"I Don't Just Want to Be the Angry One Anymore" – A Psychodynamic Case Study on Emotion Work, Confrontation and Symbolic Self-Integration in a Traumatized Veteran in Online Counseling

"I Don't Just Want to Be the Angry One Anymore" – A Psychodynamic Case Study on Emotion Work, Confrontation and Symbolic Self-Integration in a Traumatized Veteran in Online Counseling | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "I Don't Just Want to Be the Angry One Anymore" – A Psychodynamic Case Study on Emotion Work, Confrontation and Symbolic Self-Integration in a Traumatized Veteran in Online Counseling Sora Pazer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7063862/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This psychodynamic case study presents a 12-session online therapy process with a 37-year-old German veteran suffering from affective dysregulation, psychosomatic symptoms, and relational conflict following military deployments in Mali and Afghanistan. Rooted in early violence and neglect, the client exhibited narcissistic defenses, alexithymia, and identity diffusion. Therapy combined structured confrontation and symbolic emotional work through art. Central to the process was the emergence of a self-representation—a lion embodying both threat and care—which enabled narrative and emotional integration. Despite the digital format, a stable therapeutic alliance developed. The client gained access to previously split-off affective states and redefined his role as father and partner. This case highlights the depth potential of psychodynamic online work with structurally vulnerable, trauma-affected clients. psychodynamic online counseling trauma narcissistic structure emotion work confrontation symbolization veterans art therapy transference countertransference 1. Introduction Veterans after deployments abroad often face profound psychosocial challenges that go far beyond classic post-traumatic stress symptoms. Clients with pre-existing attachment disorder, early violence and narcissistic injuries are particularly likely to exhibit pronounced affect dysregulation, emotional separation and destructive relationship patterns (Fonagy et al., 2002 ; McWilliams, 2011 ; Shay, 2002 ). Psychodynamic casework with such people requires a high level of integration: between empathic understanding and structuring confrontation, between emotional expression and supportive mirroring (Kernberg, 1975 ; Kohut, 1977 ). The present case study describes the course of therapy of a 37-year-old man with four years of military service – including deployments in Mali and Afghanistan – who suffered from severe mood disorders, psychosomatic complaints (chronic headaches, daily ibuprofen intake), relationship breakdowns and professional instability after his return. In early childhood, he was characterized by a violent father and an emotionally disconnected mother, which led to a rigid self-image and a dominant defense against emotional closeness (Bowlby, 1988 ). Affects were initially only accessible in the mode of anger, other emotional qualities seemed unattainable. In the course of twelve video-based online sessions on BetterHelp, a dual methodological approach was pursued: On the one hand, an emotion-focused use of art therapy techniques (Gantt & Tinnin, 2009 ; Winnicott, 1971 ), on the other hand, a confrontational conversational approach that confronted the client with his dysfunctional patterns (Farrelly & Brandsma, 1974 ; Mahoney, 2001 ). This combination allowed for a profound therapeutic process in which emotional expressions developed, self-esteem was restructured and a new positioning in relation to relationship, fatherhood and autonomy was achieved. The study aims to present the psychodynamic mechanisms of action – in particular transference phenomena, affect processing and narcissistic self-regulation – in a differentiated way in the digital setting. She positions herself in the current research discourse on the effectiveness of psychodynamic online work (Lemma, 2017 ; Simpson & Reid, 2014 ) and wants to show how even profound destructive patterns can be worked on through a supportive, clearly structured and creative therapeutic relationship. 2. Theoretical framework The present case study is theoretically guided by five interlocking reference systems within psychodynamic theory formation: (1) the affect-psychological significance of early traumatization and attachment disorder, (2) the narcissistic self-structure in the field of tension between compensation and disintegration, (3) transference and countertransference as a clinically effective relationship category, (4) the use of confrontational therapeutic interventions, and (5) the importance of creative Forms of expression to symbolize non-integrated inner states. These dimensions form the interpretative framework for interpreting the clinical process. 2.1 Attachment trauma, affect dysregulation and self-development Early experiences of violence and neglect have been shown to have profound effects on the development of self-regulation processes, especially with regard to the ability to perceive affect, differentiate and symbolically represent emotional states (Schore, 2003 ; van der Kolk, 2014 ). Neuroaffective research shows that complex traumatization in childhood – especially through disorganized attachment and interpersonal violence – leads to structural deficits in the right hemisphere, which is central to the processing of unconscious affective information (Schore, 2012 ). In psychodynamic terminology, this can be interpreted as a fixation on preverbal forms of affect experience that cannot be symbolized and can therefore often only be experienced as somatic or destructive impulses (McDougall, 1989 ). According to Bowlby ( 1988 ), the inner representation of early relationship experiences is organized in so-called "inner working models". If these are characterized by fear, unreliability and emotional coldness, any form of closeness is associated either with self-loss or with threat. In the long term, this leads to a profound distrust of emotional resonance and to a cognitively controlled interaction structure, as was also observed in the client of this study. Following Crittenden ( 2006 ), behavior can be interpreted as a form of the dismissive-avoidant pattern, in which emotional content is systematically suppressed and replaced by hyperfunctionalization. 2.2 Narcissistic Injury, Compensation and Self-Coherence The psychodynamic self-psychology according to Kohut ( 1977 , 1984 ) provides a differentiated approach to understanding the narcissistic structural problems of the client. Kohut describes the self as a dynamic structure that is highly dependent on the resonance of so-called self-objects – i.e. on relationships in which the individual is mirrored, idealized or experienced as belonging. In the absence of such self-object experiences, no coherent, stable self can develop. Rather, so-called narcissistic wounds arise, which are covered up by hypercompensation, grandiosity fantasies or – as in this case – by rigid separation of need. In this reading, joining the Bundeswehr represents a massive compensatory self-object experience: for the first time, the client is mirrored as capable, brave and meaningful; Discipline and obedience create a stabilizing outer shell. The end of this phase – i.e. the transition to civilian life – also marks the collapse of the compensatory system. In Kohut's terminology, it is a "self-object failure" that favors a narcissistic breakdown (Kohut, 1984 , p. 77). Kernberg ( 1975 ) also describes comparable dynamics as "narcissistic regression" when externalized structures (e.g., institutions) are no longer available. In the sense of Stolorow et al. ( 2002 ), this is an intersubjective trauma: the emotional disorganization arises not only from inner fragmentation, but also from the lack of a compassionate, resonant other. At this point, therapy tries to contribute to a reorganization of the self through responsive counterparts and structure givers at the same time – not through mere insight, but through relationship processes. 2.3 Transference, countertransference and depth of relationship In the psychodynamic framework, the therapeutic relationship is not understood as a neutral exchange of information, but as a space for the re-enactment of early relationship patterns. Transference and countertransference are not regarded as disturbing artefacts, but as a central diagnostic and interventional tool (Racker, 1968 ; Heimann, 1950 ). In the therapeutic encounter with the present client, the transference manifested itself in the form of an ambivalent relationship experience: the therapist was imagined both as an authoritarian father figure and as a saving mentor. This tension created a high emotional charge – both on the part of the client and the therapist, which required constant reflection on the countertransference reactions (Tansey & Burke, 1989 ). The proximity to the concept of projective identification is evident here: the client often induced feelings of helplessness, powerlessness or even irritability in the therapist – affects that may have originated from his own childhood experience, but have not yet been consciously integrated (Ogden, 1982 ). The therapeutic task was not to ward off these projective processes, but to reflect, hold and transform them into understandable relationship experiences. 2.4 Confrontational Intervention and Therapeutic Authority Especially in the case of strongly defensive, narcissistically structured or alexithymic clients, a purely interpretative attitude can reach its limits. As Mahoney ( 2001 ) points out, such clients need not only empathy, but also clear boundaries, structure, and a level of confrontation that irritates their inner survival patterns without destroying them. The present case shows that provocative or confrontational interventions – such as the direct mirroring of self or relationship patterns – can have a potentially corrective function if they are embedded in a supportive therapeutic relationship (Farrelly & Brandsma, 1974 ; Wachtel, 2011 ). The therapeutic attitude oscillates between responsiveness and directness: the therapist becomes an emotional mirror, but also a boundary – especially where destructive patterns urge repetition. In the sense of Benjamin ( 1990 ), it is an "intersubjective space of negotiation" in which relationship is not predetermined, but constituted through confrontation. 2.5 Symbolization, Art and Therapeutic Transition Space The ability to symbolize inner states is considered a central criterion of psychological maturity and affect integration (Krystal, 1988 ). In traumatized, alexithymic or psychosomatically fixated clients, this ability is often disturbed: feelings appear diffuse, overpowering or physical. Here, art therapy methods open up a space of symbolic representation that lies between direct expression of affect and reflective language (Gantt & Tinnin, 2009 ; Malchiodi, 2012 ). Following Winnicott ( 1971 ), this space can be described as a "transitional space" in which inner experience can be held, externalized and transformed for the first time. The client of this case study began to depict nightmares, and later also to symbolically outline father roles ("lion" as an ambivalent figure of protection and danger). The development from the image of "shadow" to images with colors, light and movement can be understood as a pre-linguistic expression of a new affective differentiation. This creative externalization became a resonance space for affective self-encounter – not in the sense of expressive catharsis, but as a symbolic restructuring of inner world views (Levine, 2009 ). 