With respect to imagery and imaging, three phases of J's treatment have been identified. These are the Pre -Representational (Pre-Impasse); Representational (Impasse-Transitional); and Limitations stages. The following discussion will relate the data from these three phases to theory and derived implications for treatment.
Phase I. Pre-Representational (Pre-Impasse)
Imagery and the imaging process associated with schizophrenia and bulimia are perhaps best viewed from the perspective of ''normal'' imagery and Imaging. Survival depends on a person's ability to make sense out of the ''booming, buzzing confusion of sensations.'' The cohesive self, through the agency of the mind, orders the raw data of experience by a process of symbolization. Langer, (1942) indicates that the self always adds something of itself in the form of interpretations when ordering experience. Thus this ordering process may be referred to as active meaning making. Images and imaging play an essential role in this active meaning making process. Meaning making begins with perceptions leading to mental images moving in turn to concrete signs (denotations) and to abstract concepts (connotations). These components become attached to language which may be shared by communication (p. 52). Langer distinguishes between two levels of symbolization: discursive (associated with linear logic and language) and representational (associated with images) (p. 52). Normal meaning making assumes a self that is cohesive enough to add perceptions to images and move on to denotations and connotations.
In schizophrenia there is a regression from discursive symbolization to pre-representational symbolization. Arieti (1955) understands schizophrenia to be a ''particular reaction to unbearable truths about objective reality'' (p. 384). Schizophrenia is a thinking disorder wherein there is a substitute of emotional thinking in the place of rational or objective thinking. The major symptoms of schizophrenia then are a retreat from objectively validated reality accompanied by a retreat from reason (linear logical discursive symbolization) and a retreat from society (self imposed isolation). Imagery associated with schizophrenia is usually noted in the form of hallucinations (Prouty, 1977). However, what is most notable in J's case is the relative absence of imagery and the lack of lively interest in whatever little spontaneous imagery produced in the first stage of her treatment. Some researchers in the field of schizophrenia suggest why this may be so.
Salonen (1979) understands the central psychological mechanism in schizophrenia to be a ''breakdown of the primal representational matrix accompanied by a radical disappearance of psychic liveliness, a breakdown of ideational contents. This is due to a loss of the synthetic function'' (p. 79). A missing synthetic function is another way of describing the subjective feeling of unwholeness (an experience of an incohesive self). This loss of self is the experience of a person in the state of pre-representational (pre-imagistic) symbolism.
Ende (1983) refers to this state of pre-imagery as the pre-representational self. For Ende, the self is understood to be a process that gradually develops over time, moving from the pre-representational self to the representational-self stage. To accomplish this developmental progression, the self has to have achieved three basic tasks.
(1) self esteem regulation, (regulating the self, being resilient);
(2) social fitness (process information and adapt to other human beings); and
(3) affective monitoring (be motivated toward pleasure and away from pain) (p. 169).
Failure to negotiate these three tasks leaves the self, unformed and the person in a state of pre-imagery and/or incapable of lively interest in whatever imagery is produced.
In reflection, J was in the first stage of treatment for three years (approximately three hundred therapeutic hours). Her attitudes, behavior, style of living, symptoms, preoccupations, and style of coping or avoiding her problems are congruent with the theoretical constructs mentioned above. J entered treatment at a time when she failed to meet any of the criteria needed to build a cohesive self. Thus she was stuck in the pre-representational stage of self- development. It is noted that J did produce some spontaneous imagery in this first stage of treatment, but it seemed blocked and devitalized. In connection with this observation, Arieti (1955) states: '' The schizophrenic is aware of social discursive symbolism but disconnects from the emotional or affective tone of the symbol. Thus it isn't that he represses emotion - it is that he can't experience them'' (p. 308).
What explains the emotional deadness and blocked flow of imagery? Rosser (1979), whose schizophrenic patient suffered from a similar blocked flow and devitalization of imagery, concluded that he had an inability to think at all (p. 183). This inability to think precedes the awareness of thoughts. Tahka (1987) describes this pre-thinking stage associated with schizophrenia as one in which the person enters into "a blank void of painful affect, anxiety, and meaninglessness. This Is felt to be a powerful loss of self" (p. 248). In 3,5 case, the blocked flow of imagery and devitalization is seen to be motivated blockage and motivated devitalization. Yahalom's (1967) theoretical observations are helpful in understanding this blockage and devitalization in greater detail.
