Bassat: Linking Immunology with Psychoanalytical Psychotherapy

The groundbreaking metaphor of “the body keeps the score,” found in trauma research, aligns seamlessly with Bassat’s article exploring the profound impact of embryonic experiences on human development. Her work underscores the convergence of modern biological research with earlier theoretical and clinical insights into primitive mental anxieties, explored by pioneers like Tustin in the 1980s.

Bassat emphasizes that from conception, the human embryo faces a biological challenge: overcoming the mother’s immune system to implant in the uterine lining. This process lays the foundation for what Bassat terms a “neuro-immuno-psychoanalytic” discourse, revealing how the formative experiences of embryonic life shape both our psychological and physiological makeup.

Building on this concept, Bassat references authors like Wilfred Bion, who posited a link between autism and immune system dysfunction during early pregnancy. She further explores the idea that adverse environmental factors in the prenatal period can evoke unbearable states of dread within the fetus, disrupting psychological development and leading to the formation of autistic defenses.

Bassat redefines autistic states as psychophysical protective reactions rooted in bodily sensations rather than solely psychodynamic defense mechanisms. The overwhelming sense of vulnerability and threat experienced in the pre-verbal stage can lead to profound anxieties: a dread of annihilation, disintegration, a sense of boundlessness, or the absence of a safe, containing presence. This bodily experienced terror is not susceptible to rationalization.

Consequently, the autistic infant may resort to clinging behaviors, fixating on autistic objects or shapes. They experience a profound terror of separateness, which equates to a fear of death in their perception.

The author describes how the immune system, with its function of recognizing and responding to ‘self’ vs. ‘non-self’, mirrors the mental processes that determine our sense of individuality and connection with others.

As a psychotherapist with a background in biochemistry and microbiology, I find Bassat’s work both fascinating and deeply resonant. Her writings illuminate the profound impact of prenatal development on psychological wellbeing. Clinically, we frequently encounter clients with deep-rooted anxieties, dread, emptiness, irrational fears, and uncontrollable compulsions – states resistant to rationalization or traditional talk therapy.

These psychophysiological states defy cognitive resolution because their origins lie in pre-verbal trauma. Such experiences, occurring before language acquisition, cannot be consciously recalled. Many psychotherapists recognize the importance of physical presence, movement, and aesthetic connection alongside verbal processing. Metaphors and imagery often prove more potent than purely rational problem-solving in talk therapy.

The Podcast

Episode 129: From Immunology to Psychoanalysis: Reflections on Primitive Mental States with Shiri Ben Bassat (Tel Aviv)

MARCH 4, 2023 00:45:21

The Psychoanalytic Case study

This podcast case study @26:42 is compelling for several reasons. Firstly, it documents the author’s initial case as a psychoanalyst, highlighting the challenges and rewards of working with a child diagnosed with autism and psychosis. The dedication of both the analyst and the child’s adoptive mother to persisting through the child’s violent reactions to therapy demonstrates remarkable commitment. Additionally, the therapist’s innovative use of movement as an embodied mode of communication aligns with psychoanalytic theory, showcasing a thoughtful and adaptable approach within this framework.

In her paper, Bassat (2021) writes: “

  1. I created a stable, consistent setting of five sessions a week at a regular hour – a
    concrete action- needed to rebuild a functional container that would hold her, while
    also remaining flexible and changing, allowing her to take objects from the room
    (Quinodoz, 1992).
  2. I cultivated an accepting and total presence – offering the room, my body, and my
    internal objects so that they could be invaded and even destroyed. I thus enabled her
    to destroy my books, scrawl on my walls, bite me, dribble, and leave behind a
    destroyed, chaotic room – only to re-encounter it in a clean, orderly state upon her
    return. My internal objects had similarly been attacked and injured by evoking
    unbearable memories of my own personal traumas. I understood to what extent Yael’s unrepresented traumas were destructive and painful, in need of a mother-analyst womb to be contained in as Klein’s notion that our consulting rooms are equated, in the unconscious, with the maternal body (1961)
  3. An extensive use of a live, active presence and reparation in action (Alvarez, 1992,
    Pollak, 2009) aimed to distinguish and connect bodily functions, inside and outside,
    self and object, and different emotional states. So, by standing behind the wall to
    concretely separate myself from her, darkening the room, remaining silent, averting
    my gaze, and attempting not to breathe, I was trying to prevent the exterior world
    from intruding while she was still unready. Later, I helped her to envelop herself in
    tape so that she would feel less disintegrated.”