3. Methodology and case description The present case study is based on a qualitative-reconstructive design with a hermeneutical-psychodynamic perspective. It does not claim to be generalizable statements, but aims at a theory-based in-depth hermeneutics of individual psychological structures, their relational dynamics and possible change processes in the context of digital counseling (Flyvbjerg, 2006 ; Stake, 1995 ). The approach follows the paradigmatic principle of "individual case condensation" (Yin, 2018 ), in which a particularly characteristic or complex case is analysed in an exemplary manner. The data basis is formed by written protocols, meeting notes and therapeutic reflections by the author as the practitioner. The contents were retrospectively anonymized and hermeneutically analyzed in their entirety. All quoted statements and descriptions have been changed in their form in order to exclude conclusions about the real person. The client was informed about the scientific use of the material and agreed to an anonymized case publication in principle. The ethical responsibility lies entirely with the author, who adheres to the professional standards of social work and psychodynamic therapy orientation (American Psychological Association, 2017 ; NASW, 2021). The case work is also deliberately designed to be reflexive: the therapeutic process is not presented in an objectifying way, but is understood as an intersubjective co-production between client and therapist (Stolorow et al., 2002 ; Orange, 2011 ). This perspective requires not only the description of the client, but also the reflection of therapeutic attitudes, countertransferences and methodological decisions. The course of the case is presented in Chap. 4 along four structured phases that were clearly identifiable in the process. 3.1 Sociobiographical profile The client (changed) is a 37-year-old German-speaking man, living in an urban-peripheral environment, divorced, father of a child of primary school age, currently again in an unstable partnership. Professionally, he initially worked in retail, but was dismissed due to recurring outbursts of aggression and interpersonal conflicts. He currently works as a fitter, but here too he shows a high degree of stress, inner overload and psychosomatic complaints. His early childhood was characterized by biparental disintegration: his father regularly became violent, his mother reacted with emotional coldness, unavailability and structural undersupply. The school career took place in a "residual branch" of the Hauptschule, which was characterized by chronic experiences of devaluation, resignation and failure to perform. Already here, a self-definition as a "failure" was established, which was internalized. Joining the Bundeswehr at the age of 19 was described by the client as the only turning point in his life: "That was the first time that someone saw something in me." During his four-year service – with foreign deployments in Mali and Afghanistan – he was trained as a sniper and, according to his own statement, experienced "clarity, order and purpose". Looking back, he described the military structure as a "surrogate family" and "my first safe place". After leaving the service, however, he fell into a phase of professional and psychological disintegration. In addition to the experience of devaluation in the civilian work context (Rewe), he increasingly developed symptoms: chronic headaches, constant irritability, inner feeling of emptiness, episodic shifts in perception, impulse breakthroughs. He himself spoke of "psychotic episodes", but without ever having been diagnosed psychiatrically. 3.2 Psychodynamic starting point Psychodynamically, the client shows a massive structural imbalance in affect regulation. At the beginning of the therapy, only one affect could be named and experienced: anger. Other emotional states – such as grief, fear, longing, guilt – were initially completely externalized, devalued or dissified. Emotionality was equated with loss of control, weakness or threat. In the sense of the alexithymic structure according to Sifneos ( 1973 ), there is a considerable limitation in the ability to mentally represent emotional processes. The relationship patterns were characterized by ambivalence: intense longing for closeness, at the same time deep mistrust and the tendency to aggressive avoidance. In partnerships, emotional overload, escalation and withdrawal regularly occurred. The role of father in particular was ambivalently charged: on the one hand, the client wanted to be a "better father" than his own, but on the other hand, he lacked any access to the affective nuances of parental relationships. 3.3 Setting and therapeutic framework model The psychodynamically oriented counselling took place over a period of six weeks with two video-based sessions per week (60 minutes each) via the BetterHelp platform. Despite the digital format, the client was highly reliable, showed up on time, completed all therapeutic tasks conscientiously and showed an unusually high willingness to open up himself – but only after the third session, in which there was a first emotional breakthrough. The therapeutic relationship increasingly developed as a stable resonance chamber in which both affects and resistance emerged and could be worked on. The methodological approach was two-pronged:(1) Confrontational Conversation Conduct according to the Principles of Provocative Therapy (Farrelly & Brandsma, 1974 ; Mahoney, 2001 ) with a focus on dysfunctional relationship patterns, narcissistic defense strategies and self-image distortions. (2) Emotion-focused creative work: The client was invited to symbolically resort to painting inner images, nightmares, or metaphors – which led to the externalization of emotional content, especially in later sessions (Malchiodi, 2012 ; Gantt & Tinnin, 2009 ). 3.4 Indicators of change In the course of the sessions, a successive differentiation of affect became apparent: the client began to name grief, shame and also fear – at first hesitantly, later more clearly. For the first time, he described feelings towards his daughter as "tender" and confessed a "need for recognition" that he had previously always rejected as "weakness". The images changed visibly: from gloomy motifs ("Shadows", "Empty Space", "Decay") to more structured representations with colour dynamics ("Rainbow", "Path with Light", "Lion Who Protects and Loves"). The client began to talk about himself in other words – no longer exclusively in categories of failure, threat or withdrawal, but with first affirmative statements such as: "I am not my father" or "I can do things differently." These narratives mark an incipient inner restructuring of the self-concept (Kohut, 1977 ; Fonagy et al., 2002 ). 4. Process course and phase analysis The therapeutic process was divided into four clearly distinguishable phases, each of which was characterized by specific relationship constellations, affect dynamics and symbolic forms of expression. These phases are presented in a structured way and psychodynamically interpreted in the following. 4.1 Phase I: Rational Defense and Control (Sessions 1–2) The first phase was characterized by a pronounced rational distancing. The client presented himself with cognitive clarity, structured language style and detail-oriented reporting, but completely disconnected from inner experience. Affects were named, but not felt: statements such as "I'm not angry, I'm efficient" or "Feelings don't help" dominated. This form of defense is classic for a so-called operated mindset (Marty, 1990 ) and refers to an alexithymic level of processing (Sifneos, 1973 ). Psychodynamically, this attitude can be interpreted as a secondary narcissistic protective mechanism that is intended to avoid a regression into the affective (McWilliams, 2011 ). The rigid rationality functioned as a barrier against emotional activation and at the same time reflected an internalized superego that sees weakness, neediness and emotional resonance as a threat to the self (Kernberg, 1975 ). The therapeutic relationship at this time was characterized by obedience and external cooperation, but without emotional involvement. First confrontations – such as: "If you have everything so well under control, why are you here?" – led to irritation, but not to withdrawal. This indicated an unconscious readiness for relationship confrontation, which, however, did not yet allow affective permeability. 4.2 Phase II: Opening of Affect and Symbolic First Contacts (Sessions 3–5) A break in the dynamics became observable in the third session. After a confrontational intervention on the client's role as a father ("You expect your daughter to be strong – who actually allows you to be weak?"), a non-verbal emotional breakthrough appeared for the first time: The client cried silently, visibly shaken, but then spoke for the first time of "loneliness" and "fear that I won't make it". This moment marked the beginning of a new therapeutic phase. As a structuring intervention, the painting of inner images was then introduced – with the open task of visualising a feeling or a nightmare. The first picture he created was an empty room, black, without doors or windows. In its emptiness, this motif symbolizes a form of introjective isolation that is often observed in patients with severe attachment disorders or narcissistic structures (Gantt & Tinnin, 2009 ; Krystal, 1988 ). The subsequent sessions deepened this process. Images of shadow figures, crumbling buildings, and isolated landscapes became symbolic carriers of preverbal anxiety that could now be externalized, viewed, and reflected. Affects such as grief and fear were named, albeit still with uncertainty. The client spoke of "something that moves inside me, but has no name". 4.3 Phase III: Confrontation, Resistance and Renegotiation (Sessions 6–9) In the third phase of the therapeutic process, the focus shifted significantly to the processing of relational patterns and affective repetitions. The aggression that had previously only been hinted at, which had been masked as "discipline", "clarity" or "responsibility" in early sessions, now began to appear more openly in the therapeutic relationship – not as a destructive discharge, however, but as a means of relation. The client was increasingly willing to accept confronting feedback without experiencing it as devaluation or attack. This marked a crucial differentiation achievement in dealing with early transmission anxiety. Central to this was the therapeutic strategy of directly naming destructive patterns and translating them into language. In a key session, the therapist confronted the client's romanticizing self-narrative, in which he repeatedly presented himself as a victim of toxic women. The intervention was: "You keep telling me how you were hurt – but you never tell me how you hurt others. Who are you in this story: the victim or the one who shoots first?" After a long pause, the client replied: "I don't remember anymore. I think I'm just afraid that someone will see me. Really sees. And then you realize how empty it is. So I make sure they hate me before they leave me." This sequence marked not only a partial insight into his self-sabotaging behavior, but also a cautious approach to shameful affects. Particularly striking was the mixture of obedience and provocation in his behavior towards the therapist – a pattern that can be explained by early attachment dynamics. Repeatedly, the client uttered phrases like, "Just tell me what you want me to do. I'm good at following orders." This statement can be read as a residual internalization of military transmission – but also as a regressive need for a structuring object that offers support through authority (Kohut, 1984 ). A recurring symbol in this phase was the figure of a lion, which the client first mentioned spontaneously during a painting task: "I have an image in my head. There's a lion. It lies quiet, but everyone knows: If it jumps up, it's all over. I think I'm the lion. I can protect, but I can also destroy." In later sessions, the client drew this motif several times – sometimes in sparse lines, sometimes with strikingly contrasting colours: red for the throat, black for the mane, light blue for the background. The lion figure became a central transitional object in the therapeutic work: as a representation of his self-image, but also as a figure of identification for his inner struggle between care, violence, control and neediness. The psychodynamics of this metaphor run deep: it combines narcissistic grandiosity with a regressive longing for protection – an ambivalence that ran through many of his relationship narratives (Stolorow et al., 2002 ; Krystal, 1988 ). This phase also showed an increasing emotional activation in the therapeutic relationship. After a particularly confrontational session, in which the therapist again addressed the avoidance of his role as a father ("You say you want to be a good father to her. But what does that mean – keep quiet and be tough?"), the client burst into tears. "I don't want her to yell at me like I yell at my father. I don't want her to be afraid of me. But I don't know how to do it any other way." This moment was highly condensed and for the first time made it possible to consciously distance oneself from one's own pattern of re-enactment. The tears were no longer experienced as weakness, but as part of a necessary process of change. Contrary to the usual dynamics of resistance, the confrontation had not triggered a regression, but became effective as a catalyst for emotional integrity. This underlines the thesis that confrontation in a supportive relationship can not be destructive, but can promote development (Mahoney, 2001 ; Wachtel, 2011 ). 