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Integrating body, imagination and language:

Case study from the psychological and from the


body oriented psychotherapeutic viewpoint.1
Ulrich Kobb & Andrea Radandt
Abstract
In this case study from forensic psychiatry we report on the developmental process of a young woman suffering
from a severe form of PTSD (post traumatic stress disorder). Symptomatic characteristics of the borderline dynamic accentuated through imprisonment were mutism, dissociations, suicidal behaviour and pronounced bodily
misperceptions. Next to psychological and body-oriented psychotherapy psychopharmacological therapy, DBT
(Dialectic Behavioural Therapy), milieu-therapy and creative therapy were applied.
In everyday life the client imposed not only through frequent attempted suicides and episodes of dissociation
but also through an ambivalent construction of relationships with polarization of provocation and avoidance, of
fear, longing and aggression, of a corporeality changing between presence and absence. The psychotherapeutic
setting was designed as a complementary treatment structure: based on the DBT-concept of the treatment unit
the therapeutic tenor was characterized by composure, fearlessness and certainty, by acceptance, holding and
containing, by confidence and humour.
Five phases of the therapeutic process will be described with their main aspects and the relation between psychological and body oriented psychotherapy will be outlined.

Zusammenfassung
Integrationprozesse von Krper, Vorstellung und Sprache: Kasuistik aus einem psychologisch-psychotherapeutischen und einem krperpsychotherapeutischen Blickwinkel.
In dieser Falldarstellung aus dem Kontext der Forensischen Psychiatrie wird ber den Entwicklungsprozess einer
jungen Frau mit einer schweren Form der PTBS berichtet. Symptomatische Charakteristika der (durch den Freiheitsentzug akzentuierten) Borderlinedynamik waren Mutismus, Dissoziationen, Suizidversuche und ausgeprgte krperliche Missempfindungen. Neben der psychologischen und krperbezogenen Psychotherapie kamen Psychopharmakotherapie, DBT, Milieutherapie und Kreativtherapie zum Einsatz.
Die Klientin imponierte im Alltag nicht nur durch Suizidversuche und dissoziative Episoden, sondern darber
hinaus durch eine ambivalente Beziehungsgestaltung mit Polarisierungen von Vermeidung und Provokation, von
Angst, Sehnsucht und Aggression, von An- und Abwesenheit wechselnder Krperlichkeit. Das psychotherapeutische Setting war als komplementre Behandlungsstruktur (intra-/extramural, stationr/ambulant, Mann/Frau,
Psyche/Krper, verbal/nonverbal, reflexiv/expressiv) konzipiert: Als therapeutische Grundhaltung ging es, fundiert durch das DBT-Konzept der Station, um Gelassenheit, Angstfreiheit und Gewissheit, um Akzeptanz, Holding und Containing, um Zuversicht und Humor.
Es werden 5 Phasen des therapeutischen Prozesses mit ihren Hauptmerkmalen beschrieben und die Bezge
zwischen psychologischer und krperbezogener Psychotherapie verdeutlicht.
1

Documentary transcript of a powerpoint-based oral presentation. 4th International Congress on Borderline Personality Disorder and Allied Disorders Bridging the Gap from Basic Science to Treatment Implementation. 8
10 September 2016, University of Vienna (Austria). [The acronym UK stands for ULRICH KOBB, the acronym AR
for ANDREA RADANDT.]

Kobb & Radandt 2016: Integrating body, imagination and language.

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_ Our report concerns the treatment of a female patient in forensic


psychiatry. So, the context is a high security hospital at Lippstadt in Germany, an institution which is responsible for about 350 patients placed
there because of severe delinquent acts in a so-called security measure of
detention and recovery.2

_ To describe the concrete institutional context: Im the therapeutic


chief of the only womens ward with 16 places, actually overcrowded with
19 female patents. Concerning the psychopathology, our patients suffer
from borderline, complex traumatic, suicidal, self-injury, and/or addictive
problems respectively diagnosis. Thats why the ward is working with a
dialectic behavioural therapeutic concept concerning the commitment,
self-awareness, self-management and self-responsibility, the skill training
and other DBT-measures.
2

Maregel der Besserung und Sicherung.

