old do you feel right now?” Or the patient only realizes through a question about clothing that he experiences himself as a four-yearold boy with his first leather pants. Within an imagination, age states can change repeatedly: “Now I am an adult again.” Emerging age regressions can be used to explore certain life history sections and re-

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lated conflicts in a memory image and make them relivable. As an example, an imagination description is inserted from Case Eichel, 7 Sect. 6.5 (145): The patient imagines a “spring landscape” with a rolling green expanse, carpets of wood anemones, a stream with yellow marsh marigolds. I pick a bouquet of cowslips. Under white flowering trees. I see myself as a child with a white ribbon under an apple tree. But why do I look so serious, so pale? So joyless? 5 Would you like to ask the child? (confronting focusing) 5 It says: “I left the party. I did something wrong again.” 5 Do you have an idea of what might be good for the child? (Encouragement intervention instead of conflict focusing, see 7 Sect. 6.5) 5 Playing ball… The child plays as if transformed. It gets a friendly woman to play with. It’s fun—we’re doing well, colorful ball, flowers. Long playing by the stream. The girl is worried that someone will call her. She has to go back. Her teddy is there. We make wreaths for him. We are now plotting a conspiracy against the others. While at this point in the process it was important to encourage Ms. Eichel against her strict superego, working with age regressions can also serve to work through conflicts (see 7 Sect. 6.5 (392), where there is a confrontation with the mother in the kitchen and the patient as a child becomes possible for an otherwise warded off aggression). Interventions with intensity-enhancing strategies are particularly indicated for “over-structured” patients, such as those with a strict superego, compulsive structural components with affect isolation, or otherwise difficult access to the affective area. (Patients with structural deficits, on the other hand, could be described as “un-

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der-structured,” for whom these intervention strategies would be contraindicated, see below.) In working with ego-stronger patients and in a treatment framework that approaches the psychoanalytic setting more closely, one will spontaneously encounter associative loops and age regressions. The therapist can then largely dispense with both suggestions for this and supportive interventions, and instead focus on basic presence interventions. This form of imagination design corresponds in analytical psychotherapy partly to the so-called free association, where the patient lying on the couch continues his free associations at times in the form of associative imagining, as it were, “migrating” into the imaginative realm. In these advanced treatment phases (see Case Eichel, 7 Sect. 6.5 (452)), the patient manages almost without verbal therapist interventions, which is why we speak of a minimally structured intervention technique: “Mrs. Eichel is silent. After a little while, I ask: “Where are you right now?” She answers, picking up on a previous imagination: I am curled up like a cat in a hollow. I see the cat in front of me, petting it. Then I am the cat myself. I can come to rest, I don’t have to achieve anything, not even here, I don’t have to fix anything, I can just be. But I still need you to remind me of this again and again. The perception of countertransference is nevertheless also important here, in order to be mindful of both the extent to which the patient maintains his therapeutic concern, confronts himself, and deals with himself and works through remembered material, as well as to intervene supportively or confrontationally if necessary. Typically, this characterizes the therapy phase of working through, the necessity of anchoring the gained affective insights, replacing dysfunctional relationship patterns with more functional ones, and broadening their basis with regard to life areas, as it exists in KIP (Katathym Imaginative Psy-

chotherapy) just as much as in any other psychodynamic therapy process. At this point, it should be mentioned that the approach called “living through and suffering through” by Leuner (1985, p. 233) does not represent a technique in the narrower sense, but is to be understood as an affective emphasis of this working-through process in imagination, especially when it is accompanied by detachment and mourning processes. Inner detachment processes—whether from real people or from earlier self-images and internalized object images—are associated with new steps towards autonomy. Trying out new behaviors can initially be tested in imagination. Accompanying the patient in this trial action does not require specific intervention strategies. At this point, the aesthetic potency of imaginations (7 Sect. 3.3) with the aspects of surplus meaning and play process should be mentioned again: The joy of one’s own actions in imagination can strengthen self-occupation; and for patients restricted by a rigid superego, imagining allows them to try out previously unexplored ego possibilities and thus work on constricting superego impulses. Examples include the imaginations with grasshopper and lion (Case Musat, 7 Sect. 4.4 (15)), where such trial action takes place in the realm of the unfamiliar and uncertain; similarly, the promotion of taking possession of the initially eerie and foreign house in Case Grün, 7 Sect. 5.4 (24). z Intervention Strategies and Forms (5) In the Extended Indication Spectrum of Kip

The treatment of ego-weak or patients with structural disorders with KIP is also possible for trained therapists (Bahrke 2005; Bartl 1989; Dieter 2000, 2012). In this case, the intervention techniques must be modified according to the lower structural integration level (Working Group OPD 2014) as in other psychodynamic psychotherapies (Rudolf 2010, Wöller and Kruse 2010).

7.4 · Embedding Imagination in the Therapeutic Session …

Since the limited availability of mental functions for organizing the self and its relationships to internal and external objects can vary greatly, no normative rules can be formulated. At the beginning of treatment, imaginations are rarely indicated, as these patients often come into treatment in states of emotional flooding and social disintegration, which requires stabilizing interventions and the provision of auxiliary ego functions in the sense of external affect regulation and supportive structuring of the social situation. However, as soon as they are sufficiently stabilized to cope with their everyday life, the treatment planning should focus on the subsequent development of deficient ego functions, the improvement of affect tolerance, more autonomous affect regulation, and the promotion of mentalization. In doing so, the basic principles of structure-building psychotherapeutic techniques should be observed, as they have been particularly presented by Heigl-Evers et al. (1993), Rudolf (2010), and Allen and Fonagy (2009). Within such a framework, the inclusion of imaginations, especially in their stabilizing and structure-promoting function, is possible and helpful (Bahrke 2005, Dieter 2000, 2006, 2012), particularly for improving affect differentiation, self-object differentiation, and mentalization or symbolization ability (see Case Grün, all imaginations). Fonagy and Target (2002) have described a developmental sequence of states—psychic equivalence mode—pretend mode—reflective mode—leading to an increasing ability to symbolize, which is not or only limitedly achieved in these patients. Since object and self aspects are not represented symbolically (7 Sect. 7.2, “7 Excursus 7: Symbol”), but are experienced in a “one-to-one” mode (Hanna Segal introduced the term “symbolic equation” for this in 1957), the ability to form symbols and the associated ability to distance oneself from the immediate situational pressure is lacking (see also Fonagy et al. 2004).

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The lack of affect tolerance is accompanied by greater splitting tendencies, and affective flooding can also occur in imagination. The anxiety states experienced in imagination can then no longer be “banished” with the test of strength intervention, but can reach a level that raises the fear of “falling out of the picture”—which can then actually happen in imagination or by breaking it off. In these cases, further distancing strategies are indicated in addition to the interventions already listed: If the request to closely observe the scene and have it described in detail does not sufficiently alleviate anxiety, one can suggest perceiving and describing it “in slow motion” (Slow motion intervention). The aim is to contain the affect by the therapist. An even further distancing possibility is the use of splitting tendencies for defense stabilization by asking the patient to “look at the whole thing from the outside, preferably from a bird’s eye view” (Bird’s eye view intervention). A defense strategy frequently spontaneously employed by schizoid patients, to evade into an affect-controlling observer position, is thus specifically applied therapeutically in the case of affective flooding. The resulting affect relief is now combined for patients with a structural pathology with the possibility of identifying with the observing third position of the therapist. This creates a triangular situation that stimulates symbolization processes: For example, one can ask the patient what the possibly threatened self-representation “down there” needs, and one can have him intervene in a self-caring manner. The triangular psychic thinking and symbolic space thus created (Schnell 2005) should be used repeatedly in further imaginations, especially when the patient is repeatedly exposed to the illustrations of his negative introjects and the accompanying affective pressure. In this way, reflexivity can be systematically promoted (see the vivid descriptions in Cullberg 2011). Such a patient usu-

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ally experiences interpretations as intrusive attacks, which is why they should be largely avoided. In order to help develop his self-observing part, however, in a further step, the respective defense movements he makes and needs should be shown to him when the contact with an imagined inner object or the closeness to the therapist becomes too intense or when he is too exposed to his affects. In this way, the important work on triangulation in the sense of a hermeneutic spiral movement becomes the focus of treatment and the ability to symbolize and use symbols can gradually improve (see case Green). The treatment of patients with weak structure requires the therapist to have a special ability for affect containment, but this should be done with careful consideration of countertransference: The therapist must not allow themselves to become a witness to masochistic or sadistic behavior during the imaginations and must not tolerate aggressive-destructive actions against themselves or imaginative figures: They are responsible for maintaining boundaries and ensuring that the introjects resulting from massive abusive assaults and neglect do not dominate the therapeutic space and destroy the therapeutic relationship. With regard to these interventions and the treatment technique of patients with weak structure using KIP in general, reference must be made to further literature at this point (e.g., Bahrke 2005; Bartl 1989; Dieter 2000, 2006, 2012). This also applies to the various intervention techniques of psychotrauma treatment with Katathym Imaginative Psychotherapy. Of course, the general rules of any psychotrauma therapy must also be taken into account here (Fischer and Riedesser 2009). Steiner and Krippner (2006) have provided a solid presentation of how imaginations can be used to promote stabilization in a protective framework as well as to shape the conflictual confrontation with the traumatic

event and the discovered coping strategies. There, you can also find detailed case presentations on when and how specific motifs such as the “safe, protected place,” working with the safe motif, encountering the “inner helpers,” working with the concept of the “inner child,” confronting the perpetrator, encountering the traumatogenic introject, or imaginations for trauma integration can be therapeutically used and accompanied in a psychodynamic sense. What is now available in a developed, systematized form regarding the stabilization of traumatized patients using imaginations elsewhere (Reddemann 2001) has precursors in Katathym Imaginative Psychotherapy and is still used here when— for non-traumatized patients—primarily ego-strengthening is indicated. If a patient comes in a stressful external conflict situation, an adjustment disorder, and crisis intervention is indicated, a series of regression-promoting interventions can be used that enable fantasized wish fulfillment or basic need satisfaction on the imaginative experience level. Similarly, a conflictual confrontation must be withdrawn in an ongoing psychodynamic process if—for example, due to a (newly added) threatening physical illness—the patient has become unstable. The process goal in these cases is stabilizing ego-strengthening or strengthening the self-system. Leuner (1985, p. 259) spoke of the effect dimension “satisfaction of archaic needs,” for which terms such as resource activation and regression in the service of the ego (Kris 1952) are common today, meaning primarily the activation of positively toned early relationship experiences. Specifically, in addition to the intervention strategies—the therapist will behave supportively—the stimulation motifs listed under 7 Sect. 7.2 are intended to help mobilize psychological resources and self-healing powers, also understood as trust-building relationship messages.

7.4 · Embedding Imagination in the Therapeutic Session …

All the intervention techniques described here can be arranged differently: 5 according to their application with regard to the therapy phase, 5 according to their use related to the structural level, 5 assigned to the three basic therapeutic functions: the expression and clarification function, the ego-strengthening regression promotion in the form of the stabilization function, or the structure-promoting function, 5 with regard to the respective partial or process goals aimed at (e.g., affect experience and differentiation). Since these ordering principles overlap, the following table above (. Table 7.1) is only intended as a compromise. In conclusion, it should be emphasized once again that the intervention strategies in KIP, as presented, follow the basic principles of psychodynamic therapies—the difference lies only in the embedding of imaginations in the therapeutic session and the therapeutic process (7 Sect. 7.4): In dialogue as well as in imagination, the therapist will try to promote affective insight. This will be supported by approaching the focus, interpretive statements on the scenic material, addressing details, and preparatory clarifying steps towards an interpretation. Affective insights are more easily and sustainably gained in vivid imagination, but understanding also often takes place in dialogue, for example, through “aha” experiences where understanding is affect-driven. The interpretation itself is never done in imagination, but exclusively in dialogue: interpretation is the attempt to verbalize the complexity of psychic material, taking into account countertransference, and to make connections consciously understandable. Different forms of interpretation, such as content, resistance, genetic, and transference interpretations, can be distinguished. Such interpretive processes would be expe-

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rienced as intrusive in the state of imagination and should therefore not take place there. Further confrontations, working through, and deepening affective insights (interpreted) can then be promoted again in imagination (more on this in 7 Sect. 7.4). 7.4  Embedding Imagination

in the Therapeutic Session and the Therapeutic Process

The basic indication for the inclusion of imaginations in the psychodynamic therapy process was—related to the three general therapeutic functions of imaginations—presented in 7 Sect. 3.3: Imaginations enable work on internal conflicts and their defense (expression and clarification function), ego-strengthening regression promotion in stressful situations (stabilization function), they are suitable for structure promotion, have a vitalizing potential due to their affective enrichment, and have a potential similar to transitional phenomena, which was described as aesthetic potential. These possibilities of using imaginations in the therapeutic process exist in every single session. The various ways of announcing the initial imagination to the patient have already been presented (7 Sect. 3.5) and familiarizing them with the concept of imagining in general (7 Sect. 7.3; see also Sects. 4.3, 5.3 and 6.3). Beyond the agreement to include imaginations in the therapy process, the KIP therapist has to make very specific decisions: How often, in which session, at what point in the session or triggered by what does he suggest an imagination? And how does he design the transition from dialogue to imagination and vice versa in the session—in short: How are the individual imaginations embedded in the therapeutic sessions and the therapeutic process?

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z On the Frequency of Imagining in the Therapeutic Process

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In catathym imaginative psychotherapies, it is generally common to encourage imagining about every 3rd to 4th therapy session, but it can also take place in every session or much less frequently. Agreeing on a specific frequency with the patient from the outset and establishing it can provide a supportive orientation, similar to a fixed regulation to structure the therapy session in which an imagination occurs in the same way each time: Starting with a “preliminary talk”, then allowing 20–25 min for imagining and ending with a short “posttalk”. Such pre-determinations and ritualizations can be useful in individual cases, but it should be noted that they entail certain transfer implications: On the one hand, they emphasize the asymmetry of the relationship in which the therapist has expert knowledge that is helpful for the patient; moreover, they can suggest that imagination is “the real thing” and not all sections of the session are equally important in their relation to each other. We advise against such determinations because they accentuate the transfer relationship in the sense of a seemingly security-providing therapeutic position and can artificially provoke resistance, but above all because such determinations narrow the space for both the patient and the therapist and do not do justice to the complexity of the psychodynamic process to be designed: Imaginations can—for example, in their effects on affective experience and proximity-distance regulation in the transfer—intervene so decisively in the course and intensity of the psychodynamic process and its sections that the therapist would deprive himself of many potential possibilities to control these according to the respective requirements with principal determinations. Beyond the initial phase of becoming familiar with imagining using stimulus motifs and the intervention techniques of introductory accompaniment, we therefore

advocate choosing and proposing the timing of imaginations from the flow of the therapeutic process. An established therapeutic relationship will also—sooner for some, later for others—include the patient expressing the desire for an imagination and stimulus motifs and their thematic orientation (Sects. 5.4 (4) and 6.5 (415)). In both cases, resistance, countertransference, and transference moments contained therein must be reflected upon (7 Sect. 7.7). z Selection Criteria for the Therapeutic Imagination Proposal

The detailed presentation of three therapy processes in the Sects. 4, 5 and 6 was carried out with the intention of demonstrating and making transparently comprehensible typical moments of transition from dialogue to imagination and their integration into the overall process. The following typical moments can be distinguished: a. In the dialogue, the therapist and patient have approached a biographical episode that remains “pale” in terms of both memory and affective resonance— here, an imagination can promote both and illuminate the overall situation (7 Sect. 6.5 (392)). b. In the dialogue, a recognized conflict was discussed again, for example, a hurt or anxiously submissive retreat in confrontations. Such a conflict could be affectively relived in the imagination using a concrete example, more deeply understood with the help of the associative loop regarding formative object relationship experiences, possibly resolved differently on a symbolic level, and further worked through in conversation or in a later imagination. c. Furthermore, it generally applies that imaginations can represent the further therapeutic step when insight and experience have already been brought close to the determining focus through the conversation in the session, but the associated ambivalences and conflict

7.4 · Embedding Imagination in the Therapeutic Session …

a­spects should be affectively enriched more clearly in the imagination (7 Sect. 4.4 (9), “animal family”; 7 Sect. 6.5 (115), “path”). In this context, specific stimulation motives (7 Sect. 7.2) such as the “mountain” for the performance theme or “lion” regarding the aggressive theme (case Musat, 7 Sect. 4.5 (14)) can be suggested to address certain, possibly latent dimensions of the conflict discussed in conversation. d. Conversely, it is possible to propose an imagination to metaphorically illustrate a current emotional state (7 Sect. 7.2, 7 Excursus 7: Symbol) with the aim of better understanding the motives associated with it (7 Sect. 6.5 (59)), which can also involve a strongly expressed affect such as anger (7 Sect. 6.5 (482)). In an analytical therapy, the imagination can also act as an “imaginative flash” at the end of sessions to make the respective emotional state more conscious (Mrs. Eichel called them “emotional images”, 7 Sect. 6.5 (452) (482) (522)). e. According to the enlivening potential of imaginations, imaginations can in affect-splitting patients, for example those with somatoform disorders or a rigid superego problem, be repeatedly encouraged whenever the patient seems to signal a certain affective readiness. (The case of Eichel, 7 Sect. 6, provides numerous examples: the general encouragement for regression, especially in the first treatment section (6), (20), the encouragement to initiate an affectively involved self-confrontation (12), (15), (18), (51) or to make wishes transported through the promotion of affective experience more apparent (105).) This applies similarly to patients with an intellectualizing defense who are inhibited in their affective expression and in whom it can be expected that their emotional side and thus their desires will be more easily and clearly revealed through imaginations, as illustrated by the case