4.4 Phase IV: Integration, Self-Esteem and Narrative Reconstruction (Sessions 10–12) The last phase was characterized by growing differentiation of affect, narrative re-evaluation and a stabilizing relationship to one's own self. The former monopolization of emotional expression on anger and destruction was now replaced by a more complex emotional landscape in which grief, care, vulnerability and pride could also be articulated. The client began to look at previous achievements with a new attitude. In the eleventh session, he reflected: "I always said: It was all nothing. But that's not true. I was out there. I protected my people. I worked. That wasn't all bad." This sentence, spoken in passing, marked a central narrative turn: the totalizing self-devaluation gave way to an ambivalent but more coherent perspective. In the sense of Kohut ( 1977 ), this can be understood as the beginning consolidation of the self – no longer as a grandiose defense or depressive devaluation, but as a realistic integration of abilities, vulnerability and history. There was also a significant change in his role as a father. While at the beginning of the therapy only functional aspects were addressed ("I work, I pay alimony, I'm there"), the client now spoke of emotional concerns: "I don't want her to be afraid. I want her to be happy when I come. That she knows: I'm not only strong, I'm also safe." This differentiation between strength as threat and strength as security was also evident in his paintings. In the last session, he presented a drawing of a bright, gold-colored lion sitting next to a small child, with softer lines and a pastel background. "This is the same lion as before," he said. "Except that he doesn't roar anymore. He's paying attention now." This statement impressively symbolized the integration of projective components that had previously been experienced as destructive or uncontrollable. The aggressive energy was not denied, but recontextualized: as a resource for care, not for escalation. From a psychodynamic point of view, this corresponds to progress in affective self-regulation, but also in the internalization of a supportive inner object (Fonagy & Target, 2000 ; McWilliams, 2011 ). In the final session, the client spontaneously formulated: "I've broken a lot in my life. But maybe now is the moment when I can start to build something. Maybe for the first time." This sentence forms the emotional culmination of the counselling process: the possibility of stepping out of the destructive re-enactment and relating to oneself as an acting, affect-bearing subject – not in spite of the biographical burdens, but by dealing with them. 5. Analysis and Clinical Implications The preceding case description reveals a therapeutic development that is not to be understood as linear progress, but as a recursive movement between repetition and difference – in the sense of a "spiral dialogue" between destructive defensive structure, symbolic self-encounter and the beginning integration of affective-attachment-related parts (Stolorow et al., 2002 ). The clinical analysis of the course can be unfolded along five central dimensions: (1) narcissistic structure and self-coherence, (2) transference and countertransference as effective factors, (3) affect differentiation and emotion development, (4) symbolization and creative externalization, and (5) structural qualities of the digital therapeutic relationship. 5.1 Narcissistic structure and self-coherence The central finding in the client's initial structure was a massive narcissistic injury dynamic, combined with a fragile self that was either grandiosely split off or self-devaluing. Kohut ( 1977 , 1984 ) describes this dialectic as an expression of a compensatory self that relies on external self-objects to maintain coherence. In this case, the Bundeswehr fulfilled such a self-object function in an ideal-typical way: it offered a clear structure, a performance-related attribution of identity and positive reflection. With the end of the military career, there was a rapid collapse of this external self-support – a classic scenario of narcissistic decompensation (Kernberg, 1975 ; Kohut, 1984 ). The inner emptiness that manifested itself after leaving the army is not to be understood as a "symptom" in the narrower sense, but as an expression of a lack of reference to the self-core (Krystal, 1988 ). Statements by the client such as "I'm either angry – or nothing at all" reflect these states of non-affective dissociation. The therapy started here via a twofold axis: the confrontational endoscopy undermined the narcissistic split; at the same time, the creative work created a cautious bridge to self-awareness without having to rely on cognitive verbalization. 5.2 Transference and Countertransference as a Transformative Matrix A central field of action of the therapy was the transference relationship, which did not function as a rigid father substitute scheme, but as an oscillating re-enactment of multiple relationship figures. At various times, the therapist was imagined as an authoritarian superior, as a derogatory father, but also as a saving comrade. This multivalent transference dynamic made it possible to work on regressive relational needs under symbolically "permitted" conditions – comparable to the transition space according to Winnicott ( 1971 ). Countertransference reactions were – as described in the third phase – ambivalent: the therapist experienced feelings of irritation, annoyance, and at times powerlessness. These affects were understood not only as a reaction to the client's behavior, but as an induction of unconscious relational experiences in which control and devaluation are used to protect against dependence (Tansey & Burke, 1989 ). The conscious reflection of this countertransference was crucial in order not to enter into a projective spiral of identification, but to use the affects as diagnostic signals (Heimann, 1950 ; Ogden, 1982 ). The crucial point is that the therapeutic relationship was not idealized – in the sense of a "good object" in the simple sense – but was kept conflictual, ambivalent, but stable. The ability to remain in relationship despite the therapist confronting, refusing, irritating, or questioning represented a corrective emotional experience for the client (Alexander & French, 1946 ; Wachtel, 2011 ). 5.3 Affect differentiation and emotion development A particularly impressive finding was the development of affective differentiation skills during the course of therapy. While at the beginning there were only rudimentary emotional schemata – primarily anger, control and emptiness – a growing ability to name and endure ambivalent states developed through the work with inner images, relationship conflicts and symbolic self-representations. The ability not only to name complex affects such as shame, care, guilt or longing, but also to anchor them relationally is a central goal of psychodynamic development (Fonagy & Target, 2000 ; Bateman & Fonagy, 2006 ). Particularly relevant was the shift in the representation of paternal care – from identification with violence to the reinterpretation of strength as security. The statement "I want her to be happy when I come – not that she is afraid" points to a profound symbolic restructuring of affective scripts. This development is also an expression of a growing "affective tolerance" (Greenberg & Mitchell, 1983 ), i.e. the ability to keep affects in their ambivalence without dissolving them into action or separation. This performance – as clinical research on structurally impaired patients also shows – is a predictor of therapeutic efficacy (Schore, 2012 ; Buchheim et al., 2008 ). 5.4 Symbolization, Creative Externalization and Transitional Space A central effective factor of the therapy was the symbolic externalization of inner states through painting. The creative medium served the client as an affective "intermediate object" that mediated between subjectivity and reality, between inside and outside – in the sense of Winnicott's (1971) conception of the "intermediate space". The images enabled the client not only to experience preverbal affects such as fear, loss of control, shame or feelings of abandonment, but also to externalize and look at them. The image of the lion is particularly noteworthy here: it was modified several times in the course of the film, but remained as a central ego symbol. The statement "This is the same lion – only that it no longer roars" refers to a structural transformation of self-representation in the sense of "containment" (Bion, 1962 ). The client transferred archaic impulses – anger, need for protection, compulsion to control – into an integrated image that contains both the destructive and the relational aspects of the self. This ability for symbolic ambivalence tolerance is described in the literature as an indicator of therapeutic progress, especially in patients with early developmental disorder or complex trauma (Levine, 2009 ; Malchiodi, 2012 ). 5.5 Digital Relationship as a Therapeutic Space of Possibility Finally, the special nature of the digital setting must be reflected. The therapy took place entirely online, as part of the BetterHelp platform – a format that is often viewed critically and has hardly been systematically evaluated in the psychodynamic literature so far. However, the present case shows that profound relationship experiences, transference processes and symbolic work are also possible in the digital space – provided that the therapist succeeds in establishing presence, structure and affective responsiveness (Lemma, 2017 ; Suler, 2010 ). The client reflected on this aspect himself in one session: "I know this is just a screen. But somehow we talk differently here than in real life. Maybe because no one is listening." This statement points to the paradoxical intimacy of digital settings: physical distance sometimes creates psychological closeness because it reduces the threat of immediate presence. This corresponds to findings from online psychotherapy, which show positive effects especially in shameful topics and in severely traumatized patients (Simpson & Reid, 2014 ; Weitz, 2020 ). The stability of the therapeutic relationship – despite its mediality – was ultimately a decisive factor for the change. The digital structure was not experienced as a lack, but as a protective space in which vulnerability became possible. 