Guided imagination and video therapy

We are in early March, we start talking about social distance, quarantine, lockdown. The thought runs quickly to my patients: will we have to stop the therapies? How many of them will agree to continue online?

 

Will we be able to feel comfortable with a screen that separates us (in hindsight, I would say more “that unites us”)? But above all, will video therapy be equally effective and can we benefit from this new setting? The social isolation to which we have been called has required psychotherapy to adapt significantly to, I dare say, unique conditions.

Before March 8 this year, I had only had Skype sessions with one patient and only 4 or 5 times. The idea of ​​video therapy was not particularly appealing to me, mostly because I wasn’t sure I was able to, actually without ever having really tried.

Now, however, the issue of video therapy is becoming more pressing, going to the studio puts me and others at risk: I decide not to interrupt the sessions because some therapies are in full assessment and we are laying the foundations for the reconstruction of interpersonal patterns, others are in the middle of sharing the functioning, still others are at an advanced stage of promoting change. So I decide to offer it to all the patients, but for some in particular I felt the questions I asked myself even more oppressive.

Over the years, Interpersonal Metacognitive Therapy (TMI) has been increasingly enriched with experiential techniques including bodily, dramaturgical and meditative techniques (Dimaggio et. Al., 2019). In using these tools, we can pursue different purposes depending on the therapy phase and, more specifically, on the decision-making procedure we are following (Dimaggio et al., 2013). In TMI, if we are in the initial macro-section of shared formulation of functioning, with the use of experiential techniques we aim to improve access to the patient’s internal world and increase his sense of agency on it, to improve metariflexive skills, to reconstruct interpersonal patterns, to promote differentiation. At a more advanced stage, promoting change, we will set ourselves the objectives of widening differentiation, adopting new points of view and accessing healthy parts, building an integrated vision of oneself (Dimaggio et. al., 2019). The use of these techniques is fundamental, paying constant attention to case formulation and decision-making procedures, always trying to work in the therapeutic zone of proximal development (Leiman, Stiles, 2001).

What emerges from clinical practice and research is that the use of experiential and bodily techniques such as guided imagery, role-play, game of the two chairs, mindfulness improves access to the internal world and accelerates change, undoubtedly assisting the techniques purely cognitive (Arntz, 2012; Brewin et al., 2009; Lee & Kwon, 2013; Morina, Lancee, & Arntz, 2017; Norton & Abbott, 2016; Reimer & Moscovitch, 2015).

The quarantine forced me to resort to building a massive dose of self-regulation of my mental setup regarding my fears about the effectiveness of video therapy, but above all about being personally able to work in this new setting. So I realigned myself with the aims of the ongoing therapies that would continue online. Put simply, I decided to experiment with my patients what we already had / had not yet experienced in a live session.

The guided imagination has always fascinated me and I decided to deepen its study. It is often repeated that the therapist should use tools that are well mastered and that – above all – he likes and makes him feel at ease, right? And that’s what I wanted to do.

Initially I wondered if a PC screen could make using this technique more difficult. Then I also thought that after all in the guided imagination the therapist is not properly included, it is a sort of voiceover, the patient has his eyes closed and is immersed in the memory. We will see it soon, I tell myself.

Rather than describing the theory at the risk of getting bored (and bored), I preferred to rattle off the application of the guided imagination through the story of a patient. Together we decided to relive a memory that emerged in the last two weeks of therapy on Skype and identified by himself as the central element of his current relationship problems: if I express my emotions and my needs, or if I pursue my plans, the other suffers and I feel guilty because I hurt the people I love.

Mirko is a 27 year old boy. Avoiding the criticism of the other for fear of rejection and abandonment has always been a constant in his existence, the profound conviction of being worth less than others and being intellectually limited have blocked him for some time, the rest of the world is described as “capable ”And dominant over him. After a life lived in the name of cognitive and emotional avoidance, getting in touch with your emotions seems like a real challenge.