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of Musat, 7 Sect. 4.5 (14) in the lion imagination. f. The patient has made an affective statement at the beginning of the session, possibly reported a dream, but then becomes affect-avoiding-rationalizing during the course of the session. In such situations, depending on the agreed therapy—i.e., short-term therapy or longer forms—and therapy phase, it can be weighed whether this process itself should become the subject of a resistance analysis or whether an imagination can be attempted as another possibility of dosed resistance processing to reconnect to the more affective statement at the beginning of the session (7 Sect. 4.4 (6)) and to understand the transfer-related reasons for affect suppression. g. The patient steps somewhat out of the dialogical conversation and enters a state moved by their fantasies. In this situation, it is appropriate to suggest “transferring” this state into an imagination and continuing it with increased affective intensity (7 Sect. 4.5 (15)). h. Regardless of the fact that some therapies primarily aim at strengthening the ego (7 Sect. 3.3), there may also be phases in conflict-oriented treatments where it makes sense to suggest imaginations with the goal and choice of motives for a narcissistic strengthening, for example, when the patient is under acute additional stress due to “critical life events” such as serious physical illness, relocation, death, illness, or caregiving in the family (7 Sect. 7.3). This can help the patient not only to cope with this crisis caused by special external circumstances but also to be able to abandon a defense reinforcement caused by the crisis earlier in terms of their conflict-dynamic therapy process. i. An imagination can be suggested to imaginatively connect to a (interrupted or only incompletely remembered) night dream. Or a dream figure or a detail

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from the dream can be picked up with it, which should be further understood (“tomcat”, 7 Sect. 6.5 (210)). Likewise, a metaphor expressed in conversation can be suggested as an entry motif for an imagination if the meaning of the metaphor promises to become clearer through such a process (7 Sect. 6.5 (175)). j. Following a similar principle as the imaginative continuation of the night dream, imaginations can write an imagination history by continuing to imagine in each session where the last imagination left off—as a progressive association process on an imaginative level. It is important that such a metaphorical condensation does not become an end in itself, i.e., it does not—this would be an esoteric misunderstanding of therapeutic imaginations—detach itself from understanding its meaningful content. However, it can make sense that the secondary process-like integration of the primary process-like experience (7 Sect. 3, 7 Excursus 4: Primary Process) does not occur in every session and after each imagination, but the imaginative, affectively enriched experience remains in the metaphorical “as-if ” suspension for a certain period. k. Patients who are in a longer therapy process and repeatedly imagine during it will make active and self-determined use of this possibility parallel to their other development steps towards more autonomy: In the presentation of the third treatment section of Mrs. Eichel, there are situations where the conversation transitions into an imagination initiated by the patient herself (e.g., Mrs. Eichel sees herself, 7 Sect. 6.5 (452), curled up like a cat near the analyst during a pause in conversation, in the 522nd session she begins an imagination in which she lets herself drift by boat into a water lily area; the understanding of the “turbulences” occurring during this and

the overall imaginative immersion is integrated into the process of self-understanding). 1. Imaginations are overdetermined according to their aesthetic potency. In this respect, there is often “always more to discover” when they are repeatedly traced. In this respect, they are well suited for separation situations, such as before therapy interruptions. (Thus, the initial imagination for Mrs. Musat is helpful for the transition to the first treatment section; likewise for Mrs. Eichel during the one-year waiting period.) The same applies to a balancing, ambiguous farewell imagination as in the case of Grün. In these cases, the imagination can be suggested to act as a transitional object due to its aesthetic potency; this can be emphasized by suggesting a re-creation. An imagination can also be suggested to improve the possibilities of proximity-distance regulation for the therapist, for example in the sense of a situational distancing from a strenuous transference relationship. In this case, it would be important for the therapist to analyze his countertransference message within himself or in supervision: Often, a patient brings the therapist into the difficult-to-bear state that he himself experiences through projective identification (7 Sect. 7.7.5). If this is not reflected, imagining can become an acting out of countertransference resistance. By momentarily relieving the therapist through imagining, the suggestion of an imagination made to the patient can, however, help him to regain emotional access to the patient’s suffering and therapeutic concerns through the distance thus created (further elaborations in 7 Sect. 7.7). In general, regarding the selection criteria for imagination suggestions, the inclu-

7.4 · Embedding Imagination in the Therapeutic Session …

sion of imaginative material is subordinate to the course of the therapy process and its control: The patient should learn to understand himself better so that he can change in a beneficial way based on this understanding. Optimal for this is, on the one hand, an affective involvement of the patient, not only in the sense of an aha experience, but in the kinesthetic opening out of defense-related constrictions. On the other hand, this involvement should not take on an extent that again mobilizes the defense too strongly and thus prevents an affectively gained insight from being allowed and integrated into self-understanding in a comprehending manner. As explained above, imaginations can promote affective involvement, they can illustrate still bland or diffuse affects and thus support the understanding process of one’s own conflict dynamics. Appropriately used imagination work is therefore particularly suitable for targeting the optimal affective level conducive to emotional insight. The presentation of the three treatment courses also makes it clear: There is an interaction between imagination work and night dreams: Night dreams can be picked up and deepened by imaginations, but the dream experience and dream memory can also be stimulated and positively influenced by imaginations. The fact is that in KIP therapies, possibly because the patient experiences the therapist’s basic appreciation of dreamlike things, many dreams are reported. Since imaginations and dreams have a similar effect on the therapy process, it can happen that imaginations occur less frequently due to an increase in dream reports, just as imaginations are suggested more frequently as long as no dreams are reported. This interlocking can be seen in all the treatment courses presented (particularly vivid in the case of Grün: the “bird” imagination, 7 Sect. 5.4 (9) immediately triggers the first dream report).

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z Design Possibilities for Transitions Between Dialogue and Imagination

The patient and therapist are in a very sensitive phase during the transition from imagination back to dialogue—especially when it is associated with a change in spatial setting (7 Sect. 3.7): The patient may still be preoccupied with their astonishment or other emotions and must return from the self-focused experiential state to direct encounter and eye contact with the therapist. The therapist, on the other hand, only knows the imagination from what the patient reported during the sequence and their own thoughts and feelings about it and must accompany this transition. Such a “finding one’s way back” does not apply to patients’ night dream reports and represents a specificity of imagination work. There are no normative rules for designing the transition from imaginative to conversational phases. Often it is appropriate to give the patient a lot of space at first and wait to see what they can and want to express, while it is important to “dose” the silent waiting depending on the patient, for example, not to extend it too long for those patients in whom it leads to an increase in anxiety or mistrust due to a negative transference. After the therapist has inquired with interest during the familiarization phase with imagining, similar to what is described in 7 Sect. 3.7, how they feel, what has affected them in which way emotionally, the patient will usually report on their own in the further course of therapy and search for the appropriate (or: corresponding) language for it. In this process, the therapist can empathically support them through clarifying questions and the tentative provision of formulations (see the follow-up conversation of the “bird” imagination, 7 Sect. 5.4 (9) with Mrs. Grün). Comparable to a dream discussion, the patient will usually explore their imaginations in a self-exploratory manner, and the therapist

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will additionally encourage free association to details. It should be explicitly pointed out that as a KIP therapist, one should not put oneself under pressure to understand the imaginatively designed scene as quickly as possible and still within the same hour “completely.” As can be seen from the case reports, this understanding takes place from the regularities of a concentrically unfolding hermeneutic circle. But even for purely practical reasons, such a false claim to completeness is obstructive, simply because the hour is over. Imaginations, like dreams, unfold in several sections: in the first follow-up conversation, in the following session, or even at a much later point in time. Since both represent overdetermined and aesthetic struc-

tures, a multi-stage aftereffect is inherent in them. In this respect, one will repeatedly come back to some imaginations in the further course, as is also the case for other therapy components such as scenes, dreams, central interpretations, and conflict themes. This resumption of what has already been addressed, renewed reflection, and new linking of all these components of a psychodynamic therapy is intended: The “unfinished” understanding, which always “leaves something in the balance,” maintains the desire for understanding and development and at the same time stabilizes the relationship with the “understanding partner therapist“—precisely through this, the therapeutic hours become part of a “dynamic” process event. 7 Excursus 9: subject-/object-level dream interpretation

Excursus 9: Subject-level/Object-level Dream Interpretation

In his century-defining work “The Interpretation of Dreams”, Sigmund Freud (1900) presented his dream theory, introduced free association as a method of dream analysis, and demonstrated this approach extensively using numerous examples; his explanations of the “Dream of Irma’s Injection” became famous. C. G. Jung (1917) further developed the technique of dream interpretation by emphasizing certain aspects or adding new ones; he introduced the “final” alongside the revealing “causal” and the “synthetic” method alongside the “analytical” method. In this context, he also developed the contrasting pair “subject-level interpretation—object-level interpretation“. In object-level interpretation, the dreamer is asked about the real and fantasized relationships to the individual dream contents (such as people, objects, situations). If the patient dreams of their father or an animal, the therapist encourages associations with the father and animal and speculations as to why these figures appear in the dream at this time and in this way (analytical method).

The focus is on the question of the dreamer’s relationship to real figures or situations in their life. In subject-level interpretation, on the other hand, all dream contents are related to the dreamer’s self. The dreamed father is thus understood as the internalization of the father and thus as an aspect of the self (synthetic method). The therapist equates the dreamer with the “father” or “animal” and asks about the “father” or “animal” part within the dreamer. These methods of dealing with dreams can be adopted for working with imaginations. Object-level interpretation usually encounters less resistance, while subject-level interpretation requires a higher level of integration and therefore often provokes resistance movements. The more aversive or problematic the imagination (or dream) contents are (a hostile animal, a barren desert, a wilted flower), the more cautious and gentle the approach should be in subject-level work. Object-level interpretation generally precedes subject-level interpretation.

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7.5 · On the Post-Imagination Adaptations

Object-level question possibilities include: 5 “Who do you associate with this animal/ this flower?” 5 “Does anyone from your life come to mind who is or was like this?” 5 “What life situation/area of life do you associate with this desert?” Subject-level questions include: 5 “Could there also be such an animal inside you?”

Rather independent of the transitional designs, but influencing them, are the therapist’s transfer reflections. Just as the suggestion to imagine a certain motif originates from a countertransference impulse that he should reflect on, dealing with the question, “What could this imaginative event say about the state of the transfer relationship?” is important for further process decisions (7 Sect. 7.7.4). These transfer aspects do not necessarily always have to be discussed explicitly; however, basic inquiries about how the patient felt during the imagination with the therapist’s interventions are important. These help the therapist to reflect internally on when it is appropriate to address the transfer events because resistance entanglements threaten to dominate the proceedings (7 Sect. 7.7.6, see also 7 Sect. 4.5 (12)). 7.5  On the Post-Imagination

Adaptations

Recreations are not an integral part of working with imaginations in psychodynamic psychotherapy. Including them can offer the advantages described below. However, refraining from them can also be advantageous, especially when the psychological material already takes on a scope without them, through addressed conflict issues,

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5 “When do you experience yourself like the animal?”

5 “Is there also such a barren zone within you?”, “Where do you create a drought for yourself, in what way do you give yourself too little water?” 5 “What have you had difficulty or hardly or not at all been able to fertilize in your life?” 5 “Do you also know this about yourself: to ‘bend’ like the flower?”

reported dreams, scenes, and imaginations, which makes the understanding and processing integration of the same more difficult. Recreations are most likely to promote the process when the therapist is convinced of their use, for example, because they have experienced that this opens up a particularly useful channel of expression for the patient. Insofar as they represent additional material that can be used, but whose use is not mandatory, we limit ourselves to some essential suggestions and problematizations. Recreations, made by the patient at home with or without therapist suggestion and brought to one of the next sessions, require a special kind of embedding in the therapy process. Usually, these are paintings or drawings made by the patient. However, some patients also bring other artistically processed items such as sculptures, collages, self-written or selected texts and text excerpts, photos or postcards, stones, and even compositions or selected music on CDs. Recreations usually refer to imaginations, dreams, or specific self-states that are difficult for the patient to grasp verbally (such as confusion, resignation, despair, or tension, lightness). In contrast to the imaginations, the patient is responsible for the recreation brought along and then jointly viewed at home alone, of course, internally related to

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the therapeutic process and never detached from the transference dynamics. However, since the recreation is created without direct therapeutic resonance, there are often different emphases of the previously jointly conducted imagination. For example, patients who feel they need to “protect” the therapist in the immediate treatment situation, not to “burden” them, often have “more beautiful” imaginations, but their recreations then appear “darker” or more desolate (see Case Eichel). Since the therapist is “not there,” they can express something painful or sad more directly. Conversely, images of conflict-laden or burdensome imaginations may appear harmonized in the recreation because the immediate rapport with the therapist is missing, which the patient would need to expose themselves to the corresponding feelings (Case Grün). These are just two examples of many possibilities. The processing of such discrepancies between imagination and image, which arise from transference reasons, represents an important medium for working through, especially central defense configurations of the patient. The basic acceptance or rejection of the recreation suggestion is—similar to the imagination suggestion—also to be seen as resistance regulation and thus represents a transference message from the patient—just as the suggestion represents a relationship message from the therapist (7 Sect. 7.7.2). Beyond aspects of transference and resistance processing, there are further reasons for including recreations in the therapeutic process: On the one hand, the therapeutic gain lies in promoting autonomy, self-care and generally ego strength by encouraging self-initiative and self-exploration outside the shared therapy room. These goals are particularly important for passive-dependent and depressive patients and people in acute, destabilizing crises. Dealing with the therapeutically initiated material alone at home is, for many, synonymous with taking space for themselves,

which is difficult for patients with altruistic relinquishment (Case Eichel). Turning to a recreation, therefore, also represents a relationship message to the self: “I am worth it,” and can thus help to strengthen self-esteem and change the negative self-occupation (Case Grün). For acutely destabilized people, creating can be a form of self-soothing when the quasi-artistic self-emptying reduces or even momentarily disappears the feeling of powerless exposure to the pressing issues. Ultimately, incorporating reconstructions, as well as working with imaginations themselves, can strengthen object constancy and thus provide assistance in bridging potentially challenging therapy interruptions and especially in stabilizing therapy successes after terminations, generally in separation experiences. This is particularly true for working with patients with weaker structures, but in many cases, it is beneficial regardless of the patient’s structural level. In low-frequency therapy constellations, they can help maintain inner contact with the therapy process. The strengthening of object constancy through reconstructions is explained by the fact that the reconstruction represents an externally visible “therapy product,” symbolically a joint “child,” and can act similarly to a transitional object. In particular, patients with separation damage (Case Eichel) can more easily hold on to new inner occupations or positive identifications during therapy breaks by viewing, modifying, or further processing reconstructions. Their tangible “proof ” can counteract denials and other defensive movements that there was once a certain (positive) relationship experience “existed.” After terminations, the reconstructions represent something “lasting,” “enduring”; some patients also keep the designing as something beneficial for them “instead of the sessions” and remain positively internally identified with therapy and therapist in this way, which has been proven to help

7.5 · On the Post-Imagination Adaptations

stabilize the success of therapies (Diederichs 2002). The painted mallow picture from the initial imagination helped Mrs. Eichel to bridge the one-year waiting period for her analysis place and to hold on to the therapy motivation (7 Sect. 6.5 (6)). z Guidelines for Practical-Therapeutic Handling of Reconstructions of Imaginations

The practical-therapeutic handling of reconstructions is characterized by a fundamentally understanding-open attitude that includes the transfer dynamics (7 Sect. 7.1). Since reconstructions are not always an integral part of teaching therapies in the training of KIP therapists, some didactic guidelines are given here to help implement this attitude. These guidelines refer to typical resistance scenes around the reconstructions and to the methodology of discussing painted images. The stimulation of reconstructions in the process.  At the end of a session, the therapist

can, if it seems appropriate or useful, make a corresponding suggestion:

“Perhaps you would like/have the desire to paint or write or otherwise design something from your imagination (or also about your dream discussed today, about your feeling that played a role in the session). If that is the case, I would appreciate it if you could bring the design so that we can look at it together.” As a justification, one can add: “It helps with our work because it represents a different way of dealing with your topics than just thinking and resonating and sometimes allows for surprising insights.”

Dealing with resistance aspects.  The pa-

tient’s reaction to the reconstruction suggestion is important, but does not always have to be addressed immediately—in the

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sense of searching for the optimal anxiety level (7 Sect. 7.3). The following frequently occurring reactions can be expected: “What? Painting? I can’t do that at all.” Or: “I don’t have time for that.” Or: “That’s for children.” Or: “Oh great, that’s what I missed in my previous therapy. Gladly.” “I can’t do that” is an expression of a performance problem that embeds itself differently in the transmission situation. Depending on how pronounced it is and what is already known about the possible backgrounds of this problem, a combination of encouragement or problematization, or both, can be useful. To do this, the patient’s statement must first be understood by asking, for example:

“What exactly do you mean by: I can’t paint?” For some patients, this inquiring interest is already sufficient encouragement. It also serves as encouragement when emphasizing that it is not about creating something “good” or “right” or “beautiful.” It is only about “how to create without intention.” If this is not enough, one can—always parallel or complementary to the understanding work—suggest closing one’s eyes while painting to “temporarily outsmart” one’s critical censorship, or encourage righthanded people to paint with their left hand.