6. Discussion and conclusion The case study analyzed here impressively illustrates how psychodynamic processes – in particular transference dynamics, narcissistic compensation mechanisms, affect differentiation and symbolic integration – can also be activated, held and transformed in the digital therapeutic space. The focus is less on "success" in the sense of quantitative symptom reduction, but on the qualitative development of a subject structure that is capable of dialogue, capable of symbolizing and relationally oriented, as it is constitutive of psychodynamic therapies (McWilliams, 2011 ; Fonagy et al., 2002 ). The case exemplifies that a highly structured but internally fragmented client with a severe biographical predisposition – consisting of early violence, emotional neglect and secondary traumatization due to the loss of stable external structures (Bundeswehr) – is able to gradually gain access to previously split affects through a supportive, yet confrontational therapeutic relationship. The combination of structured authority attachment and creative emotional work was decisive. The integration of the lion motif as an ambivalent self-representation marked a central symbolic transformation point in this process. It was particularly remarkable that the digital space did not represent an obstacle to the development of psychodynamic depth, but even had a beneficial effect under certain conditions. The distance of the medium apparently enabled increased emotional security, in which affectively threatening content could first be externalized and then gradually processed internally. This is in line with recent studies on the effectiveness of psychodynamic online counseling, which point to the paradoxical potential of the digital as a container (Lemma, 2017 ; Simpson & Reid, 2014 ; Weitz, 2020 ). At the same time, the case raises important questions for clinical practice. The ethical balancing act between confrontation and re-enactment must be sensitively balanced, especially in the case of clients with narcissistic or traumatic vulnerability. As Mahoney ( 2001 ) points out, what is needed is a therapeutic attitude that is at once structured and resonant, directive and empathetic – an attitude that is not authoritarian but can embody authority. The therapist does not become an interpreter here, but a player in the intersubjective space (Benjamin, 1990 ). In addition, the case shows that psychodynamic work with male clients in special situations – such as after military service, separation and professional degradation – often requires non-traditional method integration. The openness to art therapy, to provocative confrontation and to working with narrative symbols should not be understood as eclectic, but as a functional adaptation to the client's structural conditions. It is not about methodological pluralism, but about structural adequacy (Kernberg, 2004 ). Limitations of the present case concern the lack of long-term perspective and the therapist's exclusive self-observation as a data basis. It also remains unclear to what extent the developmental steps described here have been sustainably anchored in everyday life – especially with regard to the partner relationship, professional behavior and fatherhood. A qualitative follow-up survey (e.g. through self-reports, family interviews or external evaluation) would be desirable. Despite these limitations, the case provides substantial evidence of the potential of psychodynamic online work in highly stressed, structurally ambivalent cases. He shows that confrontation is not to be equated with therapeutic harshness, but – embedded in relationship – can be a form of loving boundary-setting. He shows that emotion does not only reside in speech, but also in the image. And it shows that a screen can also be a space in which people meet themselves – perhaps even for the first time. Declarations Author Contribution The author confirms that they are solely responsible for all aspects of the manuscript. This includes the conceptualization, design, data collection, analysis, interpretation, drafting, and final approval of the submitted version. References Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and application . Ronald Press. American Psychological Association. (2017). Ethical principles of psychologists and code of conduct . https://www.apa.org/ethics/code Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions. Journal of Technology in Human Services , 26 (2–4), 109–160. https://doi.org/10.1080/15228830802094429 Bateman, A. W., & Fonagy, P. (2006). Mentalization-based treatment for personality disorders: A practical guide . Oxford University Press. Benjamin, J. (1990). The bonds of love: Psychoanalysis, feminism, and the problem of domination . Pantheon. Bion, W. R. (1962). Learning from experience . Heinemann. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development . Basic Books. Buchheim, A., Erk, S., George, C., Kächele, H., Kircher, T., Martius, P., & Walter, H. (2008). Neural correlates of attachment trauma in borderline personality disorder: A functional magnetic resonance imaging study. Psychiatry Research: Neuroimaging , 163 (3), 223–235. https://doi.org/10.1016/j.pscychresns.2007.07.018 Crittenden, P. M. (2006). A dynamic-maturational model of attachment. Clinical Child Psychology and Psychiatry , 11 (3), 367–397. https://doi.org/10.1177/1359104506066145 Farrelly, F., & Brandsma, J. (1974). Provocative therapy . Meta Publications. Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative Inquiry , 12 (2), 219–245. https://doi.org/10.1177/1077800405284363 Fonagy, P., & Bateman, A. W. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology , 62 (4), 411–430. https://doi.org/10.1002/jclp.20241 Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self . Other Press. Fonagy, P., & Target, M. (2000). Playing with reality: I. Theory of mind and the normal development of psychic reality. International Journal of Psycho-Analysis , 81 (Pt 4), 853–871. Freud, S. (1999). Inhibition, Symptom and Anxiety (Original 1926). In: Gesammelte Werke , vol. 14. Gantt, L., & Tinnin, L. W. (2009). Support for a neurobiological view of trauma with implications for art therapy. The Arts in Psychotherapy , 36 (3), 148–153. https://doi.org/10.1016/j.aip.2009.02.005 Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory . Harvard University Press. Grossman, D. (2009). On killing: The psychological cost of learning to kill in war and society (Rev. ed.). Back Bay Books. Heimann, P. (1950). On counter-transference. International Journal of Psychoanalysis , 31 , 81–84. Herman, J. L. (1992). Trauma and recovery: The aftermath of violence–from domestic abuse to political terror . Basic Books. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism . Jason Aronson. Kernberg, O. F. (2004). Aggression in personality disorders and perversions . Yale University Press. Kohut, H. (1977). The restoration of the self . International Universities Press. Kohut, H. (1984). How does analysis cure? University of Chicago Press. Krystal, H. (1988). Integration and self-healing: Affect, trauma, alexithymia . The Analytic Press. Lemma, A. (2017). The digital age on the couch: Psychoanalytic practice and new media . Routledge. https://doi.org/10.4324/9781315729550 Levine, S. K. (2009). Poiesis: The language of psychology and the speech of the soul . Jessica Kingsley Publishers. Mahoney, M. J. (2001). Human change processes: The scientific foundations of psychotherapy . Basic Books. Malchiodi, C. A. (2012). Handbook of art therapy (2nd ed.). Guilford Press. Marty, P. (1990). Operative thinking . PUF. McDougall, J. (1989). Theatres of the mind: Illusion and truth on the psychoanalytic stage . Free Association Books. McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. NASW – National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers . https://www.socialworkers.org/About/Ethics/Code-of-Ethics Ogden, T. H. (1982). Projective identification and psychotherapeutic technique. International Journal of Psychoanalysis , 63 , 357–373. Orange, D. M. (2011). The suffering stranger: Hermeneutics for everyday clinical practice . Routledge. Racker, H. (1968). Transference and countertransference . International Universities Press. Schore, A. N. (2003). Affect dysregulation and disorders of the self . W. W. Norton. Schore, A. N. (2012). The science of the art of psychotherapy . Norton. Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming . Scribner. Sifneos, P. E. (1973). The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychotherapy and Psychosomatics , 22 (2–6), 255–262. Simpson, S., & Reid, C. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. Australian Journal of Rural Health , 22 (6), 280–299. https://doi.org/10.1111/ajr.12149 Stake, R. E. (1995). The art of case study research . Sage. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2002). Working intersubjectively: Contextualism in psychoanalytic practice . The Analytic Press. Suler, J. (2010). Psychology of the digital age: Humans become electric . Cambridge University Press. Tansey, M. J., & Burke, W. F. (1989). Understanding countertransference: From projective identification to empathy . Psychology Press. van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma . Viking. Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when . Guilford Press. Weitz, P. (2020). Psychotherapy 2.0: Where psychotherapy and technology meet . Karnac Books. Winnicott, D. W. (1971). Playing and reality . Tavistock Publications. Yin, R. K. (2018). Case study research and applications: Design and methods (6th ed.). Sage. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7063862","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":483086482,"identity":"f1191b9b-6f43-4891-84c4-378456b4e21e","order_by":0,"name":"Sora Pazer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYHAD5gMHSNXClkCyFh4D4tTJt/c+/MC4w86eX/rMx8M8DDb58g4EtBicOW4swXgmmVmyL3cDUEua5UZCzjOQSGOQYGxjZjM4wwvSctjAsIGQw2akMf9gbKvnsT/D84A4LQw30tiAthyWMOABqgdpkSekw+DMMTaLxDPHDSTOsBkcnGOQZkAw3OTb25hvfNxRbc/fw/z4w5sKGwN5gg4DgUS4KqAVBgeI0cKIbDBxtoyCUTAKRsFIAgDOvzi9mUAJiAAAAABJRU5ErkJggg==","orcid":"","institution":"IU International University of Applied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sora","middleName":"","lastName":"Pazer","suffix":""}],"badges":[],"createdAt":"2025-07-07 09:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7063862/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7063862/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98621782,"identity":"6ce434af-57ec-4e5b-be75-46e89f5a1511","added_by":"auto","created_at":"2025-12-19 16:11:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":944812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7063862/v1/3b02259f-c82b-405e-b4ec-a56edb498563.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\"I Don't Just Want to Be the Angry One Anymore\" – A Psychodynamic Case Study on Emotion Work, Confrontation and Symbolic Self-Integration in a Traumatized Veteran in Online Counseling","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eVeterans after deployments abroad often face profound psychosocial challenges that go far beyond classic post-traumatic stress symptoms. Clients with pre-existing attachment disorder, early violence and narcissistic injuries are particularly likely to exhibit pronounced affect dysregulation, emotional separation and destructive relationship patterns (Fonagy et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; McWilliams, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Shay, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Psychodynamic casework with such people requires a high level of integration: between empathic understanding and structuring confrontation, between emotional expression and supportive mirroring (Kernberg, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1975\u003c/span\u003e; Kohut, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1977\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe present case study describes the course of therapy of a 37-year-old man with four years of military service \u0026ndash; including deployments in Mali and Afghanistan \u0026ndash; who suffered from severe mood disorders, psychosomatic complaints (chronic headaches, daily ibuprofen intake), relationship breakdowns and professional instability after his return. In early childhood, he was characterized by a violent father and an emotionally disconnected mother, which led to a rigid self-image and a dominant defense against emotional closeness (Bowlby, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1988\u003c/span\u003e). Affects were initially only accessible in the mode of anger, other emotional qualities seemed unattainable.