*The first chair now represented the 'clingy, needy Ms. M., who likes to come to the group and wants to make serious progress'. For her, the director was 'the* *good therapist she wants to learn from'. Her second chair represented 'the radically autonomous, authoritarian Ms. M'. In self-supervision, the therapist switched to her authoritarian role and played it out. He experienced that in this role, he was internally triggered by the friction and the argument with the group members. As Ms. M, he perceived the director as 'a ridiculous nitpicker who wants to enforce arbitrary rules that he has read or learned!' The therapist changed into the role of 'the clingy, needy Ms. M'. He noticed that he was mentally blocking out the previous provocative behavior in the other role. Back in the role of authoritarian Ms. M., he experienced his neediness and 'yesterday's news' and his arbitrariness as a mere reaction to the therapist's actions: "Your criticism is ridiculous! I have paid for the weekend. I can therefore decide what I want to do and what not! This is exactly what we should learn here!" The therapist switches back to his role and responds in the fictional psychodramatic dialogue: "I find this arbitrary!  Nevertheless, if you really want to learn something here, I need a certain degree of reliability from you. I am therefore asking you to try and follow the group rules!".*

*After self-supervision, the therapist felt more free in the group the next day. He was interested in the other group members again. His sense of chaos was gone. He no longer felt unsettled by Ms. M's actions and could remain at an acceptable distance from her. He thought: "She simply lives out what she is currently feeling and thinking authentically and honestly, without being bothered by her own contradictions." Amazingly Ms. M. came to the following sessions on time without the therapist informing her of his new findings. However, she did not stand the therapist's benevolent distance for long. Four weeks later, in the group session, she addressed the disorder in the relationship with the therapist herself. The therapist took the opportunity to clarify the relationship with her. He told her: "I have decided to fully believe that you are looking for trust here and want to work on yourself. But there is also an independent, authoritarian side in you, with which you hinder yourself! I am placing a second empty chair next to you for this side." The therapist and Ms. M. concluded that her arbitrary behavior was an expression of her 'inner angry child'. Anger had always helped her push her feelings of hurt and sadness away.*

The work on the metacognitive disturbance of patients with borderline personality organization comprises the following steps:

ego state of the patient frees the therapist from the *double bind* imposed by the patient (see Sect. 4.3).

#### **Central idea**

The therapist perceives the two contrary ego states by setting up two chairs *spatially separated from each other*. This makes it easier for her to *empathize with each of the two*  opposing ego states internally *as a metacognitive doppelganger, separate from one another*, without getting caught up in the contradiction. She internally develops *two contradicting psychosomatic resonance patterns* as a response to the patient's contradicting behavior: In the as-if mode of play, she is the *metacognitive doppelganger* who, together with the patient, feels sad and needy, *and* also the metacognitive doppelganger who feels happy about the patient's autonomy and likes to provoke. When the patient switches to his contrary emotion, the therapist *also* switches to *her own contrary* psychosomatic resonance pattern. Switching to the as-if mode of play resolves her disorientation and helplessness and she can therapeutically act again.

#### **Central idea**

Defense through splitting is ingeniously simple self-protection in emotional instability. The patient voluntarily switches to the pseudo-independent position if he can't stand the closeness and is afraid of becoming dependent. However, he will arbitrarily switch back to the sad needy position when he has hurt and driven away everyone and feels alone. The patient should *psychosomatically* experience the *positive function* of his switching in the holistic process of his self-regulation in the *as-if mode of play*. He thus learns to notice it more easily when he again switches to the contrary position in everyday life. He gradually gains some control over his oscillation. Gaining ego control means: He acts out his oscillation less frequently in the equivalence mode because he understands it as an internal representation of an old solution in his self-regulation and can think of it *in the as-if mode.* He becomes free to examine the impact of his oscillation *in the actual* conflict situation and to decide whether he wants this effect or not. The patient no longer has to deny his contradictions to himself. Over time, the patient learns to realize that he is oscillating. His dysfunctional acting out becomes shorter and weaker. He may even laugh sometimes before acting destructively again (see case example 8 in Sect. 2.6).

#### **Central Idea**

"The new split, caused *psychodramatically*, makes it possible to overcome the earlier *defensive* splitting" (Powell, 1986).

Some patients with borderline personality disorder experience severe mood swings, seemingly for *no external reason*. They alternate seemingly arbitrarily between "sadness" and "anger".

#### *Case Example 25* **(Powell, 1986, Quoted from Krüger, 1997, p. 101)**

*'Jane tells the director that she feels confused. She cannot describe what it is because 'it's messed up'. But she knows: it's about her family. Her face is flushed with agitation. She looks angry and is close to tears at the same time. The director suggests* *that she look at her feelings one by one. This encouragement, put forward kindly, makes Jane cry. She thinks she needs to be sad. The director places a "sad chair" for her and asks her to sit on the chair. He takes a few steps away from her. Jane sits down. She squeezes her handkerchief and realizes: 'It is not good. I'm too angry.' The director lets her sit on an 'angry chair' and says: 'Allow yourself to express all that belongs to this chair. Be as angry as needed!' Jane suddenly thinks of what she wants to say and where she wants to say it: her family has bought Christmas presents, and she is standing in front of Selfridges. The street is full of people. Jane chooses some group members to fill the roles of her family members. The rest of the group takes on the role of the crowd. Then Jane accuses the family publicly (this is important because her family always claims to get on well) of repeatedly being pretentious and dishonest. Jane exchanges roles with her father, mother, and so on. It turns out that none of them regrets their behavior in any way. Rather, they are ashamed of Jane's outburst and try to calm her down. This time, Jane screams back. She explains why she is happy not to be like her father, not to be like her mother, and so on. She bravely defends her individuality. But then she shows the therapist that she wants to leave the chair. She is overwhelmed with sadness and starts to cry. Now, sitting on the "sad chair," Jane reveals her longing for love and intimacy with her family. Again she comes up with a scene that reflects her needs. She doesn't want to be hugged physically, that would suffocate and devour her. Instead, she chooses a Christmas scene. The family sits around the Christmas tree. Jane sees herself as part of the whole family, but also has her independence.'*

11. The therapist represents the patient's *other* defense patterns as ego states with chairs. In patients with borderline personality disorder, *healthy adult thinking*  is initially not easily accessible during the external conflict. The contradictory ego states are also always trapped in a defense system. This consists of selfprotection through denial and self-injurious thinking in acting out a sadistic superego. Both stabilize each other and are additionally protected by the defense through splitting.

At some point in the course of therapy, the therapist symbolizes the patient's difficult childhood experiences as his 'inner traumatized abandoned child' with an additional empty chair next to him in the therapy room. In addition, she occasionally places an empty chair next to the chair of his 'pseudo-autonomous authoritarian ego state' to represent the 'distancing self-protective behavior' that developed in his childhood, and later other chairs representing his 'inner angry child' and his 'self-injurious thinking'.  He should look at the 'knight in shining armor' and the 'angry little boy' once a day and maybe even talk to them. This helps him to justify his anger and understand the anger as a personal allergic reaction to negative traumatic feelings. In this way, the patient *integrates* his defense system with his life experiences from childhood. The therapist and the patient are better able to understand the distress hidden in the acting of the contrary ego states. Subsequent therapy follows the treatment process used in the therapy of people with other personality and trauma disorders (see Sects. 4.8, 4.10, 4.12, and 4.5).

Patients with severe borderline organization create chaos in the therapeutic relationship. In such a case, the therapist also uses the technique of psychodramatic responding (see Sect. 4.13). If the patient's transference is negative, she also differentiates the real conflict from the transference conflict (see Sect. 2.10). Some patients act destructively in their pseudo-autonomous, authoritarian ego state. In such a case, the therapist sticks to her metacognitive understanding of the disorder, makes I statements, and acts consistently in a disorder-specific manner. I call this 'disorderspecific psychotherapy' for people with borderline organization 'Encounter-Focused Therapy' (EFT).

### **4.10 Resolving the Fixation in a Whole Defense System**

Metacognitive defense processes are internal processes of reality construction used by humans to generate thought content and to process conflicts. They fixate one's internal process of self-development, self-image, and object image on old solutions from the past that are inappropriate in the current external situation. The defense processes in people with personality disorders are trapped *in a system of defense mechanisms*. The defense mechanisms include splitting, projective identification, denial, introjection, projection, and rationalization.

#### **Central idea**

Psychodramatic metacognitive therapy liberates the metacognitive processes from their fixation. It is a *systemic therapy* of the holistic process of metacognition.

1. The work on the respective *dominant* defensive pattern also opens access to the patient's *other defense patterns*.

 For example, patients who act masochistically are often fixed in defense through grandiosity. Grandiosity helps them silence the voice of their inner soul killer. Naming and representing defense patterns with chairs help them psychosomatically experience the relationships *between the defense patterns*.

If *counseling* or therapy is limited to 10–20 sessions, the therapist should *only* work *on the dominant* defense pattern (see Sect. 3.3). But, in *long-term therapy,* the therapist also works on the *other* defense patterns.

memory centers of sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thoughts in this ego state into a holistic psychosomatic resonance pattern (see Sect. 2.7). The more the patient is structurally disturbed, the more important it is to act out the defense pattern in therapy. For example, after a patient had creatively played the role of his 'inner soul killer as a hand puppet, he said: "It is good that the soul-killer has so many facets. That makes it clearer for me! Before, I couldn't fight him back so well because I didn't know when he would appear!" Another patient, a fifty-year-old artisan, often thought in a masochistic self-injurious manner during his psychotherapy. At the beginning of the therapy session, he would always pick out the hand puppet of the grinning red devil from the closet. He would position it on the chair of the 'self-injurious thinking' and inform the therapist that he had 'slipped' into his trauma film again.

4. The therapist asks the patient *about the age of the dominant dysfunctional ego state*, for example, of his *self-protective behavior*: "For how long have you been adapting in conflict situations, in a way that you push your emotions away and only focus on being functional?".

#### **Central idea**

In thinking about the genesis of his defense pattern, the patient links and integrates his defense pattern with appropriate difficult childhood experiences. Thus, he recognizes the original positive meaning of his defense (see Sects. 2.4.4 and 6.4).

Self-protection through adaptation was *a creative solution* for the child to pretend nothing was wrong. This helped the child avoid attracting any attention when his father screamed again under the influence of alcohol. Some patients boost the process of their inner change by working on it *daily*. They buy themselves a hand puppet or a suitable Playmobil for their 'abandoned child', their 'self-injurious thinking', or their 'self-protection through grandiosity'. They put them up *at home* and talk to them. Sometimes they keep their 'child ego-state' in a small 'bed' at home and cover it with a pillow. One patient would let the doll for her 'traumatized inner child' sleep next to her in bed at home. Whenever she felt bad for herself, she would complain about her suffering to her doll. Thus she would justify her feelings and ascribe them to her traumatic experience as a child. Then she would hug the doll and comfort her. Comforting the traumatized inner child helped the patient feel better again (see Sect. 5.8).

5. Patients diagnosed with personality disorders switch back and forth between the different defense patterns of their defense system relatively quickly when thinking. This change *happens* unconsciously.

#### **Central idea**

By naming, representing, and interacting, the patient completes the psychosomatic resonance patterns of each involved ego state with missing elements (see Sect. 2.7). Each ego state gets its own right to exist in self-regulation.

The psychodramatic work on the *intrapsychic* conflicts of the patient shows (1) The 'self-protective behavior' and the 'self-injurious thinking' usually work well together (see case example 26 below). They stabilize each other as a defense system in the fight *against* the 'healthy adult thinking' and the 'angry child'. (2) The 'selfinjurious thinking' suppresses the 'angry child'. The 'blind inner critic' and the 'angry inner child' *cannot coexist*. *Either* the 'inner critic' *or* the 'angry child' is in charge. (3) The 'Self-injurious thinking' and 'the abandoned or traumatized child' often live together in a pathological symbiosis. (4) Even the 'self-protective behavior' suppresses the 'abandoned or traumatized inner child'. (5) The 'angry child' can suppress healthy adult thinking. (6) The 'abandoned child' and the 'angry child' appear *alternatingly* in patients with borderline organization and paralyze the 'healthy adult thinking'. However, they can learn to help each other in therapy.

