Personality Disorders, Narcissism and Borderline-Organization

Abstract

Patients with a borderline organization or other personality disorders suffer from a structural disorder. Their metacognitive processes are fixed in a character resistance and cause severe relationship disorders in the present. However, they experience the rigid defenses they developed in childhood as part of their identity. This fixation also disrupts the therapeutic relationship. The therapist is required to make an internal paradigm shift. She justifies her own appropriate negative affect, triggered by the patient's character resistance, in the therapeutic relationship and uses it in a therapeutically beneficial manner. In doing so, she uses the principle of response instead of interpretation. The constellation of metacognitive ego states enables the patient to gain ego control over his neurotic acting out in equivalence mode. This work is a central action method in disorder-specific psychodrama therapy. The therapist works not only with dysfunctional parts of the self, but also works out the positive meaning of the patient's rigid metacognitive defense pattern within the framework of his or her self-regulation. The treatment of metacognitive disorder is the prerequisite for long-term success in the therapy of people with a personality disorder. The disorder-specific psychodramatic action methods qualitatively enhance the depth psychological, behavioral and systemic psychotherapy of people with personality disorders.

4.1 What Are Personality Disorders?

The diagnostic category of ‘personality disorders’ (ICD-10 F60–F62) includes patterns of pathology that belong neither to the group of the psychoses nor to that of the neuroses. They are not defined by symptoms or combinations of symptoms. Instead, they present “lasting patterns of experience and behavior that […] deviate from the socio-cultural expectations and […] are defined more based on character traits and less by functional impairments” (Mentzos, 2011, p. 149). According to the DSM-IV, such lasting patterns manifest in at least two of the following four areas: cognition, affectivity, formation of interpersonal emotional reactions, and impulse control […]. The patterns are stable and long-lasting and begin during adolescence at the latest (Mentzos, 2011, p. 151 f.). According to Mentzos (2011, p. 150), the clinical patterns that are termed “personality disorders” today include what was known as “borderline states”, “psychopathy”, “abnormal personalities,” and “character neuroses” in the past. In the case of personality disorders, Mentzos (2011, p. 157 ff.) differentiates between the paranoid personality disorder, the schizoid, the schizotypal, the dissocial, the narcissistic, the hyperthymic, the dependent, the histrionic, the avoidant, the depressive, the compulsive, and the borderline personality disorder. The most common form is reportedly borderline personality disorder. The ICD-10 describes borderline personality disorder (F 60.31) as follows: in addition to emotional instability and lack of impulse control, the individual also experiences disturbances in self-image, aims, and inner preferences, as well as a chronic feeling of emptiness, intensive but unstable relationships and a tendency toward self-destructive behavior with parasuicidal actions and suicide attempts. Research shows that 30%–90% of people with borderline personality disorder are traumatized (Gunkel, 1999, p. 54 ff.). It is, therefore, always important to ask about relationship traumas in childhood and/or trauma experiences in adulthood during the diagnostic phase. One can then include trauma therapy elements (see Chapter 5) in the treatment, if necessary. The therapist should also actively ask her patients about alcohol abuse or other addictions, or abnormal behaviors (ICD F10–F19, F63, and F65). These are present in approximately 30% of patients with personality disorders. In the case of patients with addiction disorders, the treatment plan must also include addiction therapy right from the beginning (see Sect. 10.6.6), for, if left untreated, they impair the success of the therapy process.

4.2 Particularities in the Treatment of People with Personality Disorders

People with personality disorders suffer from a long-term fixation of their inner process of self-development in a defense system. Thus, the development of their inner self-image and object image is also inadequate in the conflict situation. The defense system usually develops in childhood. It repeatedly produces the same dysfunctional thought content in the patient’s inner reality construction. It helps patients to cover up or compensate for the deficits in the development of their mentalizing tools (see Sect. 2.2) and their trauma experiences. With time, they start identifying with their different ways of being and experience their dysfunctional inner reality construction as part of their identity and personality. Their defense system serves the function of concealing an identity problem, a problem of self-worth, or serious relationship problems (Mentzos, 2011, p. 154). Psychodynamically speaking, the dysfunctional character traits of people with personality disorders are “pseudo-solutions to fundamental conflicts which are sensible in some respects and were probably necessary at the time of their genesis. However, they are not only faulty but also cause suffering in the long run” (Mentzos, 2011, p. 152 f.).

Central idea

Patients with personality disorders have no awareness of their rigid defensive patterns. They do, indeed, experience that they are different from others. However, they only know their defensive inner reality construction. Their otherness is part of their self-image.

This results in limited flexibility of the afflicted person (Young et al., 2008, p. 32 f.): “They often express that they have no hope of finding any possibility to change themselves. Their trait problems are ego-syntonic. For example, their self-injurious patterns are such fixed components of their being that they cannot imagine changing them. Because their problems are central to their sense of identity, giving them up feels like death to them—the death of a part of themselves. If you try to confront them with the problem, they cling vehemently, almost as a reflex, sometimes even aggressively, to what they already hold to be true about themselves and the world around them. […] As difficulties in interpersonal contact are often the central problem, the therapeutic relationship is one of the most important aspects, both for the initial assessment of these patients and their treatment process […].”

The defense system of people with personality disorders is a form of self-protection that stabilizes their precarious psychological balance. While their dysfunctional character traits cause varying degrees of suffering in their social environment, they usually seek therapy only when the problem has secondarily led to a “clinically significant illness or impairment in the social, or professional, and other important functional areas of their lives” (Mentzos, 2011, p. 152). Often they ‘only’ report these secondary problems to the therapist in the beginning. They would like the psychotherapist to support them in their inappropriate perception of reality (see Sect. 4.13). When the therapist fails to fulfill this expectation, it results in a more or less open power struggle in the therapeutic relationship. For example, patients with depressive personality disorder (see Sect. 8.5) act out masochistic, self-injurious thinking, and self-protection through adaption. They constantly devalue themselves. The therapist often responds spontaneously: “Yes, alright. But if you were as inefficient as you say, you wouldn’t be able to cope with your demanding work! And you wouldn’t have received your performance bonus.” In doing so, the therapist resists the patient’s defense and gets entangled in his dysfunctional self-organization.

Patients with personality disorders must be treated differently than those with neurotic disorders (Rudolf, 2006, p. 2). This means not just “being supportive, promoting emotional experience and interpreting unconscious conflicts and resistance”. Otherwise, psychotherapists run the risk of realizing “towards the end of the available treatment period” that “while their patients have managed to make some changes, they are still entwined in many intractable difficulties on the whole, including those originating from an increasingly entangled and unresolved transference relationship” (Rudolf, 2006, p. 2).

Central idea

It isn´t enough if the therapist focuses only on the patient’s cognitive thought content. Because in doing so, she will continue to follow the changing subjects of his conflicts, from one crisis intervention to the next. Even though she can moderate the effect of the patient’s crises in doing so, there will hardly be any change in the fundamental metacognitive problem by the end of therapy.

Case example 17

A 42-year-old administration employee with intermittent thoughts of suicide and a schizoid personality disorder (ICD F60.1) was repeatedly ‘bullied’ by his superiors due to his arrogant behavior. In the ensuing conflict situations, he managed to resist the degrading hostilities, completely undeterred, like no one else could. In the therapeutic relationship, he usually demanded purely functional “concrete perspectives and help” without any emotional involvement. The therapist accompanied the patient through his recurring crises. They repeatedly worked out solutions that were socially acceptable in his ‘bullying situations’.

The psychotherapy contract was planned to last for a total of fifty sessions. At the end of therapy, the patient was dismissed from his job and then again from his next position. The patient decompensated into a major depressive episode. It was not until the event of the unsatisfactory result at the end of the therapy that the therapist had the idea to link the patient’s manifold relationship problems with his early childhood experiences: a one-and-a-half year-older sister drowned shortly before his birth. The traumatized mother had wanted to retreat to a convent at that time. But a priest prevented her from doing this. The patient, who was conceived shortly after this, was presumably the ‘wrong child’ for his mother. The patient was latently unwanted. As an infant, he probably couldn’t connect emotionally to his mother, who was in shock. The patient did not learn to read his emotions and regulate them. Now he reacts to fearful situations with outwardly arrogant, self-protective behavior (see Sect. 4.7). This has helped him avoid feeling the underlying panic reaction of the ‘small, unwanted child’.

In the therapy of people with personality disorders, it is not enough to work only on the resulting effects of metacognitive fixation in the patient’s relationship conflicts (see Sect. 8.4.2). The therapist must also explicitly metacognitively make the patient’s internal process of self-development and thereby the patient’s defense system, which causes the patient’s relationship conflicts, the subject of joint therapeutic communication. Otherwise, the therapist becomes entangled in the patient’s dysfunctional self-regulation in relationship conflicts. For example, a masochistic acting patient says: “I can’t do anything.” The therapist replies: “But you have studied and worked as an engineer!” The patient: “But the others in the company are much better.” The therapist: “But your boss has not had any complaints about you. So it is likely that you are doing well after all!” The patient: “But I am always so insecure and feel worthless.” The therapist: “But you are there for your children. Your wife also stands by you.” It is therapeutically not enough to replace the unfavorable thought contents with more favorable ones in every conflict.

In explicit metacognitive therapy, the therapist also makes the general principle which causes the patient to produce inappropriate thought content in the external situation and obstructs his internal self-development (see Sect. 4.1), the subject of therapeutic communication. The dominant defense pattern in each case is stabilized through other defense patterns. The therapist initially represents the dominant defense pattern externally with an additional chair and a matching hand puppet (see Sect. 4.8). The patient sits in the chair for his healthy adult thinking. The chair for realistic, healthy adult thinking and the chair for his dominant defense pattern are placed next to each other on the outside. Thus, the internal metacognitive confusion between the dominant defense pattern and healthy adult thinking is resolved. In case example 17, this is the confusion between healthy adult thinking and his metacognitive process of “self-injurious thinking”. “Metacognitive therapy focuses … shifts the examination of cognitive contents to the metacognitive level … Metacognitive therapy deals with the metacognitive factors that lead to persevering metacognitive processes and misguided coping strategies” (Wells 2011, p. 18) (see Sect. 4.8).

Important definition

Other people perceive the dominant defense pattern of persons with personality disorders as their character trait. The defense system results in biased thinking, feeling, and acting in conflicts and is also actualized in the therapeutic relationship. I refer to the metacognitive defense patterns of a person with a personality disorder as “dysfunctional metacognitive ego states”.

Fig. 4.1

The three stages of internal self-development of patients with personality disorders in the therapeutic relationship and their representation using empty chairs in the therapy room

Important Definition

Watkins and Watkins (2003, p. 45) define an ego state as “an organized system of behavior and experience whose elements are bound together by some common principle, and which is separated from other ego states by boundaries that are more or less permeable”. Putnam (1988, p. 24 ff.) speaks of states of individual consciousness that center around specific emotions, body images, forms of cognition, and perception, as well as memories and behaviors that are dependent on particular states, which occur repeatedly and appear to be relatively stable. These are self-organizing and self-stabilizing structures. I attribute individual defense patterns to the ‘common principle’ of an ego state (see Sect. 4.10). Each metacognitive ego state has a specific psychosomatic resonance pattern in the neural connections between the memory centers of sensorimotor interaction patterns, somatic sensations, affects, linguistic concepts, and thoughts (see Sect. 2.7).

Exercise 10

The following exercise will help you learn what a metacognitive ego state is and work with it constructively: (1) Identify a character trait or a reaction in yourself that you dislike or find problematic. (2) Project this quality, internally, onto a strange fictional figure, a person who, definitely and quite naturally, lives out your trait in their context, perhaps just in hard times. For example, you can attribute your instinctive helper and rescuer behavior to a fictional hero figure. (3) Choose an object, such as a doll or a puppet, to symbolize this fictional character. (4) Give this figure a suitable name, for example: “This is the white knight in me” or “This is my inner Mother Teresa”. (5) Let the hand puppet tell an episode from their life: “Once when I …”. The narration of an experience always includes a beginning, a minor conflict or something astonishing, and an end. Write the story on paper. (6) Over the next ten weeks, make up another ten stories from the life of your fictional figure and write them down.

This exercise helps you capture your unpopular way of reacting and acting as a metacognitive ego state. Through these stories, you give your unpopular character trait a coherently different frame in a different world where its acting gets a positive meaning. You differentiate and expand your knowledge of the metacognitive functioning of your undesirable trait. You learn to integrate the as-if mode into the equivalence mode in acting your trait. Perhaps, you befriend the trait you rejected and recognize its positive sides (see Sect. 7.3). You become free to act out or to omit your character trait in control.

Everyone has more or less strong, individual traits. A peculiar character trait does not make someone have a personality disorder. Traits are only considered pathological if the affected person (1) causes damage to others and/or himself due to the peculiarity of his inner reality construction and (2) he or she is unable to learn from the damage. The defensive, inadequate internal reality construction in patients with personality disorders repeatedly lands them in the same biased interpretation of the world.

For example, people with narcissistic personality disorder tend to abuse their interaction partners narcissistically. This helps them to stabilize their defense through grandiosity. Their defense through grandiosity is stabilized through a more or less sadistic superego. The grandiosity helps them to split off and deny feelings of inferiority, loneliness, shame, and emptiness. There is overt, autonomous grandiosity and covert, dependent grandiosity.

• 1. With open grandiosity, the patient must always be cool, the best, a great guy, and a hero. He tries to push the boundaries of human capacity. He is not interested in the normal problems of everyday life. A person with problems is a weakling for him, and he believes they are responsible for their own problems. President Donald Trump once said: “Anyone who lets themselves be captured in war is a loser.”