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_ Our patient, well call her Mary3, came 20 years old form a psychiatric hospital where she had been isolated for about 5 months because of a
non-specified dangerousness. The index-delinquency was a suicidal acting-out: She had tried to burn herself during a hospitalisation and exposed many people to danger.
We met a hostile autistic young woman which avoided any contact, which
seemed to be seriously disturbed, sometimes hallucinating, often dissociating.
Biographic information were very vague. We knew that she had been violated by her father and other male family members during almost 10
years.

The anonymous patient gave the permission as well to report her case as to reproduce her drawings.

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_ My therapeutic position was a sort of blind research for a strategy


how to get in contact without confronting her, without evoking anxiety,
defence and/or withdrawal.
The daily experience with Mary was characterized by dissoziative stages
where she was found completely nude and disorientated in the floor or
with all her clothes and soaked to the skin under the showers.

_ My main questions were how to manage the actionism of the staff,


how to guarantee a therapeutic response, how to prevent non-dialectic
reactions like isolation a fixation and how to open transitional spaces.

_ Just after having tried a suicide by strangulation, Mary came to me in


a sort of automatism and addressed to me with the words I just tried to
suicide me please help me!. The next day she asked for a short conversation and stated in her sudden manner: Everybody said it was impossi-

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ble, until someone came along who didnt know that and just did it. This
was a step to another work.
One of the first interventions was to create containers for her intrusive
recollections and flash-backs.

_ She came back with the drawing of a brick wall container for her violating past, of a steel container for her nightmares and a third container
for her fears to loose her 2 years old son here named Giorgio who had
been placed in a foster family.
In the same time, the patients group was occupied with zen-related reflections concerning the principles of DBT and the idea of hope.

_ The zen-motto said: May we exist like a lotus, at home in the


muddy water, thus we bow to life in the light of fear and of death.

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In this phase I was convinced to have enough bases with Mary to ask Andrea Radandt [AR] to come inside the forensic hospital and to work with
her:

_ My very rst impression of the client I was just being informed


about her case by Ulrich Kobb [UK] was when she knocked at the door,
was let in and asked my colleague to put tape on the electrical sockets in
her room, because her father could watch her through these devices. She
was full of dread then The first therapy session - most of the time they
would take place in her room that was quite large and she was not able to
go to the designated room in the basement - we agreed on the setting.
Room and place in the room, duration of the therapy setting that should
be estimated by her in the beginning and was held flexible to a certain
degree, explaining every step., which was my job. The client asked for an
example so that she could understand, what body-oriented psychotherapy
meant.

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_ I demonstrated the first exercise and she reacted with ambivalence,


it seemed she didnt like standing in the middle of the room. I explained
that ambivalence could mark a boarder: not to go further until there is a
clear an well founded decision to try out. The client switched to a different
topic and we kept talking for a while. At the end she announced, that she
might want to try the exercise while being alone. Being watched by the
therapist could be connected to her ambivalence. I validated her self-care
and we came to an end.
Knowing the overwhelming traumatic experiences of the client I decided,
not only to focus on transparency but also on continuity, so that she could
develop a feeling for her actual developmental process and connect one
therapy session to the other. And hopefully see and feel a progress after a
while. Thus I would always ask her, what she could remember from the
previous session and ll it up if she couldnt remember all or nothing at all.
Making my way of therapeutic acting transparent to her aimed at enhancing her experience of self-control and self-efficacy and would in the long
run hopefully allow her to take more and more responsibility.
Transparency also meant, that she was informed about my continuous reporting to her psychotherapist, so that we could always cooperate in the
best sense. Altogether these therapeutic principles so I hoped would
built up trust. Trust in other people as well as trust in herself.