If necessary, the therapist lets the patient conduct psychodramatic dialogues between his healthy adult thinking and his suppressed ego state. In doing so, she herself joins as a doppelganger and an auxiliary ego. Every now and then, she takes a small step beyond the given reality. For example, the patient works out what his adult ego state and inner child have to *tell each other* in the dialogue between his inner 'abandoned child' and his 'healthy adult thinking'. As an auxiliary ego, the therapist accentuates the *childlike logic* in the role of the child and the *adult logic*  of thinking in the role of the adult. The 'child ego state' wants to be seen by the 'adult ego state' and wants to have his needs met *immediately*. When in the role of his 'adult ego state', the patient allows space for the feelings and wishes of his 'child ego state'. But, as a person with life experience, he also has an overview of the life situation. He, therefore, explains the world to the 'abandoned child' and helps him take everyday life's necessities seriously. Out of consideration for the 'traumatized child', the 'adult ego state' *should not* 'chicken out' and avoid all conflicts.

In disorder-specific therapy, the 'abandoned child' or the 'traumatized child' should be integrated into the patient's inner process of self-development in the external situation. Thus, the traumatized child can develop into a 'healthy inner child' and eventually become a *consultant for* the adult ego state. For example, a 60-year-old patient noticed that he was 'feeling bad' when he was at his workstation at 4 p.m. He took his 'inner little John' out of his backpack and asked him: "Do you know why I feel so bad?". His 'child ego state' replied: "Isn't that clear! You have worked *continuously* from 8 a.m. to now 4 p.m. today. You haven't taken a single break and haven't eaten anything yet!" The patient immediately left everything behind and went for a walk in the nearby park. His child ego state had helped him to get out of his blind self-protection by adapting to the expectations of others.

The *dominant* defending ego state is different in *different* personality disorders. In people with narcissistic personality disorder (see Sect. 4.2) or panic attacks (see Sects. 6.4 and 6.5), self-protection through grandiosity or perfectionism is dominant. This helps ward off feelings of failure, humiliation, or insecurity. In people with depressive personality disorder and masochism (see Sect. 8.5) and with obsessive– compulsive neuroses (see Sect. 7), self-injurious thinking plays a dominant role and blocks the patient's self-actualization. In people with borderline organization (see Sects. 4.3 and 4.9), the unconscious oscillation between the needy and the pseudoautonomous ego helps the patient stabilize himself. 'Inner maturing is the ability *to realize* in an increasingly shorter amount of time that I am on the wrong path' (Dürckheim 1985, only oral communication).

#### **Central idea**

Process-oriented metacognitive therapeutic work on the defense patterns helps the patient to learn to psychosomatically recognize the "wrong path" of his rigid defenses in increasingly shorter periods, to integrate the defense pattern into the genesis, and thus to gain ego control over his defense pattern.

At the end of therapy, patients can *also* often *resolve new blocks* in their metacognitive work *by themselves*. This helps them to orient themselves, if necessary. A patient reported: "My four ego states help me a lot. If I feel bad, I examine which ego state I am in internally. Then I find my inner balance again." The patient's four ego states included his 'inner child', his 'inner soul slayer', his 'self-protection through adaptation', and his 'healthy adult thinking'. In such autonomous orientation work, the patient first *recognizes* and *names* the *dominant dysfunctional* ego state he is currently living in. He then reflects on the *other* ways of thinking and feeling he is neglecting in the here and now. Internally, he establishes a relationship with these possible alternatives, brings them to life within himself, and thus frees himself from his fixation in his *dominant defense.*

#### *Case example 26*

*A 38-year-old patient diagnosed with an emotionally unstable personality disorder (F60.31) learned that "she should pay more attention to herself and her feelings" in her eight-week of inpatient psychotherapy. After being reintegrated into her professional life, she found herself in a high psychophysical state of excitement during a conflict in the workplace. In the therapy session, she complained: "Again, I did not pay sufficient attention to myself and my inner child in the argument with my colleague. I'm annoyed with myself!" The patient attributed sole responsibility for the problems at work to herself. The therapist and the patient together elaborated on the dysfunctional ego states in her self-regulation during the said conflict. The patient represented her 'self-injurious thinking' with the hand puppet of a 'demeaning, blindly acting bureaucrat' and her 'self-protective behavior through adaptation' with the hand puppet of a 'nerd'. The therapist: 'Your blindly demeaning bureaucrat and your inner nerd work wonderfully together!" The patient: "Yes, I always notice it from my states of excitement that my 'inner bureaucrat' and my 'nerd' are already at work again".*

*The patient found it difficult to look at the hand puppets of her inner 'nerd' and her inner 'bureaucrat' from the outside: "Mr. Krüger, tell me how to resolve this!" In the next therapy session, however, she had already found a solution on her own: "I created some distance internally and looked at the conflict situation with my colleague again from the outside. Then I noticed: 'What is the problem if I miss my bus and reach home only an hour later because of her? Nothing at all! Nothing would happen!' Having considered that, I nevertheless requested my colleague again to end her work on time. I was then able to lock the office in peace and still got my bus on time!'" The therapist: "So you created some internal distance and looked* *at the conflict from a different perspective from the outside. You found a solution to your conflict on your own and thought like a healthy adult. I congratulate you!".*

Patients with personality disorders often have *transpersonal experiences*. The affected patients are mostly not aware of this. They often even devalue the special transpersonal quality of their self-regulation. One patient, for example, complained: "I am too sensitive for the world. In my relationship with people I meet, I blindly give out everything positive I have in me. Afterward, I am completely exhausted. My husband thinks I'm too good for this world!".

#### **Central Idea**

The therapist should not misunderstand a transpersonal experience as *a defense pattern.*  A *transpersonal* character trait must be recognized and named according to its *transpersonal*  quality. Only then can the patient also gain control over his thinking, feeling, and behavior in his *transpersonal* identity (see Chap. 1) and think about it in the as-if mode.

The patient's fixation on a *transpersonal quality* is an attempt to remain true to his *transpersonal* experience. Initially, the therapist and the patient work out the positive value of this quality. For instance, in case example 26 (see above), the therapist asked the patient (see Sect. 7.3): "Please attribute this special character trait you experience as stressful to a fictional person. 'Be too good for the world' should be natural and make sense within the context of their living environment. Afterward, please tell me an episode from this person's life." The patient found the figure of a nun in a monastery: "This is only a soul, almost something like a saint. Her name is Clare". The patient continues: "The nun cares for an old woman in the hospital ward and delights her with her mere presence. When she is exhausted, she spreads her arms as she stands in her herb garden and lets the light of heaven flow into her body." The patient burst into tears during this therapeutic work. With the therapist's help, she understood her crying as sadness about the world not being as good as it should be. The therapist asked the patient to think of ten more episodes from the life of 'St. Clare' in the following weeks and write them down. The transpersonal interpretation and the symbolization of her special character trait as 'holy Clare' helped the patient gain more control over the external behavior of her transpersonal identity. This put the patient in the yes-but position with regard to her special character trait, and she was free to think as a healthy adult.

An inner transpersonal identity is an expression of a *transpersonal conscience*  (see Sect. 8.8.4).

#### **Central idea**

A patient with a personality disorder thinks like a healthy adult when he orients himself in his self-regulation in the as-if mode and identifies the metacognitive ego state he is possibly stuck in with his thinking, feeling, and behavior in the current situation. Thus, he is free to choose whether to act out his old defensive pattern or to think, feel and act in a new and more appropriate way.

If necessary, the therapist can promote the development of 'healthy adult thinking' with *amplifications* (see Sect. 2.4.4) or with the technique of the *fictitious supportive doppelganger*: for example, she explains how *other patients* have found themselves in their therapy. Or she places a second chair next to the patient's chair. She invites the patient to assign this chair to a good friend or a wise old man and asks him to switch to the role of 'friend': "What would your friend advise you in this situation?" The patient then starts a psychodramatic dialogue with his 'friend'. During role reversal, he steps into the role of the friend, playfully brings *the ideas of the 'friend'*  to life, and gives himself some advice (Leutz, 1980, pp. 17 ff.). The therapist can also ask the patient to find a *fairy tale character* to support his 'healthy adult thinking': "Imagine this fairy tale character sitting on the chair next to you". The fairy tale character is said to have already experienced the patient's suffering. However, unlike the patient's tales of woe, fairy tales usually end well. 'Cinderella', for example, can be a *role model* for the patient. She never gave up on herself and hoped that something would change, even when she had to sleep in the ashes. She complained about her suffering to the doves. And despite the humiliation by her sisters, she planted the branch brought by her father into the earth at her mother's grave.

Relapses into old behavior can indicate that the therapist did not pay enough attention to the stabilization of the dominant defense pattern through other defense patterns. The following three case examples demonstrate this:

*Therapists* need to have a good relationship between their *own* inner child and their adult ego state when working with people with personality disorders. This is because the therapist must be able to *instantly feel* her *own* emotions in the relationship and be curious, just like a child. The access to the therapist's own inner child is repeatedly blocked by adaptation, grandiosity, or self-injurious thinking. In such a case, the therapist should name *her own* dominant defense pattern and symbolize it as an ego state with a hand puppet. For example, she can represent her great sense of duty with a 'blind inner slave'. She places her 'inner slave' in her study and examines it every once in a while if and when she may have obeyed him again in her everyday life. Thus, the therapist gains ego control over her masochistic submission to her 'blind inner slave'. She becomes more flexible and creative. Therapists should have experience in dealing with their metacognitive processes if they want to do metacognitive therapy.

### **4.11 What Can Psychodrama Offer to Schema Therapy?**

*Psychodramatists* introduced constellation work into the world of psychotherapy. They developed techniques such as the setting up of roles in the '*social atom*' or the inner roles in the '*cultural atom*'. They help the patients symbolize their own negative feelings, aching parts of the body, or inner attitudes with the help of hand puppets, objects, or other players (Krüger, 2007) and led psychodramatic dialogues between them. For example, the therapist symbolizes the patient's fear (see Sect. 6.8.3) or his 'fearful inner child' by placing a chair next to him.

Schema therapists (Young et al., 2008) have systematized the constellation work against the background of psychoanalytic and behavioral theories and made them useful for the *metacognitive* therapy of people with personality disorders. They say: Schema therapy "is an innovative, integrative therapy. […] It combines elements of cognitive behavior therapy, attachment theory, gestalt therapy, object relations theory, constructivist psychotherapy, and the psychoanalytic schools to form a multifaceted, holistic concept and treatment model" (Young et al., 2008, p. 29). Half of the schema therapy techniques are known as psychodrama techniques: chair work with the patient's ego states, psychodramatic dialogue with role reversal with *childhood*  attachment figures, psychodramatic dialogue with *current* conflict partners, and the doppelganger technique.

#### **Central idea**

Psychotherapy methods that aim to *directly* change the patient's *metacognitive* processes *have to* use psychodramatic techniques. Because the psychodrama techniques directly implement the *naturally existing metacognitive* tools of inner conflict processing (see Sect. 2. 4).

Unlike in the past (Krüger, 2007), I have relied on the *terms used in schema therapy*  when naming the metacognitive ego states in this book (Arntz & van Genderen, 2010, pp. 10 ff., Young et al., 2008). The names are closely associated with a patient's ego. This makes it easier to communicate with patients about their *metacognitive* processes. However, the *psychodramatic metacognitive therapy* (described in Sects. 4.7–4.10) for the dysfunctional metacognitive ego states and defense patterns of patients differs from the schema therapy work in the following ways:

5. A few years ago, schema therapists Arntz and van Genderen (2010, p. 67 ff.) had their patients psychodramatically re-enact *traumatic* childhood experiences. After an interim discussion, the patients had to enact their childhood scenes a second time but behave *more courageously as a child in the scene*. The therapist took on the role of the harmful caregiver from childhood in this 'revision of the situation'. But, she enacts the role *differently* in the repeated scene *from how it was before*. As a mother, for example, she was sufficiently attentive and loving. *Psychodramatists* never ask a protagonist to act more boldly *as a child* in their *own* childhood scene. Patients with personality disorders often misunderstand such instructions and conclude that the therapist believes that they *behaved incorrectly as a child* at the time. Additionally, the improved self-actualization in the inner relationship images of attachment figures from childhood can also lead to an increase in pathological symptoms because of the actualization of the sadistic superego. Patients often struggle with guilt after such work (Arntz & van Genderen, 2010, p. 70 f.), "because they did not react adequately in the situation at the time". Psychodrama therapists, therefore, always let their patients *change*  their old inner images of childhood relationships in a psychodramatic dialogue *while in their current role as adults* (see Sect. 4.12). Or they introduce supporting fictional doppelgangers in the childhood scenes, for example, *other fictional good parents* (see Sect. 5.14). Even schema therapists are doing this sometimes. They call this method "imaginative rewriting by an assistant" (Jacob & Arntz, 2011, p. 134 ff.).

#### **Question**

What can psychodrama offer to schema therapists?