The understanding problematization takes place depending on the situation through an inquiring exploration of where the patient knows this from, whether it only refers to “artistic” things, where it comes from, etc. “I don’t have time for that,” patients say out of their overwork or overwhelm, or to avoid a performance issue. Possibly, the statement is simply a form of rejection they can use for something they experience as a demand, from which they cannot otherwise

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distance themselves. This response also provides an opportunity for conflict resolution if the therapist asks with interest. Encouragements intervene in the transfer dynamics and pose a challenge, especially for altruistically oriented patients who find it difficult to appreciate anything concerning their self (7 Sect. 7.7.5). Sometimes it is enough if they are repeated and varied more frequently. In extreme cases, such suggestions are experienced as a “temptation” for luxurious or selfish self-employment (Case Eichel, 7 Sect. 6.5), which must then be fought indirectly or directly. “That’s for children—what’s the point?” represents a devaluation that should also be explored, as it illustrates the transfer constellation like everything described so far: “What kind of person are you to offer me something like this?” It is important not to act out the offense from an unreflected countertransference. Reflecting on this, it is helpful to patiently inquire why the patient has to be so rejecting. For example, there may be a displacement; the patient is still dealing with disappointment from the session, which is discharged in this way; there may be a habitual devaluation of things that are not “useful,” not “adult,” which has impoverished the patient’s life but must be maintained for defensive reasons. It may show a general resistance to getting in touch with one’s own childlike side and the memory of one’s own childhood, etc. The therapeutic encouragement is then even more decisive than in the first two cases as a transfer message: “I am not damaged by your devaluation because I see it as an expression of something difficult for you, which is useful to understand.” Of course, one should consider whether it is more favorable for the process to address the transfer, stick to the encouragement, or (temporarily or fundamentally) refrain from a post-shaping suggestion (7 Sect. 7.7.6). The positive or eager or enthusiastic adoption of the painting suggestion is only offered for problematization at a later point

in time, for example, when it becomes clear how much the patient believes they have to buy their “right to exist” from the therapist through their willingness to perform or when other adjustments can be addressed. “What should I paint?” and similar questions, on the other hand, express a differently motivated superego externalization and can be dealt with directly, e.g., humorously or understanding-associatively. For example, one can ask back “Why should?” and thus address the patient’s inner orientation to do it right. Or smile: “Should? Don’t you want to find out here?” The oscillating intervention between problematizing confrontation and supportive encouragement thus precedes the actual examination of the reenactment and also plays a major role in dealing with the brought or omitted reenactment. In any case, it is important that the therapist remembers his suggestion and inquires about it in the next or the following session. If the therapist avoids asking, for example out of fear of appearing like a teacher asking for homework, he is acting out a countertransference resistance. Because such an inquiry fundamentally represents an interest in the joint process and the form of working through the patient’s conflicts, even if it can, of course, be projectively misunderstood by the patient as a “performance record.” Then this will be expressed in his “apologetic” comments, such as “I just painted that in the waiting room” or “I left it at home” or “I didn’t think about it anymore.” Similarly, this applies to scenic peculiarities around the reenactment. It makes a difference whether something is crumpled out of the bag or transported in a specially purchased folder, “slammed on the table” or ceremoniously spread out there. It is a matter of therapeutic tact how to deal with this, but in principle, all these scenic messages are important relationship enactments (7 Sect. 7.7, 7 Excursus 11: Scene). All scenic “communications” thus represent a fruitful source of tactful-understanding

7.6 · Termination of a Therapy with Imaginations

r­ esistance work in addition to the aspect of faulty action. Notes on the Methodology of Image Discussion (Reconstruction Discussion).  After ask-

ing the patient to place the reconstructions on the floor or table so that both can view them well, the image discussion in the narrower sense usually begins. However, it also happens that patients put down their image but initially address a more pressing topic. Then there is the possibility to transition to the image after a while with the question:

“What might all this have to do with your painted image?”

Typical self-deprecating resistance expressions of patients at the beginning of the conversation consist of devaluing the reconstruction (“It turned out quite ugly”—“I just can’t paint”—“Doesn’t represent the imagination at all” etc.), having no ideas about it and not “seeing” anything in it, overlooking conspicuous features or asking the therapist what the painted image means. In practical handling, the mixture of problematizing confrontation and encouragement described above applies here. Once occasional primary threshold anxieties are overcome, the therapist can encourage the patient to let themselves be guided by the most clearly felt emotions that the image triggers, associating freely. To wait and see “if and where the inner divining rod (7 Sect. 4.5 (20)) reacts”, for example, where—on which element of the image—one keeps looking or is looking right now. Or, if several reconstructions have been laid out, which one currently attracts more attention. One can also suggest looking at the image as if someone else had painted it: What would then spontaneously stand out? With such self-distancing, a reflection that is less obscured by defense processes ­ sometimes

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succeeds; Ms. Musat, 7 Sect. 4.4 (6), engages in the discussion of her meadow painting, which leads to interesting insights. The therapist can only successfully initiate free association if they do not put themselves under pressure to “recognize” or even “interpret” something immediately, but if they allow themselves to be affected by the overall effect or details and cautiously stimulate neutral associations in the patient: “I notice that the house has no windows” or similar. One can also simply ask how the patient felt while painting and with the painting. Equally fruitful conversation starters are, as mentioned above, striking discrepancies between reconstruction and imagination or a reported dream. In the case of Musat (12), it is suggested to look at all previously painted images again, now from a different perspective, namely to see them only as expressions of self-states (7 Sect. 7.4, 7 Excursus 9: subject-/object-level dream interpretation). (This technique of a summarizing image review, even without a specific focus, is particularly suitable before breaks or endings, see 7 Sect. 7.5) However, it is always central that the thematization is oriented towards what is currently close to consciousness and affect, and that the therapist refrains from premature interpretations. Valuable hints for dealing with painted images, which help the therapist to “read” images and to encourage their patients to do so, can be found in Furth (1991) or can be obtained at training events of the KIP societies. 7.6  Termination of a Therapy

with Imaginations

The time-limited nature of therapy and thus a relationship experienced as unique is a central component of every psychotherapy. Depending on the conflict dynamics, it gains importance very early in the therapy process and is consciously reflected upon,

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but can also be denied by the patient—and occasionally also by the therapist if they act out their own separation conflicts— throughout the entire process duration, to name two extremes. Often, feelings of grief, abandonment, and disappointment about the limitations of the therapeutic encounter framework must be fended off by the patient as too destabilizing; likewise, feelings of guilt in the face of gained autonomy and the experienced joy in the post-therapy period. These defense mechanisms can be further reinforced by possible countertransference conflicts of the therapist. The therapist should therefore ask themselves: How well can I “let go” of my patient? Can I rejoice in and appreciate what has been achieved, or do I have to devalue it, for example, due to my own perfectionism? Sometimes a therapist sees primarily the “still in need of treatment” in a deficit-oriented way and tries to keep the patient in therapy. Or they may even label the patient as a “dropout” if the patient ends the therapy against the therapist’s expectations. All of this can exacerbate internal conflicts and significantly influence the patient’s self-image. The same applies to an opposite countertransference problem: If the therapist has not addressed important transference conflicts, they may be relieved that the approval framework of the health insurance is exhausted because they can now “get rid of ” the patient with this external help. This points to another complication that can arise in this phase: In health insurance-funded psychotherapies, there is often a tendency during the termination process to make the approving or therapy-extending assessor a projection surface: The patient can shift feelings such as anger and disappointment onto them as an “anonymous authority,” which actually apply to the “failing” therapist in the transference. For a successful conclusion of the therapy, it is important that the therapist does not act out this projection or use the health in-

surance framework to fend off countertransference feelings, but rather that they bring the affects and conflicts located there back into the processing of the relationship between themselves and the patient. This problem does not arise in self-paid processes and, of course, also when the patient pays for their therapy beyond the health insurance benefits. However, the last therapy sessions must be considered a vulnerable phase for the patient even without such complicating issues. It can bring them into intensive contact with the conflicts that led them into therapy and which they and the therapist generally believed to have worked through sufficiently. For patients with separation damage, the end of therapy almost invariably revives the corresponding traumatically experienced loss situations. For narcissistically disturbed patients, the self-esteem regulation possibilities gained in therapy can become unstable. Anxious-dependent patients who initially used the therapist as a controlling object may now distrust the gained autonomy and revert to clinging behaviors, etc. This explains why the original symptomatology is often temporarily reactivated towards the end of therapy, or there are “inexplicable” setbacks and destabilizations. Feelings of guilt about the “autonomous” separation, fear of loneliness or abandonment, grief over the loss of the now familiar, comforting framework and the therapist as sometimes the first empathic counterpart in the patient’s life, disappointment and separation aggression can fuel the transference dynamics and occasionally cloud, diminish or even prevent the joint positive appreciation of what has been achieved and the joy in the patient’s new design possibilities. However, all these emerging difficulties can often be reflected very productively and with affect-laden insight against the background of the now jointly understood conflict and transference dynamics, and can once again positively reinforce the working-through process. In any case, good handling of separation issues is crucial for a good farewell.

7.6 · Termination of a Therapy with Imaginations

For further fundamental thoughts on the important topic and dynamics of therapy termination, we refer to Reimer (1996) and Reimer & Rüger (2000) for psychodynamic psychotherapy, to Thomä & Kächele (1985) and Diederichs (2002) for analytical psychotherapy, and to Novick & Novick (2008) for both therapy forms. Although the design of therapy termination is handled very differently by therapists, there is a prevailing assumption for psychodynamic therapy forms that therapeutic growth is protected if, on the one hand, the therapist keeps a close eye on the time limit during the process and addresses it if necessary to prevent denials; if, on the other hand, a joint critical appraisal of what has been achieved and not achieved is carried out, and if, finally, feelings and fantasies about the farewell itself and life without therapy are given space. Particular possibilities for accentuating this process through work with imaginations include, on the one hand, designing a “final imagination” with the patient during the farewell process through suitable stimulation motifs (7 Sect. 7.2), which should not take place in the penultimate or last session, so that there is time for discussion. An agreement on this should be explicitly reached with the patient, for example through a formulation such as:

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message to the patient that they are now emphatically trusted to dose their self-balance.

Suitable stimulation motifs can be: “Imagine you are in a room and looking out of a window.” Or: “Please imagine a gate.” Or: “Please imagine a river landscape.” Or: “Imagine you are on a mountain peak and looking around.” Many other possibilities are conceivable, especially those that pick up on “scenes” developed together with the patient from the specific process.

These “last imaginations” often illustrate for the patient and therapist quite detailed fears, desires, and resistances with regard to the experience of grief, anger, or even joy about the termination. In the imagination, patients can also “rehearse” the farewell, gain insight into their emotional world, and thereby reduce fears.

”Would you like to perform another imagination here/dive into your inner world of imagination during this time of our farewell, or is it rather distant to you? Would you rather not do that?“

In addition to the usual interventions (7 Sect. 7.3), it may be advantageous towards the farewell to encourage taking something “with you” from the landscape or the room: “Is there something you see there that you would like to take with you?” Sometimes patients come up with this idea on their own (see case Green, last imagination). Taking a symbolically charged object can facilitate or stimulate the important appreciation of the process.

Although we always orient ourselves to the patient’s differently signaled consent when suggesting an imagination (7 Sect. 7.3), it is particularly crucial in the farewell phase, due to the possible destabilization, to make sure of this precisely and explicitly. In the act of assurance, there is also the relational

Another possible emphasis of the termination process lies in the re-enactments, the importance of which for the internalization processes essential for a successful farewell has already been pointed out (7 Sect. 7.5). The therapist can suggest that the patients bring all painted pictures or other re-crea-

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tions to one of the last or even the last session. Some patients also like to deposit their pictures in the therapist’s file; then it is necessary to return and give them back. The joint viewing of the re-creations laid out on the floor or table in the room (cases Musat and Eichel, last hours) can provide valuable assistance in taking stock. It is interesting for the assessment of the process status to trace why some pictures are completely forgotten, while others are very present, and this applies to both patients and therapists! The re-creations as a “therapy product” that can be taken along serve as a reminder of the therapy and the therapist as a “good object” (7 Sect. 7.5) and are— like the photos of significant family celebrations—special “emotional signposts” in the various directions of the memory landscapes. 7.7  Dealing with Transference,

Countertransference, and Resistance in KIP

7.7.1  Introductory Theses

In all previous sections of this book, the therapeutic relationship, the transference-countertransference dynamics, and the therapeutic handling of the patient’s resistance have already been consistently addressed implicitly and explicitly, as these are the essential elements of any psychodynamic therapy that also affect every other aspect discussed. Ultimately, dealing with transference and handling resistance show what distinguishes a psychodynamic therapy approach from a non-psychoanalytic therapeutic approach and, of course, from lay counseling or assistance conversations. With the topic of transference-countertransference dynamics, the KIP therapist himself now moves into the center of reflection. Therefore, the summary presented in

this chapter on this topic is the least learnable from textbooks alone but requires the therapist’s ongoing reflection process, as initiated in particular by a training analysis or training therapy and maintained continuously through supervision and intervision with equally psychodynamically oriented colleagues. Regarding the presentation of further contexts and derivations, reference must also be made in this case to the relevant literature (Mertens and Waldvogel 2000; Thomä and Kächele 1985). Since this complex of topics within psychoanalysis is continuously being rewritten, controversially discussed, and by no means viewed uniformly, the following central positions will be presented in a thesis-like manner for the sake of clarity: 1. Therapeutic relationship, transference/ countertransference, and resistance are closely and directly related and cannot be considered separately. Insofar as individual aspects are nevertheless focused on separately in this chapter, this is done for didactic reasons. 2. This is based on the fact that in a KIP therapy, as in any psychodynamic therapy, there is no transference-free space: The transference relationship cannot be separated from a therapeutic relationship not influenced by transference, as older psychoanalytic concepts such as the working alliance (Greenson 1965) had suggested. The therapeutic relationship and the transference-countertransference relationship are therefore identical. 3. The various forms of resistance originally formulated by Freud (1926) are therefore not considered separately because they ultimately all merge into transference resistance: It depends on the therapeutic relationship when exactly which resistance can be given up in this therapeutic relationship and the underlying, previously defended expression can be found. In this respect, the processing of resistance cannot be treated

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separately from transference; and therefore, the consideration of the transference-countertransference process must be at the center of this chapter. 4. The above applies in full to working with imaginations: The entire therapy process in KIP, i.e., the sections of therapeutic work with and without imaginations, are equally determined by the transference-countertransference dynamics. There has been the occasional older view still held today that during imaginations, the transference applies only to the imaginations themselves and not also to the therapist (7 Excursus 10: Projection Neurosis; see below). 5. This also means that it would be a complete misunderstanding to assume that a difficult transference constellation can be resolved by switching from dialogue to imagination as a therapist. Of course, in such an approach that supposedly bypasses the transference process, the transference remains effective in and through the imagined! The decision for or against an imagination is part of the therapeutic relationship design, taking into account the countertransference. For the sake of clarity, it should be mentioned that there are therefore no therapy rooms with different effects on transference, i.e., a “more transference-effective” pre- and post-conversation and a “less transference-effective” imagination room. Corresponding classifications are ultimately futile attempts to deny or trivialize the power of the transference-countertransference process, instead of acknowledging this power and working with it in mind. 6. Within the framework of the intersubjective paradigm represented here (see below), the reflection of countertransference is just as important as the observation of the patient’s transference manifestations, because according to this view, as therapists, we are not only sig-

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nificantly “involved” in the patient’s expressions and imaginations within the complex transference-countertransference dynamics, but also “co-create” them with the patient. The countertransference-transference process determines all psychodynamic therapies in the same way, regardless of whether they are conducted as short-term, longterm, or psychoanalytic psychotherapies. However, what is different and central is whether and how it is addressed and made the subject of the joint reflection process with the patient. 7.7.2  The Concept of Transference

in Kip

Within the scope of this textbook, it is not possible to derive the transference and countertransference concept used in detail, but it will be explained and further elaborated according to the concern of this book. With transference, “in the broadest sense, all phenomena of subjective attribution of meaning within an encounter” are meant (Mertens and Waldvogel 2000). In every interpersonal encounter and also in the therapeutic relationship, they are staged against the background of unconscious object relationship experiences. Transference is determined primarily, but not exclusively, by the child’s relationship experiences, fantasies, and drive conflicts: Sandler (1983) distinguished the “past unconscious” corresponding to the child’s relationship experiences from a “present unconscious” determining the current transference desires and fantasies. The latter encounters us in the therapeutic situation in an interactional way: the constantly acting presence of countertransference responds to the constantly acting presence of transference and vice versa (Racker 1978).