• 2. People with hidden, dependent grandiosity are less likely to be noticed as individuals with narcissistic personality disturbances and are more difficult to recognize as such (see case example 21 in Sect. 4.6). They are followers of apparent heroes or charismatic leaders in authoritarian systems. They are fans of their stars and bask in their glamor. They adapt to their idol. They allow their star to assign them a role in their institutional system, passively take over the explanatory method of the star or the hero, and allow themselves to be exploited and corrupted. In doing so, they try to realize their inner grandiose self-image in everyday life. They deny everything disturbing in their perception. It’s all about the common illusionary goal. If the goal is not achieved and they risk failing, there is a self-injurious, blindly accusing authority in them that says: “You are nothing! You can do nothing! You are a loser! You have to make more of an effort! Then it will work!” In this way, people with hidden grandiosity deny their inner emptiness, feelings of inferiority, and meaninglessness and split them off.

4.3 Particularities in the Treatment of People with Borderline Personality Disorder

Important Definition

Inconsistency in thoughts and feelings is characteristic of people with Borderline Personality Disorder. According to Mentzos (2011, p. 167), in contrast to other personality disorders, borderline personality disorder is characterized “by definition, by unstable states and structures. […] The changeability […] represents its most important characteristic”. The changeability is in itself constant. It is the alternation of two contrary ego states, as a result of the defense of splitting, that is the most prominent characteristic of this disorder (see Fig. 4.2  below). One speaks, therefore, of a “stable instability of the borderline” (Mentzos, 2011, p. 167).

I once asked therapists in a workshop: “What makes the therapy of people with borderline personality disorder so difficult?” They answered: (1) These patients demand help in their battle with their adversaries and expect that the therapist provides this help unconditionally. (2) They idealize the therapist blindly from the first encounter. (3) They terminate the therapy abruptly. (4) They accuse the therapist out of the blue and debase them. (5) They think in black-and-white patterns. There can be no two differing truths alongside each other. For example, the patient interprets help that is attached to a condition as a refusal to help. (6) The patients constantly override the rules of the setting. For example, they break the rules of the group setting. (7) Negative transferences suddenly appear without warning. (8) They often act apparently without any awareness of the problem. (9) The therapist feels she has to start from scratch in every session, although the therapist and the patient were in agreement in the previous session. (10) The therapist feels trapped in the black-and-white thinking of the patient. She does not know what she should believe. She suspects that the patient is lying because he constantly contradicts himself. (11) The patients react to supposed rejection with anger or indifference and are no longer emotionally available to the therapist. (12) The therapist oscillates between compassion and anger. It is not seldom that she feels helpless and incapable as a professional.

Kernberg (1981) made significant developments in the psychotherapy of people with borderline syndrome. For this, it was important to understand the ‘stable instability’ of these patients as ‘temporally sequential activation between two contrary ego states’ (Kernberg, 1981, p. 14) (see Fig. 4.2 below). The patients oscillate between the dependent, needy ego state and the pseudo-autonomous authoritarian ego state.

Central idea

In patients with borderline personality organization, the process of inner reality construction is disturbed due to the defense through splitting. The patients alternate more or less quickly between two contrary emotions. They randomly feel angry and then sad and distressed again. There is no healthy adult thinking.

Their oscillation between the two contrary ego states helps with self-stabilization. The defense through splitting helps to protect a defense system of self-protection through denial and a sadistic superego. Therefore, the oscillation shouldn’t be understood as an attempt to manipulate the therapist. The oscillation between the contrary emotions helps the patients to get rid of the internal tensions that occur when their early experiences of deprivation, loss, or trauma are triggered in the present. These patients begin to feel helpless, unable to act, and dependent when they allow their neediness and sadness in relationships to prevail for some time. Therefore they react to closeness in relationships with anger, indiscriminate behavior, and pseudo-independence as a precautionary measure, acting on the belief “Help yourself, otherwise, nobody will help you!” They have learned ‘not to trust’ from their childhood experiences. In doing so, they drive their attachment figures away from themselves. As a result, they find themselves alone. Once again, they feel needy and act this out.

Fig. 4.2

The sequential oscillation between the two contrary ego states in the defense through splitting

Patients with borderline personality disorder explain the rapid changes in their feelings with external actions toward their current attachment figures. This means they think in equivalence mode (see Sect. 2.6) during a conflict: When they feel needy, they idealize their attachment figure and see them as a helper in their battle against the evil in the world. When their illusory expectations are unfulfilled, they react with anger. In an angry state of mind, they conclude that their attachment figure has done something to make them angry. Therefore they start to fight with them. After acting out their emotions, their anger can return seamlessly to the dependent, needy ego state. As a consequence of this instability, they experience people either as a friend or as a foe. They find themselves either in a good or an evil world. For these patients, their suffering “results […] less from the blocked beginnings of their action (as in a neurotic conflict) and more from the actions of others, which is difficult to bear. It is the failure of fulfillment by others, the denied approval, the withdrawn attention, and the demand made that causes the suffering. The suffering is experienced as unbearable tension with fearful or angry feelings. It is an intolerable suffering and thus demands immediate action” (Rudolf, 2006, p. 50).

Kernberg (1991, p. 49) understands the defense of splitting as “the active separation of contrary introjections and identifications.” The patient acts out his sadness and despair in the needy, dependent ego state. These emotions include the thinking, feeling, and acting of the ‘abandoned or abused child’ (see Sect. 4.7). In the pseudo-autonomous, authoritarian ego state, the patient acts out his anger and fury. This ego-state fuses the ego states of the ‘angry child’, the ‘self-protective behavior’, and the ‘pathological introject’ (see Fig. 4.1 in Sect. 4.2). This can go to the extent where patients who were traumatized in their childhood engage in an unconscious role reversal and sequentially re-enact the drama of their trauma experience without even noticing it. First, they act out the role of their pathological aggressor introject. After that, they are “beaten” by the reaction of their social environment to their dysfunctional behavior and feel rejected and devalued, as they did in their childhood. They are once again the ‘traumatized child’ they had been.

Important Definition

According to Kernberg (1991, p. 49), the defense of splitting manifests clinically “in the way that […] contrary sides of a conflict dominate the scene alternately whereby the patient demonstrates a flat denial of the other side and appears completely unaffected by the contradictory nature of their behavior and experience”.

The therapist often reacts to the patient’s contradictory behavior with the feeling that the patient is manipulating her. She believes he is ‘lying’ and consciously telling her only half of the story.

Case example 18

A psychotherapist reports in supervision: “The in-patient therapy with my 35-year-old patient, Mrs. E., is getting nowhere! I like the woman. But she leaves me baffled and helpless. Whenever she makes some progress in her therapy and can finally admit her feelings of loneliness and neediness, she suddenly flips out again. She throws tantrums and smashes things in the ward. Afterward, she behaves as if she wasn´t the person who acted!” The patient’s acting out had left the therapist helpless and caused her to doubt herself. However, the patient had probably not experienced herself as being contradictory at all. The supervisor let the therapist re-enact a typical encounter with the patient psychodramatically. It then became clear: So far, the therapist had treated this patient as a neurotic person. She had interpreted the patient’s suffering only as the suffering of the ‘abandoned child’, which the patient was in her childhood.

Central idea

Persons with borderline personality disorder unconsciously defend against the perception of their contradictory nature through denial (Rohde-Dachser, 1979, p. 70). They actively hide their inconsistency, true to the motto: “For, he reasons pointedly, that which must not, cannot be.” This quote is from the poem The Impossible Fact by Christian Morgenstern. When the therapist tries to address the contradictions in the therapeutic relationship and to clarify the causes of ‘misunderstandings’, the patient experiences this attempt as an attack and denies his inconsistency. The patient imposes a ‘Double Bind’ on the therapist.

Important definition

A double bind exists when a person in a relationship places an inherently contradictory demand on the other person, either implicitly or explicitly, and also refuses the other’s attempt to discuss the contradiction with them.

The therapist feels helpless when caught in the double bind of a borderline patient. She gets angry, projects her rejection and devaluation on the patient, and acts out character-related countertransference (see Sect. 2.10). Or she attempts to make sense of her patient’s contradictions, and herself goes ‘crazy’. This can go so far that, in the end, she begins to doubt her abilities as a therapist and seriously considers whether she should give up her profession. According to Rohde-Dachser (1975, only verbal communicated), such a reaction is a diagnostic criterion indicating that the patient is suffering from borderline personality disorder. The patient’s mood swings cannot be explained causally by the real events in the therapeutic relationship. The patient’s oscillation between his contrary ego states only helps him vent his inner tension and stabilize his volatile intrapsychic balance. In such a situation, the therapist has to consciously accept the patients’ contradictions as they are and confront them by setting up the contrary ego states externally on stage (see Sect. 4.9).

4.4 Structural Disorder as a Fundamental Problem and Additional Diagnosis for People with Personality Disorders

Recommendation

In the psychotherapy of people with personality disorders, the secondary diagnosis of ‘Structural Disorder’ should always be made after the descriptive diagnosis of ‘Personality Disorder’. This is because “personality disorder” refers to a group of interrelated symptoms. But, the structural diagnosis describes the level of mentalizing in internal conflict processing and the gravity of the deficits in the ability to mentalize (see Sect. 3.2).

Mentalizing is the internal process of reality construction that helps us understand ourselves and others in the context of a situation, process conflicts, search for new or adequate conflict solutions, and plan our actions (see Chap. 1). The literal sense of the term ‘structural disorder’ (Rudolf, 2006, p. 48ff.) emphasizes the structural deficits in the self-organizational processes of the patient (see Sect. 3.2). However, these deficits arise through metacognitive blocks in the internal process of self-development and result in functional deficits of mentalization. Rudolf states (2006, p. 50) that “structure refers […] not to content […], but to the level of organization of the mental functions that regulate one’s sense of self and behavior in relationships.” “The diagnostic question is not: ‘What occupies this person in terms of content?’ but ‘How does his personality function in particular situations?’”.

Important definition

Rudolf (2006, p. 49) defines the term ‘structural disorder’ as “the limited availability of functions required for regulating the self and its relationships. The structural functions affect the ability to cognitively differentiate between oneself and others, to control one’s actions, feelings, and self-value, to understand oneself and others emotionally, to make emotional contact with others, to maintain emotionally important relationships internally, to keep oneself in balance, and to find orientation.”

The basis of every structural disorder is the block in the inner process of self-development through a defense system. The splitting results from traumatization or severe deficit experiences in childhood (see Sect. 5.2). People with structural disorders have lacked sufficient positive experiences of supportive and flexible relationships in their initial years of life. Their inner process of self-development remains unstable. They experience enormous tension when emotionally aroused. But their unstable self-development is protected through a defense system of self-protection through adaption or grandiosity and self-injurious thinking. Neurotic patients ‘only’ defend through blocks in inner interacting, rehearsing, and integrating in their relationship conflicts (see Sects. 2.2–2.4). They are able to remember their childhood conflicts and, therefore, represent their current conflicts appropriately. However, patients with severe structural disorders cannot adequately remember the events in their past relationship conflicts because they didn’t even notice them due to their complex defenses. According to Rudolf (2006, p. 22), in cases of severe disorders in mentalizing, it is futile to ask the patients about their negative memories from childhood. The patients could not perceive the negative relationship experiences in their childhood as negative because nobody mirrored their negative emotions adequately. Their negative relationship experiences from childhood are ‘only’ indirectly ‘stored’ as blocks and mentalization deficits in the inner process of self-development. The patients experience their rigid defense patterns as part of their identity. Indeed, they suffer from the resulting relationship conflicts. But they don’t suffer from their dysfunctional character trait or the metacognitive disorder that produces relationship conflicts because they are not aware of the blocks in their inner self-development.

Recommendation

In the disorder-specific therapy of patients with personality disorders, the therapist lets the patients work out their relationship conflicts also with psychodramatic dialogue and role reversal (see Sect. 8.4.2). But she also focuses her attention on the more or less pronounced metacognitive blocks in the patient’s inner process of self-development and tries to resolve their rigid defense (see Sect. 2.2).

Persons with severe structural disorders are less able to play and feel quickly overwhelmed when processing current conflicts psychodramatically because of blocks in their inner process of self-development. It is not unusual for the connection between their internal mentalizing and their external psychodramatic play to be interrupted during a ‘normal’ psychodramatic play (see Sect. 2.12.2). In a psychodramatic play, they are often not able to fill their own role or that of their adversary and are not capable of role reversal. The patients are used to thinking in black-and-white patterns according to the belief: “Either I am right or my opponent”. The as-well-as attitude in role reversal would challenge their stable defense and identity. The incapability to reverse roles is, therefore, a diagnostic indicator of a structural disorder.

Case example 19

Mr. A., a 48-year-old patient, suffers from a borderline personality disorder, chronic alcohol abuse up until ten months ago, and a major structural disorder (ICD F60.31, F10.2). During a period in which he was feeling relatively well, Mr. A. reported having feelings of guilt toward his 23-year-old son: “He no longer speaks to me. At present, he is taking his final examinations at school. But I’m worried that he may not be able to cope with his life. I try to be good to him. I do everything for him. I tidy his room, cook food, and bring it up to him. I try to pamper him.” The therapist asks Mr. A.: “Would you like to try telling your son, in a role-play, that you are concerned about him and that you have feelings of guilt towards him?” Mr. A. heeds the request reluctantly. During the role reversal, he answers his own question while in his son’s role: “But I have made it through my apprenticeship and managed to do shift work after that. And now I’m in night school with an average grade of three!” Mr. A. is confused and notices: “I don’t know what my son expects of me!” The therapist: “Then why don’t you just ask your son here in the role-play!” Mr. A. is surprised: “That is true! Can I do that?” The therapist: “Why not! You have already told me that you grew up in a children’s home and that no one took any interest in you. If you ask your son now, he will realize that you are interested in him as a father. That is what children experience as love!”.

Mr. A. overcomes his hesitation and asks his “son”: “What do you expect from me?” In the following repeated role reversal, the therapist takes on the role of the protagonist. Going beyond the boundaries of reality, he asks the “son”, played by Mr. A.: “What do you need from me? Do you notice that I am making an effort?” In his son’s role, Mr. A. takes the time to experientially “search” for what his son feels toward him, thinks of him, and wants from him. Thus, the patient completes the external role reversal in the as-if mode of play (see Sect. 2.6) also internally. He develops a theory of mind about the inner reality of his son. At the end of the session, he groans: “This is hard work here! This is not what I was expecting!” He smiles at the therapist, half despairing: “I work up a sweat here!” (Continued in Sects. 4.6, 4.13, and 4.14).