### **4.12 Integrating Inner Change into Inner Relationships' Images**

The defense system of patients with personality disorders blocks their internal process of self-development in relationship conflicts. Therefore, from the very beginning, the therapist repeatedly works on the patient's fixation in the development of inner selfimage and object image (see Sect. 8.4.2) in their current conflicts. The patient thereby releases his healthy adult thinking from his fixations and gains awareness of his rigid defense.

During the last third of therapy, the therapist helps the patient, with the help of psychodramatic dialogues and role reversal, to integrate his new understanding of himself into his *old internal relationship images* (see Sect. 8.4.2). As a result, they get updated, so to speak. The following options have proven successful in this integration work:

1. The patient writes a *fictional letter* to an attachment figure from childhood while he is at home in a stress-free environment. The attachment figure should *not*  be a perpetrator who had abused the patient because that would be equivalent to exposure to trauma. The patient must *never post the letter*. In the letter, he explains to the attachment figure all that he has now learned about the connection between his *current* problems and his *childhood* experiences. He mentions things by name (see case example 55 in Sect. 6.6). He specifies how *he wants* to understand the development of his symptoms and their causes.

The patient gives the letter to the therapist to read. The therapist uses the content to diagnose the patient's progress and recognize possible gaps in therapy. The patient himself can retrieve the letter in *later crises* and read the reasons for his earlier decompensation once again. In reading the letter, he will also become aware of the constructive steps that led him out of his illness. In writing such a letter, the patient appropriately integrates his current inappropriate interaction patterns and affect with his childhood experiences. This helps him to act them out less often in his current conflicts. One patient was moved to tears when her therapist asked her to write such a letter. She immediately noticed that the letter would give her the opportunity and permission to accept her own feelings and insights. In writing the letter, she allowed herself to *oppose* the recurring devaluations of her family *internally*.

2. When *writing a fictional letter* to attachment figures from the past, the patient often remembers *traumatic experiences* from his childhood that have *not yet*  been discussed in therapy. The therapist uses this opportunity to help the patient process the hurtful experiences from his childhood by applying techniques of trauma therapy (see Sect. 5.10).

#### **Recommendation**

For example, the therapist and the patient, together, reflect on (see case example 21 in Sect. 4.6) what the patient *would have needed* to help with their traumatic experience in the past (Sáfrán & Czáky-Pallavicini, 2013, p.274 ff.). If necessary, they look for a *fictional helper* who comforts the child in imagination and, as a fictional doppelganger, protects and supports him in his traumatizing situation (Kellermann, 2000, p. 31; Arntz & van Genderen, 2010, p. 29 ff.; Grimmer, 2013). They use the table stage to determine how the *fictional*  helper should have acted and what the patient would have felt as a child (see Sect. 5.10.10).

3. The therapist can also ask the patient to write a *fairytale of coping* (Krüger, 2013; Sáfrán & Czáky-Pallavicini, 2013). This technique is described in detail in Sect. 5.14. In it, the patient tells the story of a childhood incident that caused him suffering and transforms it into a fairytale in the *second* part. In the *third*  part, his needs and wishes are to be fulfilled. In doing so, the patient expands his tale of childhood trauma with supportive fantasies to resolve the blocks in the internal process of self-development in relationship images from childhood. It is advisable to work with the fairytale of coping when the patient has little access to his needs and desires (see case example 40 in Sect. 5.14). Working with the fairytale of coping, the therapist can diagnostically notice the patient's therapeutic progress or any gaps in his development (see Sect. 5.14).

#### **Central idea**

Patients with structural disorders often accept difficult living conditions without any complaint. Life happens to them. They didn't learn anything different in their childhood. They have no idea about what is 'normal'. They often consider 'normal' an illusionary wish. Experiencing the *'normal'* at least in fantasy, frees the internal process of self-development from its fixations and promotes self-actualization in conflicts.

the relationship with his conflict partner. In the role reversal, he also recognizes the inner truth of *the 'conflict partner'*. Patients who have been trapped in their defense systems are often amazed at how differently other people 'tick' internally.

6. The therapist teaches the patient the method of *psychodramatic self-supervision*  (see Sect. 2.9) (Krüger, 2011, p. 201 f.). Patients can use it to work independently on their current relationship conflicts at home and reduce their defenses through introjection and projection. This will also help them reduce their therapy sessions. In addition, they will recognize themselves and others more clearly in the conflicts in their everyday life.

#### *Case example 27*

*A woman who was traumatized in childhood felt dizzy whenever she did not sufficiently define her boundaries in relationships. She learned psychodramatic selfsupervision in therapy (see* Sect. 2.9*) and used it regularly. After four weeks, she reported: "The chair work is great! I use it to clarify my position. My dizziness has reduced a lot by now. I have noticed: 'Sometimes people are not against me at all, they only focus their attention on themselves!' I always thought that I was narrowminded when I wasn't generous. But when I work with the empty chair, I learn to justify my feelings. Additionally, when I am in the role of the other, I often do not understand what I want. I have to make my position clearer in relationships!".*

7. Patients with personality disorders often struggle to *stabilize* their *internal changes over time*. Their anger or the wishes of their 'inner child' are paralyzed by their 'self-protection' and their 'self-injurious thinking'. In such a case, the therapist helps the patient symbolize their anger as an 'anger stone'. The patient should *put it in his pocket*. When in conflict, he can touch the 'anger stone' and in doing so, justify his anger internally. Or the patient can buy a *finger puppet*  for his 'inner child' and put it in his handbag. He pulls it out when necessary and talks aloud to his 'little John'. The concrete *external* presence of his 'anger stone' or his 'inner child' stabilizes the patient's internal process of self-development in external conflict. Thus, he justifies his own feeling and thinking.

The temporal stabilization of new knowledge through external symbolization promotes the development of new neuronal circuits in the brain's memory centers. Patients with psychosomatic complaints like to avoid arguments with their conflict partners. They say, for example: "My wife can talk better than me anyway!" However, if the patient refrains from arguing with his wife, he switches back to his old psychosomatic resonance pattern in which he was afraid instead of being angry. His defense through identification with the aggressor (see Sects. 2.4.3 and 8.4.2) and the resulting confusion between the roles of the perpetrator and the victim then lead to psychosomatic complaints. In such a situation, the 'anger stone' or the puppet for his 'angry inner child' helps the patient regain *internal* access to his feelings of anger. That opens the door to other solutions in his brain. The patient does *not* have to 'let out' the anger.

### **4.13 Self-Development of Therapist and Psychodramatic Responding**

Patients with personality disorders often draw the therapist or the counselor into their defensive behavior through projective identification and their actions in the equivalence mode.

A biased adaptation to the patient's expectations blocks the therapist's internal process of development of their self-image in the therapeutic relationship: (1) The more hopeless a person with personality disorder feels, the more the therapist is fixated in the ego state of *empathically compassionate people*. (2) The more demanding and grandiose a patient appears, the more the therapist tries to grandiosely expand her boundaries as a human being during therapy and to make the impossible possible. (3) The more factual and unemotional the patient is in describing his problems, the more likely it is that the therapist will react *as a competent expert* with premature explanations and factual information. (4) The more a patient oscillates between two contrary metacognitive ego states (see Sect. 4.3), the more the therapist feels torn between compassion and anger.

In such a case, the therapist can free herself of her fixation through psychodramatic responding. In doing this, she alternatingly realizes her three task-related self-images (see below) directly in the encounter with the patient. Psychodramatic responding is indicated when *two* of the following *five* criteria are met: (1) The patient has moderate or low structural disorder. He thinks and acts in black-and-white patterns and equivalence mode. (2) He is not mentally open to engaging in chair work with his metacognitive ego states. He quickly moves from one subject to another. (3) He makes contradicting demands on the therapist without developing awareness of the contradiction. (4) The patient violates the therapy setting or does not agree to the appropriate therapy conditions. (5) The therapist has compassion for the patient who acts in equivalence mode but also wants to say difficult things and state reality clearly.

#### **Important definition**

The psychotherapist has *three tasks* in therapy: She thinks and speaks as *an encountering person, a competent expert*, and a *healer*. She understands these three tasks as her *three* inner self-images (see Fig. 4.4) and represents them with chairs in the therapy room. Thus, each of the three self-images develops its own psychosomatic resonance pattern between the memory centers of sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thought (see Sect. 2.7).

The therapist uses the following three steps in using the technique of 'psychodramatic responding: (1) She *names* the chair she is currently sitting on as the chair for her as the *encountering human being*—the person the patient meets (see Fig. 4.4). As the 'encountering human being', she steps out of her systemic role as therapist and allows herself to express her thoughts and feelings *freely*. She justifies her feelings in the relationship and verbalizes them. (2) The therapist *sets up* a chair to her *right*  for herself as a *'professionally competent expert'*. As a *'competent therapist'*, the therapist informs the patient factually about the conditions of therapy and general therapeutic experiences. She asks diagnostic questions and offers interpretations. (3)

**Fig. 4.4** The therapist's three task-related inner self-images and the chair for the negative transference figure

The therapist places another chair to her *left* for herself as a *'grandiose therapist'*. As a *'grandiose therapist'*, she behaves true to the motto 'Why not?' She follows her ideals as a healer and helper. She creatively searches for a way of healing for the patient, even if she has little hope, and fails in doing so in the end.

When talking to the patient, the therapist pays attention and notices which of her task-related self-images is active in her thinking, feeling, and acting *in the moment*. If she spontaneously switches to another task-related self-image *internally*, she communicates this with the patient by physically moving to the respective chair. She verbalizes this shift: "As a professional, competent therapist, I mean…" (Krüger, 2007). Thus, the therapist frees herself from a biased fixation in only one of the three task-related self-images.

#### *Case example 19 (2nd continuation, see* **Sects. 4.4** *and* **4.6***)*

*At the age of 39, Mr. A. received outpatient psychiatric treatment for severe depression and suicidal ideas. The therapist diagnosed him with borderline personality disorder (ICD F60.31) and chronic alcohol abuse (ICD F10.2) with severe structural disorder. In the first year of his life, Mr. A. was placed in a Catholic children's home by his mother. He was raised by nuns. His caregivers forcibly excluded him from the children's home at the age of 17 because of a sexual love affair with an intern. Mr. A. had already physically injured his wife several times in aggressive breakthroughs. In the first interview, Mr. A. replies to the question about his therapy goal: "I'm coming here somewhat scared. I cannot be treated at all!" In the therapeutic relationship, he sees himself 'as a Playmobil dwarf ', but the therapist 'as a ten-meter-tall giant'. The patient expects from the therapist: "You should totally see through me. Then you can fix me quickly! I want to work through my childhood!" The therapist is startled. He feels overwhelmed by the patient's expectations.*

*(Due to lack of space, some of the patient's reactions are missing in the following text.) The therapist responds to the patient from the middle chair of the 'encountering* *human being': "I think it is very kind of you that you trust me so much." The therapist places a second chair to his right and sits on it: "That is the chair for me as a professionally competent therapist. As a competent therapist, I say: Working through your childhood will not help you deal with your depression. On the contrary, it is more likely to harm you. Because in doing so, your past experiences of feeling deprived will come to life again. That will probably make you more unstable." The therapist places a third empty chair to his left (see* Fig. 4.4 *above) and sits on it: "This is the chair for me as a great therapist. As a grandiose therapist, I would like to fulfill your wish to come to terms with your childhood. Why not! Where there is a will, there is a way!" The therapist sits back on the middle chair: "But this task scares me as a human being. Because in my experience: 'If I have wanted too much as a therapist, I have failed. I started as a tiger and ended up as a bedside rug!'" The therapist switches to the chair on the right: "I see myself as a professional, competent therapist! And I mean: 'Please let us tackle your problems one by one!'" Mr. A. is irritated: "I feel a real depressive surge, there is again pressure in my stomach, my head, my legs! I feel left alone. I'm not getting the help I wanted. I can already see: I am too complicated for you, I cannot be treated!".*

*The therapist interprets this statement by the patient as jumping in for a negative transference. He sets up an additional empty chair a little further away.  And I also see your teacher sitting there, the one who did not want to accept you as a foster child. As a therapist, I am not meeting your expectations either! But unlike your mother, I am not pushing you away. I will not leave you alone! I want to work with you. But I want to work with you on the problems you have in the present. I would like to walk with you step by step and look at one problem at a time!".*

*The therapist speaks to the patient about his alcohol problem in the last twenty minutes of the therapy session. He symbolizes this with the help of an empty chair next to the patient (see* Sect. 10.5*): "I'll put another chair here, next to you, for you as someone who drinks too much alcohol. Maybe your depression is also related to your drinking. You drink a lot more than you want and cannot fulfill your resolutions of changing it. That makes you feel guilty and inferior. This makes you depressed!" The therapist has the patient fill out Jellinek's 30-item questionnaire (see* Sect. 10.4*). Mr. A. ticks 17 of the 30 questions with 'Yes'. Five affirmations are enough to assume that one is 'probably an alcoholic'. Mr. A. is shocked: "My father was an alcoholic and perished from it." Mr. A. joins a therapy group for addiction disorder (3rd continuation in* Sect. 2.14*).*

#### **Exercise 12**

You cannot understand the therapeutic effect of 'psychodramatic responding' just by reading about it.  Imagine one of your patients with a personality disorder is sitting on it. Talk to the 'patient' *as the 'encountering human being'.* In doing so, express authentically and share the feelings triggered by the patient. Now place an empty chair to your right for you as a *'professional,* *competent therapist'*. Touch the chair and confirm your *own competence*. Feel the relationship with your 'patient'. Now remove this second therapist's chair again. Talk to the 'patient'. Notice how you feel as the 'encountering human being' *without*  having the 'competent chair' next to you, representing your theoretical knowledge and practical expertise. Once again, place the chair of the 'competent therapist' next to you and check whether this changes anything for you in the given situation. If so, what is the difference?