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­ ountertransference is understood as the C totality of the therapist’s emotional reactions to the patient, regardless of whether

they originate from the patient or the therapist (further elaborated in 7 Sect. 7.7.5). 7 Excursus 10: Projection neurosis

Excursus 10: Projection Neurosis

7

The term “projection neurosis” was introduced by Leuner (1985, p. 418) for the “projective transfer relationships in the setting of catathymic image experience” in reference to the psychoanalytic concept of “transference neurosis.” He conceptualized, analogous to the idea of the working alliance (Greenson 1965), a therapeutic field that distinguishes between a transfer space and a non-transfer space. Leuner vividly formulated this with his diver metaphor: Within a trusting, positively toned, and supportive relationship, the imaginer, connected to the therapist “on deck of the ship” by a “supply hose,” should “explore his unconscious on the ocean floor.” While the patient thus projects his transfer readiness onto the screen of his imaginations according to his emotional state, the therapist—dry on deck—sits next to him, watches, accompanies, stimulates, is thereby touched and internally involved, but is “only slightly or not at all affected” (Leuner 1985, p. 418) by the transfer itself. (The fact that each of his statements, everything he says or does not say, even his mere presence, is part of the imagination process (7 Sect. 7.7) is not taken into account in this conception.) Various factors have contributed to this now untenable idea: Leuner (1995) was influenced by Jung’s Analytical Psychology, which reflected less on transference than the Freudian direction forced into emigration. It was not until the 1960s that German psychoanalysis gradually returned to Freudian basic assumptions, particularly the consistent consideration of transference in the treat-

Historically, transference gained its outstanding importance for psychoanalysis mainly through Freud’s discovery that pa-

ment process. However, there were also views in international psychoanalysis at times (see above) that assumed a transfer-free therapeutic space (detailed explanations in Bahrke 2007; Bahrke 2010b). Leuner himself was not clear in his position: Although he adhered to the diver metaphor and neglected a differentiated reflection of the transference-countertransference process in his later theoretical representations, many of his case examples contain fruitful considerations of the transference-countertransference process. Following Leuner’s death, various KIP therapists have dealt with this fundamental problem: “What is the relationship between transference dynamics and therapeutic imagination?” Examples include Dieter (2001), Hennig (2007), Schnell (2005), and in their basic “position determination” Bahrke and Nohr (2005). In these contributions, the authors also deal with Leuner’s transference complexity-reducing idea that during therapy sessions, two separate spaces exist: the space of pre- and post-conversation and the separate space of imagination. Our current understanding, according to which the entire therapeutic space is determined by the transference-countertransference process, does not allow for such a fundamental distinction. In contrast, Schnell (2005, p. 73) writes that “in KIP, the relationship is shaped in every phase, in verbal confrontation, in motif suggestion, in imagination, and in post-processing in the therapy session and between sessions by the transference-countertransference dynamics.“

tients in the relationship with the psychoanalyst can only behave in a characteristically limited way for them—for example,

7.7 · Dealing with Transference, Countertransference, …

being inhibited or concealing something— until these limitations were mirrored, interpreted, understood, and worked through. Transference thus became the center of perception as the decisive location of psychotherapeutic change, turning from the “greatest obstacle” to the “most powerful tool” of treatment, “if it succeeds in guessing and translating it to the patient each time” (Freud 1905, p. 281). Originally, the role of the psychoanalyst in this view was that of a recognizer who uncovers, describes, clarifies, and thus helps to correct transference-related distortions in the patient. However, Freud already recognized that the analyst is not only the observing interpreter who helps the patient to recognize his reality distortions within the transference neurosis, but that he inevitably exerts his own influence on the transference. Since Balint (1952), the view has prevailed that the analytical situation is fundamentally constituted by the interplay between transference and countertransference, which was accompanied by a stronger focus on the design of the therapeutic relationship. With the described distinction between past unconscious and present unconscious, there has been a shift in emphasis on the view of transference since the 1980s with significant treatment-technical consequences: “Before one asked: what does the patient’s material reveal about his past? one now asked: what is happening right now?” (Sandler 1983, p. 589). The history of transference concepts in psychoanalysis (see Mertens 1993, Mertens and Waldvogel 2000) and their effects on the understanding of transference in KIP (see Bahrke 2010b) cannot be presented in detail here. However, these two effects are important: That transference is not solely determined by the infantile past and that the psychoanalyst or KIP therapist today can no longer only understand themselves as the observing interpreter who helps the patient to recognize their reality distortions

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within the transference neurosis (intrapsychic paradigm), but that they acknowledge their own influence on the transference, which they inevitably exert (intersubjective paradigm of transference). For example, the entire analytical process, as presented in the case of Eichel, is set in motion by a special transference dynamic—the analyst reads the unspoken and at that time unspeakable therapy request of the patient from her countertransferences (see especially 7 Sect. 6.1). This position has been most consistently developed in the social-constructive paradigm (Gill 1996) of transference, according to which transference phenomena are a co-production of analyst and patient: The patient’s contribution to transference is given by the neurotic repetition compulsion, which causes the patient—in life as well as in the therapeutic situation—to enact their conflicts on the stage of interpersonal relationships. The analyst’s contribution to transference is derived from their individuality, their treatment technique, which is controlled by implicit private theories, their latent human image, as well as their personal interpretations and handling of therapeutic rules. According to Gill, a pathological transference is primarily characterized by a stereotypical rigidity with which the patient explains situations, and by the compulsive, largely scenically expressed efforts the patient makes to ensure that others behave as they expect them to. As an example, the typical encounter pattern of Mrs. Grün is mentioned, with which she tried to make the therapist an ally of her experience at the beginning of each session (7 Sect. 5.4). In addition to the question of the patient’s repetitions, the analyst in this conception reflects on their own influence on the observed relationship system. This “work with and in transference” in the sense of the questions: “What does the patient do with the therapist, what does the

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therapist do with the patient, and how is this to be understood and brought to language in the therapeutic situation against the background of internalized object relationship experiences?” is only meaningfully possible and indicated in a psychoanalytic treatment framework. Nevertheless, it should be considered in every psychodynamically oriented therapy, whether it is a short-term or long-term therapy, because only on this basis can planning, design, and understanding of a revealing therapeutic process be achieved (see the sections on treatment planning for all three case presentations). Even in a KIP, all statements of the patient within and outside of the imaginations are considered to be determined by the transference-countertransference dynamics against the background of this intersubjective paradigm. It is also crucial for what the patient imagines. The KIP therapist therefore continuously reflects on his own influence on the observed relationship system and imagination process. For this complex dynamic, Nohr (2006, p. 8) has suggested a vivid illustration: “When I hear the first words of an imagination, I am already swimming, to use a metaphor for the time being, deep in a river, one bank of which is formed by me, the other by the patient, and the water and flow of which is a mixture of our emotional and mental substance. The water represents a mixture of permanently oscillating projective occupations of representations of the other … There are places on the bank from which I can strive for an overview of the whole, and I can keep my head above water while swimming or always head for an island, just as the patient can … We form or reach other islands together when we have succeeded in dissolving one of the many desire-defense entanglements through empathy and understanding.“ The intersubjective transference-countertransference paradigm will be illustrated by a vignette below:

In a training course, the leader wants to familiarize the participants with the motif of the “forest edge” on the last day and suggests an imagination performed by him in front of the participants with a colleague prepared for this purpose. Immediately, a slightly younger colleague volunteers and sits down on the “protagonist chair” next to the leader. The leader is satisfied with the course of the training, as most of the participants, almost all female colleagues, had been quite open. He had to repeatedly limit two participants with their rule-demanding inquiries. The protagonist colleague had so far appeared to him as cautiously interested, which he had also associated with the female dominance in the group. Therefore, the leader is also pleased, out of gender solidarity, that the colleague now takes this last opportunity in the course to present himself in front of the group with him as the therapist in the patient role. However, the leader notices the suddenness of his volunteering—he gets the impression that the colleague is somewhat contraphobically skipping his need for protection. He decides to focus on providing complementary support during the imagination guidance. Even now, as it were, “jumping into” the imagination, the colleague describes a meadow and to the left—where the leader is sitting—a dark edge of the forest. There he recognizes a small, hunched man with a pointed, tall hat, who somehow crawls out of the ground. The imagining colleague feels amused, while the leader—who takes this statement as a hint of a narcissistic dynamic—feels ridiculed in his countertransference. The leader now suspects a devaluation fear projected onto him (to “belittle” the other in order not to be belittled oneself), from which he deduces the desire to feel even clearer acceptance from him. By therefore confirming the colleague’s statements with interest, the atmosphere changes, and the colleague now experiences his desire for an encounter with the hunched

7.7 · Dealing with Transference, Countertransference, …

man, which is imaginatively implemented as the man coming closer: This man, however, wanders along the edge of the forest, comes closer now, suddenly hisses past me. In the leader’s impression, however, an encounter still frightens him too much, which he concludes from the “hissing past,” and so he suggests a distancing. The imaginer picks up on this: I now retreat from the edge of the forest a little to a hill. Then I am above him. Again, the accompanying leader becomes aware of the narcissistic dynamic, which only allows the colleague to experience an “above” or “below.”—From here, that is, from “above,” the colleague can see the man’s face for the first time, which has kind eyes and reminds him of an older psychotherapy professor, whom he must assume the course leader also knows.—I would like to meet him, get closer to him, he interests me—but is he also interested? Again, the leader senses a narcissistic ambivalence in his countertransference: He feels flattered to be identified with this celebrity, but at the same time devalued, as this other person is “put in front of his nose.” And he senses in himself the desire for an authentic encounter without idealization and devaluation—with which he perceives the deeper desire of the imaginer in a concordant countertransference reaction (7 Sect. 7.7.5): And indeed, at the moment when the leader has sensed the imaginer’s actual need in himself, he can formulate: I want to be seen by him, accepted, accepted as I am, while he logically also expresses the concern that this might not be the case: that he has no interest in me and rejects me.—A long sequence follows, in which he negotiates this conflict with the course leader on the imaginative stage, who goes through his ambivalences and possibilities in this situation with him, which now demands a lot of inner, strenuous conflict work from the colleague. He considers: Should I address him? Greet him as he passes by? Postpone the encounter? And: What speaks for and against it, etc., until the imagination ends.

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How can we understand this imaginative event? Clearly, there is an initial devaluation of a fatherly mentor figure, as embodied by the course instructor. He is given a magic hat as a kind of earthworm, ridiculed as a Harry Potter figure, and at the same time magically equipped, but characterized as “small” and “bent,” with which the imaginer projects his fear of being devalued by the course instructor onto him. Behind the fear of devaluation, the desire for contact is great: The colleague had immediately signed up for the protagonist’s dream and negotiates the theme of closeness to a man he admires in the imagination. He may wish to be like that, perhaps even to be able to lead a course like the instructor here. Possibly also, as a man, to be able to set limits on women regardless of fears of devaluation, as he could observe in the course. Temporarily, he must elevate himself above the instructor in order to then notice “kind eyes” that reveal his biographically conditioned fear of devaluations by father figures as part of the transference dynamic. Ultimately, however, he is preoccupied with his self-esteem problem and the desire to be able to meet this course instructor and other father figures on an equal footing. The above-described joint imagination design is expressed at several points, most strikingly at the moment when the instructor answers the second ambivalent evaluation not acting offended, but through countertransference reflection can feel the patient’s desire for contact within himself. Being a KIP therapist in the intersubjective paradigm means not only finding oneself as a therapist as a transference figure in the imagination at certain points. And it also does not mean only assuming that the person in question could imagine these images from his inner conflict situation because a good therapeutic relationship situation had been established between the two of them in the situation. Moving in the intersubjective paradigm means a­ssuming

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that this imagination was jointly produced by both: And only in this way here and now, because it sprang from a specific situation and a specific relational experience here in the course and a conflict that was thereby actualized. Affirming the intersubjective paradigm means, as a therapist, not only asking oneself: “What kind of hat is the patient putting on me here? How do I experience this and what does this experience mean?”, but also, what I, for example, by the way I lead this course, actualized his fear of devaluation as well as his impulse to deal with it now and with me. In this case, the instructor was aware that he had been inclined to a clear structuring in this course and had enforced it. As mentioned, he had also limited some participants in the service of the course’s concern, sometimes even revealing their rationalizing defense behavior. Perhaps the imagining colleague had been both attracted and frightened by this. It was then important that the instructor sensed his vulnerability during the imagination, but did not act against his devaluations directed not only against himself but also against him. On the contrary, through the reflection of the countertransference, a closeness to the imaginer had become possible, through which he could renounce his narcissistic defense. As illustrated in this example (see also, for example, the Musat case, 7 Sect. 4.5 (14), (20), further vignettes can be found in Dieter 2006; Nohr 2006; Schnell 2005), the transference-countertransference dynamic is fully integrated into the imagination process: Every statement, everything the therapist says or does not say, even their mere presence, the way they are treated by the patient, the reactions this triggers and how they respond to it—all of this becomes part of the catathymic imagery. “Catathym” (7 Sect. 1, 7 Excursus 1: catathym) is thus never an image-like feeling arising independently from the therapist’s mind, but these emotional images are expressions of

the relationship desires and defenses mobilized by transference. And these desires and fears from internalized relationship experiences combine with what the therapeutic relationship specifically addresses and triggers.—Similarly, we understand the dream report in psychoanalysis: When and how a dream is reported is a function of transference. This complex interplay is always effective in its entirety. Within the transference-countertransference dynamic, we find ourselves in an area where there is no fixed, process-independent point of reference from which an overview-like description of the therapy process would be objectively possible (Deserno 1994). In essence, this is precisely the special, creative, challenging, and sometimes difficult-to-bear element of a psychoanalytic and derivative therapy, always remaining in search and not being able to hold on to anything as valid detached from oneself as a therapist (7 Sect. 7.1). With this in mind, the phenomena associated with this overall process will nevertheless be treated separately for didactic reasons in the following. 7.7.3  Resistance in and Outside

of Imaginations

As resistance all phenomena in the therapeutic process are referred to, which oppose its successful continuation. Unlike the concept of defense, which characterizes a ubiquitous intrapsychic protective process and concerns the level of content and affects that should not become conscious situationally or permanently, resistance is a therapy-specific phenomenon: Resistance is directed against the effectiveness of a therapeutic intervention; however, the patient will use intrapsychic and interpersonal defense mechanisms. Resistance phenomena can be triggered by the therapist through interventions that

7.7 · Dealing with Transference, Countertransference, …

overwhelm the patient’s current willingness and ability to deal with their painful feelings or dysfunctional relationship patterns. However, they can also occur with appropriate interventions (7 Sect. 7.3), simply because a therapy process fundamentally has to confront every patient with frightening, shameful, and painful facts at times, and the extent of this confrontation cannot always be balanced in an optimal fit. A particularly unstable phase, in which resistance intensifies, is often when the patient begins to suspect that their problems “in life” are now also finding their way into their protected and valued therapy room. That what they experience with their spouse, in some ways, resembles what they feel towards the therapist. And that they therefore suppress expressions of anger and criticism or affection and desires that relate directly to the therapist (resistance against becoming aware of the transference: Gill 1996; Thomä and Kächele 1985). Other phases with increased resistance levels arise around expressions of shame- or guilt-laden, previously repressed, denied, or otherwise “downplayed” inner issues, as well as in the final phase of therapies (7 Sect. 7.6). In order to successfully design a therapeutic process, it is of fundamental importance to know and recognize resistance phenomena. According to a general rule, they should be made the subject of the therapeutic conversation and understood together before the defended content is analyzed (“resistance before content analysis”), since the resistance indicates that the content is not yet negotiable for protective reasons. Resistance phenomena can be easily recognized, for example, in the form of prolonged silence on the part of the patient, extensive storytelling about “side scenes” or therapeutically irrelevant everyday events (in which, of course, very relevant transference clues can also be hidden!) and in the form of all violations of the therapeutic framework such as delays, errors regarding

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appointments, cancellations, non-payment, etc. For beginners, it is more difficult to identify resistance phenomena, which only indirectly find their expression in linguistic form, through behaviors and small scenes or in the imaginations, as the following examples should illustrate: 5 In the 9th session, Mrs. Grün asks her therapist if she can imagine. One can assume a positive transference to the therapist, which allows her to express this wish at all—also because she adds that the therapist should suggest the topic. Obviously, Mrs. Grün is trusting, open to her inner world, and can thus relinquish control. The context also makes it clear that she is not submissively submitting to an excessive fear in a contraphobic manner. At the same time, however, this openness can also be understood as resistance to her autonomy development. More specifically, she wants to avoid a deepening of what was previously discussed in this transference situation in order to maintain her affect control. 5 A therapist suggests an imagination to his patient at a certain point in the session. The patient agrees to the suggestion but says he wants to “quickly get something off his chest” first and then speaks so quickly or extensively that an imagination is no longer possible due to time constraints. The transference situation here was such that he could not directly express his concerns about an imaginative deepening of what had just been discussed due to certain transference fears, but acted in the form of this resistance. 5 A patient remains lying on the couch for a longer period of time after the imagination has ended, until he takes a seat opposite the therapist again; although a certain thoughtfulness after the imagination is often appropriate, in this case

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the therapist feels excluded from the events due to his countertransference, cut off and experiences anger that what has just been brought up together—so his assumption—is being “pre-sorted” and “hidden” from him in a controlling manner by the patient before the possibility of a deepening discussion. Here, too, the resistance appears as a transference phenomenon. 5 The patient is deeply relaxed and emotionally moved during the imagination but immediately begins to problematize in the follow-up discussion. The resistance is shown here through rationalizing defense processes in a transference constellation in which the patient has to maintain his resistance in the conversation from transference fears in a different way than in the imagination. 5 Similarly, in the case where a patient is emotionally very involved in the imagination but devalues the imagining in the next session. If this is not understood as a resistance phenomenon, it can lead to the therapist refraining from imaginations. If the therapist himself feels devalued, he quickly enters into a transference-countertransference collusion. If the resistance is discussed, it can be understood, for example, why the patient habitually has to devalue the emotional in himself and why this may have to take the form of devaluing others. 5 In another case, the imagining is gladly accepted, but never followed up or discussed by the patient; here the resistance is acted out, since, as in the example above, the imagining cannot be openly enjoyed, devalued, or trivialized due to transference fears. In the imaginations, the resistance can be shown through the imaginative process itself and/or through the imagined contents: Through “blurred images”, their fleetingness or immobility (for example, a comic image or a photo may appear instead of

a vividly imagined mountain), by ignoring and “overhearing” therapeutic interventions up to “breaking off ” the imagination. “Fog” can prevent “clear vision”, “many flowers” can be a means of avoiding authentic self-examination, just as “none” can. When following a watercourse, resistance can take the form of a “dam” or the bridge shaking and the shore crumbling (Case Eichel, 7 Sect. 6.5 (12)). For the sake of importance, the following is systematically listed when resistance phenomena should be considered: 1. Related to the patient’s attitudes towards imagining: 5 the patient rejects imagining 5 he always wants to imagine 5 he trivializes or devalues imaginations 5 he forgets his imaginations 5 he behaves noticeably differently in the imaginations than in the conversation. 2. In the imaginations/related to the imagining itself: 5 the patient “cannot” imagine 5 his ideas remain blurred, everything is “like in fog“ 5 instead of the given motif, another one often appears/never anything else appears 5 the patient cannot move in his catathymic landscape, he sees everything “from above” or “from the outside“ 5 instead of vivid imaginations, photos or pictures or comics are seen 5 suddenly the patient is “thinking elsewhere“ 5 the patient describes his imagination in great detail but ignores questions about effects, 5 the patient produces a wealth of ideas and cannot immerse himself in an imagination 5 the patient always imagines the same imaginative content. If post-processing is used, it is useful to also consider the processes that result from the painted or unpainted, shown or ­unshown,

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or strongly deviating image content under the aspect of resistance (7 Sect. 7.5). Thus, the strikingly frequent painting in certain analysis phases by Ms. Eichel can also be seen as a resistance phenomenon, as it served in one dimension of statement to prove to the therapist how much the patient “tried” as an “eager child” (cf. 7 Sect. 6.5 (13)). The painted image of her cave, on the other hand, showed that the previous imagination (7 Sect. 6.5 (415)) was driven by resistance, insofar as the patient “spared” the therapist, the imagined cave had to be made “more beautiful”, while the painting done alone at home showed the true extent of the problem (7 Sect. 6.5 (416)). In general, one should think of forms of resistance related to the re-creation of imagination (7 Sect. 7.5) when: 5 the patient “cannot paint” 5 they paint, but forget to bring the picture 5 they paint, bring the picture, but keep it in their pocket 5 they show the picture, but remain silent about it 5 or when they say they “see nothing” in their picture 5 they overlook or do not address central aspects of the picture 5 they paint something completely different from the imagination 5 when they do not consider central aspects of the imagination 5 the pictures are “better” or “worse” than the imaginations. In summary, it should be emphasized once again that, in principle, any form of expression can be used for resistance—whether resistance is present is an assessment of the therapist by reflecting the context and relationship state using countertransference (see below). Thus, no rules can be established regarding imagination, and seemingly contradictory signs of resistance can occur, such as when the patient devalues the imagination as well as when they overvalue

