11.1 Peculiarities in the Treatment of Persons with Pathological Deviant Behavior

Similar to people with addiction (see Sect. 10.5), patients with pathological deviant behavior suffer from a metacognitive confusion between healthy adult thinking and a deviant dysfunctional ego. In this case, it is the “stealing self,” the “gambling self,” or similar.

Case example 130

Ms. B suffered from alcohol addiction. She had become abstinent with the help of a therapy group for people with addiction. Four months later, she reported to the group with shame: “I want to tell you something. But I would like this information to stay in the group!” In response, the group participants renewed their promise of confidentiality and assured that they wouldn’t share information with anyone outside the group. Ms. B. said: “I have recently started stealing from department stores.” She reported on seven such events: “As a manager in the public sector, I cannot afford it at all! I see this as a displacement of my addiction.” The group discussion made it clear that “stealing” gave Ms. B a “kick”. It was about playing with the boundaries. Ms. B. felt driven to do something crazy so that she could feel: “It worked!” She further added: “I thought I must address this openly here. Perhaps then I’ll be able to stop doing that.” In sharing this, the patient “openly admitted her mistakes” to the group (5th step of Alcoholics Anonymous). Five years later, she reported that she stopped stealing (ICD10: F63.2) soon after this group session. In addition, she continued to abstain from alcohol and stabilized herself mentally.

People with pathological deviant behavior often suffer from a personality disorder or trauma-related disorder. However, their deviant behavior causes additional secondary symptoms, similar to Jellinek’s list of addiction symptoms (see Fig. 10.1 in Sect. 10.4 and case example 108 in Sect. 10.4). Patients carry out their symptomatic behavior secretly (2nd question in Jellinek’s questionnaire). They think about their symptom behavior consistently (3rd question), feel guilty about their deviant behavior (5th question), avoid talking about it (6th question), use excuses to justify their behavior (8th question), and try to be completely abstinent from time to time (11th question). The patient in case example 116 (see Sect. 10.6.6) repeatedly drove to his vacation spot on his own to indulge in his acts of fetishism for days in a row (22nd question). The following symptoms can additionally appear: The patient behaves aggressively toward his environment (9th question). He has a system for when to act on his impulses and when not (12th question). His pathological deviant behavior became a compulsion for him (29th question).

11.2 Case Example of a Patient with Fetishistic Disorder

Case example 131 (Krüger & Lutz-Dreher, 2002, p. 231 ff., Modified)

31-year-old Mr. A. had been married for five years and had a daughter. He was seeking treatment because, after being haunted by it for a long time, his “problem was exposed” four weeks ago. His wife had discovered lingerie in the packages he had ordered. She felt jealous at first, thinking he had a mistress. Then she feared that he might sexually abuse his own daughter. She confronted him. Eventually, she believed him that he wore the lingerie himself. With his consent, she arranged an appointment with a psychotherapist for him.

In the initial interview, Mr. A. reported a ‘liking for lingerie’. He described his rituals of fetishism. He usually retired to a room alone. He would secretly wear women’s clothes and imagine being a 17-year-old girl. As a girl, he is standing in front of an attractive middle-aged woman with a voluptuous form. The woman sternly orders him, the “girl”, to wear the ugly clothes of an old woman. As a girl, he had to obey this demand. Following the orders would arouse Mr. A sexually, and he would masturbate. After such rituals, he suffered from feelings of guilt and shame.

Mr. A. was usually anxious, inhibited, and insecure in social contexts. He always tried to meet the expectations of his superiors, colleagues, and his wife. He tried to gain recognition through extra work to stabilize his frail self-esteem. In doing this, he would overwhelm himself. He was often exhausted. He suffered from stomach pains whenever he was under tremendous pressure at work.

His therapy lasted only 24 sessions (see Sects. 11.3 to 11.6). In a follow-up examination two years after the end of therapy, Mr. A. reported that he had not practiced his fetishistic acts for more than two years. He hadn’t ordered any more lingerie. The disorder-specific therapy of his fetishism resolved his low self-esteem, inhibitions, and longstanding depressive symptoms (see Sect. 11.5). He was able to assert himself well in all his relationships. He drew clear boundaries at work, represented his point of view more convincingly, and thus gained recognition. He no longer allowed his colleagues to put all the work on him. He no longer felt overwhelmed: “I work a lot. But I enjoy that.” He was also better able to assert himself toward his superior and dared to ask for a higher salary: “I outdo her. A few weeks ago, she asked if I could imagine being a manager. I want to do that, but not yet.” Mr. A. built a new house with his wife and moved out of his in-laws’ house. They fought an awful lot over there. The patient openly asked his wife about her sexual fantasies, which embarrassed her. Now, the couple enjoyed being sexually intimate more often: “My sexual idiosyncrasies have taken a back seat. These sexual feelings do surface now and then. But it helps that my wife is proactive again.” At the end of the treatment, the patient said: “In therapy, it was important for me to recognize the causes. It helped that we examined the connection I made to my childhood experiences” (continuation in Sects. 11.4 to 11.6).

