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The author observed that in some patients interruptions in verbalization during the analytic hour are coincident with unverbalized visual images. These are found when the relationship to the analyst is threatened by the emergence of derivatives of anxiety-producing drives in the transference. A topographical regression occurs which is analogous to the process of dream formation when thoughts are transformed into images, mainly visual, and in accordance with considerations of suitability for plastic representation. With this regression, the patient withdraws temporarily from the analytic situation by not verbalizing his psychic processes; also, by means of the visual images, he is able to discharge those impulses which he fears might disturb the wished-for relationship with the analyst. The technical use of these visual images in the analytic session is therefore of help in overcoming resistance. When there is a pause in the patient's verbalizations, Warren asks the patient to describe what he sees; if the patient describes a visual image, he is asked to relate what he had been thinking about just before its occurrence. The verbalization of the visual image re-establishes the patient's communication with the analyst and blocks the patient's efforts to keep the analyst 'out of the picture'.
The author illustrates his points with incidents in the analyses of four patients. He postulates that patients in whom visual images occur in lieu of verbalization are highly narcissistic, sadomasochistic persons who experience repetitive humiliation fantasies and express a great need for love and approval.