You will notice: It relaxes you when you, as the therapist, verbalize your own feelings as the 'encountering person' *and when* the chair for the 'competent therapist' is placed next to you in *real*. As a result, you stop adapting to the systemically expected role. You feel more spontaneous, sociable, curious, and compassionate as a therapist. You give yourself more permission to be helpless and *not know everything*. But you are still able to act appropriately.

#### **Exercise 12 (continued)**

In the next step, please sit on the chair of the 'professional, competent therapist'. Now remove the chair for the 'encountering therapist' for a while. Give the 'patient' some factual information from the role of the competent therapist. Notice what it is like for you *without* the chair for the 'encountering human being'. Once again, place the chair of the 'encountering therapist' next to you. Focus on how you feel internally again. Do the same experiment with the chair of the 'grandiose therapist'. First, place it next to you. Then sit down on the 'grandiose therapist's chair'. Feel the relationship with the 'patient'. Then sit back on the chair as the 'encountering person' and *remove* the chair for the 'grandiose therapist'.

You will notice: If you are *just grandiose without* having the chair for the 'encountering human therapist' on the right and the chair for the 'professional, competent therapist' further to the right, it feels like a hike on a narrow line in the high mountains. You don't exist as a *normal* human being.    The ego state of the 'grandiose therapist' stands for the conscious, playful identification with the healer god (Hillmann, 1980, p. 107), that is, for the dream of being an *ideal* therapist. Also, limitless empathic compassion for the patient, even to the point of burnout, is an expression of the ego state of the 'grandiose therapist'. Some *therapists* find the chair for the 'grandiose therapist' to be superfluous. But if you switch to the role of the patient, you will notice: *For the 'patient'* it is important that the therapist, like a good mother in need, *at least tries* to make the impossible possible, *even if she fails*. The therapist's grandiose fantasies make the patient feel that *his wishes* are being taken seriously.

The therapist follows her intuition (see Sect. 2.2) in 'psychodramatic responding'. In doing so, she takes the following steps:

1. While sitting on the middle chair of the 'encountering human being' opposite the patient, she verbalizes how she *feels in the current interaction*, for example: "I feel sad if you say this", "I feel helpless listening to you", or "I feel overwhelmed if I identify with you". The therapist's *negative* affect often is an *appropriate*  response to the *dysfunctional* acting out of the patient in the equivalence mode (see Sect. 2.9).

explain her dilemma to the patient *through a psychodramatic dialogue with role reversal between* her various task-related self-images in the as-if mode of play. For example, she moves to the chair of the 'grandiose therapist', looks at the chair of the 'encountering human', and says: "You could still try harder and let go of your rules for once. You can see: Mr. A. is not doing too well! He is suffering!" The therapist now reverses roles with the 'encountering human therapist' and addresses the 'grandiose therapist': "I would like to remind you, Renate, as a human being, that you have often tried to make the impossible possible. And then you have failed. Please remember that you cannot work 24 h a day. If you end up burning yourself out, it is of no help to Mr. A.!" Or the therapist moves to the chair of the *'professional competent therapist'* and responds to the 'grandiose therapist': "But, as a competent therapist, I am telling you: Don't fool the patient. I know from experience that you won't be able to do that in five or ten sessions. Mr. A. needs long-term therapy of at least 100 sessions."

#### **Recommendation**

In psychodramatic responding, the therapist shares essential factual information with emotionally unstable patients*, without saying it directly to them*. For this purpose, she acts out her *internal* reflections *in the form of an external psychodramatic dialogue between the two patient-related ego states* of 'encountering ' and 'competent therapist' in the as-if mode of play*.* The patient, who is thinking in the equivalence mode, feels that his expectations are being taken seriously because the therapist allows her inner self-image, which *matches*  his expectations, *to exist externally* as a chair. However, he *also* unwillingly hears factual information from the "competent therapist" on *the other* chair.

#### **Central idea**

In the therapy of patients with severe structural disturbances, who think and act in equivalence mode, 'psychodramatic responding' *helps the therapist* free the development of her inner self-image in the therapeutic relationship from fixation and prevent *secondary* countertransference. She experiences the three *externally* represented inner self-images as *three different possibilities* of acting in the encounter with the patient. She thus gains ego control over the *cooperation between her three task-related self-images* and can use all three of them freely and appropriately.

*The patient* experiences the therapist's contradicting inner self-images externally as chairs *in the therapy room*. His inner *object image of the therapist* is thus differentiated into three images side by side. This also leads to a *differentiation of his inner self-image* in the therapeutic relationship. The patient usually does not want to let go of any of the "three therapists". He realizes that he needs authentic personal encounters in order to learn to trust again. He realizes that despite all reservations, he wants to feel secure in therapy with a supportive and competent therapist. He realizes that he can have high expectations of therapy, which only a great therapist can fulfill, but that he has to lower his expectations because of his need for stability in the therapeutic relationship. Even if the patient thinks in the equivalence mode, he can also internally perceive and understand the co-existence of the therapist's three different tasks *through the external representation* of the three self-images *with three chairs*. Psychodramatic responding is an important method of encounter-focused therapy (EFT) (see Sects. 2.9, 4.5, and 4.14).

You can take on the *role of the patient* in exercise 12 (see above) and notice how you feel in the interaction when the 'therapist' moves back and forth between her three internal self-images. You will notice: As a patient, you would like to experience your 'therapist' *not only* as an empathetic person. You would also want them to prove to be a professional, competent specialist. The 'grandiose therapist' should not be missing either. When the 'therapist' sometimes dares to wish for crazy things as a 'grandiose therapist', you, as a patient, feel free and can laugh.

Heigl-Evers, Heigl, Ott, and Rüger (1997, p. 176 ff.) have already recommended the '*principle of response instead of interpretation*' in the therapy of people with personality disorders. This is similar to the technique of psychodramatic responding.

#### **Central idea**

In using the psychoanalytic principle of 'response instead of interpretation' the therapist names her affect and describes the specific behavior of the patient which triggered her feelings: "When I listen to you, it feels a lot for me, and I can't take it anymore! I'm starting to feel some chaos internally." She can also add: "I'm confused when I listen to you. I think I feel something that you feel too." Thus, the therapist helps the patient to represent his *inner object image of the therapist* with a lot more complexity and to free it from projections. The patient perceives the therapist's inner mental state more clearly and realizes that he can influence it. In 'response instead of interpretation', the therapist often names the feelings that the patient defends, on his behalf (see Sect. 4.6).

#### *Case example 28*

*A 45-year-old female patient with social phobia and relational trauma in childhood reports in the initial interview, smilingly without any emotional involvement, of difficult childhood experiences. One is more terrifying than the other. Suddenly she interrupts her flow of speech and asks cheerfully: "I can tell you a lot more stories like this, Mr. Krüger, should I?" The therapist doesn't draw the patient's attention to the emotionless nature of her communication. He consciously identifies himself with her ego state of the 'abandoned, not seen child', and makes his inner experience available as an I statement: "No, please don't, I can no longer stand it because I can truly imagine what you are saying and I sympathize with your suffering as a child!" Only now does the patient begin to cry herself: "This is getting too much for me too!" The therapist's response helped the patient feel her split-off emotions.*

#### **Central idea**

In 'psychodramatic responding', the therapist names *her three therapeutic tasks*, represents them externally with chairs, and acts them out alternatingly in the as-if mode of play. Thus, she expands the psychoanalytic principle of 'response instead of interpretation' and acts not only *as an encountering human being.*

Therapists can also use the technique of 'psychodramatic responding' in group therapy or other group settings. The external differentiation between the therapist as an 'encountering human being' and the therapist as a 'professional competent expert' has proven particularly useful.

#### *Case example 29*

*A school psychologist worked in a crisis intervention team. After a school rampage, she cared for the children mentally. Afterward, she comes to supervision. She reports:* *"I often feel the need to cry when I encounter the children and the young people. That bothers me!" Unlike the therapist herself, the supervisor experiences this reaction of the therapist in identifying with the children as appropriate and valuable. He would like to check whether his assessment of the situation can help the psychologist. He lets the supervisee re-enact her encounter with a grade 10 class: the therapist listens to the students. She is close to tears. The supervisor asks her to verbalize her feelings beyond reality here and now in the reenactment of the crisis intervention. The school psychologist tells the 'children' in the psychodramatic play: "I am so sorry that you had to experience this. You are still far too young to experience violence, terror, and death!" The supervisee is unsettled during the debriefing of the play and says: "But I can't just act as a human in the situation! I was called to give the children psychological support!".*

*The supervisor: "May I test an alternative and try to deal with your shock differently in your place?" The psychologist switches to the role of a 16-year-old student. The supervisor plays the role of the psychologist. He repeats: "It makes me very sad that you had to experience such violence. When I see you sitting there, you are so young, just starting your life. And then this terror and this violence! That just wears me down!" Like the psychologist, the supervisor allows himself to be shaken internally in the play. But then he places a second empty chair to his right and touches it: "But I also came here as a professional expert to intervene in the crisis. I want to help you where you need me." The supervisor sits down on this other chair: "As a professional expert, I would like to know how you have dealt with this dire experience so far. Some of you have surely already found a way to calm yourself down and distance yourself from yesterday's horrific events. How did you spend the afternoon yesterday? We can collect all the possibilities of self-stabilization you have already found and used. After that, I can show you other ways of looking after yourself after such an experience of violence.*

*In the debriefing, the supervisee says: "If you do it like that, crying isn't that bad. As a student, I was amazed to see you, as a psychologist, so shaken. But that did me good. I didn't find that strange because you did your job as a consultant with the second chair!" The supervisor: "I am sure that your crying is the most precious thing you can give the students. If you verbalize and name your feelings authentically, you are also doing it on behalf of the boys and girls who have to act cool. But it is precisely through your emotional reaction that you are a role model. You help the students find themselves again and emotionally regulate their inner chaos."*

*In another role-play, the psychologist explores how she feels in the role of the counselor when she places the second chair next to her for the 'competent therapist'. Afterward, she puts away the chair for the 'professional competent expert' and notices how she experiences the situation without this second chair. In the end, she says in astonishment: "I never thought this would be so easy!" The supervisor: "It just seems simple on the outside. However, it's a very complex method. By placing your two metacognitive ego states side by side, represented with two chairs, you show the children: One can have two sides, a sensitive, injured side, and a competent, cool side. These two sides are not mutually exclusive. In doing so, you will become a role model for the children. The next time you have to intervene in a crisis, try to put* *this second chair next to you as a 'professional, competent expert'. See whether it changes something for you!".*

#### **Recommendation**

The method of 'psychodramatic responding' can also be used in many ways *outside of psychotherapy*, for example, in job-related communication training for educators, medical students, psychology students, teachers, or geriatric nurses. This technique helps people, who work with people, to develop their professional identity.

#### **Central idea**

With the help of this technique of 'psychodramatic responding', therapists and counselors learn that they *codetermine* the patient's or client's external reaction *with their inner attitude*  in counseling.

