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Integrating body, imagination and language:

Case study from the psychological and from the body oriented psychotherapeutic viewpoint. 1

Ulrich Kobbé & 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 dy- namic 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 psy- chological and body oriented psychotherapy will be outlined.

chological and body oriented psychotherapy will be outlined. Zusammenfassung Integrationprozesse von Körper, Vorstellung

Zusammenfassung

Integrationprozesse von Körper, Vorstellung und Sprache: Kasuistik aus einem psychologisch-psycho- therapeutischen und einem körperpsychotherapeutischen Blickwinkel.

In dieser Falldarstellung aus dem Kontext der Forensischen Psychiatrie wird über den Entwicklungsprozess e iner jungen Frau mit einer schweren Form der PTBS berichtet. Symptomatische Charakteristika der (durch den Frei- heitsentzug akzentuierten) Borderlinedynamik waren Mutismus, Dissoziationen, Suizidversuche und ausgepräg- te körperliche Missempfindungen. Neben der psychologischen und körperbezogenen Psychotherapie kamen Psy- chopharmakotherapie, DBT, Milieutherapie und Kreativtherapie zum Einsatz.

Die Klientin imponierte im Alltag nicht nur durch Suizidversuche und dissoziative Episoden, sondern darüber hinaus durch eine ambivalente Beziehungsgestaltung mit Polarisierungen von Vermeidung und Provokation, von Angst, Sehnsucht und Aggression, von An- und Abwesenheit wechselnder Körperlichkeit. Das psychotherapeuti- sche Setting war als komplementäre Behandlungsstruktur (intra-/extramural, stationär/ambulant, Mann/Frau, Psyche/Körper, verbal/nonverbal, reflexiv/expressiv) konzipiert: Als therapeutische Grundhaltung ging es, fun- diert durch das DBT-Konzept der Station, um Gelassenheit, Angstfreiheit und Gewissheit, um Akzeptanz, Hol- ding und Containing, um Zuversicht und Humor.

Es werden 5 Phasen des therapeutischen Prozesses mit ihren Hauptmerkmalen beschrieben und die Bezüge zwischen psychologischer und körperbezogener Psychotherapie verdeutlicht.

1 Documentary transcript of a powerpoint-based oral presentation. 4 th International Congress on Borderline Per- sonality 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 KOBBÉ, the acronym AR

for ANDREA RADANDT.]

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2016: Integrating body, imagination and language. - 2 - Our report concerns the treatment of a

Our report concerns the treatment of a female patient in forensic2016: Integrating body, imagination and language. - 2 - psychiatry. So, the context is a high

psychiatry. So, the context is a high security hospital at Lippstadt in Ger- many, 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

a so-called security measure of detention and recovery. 2 _ To describe the concrete institutional context:

_

a so-called security measure of detention and recovery. 2 _ To describe the concrete institutional context:

To describe the concrete institutional context: I’m the therapeutica so-called security measure of detention and recovery. 2 _ chief of the only women’s ward

chief of the only women’s 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. That’s 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.

and self-responsibility, the skill training and other DBT-measures. _ 2 „Maßregel der Besserung und Sicherung“.

_

2 „Maßregel der Besserung und Sicherung“.

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2016: Integrating body, imagination and language. - 3 - _ Our patient, we’ll call her Mary

_ Our patient, we’ll call her Mary 3 , came 20 years old form a psychiat- ric hospital where she had been isolated for about 5 months because of a non-specified dangerousness. The index-delinquency was a suicidal act- ing-out: She had tried to burn herself during a hospitalisation and ex- posed many people to danger.

We met a hostile autistic young woman which avoided any contact, which seemed to be seriously disturbed, sometimes hallucinating, often dissoci- ating.

Biographic information were very vague. We knew that she had been vio- lated by her father and other male family members during almost 10 years.

father and other male family members during almost 10 years. 3 The anonymous patient gave the
father and other male family members during almost 10 years. 3 The anonymous patient gave the
father and other male family members during almost 10 years. 3 The anonymous patient gave the

3 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.

all her clothes and soaked to the skin under the showers. My main questions were how
all her clothes and soaked to the skin under the showers. My main questions were how
all her clothes and soaked to the skin under the showers. My main questions were how
all her clothes and soaked to the skin under the showers. My main questions were how

My main questions were how to manage the actionism of the staff,all her clothes and soaked to the skin under the showers. _ how to guarantee a

_

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

isolation a fixation and how to open transitional spaces. _ Just after having tried a suicide

