Clinical Evidevce

Effective dimensions

The сonsciousness of unconscious conflicts and their change when working through them is one of the effective factors that apply to both psychodynamic psychotherapy and KIP. KIP is also able to reach and change implicit object dependencies in a special way, in that it is possible to work predominantly in implicit mode[99]. This happens on the daydream level of the symbol drama (see KIP and other treatment approaches). What has been experienced or recognised must then be marked and integrated later in the explicit mode of the depth-psychological conversation.

Through the method-specific relationship design (see procedure and application of psychodynamic concepts in KIP) and through appropriate interactions between therapist and patient on the image level, it is possible to convey new emotional relationship experiences in the here and now (empathy, sensitivity, holding) and to correct pathogenic unconscious preconceptions. By assuming auxiliary ego functions, the therapist helps with affect differentiation and reality testing. This contributes to the promotion of competencies in mentalization and symbolization (see Scientific basics, key points of diagnostics and therapy).

Neurotic conflicts and the resulting symptoms can be symbolically represented and processed through imagination. This type of ‘conflict processing’ has been described as the first effective dimension of KIP (Leuner 2012)[18]. It is basically based on the classic psychoanalytical principle of conflict processing through ‘remembering, repeating and working through’ (Freud 1914)[100]. Its domain is the treatment of clinical pictures and disorders that are based on neurotic dispositions with a relatively good level of ego-structural functioning (see Indication areas).

Psychosomatic illnesses and psychogenetically ‘early’ disorders usually have a different constellation. Here, the focus is on unfulfilled primary needs and attachment desires as well as narcissistic deficits. These areas are the focus of a second effective dimension, which is geared towards the fulfilment of primary human needs and was described by Leuner (ibid.) as ‘archaic need satisfaction’. In the catathymic imagination, the patient is allowed to make up for what they lacked in a psychophysiologically relaxed state and now have important corrective emotional relationship experiences. The therapeutic guidance supports and promotes a limited regression ‘before’ the conflict, i.e. into unquestionably “good” times of early childhood development, and ‘alongside’ the conflict, i.e. into beneficial fantasy worlds.

The two effective dimensions of mentioned are not mutually exclusive. Fantasy functions and symbolisation are involved in both. The so-called third effective dimension is primarily aimed at the moment of unfolding fantasy and creativity as the basis for change processes. On the therapeutic side, certain qualities are required for this, such as the ability to free oneself mentally from ingrained patterns of thinking, feeling and wanting in order to be able to enjoy creative achievements and ‘extraordinary’ solutions. Leuner (ibid.) saw parallels here with children’s play and play therapy.

From experiment to clinical evidence

A whole series of reports on the effects and after-effects of catathymic imagery (CI) date back to the pioneering days of KIP (see History of KIP). In experimental studies, Leuner was initially primarily concerned with the using imagery organised ‘complexes’ that occur in symbol-mediated and affect-driven imaginations. He then began to take an interest in the therapeutic possibilities contained therein and to tackle clinically orientated questions. In the course of the further development of CI into a depth-psychologically based (psychodynamic) method, numerous publications with case descriptions were presented by the emerging working group, which contain specific results and provide information about the mode of action. The first results on the general effectiveness of the method as short-term psychotherapy came from Kulessa and Jung (1980)[101] and Wächter and Pudel (1980)[102]. The work on the use of CI in anorexia nervosa (Klessmann and Klessmann 1975)[103], in gynaecological diseases (Roth 1976)[104] and in ulcerative colitis (Wilke 1979)[105] pointed out the way for the specific treatment of psychosomatic diseases and functional psychogenic disorders. A detailed overview can be found in Wilke (2012)[106].

Process research

Results on process research have been published by Stigler and Pokorny in several publications. The two authors came to the conclusion, among other things, that patients and therapists are closer to the experience in their language compared to purely verbal sequences during imagination and resonate with the primary process and emotions at the same level (Stigler and Pokorny 2012)[107]. In a randomised study of psychosomatic patients undergoing inpatient treatment, Masla (2018)[108] found evidence to suggest that improvements in the attachment system can be expected in patients treated with KIP.

Outcome research

Even in the early days of treating psychosomatic illnesses with KIP, Wilke (1980)[109] presented results on outcome research in a controlled study. The study involved patients with ulcerative colitis who benefited from CI in both somatic and psychological terms. The results showed, among other things, that self-confidence and assertiveness were promoted more strongly by the daydreaming method than by analytically orientated talking therapy in combination with relaxation suggestions. In a three-year catamnesis, it became clear that the patients treated with KIP showed more lasting somatic and psychological improvement than the control group (Wilke 1983)[110]. A naturalistic study on the effectiveness of the method in the outpatient psychotherapy of psychogenic disorders (von Wietersheim et al. 2003)[111] showed a whole series of positive changes in patients treated with KIP up to the end of therapy, which had increased even further at the catamnesis point (18 months).

In a naturalistic study on the treatment of affective disorders, anxiety disorders and somatisation disorders with KIP, Sachsse et al. (2016)[112] were able to demonstrate high effect sizes for an improvement in general psychological stress, problems in dealing with other people and the central symptoms of depression, anxiety and somatisation.

Sell et al. (2018)[113] compared the effectiveness of various psychoanalytically based methods that work with guided imagery in a naturalistic longitudinal study. They focussed on KIP and a form of hypnotherapy practised on a psychodynamic basis. The findings suggest two phases of symptom improvement: a rapid change in the first few months after the start of therapy and a second, slower but sustained change over the course of long-term treatment. The results of this study suggest that patients with good mentalisation and symbolisation skills are no longer clinically distressed within six months, which is more in favour of short-term treatment for this type of patient. Patients with low psychological mindedness and a high proportion of pathological personality traits initially benefited less, meaning that they presumably require longer treatment periods as part of a modified KIP technique (Sell et al. 2017)[114].

A research group led by Sell[115], Sachsse and Benecke is currently (as of February 2021) conducting a randomized controlled trial (RCT). By comparing depth psychological treatments with and without CI, the aim is to investigate whether and, if so, which patient, process and relationship characteristics can be identified that suggest an additional benefit of CI.