#### *Case example 30*

*In a course for psychotherapists, the leader demonstrated the method of 'psychodramatic responding'. A participant played the role of a patient with addiction from their own patient group. When treating the 'patient', the leader moved back and forth multiple times between his own three patient-related ego states represented by the three chairs. He said while on the 'grandiose chair': "As a therapist, I can tell you: We'll manage it. I have twenty-five years of experience as an addiction therapist. So where do you want to start?" In the role of the patient with addiction, the course participant felt that the self-confident therapist's behavior disempowered her as a woman and made her adopt a passive stance: "As a patient, I suddenly felt small and was afraid!" In the second demonstration, another therapist played the role of a man with addiction. The same intervention by the leader encouraged the 'patient' to spontaneously move to the chair of his 'self-protective behavior through grandiosity' and immediately compete with the therapist: "Well, not bad! Try it! Nobody has managed to crack me so far!".*

### **4.14 Disturbances in the Therapeutic Relationship and Negative Therapeutic Reaction**

#### **Recommendation**

In the therapy of people with personality disorders, disturbances in the therapeutic relationship are a result of the person's fixation in a defense system. In metacognitive therapy, the therapist understands these disturbances as the patient's *unconscious* desire to resolve his fixation. Disturbances in the therapeutic relationship should therefore be dealt with as a priority. The patient makes greater progress in therapy when the therapeutic relationship flows freely.

For this purpose, the therapist uses encounter-focused therapy (EFT) when working with patients diagnosed with personality disorders (see Sects. 2.9, 4.5, and 4.13): (1) She works on the patient's defense system (see Sects. 4.7–4.10). (2) She practices psychodramatic self-supervision including steps 13–17 (see Sect. 2.9). (3) She responds psychodramatically (see Sect. 4.13). Ultimately, there is no right or wrong in the therapeutic relationship. Instead, only the *reality in the relationship*  matters. The *patient's* soul doesn't do anything without a purpose, nor does the *therapist's*. In the beginning, some patients are overtly or covertly reluctant in working with the empty chairs. In such situations, the therapist should explain to the patient that she needs the chair work to orient *herself* to his problems and questions. In doing this, the therapist can and should believe her intuition. Even a patient with reservations usually ends up feeling taken seriously because he understands himself for the first time. The patient feels often deeply touched by the therapist's consequent empathy. The therapist feels relieved and happy with such outcomes.

Patients with *severe structural disturbance* often tempt the therapist, with their acting out and overwhelming symptoms, to focus their attention *on the thought contents* in their conflict processing (see case example 14 in Sect. 2.12.2). As a result, despite her knowledge of the disorder-specific methods in the therapy of patients with personality disorders, the therapist 'forgets' to use the psychodramatic metacognitive chair work *consistently* (see Sects. 4.8 and 8.5).

#### *Case example 23 (continued from* **Sect. 4.8***)*

*The 52-year-old Ms. F. had been dismissed by her employer without notice. That had retraumatized her. She decompensated again into a severe depression.  The therapist worked on her dysfunctional metacognitive processes with the help of chair work. However, due to the lack of resonance from the patient, he did not pursue it consistently enough. It was only when the patient attempted suicide that the therapist noticed that he had pursued her only with empathy and compassion in her conflicts.*

*During a free hour, he once again tried to understand her inner process work with the help of psychodramatic self-supervision (see* Sect. 2.9*). This helped him to work consistently and explicitly metacognitively in the subsequent therapy sessions. He set up the following ego states with chairs next to her in each session: (1) To the patient's right was the chair for her self-protection. Throughout her life, the patient had always tried to meet the expectations placed on her perfectly, for example, the expectations of her as a social worker, as a mother, and as a wife. The therapist symbolized her self-protection with the hand puppet of a pretty woman. (2) In addition, the therapist used another chair to represent the patient's recurring 'preverbal panic state'. He placed it far away in the corner of the room and symbolized it with the hand puppet of a sensitive girl in a tattered dress. (3) He set up a third chair opposite the patient with a hand puppet of a wolf with large, sharp teeth. The wolf symbolized her feeling of a 'vague threat'. The external representation of her dysfunctional defense patterns helped the patient to work her way out of the traumatized child's ego state. She named her inner panic states as 'very vague fear' and assigned it to her childhood: "The wolf keeps slipping into the present with me and threatens me again and again!" The therapist felt that he understood the patient's true distress for the first time.*

Patients *with borderline personality disorder* often develop a sudden negative transference to the therapist during therapy. This can lead to the termination of therapy. The therapist understands this negative transference as an 'allergic reaction' to one of her *real* actions. She must internally adopt the patient's perspective to recognize the specific action that triggered an allergic reaction in the patient. In a negative transference, the patient's blocked self-development is portrayed as a latent or overt conflict in the therapeutic relationship. The therapist should address this conflict *before all other topics* because the patient's emotional energy in the therapeutic relationship is tangled in it (see case example 19, 2nd continuation in Sect. 4.13 and 3rd continuation below). A *negative transference* can be resolved in the following way:

(1) The therapist addresses the disturbance in the therapeutic relationship on her own. (2) In doing so, she immediately sets up an empty chair a little away from herself for the *negative transference figure* that the patient projects onto her (see Fig. 4.4 in Sect. 4.13 and case example 19, 3rd continuation below): "*You have had enough of this in your childhood* when you were left alone. *You don't need to experience this again!*" (3) The therapist describes the *real part* of the conflict in the therapeutic relationship and her actions which were *externally quite similar* to the behavior of the harmful caregiver in the patient's childhood. (4) However, she then informs the patient that her *motivation* to act in this way was different from that of the harmful attachment figure from his childhood: "I have been critical of you. But, I wanted to be honest with you". "I want to take you seriously!" "I don't want to overwork myself. Otherwise, I'll get sick, and I would end up leaving you alone just as your parents did." In addition, the therapist tells the patient explicitly: "We have a problem in our relationship. But I won't leave you alone. I promise you. We are in the same boat in therapy. We're going through rough waves together and trying to get along." (5) In *differentiating the real part of the relational conflict from the transference part* (see Sect. 2.10), the therapist alternatingly points to the chair for the transference figure from childhood *or* to her own self at another time. In doing this, she allows the patient to feel his feelings. Differentiating between the transference conflict and the real conflict in the therapeutic relationship is an important element of encounter-focused therapy (EFT).

#### *Case example 19 (3rd continuation, see* **Sects. 4.4, 4.6,** *and* **4.13***)*

*Five years after having undergone 50 h of therapy, Mr. A. started therapy for the second time with the same therapist. He had relapsed as an alcoholic. He had been temporarily retired. However, he returned to his old office six months ago after undergoing rehabilitation therapy. Now Mr. A. wants to end the second phase of therapy also after fifty hours: "It doesn't help me anymore. The long journey is uncomfortable. And I don't want to become dependent on you either." But, the therapist offers Mr. A. an extension of therapy to work with him on his severe structural relationship disturbances: "I think that you want to end therapy because the end of your relationship with me lies ahead of us." The therapist points with his hand to the empty chair representing the patient's 'self-injurious thinking' (chair 8 in* Fig. 4.1*): "You feel this is your own free decision. But I see this as self-harming, masochistic behavior. You want to protect yourself from once again being the unwanted child you were in childhood." The therapist points with his hand to the chair of the "harmful caregiver in childhood" (chair 9 in* Fig. 4.1 *in Sect.* 4.2*): "Back then, as a child, you were* *given to the children's home by your mother!" The therapist points to himself: "In your relationship with me, you are now doing the same as was previously done to you." The patient begins to cry, he is very touched: "Oh, it is going to be tough to continue further! I don't know how I would deal with my feelings of being alone!" Therapist: "That is exactly what continuation of therapy would be about. You will recognize that you have these feelings and then learn to deal with them. Think about whether you want to learn that!" The patient did not extend the therapy. However, the dissolution of the negative transference helped the patient and the therapist to part with dignity.*

Patients with borderline organization and relationship trauma from childhood sometimes react paradoxically to the benevolent empathy and help of the therapist. Sometimes they even decompensate into a psychotic episode (see case example 31 below).

#### **Recommendation**

Even if the therapist feels that she has made every reasonable effort in therapy, she should always look for the cause of a *negative therapeutic reaction* from the patient *in the therapeutic relationship*. Again, the principle applies: "The patient's soul does nothing for free".

#### *Case example 31* **(Krüger, 1997, pp. 97 f., 103 f.)**

*A 32-year-old housewife, Mrs. L., is diagnosed with emotionally unstable personality disorder (F60.31). Before starting psychotherapy, she had already been in inpatient psychiatric treatment twice, for a short duration 'because of a psychosis'. Getting in touch with her is difficult. She appears artificial and puppet-like in her behavior. Mrs. L. plays a protagonist-centered play for the first time in her group therapy. She works on the conflict with her mother-in-law. The mother-in-law lives with the patient's family in her house. The conflict is an ordinary family conflict without any brisance. In the debriefing session, some group members encourage Mrs. L to be less subordinate to her mother-in-law. But other group members also understand the mother-in-law's needs.*

*Three days later, Mrs. L. is brought to the practice by her husband in an emergency. She is highly psychotic and in a completely fragmented state of mind. She fluctuates between gaining some insight into being ill and having absolute mistrust. She looks like a troubled child. What was the reason for the patient's psychotic decompensation? Before the psychodramatic argument with her mother-in-law, Mrs. L. had stabilized herself with the help of the defense of splitting. In the earlier psychotic episodes, she had aggressively devalued her husband. However, once she became 'healthy' again, she idealized her husband based on the inner belief: "Frank would be an ideal husband if my mother-in-law wasn't there." In this way, Mrs. L. could maintain her 'good' self-image in her relationship with her husband: she was the good-hearted victim of the 'bad' mother-in-law. She received narcissistic appreciation from her husband for her efforts to adjust and was able to deny her 'evil' side to herself. However, the psychodramatic confrontation with the mother-in-law brought Mrs. L's split-off anger and her wishes for separation to the surface. Her anger* *internally evoked the pathological introject of her abusive father. In her psychosis, she acted as if her father were present. There were many breakups in relationships, alcohol abuse, and violence in her family of origin.*

*In retrospect, the therapist interpreted his empathy for the patient and the sympathy of the group participants in the psychodramatic play as well-intentioned, but 'also bad'. He replied to the patient: "For other people, such support would be fine. But as a child, you experienced a lot of abandonment and violence. You have learned to put aside your longing for understanding.  If your longing is suddenly fulfilled in the group, then it is dangerous for you because the fulfillment of longing lets you feel your abandonment as a child again. The feelings of abandonment flood you. The group members and I meant well in the therapy session. But we have acted badly with you." The therapist also places a second chair next to himself: "This chair represents me as a therapist who has overwhelmed you with his affection and understanding."*

*The patient was able to use the representation of her inner splitting with chairs in her favor. She recognized her inner dilemma. After a short neuroleptic drug treatment for only one week, Mrs. L.'s psychotic disintegration had disappeared. When she returned to the group fourteen days after having been on vacation, the therapist was amazed: Mrs. L. had changed noticeably. She seemed softer, more authentic, and more in agreement with her feelings. The puppet-like, distant aura had disappeared and did not return in the further course of therapy.*

### **References**

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### **Chapter 5 Trauma-Related Disorders**

### **5.1 What is Special About Trauma Therapy?**

Psychological trauma can result in *different* clinical disorders: post-traumatic stress disorders, anxiety disorders, obsessive–compulsive disorders, depression, personality disorders, psychosomatic complaints, addiction disorders, and psychotic episodes (see Sect. 5.2). Therefore, in such cases, the therapist should also use trauma therapy elements in psychotherapy, if necessary.

#### **Recommendation**

Therefore, *a causal treatment* of these disorders includes methods of trauma therapy described in this chapter. The more experienced a therapist is, the more courageous she becomes to perceive and process the trauma.

#### **Central idea**

"All professionals in the field of trauma therapy agree that we must adapt conventional psychotherapeutic methods to meet the needs that arise from traumatic stress. This means that conventional psychoanalytic or behavioral therapy does not meet the needs, but neither does conventional family therapy, gestalt therapy, body therapy, etc." (Reddemann & Dehner-Rau, 2004, p. 77). The reason is the defense of dissociation in the case of trauma-related disorders (see Sect. 5.10.2).

Special experiences in the treatment of people with trauma-related disorders are: (1) Those affected dissociate as soon as their trauma experiences are 'triggered' by external events. As a result, they experience the current situation in the equivalence mode as if they are being traumatized in the *present*. (2) The flashbacks repeatedly lead to crises in the therapeutic relationship, thereby collapsing the therapeutic progress. (3) *Unrecognized flashbacks* discourage both the therapist and the patient, resulting in negative transference and countertransference reactions. (4) Patients with trauma-related disorders suffer from the impact of their trauma. However, often they do *not give* their trauma *any meaning*. (5) Some of the behaviors and ways of thinking in trauma patients appear to be neurotic at first. However, in truth, they are useful and helpful for the patient. They are self-stabilization techniques that protect him from

R. T. Krüger, *Disorder-Specific Psychodrama Therapy in Theory and Practice*, Psychodrama in Counselling, Coaching and Education 4, https://doi.org/10.1007/978-981-99-7508-2\_5

slipping into a flashback and feeling like he is losing his dignity or being scared to death. (6) Flashbacks are often triggered by *very small* scenic stimuli. These stimuli resemble memory fragments from the trauma situation. For example, a specific smell or the sight of a man in a white coat triggers a flashback sometimes.

