Multiple Uses And Limitations of Imagery and
Imaging in the Psychoanalytic Psychotherapy of a
Patient Suffering from Schizophrenia and Bulimia

Gibbs A. Williams, Ph.D.
 


Abstract

This paper is a case study of a patient diagnosed as schizophrenic, complicated by bulimia. Imagery content and imaging as a process are seen as central organizing concepts used in targeting symptoms, understanding psychodynamics, and in generating effective treatment interventions. The therapeutic work associated with imagery and imaging is related to Winnicott's concept of negotiating transitional space. While clearly beneficial in this case, imagery and imaging are seen to have their limitations with patients requiring long term psychoanalytic psychotherapy.



A review of the literature on imagery and imaging demonstrates the 'cash value' of utilizing these two concepts in the psychotherapy of patients suffer from a wide variety of psychological symptoms. Summarizing the psychotherapeutic uses of imagery, Horowitz (1983) states: ''Images are useful for full expression of ideas and feelings; to form new and creative solutions to conflicts; and to altering the balance of controls in the direction of greater personal freedom'' (p.xi).

Further, researchers point to the efficacy of utilizing the imagery process as a central organizing concept in generating technical interventions for patients receiving short term psychotherapy. Ahsen (1980), for example, refers to ''potentials of the image process itself . . . to introduce fast moving therapeutic effects'' (p. 159). Supporting this assertion are many detailed clinical examples found in the case history sections in The Journal of Mental Imagery.

Such speedy and substantive ''transformative power'' attributed to imagery and the imagery process assumes that patients have sufficiently strong psychic structures (self and ego) to be able to respond to such pointedly directed interventions. What then of the patients who, at the beginning of their treatment, lack cohesive selves and strong enough egos? What is the therapeutic efficacy of imagery and the imagery process for them? In contrast to the criterion of speed in the application of imagery through direct interventions in short term psychotherapy, the thesis of this paper is that for some patients suffering from complex symptomology, the use of imagery requires an attitude of slow pacing, emphasizing systematic self discovery.

This paper has grown out of a seven year relationship with J - a patient diagnosed as an ambulatory schizophrenic, complicated by' an idiosyncratic form of bulimia. A test battery at the beginning of her treatment accurately predicted that a treatment impasse might occur, taking the form of "resistive rebelliousness" and a covert form of boredom associated with intense inner emptiness.

This impasse came to a head during her fourth year of twice-weekly psychoanalytic psychotherapy. It was at this time that J discovered a technique allowing us to resolve this block. In J's terms, this technique is called ''scrapping,'' and in clinical terminology as ''imaging.'' This technique took the form of a feelings scrap book, allowing J to cathect her deepest and truest feelings and then give them verbal expression in her treatment sessions.

The purposes of this paper are: to describe the context from which this discovery was made; to outline the nature of "scrapping;" to delineate some therapeutic uses to which imaging has been put; and, to detail some implications of using imagery in understanding the nature of, and in facilitating the treatment of, such complex psychological problems as schizophrenia and bulimia. Additional comments present the limitations of imagery and the imaging process for such patients.

Toward this end, three phases of treatment will be outlined showing therapeutic progress related to J's discovery and growing reliance on imagery and imaging as aids in both self help and in a formal therapy context.

The uses of imagery and imaging in overcoming J's treatment impasse will be related to Winnicott's concept of negotiating the indeterminate (transitional) realm of experience. In this view, ''scrapping'' is seen to be a transitional phenomenon (process) that has enabled J to gradually break out of a seemingly intractable impasse.

Encouragement for this type of study comes from Somner (1980), who states: ''Idiographic investigations using a case study approach are strongly supportive of the importance of imagery.'' He makes the additional point that such studies are especially important when patients seem to lack a flow of imagery (p. 115).

The Patient
J was twenty-six when she entered treatment seven years ago. She was deeply troubled, and found it difficult to express herself. As an aid to understanding her symptoms, she took a standard battery of psychological tests, including the Rorschach and Thematic Apperception tests. The essential test results were as follows:

She doesn't feel she fits in. Her main problem is managing to go to work and do what she wants to do and to fit in at all, plus over-eating. Preferring to travel she is annoyed with the necessity of working. She craves intimate contact especially with a man but is exceedingly uncomfortable with herself and globally distrusts all men.

Relevant to imagery, psychological test results showed impairments in visual motor processes and visual concentration diminish her intellectual efficiency. She is identified with a very regressed and immature self - concept of a six-year old girl. Her idea of a perfect state of being is to feel free out in the sun. Reality testing is grossly impaired; autistic thinking is prevalent. Wayward affect, both sexual and aggressive drives, lay beneath an exterior of boredom. She found the TAT cards unexciting.

From an identity point of view, she is both a twenty-six year old woman and a six-year old girl inhabiting the same body. From a heterosexual point of view, she feels profound emptiness from talk or sexuality as they involve no emotionality.

This patient was diagnosed as suffering from ambulatory schizophrenia complicated by her over-eating problem. Long-term psychoanalytic psychotherapy was recommended as the treatment of choice.