Persons with structural disorders think and act out the blocks in their inner process of self-development in the equivalence mode (see Sect. 2.6). They equate their inner, defensive construction of reality with the outer reality. In disorder-specific therapy, patients must therefore resolve the blocks in their process of self-development caused by the rigid defense. To do this, the patient must understand the positive function of his unconscious defenses in the holistic process of self-regulation in the as-if mode of play and integrate the rigid defense pattern into relevant experiences from childhood (see Sects. 4.8 and 8.5). They thus gain ego control over their defenses and ‘the Creator aspect of their lives’ (Moreno, 1970, p. 78). They recognize that their image of reality is ‘only’ their own inner representation of reality and not a realistic image of external reality.

4.5 An Overview of the Different Steps of Treatment

Central idea

In therapy, persons with personality disorders should recognize the fixation of their inner self-development process in their respective dominant defense pattern and gain ego control over this defense. The patient’s defenses are actualized in his present relationships and must therefore be dealt with in his present conflicts.

Disorder-specific therapy requires a great deal of support and time in the therapeutic relationship due to the complexity of the transformation processes. The therapy takes place in an individual setting, if possible, because the therapy of metacognitive disturbances is technically complex. The therapist must be able to recognize her own character traits and metacognitive processes. When learning the method, she often takes a developmental step in her own self-experience.

• 1. The therapist diagnoses the personality disorder based on the patient’s symptoms and the consistent dysfunctional character traits in his everyday life and the therapeutic relationship. She experiments working with the patient using the table stage or the psychodramatic dialogue. Indications of a structural disorder are: The patient cannot give symbolic meaning to objects on the table stage. Or he is unable to engage in a role reversal (see Sect. 4.4). The therapist actively asks about concomitant addictions and trauma experiences. She includes these in the treatment if necessary.

• 2. Psychotropic drugs should be prescribed to people with personality disorders during their psychotherapy process only if necessary because there is “evidence that psychotropic drugs interfere with emotional and cognitive change processes and slow down the healing process” (Giesen-Bloo et al., 2006, quoted in Arntz & van Genderen, 2010, p. 116). Furthermore, it is essential to ensure close cooperation when the patient is being treated with medication by a psychiatrist because psychiatrists often prescribe very high dosages fearing decompensation in the patients.

• 3. In a psychodramatic dialogue, the psychotherapist progresses slowly but steadily, often making varying use of the doppelganger technique (see case example 19 in Sect. 4.6). In doing this, the therapist acts as an auxiliary and mentalizes the patient’s experience of his conflict vicariously.

• 4. Due to the specific metacognitive block of their inner self-development process in the therapeutic relationship, patients with personality disorders evoke a complementary negative affect in the therapist, for example, helplessness, anger, or powerlessness. In psychodramatic self-supervision (see Sect. 2.9), the therapist defines this appropriate negative affect, grasps the patient’s dominant defense pattern, which evokes her negative feeling (see Sect. 4.8), names this, and represents it in the therapy room with an empty chair. For example, when she suspects borderline personality disorder (see case example 24 in Sect. 4.9), she places two empty chairs for the “patient”, one for his pseudo-independent-authoritarian ego state and another for his clingy needy ego state.

Central idea

The disorder-specific psychodramatic treatment transforms the unsuccessful therapeutic relationship encounter into a successful one. This psychotherapy can therefore be called “Encounter Focused Therapy” (EFT).

• 5. In the therapy session, the therapist works explicitly metacognitively on the patient’s dominant defense pattern (see Sect. 4.2). In explicit metacognitive therapy, the patient learns to recognize his dominant defense pattern and gain ego control over his defense pattern. In doing so, the patient has to take the following steps of mentalizing: naming the ego-state, representing it, acting it in the as-if mode of play, rehearsing dialogues with other defense patterns, and integrating the ego-state with childhood experiences (see Sect. 2.2).

  • 5.1 The therapist marks the patient’s dominant defense pattern as an ego state by explicitly naming it when the patient is acting it out.

  • 5.2 She represents the dominant defense pattern with an empty chair in the room. In doing so, she explicitly makes it the subject of joint therapeutic communication (see Sect. 4.8). For example, a patient acts masochistically and says to the therapist: “In any case, no one wants me! I always make mistakes! I’m a loser!” The therapist then does not empathically share the individual contents of his statements. She does not even contradict him in terms of the content. Instead, she captures the general underlying principle that creates his many different dysfunctional thought contents. She names this principle for the patient: “You think in a self-injurious manner”. She then uses an empty chair to symbolize his ‘self-injurious thinking’ as an ego state in the therapy room (see Sect. 8.5). In doing so, the therapist characterizes his masochistic thinking, feeling, and behavior outwardly as deviating from his healthy adult thinking.

  • 5.3 The therapist lets the patient switch to the chair representing his dominant dysfunctional ego-state and enact it in the as-if mode. Thus, the patient actively differentiates it and completes the associated psychosomatic resonance pattern into a holistic resonance pattern (see Sect. 2.7). He psychosomatically feels the difference between the dysfunctional inner reality construction and ‘healthy adult thinking’ (see Sect. 4.8). In the course of therapy, the patient learns to think in his dominant defense pattern in the as-if mode (see Sect. 2.6). In this way, he gains control of the ego over his dysfunctional thinking, feeling, and acting. He no longer has to act out his defense in everyday life with the same duration and intensity. His self-image changes in the equivalence mode (see Sect. 2.6). A patient needs to engage in 10 to 20 therapy sessions before he can think in his dominant defense pattern in the as-if mode (see Sect. 3.3).

• 6. If necessary, in addition to the dominant defense pattern, the therapist also represents, with empty chairs, other defense patterns of the patient that stabilize the dominant defense pattern (see Sect. 4.7). The higher the severity of a patient’s structural disturbance, the sooner (see case example 21 in Sect. 4.7). Sometimes this happens in one of the first sessions (see case example 21 in Sect. 4.7).

Central idea

The various defense patterns of the patient’s defense system stabilize and mutually reinforce each other’s dysfunction (see Fig. 4.1 in Sect. 4.2 and Sect. 4.10). The therapist works on all of a patient’s defense patterns only in long-term therapy. At the end of therapy, the patient should be able to think in each of the four qualitatively different metacognitive ego-states in the as-if mode (see Sect. 2.6).

• 7. The therapist lets the patient interact with his own defense patterns, represented as ego states, using the psychodramatic dialogue in the as-if mode of play (see Sect. 4.10). The role reversal between them clarifies the mutual relation of their work in the overall process of internal conflict processing. The dialogue helps to compensate for deficits in the development of mentalizing. The resolution of a defense system and learning to develop one’s self in the current situations can take one to three years.

• 8. The therapist combines the work on the patient’s defense system with elements of trauma therapy if necessary (see Sect. 4.5). For example, she lets the patient develop a ‘safe place’ (see Sect. 5.10.5) and a coping fairytale (see Sect. 5.14). Or she processes, together with the patient, his old traumas from childhood (see Sect. 5.10.10).

• 9. The patient integrates the progress of his development into his family and social relationships. The therapist supports him with the help of psychodramatic dialogue and other methods (see Sect. 4.10).

4.6 Doppelganger Technique in a ‘Normal’ Psychodramatic Play

In patients with severe structural disorders, the inner process of self-development in external situations is blocked through a defense. The patient often thinks in equivalence mode (see Sect. 2.6) and is unable to distinguish between the real and the imaginary. He, therefore, perceives, for example, the therapist’s verbal doubling (see Sect. 2.1) not as an offer but as a demand to think and feel like the therapist. However, the therapist can still use the psychodramatic dialogue with role reversal for crisis intervention (see Sects. 2.14 and 8.4.2). Then, she must adapt her method to suit the patient’s low mentalization capacity (see case example 19 in Sect. 4.4).

Central idea

The lesser a patient’s capacity to engage in the play, the more often the therapist must enter as a doppelganger (see Sect. 2.4.1) in the psychodramatic play of his conflict situation (Krüger, 1997, p. 117 ff.). As a doppelganger, she verbalizes the experience she has in his role and interacts with his ‘conflict partner’ on his behalf. Thus, she processes the conflict with the patient in the as-if mode of play.

Case example 19 (1st continuation, see Sect. 4.4):

Mr. A. has significant problems with his manager during his reintegration into the work process after one year of invalidity: “It’s been three weeks since I am back at work, and I am being asked to sign a performance review. The performance stated that I have a backlog in my casework and lack elementary knowledge. I refused to sign it. My boss wants to get rid of me! I’ve got severe stomach pain again.” The therapist tries in vain to point out the reality of the workplace situation to the visibly agitated man: “You’re a civil servant! You manage to do 95% of the required work! Your boss has got nothing on you!” The words fall on deaf ears. Mr. A. reacts to the rejection at work with panic and anger, like the unwanted child from his childhood. He is thinking in the equivalence mode and is angry with the therapist because he doesn’t seem to recognize his distress. The therapist is concerned that Mr. A’s attitude of denial could cost him his position as a civil servant. But, Mr. A. needs this job to stabilize his mental state.

The therapist, therefore, moves the conversation about the conflict to crisis intervention in the as-if mode of play. He places two empty chairs facing each other on the stage: “Please come and have a fictional discussion with your boss and tell him about your anger and resentment. Maybe that will give you some emotional relief.” Mr. A. obliges to this invitation feeling embarrassed and awkward. Surprisingly, he behaves rather humbly and is not as angry toward his boss in the play. When Mr. A. moves into the role of his boss, the therapist takes on the role of the patient as a doppelganger. He repeats what Mr. A. had said to his boss. But he also verbalizes on behalf of the patient what he, the therapist, feels, thinks, and wants in his role. In doing so, he integrates the information given by the patient earlier in the conversation: “I am disappointed and angry. It takes time to present each of my cases to one of the five team leaders! I am losing my time at work in this process. If you consider the meeting time, I’m pretty good at my work performance! Besides: I am not asking the team leaders because I lack basic knowledge. First, you insist I ask them if anything is unclear, and then you interpret that as a lack of knowledge. That is unfair! You are treating me badly!” In the play, Mr. A. doesn´t fully embody the role of his young, ambitious boss. He answers awkwardly and often slips back into his own role. However, he listens to the therapist in the role of his doppelganger with great interest. He corrects the statements where necessary. Sometimes he coaches him as a trainer would his apprentice. At the end of the psychodramatic enactment, he spontaneously says: “Oh, I’m feeling better already: my stomach doesn’t pain anymore!” In the follow-up discussion, the patient and the therapist summarize the possible courses of action worked out in the psychodramatic scene for dealing with the conflict with his boss. Therapist: “Just keep doing what has to be done, and don’t let yourself be misled. The important thing is that you learn to stand your ground in the conflict. This is difficult for you. But it will also give you a lot, for example, self-confidence and money. You will receive €1000 less in your monthly salary if you take early retirement” (continued in Sects. 4.13 and 4.14).

There are three different forms of mentalizing on behalf using the doppelganger technique:

• 1. Fuhr (1991, only verbally communicated) recommends in general: “The higher the severity of a patient’s illness, the greater the need for the therapist to act out the patient’s conflicts on his behalf in his presence at the beginning of therapy.” This can go as far as the therapist having to perform the psychodramatic enactment alone using role reversal at the beginning of the therapy. While doing so, the patient will usually spontaneously correct and coach the therapist (see case example 15 ion Sect. 2.14).

• 2. The therapist takes on the role of the patient in his psychodramatic enactment and expresses, as a doppelganger, what she perceives, thinks, feels, and wants in his role. At the same time, the patient plays the role of his adversary (see Sect. 8.4.2).

• 3. Scharnhorst (Ursula Scharnhorst 1987, only verbal communication) suggested, as a therapist, if necessary, one can change into the role of the patient directly in the real relationship and mentalize on his behalf. The therapist thus psychosomatically explores what it’s like to be the patient by imitating him (see case example 20). This approach is indicated when the therapist, despite their concerted mutual efforts, does not understand the patient but would like to understand him. This procedure is also possible in a group setting.

Case example 20 (Krüger, 1997, p.144 f.)

The 22-year-old Mrs. B. is diagnosed with borderline personality disorder (ICD F60.31). She informs the group in their tenth group session that she wants to end group therapy: “The group doesn’t help me, I’m feeling worse.” Mrs. B gets angry and devalues anyone who speaks to her. Initially, the group members react helpfully but then become increasingly aggressive. Any attempts to clarify relationships make the patient more uncertain. Mrs. B. withdraws in the end. She appears extremely tense. The therapist is helpless. He does not understand what is happening inside Mrs. B. He asks her: “May I reverse roles with you? I would like to understand how it is to be you and how I would feel in your role.” Mrs. B. is surprised. But she agrees. She sits on the therapist’s chair without taking on his role. The therapist sits on the patient’s chair and, as a doppelganger, assumes her posture: He crosses his legs, moves his right hand around his mouth playfully, and repeats: “Everything is so tense here. – Nobody is concerned about the other. Nothing is happening. I’m feeling worse!” As the therapist models the patient, he concentrates closely on what he is feeling in her role. He notices that he is feeling increasingly paralyzed. He verbalizes what he experiences: “I notice that I am feeling numb. I’m drifting off completely. It’s a vague feeling. I don’t want this!” With great internal effort, he pulls himself out of the non-verbal state of paralysis and becomes angry: “I’ve had enough of this here! I want out of here! This is pissing me off! It’s not helping me! I want to go to a clinic! Everyone is just sitting around, all uptight! I’m just getting worse!”.