#### *Case example 32*

*The 67-year-old Mr. A. sought outpatient psychotherapy to treat his recurrent moderate depressive episodes (F33.1). Five years ago, his thyroid had been removed because of cancer. He decompensated into depression once again four weeks ago. This was triggered by a regular check-up concerning his cancer. He groans in agony in the psychotherapy session: "It was good all summer! I could really enjoy the time! But now I am again powerless, resigned, and helpless. I'm afraid!" The therapist understands the patient's depression as the result of retraumatization: the patient contracted polio meningitis when he was a four-year-old little boy. He had to spend eight months alone in an isolation room in the hospital. His family was not allowed to visit him. Doctors and nurses clothed in white 'attacked' him at regular intervals. They held him with physical force and stabbed him with a syringe in the back to withdraw nerve fluid from his spinal canal. At age 67, if Mr. A. sees a man in a white coat, he again experiences a flashback. The therapist recognizes the flashback through the significant negative effect of a small specific scenic trigger. His flashback does not occur if he sees a woman in a white coat or a man in a green coat.*

*Mr. A. hates himself in his depression because of his 'weakness'. He comments sarcastically: "I am obedient again." The therapist feels helpless in the face of the patient's depression. In the beginning, he interprets his behavior as a neurotic adaptation. He asks why Mr. A. is still doing the follow-up examinations for cancer more than five years after his operation: "Your cancer never metastasized. If the doctors offer you check-ups, you blindly obey them!  A reports: "I canceled the last follow-up. But I did it because of the flu. My wife encouraged me to do this. I felt as helpless and dependent as a child! I needed someone who would allow me to do that!" Only now does the therapist realize that the patient felt and behaved like the little four-year-old boy in the hospital during the last therapy session. In his flashback, he had been unable to engage in healthy adult thinking (see* Sect. 4.7*). The therapist apologizes: "I'm sorry! It was unfair of me to get angry and ask you to be less conformist. You couldn't help it! When you are having a flashback, you have no choice. It is as if you are sleepwalking under hypnosis." The therapist places an empty chair next to the patient. He places the hand puppet of a little boy on it and points with his hand to this second chair: "The chair represents the little four-year-old boy in you who is traumatized." The patient looks at the doll and is visibly annoyed. The therapist: "I notice that the chair for the little traumatized boy is too close to you. I'll put it here in the corner of the room." The therapist and the patient work together to find indications for the flashback. The patient writes them down: (1) "When I feel like a child again." (2) "When I feel lethargic again." (3) "When I internally feel: You must be nice!" (Continuation in* Sects. 5.5 *and* 5.9*).*

### **5.2 Definitions of a Trauma-Related Disorder and a Traumatizing Situation**

According to the ICD-10 (2004, p. 187), post-traumatic stress disorder (ICD-10 F43.1) (PTSD) arises "as a delayed or protracted reaction to a stressful event or a situation of shorter or longer duration with an extraordinary threat or catastrophic magnitude that would cause deep despair in almost anyone. […] The beginning follows the trauma with a latency lasting from a few weeks to months. […] In a few cases, the disorder takes a chronic course over many years and then turns into a permanent personality change (F62.0)."

There are two main forms of *coping* with psychological trauma–internalization and dissociation. Analogous to this, one can differentiate between two forms of trauma-related disorders, (1) relationship trauma in childhood and (2) post-traumatic stress disorder caused by trauma in adulthood. Patients who were *traumatized in childhood* often suffer from borderline personality disorder (Mentzos, 2011, p. 170), another personality disorder, depression, or anxiety disorder. These patients are fixed in a mutually stabilizing defense system of *masochistic self-censorship and compensatory mechanisms* (Mentzos, 2011, p. 39) that they developed as children in response to their childhood trauma*.* The defense system helped them avoid giving meaning to the traumatic experiences. Self-protective behavior (see Sect. 4.7) includes defense through grandiosity, perfectionism, or functioning in the role assigned from the outside (see Sect. 4.7). Patients with post-traumatic stress disorder because of *trauma in adulthood* have *not yet* developed a rigid defense system.

1. *Direct traumatization* in childhood occurs through sexual abuse, violence, or severe experiences of loss. These events mostly take place in the family context. *Indirect traumatization* in childhood occurs when a child is physically and emotionally neglected by traumatized or severely mentally ill parents. The child then experiences his wishes and needs as 'wrong' and thus develops reactive masochistic self-censorship and defense through grandiosity and perfectionism to avoid rejection by emotionally unstable caregivers. In adulthood, this leads to masochistic thinking and acting (see Sect. 8.5). The unseen, *"abandoned child"* could not sufficiently develop the tools of his inner conflict processing in interacting with his childhood caregivers.

Traumatized children cope with the trauma through internalization (Hirsch, 2004, p. 2). "A traumatic introject persists, threatening like a dreadful hostile, archaic superego (causing symptoms and pathological behavior), which is only partially held in check by various forms of identification with the aggressor (primarily fusing and secondarily identification)" (Hirsch, 2004, p. 1). Those affected internalize their trauma experience in the form of a perpetrator-victim complex.

2. Patients with adult-onset *post-traumatic stress disorder* (PTSD) suffer from flashbacks in response to even minor external triggers. They cope with their trauma through dissociation. A sudden, extreme impact of violence had initially overwhelmed their psychic apparatus. They split off their observing ego (their cognitive processes) from their acting ego (the perception of affect, physical sensations, and sensorimotor interaction patterns) when dissociating (see Sect. 5.4). This helps patients survive mentally, *at least in the beginning* (Hirsch, 2004, p. 2). However, dissociation persists as a response and becomes a permanent *pathological defense* if the trauma is *not processed*. As a result, the clinical picture of post-traumatic stress disorder develops with recurring flashbacks.

#### **Important**

Three conditions define a traumatizing situation: (1) The person concerned is emotionally overwhelmed by the situation. (2) He cannot fight and (3) He cannot flee. He, therefore, *cannot physically act* to protect himself.

#### *Case example 33*

*Kurt Lewin (Hans-Ulrich Wolf, 1999, oral communication) reported on school children locked in a cave while visiting the cave. The teacher was outside the cave when the entrance to the cave collapsed. All children suffered from post-traumatic stress disorder after their rescue. Only one boy was not affected. They investigated why this child had processed the event differently than the other children. It turned out: this boy had not been overwhelmed with panic like the others and had not just waited passively. Instead, he continued to look for an exit from the cave. Eventually, he found an exit and led the other children out of the cave. A short while later, the cave collapsed completely. So the boy wasn't frozen in shock. He had acted and tried to change the threatening situation.*

*The same happened to a cashier and his colleague in a bank robbery. The cashier kept negotiating with the perpetrator about handing over the money. But, his colleague hid under a table in panic and feared the perpetrator might discover her at any moment and shoot her. Unlike his colleague, the cashier did not develop any post-traumatic stress disorder afterward.*

#### **Recommendation**

Therapists should know *which* events *can potentially* traumatize a person.

Gunkel (1999, p. 54 ff.) has made a list based on international literature: 46– 78% of Holocaust victims are traumatized. 30% of soldiers who experienced combat missions and 12% of soldiers without any experience of combat mission suffer in retrospect from a trauma disorder, 16–35% of Vietnam veterans, 10–20% of Canadian UN soldiers, 25–50% of refugees, 31% of victims of state repression or violence, 90% of political prisoners from Vietnam who have experienced torture. Three months after sexual abuse or rape, 48–80% of those affected have a trauma-related disorder, four times as often in *sexually* abused children as in *physically* abused children. 10–23% of the bus drivers who were attacked while driving suffer from a trauma-related disorder. 7–34% of police officers develop trauma-related disorders after rescue missions or violent experiences, for example, 31% after the collapse of a grandstand. 16% of those affected develop post-traumatic stress disorder after a cardiac infarction, 13% after heart transplants, and around 10% after blood cancer treatment. Between 30 and 40% of parents suffer from trauma-related disorders after treating a child with cancer, between 18 and 23% after traffic accidents, 22% after a plane crash, 5–42% after natural disasters such as earthquakes, and 14% after losing a close reference person. There is also a high trauma potential if one was unwanted as a child, had to experience cancer themselves, or had to provide long-term care for a seriously ill family member. Patients with post-traumatic stress disorder (PTSD) have often experienced not just one but multiple traumas in their life.

#### **Central idea**

PTSD can be a result of accidents or natural disasters. Trauma experiences caused by *violence by people* are more likely to result in PTSD because those affected also lose their basic trust in relationships.

Not *everyone* is traumatized by a *potentially* traumatizing event. The percentages in the list above show this. The consequences of traumatizing events depend on (1) the age at which the traumatizing event occurs, (2) the severity and duration of the traumatizing events, and (3) the number of traumatic events the individual had to experience. A history of mental illness can lower the threshold for developing a trauma-related disorder. The patient's psychological resilience is an important protective factor. Sensitive people are more easily traumatized.

#### *Case example 34*

*A student who was repeatedly depressed for months sought help in an esoterically oriented group that offered 'guided regressions'. The group members searched for their own experiences of violence in their 'past lives' under the guidance of a 'guru woman' who seemed to be traumatized herself. Anyone who did not participate in the 'regression' or left the group was considered 'evil and devilish'. After spending six months in this community, the student decompensated into paranoid psychosis. The sensitive young woman had not been able to endure the tension of the conflict with the idealized 'master' and had collapsed mentally. She was convinced that the sect's leader had become influenced by extraterrestrials and became 'evil'. That was a true symbolic image of the actions of the 'master'. But, the student experienced this symbolic image as an external reality in the equivalence mode (see* Sect. 2.6*).*

### **5.3 Symptoms of Trauma-Related Disorders**

According to Gunkel's review of the literature (1999, pp. 54 ff.), around 5% of male and 10% of all female Americans develop post-traumatic stress disorder as a result of a traumatic event at some point in their lives. Around 26% of bulimia patients have experienced sexual assault or rape and suffer from trauma-related disorders, as do 68% of prostitutes and 52% of patients with eating disorders. Around 35– 52% of persons with psychotic disorders suffer from trauma-related disorders four to eleven months after an acute phase of illness, as well as from 'invasive psychiatric treatments'. According to the study, 30–90% of people with borderline personality disorder are traumatized. According to a more recent review (over 53 studies) by Simpson and Miller (2002) (quoted from Schäfer & Reddemann, 2005), 27–67% of women and 9–29% of men with addictions were sexually abused in childhood. 33% of women and 24–33% of men with addictions were physically abused in childhood. A Dutch study of patients with alcoholism demonstrated that 28% of men and 46% of women experienced physical *or* sexual violence or physical *and* sexual violence in childhood.

According to Reddemann (1999, p. 88), traumatized people suffer from constant agitation (DSM-IV criterion D: 'hyperarousal') and sleep disorders. They are easily vulnerable, excessively nervous, and find it difficult to calm down. They are constantly in fear, are easily insulted, and are less capable of dealing with conflict, especially when the topics of conflict are related to their traumatic experience. "The repeated experience of the trauma in the form of intrusive memories (DSM-IV criterion B: intrusions) […] against the background of a constant feeling of numbness is characteristic of people with traumatic experiences" (ICD-10). 'The Broca speech area is not activated or not sufficiently activated during a flashback. In other words, speech and language are not or hardly accessible" (van der Kolk & Fisher, 1995). People with traumatic experiences exhibit one or more of the following symptoms: acute anxiety states, depression, multiple psychosomatic symptoms, somatization disorders, phobic or compulsive behavior, a constant feeling of numbness and emotional dullness, recurring nightmares and flashbacks, outbursts of anger, indifference in interpersonal relationships and the inability to love, mysterious behavior, drug or alcohol abuse, distracting, 'sensation-seeking' lifestyle and/or dissociative states with depersonalization and derealization through to mini-psychoses. Avoidance (DSM-IV criterion C) of activities and situations that could trigger memories of the trauma is also pronounced. Thoughts of suicide are not uncommon. Often there is an unconscious wish to control everything to avoid being helpless at the mercy of a threatening or chaotic situation again.

### **5.4 Dissociation as a Central Characteristic of Trauma-Related Disorders**

#### **Important definition**

According to van der Kolk and Fisher (1995), the 'nature of trauma is to be dissociative'. People with relationship trauma in their childhood *also* dissociate when their trauma experience is triggered (see case example 32 in Sect. 5.1).