Phase I. Beginnings - Pre-Impasse: Pre-Representational Stage
To understand the nature of the impasse, it is necessary to get an idea of this patient and the way her treatment unfolded. J responded well to an attitude of unconditional acceptance. We settled on two times a week. The initial aim was to build basic trust in both the object world (the therapist) and in herself. Trust would be based on

(a) establishing a good therapeutic alliance, and
(b) slowly constructing strong psychic structures (self and ego)
     by a process referred to as structuralization.

Her major symptoms emerged in the form of intense feelings of isolation from herself and the world; alternating feelings of bursts of aimless energy followed by chronic fatigue, crankiness, boredom, purposelessness, and meaninglessness. She complained of a major problem in making even the simplest of decisions. Added to these burdens was an entrenched set of compulsive rituals designed to counter her emptiness and/or to drain her of the bursts of uncontainable energy. These rituals took the form of binge eating followed by compulsive bicycle riding. Fearing she would become fat (in reality, she is slight and well-proportioned), she would ride twenty-five to fifty miles each day after work. This compulsive biking was seen to be an equivalent to the usual purging associated with binge eating (bulimia).

Most noteworthy in this first stage of J's treatment is the relative paucity and/or lack of interest and aliveness associated with spontaneous imagery. Gradually there emerged a clear sense that J had systematically cut herself off from external reality, withdrawn from the object world, decathected (divested interest in) her natural flow of imagery, and overemphasized her body at the expense of her mind.

Following are summary notes of key sessions from the first phase of treatment. Highlighted are the major themes that form the therapeutic context from which her treatment impasse will later emerge. These notes begin with the last eight months of this first stage.


(5/30/83) ''I wish I could do what I want to do. I feel that eating is a substitute for a guy. I feel empty and lonely. I can't be naturally alive. I've pulled away from life. Now I feel like I'm gradually coming back.''

(9/19/83) J mentions a rare and notable reference to an important childhood memory. She and her father learned Morse Code together. She felt stimulated. This was in contrast to being with her mother whom she experienced as a compulsive house cleaner. (The reference to her father stimulating her is later seen to be a key motivation in her search for father substitutes who will stimulate her. This search will directly lead to the treatment impasse some two years hence.)

(9/26/83) J feels she is locked in the way she does things. She feels empty and in need of a man to fill her up. Without a man around, she literally feels un-whole. A man ''evens up'' her feelings. She feels trapped in herself, ''no projects, no goals, no friends, aimless - always on an endless repetition of sameness.'' It is particularly bad at night. Then she feels she has no options: too restless to go to sleep and too tired to go out. She needs a feeling of meaningful connections. This lack of meaningful connections stirs desertion anxiety.

(10/10/83) J wants to be rescued by a man. ''You (the therapist) are the only one I see and call. I'm scared I'll drive you away.''

(10/11/83) J feels that she holds herself back. She describes her endless repetition of compulsive rituals. Despite her despair about changing, she faithfully comes to the sessions. She has begun to balk at the perceived rigidity of the time schedule and has requested the therapist to be 'more flexible.' I decided to grant her request. J began experiencing the therapist as someone she could cling to and depend upon. But she was unable to feel comfortable with herself.

(11/1/83) ''I have no faith I can derive positive energy from myself.'' Throughout this phase of treatment it became increasingly apparent that J was acting as if she were all body and very little mind.

(11/3/83) Nothing interests her. ''Men come and go, but the bike is constant.'' Despite repeated attempts of the therapist to encourage the development of some mental interest, J actively resisted all of them. All directed attempts to encourage mental stimulation of J's initiative were futile.

(11/30/83) I feel I understand her better. J's complaint of nothing to do at night means she is feeling bored with being passive and inert. She experiences herself as fat, ugly, and restricted. The issue is not to try to get her to will herself into meaningful activity (mental), but to try to understand why she apparently needs to hate and restrict herself. This new understanding led us back to pivotal memories of being forced to do things that conflicted with her basic needs and values. Her way of coping with this climate of perceived unfairness was unconscious defiance expressed in the form of passivity, inertness, and self-imposed isolation.

(12/07/83) Things have come to a head. ''All roads lead to blank spaces. This is my life: a dark hole.''

(12/21/83) J identified the beginnings of her present illness. She feels she lost all of her fun and hope when her boyfriend abandoned her. Soon after this traumatic loss, she began a slow but steady retreat from reality, the object world, and her own mind.

(12/26/83) We reached an impasse in the treatment. J says she is tired of her routines, but nothing she does helps her break out of them. Now she experiences treatment as a routine too. It is good to come, but nothing really changes. She feels she needs a bridge to get out of this psychological trap.