11.3 The Psychodynamics of Patients with Pathologically Deviant Behavior

Some depth psychology-oriented therapists immediately try to grasp and treat the “conflicts behind the symptom” in a patient with deviant behavior. They suspect that the deviant behavior disappears when the depressive symptoms are treated therapeutically.

Central idea

In the beginning, the deviant behavior helped the patients reduce inner tensions and deal with self-esteem issues resulting from childhood deprivation or trauma. Later, however, the cause and effect are reversed. The shame and guilt resulting from the deviant behavior lead secondarily to depression and self-esteem disorders. The therapist should, therefore, first treat the symptom of the deviant behavior in a disorder-specific manner. The patient’s depression dissolves on its own when he stops his deviant behavior.

The patients in case examples 131 (see Sects. 11.2 and 11.4 to 11.6) and 132 (see Sects. 11.6 and 11.7), for example, developed depressive symptoms as a result of their acts of fetishism. Understandably, they hid their symptoms from the outside world. Thus they ended up developing the defense mechanism of splitting. They alternated between two contrary ego states—the ‘everyday logic’ and the contrary ‘disguise logic’ (see Fig. 10.2 in Sect. 10.5). Over time, identity confusion arose. After all, they justified their actions to themselves with excuses and believed they were bisexual. The patient in case example 131 seriously considered sex reassignment surgery.

Sigmund Freud (1975, p. 384) interpreted acts of fetishism as substitute acts caused by castration anxiety: the little boy would discover that his mother does not have a penis like himself. That would trigger castration anxiety in him. The boy is afraid of losing his penis and therefore has to deny that his mother does not have a penis. He, thus, shifts his interest to the ‘mother’s’ breasts as a substitute for a penis.

Central idea

Freud confused cause and effect in his interpretation of the psychodynamics of fetishism. The castration anxiety is a consequence of fetishism and not its cause. The boy initially identifies as a child when wearing women’s clothes in a kind of role-play with his mother. By wearing women’s underwear in the as-if mode (see Sect. 2.6), he creates the intimacy he longs for but is missing in his relationship with his mother (see case examples 131 and 132 in Sects. 11.2 and 11.4 to 11.7). But the reaction from the social environment shames him. Therefore, he begins to enact his role plays secretly. Only the concealment of the enactment gives rise to pathological defense through splitting and identity confusion.

Freud (1975, p. 224 ff.) used the example of his grandson, who was just under two years old, to describe the ability of children to process conflicts in the as-if mode of play (see Sect. 2.6). His grandson’s mother regularly went out of the house during the day and only returned after a while. The little boy obviously didn’t like that his mother separated from him of her own will. In response, he invented the following game: He let a spool of thread roll under a cupboard and sadly commented, “Oh”. Then he pulled the thread out again and greeted the reappearance of the spool with a joyful “Aah!” Freud recognized that his little grandson was actively staging the separation from his mother, which had happened to him painfully passively at first, in a play of symbols (see Fig. 2.11 in Sect. 2.14). In doing so, the little boy controlled the painful separation with his own will and determined when his “mother” disappeared and when she returned to him. He developed “the aspect of the creator” (Moreno, 1970, p. 78) of his destiny by symbolically representing the passively suffered separation by playing with the thread spool. In his fantasy, he became the director in his interaction with his “mother”. In doing so, he got rid of the blocks in his fantasy caused by the passively suffered separation.

In childhood, acts of fetishism are initially a creative solution to conflict processing. However, in adulthood, they are accompanied by shame and guilt due to the sexualization of latent desires for intimacy. The acts of fetishism then become self-injurious acts. Indeed, as the creator of the “game”, the patient establishes closeness to his “mother”; however, after masturbating, he once again becomes the little boy who acted out a “forbidden” desire for intimacy. His shame intensifies his feelings of loneliness and worthlessness.