#### **Central idea**

For people with traumatic experiences, dissociating is "like everything that we can later describe as pathology [...], a normal way of coping with the trauma" (Reddemann, 1999, p. 87). It helped those affected *by the original traumatizing situation* to detach themselves from the overwhelming and destructive feelings and to experience the trauma as if it happened to someone else (Putnam, 1988, p. 53).

"When the physiological mechanisms of fight and flight no longer work, the only thing left for humans is dissociation as a quasi-psychological flight mechanism. […] Traumatized people often describe these experiences by reporting that they left their bodies in the traumatic situation" (Reddemann, 1999, p. 87). "Dissociation leads to the trauma memories […] being organized as sensory fragments and intense emotional states […]" (van der Kolk et al. 1996). Dissociation in the traumatizing situation can help those affected *still function externally* and, for example, save their lives (see case example in Sect. 5.17.2). The consequence, however, is that later the trauma experience is not processed like other experiences because the patient immediately dissociates when attempting to deal with the trauma. His ability to process conflict freezes. In the case of post-traumatic stress disorder, the traumatic memories often only become conscious in a new, protected environment. By definition, however, they are then *unprocessed*. Those affected get caught in the vortex of their unprocessed trauma memories and are tormented by their trauma images. Even small triggers evoke the dissociation again. Dissociating becomes a *symptom*.

#### **Central idea**

According to Reddemann (1999, p. 89), the agonizing thing about flashbacks is "that they are experienced as if they were happening now, which means the reliving of traumatic states is not remembrance, but retraumatization." "Triggered by a memory, the past can come alive with sudden sensory and emotional intensity such that the victim feels as if the entire event is happening again in the present. Patients with PTSD seem trapped in their trauma and cannot distinguish it from the present" (van der Kolk, Burbridge, and Suzuki, 1998, p. 58 f.). They experience their flashback in equivalence mode (see Sect. 2.6).

Dissociating is a "complex psycho-physiological process involving the disintegration and fragmentation of the consciousness and […] the memory, the identity and the perception of oneself and the world around" (Gast, 2000, p. 170). According to Gast, there is a distinction between five main dissociative symptoms: amnesia, depersonalization, derealization, identity insecurity, and identity change.

A flashback with dissociating leads to an uncontrollable full-blown stress reaction. If the fear is uncontrollable, the hippocampus in the human brain begins to pull in the extensions of its nerve cells (Hüther, 2002, *only* from oral communication). In people with severe post-traumatic stress disorder, the hippocampus volume can decrease by 8–22% (van der Kolk et al., 1998, p. 69). This leads to hyperexcitability and disinhibition of behavior because it is more difficult to bear and process *emotionally arousing information* with a reduced hippocampus volume. Those affected often estimate new stimuli as a general threat and react immediately with aggression or withdrawal (van der Kolk, Burbridge, and Suzuki, 1998, p. 72).

#### **Important definition**

Wurmser (1998, p. 425 f.) has developed a definition of dissociating that captures *several metacognitive processes*. He understood dissociating as 'a *form of a split between the observing and acting egos* with depersonalization as an important event. This split or dissociating involves a massive denial of inner reality, namely overwhelming emotions (blockade of emotions). Other forms of defense also play a role but pale in comparison to the defense through denial/blockade of emotions. This also includes a *counter-fantasy* that supports denial and is intended to invalidate the perception of reality'.

#### **Central idea**

When dissociating, those affected split the current psychosomatic resonance circuit (see Sect. 2.7) in the *internal* process of self-development in the *external* situation into (1) the cognitive process of thinking and naming and (2) the psychosomatic process of sensorimotor interaction, physical sensation, and emotional experience (see Sect. 2.7).

### **5.5 The Therapist Witnesses the Traumatization and the Dissociating**

Many patients with trauma-related disorders ascribe *no meaning* to the traumatic events in their mental development. They defend through denial and don't talk about it either. Because if they did, they would potentially activate the associated psychosomatic resonance pattern and with it their *unprocessed* panic, horror, and alienation of the traumatizing situation and have a flashback. Traumatized patients thus feel defenseless in response to the trauma-related symptoms. They aren't able to do anything which further intensifies the symptoms. They are afraid of going crazy when they have a flashback. But they 'don't want to burden other people with their problems'. They are *ashamed* of their 'abnormal' thoughts and feelings. They notice that they are different from others and fear being excluded from the community. Only 2.9% of the soldiers in the German Armed Forces allegedly suffered from posttraumatic stress disorder after a deployment in Afghanistan (Schulte-Herbrüggen & Heinz, 2012, p. 557). But 9–20% of American soldiers developed depression or posttraumatic stress disorder after deployments in Afghanistan (Wittchen et al., 2012, p. 559), 14% of them even became seriously ill (Süddeutsche Zeitung, December 20, 2011, p. 9). Many US employers are reluctant to hire veterans from the Iraq wars because of the reputation of emotional instability that precedes them. Presumably, German veterans *only rarely talk about* their trauma experience because they rightly fear the hindrances in their promotion in the Armed forces.

#### **Central idea**

Patients with PTSD develop masochistic self-esteem issues or compensatory behaviors in response to their flashbacks. The therapist *must not* interpret and treat a traumatized patient's self-esteem issues or depressive inhibition *as neurotic* because that often *intensifies* the patient's depression.

#### **Recommendation**

The therapist informs the patient as early as possible that his depression results from a traumatic experience and puts a second chair next to him for his traumatized ego (see Sect. 5.8): "The chair symbolizes your traumatized ego and your trauma film. You don't understand yourself because you experience flashbacks even with small triggers. This causes you to devalue yourself in addition to your traumatic experience."

The patient needs at least five therapy sessions to integrate the terms "trauma" and "flashback" with his own life experiences. But then he *feels relieved*, re-interpreting his symptoms. He no longer feels defenseless in response to the trauma-related symptoms because *he can act.* The therapist and the patient develop a plan for trauma therapy. The masochistic vicious circle disintegrates gradually. The patient understands himself for the first time. He develops a new motivation for therapy. The new self-knowledge opens therapeutic access to the patient's psychodynamically important conflicts.

#### *Case example 32 (1st continuation, see* **Sect. 5.1***)*

*In the first interview, Mr. A massively devalued himself because of his internal depressive paralysis: "Actually, I just want some peace! But my wife always criticizes me for being so withdrawn. I should play some sports and pursue some hobbies. I want that, but it doesn't work! We quarrel quite often." While taking the case history, the therapist discovered the trauma the patient experienced when he was four. He placed a second chair next to him and placed the puppet of a little boy on it: "Mr. A., that's the little boy in you who, at the age of four, had to spend eight months alone in an isolation room in the children's hospital. I suspect that you were traumatized by this dire experience as a child! How do you feel when you see the little boy you were, sitting over there on the chair?" Mr. A: "Not so good." The therapist places the chair of the 'traumatized child' in the other corner of the room behind the window curtain: "I think it is better for you this way! Otherwise, the old memories will flood back to you." The therapist places a second empty chair next to him and places the hand puppet of a knight on it: "This other chair represents your selfprotection through adaptation and grandiosity. You learned in childhood not to give meaning to your trauma experience. You were a brave hero who could do anything and take anything." The therapist points his hand to the 'traumatized child' behind the curtain: "But now, if you go to the clinic for a follow-up examination and see the doctors' white coats, you slip into your old trauma film. You feel and think like you did when you were four years old! Please, just read about trauma and flashback on Wikipedia!" Mr. A. initially reacted skeptically. But he then gave more details about his experiences at the age of four. He came home after the hospital stay and longed for safety and security as a four-year-old boy. But his mother immediately sent him with his grandmother to the Black Forest for a cure. He was supposed to learn to walk again after polio. The patient's parents were rigidly fixated on the old norms and values from World War II. It was only his performance that mattered to them. His father had been a hero in the war.*

*After two years of individual therapy, the patient finally saw himself as 'traumatized.' The patient's 'depressive phases' had disappeared except for the week he went for a medical follow-up. Mr. A. enjoyed his life and, for example, played creatively with his grandchildren. His wife, a former nurse, understood him better now. She allowed him to be different from others and to withdraw when necessary. The patient no longer devalued himself masochistically. He had developed a good relationship with his inner traumatized little boy. Mr. A. also informed the hospital doctors about his trauma disorder. He negotiated special conditions for himself. For example, he ensured he did not have to wait five hours for the examination in the outpatient clinic as he usually did. He had always met a lot of men in white coats there. But now, he would be the doctor's first patient to be examined at eight o'clock in the morning. The doctor spontaneously offered that he would take off his white coat.* *During his follow-up, the patient remained in the hospital alone in an isolation room for three days because he was injected with radioactive substances as a precaution to combat possible metastases. But he got a hospital room on a higher floor with a better view. And he was allowed to go for a walk in the park on the third day but could not approach other people that day because of his radioactive radiation. The patient thus experienced that, unlike in childhood, he could change his unbearable situation in the hospital of his own free will. He had gained some control over the retraumatizing situation. (continued in* Sect. 5.9*).*

#### **Central idea**

In metacognitive psychodramatic trauma therapy, the therapist symbolizes the patient's traumatized ego with a second chair next to him. In this way she separates his psychosomatic resonance pattern *in the traumatizing situation* there and then from his psychosomatic resonance pattern *here and now in the therapeutic relationship.* A psychosomatic resonance pattern includes the *inner* sensorimotor interaction pattern, the physical sensation, the affect, linguistic concepts, and the thoughts in the *external* situation (see Sect. 2.7). In the two-chair technique, the patient and therapist stand shoulder to shoulder and look at the patient's traumatic experience *from a meta-perspective*. This strengthens his cognition. He can talk and think more freely about the traumatic event. *Without* the second chair, the two psychosomatic resonance patterns would mix and most likely cause a flashback.

By naming and externally representing the 'traumatized ego' with a chair, the therapist becomes *a witness to the truth* of the patient's *existential* need. She acts *retrospectively* in the present as the patient's close caregivers *should have* acted in the past. Often a witness to the truth is *missing* during or after the traumatic event. The caregivers looked away. They were comfortable or fearful of aggression. But the therapist, as the witness, pays attention to what happens. She calls a spade a spade. She stands by the victim's side. Experience shows that this reduces the secondary self-devaluation after a traumatizing experience (Mentzos, 2011, p. 38 f.). Self-doubt arises, for example, when a mother actively looks the other way as the father sexually abuses their daughter. Everyday life in the family goes on as if nothing had happened. The abused girl then secondarily begins to doubt whether the crime actually took place.  In such a case, the victim develops a false self-image. The traumatized child needs a witness to the truth, who *validates* their feelings of betrayal, fear, and shame as a victim and counteracts *unjustified* feelings of guilt.

#### **Central idea**

In metacognitive trauma therapy, the therapist is an implicit doppelganger in the patient's inner process of self-development in the external situation (see Sect. 2.5). She must actively decide whether or not she wants to understand the patient's adverse experiences from adulthood or childhood as traumatic experiences. If she decides to do so, as a witness of the truth in her interaction with the patient, she calls the spade 'a spade'. This, *at least retrospectively,*  removes the secondary insecurity of the patient caused by the flashback.

#### *Case example 35*

*A 42-year-old patient gave the therapist feedback in the final therapy session: "In the beginning, the work on the relationship with my partner was actually a skirmish.* *However, there was a turning point for me in therapy. This was when you told me that my experiences with my father in childhood were a trauma. That's when my experiences became real for me. That gave me the right to feel what I feel. I believed that my fear of death was a real fear of death from the physical abuse by my father. That it was true! Before, I thought: 'You have to pray! Others have it worse!' By naming it as 'Trauma', you took me by the hand and walked with me for a while. It hurt me! But it was a crucial moment. I got to the core of it myself. I opened the door to my inner child, who was sitting behind the door: I opened the first door first. The child wasn't there. Then I opened the second door. She wasn't there either. She wasn't behind the third door either. But then there she was, behind the fourth door, sitting fully wet and feeling afraid!" (Continued in* Sect. 5.15*).*

Some therapists avoid openly naming a patient's trauma and flashback directly in front of the patient. They fear that it will retraumatize the patient. In doing so, they unconsciously identify with the patient's defense through denial and act out countertransference. But in patients with trauma-related disorders, *dissociating* contributes to the development of symptoms. Therefore, it is essential to treat *dissociation* in psychotherapy.

### **5.6 The Seven Phases of Psychodramatic Trauma Therapy**

#### **Recommendation**

"Trauma is chaos, and chaos needs structure" (Reddemann, 2007, *only* oral communication). The patient had no influence on the traumatizing event *in the traumatic situation* itself. *In therapy*, he should therefore have control over what happens to him. The individual steps of trauma therapy are to be discussed openly and clearly with him.