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it. And just as avoiding imagining can be a resistance, frequent, perhaps even “hourly” desired imagining can also be a resistance. The unreflected response to the respective patient’s wish, for example, for never or for much imagining, represents a co-acting of resistance by the therapist, i.e., a transference-countertransference collusion (see below). And just as “everything can become resistance” in general, an imagined content can simultaneously show and hide something, thus serving to defend against another aspect—the decisive factor for the assessment is always the context and the understanding of the transference-countertransference dynamics. 7.7.4  Transference Phenomena

in KIP

After what has been said so far, it should have become clear that by focusing on transference phenomena in this section, the topic of resistance is, so to speak, dealt with from the “other side of the same coin.” For to the extent that the transference can be characterized as “positive,” “negative,” “unobjectionable,” etc., it shows the degree of resistance against the mobilization of painful feelings and insights or the degree of cooperation in the progress of the therapeutic process. It has also been emphasized that countertransference is the decisive “instrument” for the perception of transference phenomena (7 Sect. 7.7.5). Guiding questions in the therapeutic effort to recognize transference phenomena can be similar to those formulated by Balint: How does the patient treat me? And— reflecting on countertransference—how do I treat the patient? Or also: What does the patient want to tell me (actually), what does he want to achieve with me, what does he do to me? What does he see in me? What role does he suggest I take on? The therapist asks these questions especially when

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he feels inappropriately, perhaps even distorted and strangely accentuated, perceived regarding the current therapeutic situation or when he notices a possibly even repetitive, unusually perceived reaction of the patient. The same applies when the reported reactions of the patient to third parties seem incomprehensible, unusually exaggerated, or when their behavior within the therapeutic context appears inappropriate. A mild positive transference, which Freud (1912, p. 371) called “inoffensive,” is therapeutically helpful. The patient then has positive introjects that they can activate towards the therapist, making it easy for them to trust the therapist and understand critical inquiries as supportive offers regarding their therapy goal. (A mild positive transference in the case of Musat, 7 Sect. 4.5 (14), enabled beneficial insights after a relatively short time). A complicated course of therapy can be expected when there are grossly distorting idealizations of the therapist, who is then experienced as a “savior” and the only helpful being due to the need for grandiose projection, but is latently feared because of the importance attributed to them (such a transference occurred in the case of Eichel, with the therapy-impeding consequence that the patient had to process mirroring or positively resonant or understanding-promoting interventions as criticism for a long time, cf. 7 Sect. 6.5). Similarly complicated processes occur when devaluations of the therapist or their method must be openly presented from the outset. Since patients usually become patients because they primarily bring negative relationship experiences, negative transference is of greater practical importance. In this, the therapist is confronted—openly, latently, or unconsciously—with fears, accusations, and mistrust for which they do not feel responsible in this form, even if there may have been real triggers for it in their behavior (interpersonal paradigm of transference, see above). For example, Ms. Mu-

sat experiences her therapist as a strict, homework-demanding “teacher” in 7 Sect. 4.4 (5). Often, negative transference is suppressed, repressed, or split off at the beginning of therapy, as happens with varying emphasis in the cases of Musat, Grün, and Eichel. Transference phenomena can manifest themselves in KIP at all levels of the therapeutic process, i.e.: 5 They can be related to the therapeutic framework (see the payment behavior of Ms. Eichel between (79) and (83)). 5 They can be expressed in scenes (7 Excursus 11: Scene) that can casually happen at the beginning or end of the session, e.g., through a glance and a special handshake during the greeting, conspicuous behavior when putting away the umbrella, when taking off wet shoes, etc. A scene that carries a transfer message is also referred to as an “action dialogue” (Klüwer 1983), as it is not represented in words or imagination, but in gestures and behavior (detailed descriptions of three scenes in the case of Eichel, 7 Sect. 6.4). Their meaning often only becomes apparent in the further course—precisely because these non-verbalized transfer manifestations often contain more strongly defended aspects. For example, the therapist may initially only notice: – My patient is offered the couch for the imagination, but prefers to stay in the armchair. – My patient sits exclusively at the very front of the armchair edge, she cannot occupy the entire armchair space even for the imagination. – My patient lies down on the couch, also takes a blanket—and always folds the blanket very carefully afterwards. Or another one arranges the pillows neatly with a “slap” every time, or leaves them unfolded (see also the scene described in the case of Eichel regarding toilet use, 7 Sect. 6.4)

7.7 · Dealing with Transference, Countertransference, …

5 Transfer phenomena can, of course, be found particularly in dialogue, in attributions to the therapist or subtle allusions, in which he experiences himself as inappropriate and distorted (see all three case presentations, for example the “angel” imagination of Mrs. Eichel (86), and the vignette in 7 Sect. 7.7.2). 5 Transfer manifestations can also be hinted at in narratives and reports about third parties, the so-called “external transfer relationships“: For example, if the patient talks about a friend who was disinterested in him, he may mean that he experienced me as a therapist as disinterested in the last session and now fears this again in this session (external transfer according to the principle of displacement).—Such an external transfer seems to be present in the case of Green, 7 Sect. 5.4 (9), when the patient reports a school scene and how important it is to her to show “them” that she is “not stupid“. It resonates that she also assumes this towards the therapist when she reports, for example, about her readings and other intellectual interests (see (23), learning English). Or the patient describes himself in a way, e.g., being disinterested in others, as he unconsciously fears it from the therapist (transfer allusion according to the principle of identification). 5 Specific to KIP, the transfer phenomena are also evident at the imaginative level, both in terms of the imaginative process and directly in the imaginative content. They can manifest themselves in the way the patient communicates with the therapist during the imagination: through silence, talking a lot, involving us, keeping distance, etc. 5 Or the transference manifests itself imaginatively quite directly: The specific design of the symbolic figure can refer to the therapist (cf. the vignette in 7 Sect. 7.7.2 or the “hand from above” in the case of Eichel, 7 Sect. 6.5 (18),

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as a symbolic representation of idealization wishes). And the transference can be shown in the patient’s behavior towards the symbolic figures, as in the case of Grün, when the patient in the initial imagination thinks about tearing out the flower, or in the final imagination, the yellow powder of the sunflower as a positive internalization, that nothing is lost, takes from the therapeutic relationship into her life. 5 Transference messages are also connected with and within the re-enactments, for example, when a patient imagines pleasant-relaxing scenes, but then brings the therapist into worry about him with a threatening-looking re-enactment. This should demonstrate that manifestations of transference are not only present when the patient encounters the therapist directly or in imagination in a way that speaks for such a suspicion due to its conspicuous or inappropriate nature, but that they can also be shown indirectly in the conspicuous, emphasized or distorted description of third parties or in actions experienced as inconsistent. It is not possible to further explore the complexity of transference manifestations within the scope of this textbook, and again, reference must be made to the relevant psychoanalytic literature (see above). However, their forms of expression in connection with and during the imagining and in the imaginations themselves should be explained. Already the suggestion of an imagination can meet a readiness for transference, which is shown with regard to the disorder-specific psychodynamics, for example: A depressive patient may experience that the suggestion of imagination means that he “did not suffice” again with what he could express in the conversation—and stages his experience of deficiency on the level of imagination. A hysterical patient could produce a wealth of ideas if she feels

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that she should finally reveal in the imagination what she seeks to hide in the conversation. A phobic person who clung to the presence of the therapist in the conversation and the “messages” read from his facial expression may now feel “sent away”, referred to himself, as if sent away by the parents to play so that he does not “disturb” or “annoy”, and that, although he wanted to be very close to the therapist. On the level of imagination, there may then be avoidance of contact, or the imagining may be completely evaded. Patients who try to avoid pre-oedipal desires by competing in the Oedipal rivalry could use imaginations to demonstrate their adventures and hide their narcissistic attachment wishes. Parentified patients may perhaps be relieved to accept the announcement of imagination because they can relax from the exhausting face-to-face object relation, which prevents them from being with themselves because they always have to be on the lookout for potentially negative signals from the powerful other; they then make their mountain tours well and alone in the picture, striking are only the many inviting mountain meadows and benches that they leave on the left, and the feelings of resignation and exhaustion. Narcissistic patients can devalue the offer with mistrust or “complete” it in an affect-isolated manner. Finally, anxiety neurotics can develop fear of losing control in the imagination. Knowing and recognizing such “typical” ways of patients dealing with imaginative suggestions and sequences with regard

to transference protects against misunderstanding, for example, the “positive uptake” of suggestions as “process-promoting” (cf. the two “readings” of the initial imagination in the case of Eichel, 7 Sect. 6.3). Consistently “reading along” with transference in a KIP therapy before, during, and after the imagination means paying attention to and reflecting on everything that is communicated, discussed, and imagined, considering what this may possibly express about the patient’s current relationship with the therapist, without the patient addressing it directly. (For example, Mrs. Eichel, 7 Sect. 6.5 (145), plays with the “therapy ball” of a “friendly woman”). Comparable to any other form of psychodynamic psychotherapy, I will therefore pay attention to what the patient “does” with me as a therapist, how he “treats” me, and how he “incorporates” and “represents” me in his imaginations. “I am always meant as well” is, so to speak, a second level on which the entire clinical material is simultaneously pursued. However, understanding the transference situation is not always as obvious and straightforward as it was mentioned in connection with the motif “mountain” (7 Sect. 7.2): Namely, that the therapist can be experienced as “jagged”, “unapproachable”, “sublime and dominating”, etc., according to the patient’s superego and ego-ideal issues. Or as in the case of Eichel, 7 Sect. 6.5 (352), where the therapist appears as a supportive object against the mother imago in the form of a helpful neighbor. 7 Excursus 11: Scene

Excursus 11: Scene

By a scene, one understands a “snapshot” in the therapeutic situation in which an unconscious relationship situation is shown in the patient’s actions or behavior, which is actualized through transference (Klüwer 2002). The action or behavior often takes place quickly and seemingly unimportantly, for ex-

ample, a patient moves an object on the table while speaking, suddenly gets up and opens the window, or heads straight for the therapist’s chair at the first appointment. The term “scene” belongs in the context of the concepts of acting, enactment (acting out), and action dialogue. Historically, “act-

7.7 · Dealing with Transference, Countertransference, …

ing” initially referred to actions that the patient “produces” instead of memories and took on a negative connotation in the sense of undesirable or even immature. However, the understanding of acting or enactment has undergone a considerable expansion of meaning: on the one hand, still as resistance to remembering, but on the other hand, also as communication of life experiences that, not yet sufficiently verbally represented, are initially “staged.” In the latter sense, acting is now considered a necessary component of an analytical process; for this positive evaluation, the term “staging” is usually used, from which “scene” is derived (Mertens and Waldvogel 2000). While scenes consist of action patterns and interaction forms that are activated by the transfer and refer to unconscious, mostly early and/or traumatically conditioned pre-experiences (see under 7 Sect. 6.4 three detailed examples—blanket, giving, body language—in the case of Eichel), the term action dialogue (Klüwer 1983) is used when the analyst temporarily participates in the acting (see bottle scene in 7 Sect. 6.5 (381)). The action dialogue is actively and unconsciously shaped by both parties over some stretches; in this way, material from relationship experiences that were not previously verbalizable is created for further analytical processing. Especially for Argelander (1992), scenic understanding was the actual understanding mode because it was directed at the unconscious. In countertransference, the scene is usually experienced as crossing a boundary, through which the patient introduces a traumatic or inexpressible relationship experience into the process. Therefore, it is important for the decryption of scenes that the therapist carefully perceives his counter-

Since reading along with the transference level is not always as easy as in these examples, it must be “learned” (see initial

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transferences. They are his “signposts” to register, decrypt, and interpret scenes. To register them requires evenly hovering attention, as scenes can easily be overlooked compared to the spoken. Streeck (2004) has demonstrated, using video-supported analyses of greeting and farewell rituals as well as other fleeting body language encounters in therapy—he calls them incidentalities, micro-acting—how diverse scenic signals can appear. The decryption of scenes begins initially through an understanding process taking place solely within the therapist (7 Sect. 7.7.5). All further communications from the patient are then related to the scenically registered and presumed internal connections are established, which result in clarifying questions that initiate joint understanding, such as: “Could it be that …”, “I connect … with …”, “How can we understand this?”, “What plays into it?“ The scenic understanding, often in the sense of an aha experience, culminates in the meaningful interpretation presented to the patient. Since the scene often concerns an “unintended triviality” but is related to the patient’s unconsciously intended and usually shame-laden body language, it can only be fruitfully interpreted when trust in the therapeutic relationship outweighs the potential for injury and shame. Often, scenes that the therapist notices during the sessions can only be processed much later through a joint understanding effort. On the other hand, trust is created precisely through a joint scenic understanding; in this respect, it is important to encourage it with the necessary tact in due course. If the scenic material is not understood or not processed, there is a risk of limiting oneself to the stabilization of defense and thus an insufficient therapy result.

imagination in the case of Eichel, 7 Sect. 6.3); this also includes not putting oneself as a therapist under the unfulfillable claim

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to understand the transference dynamics “immediately” and “clearly“. On the other hand, it is helpful and best reflects the events within the intersubjective paradigm if the therapist regularly asks questions like these: “For what transference reasons could my patient not accept my intervention or my suggestion motif during the imagination today?” But also: “What did I contribute through my countertransference or how did I cause my patient to behave this way or that way today?” Because a complete reflection of the transference-countertransference events within the intersubjective paradigm also includes the question of to what extent we as therapists have been “involved” in these expressions and also in the imaginations in the sense of being co-causing (7 Sect. 7.7.2). It would be too short-sighted to consider Mrs. Grün’s refusal to perform imaginations before the exam as stress dosing in the sense of “coping“. From the transference dynamic perspective, it is also her fear of losing control or an unconscious protection against the equally unconscious fear of appearing weak or “stupid” to the projectively unempathetic-strict counterpart. The countertransference analysis makes it clear that the growth of such fears was favored by the disappointment-causing response to the patient’s request for a break (reflection of the end of the middle therapy phase in the case of Grün). 7.7.5  Perception and Handling

of Countertransference

Under the term countertransference, the totality of the therapist’s emotional reactions to the patient is understood, including their unconscious component. In the earlier objectifying one-person model, countertransference as a reaction of the analyst to the patient’s transference offer was considered a source of dis-

turbance for the therapeutic process or as an obstacle in the effort to turn the patient’s own unconscious into a “receptive organ.” It was attributed to an insufficient self-analysis of the analyst, their “residual neurosis.” The decisive change in this view, initiated by Paula Heimann in 1950, can only be mentioned here, but it is radical, as countertransference has now become a significant diagnostic-therapeutic instrument and its understanding has become the core competence of psychodynamic therapists. For today’s countertransference concept, a non-pathological form of projective identification is crucial: In practice, countertransference is primarily understood as a manifestation of what cannot be processed in the patient and is therefore “housed” in the therapist, experienced by them through projective “absorption.” This connection between the intrapsychic situation of the patient and the interpersonal process represents the guiding principle of today’s handling of countertransference. This view of countertransference also no longer distinguishes whether the therapist’s emotional reactions originate in the patient or the therapist. This acknowledges that it is usually impossible to determine to what extent they are reactions to the patient’s transference behavior and to what extent they stem from the therapist’s conflict, especially since we therapists ourselves are subject to various changes in our life course: Our emotional reactions during treatments are not only dependent on the quality of our previous training analyses and supervisions, and not only on our “daily form,” but also on our current conflict burdens, which affect us—like all other people—in the form of various crises and fateful events and can influence our ways of reacting. Good self-experience, however, is the basis for dealing with such new experiences and thus keeping the “countertransference source” fresh and alive throughout life and being able to continue to do justice

7.7 · Dealing with Transference, Countertransference, …

to the patient. This is also why continuous professional intervisory and supervisory exchange is necessary. In practice, it has proven useful to initially assume that countertransference reactions are a mixture of patient-induced and therapist-originating components, which should be perceived and reflected upon without prejudice. Such reflection can also reveal that in individual cases, they predominantly stem from one of the two poles: it is not the patient who made me tired, but I simply did not get enough sleep—my sadness does not stem from one of my own insufficiently processed loss experiences, but from a projective identification of the patient. However, before such reflection, it is important to perceive the manifestations of countertransference within ourselves first. The “totality of the therapist’s emotional reactions to the patient” refers to thoughts, feelings, physical sensations, impulses, and fantasies that arise within us during a therapy session, but also those that can reach us later, when consciously thinking about the patient or unconsciously suddenly encountering them: during reading, watching a movie, doing housework, or engaging in sports activities—even up to countertransference dreams. Reflecting on their meaning is an important, often decisive part of our understanding of the therapeutic process: “Why do I feel impatient, sad, paralyzed, elated, or find the time with this patient excruciatingly long?”, “Why do I feel physically uncomfortable, tense, or short of breath during this session?”, “Why do I start doubting my competence, developing feelings of guilt, or engaging unusually?”, “What does my impulse to reprimand this patient, to ‘wipe them out,’ to take them in my arms or ‘on my arm’ mean?“ In a KIP, such internal reactions occur in the same way as in any other psychodynamic therapy, only that they also occur here during the imagining process.