_ 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 conver- sation and stated in her sudden manner: “Everybody said it was impossi-

The next day she asked for a short conver- sation and stated in her sudden manner:
The next day she asked for a short conver- sation and stated in her sudden manner:

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ble, until someone came along who didn’t 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.

containers for her intrusive recollections and flash-backs. _ She came back with the drawing of a

_ She came back with the drawing of a brick wall container for her vio- lating 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 patient’s group was occupied with zen-related re- flections concerning the principles of DBT and the idea of hope.

concerning the principles of DBT and the idea of hope. _ The zen-motto said: “ May
concerning the principles of DBT and the idea of hope. _ The zen-motto said: “ May
concerning the principles of DBT and the idea of hope. _ The zen-motto said: “ May

_ 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.

“ May we exist like a lotus, at home in the muddy water, thus we bow
“ May we exist like a lotus, at home in the muddy water, thus we bow

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

to come inside the forensic hospital and to work with her: _ My very first impression

_ My very first impression of the client – I was just being informed about her case by Ulrich Kobbé [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.

which was my job. The client asked for an example so that she could understand, what
which was my job. The client asked for an example so that she could understand, what
which was my job. The client asked for an example so that she could understand, what

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2016: Integrating body, imagination and language. - 7 - I demonstrated the first exercise and she

I demonstrated the first exercise and she reacted with ambivalence,2016: Integrating body, imagination and language. - 7 - _ it seemed she didn’t like standing

_

it seemed she didn’t 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 fill it up if she couldn’t remember all or nothing at all. Making my way of therapeutic acting transparent to her aimed at enhanc- ing 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 re- porting 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.

up trust. Trust in other people as well as trust in herself. I planned to begin
up trust. Trust in other people as well as trust in herself. I planned to begin

I planned to begin with little functional and experience-focused „ex-up trust. Trust in other people as well as trust in herself. ercises“ allowing her to

ercises“ allowing her to feel her body, move it on purpose and give per- sonal 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 flash 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)

o positive accommodation (support + protection) _ The clinical phase of the body-oriented psychotherapy

_ The clinical phase of the body-oriented psychotherapy lasted for 17 months in which we had 53 individual sessions. The first 7 sessions I fo- cused on exercises with regard to moving, breathing, giving meaning to movements and to experience herself with regard to another person (dis- tance vs closeness). Session 8 and 9 were done together with the col- league - 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, ex- panding 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 find movements to get rid of bodily misperceptions. In between we talked a lot.

mindfulness based exercises. We tried to find movements to get rid of bodily misperceptions. In between
mindfulness based exercises. We tried to find movements to get rid of bodily misperceptions. In between
mindfulness based exercises. We tried to find movements to get rid of bodily misperceptions. In between

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2016: Integrating body, imagination and language. - 9 - About the daily and sometimes stressful life

About the daily and sometimes stressful life on the ward, about her2016: Integrating body, imagination and language. - 9 - family, her wish to be dead, about

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 experi- ence the basic needs of protection and support through her body. Ses- sions 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.

_

to go to the designated therapy room in the basement. _ The final session was characterized
to go to the designated therapy room in the basement. _ The final session was characterized

The final session was characterized again by ambivalence: being veryto go to the designated therapy room in the basement. _ sad about the end of

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 psy- chotherapy/ me, trying to get along by herself. She was informed, that the body-oriented psychotherapy could be continued. She denied.

_

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2016: Integrating body, imagination and language. - 10 - _ During this process Mary was occupied

_ During this process Mary was occupied with emotions of hate while she tried not to reveal her counter-aggressive and self-aggressive im- pulses. 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 indefin- able black holes.

space but let also see indefin- able black holes. _ These black holes repeated Mary’s double-bind
space but let also see indefin- able black holes. _ These black holes repeated Mary’s double-bind
space but let also see indefin- able black holes. _ These black holes repeated Mary’s double-bind

_ These black holes repeated Mary’s 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.

to explore her dark side but also for the warning not to go too far, not
to explore her dark side but also for the warning not to go too far, not

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2016: Integrating body, imagination and language. - 11 - Step for step we were able to

Step for step we were able to identify and to rename emotions or af-2016: Integrating body, imagination and language. - 11 - fects like hate, rage, pain, sadness, emptiness

fects 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”.

has been transgressed, everything will be permitted”. _ Concerning the therapeutic process, we used or varied

_

has been transgressed, everything will be permitted”. _ Concerning the therapeutic process, we used or varied