First, I share with Mirko the usefulness and possible benefit of the exercise that I am proposing. I also tell him that in all likelihood this will evoke psychological pain, but that we will be able to regulate it together, even through the screen. It is the first time that we return to this scene, so I explain to the patient that our primary goal is to increase the emotional experience. In reality, even for him to get in touch with an emotion would be an excellent result, so the goal is demanding. But we are both aware of this because the sharing of functioning has long been established. Mirko says he is curious about what will happen. The therapeutic alliance is solid and we are both ready to embark on this journey into the past.

We have a structured summary of the episode from the previous session, so I propose a brief summary for both, paying attention to include who was present in the scene, where and when the episode took place and keeping in mind the structure of Mirko’s interpersonal scheme .

I explain to the patient that he will have to tell the scene using the first person and the indicative present, describing the sounds, colors, voices of the people present, everything that helps him relive the memory as if it were there at that moment, in the here and now, avoiding to comment on it to bypass the narrating self. I prepare Mirko for the possibility that I can intervene to get him back on the scene and postponing any reflection that emerges to a later time. This prevents the possibility that he might feel invalidated if he were to temporarily leave the memory to think, rather than relive (note: he himself had previously recognized his avoidance mechanism “I start to reason in order not to feel emotionally”, so it was easier to share with he intent to bypass the narrative).

Mirko is sitting on the chair in the kitchen, his legs curled up in his chest. I offer him a brief grounding and mindfulness exercise. I ask him to try to arrange the shot so that he can see the whole torso, to monitor as much of the body as possible (position of the shoulders and torso, breathing speed, hand movements). It assumes a more composed position, with the feet touching the floor, the back straight but not rigid, the hands softly on the legs. I ask him to close his eyes if he likes. He closes them. He feels body contact with the chair. Imagine that roots emerge from the soles of your feet and anchor it firmly to the floor. Bring attention to the breath, without changing it. He feels relaxed and connected. We can start.

Mirko is 7 years old and is in her bedroom with her younger brother of 4. The parents are arguing violently in the next room, screaming, throwing objects, moving furniture. The two children are behind the half-open door listening to what is happening. I realize that Mirko is telling, rather than reliving the memory, because he describes everything in a neutral way, with his typical emotional detachment, his expressionless face, he uses expressions like “I think I am afraid”. The narrating self is active. To help him enter the scene, I ask targeted questions about sensory details: “What do you see around you?” “The bed, the toys”; “How’s the light coming in through the window?” “Warm, orange, the sun is setting, it is late afternoon”; “Look at your brother and notice what expression he has” “He’s scared, he’s about to cry, his face asks for help,

I continue. “What are you thinking while looking at your brother’s face asking for help?” “I don’t have to show him that I’m afraid too, otherwise he gets even more scared, I can’t cry.” “Look at his face asking for help. What do you feel? ” “I feel like a double fear: my parents are about to separate and my brother is scared, how can I calm him down?”

Mirko moves nervously on the chair, appears agitated. “What are you feeling now?” “Anxiety, I have to keep control. It is my duty not to make the situation worse. If I take it myself … I can’t handle the situation. ” From the video I notice that Mirko’s expression changes, I ask him how he feels. “So much sadness for my brother who is afraid and for my parents who are about to separate”.

I notice again that Mirko has returned to tell a story, he is not experiencing the painful emotions he brings back. I decide to use the technique of repeating emotionally charged phrases with marking, giving emotional emphasis and accentuating the negative nuances of the pattern: “It is wrong to show what I feel, If I show what I feel, the other suffers, If I let myself go emotionally , I lose control over the situation and the other suffers. It is more important what other people feel than what I feel. I can’t ask for support, I have to give support. “

“I would like to go back to the day before, to act as if nothing had happened. Now it ends, now it ends, now it ends. The more I repeat, the more anxiety increases. I’m showing my brother that I’m scared. Yes, but not voluntarily eh, anyway I won’t show him that I’m going to cry, that’s not it! ” He’s thinking again, so I ask him to repeat those sentences aloud, paying attention to how he feels.