11.4 The Disorder-Specific Therapy of Pathological Deviant Behavior

A criminal thief has different psychodynamics than a patient who suffers from “pathological stealing” (F63.2) (see case example 114 (see Sect. 10.6.4). A thief exactly plans his criminal acts before executing them in the as-if mode of thinking. He strives for real external gain from objects, wealth, or power. Pathological stealing, however, primarily serves internal gain. The patient builds up a pleasurable tension before his act of theft and works it off, feeling a kick, through stealing. He thinks self-hypnotically in equivalence mode (see Sect. 2.6): He looks for the proper external framework, for example, a department store, in which he can act out his inner fantasies of power or potency in a kind of role-play. Thinking in the equivalence mode is the basis for pathological deviant behavior in pathological stealing (F63.2), pathological arson (F63.1), acts of fetishism (F65.0, F65.1), and also in deviant sexual behaviors (F65.2-F65.8) such as sadomasochistic practices.

Central idea

Pathological deviant behavior is the manifestation of a metacognitive disorder. A purely cognitive behavioral therapy approach is, therefore, not sufficient. Instead, the metacognitive disorder must be treated with metacognitive therapy. In the disorder-specific therapy of deviant behavior proposed here, the therapist makes the patient’s metacognitive confusion the subject of therapeutic communication.

The patient acts out his pathological deviant behavior in the equivalence mode. In doing this, he precipitates himself into a hypnoid state seeking a ‘kick’, and believes that he has to act in a deviant manner to reach that state. In metacognitive therapy: (1) The patient separates the psychosomatic resonance pattern (see Sect. 2.7) of his pathological deviant behavior from his healthy adult thinking. (2) He thinks through his deviant behavior as a holistic story with all consequences. (3) Internally, he consciously alternates between his healthy adult thinking and his psychosomatic resonance pattern of pathological deviant behavior in the as-if mode of thinking. He thus gains control of the ego over his metacognitive confusion. He mustn’t become a new person. He shall only truly feel and think in acting in a deviant manner, and not deceive himself in the equivalence mode. Therefore, he must be able to remember the procedure of his deviant behavior psychosomatically with all consequences.

Patients with pathological stealing are more likely to act out grandiose desires, whereas those with fetishism are more likely to act masochistically. Nevertheless, the sequential steps of metacognitive therapy are the same. I describe them using the example of the treatment of fetishism (see case examples 131 in Sects. 11.2 to 11.6, and 132 in Sects. 11.6 and 11.7):

  1. 1.

    Patients with deviant behavior often justify their behavior with excuses. However, the therapist refers to this deviant behavior as “self-injurious”.

  2. 2.

    The therapist represents the patient’s two ego states involved in his metacognitive confusion in the therapy room. To do this, she sets up an additional chair next to the patient for his “disguise ego”.

  3. 3.

    She explicitly interprets the deviant behavior in the second chair as “unconscious role play”.

  4. 4.

    As a metacognitive doppelganger (see Sect. 4.8), the therapist asks the patient to verbally describe his own feeling, thinking, and acting in the course of a typical fetishism ritual or theft action from the chair of the everyday ego.

  5. 5.

    The therapist represents the person the patient interacts with in his ritual scene with an extra chair opposite the “disguise ego” in the therapy room.

  6. 6.

    She has the patient shift from the chair of his everyday ego to the chair of his “disguise ego” and also psychosomatically experience his disguising in the as-if mode of play.

  7. 7.

    The therapist lets the patient act out the interaction in his most stimulating theft scene or his most stimulating fetishism scene beyond reality in a psychodramatic dialogue with role reversal.

  8. 8.

    In a role reversal, the patient determines the conflict partner’s thoughts and feelings in the fetishism scene and the motivations behind their actions. In doing this, he determines the conflict partner’s specific behavior that is arousing for him.

  9. 9.

    The therapist and the patient look for a connection between this special interaction pattern and the patient’s traumatic childhood experiences.

  10. 10.

    The therapist recommends that the patient refrains from performing his acts of fetishism for at least two months “to experience himself” and live abstinently (see case example 116 in Sect. 10.6.6). The patient should have a tangible experience of his feelings without his symptom action.

  11. 11.

    The therapist offers the patient the opportunity to give up his abstinence on a trial basis: “Your depression has disappeared after you stopped playing dress-up as a woman. If you miss something, try dressing up as a woman again. If you feel worse, you can stop disguising yourself again.” The conscious deviant action helps to complete the psychosomatic resonance pattern and the holistic story of deviant behavior with all consequences, if necessary.