Mrs. B. openly watches the therapist with interest. She occasionally confirms his further elaboration of her role with a nod. In the end, the therapist exchanges places with the patient again. In the follow-up discussion, the therapist shares what he experienced in her role: “To begin with, I was just sitting there normally and said that I wanted to leave the group. I didn’t feel that very deeply. But then, when I was criticized, I noticed how I started feeling increasingly numb. I fell away into some abyss of darkness behind me. That scared me. I didn’t want it, and I started to fight it. I didn’t see who I was attacking at all. They all looked the same to me, man, woman, or therapist. I just wanted to escape my paralysis. Fighting it gave me strength. The paralysis went away.” Mrs. B. recognizes herself in the pictures the therapist describes. Her emotional numbness has disappeared: “That’s just how it is!” She begins to cry: “I was not feeling good in the past week. Since Thursday, when I was here in the group. It started right in the beginning, I couldn’t feel my body anymore. It was as if everything beneath me had disappeared. I didn’t know if there was any ground below me or not. I thought I was falling. The only thing I knew was that I couldn’t feel myself. As if there were kilometers of nothingness below me.” Mrs. B. continues to cry. After some time passes, she begins to breathe more gently and slowly relaxes.

In working together with symbols on the table stage (Krüger, 2005, p. 266 f.), the therapist and the patient symbolize all that is significant in their therapeutic consultation, using stones and wooden blocks: the patient’s ego, his conflict partners, but also all his feelings, his qualities, and other relevant objects. The therapist empathizes playfully with the inner process work of the patient. She helps him, implicitly as a doppelganger and an auxiliary, to name the things on the stage, differentiate them, and ‘read’ his emotions. Thus, the patient creates a symbolic landscape of the system of his conflicts on the table stage, using stones and blocks, in the as-if mode of play and further develops the truth of his soul in the play.

Case example 21

The 41-year-old Mr. D. is diagnosed with narcissistic personality disorder, major depressive episode, and internet gaming disorder (ICD F60.8, F32.2, F63.8) with a moderate structural disorder. After a lengthy hospital stay, he felt suicidal when he came for outpatient therapy. He hated himself and had masochistic thoughts. The disorder-specific treatment of his internet addiction and his decision to remain abstinent relieved him of his shame and guilt. He had made good progress over two years. In this process, the image of his ‘own magic box’ symbolized his free will. The patient’s mother had abused him narcissistically as a child. His progress in therapy, however, brought him into an intrapsychic conflict with his pathological mother introject, such that he decompensated into depression once again.

In the therapy session, Mr. D. states without emotion: “I no longer have a magic box. I have no right to it.” He notices, with the help of the therapist, that his inner ‘shoulder mother’, the ego state of his self-injurious thinking (see Sect. 4.7), is once more blindly denying him any right to his own wishes, as it had done in the past: “You are an idiot, you are bad! You are egotistical! Your illness is simply your weakness! The others don’t find it easy either!” In discussing his newly lost willpower, Mr. D. tells of his interest in dollhouses: “I remember it as clear as a bell. I was about eight years old and was visiting another family when I saw a dollhouse for the first time: I just marveled at it. There were tiny chairs and plates, lamps, and cupboards, all just like in real life but miniature. I couldn’t believe it. My hands just seemed to want to reach for the things of their own will. I was fascinated and thrilled. But the daughter of the family was standing in front of the dollhouse and wouldn’t let me play with it. Then my mother came in and took me out of the room under some pretext. I believed her!”.

The therapist would like to free the patient from his identification with his mother. Therefore, he asks the patient to set the scene of his childhood memory on the table stage, with the help of stones and blocks for himself, his feelings, the girl, his mother, and the dollhouse. Mr. D. replays the childhood memory with the stones. The therapist wants the patient to get in touch with his ‘self’ in the play differently from his experience in childhood. Therefore he takes the symbol for the mother, a large, round stone, off the table and places it two meters away on a chair: “What would you have instead needed in this situation as a child? What should a good mother have done, in your opinion? I am replacing the stone for your mother with another green stone on the table to represent another fictional good mother!” Mr. D. hesitates: “She would have come and admired the dollhouse. Perhaps she would have persuaded the girl to let me play with the dollhouse!” The therapist mentalizes as an implicit doppelganger in the ideal world of the patient, where wishes come true: “Yes. And before that, the good mother would have looked at you, noticed your shining eyes, and maybe said: ‘Oh Daniel, the dollhouse is so beautiful, don’t you think? Can you believe your eyes?’ Then the good mother would have turned to the girl and said: ‘Christine, could Daniel perhaps take the little chair in his hand?’” Mr. D. is very moved: “Yes, the good mother would have taken an interest in me!” Therapist: “Yes, she would have seen your shining eyes, shared your enthusiasm, and empathetically mirrored your enthusiasm in words.” Mr. D. feels deeply understood. The therapist and Mr. D. agree that his real mother ‘stole’ his own willpower and his ability to wish during his childhood: “A good mother would have affirmed and shared your wishes with you and not used some trick to estrange you from your wishes!”.

In the next therapy session, Mr. D. shares: “Since the last session, I have once again felt that everything is meaningless as if I am in a slump. On the day after our session, I had the feeling: I should work now. But at the same time, there was the impulse: ‘Don’t do it!’ I just let all my tasks slide.” The therapist places two chairs in the room, one for the ‘self-protection through adaptation’ and one for the ‘abused child from childhood’ (see Sect. 4.7). He points to the second chair of the ‘abused child’: “I believe the feeling of meaninglessness still belongs in your story with the dollhouse from last time. Your sense of meaninglessness is probably the feeling that you felt as a child when your mother took you away from the dollhouse under some pretext and had no interest in what you wanted! You now dare to feel that meaninglessness so clearly. That is progress!” Mr. D. physically experiences the feeling of meaninglessness ‘in his upper belly, poisonous green, like a liquid that seeps into all areas of his life.’ The therapist: “You feel the meaninglessness spread within you when your mother negates all that you yearn for and wish for.”

It is only now that Mr. D. tells, for the first time, the story of how he made a dollhouse out of matchboxes and egg cartons at the age of fourteen: “I even baked little loaves of bread to go with it. But one day, the dollhouse simply disappeared! So when I was eighteen, I bought myself some dollhouse furniture. I hid it under my coat and smuggled it back into the house. I understand it better now that my mother and the feeling of meaninglessness are so happy with each other!”.

In the next therapy session, Mr. D spontaneously says: “Today I’m somehow feeling constantly angry! Angry with other drivers who cut me off on the motorway. And with a woman on the telephone who was harsh to me. I’m going to tell her tomorrow she shouldn’t be so stern! I feel confident again! I have access to my dollhouse again! That is my magic box. Instead of sadness, I now associate joy with my dollhouse!” Therapist: “Your sense of meaninglessness and your anger belong together! We carried out some archaeological excavations together in the last session and went in search of your willpower.” Together, the therapist and the patient formulate the focus of therapy (Kämmerer, 1989, only verbal communication): “My depression helps me to feel my sense of meaninglessness. My sense of meaninglessness always arises when I dare to give permission to my desires. Or when I wish for empathy and compassion from someone. This will continue to happen until I associate my feeling of meaninglessness with my relationship with my mother and take my dollhouse back from my mother’s hands.

4.7 Representing the Working of the Ego-States Using Chairs

Patients with personality disorders get into relationship conflicts due to metacognitive blocks in their inner process of self-development (see Sect. 4.1) in the current external situation. These blocks lead to inadequate inner reality construction. The dominant defense pattern also blocks the attunement and agreement process in the therapeutic relationship relatively quickly. As a result, the present therapeutic relationship itself becomes the stage for the patient’s inner self-development. The more disturbed the patient is, the sooner and stronger the attunement process gets blocked. “The neurotic mode is that of internalizing. […] The structural mode is that of externalizing, for the tensions are ascribed to the outside and are fought there. […] Here, the tension takes effect predominantly in action and the interpersonal space” (Rudolf, 2006, p. 50).

The patient’s internal process of self-development (see Sect. 4.1) comprises three different areas of the inner reality construction represented with chairs outside in the therapy room (see Fig. 4.1 in Sect. 4.2):

• 1. The patient sits opposite the therapist on the stage of the present therapeutic relationship (Krüger, 1997, p. 250 ff.; Pruckner, 2002, p. 151) and thinks more or less as a healthy adult (chair 1 in Fig. 4.1).

• 2. The therapist represents the patient’s internal self-image and object image in his everyday conflict externally as the symptom scene with two chairs on the stage (see Fig. 2.9 in Sect. 2.8 and Fig. 4.1 in Sect. 4.2, chairs 3 and 4). In a marital conflict, for example, one chair will be for the ‘patient’ himself and the other for his ‘wife’ (see Fig. 2.9 in Sect.2.8), both facing each other.

• 3. The therapist represents the various defense patterns of the patient’s defense system as metacognitive ego-states on the stage of metacognitive processes (Fig. 4.1 in Sect. 4.2, chairs 5–9).

Central idea

Explicit metacognitive therapy of the blocks in the inner self-development process in the external situation should always be related to the patient’s current conflict, which is represented in the symptom scene, or to the work on the relationship between the patient and the therapist in the here and now. Otherwise, the work on his metacognition is lost in space and time and becomes diffuse.

The explicit metacognitive psychodrama therapy looks relatively simple from the outside. However, in doing so, the therapist is performing a complex task internally. Her work is guided by her emotional reactions to the patient’s concrete actions in the therapeutic relationship (see Sect. 4.8).

Recommendation

If you wish to integrate the therapeutic work on metacognitive ego-states in treating one of your patients, you can photocopy Fig. 4.1 from Sect. 4.2 as a template. Lay this copy on the table in front of you as you continue to work. The map of the patient’s ego-states will help you to orient yourself to the various blocks in your patient’s self-development and to remain internally flexible.

The different metacognitive ego-states of the patient are defined as follows:

• 1. The ‘self-protective behavior’ is the generic term for the metacognitive ego-states of patients whose dysfunctionality is based on defense through denial. The patient acts as if it is nothing. He unconsciously refuses to perceive his own disturbing feelings or the disturbing behavior of the conflict partner. The metacognitive ego-states belonging to the category of self-protective behavior include: (1) The patient protects himself from feeling his own emotions by adapting to the expectations of his interaction partner. (2) In protecting himself through grandiosity, the patient subconsciously has to play the role of a hero or a great guy. Nothing can harm him. A hero shows no weakness. Feelings of insecurity or failure are taboo. (3) The patient protects himself from retraumatization by controlling the external situation and other persons. Controlling the situation helps to protect oneself and others from disaster and feelings of helplessness. (4) Patients with post-traumatic stress disorder have to split off and deny their trauma experience to themselves and others. They develop self-stabilization techniques that help them deny their instability. For example, patients with post-traumatic stress disorder tend to distract themselves by working 80 h weekly. Or they control the actual situation unreasonably. They thus try to avoid situations that would make them or their interaction partner helpless and powerless and would trigger a flashback (see Sect. 5.4). (5) Patients with trauma-related disorders often automatically assume the systemic role assigned to them by their current relationship system (see Sect. 8.5). Patients functionally fulfill the tasks of the assigned systemic role. They split off their sense of self because their sense of self would activate old trauma experiences. For example, the patient takes on a role in an authoritarian political or religious system and also represents this role externally (Parin, 1977). The authoritarian system gratifies his role assumption with narcissistic appreciation. That helps him to suppress feelings of self-doubt, fear, insecurity, disorientation, or powerlessness and to deny internal conflicts. The therapist actively interprets, for the patient, each self-protective behavior through denial as ‘one of many possible solutions’ for dealing with himself and with others.

In schema therapy, the dysfunctional ego state of self-protective behavior is called the ‘avoidant protective mode’ (Arntz & van Genderen, 2010, p. 12): the patient “appears relatively mature and calm. The therapist could assume that the patient feels good. The patient applies this protective mode so that she doesn’t have to feel or show her feelings of fear (an abandoned child), inferiority (punishment), or anger (an impulsive child). […] It is dangerous to show feelings, express wishes, and state one’s opinion. The patient is afraid to lose control over her feelings. […] This becomes particularly clear when she commits to relationships with other people. The self-protective mode keeps others at a distance.”

• 2. The therapist immediately names every appropriate thought, feeling, and action of the patient in his conflict as ‘healthy adult thinking’ (chair 1 in Fig. 4.1 in Sect. 4.2). The chair on which the patient sits opposite the therapist during the consultation represents the ‘healthy adult thinking’ of the patient. Healthy adult thinking is the state of spontaneity (Moreno, 1974, p. 13): “Spontaneity drives the person to have an appropriate response to a new situation or a new response to an old situation.” When in a conflict, a patient with ‘healthy adult thinking’ can internally represent reality appropriately without any defense and deal with his conflicts appropriately.

Important definition

In every external situation, people construct an internal image of the current external reality. They interact externally according to this internal image. They think as healthy adults if their inner reality construction has not been altered by a defense.

The development of healthy adult thinking includes the development of new psychosomatic resonance patterns. A 30-year-old man with a major structural disorder presented with recurrent major depressive episodes (F33.2). Together, the therapist and the patient understood the metacognitive triggers of his depression. In the meantime, the patient has not decompensated into depression again in two triggering situations. Nevertheless, in the 18th therapy session, he says with a naive friendly smile: “The therapy has not helped me so far. I only feel that something is changing here inside me,” he puts his hand on his chest: “But I can’t describe what it is.” The therapist is happy: “You don’t need to be able to describe it either!”

In schema therapy, the healthy adult mode is “precisely the mode the patient should cultivate and ultimately retain. […] It is seldom highly developed in the early phase of therapy […] The lag in the patient’s development in areas such as relationship formation, independence, the ability to express himself, or the sense of self-worth, and a lack of experience in dealing with realistic boundaries make it necessary for the therapist to act as a representative for the ‘healthy side’. This […] is particularly true at the beginning of therapy. […] During later phases, this mode helps […] to reach healthy goals” (Arntz & van Genderen, 2010, p. 17).