\u003c/p\u003e\u003cp\u003eIn the course of twelve video-based online sessions on BetterHelp, a dual methodological approach was pursued: On the one hand, an emotion-focused use of art therapy techniques (Gantt \u0026amp; Tinnin, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Winnicott, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1971\u003c/span\u003e), on the other hand, a confrontational conversational approach that confronted the client with his dysfunctional patterns (Farrelly \u0026amp; Brandsma, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1974\u003c/span\u003e; Mahoney, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). This combination allowed for a profound therapeutic process in which emotional expressions developed, self-esteem was restructured and a new positioning in relation to relationship, fatherhood and autonomy was achieved.\u003c/p\u003e\u003cp\u003eThe study aims to present the psychodynamic mechanisms of action \u0026ndash; in particular transference phenomena, affect processing and narcissistic self-regulation \u0026ndash; in a differentiated way in the digital setting. She positions herself in the current research discourse on the effectiveness of psychodynamic online work (Lemma, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Simpson \u0026amp; Reid, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and wants to show how even profound destructive patterns can be worked on through a supportive, clearly structured and creative therapeutic relationship.\u003c/p\u003e"},{"header":"2. Theoretical framework","content":"\u003cp\u003eThe present case study is theoretically guided by five interlocking reference systems within psychodynamic theory formation: (1) the affect-psychological significance of early traumatization and attachment disorder, (2) the narcissistic self-structure in the field of tension between compensation and disintegration, (3) transference and countertransference as a clinically effective relationship category, (4) the use of confrontational therapeutic interventions, and (5) the importance of creative Forms of expression to symbolize non-integrated inner states. These dimensions form the interpretative framework for interpreting the clinical process.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Attachment trauma, affect dysregulation and self-development\u003c/h2\u003e\u003cp\u003eEarly experiences of violence and neglect have been shown to have profound effects on the development of self-regulation processes, especially with regard to the ability to perceive affect, differentiate and symbolically represent emotional states (Schore, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; van der Kolk, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Neuroaffective research shows that complex traumatization in childhood \u0026ndash; especially through disorganized attachment and interpersonal violence \u0026ndash; leads to structural deficits in the right hemisphere, which is central to the processing of unconscious affective information (Schore, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In psychodynamic terminology, this can be interpreted as a fixation on preverbal forms of affect experience that cannot be symbolized and can therefore often only be experienced as somatic or destructive impulses (McDougall, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1989\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to Bowlby (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1988\u003c/span\u003e), the inner representation of early relationship experiences is organized in so-called \"inner working models\". If these are characterized by fear, unreliability and emotional coldness, any form of closeness is associated either with self-loss or with threat. In the long term, this leads to a profound distrust of emotional resonance and to a cognitively controlled interaction structure, as was also observed in the client of this study. Following Crittenden (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), behavior can be interpreted as a form of the dismissive-avoidant pattern, in which emotional content is systematically suppressed and replaced by hyperfunctionalization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Narcissistic Injury, Compensation and Self-Coherence\u003c/h2\u003e\u003cp\u003eThe psychodynamic self-psychology according to Kohut (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1977\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1984\u003c/span\u003e) provides a differentiated approach to understanding the narcissistic structural problems of the client. Kohut describes the self as a dynamic structure that is highly dependent on the resonance of so-called self-objects \u0026ndash; i.e. on relationships in which the individual is mirrored, idealized or experienced as belonging. In the absence of such self-object experiences, no coherent, stable self can develop. Rather, so-called narcissistic wounds arise, which are covered up by hypercompensation, grandiosity fantasies or \u0026ndash; as in this case \u0026ndash; by rigid separation of need.\u003c/p\u003e\u003cp\u003eIn this reading, joining the Bundeswehr represents a massive compensatory self-object experience: for the first time, the client is mirrored as capable, brave and meaningful; Discipline and obedience create a stabilizing outer shell. The end of this phase \u0026ndash; i.e. the transition to civilian life \u0026ndash; also marks the collapse of the compensatory system. In Kohut's terminology, it is a \"self-object failure\" that favors a narcissistic breakdown (Kohut, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1984\u003c/span\u003e, p. 77). Kernberg (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1975\u003c/span\u003e) also describes comparable dynamics as \"narcissistic regression\" when externalized structures (e.g., institutions) are no longer available.\u003c/p\u003e\u003cp\u003eIn the sense of Stolorow et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), this is an intersubjective trauma: the emotional disorganization arises not only from inner fragmentation, but also from the lack of a compassionate, resonant other. At this point, therapy tries to contribute to a reorganization of the self through responsive counterparts and structure givers at the same time \u0026ndash; not through mere insight, but through relationship processes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Transference, countertransference and depth of relationship\u003c/h2\u003e\u003cp\u003eIn the psychodynamic framework, the therapeutic relationship is not understood as a neutral exchange of information, but as a space for the re-enactment of early relationship patterns. Transference and countertransference are not regarded as disturbing artefacts, but as a central diagnostic and interventional tool (Racker, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1968\u003c/span\u003e; Heimann, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1950\u003c/span\u003e). In the therapeutic encounter with the present client, the transference manifested itself in the form of an ambivalent relationship experience: the therapist was imagined both as an authoritarian father figure and as a saving mentor. This tension created a high emotional charge \u0026ndash; both on the part of the client and the therapist, which required constant reflection on the countertransference reactions (Tansey \u0026amp; Burke, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e1989\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe proximity to the concept of projective identification is evident here: the client often induced feelings of helplessness, powerlessness or even irritability in the therapist \u0026ndash; affects that may have originated from his own childhood experience, but have not yet been consciously integrated (Ogden, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1982\u003c/span\u003e). The therapeutic task was not to ward off these projective processes, but to reflect, hold and transform them into understandable relationship experiences.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Confrontational Intervention and Therapeutic Authority\u003c/h2\u003e\u003cp\u003eEspecially in the case of strongly defensive, narcissistically structured or alexithymic clients, a purely interpretative attitude can reach its limits. As Mahoney (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) points out, such clients need not only empathy, but also clear boundaries, structure, and a level of confrontation that irritates their inner survival patterns without destroying them. The present case shows that provocative or confrontational interventions \u0026ndash; such as the direct mirroring of self or relationship patterns \u0026ndash; can have a potentially corrective function if they are embedded in a supportive therapeutic relationship (Farrelly \u0026amp; Brandsma, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1974\u003c/span\u003e; Wachtel, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe therapeutic attitude oscillates between responsiveness and directness: the therapist becomes an emotional mirror, but also a boundary \u0026ndash; especially where destructive patterns urge repetition. In the sense of Benjamin (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1990\u003c/span\u003e), it is an \"intersubjective space of negotiation\" in which relationship is not predetermined, but constituted through confrontation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Symbolization, Art and Therapeutic Transition Space\u003c/h2\u003e\u003cp\u003eThe ability to symbolize inner states is considered a central criterion of psychological maturity and affect integration (Krystal, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1988\u003c/span\u003e). In traumatized, alexithymic or psychosomatically fixated clients, this ability is often disturbed: feelings appear diffuse, overpowering or physical. Here, art therapy methods open up a space of symbolic representation that lies between direct expression of affect and reflective language (Gantt \u0026amp; Tinnin, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Malchiodi, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Following Winnicott (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1971\u003c/span\u003e), this space can be described as a \"transitional space\" in which inner experience can be held, externalized and transformed for the first time.\u003c/p\u003e\u003cp\u003eThe client of this case study began to depict nightmares, and later also to symbolically outline father roles (\"lion\" as an ambivalent figure of protection and danger). The development from the image of \"shadow\" to images with colors, light and movement can be understood as a pre-linguistic expression of a new affective differentiation. This creative externalization became a resonance space for affective self-encounter \u0026ndash; not in the sense of expressive catharsis, but as a symbolic restructuring of inner world views (Levine, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Methodology and case description","content":"\u003cp\u003eThe present case study is based on a qualitative-reconstructive design with a hermeneutical-psychodynamic perspective. It does not claim to be generalizable statements, but aims at a theory-based in-depth hermeneutics of individual psychological structures, their relational dynamics and possible change processes in the context of digital counseling (Flyvbjerg, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Stake, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). The approach follows the paradigmatic principle of \"individual case condensation\" (Yin, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), in which a particularly characteristic or complex case is analysed in an exemplary manner.