The therapeutic approach can ideally be divided into seven *consecutive* phases (see Fig. 5.1): (1) The *preliminary phase* of trauma therapy addressing the patient's defense system (see Sect. 4.10), (2) *Trauma-specific diagnosis*, (3) *Trauma-specific crisis intervention*, (4) Learning *self-stabilization* techniques, (5) The *processing of trauma with exposure to trauma*, (6) the *phase of integrating the inner change*  into childhood and current relationships, and (7) The therapist and the patient work on the defense system developed in childhood (see Sect. 4.10) in order to free the self-development from its fixation.

Many patients with trauma-related disorders come to therapy with a diagnosis of personality disorder, anxiety disorder, depression, or addiction disorder. Often the therapist only notices it *first during the treatment* that the patient is suffering from a *trauma-related* disorder. A trauma-specific diagnosis (see Sect. 5.7) and learning the self-stabilization techniques require at least ten individual sessions. This work can also be done by consultants from the helping professions. But, one should proceed with *processing the trauma* (see Sect. 5.10) only during *long-term therapy* of more than 30 sessions. It requires further training as a psychodrama therapist.

**Fig. 5.1** The six phases of psychodramatic trauma therapy

#### **Central idea**

In the mentalization-oriented psychodrama therapy of trauma-related disorders, the therapist always works also metacognitively. She lets the patient realize the *metacognitive processes* of his dissociating in the as-if mode of play and focuses on them in her therapeutic communication (see Sects. 2.14 and 5.10).

Patients who suffered relationship trauma in their *childhood* developed permanent mutually stabilizing compensatory mechanisms and masochistic self-censorship (see Sect. 8.5) to help them cope with their lives to some extent. Their rigid defense patterns often lead to severe relational disorders, depression, or anxiety disorders. But, the patients experience their defense through perfectionism and grandiosity and their self-censorship as parts of their character and identity (see Sect. 4.2). They couldn't internally develop a concept of appreciation in relationships in childhood. They, therefore, give no meaning to their traumatic childhood experiences. For example, they often see their traumatizing parents as 'loving parents'. They also perceive their unfortunate living conditions in the present as 'normal' and their 'personal fate'.

#### **Central idea**

In the *preliminary phase* of trauma therapy, patients with trauma-related disorders must often first work on their defense through grandiosity, perfectionism, and masochistic selfcensorship. This is the only way they gain access to their childhood traumatic experiences (see Sects. 4.8 and 4.10).

### **5.7 Trauma-Specific Diagnosis**

Patients with childhood relationship trauma often come with presenting complaints of anxiety, depression, severe relationship disorders, or an addiction. Mostly they do not know that they are suffering from a trauma-related disorder. The therapist may recognize the traumatic quality of the patient's childhood experiences, perhaps while taking the case history. But if she works with the patient *empathically* during therapy, she often unknowingly takes over the patient's defenses and 'forgets' to give his trauma experiences sufficient attention.

#### **Central idea**

Only when the symptoms persist for a considerable period, and there are noticeable disruptions in the therapeutic relationship, the therapist becomes aware of something essential still missing in the therapy process. In such a case, the therapist can use steps 13–17 of psychodramatic self-supervision (see Sects. 2.9 and 4.8) to identify the patient's dominant defense pattern.

#### **Recommendation**

If during therapy, the therapist suspects that the patient's symptoms, for example, his depressive episodes, *may* reflect a trauma-related disorder, she *re-examines* the patient's diagnosis.

The following therapeutic experiences indicate a trauma-related disorder: (1) The patient *repeatedly* decompensates psychologically. (2) The *extent* of the psychological breakdowns is difficult for the therapist to empathize with and does not match the seemingly harmless triggering circumstances. (3) The patient exhibits *symptoms*  of a trauma-related disorder (see Sect. 5.3). (4) He is unusually *distant* in verbal communication or cannot be reached emotionally. (5) The *therapist feels incapable*, helpless, strange, or mystified in the therapeutic relationship. (6) If the therapist represents the 'inner child' of a patient with childhood trauma with a second empty chair (see Sect. 4.7), the patient *rejects his 'inner child'* instead of addressing him (see Sect. 5.8).

#### **Recommendation**

The therapist must not *depend on the patient's consent* when diagnosing a 'trauma-related disorder' because many patients ascribe no meaning to their trauma experience. If they did that, they would get caught in their flashback or activate their inner 'blind sadistic prosecutor' (see Sect. 4.7). Therefore, the therapist first decides *on her own* whether she perceives the patient as traumatized.

Some conspicuous, apparently pathological behaviors of the patient are to be understood as *necessary* self-protection through self-stabilizing actions. The therapist may reinterpret them in a radically positive way. For example, the therapist *spontaneously* sees a 90-h workweek in a person with *neurosis* as problematic and questions it. In the case of a *patient with trauma*, however, she interprets it as a 'self-discovered technique of self-stabilization in the case of a trauma illness'.

*Working with the table stage* (see Sect. 5.10.10) helps to gain an overview of the interaction between the existing conflicts when making a diagnosis. The *technique of the self-regulation circle* (Krüger, 2010a and see below) is indicated to retrace the patient's self-regulation in *recurring conflicts* and recognize any flashbacks that occur in the process. The *chair work* (see Sect. 4.7) helps to increase the patient's awareness of his defense through adaptation, grandiosity, and masochistic self-censorship.

The therapist works as follows when working with the *self-regulation circle*:

(1) She puts an A3 size sheet of paper on the table and draws a large circle on it. (2) She marks the crisis with a minus sign on the *right* side of the circle and the patient's well-being with a plus sign on the *left*. She marks the conflict process with an arrow, from the positive pole to the negative and vice versa. (3) The patient then notes his thoughts, feelings, actions as well as the events, step by step, along the circumference on the right side indicating the way *into* and on the left side indicating the way *out of* the crisis: "What did I do? What did I feel? What did I think? What did I want then? Then what happened? Then again what did I do? … feel? … think? … etc." The patient uses the self-regulation circle to understand his recurring conflicts: What is his contribution to causing the crisis? But also, what is his contribution to becoming well again?

#### *Case example 36*

*The 28-year-old Mrs. A seeks* crisis intervention *because she is 'feeling bad again'. She has had several traumatic experiences in her childhood and youth. She struggles with borderline syndrome with reactive psychotic episodes (F60.31). The small, pretty woman looks exhausted and depressed. She reports: "I have hardly slept in the last 14 days. Therefore, I had to go home yesterday while working in the supermarket. I messed everything up. Everyone points their fingers at me. They want to test me!" The therapist makes an offer: "Together, we could examine and make a note of what happens when you have mood swings." The patient creates a self-regulation circle. At the end of their collaborative work, the following is written on the paper along the circumference from well-being to crisis: (1) "We are going to my grandma's home unannounced. (2) She is happy. (In her childhood, the grandmother was the only one who gave the patient support and security in the broken family.) (3) My husband is nice. Grandma is doing fine. I am fine. (4) The vacation is over. We are driving home. (5) I'm afraid that people at work won't want me. (6) I have trouble sleeping, have stomach cramps, and I panic.  I have diarrhea. (8) I am afraid of being considered lazy. (9) I am constantly afraid that other people will see what is happening to me and laugh at me. (10) I play something for everyone. They shouldn't notice anything. (11) Nothing works at home anymore. (12) Nothing is fine at work. (13) I think other people are testing me."*

*On the way from crisis to well-being, the patient notes: (14) "Shame motivates me to perform. (15) I am afraid of being considered evil. That's why I try to be a good person. (16) I work a lot and work overtime without pay. I am good at home and a good mother. (17) My self-esteem increases. I'm doing fine. (18). But I feel bad when I have nothing to do." The therapist positively interprets the patient's imperfect solutions as 'self-discovered self-stabilization techniques'. This stabilizes the patient. She feels understood and gains distance from her dysfunctional actions and feelings during the crisis. She even smiles a little at the end of the session. She takes home the paper with the self-regulation circle.*

*Five days later, Mrs. A. reports spontaneously in the following therapy session: "I have discovered something. Something is still missing in the circle: When my husband and I returned from our vacation, the laminate floor in the hallway of our apartment had swollen. My husband accused me of pouring water on it while cleaning it. I knew very well that it was not true. I even told him that. But he didn't believe me.* *Afterward, it turned out that a water pipe had burst during our vacation. I often have to justify myself for things I am not responsible for." The therapist and the patient add four additional steps to the 'self-regulation circle' between steps 4 and 5: 4 A. "My husband or others, like my father in childhood, do not believe me. My thoughts and feelings don't matter. 4 B. My trauma film takes over: I feel I am nothing, and I am no good. 4 C. I become insecure and devalue myself. 4 D. I feel that I am being manipulated." The patient knows the feeling of manipulation from her childhood. Her alcoholic father and mother had abused her narcissistically.*

When working on the self-regulation circle, the therapist avoids any evaluation and strictly adheres to the conviction: 'The patient's soul does nothing for free'. The more inappropriate the patient's thinking and feeling in the described conflict, the more likely it is an *expression of a flashback*. The therapist names the trauma as 'trauma' where applicable. He explores, together with the patient, the external stimulus that triggered the flashback. But then he does *not* continue exploring the trauma experience so as not to destabilize the patient further. Instead, he reinterprets the patient's self-protective behavior and denial in a consistently positive way. He refers to it as a 'solution' or 'self-stabilization technique' she has found herself, even if the solution seems ludicrous initially (see steps 17, 18, and 19 in case example 36 above). Working with the self-regulation circle strengthens the patient's *cognition*. It helps her observe and describe the content of her conflict from a meta-perspective, as well as internally assign her psychosomatic experiences on the table stage. The therapist, as an implicit doppelganger (see Sect. 2.5), stands *shoulder to shoulder* with the patient during the elaboration and mentalizes on her behalf if necessary. He helps her to name and differentiate her feelings. In doing so, he activates the patient's inner mentalization in her recurring conflict and facilitates her inner conflict processing. With the therapist's help, the patient learns to think of her recurring conflict in the as-if mode. This method helps patients feel more courageous when dealing with their recurrent conflict, more hopeful, and lively in their encounters. The mutual psychosomatic resonance warms the therapist's heart.

#### **Exercise 13**

Create a self-regulation circle *for one of your own recurring conflicts*. Underline the *personally* meaningful statements and mark in red the actions for which you think: "But it can't stay that way!" You will notice: Until now, you have understood your problem in such a way that you are swaying between *two opposing poles*: "I'm not feeling well, now I'm fine again, now I'm not well again". But the image of your self-regulation circle changes the internal development of your self-image in your conflict (see Sect. 2.4.1). You can see your participation *in the emergence* of your conflict and also *in coping with it* with greater clarity.

### **5.8 The Initiation of Trauma Therapy**

#### **Question**

Why Moreno's statement 'Acting heals more than talking' is important in psychodramatic trauma therapy?

The trauma-specific *diagnosis*, the *crisis intervention*, and the *initiation of trauma therapy* merge into one another. Trauma therapy is usually initiated due to a disruption or crisis in the therapeutic relationship (see Sect. 5.7) or in the patient's everyday life. Even a therapeutic conversation about a *traumatic* experience can exacerbate a patient's symptoms or trigger a flashback. This also applies to trauma-related disorders caused by trauma in childhood. For example, a 36-year-old patient in a psychosomatic clinic had a pseudo-epileptic seizure in the initial interview as he narrated his childhood experiences. He went into a trance state in which he 'acted out' his rape as a child in the children's home.

#### **Central idea**

The therapist struggles with a *dilemma* in trauma therapy. The patient asks her to treat his trauma-related disorder. However, as soon as the patient remembers his traumatic experience and talks about it, he often feels bad and slips into his flashback. His conflict processing freezes. Therefore, he cannot process his trauma experience *through talking*.

The therapist resolves the therapeutic dilemma in mentalization-oriented trauma therapy by letting the patient retrace the three metacognitive steps of dissociation in therapy in the as-if mode of play. Over time, the patient develops ego control over his dissociating (see Sect. 2.14). The therapist thus works also on his dysfunctional metacognitive processes that produce his dysfunctional cognition and makes them the subject of therapeutic communication.

the chair over there, what emotions does it trigger in you?" The more severe the trauma and the stronger the patient's structural disturbance, the more likely he is to seek help from the therapist: "That scares me!" or: "I don't like the child. I'm disgusted with him!" Such a reaction is a *diagnostically* valuable indication that the patient has a trauma-related disorder. Non-traumatized patients are more likely to answer: "The child makes me sad." "I feel sorry for him."

6. If the patient reacts with panic or disgust to his inner child, the therapist *immediately* grabs the chair representing the patient's 'traumatized child' and moves it to another place far away in the room.