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The following example should illustrate this: A 39-year-old schizoid patient imagines a “meadow” as a surface “full of water” and immediately submerges into this water. Naively, one could assume as a therapist: This patient spontaneously and therapy-ready opens up to his unconscious—and could accompany the patient on his “dive to the seabed of his soul“. In fact, however, the therapist felt discomfort in his countertransference, a strange distance to the patient, and a resigned feeling of not being able to reach this patient. This made it clear to him that the patient was not interested in spontaneously exploring unconscious areas, but rather that he had “submerged” from the relationship with him. He then encouraged him to “surface” and come to the “surface”, which made the therapist feel closer to the patient in his countertransference. The next imaginations were also aimed at making him perceive superficial-sensual things—as a cautious approach to more affective topics. The handling of countertransference is generally unproblematic when it is characterized by a neutral or friendly-well-meaning acceptance of one’s own inner path as well as that of the patient and his constructively experienced self-confrontation in the joint therapy process. It is more difficult when we notice reactions in ourselves that—as exemplified—contain negative or even hostile and intrusive affects and impulses. Such reactions can occur to us both as a situational reaction to a specific statement or behavior, but we can also identify them as a continuous attitude and attitude towards the patient. If countertransference reactions develop slowly, this usually corresponds to a neurotic structural level of the patient. Rapidly intensifying countertransference reactions usually correspond to structural ego disturbances, intense overwhelming fright with the touch of a traumatic experience (e.g., during the initial imagination in the case of Green when t­ earing

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out the flower). This already names one of the aspects that make the reflection of countertransference a helpful therapeutic “instrument“. An important further aspect is opened up with the terms complementary or concordant identification introduced by Racker (1978). The therapist’s countertransference experience can be identical to that of the patient in his primary relationships: For example, I can feel rejected by the patient in the same way as he felt rejected by his parents as a child. We then speak of a concordant countertransference. The patient is identified with his primary objects and “lets me feel” how it “happened” to him “back then” (see the vignette under 7 Sect. 7.7.2). If, on the other hand, I feel like reacting to the patient in the same way as his primary caregivers or current relationship partners usually did or do—I am disappointed, angry, judgmental—I am complementarily identified. In this case, I correspond to the common role expectation of the patient, whose parents were disappointed and angry with him and whose partner also angrily condemned him as a “disappointment” (Rosendahl 2007). At this point, it becomes clear how important an aspect of professional competence it is for a therapist to perceive these countertransference reactions in oneself without acting them out. This competence consists primarily in creating an affective distance to them in oneself in order to reflect on these reactions, and even to explore them with interest. The reflection of both countertransference positions provides the therapist with important information about the patient’s inner object world. From the complementary identification, I, as a therapist, can sense how present and past reference persons may have felt and dealt with the patient. From the position of concordant identification, I, as a therapist, can sense how the patient feels here and elsewhere and may have felt in the past: If I feel help-

less and devalued because the patient bypasses my interventions, he is now identified with his devaluing primary objects. As a therapist, I am then no longer dependent on the patient’s possibly affect-poor descriptions of his parents, but rather experience his experiences directly, even in my bodily reactions. (For example, in the case of Eichel, 7 Sect. 6.5 (168), the analyst chooses the mountain motif from the physically intense strain of her countertransference.—At other points, it can also be well understood how the analyst was projectively identified and thus came into inner states that corresponded to the patient’s self-experience.) Using countertransference reflectively as a therapist primarily means not acting on an ascending impulse. It is obvious even to a layperson that we should not encounter a patient in a hostile and brusque manner out of countertransference and should not respond to a hostile provocation with an angry expulsion. Not responding to flattery with grateful counter-praise, but instead asking oneself which role expectation one is being pushed into or is supposed to be pushed into and what the patient may be afraid of, is also intuitively plausible. However, further professionalism is usually required where it is necessary not to act on care and affection. Of course, a therapist will not only listen empathically to his patient, especially at the beginning of therapy, but will also support him. However, it is generally advisable to become more reserved in the further course, while maintaining an empathic-understanding attitude (7 Sect. 7.1), and not to reflexively jump to the patient’s side with encouragement, as perhaps an empathic doctor in his general medical practice would do, or as has become common among some “trauma therapists” caught up in resilience concepts; in contrast to an approach that reflects on transferences, such as with Steiner and Krippner (2006). It can often be much more helpful for the

7.7 · Dealing with Transference, Countertransference, …

patient and more ­difficult for the therapist to bear the patient’s grief inwardly and empathically, rather than comforting him too quickly with words, gestures, or specific imagination suggestions. Perhaps the patient is experiencing a grief that he has never felt and never been allowed to show, and enduring and sharing it promotes something very important within him—and taking it away from him again (for example, with so-called “stabilization exercises”) would be untherapeutic. As is known from supervisions, many beginners in the profession find it difficult not to misunderstand the therapeutic duty of care in this way or not to act on the therapeutic desire to help in such a way that the patient is thereby deprived of the important experience of finding his own way to self-care. This, in turn, applies without restriction to therapeutic action during imagining, as the following example illustrates: A depressed patient imagines a desolate desert landscape and unconsciously tempts the therapist to lead the patient out of the desert to an oasis on the horizon, mentioned in passing, and by demonstrating helplessness. Depending on how controlled the therapist perceives and reflects on their countertransference, the imagination can develop in different directions: Either in the frustrating repetition of experiencing oneself as depressively inadequate—the patient does not reach the oasis, and the therapist also experiences themselves as inadequate. Or the patient is led to the oasis in a suggestive manner due to an unreflected rescue fantasy of the therapist, which is associated with a feeling of powerlessness on the part of the patient, remaining dependent on external help. Finally, the imagination can enable the patient to work on their own new perception and action patterns with the help of direct and indirect encouragement interventions (“What would be good for you?”, “What would be helpful for you?”, “What is hindering?” etc.) and to abandon the self-destructive design of their scene

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and vary it productively, which becomes possible when they can accept the transfer message contained in the interventions: “I trust you to do something!“ Already under 7 Sect. 3.6 this problem was pointed out in connection with the termination of imagination: If the therapist hesitates to do so because they feel that “it is not enough yet” or it has “not been worked on enough” or the patient has not yet reached a “good place” or “conclusion” in their opinion, it is often an acting out of, for example, an altruistic countertransference or an insufficiently reflected projectively absorbed guilt fantasy of not being “good enough” for the patient. Whether it is therapeutically helpful to explicitly express one’s countertransference depends on many factors. In general, it is by no means favorable for the therapy process to express countertransference reactions unreflectively. If they are communicated, this should be done in the sense of the objectives, as is the case, for example, with structurally weak patients with the “principle of response” and the “selective communication” of countertransference reactions in the interactional-analytical method (Heigl-Evers et al. 1993). This also applies without restriction to therapeutic behavior in connection with imagining. As stated elsewhere (7 Sect. 7.2), the suggestion of a motive is already closely linked to countertransference. The proposal of a stimulus motive is—as shown several times in all three case presentations—to some extent a reflected symbolized countertransference expression, which of course influences the transfer dynamics again. The reflective handling of countertransference presupposes that it has become conscious and has been understood. However, a part of the countertransference reactions remains unconscious or only becomes conscious later on. This is both unfavorable and inevitable. It is unfavorable because it can then—acted out by the therapist—influence the patient’s transference again,

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usually in the form of confirming dysfunctional patterns: The patient made me impatient and reproachful through their apathetic self-pitying behavior, and I behaved complementarily just as they always know it from others.—Only in the course of the therapy process do such entanglements become better understandable and avoidable. To notice them, there are various signs that always relate to a deviation from otherwise usual therapeutic work or can consist of misactions: If I, as a therapist, forget the sessions of this patient, confuse their name, talk to them about private experiences, extend sessions, excessively advocate for them on a real level, report about them to others with intense emotions, or if I behave unusually in the sessions: more confrontational or engaged than usual for me, interrupting them inappropriately often or tolerating their evasive behavior, etc. If such an entanglement becomes scenic (7 Excursus 11: Scene), we speak of an “action dialogue” (Klüwer 1983), if it is continuously acted out, we speak of a transference-countertransference collusion. Exploring one’s share in it and distancing oneself from it is an important part of therapeutic work. However, if there is resistance to becoming aware of our countertransference, we speak of a countertransference resistance: Analogous to the patient’s transference resistance, the countertransference resistance is directed against the awareness of unpleasant, painful, not easily reconcilable with our self-image, and thus unacceptable affects for us therapists. An example from a training group, in which a participant imagined in front of the group on the theme of “wanting to be taken along” and was therapeutically accompanied by a colleague, should illustrate this: 5 I walk on a narrow country road, it is dark, evening, the moon is shining, it is starry, full moon, therefore relatively bright, although it is night. I have the feeling that there is still a way ahead of me,

there are no houses here yet—it is a barren landscape. Something like in America. It is completely silent. I am looking forward to being at home and want to arrive. But it is nice to walk. 5 What are you wearing? 5 Light clothing, a summer jacket, it is a pleasant warm evening… I wonder if I might hear something after all. It could be that something is coming. I look around, but there is a dip, so I can’t see anything. I keep going, yes, there is an engine noise. A deep hum. An older pick-up is coming, it already has some scratches, I have slowed down. The car drove past me and stopped about 20 meters in front of me… A man gets out. He looks friendly and asks if he can take me with him. 5 Can you describe him? 5 He is wearing a turtleneck sweater and corduroy pants, has loaded things for a farm: feed, stuff like that, corn, hay—as if he has a farm. The things don’t match, he looks more like a city dweller. As if he were coming from work in the city.—He asks if he can take me with him. I am relieved. Riding along would be good—I check him out—how trustworthy he is. 5 And how is that? How does he seem? 5 The car, the things, so vital and friendly. I think: It’s nice if I don’t have to walk. And driving a pick-up might be fun. I get in. Climb up there, he gets in too. The car seems older, leather, smooth seats. He listens to music that I also like, swing, jazz. 5 Yes, and otherwise, how does it smell? 5 It smells a bit like hay. I have rolled down the window, put my elbow out, enjoy driving like this. I think about what to talk about, since it is so quiet. 5 How does it feel physically? 5 A little tense… He starts chatting now. It’s very uncomplicated. Tells where he comes from. I relax while doing this. I am glad that he does that and establishes contact and I don’t have to do it. It is very casual between us, nothing that would be too direct. And it is clear that it will

7.7 · Dealing with Transference, Countertransference, …

continue like this for quite a while. I lean back, just drive like this. 5 What do you feel like now? 5 I get thirsty. There are little pictures in his car: an Indian Krishna or something like that. 5 And what does the thirst do? 5 There is a car rest stop coming up. He asks if we want to stop. I think it’s a good idea and say that I’m thirsty and think it’s a good idea. We get out, go in, it’s more like a bar here. There is a large counter with many bottles. I sit down at a table and order a cola. He sits down opposite me and also drinks a cola. I feel good. It has turned into a nice evening, I don’t feel tired anymore. I am now curious how it will continue. 5 Yes, I suggest that you say goodbye to the imagination now. The group participants expressed that they were very curious, “with the tension going from negative to positive,” “the man was likable,” and “I was absolutely disappointed when it was over.” “The film breaks off at the most exciting point.” The imagination was experienced as “tingling,” “comprehensible,” “not threatening,” “it was exciting in the bar”—and in general, there was regret about the sudden ending. The therapist initially rationalized her termination of the imagination, saying that the time had been “up.” When asked about her thoughts, she said, “I thought of Kamasutra with Krishna,” and it was probably her wish to protect the imagining colleague. This was considered inappropriate by both the imagining person and the group, as she could have controlled her proximity-distance behavior in an appropriate manner. Subsequently, the colleague was able to access her countertransference: She had fended off her own erotic desires and begrudged the imagining person the possible further approach. Thus, she would have found it difficult to remain a spectator during a further erotic approach—and

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she could also mention her own doubts regarding her attractiveness and feelings of rivalry. Countertransference resistances, as in this example, are often rationalized, for example: This patient is so needy and vulnerable that he needs my attention even on weekends, that one is so susceptible to injury that I cannot confront him with his rule violations, etc. If I have overestimated a patient who then does not develop well, and I do not make this clear to myself, this can also lead to countertransference acting: By offering him “more and more” and even during vacations, in order not to have to admit my misjudgment, or finally trying to deny it by suggesting a “hospital stay” for him. In such contexts, the KIP therapist may also think that they can use “imagination as a means of enlivening” because they hope that something “interesting” will unexpectedly “emerge” and the patient will “finally” get “into feeling” through imagining. This could be the acting out of a concordant rescue fantasy of the patient. The acting out of countertransference resistances can also occur from an unconscious identification of the therapist with a model-like perceived therapist attitude: This is the case when KIP therapists generally pursue the already criticized concern that the patient should feel better in therapy sessions than in real life. They then have “good” and “pleasant” places imagined. This approach, which is necessary and appropriate in certain phases of a psychotraumatological treatment (Steiner and Krippner 2006), is a habitual countertransference resistance: Therapists ward off negative transferences in this way. They want to be “good” in the sense of nurturing therapists and give the patient in therapy what he has painfully missed in his biographical development so far. This would be the position of a conscious or unconscious manipulation of transference, taking advantage of the suggestive possibilities offered by imagination, and contradicts the basic attitude

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represented in this book (7 Sect. 7.1) fundamentally. We emphasize this so clearly at this point because the reflection of countertransference and a possible countertransference resistance has a fundamental ethical implication: On the one hand, we can only do justice to the patient and his desire for change in this way. We should consider what a significant life investment it is to enter therapy. On the other hand, we harm the patient if we—this means therapeutic abstinence—act out our own desires in the therapeutic process for unconscious or even conscious reasons: the necessity of therapy success for narcissistic reasons, keeping patients dependent to ward off our own separation anxieties, using therapies as a substitute for relationships, etc. In this entire highly significant field, it is therefore absolutely necessary to repeatedly adopt a triangulating external perspective and promote this through regular supervision and peer consultation. 7.7.6  Practical Tips for Resistance

Management and Trans­ ference Analysis in KIP

The resistance processing begins with the therapist noticing a hint of attentiveness or discomfort in their countertransference, or more concretely sensing that the therapy process is stagnating, a usual openness is missing, or similar as mentioned above. Very often, they become aware of the resistance through a lack of or inadequate emotional involvement of the patient—which they then also feel in themselves: They become tired, they get bored, feel anger—or they notice mistakes, e.g., forgetting the session of this particular patient, or experiencing impulses like reducing the frequency of their sessions. As described, all these are also phenomena of the transference-countertransference dynamics.

Sooner or later—depending on the therapeutic experience and the intensity of their countertransference resistance (see above)—the therapist essentially asks themselves: “Why is the process not going well anymore, what is wrong here?“ In a second step, the therapist will try to understand the underlying relationship conflict that has been mobilized in the therapeutic relationship due to the resistance. Knowledge of the patient’s biography and their psychodynamic hypotheses help, but above all, the reflection of their countertransference. Taking this into account, they can ask themselves: Which significant defended relationship desire of the patient towards their important reference persons was disappointed by me and through the type of interaction with them mobilized by the patient? Sometimes it is advisable to remember the hypotheses about the central unconscious relationship desires of the patient, as they may have been expressed in the initial imagination and formulated in the report to the expert: It is not uncommon for it to be helpful to reflect on what one has “forgotten” oneself—possibly also why—what was “forgotten” due to one’s own involvement in the countertransference dynamics. The therapist imagines and considers how and by what means the patient could have been frightened, disappointed, hurt, etc. Through this inner work of the therapist, understanding the relationship conflict between themselves and the patient, which they do alone, the therapy often takes a more favorable course, to some extent through a sometimes almost imperceptible readjustment of the countertransference—without having discussed the background of the resistance with the patient (see in the case of Grün, conclusion of the middle therapy phase). Whether and, if so, how the resistance is addressed in a third step of resistance processing (case Musat, Sects. 4.4 (12), 4.5 (18)) and whether the related transference and countertransference dynamics (trans-

7.7 · Dealing with Transference, Countertransference, …

ference analysis) also become the subject of therapy depends on several circumstances: 5 First, the therapist should decide whether their own insights into the dynamics (step 2) are sufficient. Each resistance analysis is an opportunity on the therapeutic path to get closer to the consciously pursued but unconsciously feared-avoided insight and change. However, each resistance processing also mobilizes fear—since it makes something shameful, painful, or otherwise previously defended conscious. Addressing the resistance is therefore a therapeutic control option of the process with regard to an optimal level of anxiety (7 Sect. 7.3). The mobilization of fear can benefit or harm the therapy process—if the patient is overwhelmed. As can be seen from the case of Grün (7 Sect. 5), it is usually therapeutically more favorable, especially for structurally disturbed patients, not to address the resistance directly. 5 Less frightening is the resistance processing when it is not related to the transference at the same time, that is—at least initially—carried out separately from the transference analysis. In the context of a psychodynamic short-term therapy, transference interpretations will generally be dispensed with, especially since the limitation of the transference dynamics is sought from the outset. It only needs to be addressed here if it begins to dominate the therapy process, i.e., when the transference has become resistance— which cannot be resolved by modifications of the therapeutic approach—or has ended up in dead ends of a consistently negative, erotically-sexualized, or distortedly idealizing transference. With regard to KIP, for example, it can become scenically noticeable over a longer period of time how the patient aligns his imaginations entirely with the therapist or how he has to fight against motif suggestions. Omissions (con-

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sciously or unconsciously unreported), silence, or symbolic signs on the imaginative level such as fogging, inhibitions, stagnations in the flow of imaginations, and much more, indicate such transference resistances. They must not only be recognized as such but also processed in these cases to ensure and deepen the therapeutic effectiveness. This can also be done directly in the imagination (7 Sect. 7.3). The alignment with the therapist can be processed by repeatedly encouraging self-assurance: “Feel once again whether this is really what you want now.” If the resistance is expressed by always imagining other ideas (instead of “mountain” “animal”, instead of “animal” “tree”, etc.) when suggesting motifs, one can initially help shape this direction of imagination by going along with the resistance—especially since it will usually still show therapy-relevant material—in order to focus on the initially warded off content later on. 5 If the therapist decides to address the resistance expressly, he should be aware of the associated affect mobilization. With the resistance, the patient regulates the therapeutic relationship and the degree of his self-confrontation. If the therapist decides to analyze the resistance, he intervenes in this unconscious balance—if this never happened, the therapy would not differ from a helpful lay conversation; if it happens too confrontationally, the patient will increase the resistance and possibly break off the therapeutic relationship. At this point, it should be emphasized again that these approaches address a core area of therapeutic competence that cannot be learned from books alone and does not allow for the formulation of general behavioral rules. 5 At least it can be said that for the reasons mentioned, it is advisable to initiate the processing of resistance in the

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form of a cautiously questioning, avoiding any accusatory approach, tactfully interested intervention. Here is just one example: “I notice that lately you often give away the first minutes of your session by arriving late. What could be the reason for this? I would like to understand it better.” Such a formulation is more likely to initiate understanding than, for example, the neutral sentence: “I notice that you have been late a lot lately,” which will make the patient feel criticized and probably lead him to rationalizing justifications that do not promote understanding. Although one can also address this: “I think you feel criticized, but I just want to understand.” However, this usually does not allow a patient who is easily unsettled to “believe” the understanding interest (see case Eichel, 7 Sect. 6.5 (452)), so that the resistance is rather reinforced. In the suggested example, one could continue depending on the reaction: “Was there anything in my way of dealing with you during the last session that irritated or bothered you? Maybe just a little thing?” In this way, an attempt can be made to bring the reasons for resistance into the conversation together in dialogue. 5 A more extensive intervention would be the transference interpretation, which is formulated hypothetically, e.g.: “I have considered that you might have experienced my remark x similarly to how you described it to me from your supervisor and earlier with your father: As if I, too, do not really take you seriously.“ 5 In a conversation that combines resistance and transference analysis, it can be attempted to clarify together whether or why a certain behavior exists. For example, due to transference, it could be important for the patient not to do exactly what they suspect the therapist wants.