_ I planned to begin with little functional and experience-focused exercises allowing her to feel her body, move it on purpose and give personal meanings to certain movements. It was all about enhancing the
ability to perceive herself: inward and outward bodily movements,
thoughts, associations, feelings, impulses. In the course of time we also
tried to find movements that could support the exercises she had already
learned to regain control, when being flushed by traumatic memories and
body-memories.
o finding movements to support known techniques to stop ash backs

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o awareness exercises: breathing, walking, 3-minute-breathing space


o controlled approach
o body scan - contact to ground + breathing
o positive accommodation (support + protection)

_ The clinical phase of the body-oriented psychotherapy lasted for 17


months in which we had 53 individual sessions. The rst 7 sessions I focused on exercises with regard to moving, breathing, giving meaning to
movements and to experience herself with regard to another person (distance vs closeness). Session 8 and 9 were done together with the colleague - experience the cooperation seemed to be very important. And it
was like an antidote to what she had experienced in her family. Sessions
10 to 31 we would focus on developing exercises we had done before, expanding them to the aspects of centre, strength out of the felt centre,
moving out of the felt strength. We did mindfulness based exercises. We
tried to nd movements to get rid of bodily misperceptions. In between
we talked a lot.

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_ About the daily and sometimes stressful life on the ward, about her
family, her wish to be dead, about painful bodily memories that felt like
real. Sessions 32 to 37 I focused on PBSP-work, mainly letting her experience the basic needs of protection and support through her body. Sessions 38 to 40 she tried to convince me that she really had experienced a
sexual molesting through a staff member. I tried to keep neutral in this
complex topic.
Sessions 41 to 53: Close to the end of the clinical phase sessions were
marked by ambivalence, hostility and breaking off the therapy sessions.
Finally she could talk about the reasons for her behavior: as a therapist I
had become too close to the mother she had wished for herself as child.
She believed that this was not okay, these feelings were not allowed. I
declared these feelings as quite normal during an intense therapy process
and also as a progress.
After that she wanted to talk about her traumatic experiences during the
last clinical sessions and wanted me to write down what she reported and
she also wanted to go to the designated therapy room in the basement.

_ The final session was characterized again by ambivalence: being very


sad about the end of the therapy and having to say goodbye to me - and
making clear, that she wanted to go further without body-oriented psychotherapy/ me, trying to get along by herself. She was informed, that
the body-oriented psychotherapy could be continued. She denied.

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_ During this process Mary was occupied with emotions of hate while
she tried not to reveal her counter-aggressive and self-aggressive impulses. It was easier to come to me first with drawings like the sketch
above which opened not only a transitional space but let also see indefinable black holes.

_ These black holes repeated Marys double-bind relations: They stood


for the wish to explore her dark side but also for the warning not to go
too far, not to give in due to a non reflected temptation.

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_ Step for step we were able to identify and to rename emotions or affects like hate, rage, pain, sadness, emptiness and helplessness, but also
love, hope fear and courage.
Even the double-bind became a more conscious and a more explicated
definition: As soon as a limit has been transgressed, everything will be
permitted.

_ Concerning the therapeutic process, we used or varied a lot of methods and settings: Very difficult subjects like the violation and the torture
by her father and his partners she insisted to tell me these atrocities
could only be reported by telling it or to my dog assistant or by speaking
to the wall, by using the wall as a sort of Wailing Wall, at one and the
same time as a containing and reflecting board.

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_ In rare moments, Mary overcompensated and ignored her feelings of


shame with regard to my person and presented herself nude again, now
no more during dissoziative moments but in a conscious and anxious selfconfrontation with her sexualized self-representations of a dark and a
bright but not unharmed, thus shameful protecting little girl.

_ What we developed was a process from being overwhelmed by flashbacks and intrusions, by hate and self-hate, by fear rage and pain, by frozen affect and isolation

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_ up to the awareness of sad- and emptiness, of shame, of courage,


ambivalent hope and fragile self-esteem all that in a sort of radical acceptance of her narcissist wound.