Phase II. Impasse - Transition into Representational Stage ''Scrapping'' During this phase of J's treatment (approximately four hundred therapeutic hours), the question of frequency and the regularity of her sessions became a therapeutic issue once again. I suggested that J might well be able to tolerate a more regular schedule. She balked. This time, regularity was associated with a rigid mother who, the patient felt, never gave her a break. A compromise was worked out that led J to begin making boundaries for the first time in her life. These boundaries took the form of differentiating inside from outside and distinguishing the present from the past. She began to feel as if she had a will of her own and had the right to use it. This represented a turning point for J as she was beginning to construct the concrete foundations of her core self.


(1/5/84) J requests a break from treatment. Despite many fears, she survives well. (So does the therapist.) The emptiness problem remains intractable.

(2/1/84) J needs to learn how to be a friend with her feelings and her mind in order to reduce her many childhood fears. She has to find some significantly different activity to break up her compulsive routines. J surprisingly picks up on the suggestion that she try to find some meaningful activity to stimulate her mind.

(2/3/84) J enrolls in a dream class. She begins keeping a dream book. She looks through magazines looking for pictures that correspond with her dream images, putting them in a scrap book. This discovery ushers in a preoccupation with imagery and imaging, which J begins to put to multiple therapeutic uses.

(2/7/84) J is beginning to feel more alive and interested in her thought processes. She is beginning to learn about her psychodynamics instead of just reacting to them. Her interest in the scrapbook enables her to look forward to something. This in turn stirs more interest in her inner process.

(2/10/85) J feels inspired by the pictures. She reports feeling pleasure in self - stimulation of her mind. She feels she is making meanings. This active meaning making stands in sharp contrast to the passive, inert times associated with painful emptiness.

(3/18/85) J describes the scrap book process as something to hold onto as well as to take seriously. The scrapbook is used as a transitional object. (See discussion section.) She prefers to use the scrapbook instead of bingeing.

(4/15/85) J feels we are making active progress on the ''stuck'' problem.

(9/4/85) The scrapbook is like ''therapeutic cookies,'' indicative of a growing experience of self-trust. She feels an increasing sense of self-control, self –stimulation, and self-help. ''Getting involved when I'm bored really helps.''

(5/5/86) J uses the scrapbook to identify therapeutic themes. She picks out meaningful images and brings them to therapy for exploration.

(2/11/87) J likes that I let her ''roam'' into her conscious and unconscious. She feels more natural in the sense of feeling untampered with. "Nothing unnatural added to the process." She worked on the scrapbook for four hours.

(3/4/87) J coins the term "scrapping" and says it is a 'meaningful way to fill the day.''

(3/25/87) J used the scrapbook to define her central theme: how to negotiate a balance between a wish to fuse with a good symbiotic object while, at the same time, maintaining her autonomy.

(4/4/87) J is using the scrapbook in increasingly more sophisticated and complex ways for the purposes of identifying, clarifying, and working through her problems with and without the therapist's attention.

(4/29/87) J used the scrapbook to express her creative side.

(6/24/87) J brought in the scrapbook for the therapist to see. She pointed out how she rearranges the images in a collage to make creative meanings. '' The scrapbook makes me feel more secure; it's a good routine. It provides positive structure.''

(7/27/87) J uses scrapping to resolve the conflict of the day.


Phase III. Post Impasse - Some Limitations of Scrapping
A third stage of J's treatment with respect to imagery and imaging was identified beginning in September, 1987. Key session notes follow.


(9/9/87) J announces, "Sometimes I feel sick scrapping, sitting in the house on a muggy day in August, instead of being out there." She indicates that scrapping has become like all other activities in the last ten years including bingeing, cycling, and therapy. They can be both adaptive and defensive. Adaptively, they serve constructive purposes in providing some sort of structure and giving her a feeling of wholeness. However, defensively, they can become addictive and restrictive, preventing her from engaging in meaningful external actions.

(9/16/87) J voices the desire to shift from compulsive scrapping to concrete personal action.

(9/17/87) The felt limitations of scrapping coincide with J's cathexis of reality. ''Reality suddenly came. Before, I thought I was rich. Now I see I'm not practiced in practical experience.''

(9/23/91) J's essential meaning of imagery and imaging becomes clear to both of us. ''I've always had to hold onto something outside of myself for dear life, like a boyfriend, eating, bike riding, and scrapping. I'm always holding onto something because I have no center to base my decisions on. I'm freer with the images and the scrapbook. They don't have to make sense to me beforehand.''

(9/23/91) J is more comfortable with her personal unconscious and can better tolerate ambiguity and confusion of mixed feelings (expressed in the unhampered flow of imagery). She can play with her feelings and thoughts in the form of images and deriving pleasure in seeing where they will lead. She feels certain that despite the benefits of scrapping, it has its limitations. Scrapping can become addictive like her other rituals being used defensively as a substitute for following through on purposeful practical action.

(9/25/87) J says she is going to take a class in Tai Chi. For J, this represents an integration of body and mind. She feels that despite many unresolved practical and therapeutic problems, she feels a ''greater sense of aliveness, balance, and hopefulness.''

(10/14/87) J feels she is learning to connect pleasure with pure being. She also feels better able to let herself image naturally.


Discussion
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. These are:

(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.

Summarizing
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).

Conclusions
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.


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