• 3. The dysfunctional ego state of the ‘inner traumatized or abandoned child’ is a special type of the patient’s ‘inner child’. This ‘inner child’ is the child the patient was in childhood. The therapist can also give the “traumatized child” a personal name: the ‘inner ashamed child’ or ‘inner unseen child’. Perhaps the patient remembers that, as a child, he was beaten by his father. His father wanted him to be different from how he was. His crying would have only angered his father even more. Or he heroically endured the bad treatment of his grandparents and didn’t tell his parents anything about it as he didn’t want to cause them even more worry. The therapist represents one such painful childhood memory of the patient in the therapy room with an additional empty chair for the ‘abandoned child’ or the ‘traumatized child’ (chair 6 in Fig. 4.1in Sect. 4.2). This chair represents the patient’s denied feelings. The ‘inner traumatized child” should develop into the ‘inner healthy child’ in the course of therapy.

In such a case, the therapist names the pathogenic quality of the painful childhood experience and speaks in plain language. She names, for example, the traumatizing situations explicitly as ‘trauma experiences’ (see Sect. 5.5). When the therapist represents the inner ‘traumatized child’ with a doll on an empty chair placed next to the patient, patients who were traumatized in childhood often feel threatened in the here and now. The presence of the ‘traumatized child’ acts like exposure to trauma. The therapist, therefore, always asks the patient immediately: “What does it trigger in you when you look at your traumatized child there?” If the patient has negative feelings, she places the chair with the doll far away in the corner of the room or the front of the door (see Sect. 5.8).

Understanding the biographical origin of the patient’s self-protection makes it easier for the therapist to no longer be disturbed by the patient’s self-protective behavior in the present. The patient also understands himself better by connecting his self-protective behavior with his childhood.

Central idea

The metacognitive ego state of the ‘abused or abandoned child’ shall develop further into the ego state of the ‘healthy inner child’ during psychotherapy. It then becomes a symbol for the ‘self’ of the patient.

I have adopted the term ‘the abused or abandoned child’ from schema therapy. In this mode, the patient is “sad, despairing, inconsolable and often panic-stricken, […] her voice often changes to that of a small child. Her thoughts and behavior become like that of a four to six-year-old. She feels alone in the world. […] Everyone will take advantage of her and leave her in the lurch. The world is a scary, dangerous place. Little Nora divides the world into black and white. She demands immediate and constant validation and solution to her problems […]” (Arntz & van Genderen, 2010, p. 14).

• 4. The metacognitive ego state of the ‘inner angry child’ usually is an expression of internal maturation and development of the ‘traumatized or abandoned child’ into a ‘healthy inner child’ in the course of therapy (see case examples 16 in Sect. 2.14, 48 in Sect. 5.12, and 54 in Sect. 6.4). But, it may also surface when the patient with borderline personality disorder blindly defends the painful feelings and passive desires from his childhood through angry behavior. In such a situation, the therapist places the empty chair for the patient’s ‘angry inner child’ (chair 7) next to the chair of the ‘abandoned or traumatized child’. She understands the patient’s destructive anger as justified in the sense of defense against the negative feelings of the ‘traumatized or abandoned child’. Patients diagnosed with borderline personality disorder oscillate relatively arbitrarily between fury and despair, i.e., the ‘clingy needy ego state’ and the contrary ‘pseudo-autonomous, authoritarian ego state’. The ‘clingy needy ego state’ contains, among other things, the ‘traumatized inner child’, and the pseudo-autonomous, authoritarian ego state contains the ‘angry inner child’ (see Sects. 4.3 and 4.9).

In schema therapy, Arntz and van Genderen (2010, p. 15) name the dysfunctional ego state of the ‘angry child’ as the ‘angry, impulsive child’: “The ‘enraged Nora’ behaves like an angry, frustrated and impatient little child (approximately four years old), who doesn’t spare a single thought for others. […] The patient is verbally and sometimes also physically aggressive and makes vicious remarks toward others, including her therapist. She is upset because her needs are not being met and her rights remain ignored. […] Not only is she bad-tempered, but she also wants everyone to notice how badly she is being treated. She achieves this by attacking others […], injuring herself, and trying to kill herself or even others out of revenge […]. In a mild form, Nora will […] show her anger by missing sessions or terminating therapy altogether. […].”

• 5. The dysfunctional ego state of ‘self-injurious thinking’ is the umbrella term for a patient’s masochistic thinking, feeling, and acting. This is triggered by the demands of a sadistic superego in the present. It is based on the identification with the aggressor developed in childhood. Patients devalue themselves masochistically in their relationship to others and feel inferior and guilty even before they have been criticized or attacked by others. According to Rohde-Dachser (1976, only verbal communicated), “masochism is the cry for empathy”. What she means is that patients who act masochistically in current relationships act out their old self-censorship that was appropriate in childhood. This self-censorship helped them to protect themselves from additional harm in difficult relationships in their childhood (see Sect. 8.5).

Important definition

Internal ‘self-injurious thinking’ should not be confused with external self-harming behavior in trauma patients. The ‘scratching’ of the forearm is a clinical symptom. Traumatized patients use external self-harm as a self-stabilization technique to end a flashback. The physical pain of ‘scratching’ terminates the mental numbness of the dissociative state.

In the encounter with a masochistic patient, the therapist responds by placing another empty chair opposite the patient to represent the patient’s ‘self-injurious thinking and behavior’ (chair 8). The category of ‘self-injurious thinking’ is symbolically named with personally appropriate terms depending on the extent of self-destructiveness: the ‘sadistic superego’, the ‘blind sadistic critic’, the ‘blind inner prosecutor’, the ‘blind inner governess’, the ‘inner soul killer’, or the ‘tormentor who gives him bad thoughts’ (see Sect. 7.2).

Central idea

The ‘self-injurious thinking’ of patients with personality disorders may ‘die’ during therapy. Back when they were a child, it helped them in censoring themselves to prevent being hurt or disappointed in interaction with aggressive or neglecting attachment figures. However, the ‘self-injurious thinking’ has lost its historical protective function in the present. In therapy, the patient shall learn in the here and now not to treat themselves self-injuriously like they had to in the past (see Sect. 8.5).

The ‘ego state of self-injurious thinking or acting’ is referred to as the ‘punitive or over-critical mode’ in schema therapy (Arntz & van Genderen, 2010, p. 16). The patient is “scornful, disapproving and humiliating” toward himself. […]. This mode calls Nora a big mouth. If she fails to achieve something, it is only because she did not try hard enough. The punitive mode has little interest in feelings. […] When something goes wrong, it is her fault. In her mind, her success is dependent exclusively on her will to succeed. If she fails or something does not work, she obviously does not want it. […] She provokes punishment everywhere, even from her therapist. She refuses to cooperate with her treatment. This often leads to premature termination of therapy.”

• 6. If necessary, the therapist places another empty chair behind the chair for the ‘self-injurious thinking’ to represent the inner object image of the patient’s attachment figure from his childhood (chair 9) who had harmed him through abuse or neglect. In the case of traumatized patients, this chair can also represent a pathological introject (see Sect. 5.12).

In Fig. 4.1 (see Sect. 4.2), the positions of the metacognitive ego states in the therapy room and the direction of the arrows for the different ‘viewing directions’ are not random. The direction of the chairs informs whether the defense pattern in question is changing the patient’s internal self-image or his internal object image. The self-protective behavior, the ‘abandoned child’, and the ‘angry child’ are placed next to each other, looking in the same direction as the patient’s ‘healthy adult thinking’. In this way, the patient connects them internally with his self-image. The chairs for self-injurious thinking (chair 8) and the internal object image of the harmful attachment figure from his childhood (chair 9) are always placed face to face opposite the patient. They distort the patient’s internal object images in external conflicts.

Central idea

The therapist confronts the patient harshly when she names his dominant defense pattern and represents it with a chair on the stage in the therapy room. During this confrontation, however, she looks at the second chair on the stage in the therapy room, which symbolizes the patient’s defense pattern. In this way, together with the patient, she delegates his defense pattern to the other chair. Thus, the patient experiences: “The therapist is bothered by my character trait, but she does not challenge me as a person.” This makes it easier for the therapist to confront the patient (see Sect. 4.8).

Exercise 11

You cannot understand this experience just by reading and thinking about it. Experience it for yourself through psychosomatic acting in an exercise. To do this, try out two types of confrontational interpretation in a role play with a colleague: Confront the “patient” in a purely verbal manner in the first round. Look at him and name his dysfunctional metacognitive ego state and its positive function in his self-regulation when facing him. In a second round, please also verbally name the dysfunctional ego state acted by the patient. For the dysfunctional ego state, however, place an additional chair next to or in front of the patient and look at the chair.

Case example 22

The 26-year-old tile layer Mr. C. suffers from recurrent depressive episodes, internet gaming addiction disorder, a narcissistic personality disorder (ICD-10 F33.2, F63.8, F60.8), and a medium grad structural disorder. He has been in individual therapy for half a year now. He pretentiously asserts that with his one-man company, he can “land any contract he wants”. In the course of the therapy, the therapist learns that the patient only manages to do this because he always offers his customers the lowest price. His calculations result in lower prices because he devotes far too little time to his work. At the same time, his fear of criticism from his customers pushes him to be a perfectionist in his work. For this reason, he seldom keeps to his time plan. When his plan fails, however, he suffers significant self-esteem crises, sometimes even reaching the point of suicidal thoughts. This is because Mr. C gets caught in a flashback from his childhood. He came from a broken family. As a little boy between the ages of four and ten, Mr. C. often sat alone in the hallway on the step, crying and waiting for his parents. His neighbors would often take pity on him and take him into their apartment. As a child, despite his intelligence, Mr. C spent three years in a special needs school due to his family’s negligence and a neurotic learning disorder. At present, the patient is, as an adult, almost incapacitated for work due to his symptoms. He has frequent conflicts with his wife as a result of financial concerns. His wife wishes to separate from him soon.

In the therapy session, Mr. C. seems despairing and once again at risk of suicide. The therapist cannot reach Mr. C. with verbal communication alone. It is as if there is a glass wall between the therapist and the patient. The therapist decides to carry out a crisis intervention with psychodramatic metacognitive therapy in this therapeutic situation. Together with the patient, he maps out the patient’s dysfunctional self-regulation. The relationship conflict with his wife is represented as the symptom scene using two chairs (see Fig. 4.1 in Sect. 4.2, chairs 3 and 4). The therapist places a chair next to Mr. C. to represent his self-protective behavior through grandiosity (chair 5): “Mr. C., when planning your working hours, you heroically try to push others’ limits. You calculate far too little time for the work at hand. You are then proud to have received all contracts. Then you want to execute the work perfectly within the planned time. Furthermore, you are a white knight who cares about justice in others’ conflicts.” Mr. C.: “Yes, that is something I am good at, I can give my all for the good of others! And it works out well! I dragged my step-daughter out of the drug scene. However, I just can’t manage to do it for myself!” Therapist: “When someone else is mistreated, you feel angry inside. I’m going to place this other chair next to you for the angry child in you (chair 7). But you cannot get angry when someone criticizes you, for example, a client or your wife. Instead, you revert to being the abandoned and shamed child from your childhood (chair 6). I’m going to place this chair over here for the abandoned child you were. Please, take a seat on this chair!” Mr. C. follows the therapist’s instructions. The therapist now points to the empty chair where the patient had been sitting: “This is the chair for your healthy adult thinking (chair 1). Sitting on this chair of healthy adult thinking, you are currently feeling: ‘I would like to be able to do everything better, but I can’t!’”.

The therapist positions another chair opposite Mr. C. for his ‘self-injurious thinking and feeling’ (chair 8). The therapist stands behind this chair and verbalizes as an auxiliary ego the workings of this dysfunctional ego state: “And at the same time, you say to yourself as your inner humiliating censor: ‘You say that you can’t? You make things easy for yourself! Sooner or later, it has to be possible once only! You are quite a weakling!’” The therapist asks the patient to move back to the chair for his healthy adult thinking (chair 1) and doubles him verbally: “But I really can’t do it. I want to. But I just sit there; it’s like I’m standing on the brakes. Is that right?!” Mr. C.: “Yes, I want to do it, but when I want it, it’s as if my brain just freezes up. All of a sudden, nothing works anymore!” The therapist moves to stand next to the chair for the sadistic superego (chair 8): “Then this part of you pops up and says: ‘Well obviously that’s the way it is, you are a loser!’” Mr. C.: “Exactly. Then I think: You’re not made for this. You went to a special needs school; you can’t even write properly! The last time I heard that was from my father in 2001: ‘You’re never going to manage that!’ At that time, I wanted to become a drug representative because I worked through all of my wife’s written questions of examination 50 times with her and could answer all of the questions!” The therapist places another chair behind the chair of the ‘inner critic’ (chair 9), symbolizing the patient’s father: “I think that you devalue yourself today just as your father devalued you in the past! Perhaps in time, you can learn to let go of this self-censorship! You actually can’t need it!” By the end of the therapy session, the glass wall in the therapeutic relationship has disappeared. And it didn’t reappear in the following therapy sessions. Setting up the constellation of the dominant self-injurious ego state and the other metacognitive ego states with empty chairs helped the patient and the therapist to re-orient and understand the self-regulation of the patient.

Recommendation

I recommend adhering to the following rules when setting up the metacognitive ego states: (1) The therapist initially sets up only the dominant defense pattern and describes its positive function in the patient’s self-regulation. This opens the door to the other defense patterns involved in the patient’s defense system (see Sect. 4.8). (2) The more severely a patient is structurally disturbed, the longer he needs to orient in his dysfunctional process of self-development. (3) Using too many chairs at once tends to confuse the patient. The therapist may have to work only with the dominant metacognitive ego state for many sessions. (4) The more acute the patient’s plight, the more active the therapist acts as an implicit or interacting doppelganger (see Sect. 2.5) in the constellation work (see case example 22).

Central idea

Every person is aware that he is thinking about conflicts. However, he does not have a thinking model to grasp and understand the metacognitive blocks in his inner process of self-development (Sattelberger, 2013, only verbal communication!). Therefore, the therapist must actively help the patient combine his own experience with the described thought model of the metacognitive ego states.

The therapist helps the patient integrate metacognitive thinking into his own mentalization with the following methods:

• 1. She names the patient’s respective dominant defense pattern as a dysfunctional ego state. She describes his characteristic pattern of thinking, feeling, and acting if and when he acts it out in the present. In addition, she also names its positive function in the holistic process of his self-regulation.