Mirko begins to repeat, but with little conviction in the tone of her voice and with a facial expression that I read as shame. I ask him for feedback on what he’s feeling. He laughs embarrassed. “A very strange feeling. I am ashamed to say these things. But not about you. It’s that I realize it’s the truth, but I don’t want to say it out loud. ” I ask him to repeat in a more determined tone, the volume of the louder voice. Mirko appears agitated, his face contracted with shame, his hands move nervously. We try again. “This thing is very strong, my mother.” He sighs deeply, his voice trembles, he seems to be crying. It had never happened that he activated himself in this way in session. I let him experience the painful emotions for a few seconds, then I decide to stop the imagination. Let’s go back to breathing and anchoring to the ground through the feet. When he feels ready, he opens his eyes again.

We are back to today, he in his kitchen, I in the home study. Mirko immediately tries to detach herself from the emotions she was experiencing until just before, and laughingly says to me: “Mamma mia, my hands are very sweaty and my eyes are watering.” I ask him if he was crying, deliberately provoking him. Ride. “I will never give you this satisfaction!” Let’s laugh together. “Seriously, the emotion was very strong. How strange … “. I proceed by asking for feedback on the experience I just had, before sharing my observations with him. He says he felt strong anxiety and I ask him to specify where he felt it in the body. It brings back the feeling of displacement and surprise to my proposal to repeat the sentences I suggested, underlining the effort in repeating them and admitting that I tried to control myself while doing it the first time. He explains to me how the shame felt during the imagination was linked to the fact of preventing oneself from hearing and expressing what he feels, “it is a bad thing to do to myself”. Together we note how it did not matter that he too was a 7-year-old boy who hears his parents arguing, who fears they may abandon him (another pattern of his) and who needs comfort, because at that moment the fear of scaring the brother, having to keep everything under control, taking care of the other at the expense of one’s emotions and needs. His story was full of memories in which Mirko did not have to cry because he was his older brother, Mirko did not have to do tantrums because his brother was already there, Mirko had to take care of his father who had become seriously ill. We had talked about it before, but now we have had the opportunity to embody the power of the scheme. I notice that Mirko is still emotionally activated (and I am “therapeutically” happy), I ask him again what he is feeling. He is positively shaken because he had never felt anything so strong, it is as if he were “running his whole life before his eyes, lived always thinking about what the other thinks, how the other is, how the other. I forgot about me. ” Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. I notice that Mirko is still emotionally activated (and I am “therapeutically” happy), I ask him again what he is feeling. He is positively shaken because he had never felt anything so strong, it is as if he were “running his whole life before his eyes, lived always thinking about what the other thinks, how the other is, how the other. I forgot about me. ” Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. I notice that Mirko is still emotionally activated (and I am “therapeutically” happy), I ask him again what he is feeling. He is positively shaken because he had never felt anything so strong, it is as if he were “running his whole life before his eyes, lived always thinking about what the other thinks, how the other is, how the other. I forgot about me. ” Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. He is positively shaken because he had never felt anything so strong, it is as if he were “running his whole life before his eyes, lived always thinking about what the other thinks, how the other is, how he reacts other. I forgot about me. ” Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. He is positively shaken because he had never felt anything so strong, it is as if he were “running his whole life before his eyes, lived always thinking about what the other thinks, how the other is, how the other. I forgot about me. ” Valid Mirko’s effort in exposing himself to the painful emotions of that memory, sending him back as if they had been visible from his non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance. Valid Mirko’s effort in exposing herself to the painful emotions of that memory, sending him back as if they had been visible from her non-verbal, particularly evident thanks to the framing of the webcam. I then dwell on the importance of the emotional experience I just had, which had managed to stop the avoidance.

In the following days, Mirko thinks back to all the times in his life he has suppressed his needs, desires, inclinations, plans putting the happiness of others before his own. The day before our session, he spontaneously decides to test the pattern and stop coping. He communicates to two dear colleagues his choice to change jobs (a desire that has emerged in the last month and that was causing him great concerns not so much for himself and for the sudden change of life, but for the reactions of others). Despite the displeasure and suffering of the other – a colleague started to cry – after a minute or two in which he wanted to retract to avoid guilt, Mirko then said that his future and his professional satisfaction were the priority thing to pay attention to and care for.