Case Report: Nonverbal approaches in the treatment of a patient with fibromyalgia with anger rooted in adverse childhood experiences.

Introduction: In psychotherapy, it is important to establish and deepen a therapeutic trusting relationship, but patients who have experienced extreme adversity in childhood tend to have difficulty in building such a relationship. This paper reports a case of fibromyalgia with adverse childhood experiences (ACEs) in which a nonverbal approach was successful in building a trusting relationship. Case and methods: The patient is a woman in her late 40s. She had strong anger rooted in ACEs, including neglect by her father, a feeling of unfair parenting by her mother compared to her younger brother, overcontrol of her life by her mother, and sexual abuse by her uncle. She was filled with strong interpersonal distrust and anger, and the experience of an unsuccessful surgery compounded her distrust of medical care. The therapist initially had severe difficulty in verbal interaction with the patient. When conducting "drawing" therapy, she ignored the therapist's comments and completely blacked out the drawing paper. However, the patient-therapist relationship gradually changed, and verbal interaction became possible through the use of nonverbal approaches such as framing her drawing paper and "Towel Baby Holding." Results: The therapist was able to understand the patient's emotions through these nonverbal approaches and to communicate with the patient that she understood her feelings. This approach was also successful in the patient's understanding of her own pathology. The patient became able to honestly express her feelings in words, which eventually enabled her to be introduced to mindfulness therapy, leading to a favorable treatment course. Conclusion: For patients with ACEs, a nonverbal approach helps build a therapeutic relationship and plays an important role in understanding the patient.

Role of imaginary companion in promoting the psychotherapeutic process.

An imaginary companion (IC) has been considered to be a transitory phenomenon sometimes seen in the normal developmental process of children. In recent years, however, it has been observed that ICs are related to various disorders, and their clinical significance is again attracting notice. Although an IC may in certain ways aggravate the patient's symptoms and regression, an IC may also serve to advance the therapy, for example by indicating the location of the patient's troubles, or acting as an intermediary between the therapist and patient. In cases of dissociative (conversion) disorders, it is generally difficult for patients to verbalize their troubles, but the present patients gained insight into themselves by closely examining their ICs. Imaginary companions are not simply entities incidental to the disorder, and by incorporating them into the therapeutic strategy as a presence supporting the patient's growth, it is possible that the psychotherapy may proceed more smoothly.

[Imaginary companion in adolescence].

The phenomenon of imaginary companions, which is usually regarded as normal in children, but which when encountered in adolescence suggests a psychopathologic condition, appears to have had limited investigation. This study indicates some psychopathologic characteristics of imaginary companions by interviewing adolescent patients. Imaginary companions are experienced as one or more invisible persons who have some conversations with patients directly and mutually for a period of time. They consist of vivid images which range between pure perceptions and pure images. The position of these images is not specified, and includes images perceived internally and externally by the patient. Adolescent patients sense the reality of these images and think of them as other persons, but recognize that these are not real people. Generally, imaginary companions are beneficial to the patients. These characteristics indicate that the phenomenon of imaginary companions has a mainly pathologic structure, but some characteristics, such as the patients' recognition of the imaginary aspect of the companion and the benefit for patients, does not fall under the category of psychopathology. We suppose that elucidation of this phenomenon would lead us to productive research in the psychopathologic field.