  12. 12.

    The patient chalks up an emergency plan for himself. This plan includes thinking, feeling, and acting during his personal low point and his most humiliating experience resulting from his deviant behavior.

  13. 13.

    The therapy phases of relapse prevention and integration of the inner change in the current relationships follow (see Sects. 10.6.5 to 10.6.6). Finally, if necessary, the therapist also treats the patient’s underlying condition (see Sect. 10.6.7), for example, his narcissistic personality disorder (see case example 132 in Sect. 11.6 and 11.7).

Case example 131 (1st continuation)

In the initial therapy sessions, Mr. A. seriously considered whether his dressing up as a “girl” meant that he “unconsciously” wanted a gender change. In the fourth therapy session, the therapist placed a second chair next to him. He pointed to the chair with his hand and said, “When you put on women’s clothes, you are actually role-playing. You are creative!” The patient reacted skeptically: “Actually, I don’t see it as creative. I always think I shouldn’t do that and feel guilty.” Nevertheless, the patient was relieved by the reinterpretation of his fetishistic behavior as role-playing.

In the fifth session, the therapist asked Mr. A. to freely associate a fairy tale image for further diagnosis (Krüger, 1992, p. 230 ff.): “Tell me the name of a fairy tale. When you think of this fairy tale, which person or figure do you see in front of you? - Please describe the current situation of this fairy tale figure! What is the person doing at the moment?” The technique of fairy tale association naturally tends to bring to mind content and images with high energy. Therefore, the associated image is usually a symbol for a patient’s central conflict. For example, Mr. A. spontaneously named the fairy tale “Little Red Riding Hood”: “Little Red Riding Hood goes through the forest to see her grandmother. She is wearing red shoes.” The therapist: “Do you know why you thought of Little Red Riding Hood, who is on her way to see her grandmother?” Mr. A. spontaneously drew parallels between the seven-year-old Little Red Riding Hood and his childhood dress-up games. Between the ages of five and nine, he and his older sister found discarded clothes that belonged to his grandmother and mother in the attic. At that time, he often dressed up with his sister and engaged in role-playing games. They would enjoy dressing up: “Back then, I was just as naive and innocent as the Little Red Riding Hood.”

In the seventh session, the therapist asked the patient to tell him the exact sequence of a fetishism ritual. The therapist pointed his hand at the chair on which the patient was sitting across from him: “This is you as a grown man who comes home stressed out from work!” He placed a second chair for the “girl” next to the patient. He asked Mr. A. to move to the “girl’s” chair. The therapist questioned the patient in the girl’s role and, as a doppelganger, helped him verbalize his experience in this role. Mr. A. as the “girl”: “I always imagine an attractive elderly lady with heavy makeup sitting across from me. She is the girl’s mother. She is 45–50 years old, and the girl is 17 years old. Unlike the mother, the girl is unattractive, a wallflower. She behaves submissively. The mother orders the girl to wear an older woman’s clothes that would make the girl look ugly and inconspicuous.”

In the debriefing, Mr. A. noted with relief, looking at the chair next to him: “That’s good! I was afraid that my urge to play dress-up as a woman was a sign that I unconsciously wanted a sex change. But,” he pointed to the “girl’s” chair next to him and then to himself as “man”, “if I want, I can always go back to this chair and become a man again!” (Continued in Sect. 11.5 and 11.6).

With the help of the two-chair technique, the therapist resolved the patient’s identity confusion between him as the man and him as the “girl”. After three years of therapy, another patient with fetishism, 50-year-old Mr. C. (case example 132 in Sects. 11.6 and 11.7), described his identity confusion with very similar words: “I used to think of dressing up as part of my personality. I thought that maybe I was bisexual and couldn’t be any different. I told my wife that too. But now, after two years of abstinence, I don’t believe that anymore. My wife no longer believes that either. It would insult my wife if I were to dress up again.”

Central idea

The two-chair technique is the basis of metacognitive therapy for people with pathological deviant behavior. Using the two-chair technique, the patient perceives the second chair for his “disguise ego” as spatially separated from the meta-position. It liberates his healthy everyday self from the metacognitive confusion with his “disguise ego”. In addition, the psychodramatic role change between the two identities allows the patient to experience the contrary logic of his two opposing identities, psychosomatically and mentally separate from each other.