• 2. Together, the therapist and the patient retrace his internal process of self-development within the framework of a current conflict. For example, during the conversation about his marital crisis, the patient tells the therapist: “I hate being sad.” The therapist then reformulates his statement and points to the chair symbolizing his self-image and object image in the symptom scene: “You despise yourself because your wife has separated from you. You pull yourself together”. The patient replies: “But nobody wants to hear anything about my sadness!” The therapist: “In your experience, no one in your family cares about what you are feeling.” She points to the chair for his “self-injurious thinking”: “And now you forbid yourself from feeling your sadness and think: ‘Sadness is nonsense!’ I am representing your inner self-injurious voice with this chair opposite you.” The therapist adds: “But when you feel sad, is there also that unseen sad child in you, the child you used to be? I will place this other chair over here for your abandoned inner child.”

• 3. The therapist symbolizes the ego states with hand puppets. The puppets should have a special characteristic to demonstrate each metacognitive ego state. For example, the chair representing self-injurious thinking will have a grinning devil, a witch, a scowling robber, or a bureaucrat. Or the therapist symbolizes the traumatized child by placing a doll on the corresponding chair. In this way, the patient experiences his metacognitive ego state externally as an interaction partner on the object level. The external space between the patient’s self and the hand puppet invites the patient to interact with this ego state externally in the as-if mode of play (see Sect. 4.10).

• 4. The therapist and the patient jointly name the metacognitive ego state that the patient just acted out with appropriate individual names. Thus, self-injurious thinking becomes the ‘blind child destroyer’ or the ‘blind governess’.

• 5. Whenever the patient again switches into another ego state in the moment, the therapist points to the chair of this other ego state. She names it and says, for example: “Now you are feeling and talking from the role of your self-protection!” Or: “You then adapt your behavior and act as if nothing is wrong.” Or: “Your inner blind soul killer is telling you again: ‘You are nothing, you can’t do anything, you are good for nothing.’”

• 6. Often the patient acts out his dominant defense pattern also in the present therapeutic relationship in the equivalence mode, even when the ego state is represented as a chair next to him. In such a case, the therapist lets the patient switch to the other chair of the dominant ego state externally and act out this ego state in the as-if mode of play (see Sect. 4.8).

If the therapy room is very small, the therapist can symbolize the various metacognitive ego states with stones and wooden blocks on the table stage, instead of chairs on the big stage. However, then the patient will not experience the work of his defense patterns with all the senses psychosomatically. On the other hand, when working on the miniature table stage, the patient symbolizes his ego states with stones of different sizes, shapes, and colors, and he can use these personalized symbols once again in the next therapy session (Zilch-Purucker, 2012, only verbal communication!). In group therapy, the therapist should only ever represent the one dominant dysfunctional ego state with a chair, which the patient acts out in the here and now (see Sect. 4.8). Too many chairs will confuse the patient and the group.

Therapists should work on their own character traits for at least ten sessions in an individual setting with the help of psychodramatic chair work. This will help them gain ego control over their traits (see exercise 7) and deal with their peculiarities much better. Internally, they will become more flexible and creative.

Constellation work is a long-known method of action in psychodrama. For example, when setting up the ‘cultural atom’, the therapist represents the patient’s fear with a stone outside on the table stage or places a chair next to him for his ‘anxious inner child’. However, the therapist works ‘only’ on the patient’s cognitive thought content that has been named by the patient himself when setting up the cultural atom. In explicit metacognitive therapy, however, the therapist focuses her attention on the metacognitive blocks in the patient’s internal process of self-development. The therapist’s character-related countertransference (see Sect. 2.10) to the patient’s dominant rigid defense pattern (see Sect. 4.8) is the starting point for the therapeutic work on the metacognitive ego states.

4.8 Psychodramatic Approach to the Dominant Defense Pattern

Important definition

A defense pattern is a dysfunctional tool of mentalizing. The creative process of inner self-development, inner self-image, and inner object image in the external situation is blocked, leading to inappropriate results and also an inappropriate perception of the current external reality.

Central idea

The dominant defense pattern in the patient’s defense system is different for different personality disorders. For example, self-injurious thoughts are dominant in those with depressive personality disorder. Self-protective behavior, in the form of grandiosity, is dominant in those with narcissistic personality disorder. On the other hand, people with borderline personality disorder alternate between the ‘clingy needy ego state’ and the contrary ‘pseudo-autonomous, authoritarian ego state’ (see Sect. 4.9).

Case example 22

Mr. E. suffers from a social phobia and anxious-avoidant personality disorder (ICD-10 F60.6). He is “always exhausted” because of his work. He devalues himself in all relationships. He thus anticipates criticism from his respective attachment figure when in conflict. He is trapped in a helplessness syndrome. He acts out his helplessness masochistically, even in his relationship with the therapist. The therapist initiates a therapeutic communication about the patient’s masochistic behavior: “I see that you devalue yourself instinctively. I’ll place a chair over here, opposite you, to represent your ‘self-injurious thinking’”. Mr. E.: “But I think that’s true. I have no reason to be exhausted.” The therapist: “Please shift to this other chair, which represents your self-devaluation! What do you think of Mr. E. here? What can he not do?” Mr. E. sits on the “chair of self-devaluation” and answers while looking at his own chair: “Actually, it’s amazing how he still manages to do his job! But he will certainly not last for a long time. Others are much better than him!” The therapist: “It sounds as if you despise yourself!” Mr. E.: “Yes, that’s right!” Therapist: “Please shift back to your first chair. I will name it the chair for your healthy adult thinking. I see that your inner self-critic, here in the other chair, does not even notice what exactly you do. He knows in advance that you are mediocre. He’s blind!” The therapist sets up two other empty chairs to represent the patient’s symptom scene (see Fig. 2.9 in Sect. 2.8). He points to the chair that represents the patient’s internal self-image: “Please describe what Mr. E. is doing over there at his job. What is he doing and what is he experiencing?” At the end of the session, Mr. E. says, “I did not know the weight I am constantly lugging around with me. I think I am depressed.” The patient has at first developed an awareness of his self-injurious thinking through this disorder-specific method of treatment. His self-injurious thinking suppressed his healthy adult thinking.

Case example 23

The 52-year-old Ms. F. suffers from borderline personality disorder (ICD-10 F60.31, F33.2). Her employer has fired her without prior notice. After a short stay in the hospital, she is sitting in front of the therapist without any self-reflection, feeling agitated and furious. She rants about her former boss. However, she does not tell what has happened at her workplace. She has an unspoken demand for a complete understanding of her anger from the therapist. At first, the therapist identifies with the patient’s boss spontaneously. However, he avoids criticizing the patient due to her lack of self-reflection. Instead, he grasps the general metacognitive principle of her acting out and represents it as an ego state externally in the therapy room: “I am placing a chair beside you to represent the ‘angry child’ in you, as you are just now. Would you please sit on this chair once?” Ms. F. follows the request and spontaneously says: “That’s right! I feel like a child too! My boss behaved quite badly!” All of a sudden, as if she is a changed person, the patient calmly describes the events that preceded her dismissal. It turns out to be a bizarre story of bullying. The therapist now has a much better understanding of the patient’s emotional reaction. He develops compassion for her and can provide her with the needed support (continued in Sect. 4.13). The patient’s ego state of the “angry inner child” had suppressed her healthy adult thinking. (Continuation in Sect. 4.14)

In the therapy of people with personality disorders, initially, the therapist naturally identifies with the patient’s inner process of self-development and accompanies him in it as an implicit doppelganger (see Sect. 2.5). At some point, however, patients with a personality disorder defend themselves with projective identification (see Sect. 2.4.4). They act out their defense in the therapeutic relationship. The therapist then automatically identifies with the patient’s defended part of self and wants to help her get justice. But, the patient fights this defended part of the self. As a result, the therapist’s identification with the patient’s defended part becomes stronger and stronger. Thus, she unconsciously opposes his dominant defense pattern. For example, she identifies with the patient’s self because she feels tormented by his masochistic self-censorship (see case example 22 above).

Central idea

When patients defend with projective identification, the therapist’s negative affect is an appropriate response to the dominant defense pattern acted out by the patient in the current therapeutic relationship. Therefore, in therapy, the therapist focuses on the disturbance in the current therapeutic relationship.

However, the therapist often defends her own appropriate negative feelings and restricts herself from feeling what she feels. For example, she defends herself through introjection and rationalization: “I’m ashamed to feel so angry. As a therapist, I’m not allowed to feel this way.” In doing so, she personalizes her feelings of powerlessness or anger and devalues herself. She may even link her appropriate negative affect to a problem from her own childhood and consider that as an indication of her own need for therapy. Or she may respond to her negative affect with a projection. She then devalues the patient by interpreting his disruptive behavior as “the behavior of a stubborn child.” Or she suspects: “The patient is too severely disturbed for psychotherapy”.

A patient with narcissistic personality disorder, for example, is firmly fixated in the self-protective behavior through grandiosity. He expects a grandiose therapist to help him get better in a few sessions. The therapist first tries to meet the patient’s grandiose expectations. But her helpful offers make the patient aware of his neediness. Thus, he runs the risk of slipping into a trauma film from his childhood. He, therefore, rejects the therapist’s offers of help in order to stabilize himself. The therapist then feels helpless and inferior on his behalf. The more she tries to help, the more strongly the patient rejects her. The therapist then internally devalues the patient and acts out character-related countertransference (see Sect. 2.10).

Central idea

The therapist must undergo a paradigm shift in the therapy of people with personality disorders. She must let go of the helper attitude. She must interpret her own negative affect as an appropriate reaction to the patient’s dominant defense pattern and try to make her negative affect useful in the patient’s therapy process.

This can be done with the following procedure (see Sect. 2.9):

• 1. The therapist validates the disturbance in the therapeutic relationship.

• 2. The therapist differentiates and names the affect triggered in her by the patient. In doing so, she consciously gives herself permission and space to feel what she feels. She thus dissolves her own secondary defense through introjection.

• 3. She asks herself: “Which of the patient’s concrete actions trigger this negative feeling in me?” She describes the patient’s external defensive actions in a way that is close to the experience.

Central idea

In this step, a relatively large number of therapists confuse the patient’s external defensive actions with their own interpretation of the patient’s actions. For example, they act out the helper attitude. They then unconsciously identify with the patient’s abandoned or traumatized inner child and represent it externally. But, in doing so, they represent the suppressed metacognitive ego state, but not the defense pattern with which the patient suppresses his inner child. For example, in the case of defense through grandiosity, they set up a chair behind the patient for his ego state of the ‘unseen, abandoned child’. But, they do not talk about the patient’s dominant defense through grandiosity.

Recommendation

The therapist should work with the patient on the current conflict triggered by the patient’s dominant defense pattern in the therapeutic relationship or his everyday life. She should not switch her focus to the patient’s trauma or deficit experiences from childhood. For the initial 10–15 sessions, the therapist should use an empty chair to represent only the patient’s dominant defense pattern which triggers her negative affect in the encounter with the patient. She represents a second ego state for a short time, for example, the traumatized child, only if she wants to clarify the positive function of his rigid defense pattern in the holistic process of his self-regulation.

• 4. The therapist grasps the patient’s external defense behavior and assigns it internally to one of the metacognitive ego states (see Fig. 4.1 in Sects. 4.2 and 4.7). There are seven possibilities to do so: (1) the ‘self-protective behavior’, (2) the ‘self-injurious thinking and behavior’, (3) the ‘angry’ child “, (4) the ‘abandoned or traumatized child’, (5) the traumatized ego (see Sect. 5.2), (6) the exchange between a pseudo independent, angry ego state and a dependent, needy ego state (see Sect. 4.9), or (7) the ego state of addictive thinking (see Sect. 10.6). The habitual self-devaluation of the patient thus becomes the ego state of ‘self-injurious thinking’ (chair 8 in Fig. 4.1), his exaggerated perfectionism becomes the ego state of ‘self-protective behavior through adaptation’ (chair 5), neediness becomes the ego state of the ‘abandoned or traumatized child’ (chair 6), angry allegations become the ego state of the ‘angry child’ (chair 7), and downplaying of consumption of alcohol becomes the ego state of the ‘addicted ego’ (see Sect. 10.6).

• 5. If the patient acts out his dominant defense pattern in the current therapy session, the therapist names it verbally. In doing so, she appreciates, as a metacognitive doppelganger, its positive function in the holistic process of his self-regulation and describes it: “(1) You always have to be a great guy (defense pattern). (2) This is because you have to protect yourself from negative feelings (specific negative feelings). Or: “If you are not a great guy then you will develop negative feelings. (3) The therapist, acting as an implicit doppelganger, names the presumed negative feelings: “You would then feel insecure or helpless.” (4) Then the sentences follow: “You couldn’t handle these feelings. (5) That’s why you believe that it’s good for you if you make an effort to always be a great guy! It’s not the best solution, but it’s a solution.” The therapist creatively paints the positive meaning of his rigid defenses until the patient himself says: “Yes… but…” (see Sects. 9.8.2–9.8.5).

Central idea

First, the patient acts out his defense pattern in equivalence mode and justifies it with external reality. But he should now recognize the positive sense of his defense in the process of self-regulation. So he can learn to think of his defense in the as-if mode. He understands it as an internal representation of an old solution, and no longer as an appropriate solution for the current external situation (see Sect. 2.6). Thus, the patient gains ego control over his unconscious defense. He becomes free to choose. He can consciously act out the old behavior in the current situation or he can also seek for a new behavior. Thinking in the as-if mode is achieved through four different steps: (1) Describing the positive function of the defense pattern in self-regulation. (2) External distancing from the defense pattern by setting up the associated chair, (3) Questioning the age of the defense pattern and its integration into childhood experiences, (4) Playing out the role of the defense pattern in the as-if mode of play (see Fig. 4.1 in Sect. 4.2).