The (normal) thinking process begins with registration (ideas and images) as preceding mental representations, which in turn make possible mankind's unique ability to form and use symbols. However, mental registration cannot be transformed into mental representations except as raw sense data are modified in the light of his own experience. The entire progression depends on the capacity to find meaning in sensation. Without this capacity, the individual is unable to differentiate objects or to develop symbolic object representation (p. 382). Yahalom adds that it is a necessary pre-condition for the schizophrenic patient to experience that it is safe to experience at all.
In schizophrenia, there is a regression to a stage of pre-representational symbolism. This regression is an attempt of the person to avoid overwhelming psychic pain. There is a loss of the synthetic function with an accompanying decathexis of the normally expected flow of imagery and /or a devitalization of interest in imagery. This process is unconsciously motivated and has its ultimate roots in childhood. The theoretical findings outlined above indicate that the primary problem underlying the blocked flow and devitalization of imagery in schizophrenia is a failure in attaining basic trust.
These theoretical findings have significant treatment implications for J with respect to her relationship with imagery and the imaging process. The set of conditions prevailing at the onset of J's treatment and outlined above suggest that Arieti's (1955) three task plan for beginning treatment in the pre-representational stage is appropriate.
This plan consists of
(1) establishing basic trust,
(2) increasing the ability to communicate ''by having the patient gain
insights into the genetic and dynamic nature of his difficulties,'' and
(3) experiencing a gradual increase in self esteem (p. 436).
Added to this treatment prescription is the work of Spitz (1955) and Tolpin (1972) who both indicate that ''psychic work'' is necessary to grow a cohesive self and a strong ego. This psychic work is a process known as structuralization. For Spitz, a strong ego (self) spontaneously develops to the degree that the baby (patient) learns to bear increasing dosages of frustration (p. 147). Tolpin (citing the work of Kohut) indicates that the child needs to borrow the attitudes and the ego functions of the mother (therapist), gradually internalizing them. This gradual internalization process enables the child (patient) to bear frustration and obtain coping mechanisms and their effective utilization leading to the formation of strong psychic structures (self and ego) (p. 333).
It is important to note the emphasis on pacing and gradualness of this process of internalization. It was the therapist's experience that J had to reach a stage of basic trust in her own time before she was ready to move from the stage of pre-representational symbolism to the stage of representational symbolism. Until J experienced sufficient trust in the therapist and in herself, all attempts to direct her therapy by evoking imagery failed. This finding appears to qualify Ahsen's (1980) conclusion that ''central work through the vehicle of the image itself can bring lasting therapeutic change without involving the therapist, the transference situation, or even prior resolution of defenses''(p. 157).
The bulimia in J 's case complicates the dynamics of her schizophrenia. The literature indicates there is a variety of theoretical approaches to the understanding of bulimia. Three of these approaches are as follows.
From a structural or intrapsychic perspective, bulimia is a regression from forbidden incestuous wishes and fantasies. This may take the form of an inhibition of fantasy itself
(Sandler and Dare, 1970, p. 215).
From an object relations point of view, bulimia involves the child's unconscious need to conform to the mother's unconscious need for total obedience (Sours, 1970, p. 571).
Sugarman and Kurash (1981) conceptualize bulimia as ''an outgrowth of the self arrested at the area of transitional objects'' (p. 58).
All of these approaches share the central idea that bulimia is either a fixation or regression to the pre-symbolic (pre-representational) level of development. Additionally, despite differences, all theoretical roads lead to the basic problem in bulimia - being that of a deficit in self development. This deficit is accompanied by an impoverishment in the person's capacity to generate self-meanings.
These particular theoretical approaches toward understanding the psychodynamics of bulimia are seen as similar and complementary to the theoretical approaches used to understand the psychodynamics of schizophrenia outlined above. Both theoretical approaches assume the core underlying issue in bulimia and schizophrenia to be an arrest of self-development. This basic self deficit is initially expressed as a lack of basic trust in the object world and with the self. Symptomatically, this lack of trust in the self appears to be expressed in S's case as motivated interference with her flow of imagery and/or a devitalization in what imagery she spontaneously expressed in the first stage of her treatment.
These findings have important treatment implications. As in the early treatment of
schizophrenia, (see Arieti) researchers studying bulimia
(see Boris and Bruch)
reached similar conclusions with respect to basic treatment attitudes.
For example, one key finding is that it is especially beneficial for bulimic patients
(and other patients suffering from eating disorders) to evolve in their own time,
gradually making connections and self -discoveries.
Affirming the theoretical positions above is a summary of another schizophrenic/bulimic patient successfully treated by this clinician over a seven-year period using psychoanalytic psychotherapy. C, representative of these patients, describes the conditions and tasks that she believes led to her eventual treatment success.