Unlike in short-term psychodynamic therapy, which generally only implicitly uses the transference processes of the therapeutic relationship, limits their thematization, and seeks to keep their intensity low by focusing on partial goals and avoiding regression promotion, in analytical psychotherapy the increasingly explicitly made understanding of the transference dynamics becomes the most important means of the therapeutically sought changes: With the transference analysis, the patient has the unique opportunity to experience and accept his wishes towards the therapist, which are associated with feelings of shame, fear, and guilt, within the supportive therapeutic relationship. The immediacy of this affective experience in the here and now of the analytical relationship offers the most effective chance to truly internalize a new relationship experience, precisely because it is entirely tied to the immediate experience of affective insight. Recall Freud’s formulation (1912, p. 374) “for after all, no one can be slain in absentia or in effigie”—the analyst is involved in the patient’s illness, this illness must enter the analytical relationship, and only on the “battlefield of transference” can it be defeated. The case of Eichel demonstrates how this psychoanalytic work takes place within the framework of an imagination therapy, how the entire psychological material is processed in the service of such a restructuring change. The case presentation also makes it clear to what extent the transference dynamics represent the engine of therapeutic change, but also what support such an analytical process can receive by involving imaginations (for example, only the 175th hour is mentioned here).

References Allen JG, Fonagy P (2009) Mentalisierungsgestützte Therapie: Das MBT-Handbuch – Konzepte und Praxis. Klett-Cotta, Stuttgart

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Argelander H (1992) Das Erstinterview in der Psychotherapie. Wissenschaftliche Buchgesellschaft, Darmstadt Bahrke U (2005) Zur Förderung der Symbolisierungsfähigkeit im Behandlungsspektrum der Katathym-imaginativen Psychotherapie. Imagination 27:5–17 Bahrke U (2007) Katathym Imaginative Psychotherapie – vom Konzept der Projektionsneurose zum tiefenpsychologisch fundierten Behandlungsverfahren. In: Hennig H, Fikentscher E, Bahrke U, Rosendahl W (eds) Beziehung und therapeutische Imagination. Katathym Imaginative Psychotherapie als psychodynamischer Prozess. Pabst, Lengerich, p 115–122 Bahrke U (2010b): Übertragungskonzeptionen in der Katathym Imaginativen Psychotherapie. Imagination 32/3:5–17 Bahrke U, Nohr K (2005) Katathym Imaginative Psychotherapie: Eine Positionsbestimmung. Imagination 27/4:73–92 Bahrke U, Rosendahl W (eds) (2001) Psychotraumatologie und Katathym-imaginative Psychotherapie. Pabst, Lengerich Balint M (1952) Primary love and psycho-analytic technique. The international psycho-analytical library, No. 44. The Hogarth Press, London Bartl G (1989) Strukturbildung im therapeutischen Prozess. Ein Beitrag des Katathymen Bilderlebens. In: Bartl G, Pesendorfer F (eds) Strukturbildung im therapeutischen Prozess. Wien: Literas Chasseguet-Smirgel J (1987) Das Ichideal. Suhrkamp, Frankfurt Cierpka M, Buchheim P (2001) Psychodynamische Konzepte. Springer, Berlin, Heidelberg, New York Cottier SC (2005) Imagination in Team- und Organisationsentwicklung. In: Kottje-Birnbacher L, Wilke E, Krippner K, Dieter W (eds) Mit Imaginationen therapieren. Pabst, Lengerich, p 367–379 Cullberg Weston M (2011) Auf der Suche nach dem inneren Kind: Wege zu mehr Selbstachtung. Beltz, Weinheim Deserno H (1994) Die Analyse und das Arbeitsbündnis. Fischer, Frankfurt Diederichs P (2002) Die Beendigung von Psychoanalysen. Vandenhoeck & Ruprecht, Göttingen Dieter W (2000) Imagination und Symbolisierung bei neurotisch und ich-strukturell gestörten Patienten. In: Salvisberg H, Stigler M, Maxeiner V (eds) Erfahrung träumend zur Sprache bringen. Huber, Bern, Göttingen, Toronto, Seattle, p 147–168 Dieter W (2001) Die Katathym Imaginative Psychotherapie – eine tiefenpsychologische Behandlungsmethode. Imagination 23:5–41 Dieter W (2006) Explizite und implizite KIP-Behandlungstechnik. Imagination 28:5–29 Dieter W (2012) »Wer weiß denn, dass ich im Weltraum bin?«. Die Bedeutung einer »impliziten«

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Behandlungstechnik für die KIP bei schwersten und frühesten Störungen der Symbolisierung. Imagination 34:84–100 Fischer G, Riedesser P (2009) Lehrbuch der Psychotraumatologie. Reinhardt, München, Basel Fonagy P, Target M (2004) Neubewertung der Entwicklung der Affektregulation vor dem Hintergrund von Winnicotts Konzept des falschen Selbst. Psyche 56:839–862 Fonagy P, Gergeley G, Jurist EL, Target M (2004) Affektregulierung, Mentalisierung und die Entwicklung des Selbst. Klett-Cotta, Stuttgart Freud S (1898) Die Sexualität in der Ätiologie der Neurosen. GW 1: 491–516 Freud S (1900) Die Traumdeutung. GW 2/3 Freud S (1905) Bruchstück einer Hysterie-Analyse. Nachwort. GW 5: 275–286 Freud S (1912) Zur Dynamik der Übertragung. GW 8: 364–374 Freud S (1926) Hemmung, Symptom und Angst. GW 14: 111–205 Furth G (1991) Heilen durch Malen. Walter, Olten Gill M (1996) Die Übertragungsanalyse. Fischer, Frankfurt Greenson RR (1965) The working alliance und the transference neurosis. Psychoanalytic Quarterly 34:155–181 Heigl-Evers A, Heigl F, Ott J (1993) Lehrbuch der Psychotherapie. Fischer, Stuttgart, Jena Hennig H (2007) Das zentrale Beziehungskonfliktthema in der KIP. In: Hennig H, Fikentscher E, Bahrke U, Rosendahl W (eds) Beziehung und therapeutische Imagination. Katathym Imaginative Psychotherapie als psychodynamischer Prozess. Pabst, Lengerich, p 145–172 Hinnen P (2009) open space interlaken: Gesprächsprotokolle. Imagination 31/4 : 20–103 Höring C-M (2010) Psychosomatische Dermatologie – aus der Praxis für die Praxis. Pabst, Lengerich Jones E (1918) Theorie der Symbolik. Int. Z. ärztl. Psychoanal. Vol. 5 Jung CG (1917) Über die Psychologie des Unbewussten. GW 7 (1985), p 18–125 Jung CG (1928) Die Beziehung zwischen dem Ich und dem Unbewußten. GW 7 (1985), p 127–320 Jung CG (1934) Über die Archetypen des kollektiven Unbewussten. GW 9/I (1985), p 13–87 Klüwer R (1983) Agieren und Mitagieren. Psyche 37:828–840 Klüwer R (2002) Szene, Handlungsdialog (Enactment) und Verstehen. In: Bohleber W, Drews S (eds) Die Gegenwart der Psychoanalyse – die Psychoanalyse der Gegenwart. Klett-Cotta, Stuttgart, p 347–357 Kris E (1952) Psychoanalytic Explorations in Art. International Universities Press, New York Leuner H (1985) Lehrbuch des Katathymen Bilderlebens. Huber, Bern, Stuttgart, Toronto

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Leuner H (1990) Katathymes Bilderleben. Ergebnisse in Theorie und Praxis. Huber, Bern, Stuttgart, Toronto Leuner H (1995) Psychotherapie im Nachkriegsdeutschland: Persönliche Erinnerungen an meine großen Lehrer. Katathymer Bilderbote, Heft 7, Göttingen Lorenzer H (1970) Kritik des psychoanalytischen Symbolbegriffs. Frankfurt, Fischer Luborsky L (1995) Einführung in die analytische Psychotherapie. Vandenhoeck & Ruprecht, Göttingen Maiello S (1999) Das Klangobjekt. Über den pränatalen Ursprung auditiver Gedächtnisspuren. Psyche 53:137–157 Mertens W (1993) Einführung in die psychoanalytische Therapie, Band 1-3. Kohlhammer, Stuttgart, Berlin, Köln Mertens W, Waldvogel B (eds) (2000) Handbuch psychoanalytischer Grundbegriffe. Kohlhammer, Stuttgart, Berlin, Köln Nohr K (1985) Tagtraum und Selbsterkenntnis. Empirische Untersuchung motivgleicher Tagträume aus dem Katathymen Bilderleben. Diplomarbeit. TU Berlin. Institut für Psychologie Nohr K (2003) Die Stimmenimago. Ein Beitrag zum Verständnis heilsamer Wirkungen in Musik und Therapie. In: Oberhoff B (eds) Die Musik als Geliebte. Psychosozial-Verlag, Gießen, p 81–98 Nohr K (2006) »Meine Seele hört im Sehen« – Zum szenischen Charakter des therapeutischen Umgangs mit katathymen Imaginationen. Imagination 28/4:5–29 Otremba J (1982) Zum Zusammenhang von Persönlichkeitsvariablen und Symbolinhalten in imaginativen Prozessen. Diplomarbeit. TU Berlin. Institut für Psychologie Racker H (1978) Übertragung und Gegenübertragung. Reinhardt, München, Basel Reddemann L (2001) Imagination als heilsame Kraft. Zur Behandlung von Traumafolgen mit ressourcenorientierten Verfahren. Pfeiffer bei KlettCotta, Stuttgart Reimer C (1996) Tiefenpsychologisch fundierte Psychotherapie. In: C Reimer, J Eckert, M Haut-

zinger, E Wilke (eds) Psychotherapie. Springer, Berlin, Stuttgart, New York, p 10–77 Reimer C, Rüger U (2000) Psychodynamische Psychotherapien. Springer, Berlin Rosendahl W (2007) Zur Gegenübertragung in der KIP. In: Hennig H, Fikentscher E, Bahrke U, Rosendahl W (eds) Beziehung und therapeutische Imagination. Katathym Imaginative Psychotherapie als psychodynamischer Prozess. Pabst, Lengerich, p 173–181 Rudolf G (2010) Psychodynamische Psychotherapie: die Arbeit am Konflikt, Struktur und Trauma. Schattauer, Stuttgart Sandler J (1983) Die Beziehung zwischen psychoanalytischen Konzepten und psychoanalytischer Praxis. Psyche 37:577–595 Schnell M (2005) Imaginationen im Dialog. Zur Dynamik der Übertragungs- und Gegenübertragungsprozesse in der KIP. In: Kottje-Birnbacher L, Wilke E, Krippner K, Dieter W (Hrsg) Mit Imaginationen therapieren. Pabst, Lengerich, S 69–78 Segal H (1957) Bemerkungen zur Symbolbildung. In: Bott Spillius E (eds) Melanie Klein heute. Bd. 1. Verlag Internationale Psychoanalyse, München, Wien, 1995, S 202–224 Seifert A, Seifert T, Schmidt P (2003) Der Energie der Seele folgen. Patmos Verlag, Ostfildern Steger U (2010) Vom kahlen Rosenstrauch zur fruchttragenden Sonnenblume. Die Therapie einer Frau mit metastasierendem Brustkrebs. Imagination 32/4:31–52 Steiner B, Krippner K (2006) Psychotraumatherapie. Schattauer, Stuttgart Streeck U (2004) Auf den ersten Blick: psychotherapeutische Beziehungen unter dem Mikroskop. Klett-Cotta, Stuttgart Thomä H, Kächele H (1985) Lehrbuch der psychoanalytischen Therapie. Springer, Berlin Heidelberg Wöller W, Kruse J (2010) Tiefenpsychologisch fundierte Psychotherapie. Schattauer, Stuttgart Zepf S (1973) Die Beziehung zwischen Motivvorstellungen und imaginierten Inhalten im experimentellen Katathymen Bilderleben. Z f Psychosom. Med Psychol. 19:157 ff

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Chapter 8 · Application Spectrum and Training Organization

The Katathym Imaginative Psychotherapy is mainly conducted as individual psychotherapy, as it has been presented in this textbook. In addition, there is KIP as group psychotherapy, as a method of child and adolescent psychotherapy, and as couple therapy. Emerging as a specification from KIP is psychotrauma therapy with imaginations. Furthermore, special methodological approaches have been developed for various patient groups and indication areas, for example for psychosomatic and eating-disordered patients as well as in the field of geriatric psychotherapy. Moreover, KIP is also used as a coaching method and in supervision. KIP is listed as a method of depth psychology-based psychotherapy in the “Commentary on Psychotherapy Guidelines” (Diekmann et al. 2017) and is therefore recognized in Germany both as a form of depth psychology-based short-term and long-term therapy for health insurance purposes. Imaginations can also be used in analytical psychotherapy, for which a method-specific qualification is required in addition to the psychoanalytic one. Furthermore, KIP can also be applied and billed within the framework of depth psychology-based group psychotherapy, provided that the applying therapists have acquired additional training in KIP (Diekmann et al. 2017). KIP is not only carried out on an outpatient basis, but also in numerous clinics, both in individual settings and as group psychotherapy. It should be mentioned at this point that the widespread use of imagination work, especially with traumatized patients in clinics, has been developed from KIP, but does not always take into account its psychodynamic implications. For an initial overview, some selected publications are referred to for these application forms:

z Group Psychotherapy

Fikentscher E (2007): Catathym Imaginative Psychotherapy in the group and in the inpatient area. z Child and Adolescent Psychotherapy

Horn G, Sannwald R, Wienand F (2006): Catathym Imaginative Psychotherapy with children and adolescents. z Couple Therapy

Kottje-Birnbacher L (2003): Couple therapy with catathym-imaginative psychotherapy. z Psychotrauma Therapy with Imaginations

Steiner B, Krippner K (2006): Psychotrauma therapy. z KIP in Psychosomatics

Wilke E, Leuner H (1990): The catathymic experience in psychosomatic medicine. Klessmann E, Klessmann H-A (1988): Holy fasting—unhealed eating: The fear of anorexics of mediocrity. z Geriatric Psychotherapy

Erlanger A (1997): Catathym-imaginative psychotherapy with older people. z Coaching

Cottier SC (2008): Coaching. Accompanying leadership processes imaginatively. Further and more in-depth literature, as well as research and study results, can be found in the quarterly journal “Imagination,” in the “Handbook of Catathym Imaginative Psychotherapy” (2012) edited by Ullmann and Wilke, and on the homepages of the societies for Catathym Imaginative Psychotherapy: 5 Working Group for Catathym Imagery (AGKB), 7 http://www.agkb.de 5 Central German Society for Catathym Imagery (MGKB), 7 http://www.mgkb.org

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Excursus 12: Precursors of KIP and terms used for KIP in other countries; references to related methods

Introspective methods for imagination-based introspection have existed in various cultural and religious areas for many centuries (Bittner 1965, Singer 1974), but more targeted investigations since the beginning of the 20th century paved the way for the development of a therapeutic imagination method. Silberer (1909) explored imaginations occurring before falling asleep, which Freud repeatedly pointed out (e.g., 1914, p. 164; in the same year, Freud added a discussion on this in the “Interpretation of Dreams” and acknowledged Silberer’s “contribution to dream formation from the perspective of waking thoughts” and spoke in this context of a “self-observing instance”): “Silberer has shown, as is well known, that in states between sleeping and waking, the transformation of thoughts into visual images can be directly observed.” Other works on imaginations and observed cathartic reactions were published by Tuczek (1928), Schmid 1929 (cited in Lang 1979) and Happich (1932). As direct precursors of the KIP developed by Leuner or as parallel developed, re-

5 Austrian Society for Applied Depth Psychology and General Psychotherapy (ÖGATAP), 7 http://www.oegatap.at 5 Swiss Working Group for Catathym Imagery (SAGKB), 7 http://www.sagkb.ch Here, you can also find the continuing education and training regulations for both the Austrian and Swiss societies, as well as those of the AGKB and MGKB, which are part of the German Society for Catathym Imaginative Psychotherapy (DGKIP). This detailed continuing education and training curriculum qualifies psychologists, physicians, and child and adolescent psychotherapists with completed or advanced psychotherapeutic training for the

lated methods, the Rêve Éveillé Dirigé developed by Desoille in 1931 (1961), Sechehayes’ (1955) Symbolic Wish Fulfillment, the Active Imagination according to C.G. Jung, as presented in Hannah (1991) or Seifert et al. (2003), certain practices from the advanced stage of Autogenic Training (Schultz 1932) and Shorr’s (1983) Psychotherapy through Imagery are considered. For a time, the term “Symbol Drama” was used to relativize the more cumbersome scientific name “Katathym Imaginative Experience” (Leuner 1985, p. 15), which is now widespread in Sweden or Russia. In the USA, the term “Guided Affective Imagery” became established (Swarltey 1965); supplemented by Helen Bonny’s widely used “Guided Affective Imagery in Music” in the USA, which has only recently been taught again in Germany (Geiger 2004). The transition to the term “Katathym Imaginative Psychotherapy” took place in the 1990s in the context of the further development of psychodynamic psychotherapy methods.

application of Catathym Imaginative Psychotherapy. Courses—also for the specifications of KIP—are offered regionally and at central seminars. The learning of the KIP methodology preferably takes place in small groups, as well as through individual self-experience and supervision.