In the psychodramatic implementation of the as-if mode into the equivalence mode, the therapist follows the central principle of healing in psychodrama therapy: The patient should become “the creator of his own life.” “The as-if mode unleashes life… Prometheus gives birth to himself in the as-if mode and thus proves that his existence in shackles was the result of his own free will” (Moreno, 1970, p. 78). In describing the positive function of self-regulation (“You must do this otherwise you will develop negative feelings which you would struggle to deal with”), the therapist indirectly links the patient’s dominant defense pattern with the biographical context in which the defense arose (see Sect. 2.4.4). For example, in defense through grandiosity, the splitting off of feelings of loneliness and excessive demand was necessary to cope psychologically at one point in time.

• 6. In naming the defense pattern, the therapist immediately represents it externally with an empty chair on the room stage: “I notice that you think and behave in a self-injurious manner in the relationship with your wife. I am placing this chair over here for your self-injurious thinking. The chair symbolizes your inner sadistic critic. It says: You are an incapable husband!” The patient experiences a purely verbal confrontation without any external representation of the defense pattern as a criticism because he acts his defense in the equivalence mode (see Sect. 2.6). But, the therapist names and represents his defense pattern externally with a chair in the as-if mode of play. The patient thus gains external distance from his dysfunctional thinking, feeling, and acting. Over time, that helps him to gain awareness of his problem. He considers: “Perhaps I am thinking in a self-injurious manner and it is not true that my wife despises me. I have to examine my feelings once more.” The therapist now sees the patient externally in his own role, thinking as a healthy adult, separated from the second chair of his defense pattern. Together with the patient, she looks at his defense from a metaperspective, shoulder to shoulder, and makes it the subject of therapeutic communication. This resolves the therapist’s negative affect.

Exercise 12

Learn about the metacognitive constellation work by acting psychosomatically. You cannot understand it just by reading about it. You can only understand the effect of therapeutic action by experiencing it in your body. Look for a personal character trait that you don’t particularly love. Talk about it purely verbally with a colleague for three minutes. Then start the conversation all over again, but represent your character trait externally with a second chair next to you. You will notice: You quickly feel ashamed and criticized in the purely verbal conversation. However, when you represent your character trait as a chair next to you, you feel less guilty and hurt because you physically distance yourself from your character trait in the as-if mode. You are free to decide whether or not you want to switch to the chair next to you in the as-if mode of play and act out your disliked character trait.

• 7. When working with the metacognitive ego states, the therapist simply makes statements and does not ask any questions in the subjunctive: “Could it be that you are thinking in a self-injurious way?” This is important because the patient thinks in the equivalence mode. He can’t distinguish between the therapist’s mere consideration and a real opinion. Therefore, the therapist acts in the as-if mode of play and says: “I understand that your angry inner child has surfaced. I’m placing this chair over here for your angry inner child.” She doesn’t ask the patient if she may set up an ego state. The therapist’s statements and actions give the patient the opportunity to directly reject the second chair in the as-if mode of play. If necessary, the therapist simply removes the chair for the patient’s ‘angry inner child’: “Yes, I can see that you see it differently. I’ll put the chair for your ‘angry inner child’ back along with the other chairs in the circle! Sometimes I try something out and think out loud to make something clear to myself.”

Central idea

Using the two-chair technique, the therapist externally separates the patient’s defense pattern from his healthy adult thinking. Thus, as a metacognitive doppelganger, the therapist can alternately identify with the patient’s dominant defense pattern, symbolized as the second chair externally, or with the patient’s healthy adult thinking. She empathizes with the patient’s two opposing ego states as a doppelganger and develops sympathy for each of them one after the other. This reduces the therapist’s negative affect and her internal tension toward the patient.

• 8. The therapist represents the patient’s dominant metacognitive defense pattern with a suitable hand or finger puppet and places it on the chair of the ego state. She symbolizes, for example, the ego state of his ‘sadistic superego’ with the hand puppet of a bureaucrat, devil, or witch: “That is your inner critic. He believes that everything you think, feel, and do is wrong. But this critic is blind and doesn’t even consider your situation!” As a therapist, you can try the chair work once without puppets and then with puppets. You will notice: symbolizing the ego state with a hand puppet turns the ego state into an interaction partner in an external symbolic play. The patient in case example 23 (see above) responded to the representation of her dominant dysfunctional ego state with a hand puppet, saying, “You have always said that. But this figure makes it all so clear to me now!”.

• 9. As a doppelganger, the therapist gives the patient’s dominant dysfunctional ego state a voice and mentalizes on his behalf in his ego state in the as-if mode of play. For example, she points with her hand at the externally represented ego state of the ‘sadistic inner critic’ and says: “Your inner critic is blind and doesn’t see your reality. He says to you: ‘You are nothing, you can do nothing, and you are no good!’”.

• 10. In further discussion with the therapist, the patient often falls back into his rigid defense pattern. He thinks, for example, in a self-injurious manner and says: “Of course, I still know far too little…” In such a case, the therapist immediately ascribes this statement to the appropriate dysfunctional ego state and points with her hand to the chair of his ‘self-injurious thinking’: “Your self-injurious thinking is once again saying: ‘Exactly! The others are much better informed than you! They are also much more intelligent than you!’” In this way, the therapist immediately marks the patient’s inner role change in his dysfunctional ego state, enabling him to experience the shift between his ego states externally in the as-if mode of play.

• 11. Together, the therapist and the patient think of a personally suited symbolic name for the patient’s dominant dysfunctional ego state. In this way, for example, his ‘self-injurious thinking’ becomes his ‘blind inner critic’, his ‘governess’, his ‘blind sadistic inner prosecutor’, or his ‘inner soul killer.

• 12. If the patient inappropriately values his defensive behavior directly in the therapeutic relationship and defends it in equivalence mode, he cannot yet think of his defensive pattern in the as-if mode, even though it is represented externally as a different chair. Therefore, the therapist asks him to externally change into the role of his defense pattern: “You are thinking in a self-injurious manner. So please switch to the chair of your blind, sadistic inner critic and devalue yourself actively with statements! What do you say to depressed Michael?” This external role change lets the patient externally differentiate between his defense pattern and his healthy adult thinking in the as-if mode of play.

• 13. Together, the patient and the therapist, as a metacognitive doppelganger, act out his dominant defense pattern in the as-if mode of play.

Central idea

The patient should psychosomatically act out his metacognitive defense pattern that creates his dysfunctional thoughts. Thus, he internally activates and creates neural links between the memory centers of his sensorimotor interaction patterns, affect, physical sensations, linguistic concepts, and thoughts (see Sect. 2.7), which are part of his metacognitive defense pattern. He completes the neural connections to form a holistic psychosomatic resonance pattern. However, the new linguistic concept of the defense pattern in memory causes it to be neuronally connected differently, for example, the resonance pattern of the term ‘beautiful childhood’, is now classified under the term ‘abandoned child’ (see Sect. 2.7).

• 14. After that, the therapist points with her hand at the empty chair on which the patient had initially sat: “This is the chair for your healthy adult thinking. Look, the chair is empty at the moment!”.

• 15. She lets the patient switch back to the chair of his ‘healthy adult thinking’ and helps him, as an implicit doppelganger, to expand his healthy adult thinking in the as-if mode.

• 16. The therapist’s work becomes increasingly encounter-focused as the therapy progresses. She names the patient’s dominant defensive pattern but additionally also verbalizes her negative affect triggered by the patient’s defensive behavior: “I feel small and powerless in the here and now because you have to be the great guy again.” Thus, the therapy becomes Encounter-Focused Therapy (EFN).

• 17. The therapist’s verbalization of negative feelings may trigger a negative transference in the patient. In such a case, the therapist provides an additional chair for the transference figure and, together with the patient, differentiates between the real conflict and transference conflict in the therapeutic relationship (see Sect. 2.10).

• 18. Patients with personality disorders mostly need 10–15 sessions to learn to delegate their dominant defensive pattern to another chair in the as-if mode of play and to feel the difference between their defensive thinking and ‘healthy adult thinking’ in the therapy session. The therapist can help the patients by asking them: “Please get an appropriate puppet for your ‘sadistic inner critic’ or print out a suitable picture from the computer. Keep this puppet anywhere in your home. Look at the puppet for two minutes every day! After that, lock the puppet in the cupboard again. In doing so, you will learn to distance yourself internally from your self-injurious thinking.” The symbolic act helps the patient to neuronally wire the distance from his self-injurious thinking.

The therapist also helps herself by symbolizing the patient’s dominant rigid defense pattern because she resolves her character-related countertransference (see Sect. 2.10) or does not get drawn into countertransference at all (Fig. 4.3).

Central idea

In metacognitive therapy of patients with personality disorder, the therapist concentrates on what’s important, true to the motto: first things first. The therapist thus develops a focus for further treatment.

Fig. 4.3

Resolving metacognitive confusion using the two-chair technique

Exercise 13

Try to represent the dominant dysfunctional ego state during the treatment of a patient with personality disorder and use the method described above. You will notice: It reduces your negative affect and has a liberating effect on the therapeutic relationship when you represent your patient’s rigid defensive behavior as a metacognitive ego state externally with a chair in the therapy room and, as a metacognitive doppelganger, also explain to him the positive function of the rigid defense pattern in the holistic process of his self-regulation.

Recommendation

The therapist should not let herself be irritated by the patient’s initial resistance to working with ego states. She has to lovingly introduce the patient to the concept of working with the ego states. Many therapists are not consistent enough with the chair work at the beginning (see Sect. 8.5). As a therapist, use your intuition when working with the chairs! The patient is happy to experience you trying to understand him.

In the therapy of people with personality disorders, I differentiate between cognitively oriented constellation work and metacognitively oriented constellation work. Cognitively oriented constellation work is similar to working with the cultural atom or social atom. When setting up the patient’s rigid defense pattern, the therapist speaks of the patient’s ‘ego parts’ or ‘parts of self’ or ‘working with parts’. For example, she says to the patient: “You have a grandiose part in you.” Together, the therapist and the patient work out the differences between his healthy adult thinking and thinking in the defense pattern and try to replace unfavorable thoughts with more favorable thoughts ones. They consider the situations in which it is helpful to strive for grandiosity, and those in which it would be disadvantageous. Some therapists invite the patient to engage in a psychodramatic dialogue with their symptoms and have them reverse roles with a symptom, for example, with their anxiety, sleep disorder, or exhaustion. The therapist then helps him to recognize the positive meaning of his symptom (see Sect. 6.8.3) or to distance himself from the unwanted part of himself. In this approach, the therapist works on the patient’s unfavorable thought content and not on the metacognitive processes that produce the unfavorable thought content. The therapist and the patient do not try to understand the positive function of his defense pattern in his dysfunctional self-regulation or the genesis of his defense. However, patients with a personality disorder suffer from a metacognitive disorder and it must be treated metacognitively. Cognitive therapy does not treat the cause of the metacognitive disorder (see Sect. 4.2). The therapist gets caught up in the cognition trap (see Sect. 2.14).

Explicit metacognitive therapy is more specific and has a lasting therapeutic effect in treating metacognitive blocks in the inner process of self-development than purely cognitive therapy centered on the patient’s thinking content (see Sects. 2.14, 4.9, 5.8, 6.8.3, and 7.2). This is because the patient’s new awareness of his rigid defense pattern changes his feeling and thinking in all relationships. If a patient with narcissistic personality disorder is ‘only’ 20% less grandiose and cool in all relationships, he may not be fired from his job, or his marriage may not break.

The therapist can also apply the explicit metacognitive procedure described above in group therapy: In doing so, she will only represent the patient’s dominant defense pattern as a metacognitive ego state. For example, she will represent his self-protective behavior through adaptation with an empty chair next to him in the circle. Or she will represent his self-injurious thinking with a chair opposite him.

4.9 Resolution of Defenses Through Splitting in People with Borderline Personality Disorder

The dominant defense pattern in patients with borderline personality disorder (see Sect. 4.3) is the oscillation between two contrary dysfunctional ego states. This oscillation suppresses healthy adult thinking. Patients defend through a mechanism known as splitting. They actualize the two inner contradicting psychosomatic resonance patterns alternately in their current relationships. They subconsciously switch back and forth between their needy, dependent ego state and the contrary pseudo-autonomous, authoritarian ego state (see Fig. 4.2 in Sect. 4.3). This change is secured secondarily by the defense through denial.

Central idea

Patients with borderline personality disorder suffer from metacognitive disorder. Their defense through splitting prevents them from coherently representing their relationship conflicts internally because they oscillate between the contrary ego states of authoritarian anger and clingy sadness. This also results in the dysfunctional functioning of the more complex steps of mentalizing: interact, rehearse, and integrate (see Sect. 2.2).

In metacognitive therapy, the therapist names the two oscillating contrary ego states, represents them with chairs, and makes the oscillation the subject of therapeutic communication (see Sect. 4.8).

Case example 24

A 35-year-old physiotherapist, Ms. M., suffered from serious relationship problems due to a borderline personality disorder. She was up to twenty minutes late for almost every group therapy session. She often ‘had’ to go home as she was a single parent to her daughter. When the group participants were asked to think of a ‘safe place’ at home (see Sect. 5.10.5), she ‘did not take the time’ to do so. When asked, she reacted superficially guilty. But she did not change her behavior. The other group participants resigned and would crack some jokes whenever she was late again. They were afraid of Ms. M.‘s latent arbitrariness and aggressiveness. They were increasingly accommodating of Ms. M’s provocative behavior in the group. Ms. M. finally got used to no longer justifying the violations of the group setting.

On the first evening of an intensive weekend announced a year earlier, Ms. M. informed the therapist, “Unfortunately, I will not be there all morning tomorrow”. When asked why, she added: “I have to work”. The therapist felt helpless and angry with the patient. He was increasingly unable to concentrate on the other group members. He practiced self-supervision at home with the help of a fictional psychodramatic dialogue (see Sect. 2.9) to reduce his inner tension and to be able to sleep better. The first 12 steps of self-supervision did not lead to a new finding that would have resolved the disturbance in his relationship with Ms. M. It then occurred to him that perhaps Ms. M. is switching between two contrary ego states. Therefore he placed a second chair next to ‘her’ in self-supervision.