''I needed an opportunity to find myself, to be able to face myself, and to do so on a regular basis. I had to learn how to accept myself, to trust others and myself. I had to learn to be persistent, to struggle with struggle, to keep trying. Looking back, (I saw that) it was a process of coming alive'' (C, 1987, personal communication).
Phase II. Impasse - Transition into the Representational State - ''Scrapping''
Increasing understanding of J made it clear that her major problem was a conflict in negotiating the separation/individuation stage of psychic development. J's request to take a break from therapy in January, 1983, signaled a major turning point in her treatment. This request indicated that sufficient psychic structuralization had been obtained for to risk experiencing potentially overwhelming fears of separation from the now valued therapist.
However, once back in treatment four weeks later, her night time emptiness, binge eating, and compulsive exercising unexpectedly intensified. She felt the therapist was being too easy on her and, like her mother giving her too many ''reprieves,'' all attempts to press for direct behavioral change were met with seemingly impenetrable defensiveness.
This state of affairs led to a major treatment impasse. J needed to fill up her night-time emptiness, but neither a psychoanalytic nor a behavioral approach was of much help. Needed was a therapeutic technique to encourage the patient to begin to cathect (invest interest in) active meaning making by stimulating her mind (mental ego).
Experience with J in phase one of her treatment demonstrated a relative lack of interest in her own psychic processes.
Theoretically, this lack of interest is seen to be due to
(a) motivated defensiveness and
(b) structural deficits.
Work in phase one aimed at promoting maximum structuralization in a climate of unconditional acceptance. Increasing psychic aliveness noted in the progress notes is attributed largely to J's gradual identification with the therapist's genuine interest in her and in her psychic processes. Progress was met with resistance as J clearly balked taking over the therapist's attitudes and using them as her own.
Continuing progress would mean that J would have to become actively engaged in the psychic work of structuralization. Successful outcome of phase two of treatment would enable the patient to move from using the therapist as a good symbiotic object to experiencing the therapist as an ally and helper who is separate and different from the patient (Tolpin, 1972, p.332.).
In this connection, Winnicott's (1958) concept of negotiating the intermediate realm of experience seems particularly relevant in understanding the psychodynamics of this phase of J's treatment. Says Winnicott (1958): ''Between the self and the object world equals an intermediate area of experiencing . . . an area which is not challenged … It shall exist as a resting place to the individual engaged in the perpetual human task of keeping inner and outer reality separate yet inter-related'' (p. 230).
In terms of imagery and imaging, negotiating the intermediate realm of experience necessitates the self to generate personal meanings out of raw sensory data. ''Each of us must create his own perceptions of the world. Texture becomes feeling; sound must become perception. The integration of these processes creates the core of the healthy self'' (Yalahom, 1967, p. 382).
Successful negotiation of this transitional stage (intermediate realm) means that the self advances from the pre-representational self to the representational self. Additionally, ''Adaptive functioning at this level involves not only the coordination of perception and movement but also of images and verbal concepts''(Piaget, 1969). Thus in this transitional stage there is also a move from pre-imagery and pre-imaging and/or devitalization in imagery and imaging to a cathexis of Imagery and imaging of both representational symbolism and discursive symbolism.
How is the intermediate realm of experience negotiated?
This intermediate area is in direct continuity with the play area of the child who is ''lost in play.'' The small child typically designates a blanket, teddy bear, or doll. This object has special properties during this transitional object stage of development. The object, to be referred to as a transitional object, has the dual properties of being experienced as both part of the self (me) and not of the self (not me), (Winnicott, 1958, p. 230). The transitional object is used by the self as a substitute for the mother and thus allays anxiety by its self-soothing functions (Tolpin, 1972, p. 333).
Viewing J's impasse from the perspective of a transitional space issue has important implications in understanding the central role that imagery and imaging had for J in the second phase of her treatment. J discovered scrapping when she had developed sufficient trust in her therapist and had also developed sufficient structuralization to be able to affirmatively respond to the therapist's suggestion to find a meaningful activity to stimulate her mind. In this view, J's discovery of scrapping, when the time was ripe, was in a larger sense the discovery of a transitional object. This transitional object (scrapping or imaging) was then put to multiple therapeutic uses, leading eventually to the negotiation of transitional space.