11.5 Developing Deviant Behavior into a Holistic Story

Central idea

The patient thinks in the equivalence mode when engaging in pathological deviant behaviors (see Sect. 2.6). He realizes his inner fantasy in his external action. However, the external reality does not adapt to the imagination. As a result, the patient’s inner fantasy remains fragmented. The patient continuously needs the scenic stimulus of real external objects to activate his fantasies.

The therapist understands the patient’s deviant behavior as an unfinished story. She let the patient think through the course of his deviant behavior in the as-if mode of play (see Sect. 11.4). The patient consistently shapes the reality, the logic, and the meaning (see Fig. 2.5 in Sect. 2.3) in the scene of his pathological behavior with the help of the therapist as a metacognitive doppelganger. In doing this, he completes the narration of his deviant behavior with its consequences. He learns to think of his symptomatic behavior in the as-if mode. It liberates him from the need to act out his deviant behavior in equivalence mode using objects in the external world. He can detach it from the external objects, such as the paraphernalia of disguise as a woman, and only fantasize about the disguise scene. The external shame-inducing situations fall away.

Case example 131 (2nd continuation)

The therapist and Mr. A. understood the patient’s fetishistic behavior as “role-playing” and resolved his metacognitive confusion with the two-chair technique. In the sixth therapy session, Mr. A said: While masturbating, “I no longer have the urge to put on women’s clothes. Instead, I only fantasize about dressing up.”

In the eighth therapy position, the therapist said to the patient: “I would like to understand what goes on in you when you wear women’s clothes. What was it like the last time you did that?” The patient and the therapist set up the scene of his inner imagination with chairs in the therapy room. It consists of one chair for the patient as an adult man, a second chair next to him representing him as the submissive “girl”, and the third chair opposite for the “mother”. Mr. A. changes to the role of the “girl”. On a table between his “disguise ego” and his “mother” lay “women’s clothes”. The patient: “The mother orders me to wear these clothes”. The therapist gives the “mother” a voice: “Put these clothes on!” Mr. A. defends himself as the “girl”: “But I don’t want to wear them!” As the “girl”, however, the patient finally gives in: “The girl is sulking a little now”. The patient finds it difficult to act like he is sulking: “I can’t do that!” The therapist lets the patient change into the role of “mother”. As an auxiliary ego, he takes on the girl's role and plays her according to the patient’s instructions. In the role of “mother”, the patient commands with great delight and authority: “You must wear these clothes now! Otherwise, you can’t get out of here!” The therapist stands up, stands next to the patient, and asks the “Mother” curiously: “What do you want to achieve by ordering the girl to wear these women’s clothes?” “Mother”: “I always want the girl with me. I want the girl to accompany me when I meet my friends for coffee.” The therapist: “Just look at the girl! Do you see that the girl enjoys pretending as if she obeys you?” The patient as “mother”: “Oh that’s not good at all!” In the debriefing, the patient describes the “mother’s” behavior towards the girl as “sadistic”. The therapist: “Yes, she is dominating! But the ‘mother’ is afraid that the ‘girl’ might leave her!”

When sharing his history at the beginning of therapy, Mr. A. said he was the youngest of three children. He’d always been a good boy. There was always work at home. His father had been a craftsman and also managed a small farm. His mother had little time and was always busy: “That’s why my mother locked me in a crib when I was two and three years old. She would leave me screaming in there.” Mr. A. was a “model student” in his first two years at school. But, he usually got the short end of the stick in the scuffles. That’s why he learned judo. He wanted to be able to defend himself better. As a teenager, he was shy and inhibited, especially around girls. He moved out of his parent’s house at 21 because he “no longer wanted to be a child”. His mother was very disappointed at the time and broke down mentally.

After enacting the fetishism scene, the therapist drew the patient’s attention to the connection between his “dressing up” and his childhood experiences: “Mr. A., when you moved out of home, your mother was disappointed and broke down. In your fetishism scene, the mother also wants the girl not to leave her. The girl should therefore dress ugly.” The patient: “Yes, the way you say it makes it clearer to me now.” The therapist: “Mr. A., are you also submissive in other relationships?” Mr. A.: “Yes, if my supervisor arrives with additional work shortly before the end of work hours, then I always stay back and complete it. But I don’t want to do that at all. I then act like the girl.” At the end of the session, the patient said: “It is quite incredible to role-play in the disguising scene and go further beyond reality.” Three weeks later, the patient reported with astonishment: “I now am much better at managing different areas of my life. I can draw much better boundaries in relationships.”