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! You are so clever and behave in such a way that none of your actions is bad on their own. 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:

• 1. The patient violates the therapy setting or provokes, although he also exudes need. This creates a disturbance in the therapeutic relationship or group relationships.

• 2. The therapist feels increasingly confused and helpless by the patient's conflicting expectations and his emotional acting out.

• 3. The therapist justifies her feelings of helplessness and bewilderment. She proves the borderline personality organization by psychodramatic self-supervision (see Sect. 2.9). In doing so, she sets up a second chair next to the patient, either for his needy, dependent ego state or his pseudo-autonomous, authoritarian ego state. If the therapist’s bewilderment dissolves, she concludes that her diagnosis of borderline personality disorder is correct. Establishing the second contrary 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.

• 4. In direct therapy with the patient, the therapist initially works ‘only’ in her imagination with the image of two chairs for the patient.

• 5. She waits for a suitable opportunity to represent the contrary ego state also directly in the therapy situation. The indications to represent the contrary ego state are: (1) The patient's action in the here and now disrupts the therapeutic relationship. (2) The patient himself addresses a disruption in the therapeutic relationship. For example, some patients are irritated because the therapist no longer has an adverse reaction to her contradictory acting out (see case example 24 above). (3) The patient behaves needy in therapy but acts dissocial in everyday life without any awareness of the problem.

• 6. The therapist names the patient’s oscillation between the two contradictory metacognitive ego states as it happens in the here and now in therapy: “You just switched between your needy ego state and your autonomous ego state”. The therapist immediately represents his contrary ego state externally, next to him, with the help of a second chair: When the patient acts in a pseudo-autonomous, authoritarian manner, she places next to him ‘the chair for his needy side, which is not satisfied here’. When he is in need, she places the “chair for his angry, independent ego state” next to him. A purely verbal procedure would hurt the patient because he thinks in equivalence mode. He would think: “She insinuates that I am needy. But I'm angry!” Or: “She insinuates that I am angry. But I am needy!”.

• 7. Whenever the patient shifts back to his contrary ego state again, the therapist points to the chair of this other ego state: “I think you are now thinking and feeling from your needy ego state” or “… from your angry, arbitrary ego state”.

• 8. In her practical work, the therapist names the “pseudo-autonomous, authoritarian ego state” and the “needy, dependent ego state” of the patient with a personal name that matches the patient’s thoughts and feelings in the current situation. The contrary ego states are then called “the authoritarian Karl” and “the dependent Karl”, “the independent side,” and “the needy side,” or “the headstrong Maria” and “the loving Maria”.

• 9. The therapist lets the patient switch from one chair to the contradictory chair externally in the as-if mode of play at least once when the patient internally switches to the other ego state (see case example 25 below). For example, she invites him: “You are angry right now. Then sit down on the angry chair and be angry!” The patient performs the external role change in the as-if mode of play, acting psychosomatically (see Sect. 2.6). This helps him to notice the role change between his contrary ego states in everyday life more easily and to carry it out over time in the as-if mode of thinking. Thus, he consciously experiences his inner instability. But, the patient feels like he is taken seriously and his core suffering is understood.

• 10. As a metacognitive doppelganger, the therapist recognizes and appreciates the positive function of his defense through splitting in the holistic process of his self-regulation (see Sect. 4.8) and explains it to the patient: “You are angry right now because you are getting a raw deal for your needy side here. You are not experiencing the security you need here!” Or: “You are currently feeling sad and empty. But if someone comes close to you, you have an allergic reaction. You don’t want to be dependent. You have had bad experiences with dependence.” Over time, the patient must understand why it is the best solution for him to switch back to the opposite ego state in the current situation.

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 self-protection 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’. The patient can buy hand puppets for his ‘distancing self-protective behavior’ and his ‘inner angry child’ and give them a place in his apartment. 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 ‘disorder-specific 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.

Central idea

In a defense system, the rigid defense patterns mutually stabilize each other in their dysfunction. 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.

• 2. The therapist also names and represents the patient’s other defense patterns with empty chairs, if they currently block the patient’s inner process of self-development (see Fig. 4.1 in Sect. 4.2).

• 3. The therapist lets the patient repeatedly switch over to the chair of the defense pattern he is currently experiencing and play it out psychosomatically. In this way, the patient completes the psychosomatic resonance pattern between the 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 ‘self-injurious 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 pseudo-autonomous 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:

• 1. A patient came into the therapy session in an intense state of excitement. She reported having massive conflicts with her daughter-in-law. She was no longer speaking to her. As a result, the patient entered her childhood trauma film. In this state of mind, she had put her baby doll, which symbolized her ‘inner traumatized child’, in her own bed: “I wanted to ‘protect’ my ‘inner child’.” The therapist strongly recommended that she take her ‘child ego state’ to another room and make her a ‘cozy bed’ there. Thus, the patient stabilized her self-protection through this external distancing (see Sect. 5.8).

• 2. Another patient informed the therapist without any awareness of the problem: “My inner child is dumb. It doesn't talk!” The therapist wanted to know the reason behind it. He changed into the role of her inner traumatized child externally in the therapy room and held a soliloquy in this role (see Sect. 4.6). In this role, he vicariously figured out why it was the best solution for the patient’s ‘inner traumatized child’ not to speak. Thus, he justified the patient’s self-protection from the complaints of her inner child. In the next therapy session, the patient's ‘inner child’ had started talking. Over time, it developed into a ‘healthy inner child’.

• 3. In another case, shortly before the end of the long-term therapy, the therapist noticed that the patient had not yet specified the private name for his self-injurious thinking (see Sect. 4.7). Thus, the patient had adapted to the demands of his sadistic superego. It took the patient and the therapist, together, a total of thirty minutes to name the patient’s self-injurious thinking with the personal name ‘child breaker’. This name gave the patient a new feeling of power over his inner self-injurious thinking.

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:

• 1. The psychodrama therapist expands the constellation of metacognitive ego states (see Sect. 4.7) to include the two chairs for the patient’s symptom scene (see Sect. 2.8 and Fig. 2.9). The symptom scene includes the patient’s inner self-image and object image in everyday conflict. The creative development of the inner self in an external conflict also includes the development of the inner self-image and object image. Therefore, metacognitive psychodramatic work on defense patterns should always be related to the patient’s externally represented conflict in his everyday life or the interaction between the patient and the therapist in the here and now. Otherwise, it becomes blurred in space and time.

• 2. In the psychodramatic metacognitive work, the therapist sets up two different chairs for the ‘self-injurious thinking’ of the patient (chair 8 in Fig. 4.1 in Sect. 4.2) and the inner object image of the harmful caregiver from his childhood (chair 9). The chair for the harmful caregiver is placed behind the chair for his self-injurious thinking. The patient developed self-injurious thinking in childhood as self-censorship (see Sect. 8.5) to avoid being beaten, devalued, or left out of the relationship and to not make life even more difficult for his parents. The old masochistic self-censorship is superfluous, and it can ‘die’. The patient remains a moral person even without it. But, the inner object image of the attachment figure survives forever. Authors who wrote about their parents’ war trauma or crimes during the National Socialist era did so only after the death of their father or brother. The self-censorship against their own self-development in their relationship with their father was then no longer necessary to maintain the psychological balance of the damaging attachment figures. Writing became a liberation from self-censorship.

• 3. The schema therapists distinguish between ten (Young et al., 2008) or even eighteen different equivalent dysfunctional modes of internal conflict management (Jacob & Arntz, 2011, p. 44 ff.; Roediger, 2011, p. 110 ff.). I divide the metacognitive ego states qualitatively into four categories: self-protection behavior, self-injurious thinking, abandoned child, and angry child. The number of categories of metacognitive ego states is limited by the number of possible defense patterns (see Sect. 4.10). Therefore, in psychodramatic metacognitive therapy, the therapist sets up only a maximum of four dysfunctional ego states for each patient. These should have personal names.

• 4. The psychodrama therapist responds psychodramatically (see Sect. 4.13 and Krüger, 2007) in the therapy of persons with a personality disorder, if necessary. She also names her metacognitive ego states from which she thinks, feels, and acts in the therapeutic relationship and symbolizes them as parts of her self-image externally with chairs. I distinguish between three task-related self-images: the ‘therapist as an encountering human being’, the ‘grandiose therapist’, and the ‘therapist as a competent expert’. The therapist responds psychodramatically to the patient by externally switching back and forth between these three self-images in the therapeutic conversation in the as-if mode of play. This releases the therapist’s internal process of self-development (see Sect. 4.1) in the therapeutic relationship from its fixation in a biased self-image.

• 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?

• 1. Schema therapists can use psychodramatic self-supervision (see Sect. 2.9) as a diagnostic instrument. If steps 1–12 of self-supervision do not resolve the disruption in the therapeutic relationship and the countertransference, the patient likely suffers from a personality disorder.

• 2. Steps 13–17 of psychodramatic self-supervision help to find the dominant defense pattern and open the door to the patient’s defense system.

• 3. Simultaneously, they help to rehearse an appropriate therapeutic approach.

• 4. The metacognitive doppelganger technique (see Sect. 2.5) helps the patient to gain ego control over his defensive actions (see Sect. 4.8) so that he can think about it in the as-if mode.

• 5. The understanding of the self as a dual process helps to free not only the inner self-image but also the inner object image in the external situation from its fixations and to break down the defenses through projection in old relationship images. This then indirectly promotes the patient’s self-actualization in relationships (see Sects. 2.9, 4.12, and 8.4.2).

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 self-image 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.

• 4. The patient integrates, with the help of the psychodramatic dialogue and role reversal, his newly gained self-image into the internal image of a relationship with a close attachment figure from his childhood. In his fictional dialogue with this person, he speaks as the adult he is now (see Sect. 4.11). He chooses an attachment figure who witnessed his fate in childhood, for example, a brother or a grandmother. Under no circumstances should this person be the perpetrator who traumatized the patient (see Sect. 5.11). The patient verbally shares his new knowledge about himself and his childhood with this attachment figure in the as-if mode of play. In the psychodramatic dialogue with role reversal, he examines why they were unable to support him sufficiently in childhood by stepping into the role of his attachment figure. This helps him to reconcile with them in the present. In this process, the patient also focuses on developing his old inner object images of attachment figures from childhood through mental rehearsal and role reversal, thereby dissolving the defense through projection. He achieves this by reversing roles and further developing the inner object images in the play into a holistic psychosomatic resonance pattern (see Sect. 2.7). He psychosomatically learns the motivations behind his unconscious self-protection and conscious action. Resolving projection makes it easier to resolve the defenses through introjection in the old relationship images (see Sects. 2.9 and 8.4.2) and liberates one’s inner self-development in current relationships from old interaction patterns.

• 5. The patient integrates his newly acquired healthy adult thinking into relationships with his current conflict partners using psychodramatic dialogues (see Sect. 8.4.2). In doing so, he verbalizes his own experience and inner truth in 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 self-supervision 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 narrow-minded 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).

Fig. 4.4

The therapist’s three task-related inner self-images and the chair for the negative transference figure

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) 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. This symbolizes the patient's negative transference figure: “This is the chair for your mother who gave you away to the children's home. 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. Experience it through a role-play with psychosomatic acting: Place an empty chair in front of you in your therapy room. 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. But if you sit on the chair for the ‘encountering person’ and the chair for the ‘grandiose therapist’ is not there, it feels like you are missing something important. You lose your therapeutic vision and the reason why you became a therapist. You lose your spiritual identity and your inner fire. 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).

• 2. The therapist captures the patient’s unconscious expectations from her while he is acting and thinking in equivalence mode. She searches for the inner task-related self-image which would fulfill the patient’s expectations. She places the respective chair next to her for this desired ego state. She moves to this chair and acts it out in the as-if mode of play. For example, when working with a patient diagnosed with narcissistic personality disorder, she moves to the chair of the ‘grandiose therapist’. She verbally assures the patient that she ‘as a grandiose therapist’ would like to try to fulfill his wishes. She thinks out loud about how that might be possible and what the consequences would look like. In doing this, she paradoxically exaggerates her grandiosity and, for example, gives him advice on how to bring out inner change immediately.

• 3. But then she changes to the chair of the contrary task-related self-image. This is the chair of the ‘encountering human being’. She acts out this ego state of being herself in the as-if mode. She tells the patient: “As a human being, I have to tell you: I have often tried to accomplish the impossible. But then I mostly failed!” For example, in the case of a patient with masochistic behavior, the therapist first breaks out of her adaption and, as an ‘encountering human being’, protests against the patient’s self-injurious thinking: “I feel some pressure on my chest. If you devalue and criticize yourself repeatedly, I feel helpless and powerless.” But then she moves to the chair of the ‘therapist as a competent expert’ desired by the patient and directly contradicts the ‘encountering therapist’ next to her: “As a competent therapist, I think: Renate, it doesn’t work that way! You are the therapist! You can’t be helpless and powerless toward Mr. B! You must help him!”

• 4. In the case of an internal shift to another task-related self-image, the therapist does not have to physically move to the other chair every time. She can also point with her hand to the other chair: “As a grandiose therapist, which I am, I mean…”.

• 5. When the therapist authentically communicates her personal feelings and thoughts to the patient as the ‘encountering human’, it occasionally triggers some negative transference in the patient. In such a case, the therapist immediately symbolizes such a negative transference with a fourth chair and names the negative transference figure (see case example 19 above 2nd continuation). She places this chair three meters away from her, facing the patient (see Fig. 4.4 above). Then, together with the patient, she works out how, as a therapist, she acted similarly to the transference figure and also how she is different (see Sects. 2.10 and 4.14 and above case example 19, 2nd continuation).

• 6. The therapist often faces a dilemma in crisis interventions with patients in severe distress. As a professional, she wants and needs to give the patient a clear opinion, but she knows that the patient will react with negative transference, break off the relationship or have an angry outburst. In such a case, the therapist can 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. She had to be on sick leave for a long time. 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. I'll place a second chair here, next to you, to represent your longing. 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.