_ What I always was, what I always am confronted with, is the crucial


question how to go with such a psychodynamic flow, to navigate during
such a psychotherapeutic drift.
What we needed and asked for was the complementary approach and balancing intervention of Andrea Radandt [AR]:

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Rehabilitation phase
_ After the client rst did not want to continue the body-oriented psychotherapy she nally changed her mind. Not having seen her for 7 weeks
I drove to the small town on the edge of the Teutoburger Wald to meet
her in her new home.
She greeted me in a very friendly way and then asked me to explain to a
staff member what had been going on with her - but not too detailed - so
that the people in her new surrounding would know how she could react
experiencing stress or being in dissociative phases and how they could react to it. Thus she took control and at the same time arranged self-care in
a way, informing the new staff about her sometimes strange behavior with
loss of control, with intense ash backs, bodily misperceptions and phases
of dissociation.
She also wanted me to inform the staff about early signals for decompensation, possibilities to react to those moments and the things we developed to stop ash backs, regain control and get back into the here and
now (get in touch with the present through haptic/sensorial/acoustic tools:
cherry stone pillow4 and music she likes to hear).
We agreed to meet once a month - it was a long ride for me. During the
rst couple of sessions I seemed to have a function of supporting the
change - like a transitional object - from living behind walls to living in a
place, where the doors were always open for her. Where she could come
and go.
She would complain to me about fellow clients, about staff, about the doctor. And at the same time support the exchange of knowledge about her
between me and the new team around her in both directions.
She very soon was able to grasp the possibilities that lay in living in this
place. Within short time she arranged different staff members as her
ideal family - based on what she learned from PBSP: imagining ideal
parents or parents like she would have needed them, when she was little,
so that her basic needs could be answered in a tting way. There was a
mother, grandmother, sister, aunt, uncle. But no father.
She arranged her room like a room for a girl, declaring herself to be 11
years old, with pink as a main color. She got story books and staff members would read fairy tales to her.
At the beginning of 2016 I was informed by the team, that dissociative
phases no longer occurred. Instead the client could remember consciously
what had happened to her. Often this (overwhelming) memories would
cause impulsive aggressive outbursts.
End of April we analyzed these situations and tried to nd solutions. From
then on we met twice a month. The client showed a high motivation to
improve her situation. She had begun to meet different members of her
family. To my opinion this was understandable on the one hand - she
4

Kirschkernkissen.

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wanted her need to be part of the family, to be taken care of to be fullled.


On the other hand this would most probably cause more memories, more
stress, more outbursts. A severe crisis had to be expected.
For the time being it caused impulsive aggressive outburst.
She asked me to support her in managing this rage triggers behavior.

_ At the beginning of the summer she reported flash backs and bodymemories. She could differentiate between actual bodily sensations and
body memories.
This led to another body chart - this one also focused on emotions.
The picture shows what she was able to perceive and able to report.

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_ Following this she wanted me to sketch a sitting female figure that


was shown from the back.
This was her alter ego. A woman with a broken wing that was somehow
taped on to the shoulder.

_ In the early summer she was preoccupied with marrying. The following therapy session she would not talk at all.
The next one she talked about her family and gave the impression - despite my sceptical attitude - to be able to handle it. In July/August she
experienced a severe crisis with auto-aggressive behavior that was caused
by the problematic family constellation, experiencing negative intrafamiliar interaction (disrespect for rules she had set up for her own protection, banalizing the sexual abuse) and deep disappointments on her
side.

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She could reect the complex situation with support and in the following
session wanted to learn new techniques to handle her now frequently upcoming bodily tension.

_ A week later, I was informed that the client had wanted to go back to
the forensic clinic. I met her there. She told me, that she was afraid of
loosing control. Thus preferring the clinic.
It turned out, that the reason for her fear was the temporarily rejection of
her wish to see her family In two individual sessions with Ulrich Kobb [UK]
and me, Mary was able to understand that two Marys in conict could
have provoked the latest crisis:
The little one had powerfully made her way out of a violent and destructive family and still wanted to know more, understand and also wanted
justice.
The adult one just wanted to experience the normal family life of the present.
And at the same time she seemed to need reassurement of her second
family, especially the fatherly gure of my colleague.

Kobb & Radandt 2016: Integrating body, imagination and language.

Dr. Ulrich Kobb

Andrea Radandt

LWL-Zentrum fr Forensische Psychiatrie


Eickelbornstr. 19
D-59556 Lippstadt

Wilfried-Rasch-Klinik
Leni-Rommel-Str. 207
D-44139 Dortmund

E-Mail: ulrkobbe@lwl.org

E-Mail: a.radandt@web.de

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