11.6 Fetishistic Acts as Masochistic Behavior

Case example 131 (3rd continuation, see Sects. 11.2, 11.4 and 11.5)

In the 21st session, the therapist lets Mr. A. visualize his fantasy contained in the acts of fetishism one more time with chairs in the therapy room: “Imagine the interaction between the daughter and the mother again. Do you notice that you always determine what you play when you dress up and that you are the director of the process?” The patient is amazed: “Then I’m holding the strings in my hand!” Therapist: “That’s right!” Mr. A.: “Yes, I have always enjoyed being able to control my imagination when in the role of the girl!” The therapist: “When was the first time you experienced someone ordering you, like the mother in your dress-up game, and you felt very ashamed in the end?” Mr. A.: “As a child. We had little money. So I had to put on my sister’s discarded red boots. At first, only at home, I wasn’t ashamed of that. But then I also had to wear them outside. The other children laughed at me. That’s when I realized that I was wearing girls’ shoes!” The patient also had to wear his older sister’s clothes as a child. His mother would insist even though Mr. A. protested as a boy. Finally, she threatened that his father would punish him if he didn’t obey.

The therapist and the patient together represent the patient’s childhood conflict system with different chairs in the therapy room. They set up a chair for the patient himself as a boy, another for his older sister, one for his mother, one for his father, and a little further away, some chairs for the children who laughed at him. When looking at the family system, the patient spontaneously says: “At that time, my mother held the strings in her hand.” The therapist: “That’s true. But, as an adult, you are now harming yourself, just like your mother used to, by playing dress-up. You don’t even need your mother for harming yourself anymore!”

Central idea

Patients with fetishism act masochistically. Mr. A. was unaware that he repeatedly re-enacted his childhood trauma through his acts of fetishism. In doing this, as a director, he initiated the events and carried them out of his own will. Disguised as a girl, he obeyed the ‘elder woman’, similarly as he obeyed his mother in childhood, but defied her secretly and, thus, became sexually aroused. Afterward, however, he felt embarrassed in the presence of his attachment figures, just as he did in the presence of his classmates when he was a little boy. Masochism is “a cry for empathy” (Rohde-Dachser, 1976, oral communication).

The disorder-specific method described in case example 131 (see Sect. 11.2 to 11.6) was also the basis for the therapy of the patient in the following case example:

Case example 132

50-year-old Mr. C. sought psychotherapy because of chronic depression (F34.1 and F65.1). His acts of fetishism were so closely interwoven with his sense of identity that he subjectively did not understand them as symptoms of illness. In the 7th session, the therapist placed a second chair next to the patient for his “disguise ego” and asked him: “What does a dress-up game include for you so that everything feels emotionally right for you?” Mr. C. described the scene: Wearing white tights and a white bra, he sat down with it in front of a mirror and moved erotically. The reflection in the mirror aroused him sexually, and he used it for masturbation. The therapist asked curiously: “Can you also see your head in the mirror?” Mr. C. was amazed and irritated: “I don’t know!” The therapist: “Then please try it out at home!” In the following therapy session, the patient said: “No, of course, I can’t see my face! Otherwise, I wouldn’t see a woman in the mirror!’ The therapist asked the patient to switch to the chair of his ‘disguise ego’ and enact the scene with the ‘woman in white’ in a psychodramatic dialogue. During the role reversal, Mr. C. felt only emptiness in the role of the ‘woman in white’ (continued in Sect. 11.7).

The patient’s fetishism scene was also consistent with his childhood experiences with his mother. She was the epitome of beauty. His father admired her and fulfilled all her wishes. He shielded her from all conflict. Once, as a boy, Mr. C. had been in a Boy Scout camp. His mother visited him there. She was wearing all white. Then all the boys ran up to him and adored her for her beauty. But, when Mr. C. approached his mother to greet her, she refused to hug him. As a boy, Mr. C. couldn’t reach his mother. The therapist: “You couldn’t get a foot in the door with your parents!” The patient: “I was always nice as a child. But my intentions never counted!” Like Mr. A. (see case example 131 in Sects. 11.2 and 11.4 to 11.6), Mr. C. had been playing dress-up with his mother’s clothes since the age of seven. In this way, he felt close to his unavailable mother. Symbolically, he self-injuriously re-enacted his childhood trauma through his acts of fetishism.