Concerning the therapeutic process, we used or varied a lot of me-has been transgressed, everything will be permitted”. _ thods and settings: Very difficult subjects like the

thods 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.

to the wall, by using the wall as a sort of Wailing Wall, at one and

_

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2016: Integrating body, imagination and language. - 12 - In rare moments, Mary overcompensated and ignored

In rare moments, Mary overcompensated and ignored her feelings of2016: Integrating body, imagination and language. - 12 - shame with regard to my person and

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

but not unharmed, thus shameful protecting little girl. _ What we developed was a process from

_

but not unharmed, thus shameful protecting little girl. _ What we developed was a process from

What we developed was a process from being overwhelmed by flash-but not unharmed, thus shameful protecting little girl. _ backs and intrusions, by hate and self-hate,

backs and intrusions, by hate and self-hate, by fear rage and pain, by fro- zen affect and isolation …

by flash- backs and intrusions, by hate and self-hate, by fear rage and pain, by fro-

_

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2016: Integrating body, imagination and language. - 13 - … up to the awareness of sad-

… up to the awareness of sad- and emptiness, of shame, of courage,2016: Integrating body, imagination and language. - 13 - ambivalent hope and fragile self-esteem … all

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

in a sort of radical ac- ceptance of her narcissist wound. _ What I always was,

_

in a sort of radical ac- ceptance of her narcissist wound. _ What I always was,

What I always was, what I always am confronted with, is the crucialin a sort of radical ac- ceptance of her narcissist wound. _ question how to go

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 ba- lancing intervention of Andrea Radandt [AR]:

drift. What we needed and asked for was the complementary approach and ba- lancing intervention of

_

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Rehabilitation phase

_ After the client first did not want to continue the body-oriented psy- chotherapy she finally 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 re- act 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 flash backs, bodily misperceptions and phases of dissociation.

She also wanted me to inform the staff about early signals for decompen- sation, possibilities to react to those moments and the things we devel- oped to stop flash backs, regain control and get back into the here and now (get in touch with the present through haptic/sensorial/acoustic tools:

cherry stone pillow 4 and music she likes to hear).

We agreed to meet once a month - it was a long ride for me. During the first 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 doc- tor. 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 fitting 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 mem- bers 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 find 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

different members of her family. To my opinion this was understandable on the one hand -
different members of her family. To my opinion this was understandable on the one hand -

4 „Kirschkernkissen“.

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

me to support her in managing this rage triggers behavior. _ At the beginning of the
me to support her in managing this rage triggers behavior. _ At the beginning of the

_ At the beginning of the summer she reported flash backs and body- memories. She could differentiate between actual bodily sensations and body memories.

between actual bodily sensations and body memories. This led to another body chart - this one
between actual bodily sensations and body memories. This led to another body chart - this one

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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2016: Integrating body, imagination and language. - 16 - _ Following this she wanted me to
2016: Integrating body, imagination and language. - 16 - _ Following this she wanted me to
2016: Integrating body, imagination and language. - 16 - _ Following this she wanted me to

_

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.

a broken wing that was somehow taped on to the shoulder. _ In the early summer
a broken wing that was somehow taped on to the shoulder. _ In the early summer
a broken wing that was somehow taped on to the shoulder. _ In the early summer

_

In the early summer she was preoccupied with marrying. The follow- ing therapy session she would not talk at all.

The next one she talked about her family and gave the impression - de- spite 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 intra- familiar interaction (disrespect for rules she had set up for her own pro- tection, banalizing the sexual abuse) and deep disappointments on her side.

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She could reflect the complex situation with support and in the following session wanted to learn new techniques to handle her now frequently up- coming bodily tension.

to handle her now frequently up- coming bodily tension. _ A week later, I was informed

_ 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 Kobbé [UK] and me, Mary was able to understand that two Mary’s in conflict could have provoked the latest crisis:

The little one had powerfully made her way out of a violent and destruc- tive 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 pre- sent.

And at the same time she seemed to need reassurement of her second family, especially the fatherly figure of my colleague.

at the same time she seemed to need reassurement of her second family, especially the fatherly
at the same time she seemed to need reassurement of her second family, especially the fatherly

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2016: Integrating body, imagination and language. - 18 - Dr. Ulrich Kobbé LWL-Zentrum für Forensische Psychiatrie

Dr. Ulrich Kobbé

LWL-Zentrum für Forensische Psychiatrie Eickelbornstr. 19 D-59556 Lippstadt

E-Mail: ulrkobbe@lwl.org

Andrea Radandt

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

E-Mail: a.radandt@web.de