\u003c/p\u003e\u003cp\u003eThe data basis is formed by written protocols, meeting notes and therapeutic reflections by the author as the practitioner. The contents were retrospectively anonymized and hermeneutically analyzed in their entirety. All quoted statements and descriptions have been changed in their form in order to exclude conclusions about the real person. The client was informed about the scientific use of the material and agreed to an anonymized case publication in principle. The ethical responsibility lies entirely with the author, who adheres to the professional standards of social work and psychodynamic therapy orientation (American Psychological Association, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; NASW, 2021).\u003c/p\u003e\u003cp\u003eThe case work is also deliberately designed to be reflexive: the therapeutic process is not presented in an objectifying way, but is understood as an intersubjective co-production between client and therapist (Stolorow et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Orange, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). This perspective requires not only the description of the client, but also the reflection of therapeutic attitudes, countertransferences and methodological decisions. The course of the case is presented in Chap.\u0026nbsp;4 along four structured phases that were clearly identifiable in the process.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Sociobiographical profile\u003c/h2\u003e\u003cp\u003eThe client (changed) is a 37-year-old German-speaking man, living in an urban-peripheral environment, divorced, father of a child of primary school age, currently again in an unstable partnership. Professionally, he initially worked in retail, but was dismissed due to recurring outbursts of aggression and interpersonal conflicts. He currently works as a fitter, but here too he shows a high degree of stress, inner overload and psychosomatic complaints.\u003c/p\u003e\u003cp\u003eHis early childhood was characterized by biparental disintegration: his father regularly became violent, his mother reacted with emotional coldness, unavailability and structural undersupply. The school career took place in a \"residual branch\" of the Hauptschule, which was characterized by chronic experiences of devaluation, resignation and failure to perform. Already here, a self-definition as a \"failure\" was established, which was internalized. Joining the Bundeswehr at the age of 19 was described by the client as the only turning point in his life: \"That was the first time that someone saw something in me.\"\u003c/p\u003e\u003cp\u003eDuring his four-year service \u0026ndash; with foreign deployments in Mali and Afghanistan \u0026ndash; he was trained as a sniper and, according to his own statement, experienced \"clarity, order and purpose\". Looking back, he described the military structure as a \"surrogate family\" and \"my first safe place\". After leaving the service, however, he fell into a phase of professional and psychological disintegration. In addition to the experience of devaluation in the civilian work context (Rewe), he increasingly developed symptoms: chronic headaches, constant irritability, inner feeling of emptiness, episodic shifts in perception, impulse breakthroughs. He himself spoke of \"psychotic episodes\", but without ever having been diagnosed psychiatrically.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Psychodynamic starting point\u003c/h2\u003e\u003cp\u003ePsychodynamically, the client shows a massive structural imbalance in affect regulation. At the beginning of the therapy, only one affect could be named and experienced: anger. Other emotional states \u0026ndash; such as grief, fear, longing, guilt \u0026ndash; were initially completely externalized, devalued or dissified. Emotionality was equated with loss of control, weakness or threat. In the sense of the alexithymic structure according to Sifneos (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1973\u003c/span\u003e), there is a considerable limitation in the ability to mentally represent emotional processes.\u003c/p\u003e\u003cp\u003eThe relationship patterns were characterized by ambivalence: intense longing for closeness, at the same time deep mistrust and the tendency to aggressive avoidance. In partnerships, emotional overload, escalation and withdrawal regularly occurred. The role of father in particular was ambivalently charged: on the one hand, the client wanted to be a \"better father\" than his own, but on the other hand, he lacked any access to the affective nuances of parental relationships.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Setting and therapeutic framework model\u003c/h2\u003e\u003cp\u003eThe psychodynamically oriented counselling took place over a period of six weeks with two video-based sessions per week (60 minutes each) via the BetterHelp platform. Despite the digital format, the client was highly reliable, showed up on time, completed all therapeutic tasks conscientiously and showed an unusually high willingness to open up himself \u0026ndash; but only after the third session, in which there was a first emotional breakthrough. The therapeutic relationship increasingly developed as a stable resonance chamber in which both affects and resistance emerged and could be worked on.\u003c/p\u003e\u003cp\u003eThe methodological approach was two-pronged:(1) Confrontational Conversation Conduct according to the Principles of Provocative Therapy (Farrelly \u0026amp; Brandsma, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1974\u003c/span\u003e; Mahoney, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) with a focus on dysfunctional relationship patterns, narcissistic defense strategies and self-image distortions. (2) Emotion-focused creative work: The client was invited to symbolically resort to painting inner images, nightmares, or metaphors \u0026ndash; which led to the externalization of emotional content, especially in later sessions (Malchiodi, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Gantt \u0026amp; Tinnin, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Indicators of change\u003c/h2\u003e\u003cp\u003eIn the course of the sessions, a successive differentiation of affect became apparent: the client began to name grief, shame and also fear \u0026ndash; at first hesitantly, later more clearly. For the first time, he described feelings towards his daughter as \"tender\" and confessed a \"need for recognition\" that he had previously always rejected as \"weakness\". The images changed visibly: from gloomy motifs (\"Shadows\", \"Empty Space\", \"Decay\") to more structured representations with colour dynamics (\"Rainbow\", \"Path with Light\", \"Lion Who Protects and Loves\").\u003c/p\u003e\u003cp\u003eThe client began to talk about himself in other words \u0026ndash; no longer exclusively in categories of failure, threat or withdrawal, but with first affirmative statements such as: \"I am not my father\" or \"I can do things differently.\" These narratives mark an incipient inner restructuring of the self-concept (Kohut, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1977\u003c/span\u003e; Fonagy et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Process course and phase analysis","content":"\u003cp\u003eThe therapeutic process was divided into four clearly distinguishable phases, each of which was characterized by specific relationship constellations, affect dynamics and symbolic forms of expression. These phases are presented in a structured way and psychodynamically interpreted in the following.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Phase I: Rational Defense and Control (Sessions 1\u0026ndash;2)\u003c/h2\u003e\u003cp\u003eThe first phase was characterized by a pronounced rational distancing. The client presented himself with cognitive clarity, structured language style and detail-oriented reporting, but completely disconnected from inner experience. Affects were named, but not felt: statements such as \"I'm not angry, I'm efficient\" or \"Feelings don't help\" dominated. This form of defense is classic for a so-called operated mindset (Marty, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1990\u003c/span\u003e) and refers to an alexithymic level of processing (Sifneos, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1973\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePsychodynamically, this attitude can be interpreted as a secondary narcissistic protective mechanism that is intended to avoid a regression into the affective (McWilliams, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). The rigid rationality functioned as a barrier against emotional activation and at the same time reflected an internalized superego that sees weakness, neediness and emotional resonance as a threat to the self (Kernberg, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1975\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe therapeutic relationship at this time was characterized by obedience and external cooperation, but without emotional involvement. First confrontations \u0026ndash; such as: \u003cem\u003e\"If you have everything so well under control, why are you here?\"\u003c/em\u003e \u0026ndash; led to irritation, but not to withdrawal. This indicated an unconscious readiness for relationship confrontation, which, however, did not yet allow affective permeability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Phase II: Opening of Affect and Symbolic First Contacts (Sessions 3\u0026ndash;5)\u003c/h2\u003e\u003cp\u003eA break in the dynamics became observable in the third session. After a confrontational intervention on the client's role as a father (\"You expect your daughter to be strong \u0026ndash; who actually allows you to be weak?\"), a non-verbal emotional breakthrough appeared for the first time: The client cried silently, visibly shaken, but then spoke for the first time of \"loneliness\" and \"fear that I won't make it\". This moment marked the beginning of a new therapeutic phase.\u003c/p\u003e\u003cp\u003eAs a structuring intervention, the painting of inner images was then introduced \u0026ndash; with the open task of visualising a feeling or a nightmare. The first picture he created was an empty room, black, without doors or windows. In its emptiness, this motif symbolizes a form of introjective isolation that is often observed in patients with severe attachment disorders or narcissistic structures (Gantt \u0026amp; Tinnin, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Krystal, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1988\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe subsequent sessions deepened this process. Images of shadow figures, crumbling buildings, and isolated landscapes became symbolic carriers of preverbal anxiety that could now be externalized, viewed, and reflected. Affects such as grief and fear were named, albeit still with uncertainty. The client spoke of \"something that moves inside me, but has no name\".\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Phase III: Confrontation, Resistance and Renegotiation (Sessions 6\u0026ndash;9)\u003c/h2\u003e\u003cp\u003eIn the third phase of the therapeutic process, the focus shifted significantly to the processing of relational patterns and affective repetitions. The aggression that had previously only been hinted at, which had been masked as \"discipline\", \"clarity\" or \"responsibility\" in early sessions, now began to appear more openly in the therapeutic relationship \u0026ndash; not as a destructive discharge, however, but as a means of relation. The client was increasingly willing to accept confronting feedback without experiencing it as devaluation or attack. This marked a crucial differentiation achievement in dealing with early transmission anxiety.