The patients in case examples 131 and 132 (see Sects. 11.2 and 11.4 to 11.7) had varied their acts of fetishism over the years. In Mr. A.’s symptomatic actions, for example, the “little girl” sometimes faced a strict 50-year-old aunt. She tied her hair in a bun like a teacher. Or the “girl was younger than 17” and met a 45-year-old “strict stepmother”. Or the patient played a “younger, disobedient sister” who had to obey a “strict, older sister” in his fetishism ritual.

11.7 Importance of Abstinence from Deviant Behavior for Inner Mental Transformation

Like people with substance addiction, some patients with pathological deviant behavior become dependent on their symptom behavior (see Sects. 10.2 and 11.3). 50-year-old Mr. C. (see case example 132 in Sect. 11.6 and below) practiced his acts of fetishism from the age of seven for forty-three long years. His treatment lasted five years because of his chronic symptoms and his narcissistic deficit experiences in childhood. Before treatment, the patient firmly believed that he was bisexual. He had also convinced his wife of the same. Nevertheless, their marriage always had conflicts because of his “secrecy”. During an argument, his emotionally dynamic wife insulted him: “You are selfish!” “You are not social.” “Don’t be so rude!” “You are hysterical!” His wife’s devaluations hurted the patient. But they also served as a justification to himself for his retreat into acts of fetishism. In the “disguise world”, he was the director of the events. Nobody criticized him. He could, as it were, make the puppets dance: “I’ll recover then.” Mr. C. lived together with his wife and children. But he had no friends.

Case example 132 (continued)

In this case, too, the therapist first treated the patient’s metacognitive confusion with the help of the two-chair technique. Unlike the patient in case example 131 (see Sects. 11.2 and 11.4 to 11.6), who was twenty years younger, Mr. C. did not spontaneously stop his fetishism rituals. Therefore, after a year, the therapist recommended: “Please, try not to dress up in women’s clothing for six months! Do it to experience how you feel without dressing up!” His attempt at abstinence changed Mr. C.’s life decisively. After only a week, he reported that “Two days ago, I packed all my women’s clothing in a suitcase and took them to the loft. But now I am aggressive towards all sorts of people.” After nine days of abstinence, he said in astonishment: “I am no longer so afraid and have no guilty conscience. I didn’t even know I was capable of feeling this way! However, I am also missing something. Earlier, I always had something to do. But if my wife drives away now, I will miss her! I am not so offended anymore. I take more interest in people and am more lively!” After sixteen days of abstinence, Mr. C. felt: “I am happier and more alert. I often have a smile on my face. Work was often excruciating for me in the past, but now it doesn’t bother me so much. I also sleep more with my wife. I have more fun now. I think I took a lot away from my life by dressing up. Earlier, I used to think that dressing up gave me a lot! That was the purpose of my life. Withdrawing and disguising were like a port. It had something pleasant, something protective, something calm. But I don’t start it anymore. I’m going out of the house more now. Everything is more interesting! I'm even better at tennis now.” After eight weeks of abstinence, Mr. C. said: “I feel more now. I feel the pressure at work and then the exhaustion. As a manager, I have become more aggressive towards my people. I am less conflict-averse and clearer. I recently said to an apprentice: ‘Your mere presence is not enough for me, you have to do something!’ My colleagues have already noticed the change in me. I used to be scared of being looked at by people. I was deliberately generous to them because I thought: ‘If I am nice to them, they will not judge me later when they discover my dressing up.’ I am no longer afraid!”

The patient had invested a lot of time and energy in planning and hiding his fetishistic acts, inventing explanations, and pushing away feelings of shame and guilt. After ceasing his acts of fetishism, he felt truly free for the first time in his life. He developed new interests. He learned to face conflicts in his everyday life and take more space in his relationships. Sometimes the patient found his life exhausting. The therapist then offered: “If you want, try dressing up again! Then you will discover whether it increases your positive attitude towards life, as you used to believe. Or whether it will get worse again. You can then stop doing it again!” However, Mr. C. did not want to lose the “new life energy”. He was continuously “abstinent” during the last four years of psychotherapy. However, his improved self-esteem led to massive conflicts in his relationship with his wife. His wife had been codependent. After her husband started being abstinent, she also started psychotherapy. At the end of the treatment, Mr. C. and his wife developed a lively relationship and dealt with conflicts as equals. The patient bought his dream car and also made friends with men.