References Cottier SC: Coaching: Führungsprozesse imaginativ begleiten. In: Bürgi-Kraus M, Kottje-Birnbacher L, Reichmann I, Wilke E (Eds) (2008) Entwicklung in der Imagination – Imaginative Entwicklung. Pabst, Lengerich, pp 278–289 Dieckmann M, Dahm A, Neher M (Eds) (2017) Faber/ Haarstrick. Kommentar Psychotherapie-Richtlin-

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ien. 11., überarbeitete edn. Elsevier Urban & Fischer, München Desoille R (1961) Théorie et pratique du rêve éveillé dirigé. Mont-Blanc, Genf Erlanger A (1997) Katathym-imaginative Psychotherapie mit älteren Menschen. Reinhard, München Fikentscher E (2007) Die Katathym Imaginative Psychotherapie in der Gruppe und im stationären Bereich. In: Hennig H, Fikentscher E, Bahrke U, Rosendahl W (Eds) Beziehung und therapeutische Imagination. Katathym Imaginative Psychotherapie als psychodynamischer Prozess. Pabst, Lengerich, pp 220–254 Geiger E (2004) GIM – The Bonny Method of Guided Imagery and Music – Imaginative Psychotherapie mit Musik nach Helen Bonny. In: Frohne-Hagemann I (Eds) Rezeptive Musiktherapie. Reichert, Wiesbaden, pp 89–109 Hannah B (1991) Begegnungen mit der Seele. Aktive Imagination – der Weg zu Heilung und Ganzheit. Kösel, München Happich C (1932) Bildbewusstsein und schöpferische Situation. Zentralblatt für Psychotherapie 5 : 663 ff Horn G, Sannwald R, Wienand F (2006) Katathym Imaginative Psychotherapie mit Kindern und Jugendlichen. Reinhardt, München Klessmann E, Klessmann H-A (1988) Heiliges Fasten – heilloses Fressen: Die Angst der Magersüchtigen vor dem Mittelmaß. Bern, Huber Kottje-Birnbacher L (2003) Paartherapie mit Katathym-imaginativer Psychotherapie. Kontext 34/1 : 56–75

Lang I (1979) Beiträge zu einer tiefenpsychologischen Anthropologie des katathymen Bilderlebens. VWGÖ, Wien Leuner H (1985) Lehrbuch des Katathymen Bilderlebens. Huber, Bern, Stuttgart, Toronto Schultz JH (1932) Das autogene Training (konzentrative Selbstentspannung). Versuch einer klinisch-praktischen Darstellung. Thieme, Leipzig Sechehaye MA (1955) Die symbolische Wunscherfüllung. Huber, Bern Seifert A, Seifert T, Schmidt P (2003) Der Energie der Seele folgen. Patmos Verlag, Ostfildern Shorr JE (1983) Psychotherapy through Imagery. Thieme-Stratton, New York Silberer H (1909) Bericht über die Methode, gewisse symbolische Halluzinationserscheinungen hervorzurufen und zu beobachten. Jahrbuch der Psychoanalytischen Forschung Singer JD (1974) Phantasie und Tagtraum. Imaginative Methoden in der Psychotherapie. Pfeiffer, München Steiner B, Krippner K (2006) Psychotraumatherapie. Schattauer, Stuttgart Swarltey W (1965) Initiated symbol projection. In: Assagioli R: Psychosynthesis. Hobbs, Dormann, New York Tuczek K (1928) Über die optischen Phänomene in der Katharsis. In: Der Nervenarzt 1 : 156 ff Wilke E, Leuner H (Hrsg) (1990) Das katathyme Bilderleben in der psychosomatischen Medizin. Huber, Bern

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Chapter 9 · Imagination in Art and Intellectual Life

Friedrich von Hardenberg’s (Novalis’) novel “Heinrich von Ofterdingen” begins with a dream. In the dream, the protagonist discovers a wondrous blue flower that takes on human features and leans towards him like a woman during the climax of an initiation-like journey. Despite his parents’ warnings, Heinrich takes the dream as a reason to leave his old life behind and search for the woman. This famous “dream of the blue flower” carries more the characteristic traits of a catathymic imagination than those of a night dream in its calmly unfolding, sensually signposted narration; all “nature motifs” such as flower, stream, mountain, meadow, and forest edge are interwoven in an intensification in the sense of inner deepening, giving the impression that Hardenberg had processed the 7 Chap. 7.2 (Motifs)! It seemed to him as if he were walking alone through a dark forest. Only rarely did daylight shimmer through the green net. Soon he came to a rocky gorge that led uphill. He had to climb over moss-covered stones that a former stream had torn down. The higher he climbed, the lighter the forest became. Finally, he reached a small meadow that lay on the slope of the mountain. Behind the meadow, a high cliff rose, at the foot of which he saw an opening that seemed to be the beginning of a passage carved into the rock. The passage led him straight for a while until he reached a large widening, from which a bright light shone towards him from afar. As he entered, he became aware of a powerful beam that rose like a spring from the floor to the ceiling of the vault and dispersed into countless sparks above (…); not the slightest noise could be heard, a sacred silence surrounded the magnificent spectacle. He approached the basin, which shimmered and trembled with infinite colors (…) He dipped his hand into the basin and moistened his lips. It was as if a spiritual breath penetrated him, and he felt deeply strengthened and refreshed. An irresistible desire seized him to bathe,

he undressed and stepped into the basin (…) A kind of sweet slumber overcame him, in which he dreamed of indescribable events and from which another enlightenment awakened him. He found himself on a soft lawn at the edge of a spring that bubbled into the air and seemed to consume itself therein (…). But what attracted him with full force was a tall light blue flower that stood next to the spring and touched him with its broad, shiny leaves. Countless flowers of all colors stood around it, and the most delicious scent filled the air. He saw nothing but the blue flower and looked at it for a long time with unspeakable tenderness. Finally, he wanted to approach it when it suddenly began to move and change; the leaves became shinier and clung to the growing stem, the flower leaned towards him, and the petals showed a blue, spread-out collar in which a delicate face floated. His sweet astonishment grew with this strange transformation … (Novalis, quoted from: Schulz 1969, p. 129 ff) The appreciation of fantasizing and dreaming as creative inner forces, as well as the turn towards the dialectic of unconscious and conscious, is a main theme of Romanticism: My friend, that is the poet’s work To interpret and mark his dreams. Believe me, man’s truest delusion Is revealed to him in dreams … (R. Wagner 2002, p. 119) Thus, Hans Sachs teaches the young Stolzing in the third act of Wagner’s “Die Meistersinger von Nürnberg.” Caspar David Friedrich gives similar advice to his fellow painters: Close your physical eye so that you may first see your picture with the spiritual eye. Then bring to light what you have seen in the darkness so that it may react from the outside inwards.

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(C. D. Friedrich, quoted from: Hofmann 2006, pp. 20–31) However, it is not only Romanticism that discovers the creative potential of imagination. In every literary epoch, there are countless striking examples and theoretical discussions about imagination, so only a few can be mentioned here: Hölderlin emphasizes imagining as a seeing with the heart, which can bring back to humans the unique childhood memories in sensual plasticity, and as a visionary gaze into the never-seen, foreign. In his poems (here as an example: “The Neckar”), he brings both together:In your valleys my heart awoke to me To life, your waves played around me, And of all the lovely hills that you, Wanderer! know, none is foreign to me … The world still seems beautiful to me, and my eye escapes Longing for the charms of the earth, To the golden Pactolus, to Smyrna’s Shore, to Ilion’s forest … When its pomegranate tree ripens, when from the green night The orange glows, and the mastic tree Drips with resin … yet from a faithful mind My Neckar does not leave me with its Lovely meadows and riverside pastures. (F. Hölderlin, from: Lüders 1989, p. 229) In Goethe’s drama “Iphigenia in Tauris,” Iphigenia, who is banished from her own people and serves as a priestess in a foreign land, encounters an emaciated stranger. She gradually recognizes him as her brother Orestes, who has murdered their common mother in revenge for her infidelity. Goethe portrays Orestes as a guilt-ridden, suicidal man, pursued by the avenging goddesses, the Erinyes. The encounter between the unknown siblings and the revelation of their

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identity is staged by Goethe like a therapeutic conversation. Iphigenia brings Orestes to describe the traumatic scene of the murder, somewhat against his will, through empathetic questions: Thus the gods have chosen me As the messenger of a deed that I would so gladly Hide in the soundless, dull realm of night Against my will, Your lovely mouth compels me … (J. W. Goethe, quoted from: Trunz 1981, p. 32 ff) So he begins his description. However, this leads to a worsening of his condition: Again in the clutches of the Erinyes, Orestes’ despair escalates unbearably and turns into a hallucinatory delusion in which he feels helplessly exposed to the “hideous laughter” of the avenging goddesses. Into his agony, Iphigenia speaks the words: “Can you, Orestes, hear a friendly word?”, but they bounce off Orestes’ bitterness: “Save it for a friend of the gods.” He now experiences Iphigenia’s questions as part of the Erinyes’ punishment and Iphigenia as an instrument of the avenging goddesses, a projective process that often occurs in severely traumatized individuals in the therapeutic relationship. However, like a good therapist, Iphigenia does not give up but tries to dissolve his Medusa-like petrification in a longer friendly address. With the words Oh, if the voice of spilled mother’s blood Calls down to hell with muffled tones, Should not the pure sister’s blessing word Call helpful gods from Olympus? she finally reaches the emotional touch of her brother, who now exclaims in deep confusion: Who are you, whose voice so terribly Turns my innermost depths? Upon this, Iphigenia:

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It reveals itself to you in the deepest heart: Orestes, it is I, behold Iphigenia! I live! Even though Orestes still has deep doubts after the revelation, it does bring about a healing transformation. He suddenly remembers his love for his great, always idealized sister and loses consciousness in the overwhelming memories. While Iphigenia rushes for help, he comes to his senses and indulges in a grandiose imagination of the reunion of all family members. For the first time, undisturbed by the Furies, he develops his desire to take a worthy place, not that of the murderer, but that of the son freed from the curse of revenge, in the chain of generations:

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So I am welcome too, and I may Join your solemn procession. Welcome, fathers! Orestes greets you The last man of your lineage, What you have sown, he has reaped (…) We are all free from enmity here. Friedrich Schiller, as a theoretically imaginative, forward-thinking thinker of his time, anticipates many of Winnicott’s considerations on the transitional object. In his famous 15th letter on the aesthetic education of mankind, he develops his great cultural anthropological thesis that the “disease of culture” can be cured through aesthetic education: To say it all at once, man only plays where he is human in the full sense of the word, and he is only fully human where he plays. (F. Schiller, quoted from: Safranski 2004, p. 413) Through the medium of art, through the experience of beauty, the reconciliation of human basic drives is achieved by means of play. The aesthetic world is not only a training ground for the refinement and ennoblement of sensations, but the place where an intermediate area opens up,

a therapeutic agent in a modernity that degenerates under the dictate of utility. The path to morality and culture leads through play, imagination, and symbolizations: “It is beauty through which one wanders to freedom.” What Schiller hoped for culture, Sigmund Freud developed a hundred years later as a healing method for the individual. Psychoanalysis can also be considered an enterprise in the service of freedom. Hindered self-determination is recommended to be replaced by liberating self-reflection on the couch—so that the individual can choose instead of being forced to react in a compulsive repetition. The play of thoughts and feelings can succeed because the reality principle is temporarily disempowered and because, within a fixed framework and adhering to rules, an as-if space is opened up. It is no coincidence that Freud refers to Schiller’s letter to Körner of December 1, 1788, in a letter dated March 5, 1908: … the reason for your complaint lies, it seems to me, in the constraint that your intellect imposes on your imagination. I must throw in a thought here and illustrate it with a simile. It does not seem good and detrimental to the soul’s creative work if the intellect scrutinizes the incoming ideas too sharply, as it were, at the gates. An idea, considered in isolation, may be very insignificant and very adventurous, but perhaps it becomes important through one that follows it; perhaps it can, in a certain connection with others that may seem just as tasteless, form a very appropriate link: all this the intellect cannot judge if it does not hold on to them long enough to look at them in connection with these others. In a creative head, however, it seems to me, the intellect has withdrawn its guard from the gates, the ideas rush in pell-mell, and only then does it survey and scrutinize the great heap (Freud and Jung 1976, p. 144). While Schiller is writing this letter, Immanuel Kant is working on the third

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v­olume of his theory of knowledge, the 1790 published “Critique of Judgment,” which deals with the perception of natural and artistic beauty. The book is centered on the concept of “disinterested pleasure,” a stance reminiscent of Freud’s later so-called “evenly hovering attention”: it is as appropriate to the contemplation of art as the latter is to the perception of unconscious dynamics. Kant also elsewhere appreciates the imagination as a “fundamental capacity of the human soul” and speaks—preparing romantic ideas—of the “treasure lying in the field of dark representations, which constitutes the abyss of human knowledge that we cannot reach” (Kant: “Critique of Pure Reason,” cited after A. Vetter (1950), who also presents pre-Kantian thoughts on the formerly called “imagination” imagination). In modern times, the proximity of imagination and art studied by Freud has become a common intellectual property. For example, the daydream of the humiliated waitress Jenny in Brecht’s “Threepenny Opera,” in which she imagines a large ship coming to her rescue and punishing her hometown, taking her as a proud queen into a beautiful distance, is readily understood as an expression of a grandiose fantasy to ward off daily humiliation: And a ship With eight sails And with fifty cannons Will disappear with me … (B. Brecht 1967, p. 413) Philosopher Ernst Bloch (1980) precedes his main work “The Principle of Hope” with an intense and entertaining examination of daydreams, which is worth reading for psychotherapists. He makes the daydream the main witness of the “anticipatory consciousness,” argues against Freud’s primacy of the “backward-looking” exploration of dream content, and emphasizes the promising, “forward-pulling,” and a

9

“foreshadowing” of the desired life in front of the eyes potency of the more conscious daydream. Although Freud did not make imaginations a means of shaping the analytical process like Jung, he recognized the significance of imaginations. Early on, he dealt with the proximity of imagination and poetry. The poet, Freud emphasizes in one of his first writings, is also a kind of psychoanalyst, directing “his attention to the unconscious in his own soul,” listening to its “developmental possibilities” and giving them artistic expression instead of suppressing them with “conscious criticism.” The poet “experiences (…) from himself what we learn from others … ” (Freud 1907 p. 121). Unlike children or artists, the adult is ashamed of his fantasies because they express his secret desires: He “would generally rather confess his offenses than share his fantasies” (Freud 1908, p. 215). Therefore, he likes to dismiss fantasizing as “childish and unauthorized.” “One may say: The happy person never fantasizes, only the unsatisfied one” (p. 216). Outside of poetry, for Freud, the compensatory character of imagining long predominated, which he therefore devalued compared to “thinking” and “working” (cf. also the proximity of primary process and regression in Freud, 7 Chap. 3.3, Excursus 4: Primary Process). Later, Freud (1916/17, p. 387) comes to more positive evaluations of imagining when he sees it as a helpful compensation for the detachment of the pleasure principle by the reality principle: “In the activity of fantasy, man thus continues to enjoy freedom from external compulsion” and he compares fantasy to nature reserves in which everything can grow as it pleases: “Such a preservation exempt from the reality principle is also the mental realm of fantasy” (p. 387). Jung’s higher appreciation of imagination in its cultural manifestations and its therapeutic relevance is among the many personal and factual reasons that

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Chapter 9 · Imagination in Art and Intellectual Life

i­rrevocably separated Jung and Freud after a period of fruitful cooperation, a very significant one. In the context of a dispute with Freud about one of his treatment cases, Jung emphasizes, “… the unconscious fantasies contain so much applicable material and lead, perhaps like nothing else, the innermost of man to the outside,” and this raises the question for him, “… whether it would not be therapeutically of great importance to encourage the patients to produce the latent fantasies.” In this statement, one can see the “birth hour” of working with therapeutic imaginations. Shortly thereafter, he refers to the latent fantasies, following Goethe, as an “incredible witches’ kitchen … ” and the “womb of the spirit” (Freud and Jung 1976, p. 476). After the break with Freud and the withdrawal from his role as the “crown prince,” as Freud liked to call him, in a time of loneliness and confusion, active imagination (Jung 1971) became the gateway to exploring his unconscious for Jung, which he carried out alone for several years. Through his training analyst Schmaltz, Leuner picked up this line of tradition and developed it into a dialogical method, which today, as Catathym Imaginative Psychotherapy, has combined the central characteristics of Freudian psychoanalysis with Jung’s suggestions.

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Supplementary Information Directory of  Excursions – 230 References – 231

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2023 U. Bahrke and K. Nohr, Katathym Imaginative Psychotherapy, https://doi.org/10.1007/978-3-662-67805-3

230

Directory of Excursions

Directory of Excursions 5 Excursion 1: katathym—Chap. 1 5 Excursion 2: Hanscarl Leuner— Chap. 1 5 Excursion 3: kinesthetic—Chap. 2 5 Excursion 4: Primary process— Sect. 3.3 5 Excursion 5: Daydream and Imagination—Sect. 3.5 5 Excursion 6: Initial dream—Sect. 3.6 5 Excursion 7: Symbol—Sect. 7.2

5 Excursion 8: The acoustic dimension of imaginations—Sect. 7.3 5 Excursion 9: subject-/object-level dream interpretation—Sect. 7.4 5 Excursion 10: Projection neurosis— Sect. 7.7 5 Excursion 11: Scene—Sect. 7.7 5 Excursion 12: Precursors of KIP and terms used for KIP in other countries; references to related methods—Chap. 8

231 References

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