For J, this transitional stage spanned four years (approximately four hundred therapeutic hours). During this phase of her treatment, J made an affective reconnection with her flow of imagery, began taking it seriously, and playing with it - deriving pleasure from its multiple uses. She was able to gradually fill up her night time emptiness, holding onto it as a substitute reliable 'mother' - able to use it at will for as long or as short as she wished. Gradually J was discovered for herself the multiple uses of imagery and imaging outlined by Horowitz at the beginning of this paper. She was able, through scrapping, to name her feelings, validate them by objectifying them in her scrapbooks, identify problems, explore her conflicts, derive increasing interest and pleasure in understanding her psychological process, and learning to bear increasing doses of frustration, thus greatly aiding and accelerating her structuralization (self trust) process.
The clinical findings are in line with Eckstein and Caruth's (1966) experience with schizophrenics. Their patients were found to resist communication in linear language for a long time in their treatment, but never gave up completely. They concluded that for these patients a ''compromise language - an Esperanto of the mind - had to be fashioned'' (Ecksteln and Wallerstein, 1966). They further found that this new language had to be in the form of metaphor. ''Metaphor becomes a link between the language of inner and outer reality, and brings about primitive understanding, tolerable contact under optimum condition'' (Eckstein and Wallerstein, 1966). Milner (1952) and Sechehaye (1951) report similar treatment successes in their work with schizophrenic patients utilizing metaphor (symbolic realization) as a bridge to and from the patient's private world and external reality.
Phase III. Limitations of Imagery and Imaging
A review of the clinical data in the seven years of work with S makes a compelling argument for the efficacy of utilizing imagery and imaging in helping her negotiate a major treatment impasse. However, the data also demonstrate limitations concerning the handling and use of imagery and imaging in both the pre-impasse and post-impasse phases of treatment.
With respect to the pre-impasse stage of treatment, at least three pre-conditions had to be satisfied before J could connect with and effectively utilize her flow of imagery and the imaging process.
These preconditions are:
(1) She had to work through the motivated interference's blocking her flow of imagery.
(2) She had to have sufficient interest in her flow of imagery to take it seriously.
(3) She had to feel cooperative enough with the therapist to be able to respond to his
directed suggestions to take her imagery and imaging seriously. In the first stage of
treatment, J clearly lacked these three pre-conditions.
Therefore, in terms of imagery and imaging, the central problem in phase one of treatment was to understand that the patient's blocked flow of imagery and/or its devitalization was unconsciously motivated. Clinical evidence in this case, supported by theory, suggests that the root cause of this motivated blockage and motivated devitalization was ultimately traced to a lack of basic trust in her self and in the object world.
Building trust requires an attitude of unconditional acceptance and consistent slow pacing by the therapist. The patient must take the lead. Trust in the therapist (the therapeutic alliance) is cemented by the systematic working with the patient instead of doing something to the patient. There is the danger then that until and unless the patient has attained the three pre-conditions outlined above, directed interventions involving imagery will be experienced as intrusive. Thus the timing and the sensitivity of the therapist is apparently crucial to therapeutic success or failure. In this case, holding back until the patient signaled a clear sign of readiness to respond to her imagery, was indeed beneficial with respect to J's successful treatment outcome. These clinical findings support the caution of Weiss (1967):
Hidden images are inhibited for some reason. They probably
cannot be assimilated until the reasons for avoidance are reduced.
''Images emerge spontaneously. Once the person integrates his
defenses so that they are conscious controls rather than unconscious
avoidances, childhood memories, old traumas, and current wishful
fantasies become more accessible without any special ''techniques'' (p. 357).
There are additional limitations connected with the phase three (post-impasse) phase of treatment. J began her treatment with a hyper-cathexis of physical stimulation and a hypo-cathexis, or decathexis, of mental stimulation. Successful negotiation of the second stage of treatment brought with it a revitalization of her interest in and discovery of multiple use of imagery of imagery and imaging.
However, as J states, there came a time when she experienced the use of imagery as a defensive process to avoid dealing with more basic issues. This defensive use of imagery and imaging appears to validate the caution of Horowitz (1970) that imagery can be used as a ''substitute for real life'' (p. 312). This warning should alert the therapist to the fact that no one technique or concept is the only key to therapeutic success for patients with such complex symptoms as J's. This clinician agrees with Horowitz' (1983) conclusion: ''Image techniques… are tools to be selected within a larger array of potential therapist actions. Choice for this array is organized by formulation of the case and consensual goals for change'' (p. 283).
Both as organizing concepts and as technical Interventions, imagery and imaging are seen to have considerable transformative power, but they need to be viewed in the total framework of the Individual case.