\u003c/p\u003e\u003cp\u003eCentral to this was the therapeutic strategy of directly naming destructive patterns and translating them into language. In a key session, the therapist confronted the client's romanticizing self-narrative, in which he repeatedly presented himself as a victim of toxic women. The intervention was:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"You keep telling me how you were hurt \u0026ndash; but you never tell me how you hurt others. Who are you in this story: the victim or the one who shoots first?\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAfter a long pause, the client replied:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"I don't remember anymore. I think I'm just afraid that someone will see me. Really sees. And then you realize how empty it is. So I make sure they hate me before they leave me.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis sequence marked not only a partial insight into his self-sabotaging behavior, but also a cautious approach to shameful affects. Particularly striking was the mixture of obedience and provocation in his behavior towards the therapist \u0026ndash; a pattern that can be explained by early attachment dynamics. Repeatedly, the client uttered phrases like, \u003cem\u003e\"Just tell me what you want me to do. I'm good at following orders.\"\u003c/em\u003e This statement can be read as a residual internalization of military transmission \u0026ndash; but also as a regressive need for a structuring object that offers support through authority (Kohut, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1984\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA recurring symbol in this phase was the figure of a lion, which the client first mentioned spontaneously during a painting task:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"I have an image in my head. There's a lion. It lies quiet, but everyone knows: If it jumps up, it's all over. I think I'm the lion. I can protect, but I can also destroy.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn later sessions, the client drew this motif several times \u0026ndash; sometimes in sparse lines, sometimes with strikingly contrasting colours: red for the throat, black for the mane, light blue for the background. The lion figure became a central transitional object in the therapeutic work: as a representation of his self-image, but also as a figure of identification for his inner struggle between care, violence, control and neediness. The psychodynamics of this metaphor run deep: it combines narcissistic grandiosity with a regressive longing for protection \u0026ndash; an ambivalence that ran through many of his relationship narratives (Stolorow et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Krystal, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1988\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis phase also showed an increasing emotional activation in the therapeutic relationship. After a particularly confrontational session, in which the therapist again addressed the avoidance of his role as a father (\"You say you want to be a good father to her. But what does that mean \u0026ndash; keep quiet and be tough?\"), the client burst into tears. \u003cem\u003e\"I don't want her to yell at me like I yell at my father. I don't want her to be afraid of me. But I don't know how to do it any other way.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis moment was highly condensed and for the first time made it possible to consciously distance oneself from one's own pattern of re-enactment. The tears were no longer experienced as weakness, but as part of a necessary process of change. Contrary to the usual dynamics of resistance, the confrontation had not triggered a regression, but became effective as a catalyst for emotional integrity. This underlines the thesis that confrontation in a supportive relationship can not be destructive, but can promote development (Mahoney, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Wachtel, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Phase IV: Integration, Self-Esteem and Narrative Reconstruction (Sessions 10\u0026ndash;12)\u003c/h2\u003e\u003cp\u003eThe last phase was characterized by growing differentiation of affect, narrative re-evaluation and a stabilizing relationship to one's own self. The former monopolization of emotional expression on anger and destruction was now replaced by a more complex emotional landscape in which grief, care, vulnerability and pride could also be articulated.\u003c/p\u003e\u003cp\u003eThe client began to look at previous achievements with a new attitude. In the eleventh session, he reflected: \u003cem\u003e\"I always said: It was all nothing. But that's not true. I was out there. I protected my people. I worked. That wasn't all bad.\"\u003c/em\u003e This sentence, spoken in passing, marked a central narrative turn: the totalizing self-devaluation gave way to an ambivalent but more coherent perspective. In the sense of Kohut (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1977\u003c/span\u003e), this can be understood as the beginning consolidation of the self \u0026ndash; no longer as a grandiose defense or depressive devaluation, but as a realistic integration of abilities, vulnerability and history.\u003c/p\u003e\u003cp\u003eThere was also a significant change in his role as a father. While at the beginning of the therapy only functional aspects were addressed (\"I work, I pay alimony, I'm there\"), the client now spoke of emotional concerns: \u003cem\u003e\"I don't want her to be afraid. I want her to be happy when I come. That she knows: I'm not only strong, I'm also safe.\"\u003c/em\u003e This differentiation between strength as threat and strength as security was also evident in his paintings. In the last session, he presented a drawing of a bright, gold-colored lion sitting next to a small child, with softer lines and a pastel background. \u003cem\u003e\"This is the same lion as before,\" he said. \"Except that he doesn't roar anymore. He's paying attention now.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis statement impressively symbolized the integration of projective components that had previously been experienced as destructive or uncontrollable. The aggressive energy was not denied, but recontextualized: as a resource for care, not for escalation. From a psychodynamic point of view, this corresponds to progress in affective self-regulation, but also in the internalization of a supportive inner object (Fonagy \u0026amp; Target, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; McWilliams, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the final session, the client spontaneously formulated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"I've broken a lot in my life. But maybe now is the moment when I can start to build something. Maybe for the first time.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis sentence forms the emotional culmination of the counselling process: the possibility of stepping out of the destructive re-enactment and relating to oneself as an acting, affect-bearing subject \u0026ndash; not in spite of the biographical burdens, but by dealing with them.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Analysis and Clinical Implications","content":"\u003cp\u003eThe preceding case description reveals a therapeutic development that is not to be understood as linear progress, but as a recursive movement between repetition and difference \u0026ndash; in the sense of a \"spiral dialogue\" between destructive defensive structure, symbolic self-encounter and the beginning integration of affective-attachment-related parts (Stolorow et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). The clinical analysis of the course can be unfolded along five central dimensions: (1) narcissistic structure and self-coherence, (2) transference and countertransference as effective factors, (3) affect differentiation and emotion development, (4) symbolization and creative externalization, and (5) structural qualities of the digital therapeutic relationship.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e5.1 Narcissistic structure and self-coherence\u003c/h2\u003e\u003cp\u003eThe central finding in the client's initial structure was a massive narcissistic injury dynamic, combined with a fragile self that was either grandiosely split off or self-devaluing. Kohut (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1977\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1984\u003c/span\u003e) describes this dialectic as an expression of a compensatory self that relies on external self-objects to maintain coherence. In this case, the Bundeswehr fulfilled such a self-object function in an ideal-typical way: it offered a clear structure, a performance-related attribution of identity and positive reflection. With the end of the military career, there was a rapid collapse of this external self-support \u0026ndash; a classic scenario of narcissistic decompensation (Kernberg, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1975\u003c/span\u003e; Kohut, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1984\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe inner emptiness that manifested itself after leaving the army is not to be understood as a \"symptom\" in the narrower sense, but as an expression of a lack of reference to the self-core (Krystal, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1988\u003c/span\u003e). Statements by the client such as \u003cem\u003e\"I'm either angry \u0026ndash; or nothing at all\"\u003c/em\u003e reflect these states of non-affective dissociation. The therapy started here via a twofold axis: the confrontational endoscopy undermined the narcissistic split; at the same time, the creative work created a cautious bridge to self-awareness without having to rely on cognitive verbalization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e5.2 Transference and Countertransference as a Transformative Matrix\u003c/h2\u003e\u003cp\u003eA central field of action of the therapy was the transference relationship, which did not function as a rigid father substitute scheme, but as an oscillating re-enactment of multiple relationship figures. At various times, the therapist was imagined as an authoritarian superior, as a derogatory father, but also as a saving comrade. This multivalent transference dynamic made it possible to work on regressive relational needs under symbolically \"permitted\" conditions \u0026ndash; comparable to the transition space according to Winnicott (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1971\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCountertransference reactions were \u0026ndash; as described in the third phase \u0026ndash; ambivalent: the therapist experienced feelings of irritation, annoyance, and at times powerlessness. These affects were understood not only as a reaction to the client's behavior, but as an induction of unconscious relational experiences in which control and devaluation are used to protect against dependence (Tansey \u0026amp; Burke, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e1989\u003c/span\u003e). The conscious reflection of this countertransference was crucial in order not to enter into a projective spiral of identification, but to use the affects as diagnostic signals (Heimann, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1950\u003c/span\u003e; Ogden, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1982\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe crucial point is that the therapeutic relationship was not idealized \u0026ndash; in the sense of a \"good object\" in the simple sense \u0026ndash; but was kept conflictual, ambivalent, but stable. The ability to remain in relationship despite the therapist confronting, refusing, irritating, or questioning represented a corrective emotional experience for the client (Alexander \u0026amp; French, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1946\u003c/span\u003e; Wachtel, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e5.3 Affect differentiation and emotion development\u003c/h2\u003e\u003cp\u003eA particularly impressive finding was the development of affective differentiation skills during the course of therapy. While at the beginning there were only rudimentary emotional schemata \u0026ndash; primarily anger, control and emptiness \u0026ndash; a growing ability to name and endure ambivalent states developed through the work with inner images, relationship conflicts and symbolic self-representations.