Further reading on Immunology and Psychotherapy

This podcast covers the following topics that warrant specialization and inspires further study:

Epigenetic link to Object Relations

Martin, S. (2014) R. Yehuda, N.P. Daskalakis, A. Lehrner, F. Desarnaud, H.N. Bader, I. Makotkine, J.D. Flory, L.M. Bierer, & M.J. Meaney (2014). Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring. American Journal of Psychiatry 171:872-880.

Karla Ramirez , Rosa Fernández , Sarah Collet , Meltem Kiyar Enrique Delgado-Zayas , Esther Gómez-Gil , Tibbert Van Den Eynde , Guy T’Sjoen , Antonio Guillamon , Sven C Mueller , Eduardo Pásaro (2021) Epigenetics Is Implicated in the Basis of Gender Incongruence: An Epigenome-Wide Association Analysis. Front Neurosci Aug 19; 15:701017

Primitive Anxieties

Durban, J. (2019) ““Making a person”: Clinical considerations regarding the interpretation of anxieties in the analyses of children on the autisto-psychotic spectrum” The International Journal of Psychoanalysis 100:5, 921-939.

Prenatal and Postnatal Influence on the Psyche

Meltzer, D. & Williams, M. H. (1988) 2. Aesthetic Conflict: It’s Place in the Developmental Process. The Apprehension of Beauty: The Role of Aesthetic Conflict in Development, Art, and Violence 146:7-33

Bion, W. R. (1976) “On a quotation from Freud.” In Clinical Seminars and Four Papers, Ed. F. Bion. Abingdon: Fleetwood Press, 1987.

Joanna Wilheim (2004) The trauma of conception. Presented at a Meeting of the Brazilian Society of Psychoanalysis of São Paulo (SBPSP) on October 7, 2004.

Trnsformation of the mother’s immune system. Mandelboim, O. et al’ (2006). Decidual NK cells regulate key developmental processes at the human fetal-maternal interface. Nature Medicine 12: 1065 – 1074.

Bibliography

Bassat, S.B. (2021). “War in times of love”- Prenatal cell relations as a prototype of
autistic anxieties, defenses and object relations. Paper that won the 24th Frances Tustin Memorial Prize, 2021. Tel Aviv University, November 5th, 2021. Download pdf.

The Psychodynamic Diagnostic Process: Nancy McWilliams

This lecture by Nancy McWilliams delves into the intricacies of psychodynamic diagnosis, exploring the complexities beyond the DSM and offering insights into therapeutic approaches for various personality types. Here’s a summary of key points with timestamps for your reference:

Levels of Personality Functioning (1:00):

  • McWilliams emphasizes the importance of considering different levels of personality functioning, ranging from high-functioning to psychotic.
  • High-functioning (neurotic to healthy): Individuals exhibit good attachment security, engage in reflective thinking, and can manage complex emotions.(1:00)
  • Borderline: Characterized by intense emotions, unstable relationships, and difficulty tolerating frustration. Therapists need to set clear boundaries and provide consistent support. (2:00)
  • Psychotic: Individuals grapple with severe anxiety and may experience delusions or hallucinations. Treatment focuses on symptom management and building a sense of safety. (3:00)

DSM vs. Psychodynamic Approach (4:00):

  • McWilliams critiques the limitations of the DSM, arguing that it overemphasizes categorical diagnoses and neglects individual context and complexity.
  • Psychodynamic diagnosis, in contrast, considers a person’s history,temperament, defense mechanisms, and attachment patterns to provide a richer understanding. (5:00)

Therapeutic Considerations for Different Personalities (6:00):

  • Obsessive-compulsive: Helping them find healthier ways to manage anxiety and intrusive thoughts, rather than focusing on eliminating obsessions entirely. (6:00)
  • Depressive: Exploring the underlying causes of their self-criticism and encouraging them to develop healthier coping mechanisms. (7:00)
  • Self-defeating: Recognizing the pattern of seeking help while sabotaging progress, and setting clear boundaries to prevent manipulation. (8:00)

Qualities of a Good Therapist (50:00):

  • Caring and empathetic: Building a genuine connection with the patient is crucial for effective therapy.
  • Humble and willing to learn: Therapists should be open to feedback and continuously seek to improve their skills.
  • Interested in the patient: A genuine curiosity about the patient’s experiences fosters a deeper understanding and better treatment.