\u003c/p\u003e\u003cp\u003eThe ability not only to name complex affects such as shame, care, guilt or longing, but also to anchor them relationally is a central goal of psychodynamic development (Fonagy \u0026amp; Target, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Bateman \u0026amp; Fonagy, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Particularly relevant was the shift in the representation of paternal care \u0026ndash; from identification with violence to the reinterpretation of strength as security. The statement \u003cem\u003e\"I want her to be happy when I come \u0026ndash; not that she is afraid\"\u003c/em\u003e points to a profound symbolic restructuring of affective scripts.\u003c/p\u003e\u003cp\u003eThis development is also an expression of a growing \"affective tolerance\" (Greenberg \u0026amp; Mitchell, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1983\u003c/span\u003e), i.e. the ability to keep affects in their ambivalence without dissolving them into action or separation. This performance \u0026ndash; as clinical research on structurally impaired patients also shows \u0026ndash; is a predictor of therapeutic efficacy (Schore, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Buchheim et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e5.4 Symbolization, Creative Externalization and Transitional Space\u003c/h2\u003e\u003cp\u003eA central effective factor of the therapy was the symbolic externalization of inner states through painting. The creative medium served the client as an affective \"intermediate object\" that mediated between subjectivity and reality, between inside and outside \u0026ndash; in the sense of Winnicott's (1971) conception of the \"intermediate space\". The images enabled the client not only to experience preverbal affects such as fear, loss of control, shame or feelings of abandonment, but also to externalize and look at them.\u003c/p\u003e\u003cp\u003eThe image of the lion is particularly noteworthy here: it was modified several times in the course of the film, but remained as a central ego symbol. The statement \u003cem\u003e\"This is the same lion \u0026ndash; only that it no longer roars\"\u003c/em\u003e refers to a structural transformation of self-representation in the sense of \"containment\" (Bion, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1962\u003c/span\u003e). The client transferred archaic impulses \u0026ndash; anger, need for protection, compulsion to control \u0026ndash; into an integrated image that contains both the destructive and the relational aspects of the self.\u003c/p\u003e\u003cp\u003eThis ability for symbolic ambivalence tolerance is described in the literature as an indicator of therapeutic progress, especially in patients with early developmental disorder or complex trauma (Levine, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Malchiodi, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e5.5 Digital Relationship as a Therapeutic Space of Possibility\u003c/h2\u003e\u003cp\u003eFinally, the special nature of the digital setting must be reflected. The therapy took place entirely online, as part of the BetterHelp platform \u0026ndash; a format that is often viewed critically and has hardly been systematically evaluated in the psychodynamic literature so far. However, the present case shows that profound relationship experiences, transference processes and symbolic work are also possible in the digital space \u0026ndash; provided that the therapist succeeds in establishing presence, structure and affective responsiveness (Lemma, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Suler, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe client reflected on this aspect himself in one session: \u003cem\u003e\"I know this is just a screen. But somehow we talk differently here than in real life. Maybe because no one is listening.\"\u003c/em\u003e This statement points to the paradoxical intimacy of digital settings: physical distance sometimes creates psychological closeness because it reduces the threat of immediate presence. This corresponds to findings from online psychotherapy, which show positive effects especially in shameful topics and in severely traumatized patients (Simpson \u0026amp; Reid, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Weitz, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe stability of the therapeutic relationship \u0026ndash; despite its mediality \u0026ndash; was ultimately a decisive factor for the change. The digital structure was not experienced as a lack, but as a protective space in which vulnerability became possible.\u003c/p\u003e\u003c/div\u003e"},{"header":"6. Discussion and conclusion","content":"\u003cp\u003eThe case study analyzed here impressively illustrates how psychodynamic processes \u0026ndash; in particular transference dynamics, narcissistic compensation mechanisms, affect differentiation and symbolic integration \u0026ndash; can also be activated, held and transformed in the digital therapeutic space. The focus is less on \"success\" in the sense of quantitative symptom reduction, but on the qualitative development of a subject structure that is capable of dialogue, capable of symbolizing and relationally oriented, as it is constitutive of psychodynamic therapies (McWilliams, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Fonagy et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe case exemplifies that a highly structured but internally fragmented client with a severe biographical predisposition \u0026ndash; consisting of early violence, emotional neglect and secondary traumatization due to the loss of stable external structures (Bundeswehr) \u0026ndash; is able to gradually gain access to previously split affects through a supportive, yet confrontational therapeutic relationship. The combination of structured authority attachment and creative emotional work was decisive. The integration of the lion motif as an ambivalent self-representation marked a central symbolic transformation point in this process.\u003c/p\u003e\u003cp\u003eIt was particularly remarkable that the digital space did not represent an obstacle to the development of psychodynamic depth, but even had a beneficial effect under certain conditions. The distance of the medium apparently enabled increased emotional security, in which affectively threatening content could first be externalized and then gradually processed internally. This is in line with recent studies on the effectiveness of psychodynamic online counseling, which point to the paradoxical potential of the digital as a container (Lemma, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Simpson \u0026amp; Reid, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Weitz, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the same time, the case raises important questions for clinical practice. The ethical balancing act between confrontation and re-enactment must be sensitively balanced, especially in the case of clients with narcissistic or traumatic vulnerability. As Mahoney (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) points out, what is needed is a therapeutic attitude that is at once structured and resonant, directive and empathetic \u0026ndash; an attitude that is not authoritarian but can embody authority. The therapist does not become an interpreter here, but a player in the intersubjective space (Benjamin, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1990\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, the case shows that psychodynamic work with male clients in special situations \u0026ndash; such as after military service, separation and professional degradation \u0026ndash; often requires non-traditional method integration. The openness to art therapy, to provocative confrontation and to working with narrative symbols should not be understood as eclectic, but as a functional adaptation to the client's structural conditions. It is not about methodological pluralism, but about structural adequacy (Kernberg, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e of the present case concern the lack of long-term perspective and the therapist's exclusive self-observation as a data basis. It also remains unclear to what extent the developmental steps described here have been sustainably anchored in everyday life \u0026ndash; especially with regard to the partner relationship, professional behavior and fatherhood. A qualitative follow-up survey (e.g. through self-reports, family interviews or external evaluation) would be desirable.\u003c/p\u003e\u003cp\u003eDespite these limitations, the case provides substantial evidence of the potential of psychodynamic online work in highly stressed, structurally ambivalent cases. He shows that confrontation is not to be equated with therapeutic harshness, but \u0026ndash; embedded in relationship \u0026ndash; can be a form of loving boundary-setting. He shows that emotion does not only reside in speech, but also in the image. And it shows that a screen can also be a space in which people meet themselves \u0026ndash; perhaps even for the first time.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe author confirms that they are solely responsible for all aspects of the manuscript. This includes the conceptualization, design, data collection, analysis, interpretation, drafting, and final approval of the submitted version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlexander, F., \u0026amp; French, T. M. (1946). \u003cem\u003ePsychoanalytic therapy: Principles and application\u003c/em\u003e. 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Sage.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"psychodynamic online counseling, trauma, narcissistic structure, emotion work, confrontation, symbolization, veterans, art therapy, transference, countertransference","lastPublishedDoi":"10.21203/rs.3.rs-7063862/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7063862/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis psychodynamic case study presents a 12-session online therapy process with a 37-year-old German veteran suffering from affective dysregulation, psychosomatic symptoms, and relational conflict following military deployments in Mali and Afghanistan. Rooted in early violence and neglect, the client exhibited narcissistic defenses, alexithymia, and identity diffusion.\u003c/p\u003e\u003cp\u003eTherapy combined structured confrontation and symbolic emotional work through art. Central to the process was the emergence of a self-representation\u0026mdash;a lion embodying both threat and care\u0026mdash;which enabled narrative and emotional integration.\u003c/p\u003e\u003cp\u003eDespite the digital format, a stable therapeutic alliance developed. The client gained access to previously split-off affective states and redefined his role as father and partner. This case highlights the depth potential of psychodynamic online work with structurally vulnerable, trauma-affected clients.\u003c/p\u003e","manuscriptTitle":"\"I Don't Just Want to Be the Angry One Anymore\" – A Psychodynamic Case Study on Emotion Work, Confrontation and Symbolic Self-Integration in a Traumatized Veteran in Online Counseling","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-11 09:19:29","doi":"10.21203/rs.3.rs-7063862/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"058bba80-8162-455f-bdb4-60aeae1a8143","owner":[],"postedDate":"July 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T15:39:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-11 09:19:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7063862","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7063862","identity":"rs-7063862","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}