McWilliams emphasizes the importance of individualizing therapy based on a patient’s unique personality and level of functioning. By moving beyond the limitations of the DSM and adopting a psychodynamic approach, therapists can provide more effective and meaningful support.

Note: This summary provides a brief overview of key points. For a more comprehensive understanding, watching the full lecture is recommended.

Childhood Sketches: Understanding and Treating Childhood Trauma

This presentation was given live in Singapore at the National Counselling and Psychotherapy Conference on 21 November 2023.

This presentation took me months to plan. I was inspired to participate in the conference by my clients’ artwork.

Along the way, I heard this old song, “Anak” by Freddie Aguila, which inspired the experiential work and the poetry at the end.

Helbig-TRAUMA-SG-NOV2023-5

Francesetti: Gestalt Therapy, an Engine of Change.

This lecture was given by Gianni Francesetti in Madrid on 22nd Sept 2023 at the European Association of Gestalt Therapy conference.

This article is a work in progress…. These are my notes and personal reflections on this lecture.

@ 10:30 On the topic of “Boring.

Francesetti begins by explaining that he has tried to make his speech less “boring”. He then says, “Boring is not so bad, maybe.”

He will mention this phenomenon of boredom — which I find noteworthy due to personal experiences as someone who often gets bored myself and working with clients who feel chronic boredom as a practitioner — later on in this lecture.

Field perspectives in Gestalt therapy: there is a growing interest in the field perspectives in the current psychotherapy universe. This has much to do with current clinical issues. Frank Staemmler (2006) writes about the concept of ‘field’.

What does “Field” mean? Is it different for each person, or is the feel a “common” dimension?

@13:15 The speaker mentions that different people use the term “Field” differently, and even the same author may use different meanings of the word field, that a definition needs to be made. I tend to think that perhaps this is precisely what the term is about. The field is an all-encompassing concept, and all meanings of the word field are valid and useful to psychotherapeutic work.

@13:59 Is the field different for each person or is it a common dimension in a given situation?

The field as organism-environment contact/unity, and the key historical influencers to the concept of field theory in Gestalt psychotherapy.

@ 35:20 What are the clinical issues we are facing today?

Case study

Psychopathology, just like life, is a fractal.

References

Francesetti, G. (2023). Gestalt therapy. An engine of change. Lecture EAGT Conference on 22 Sept 2023. Madrid. retrieved from https://youtu.be/dSIGs2bbwGU?si=cQGEKwFSDBMZFTbo&t=506

Staemmler, F. (2006). A Babylonian Confusion?: On the Uses and Meanings of the Term ‘Field’. British Gestalt Journal15(2), 64.

Treatment of Compulsive Sexual Behaviour Disorder (CSBD): A Gestalt Therapy approach

Introduction

Out-of-control sexual behaviour was documented as early as the 3rd century by St Augustine and later from the mid-18th century by medical pioneers such as Benjamin Rush (1745–1813) and sexologist Richard von Krafft-Ebing (1840–1902). Krafft-Ebing observed one patient suffering:

To such an extent that permeates all his thoughts and feelings, allowing no other aims in life, tumultuously, and in a rut-like fashion demanding gratification and resolving itself into an impulsive, insatiable succession of sexual enjoyments. This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom, and even his life. (Krafft-Ebing, 1886) (in McKinney, 2014)

Definition of Compulsive Sexual Behaviour Disorder (ICD-11)

Compulsive sexual behaviour disorder (CSBD) is characterised in the ICD-11 (International Classification of Diseases, 11th Revision, World Health Organization, 2018) as,

a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.”

The classification of Compulsive sexual behaviour disorder as an impulse control disorder is being debated. Some in the DSM camp, that has not classified this disorder, argue that hypersexuality is more related to addiction than compulsion. We can consider both arguments to be true.

Diagnostic requirements (ICD 11) are as follows:

  • A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour, manifested in one or more of the following:
    • Engaging in repetitive sexual behaviour has become a central focus of the individual’s life to the point of neglecting health and personal care or other interests, activities and responsibilities.
    • The individual has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour.
    • The individual continues to engage in repetitive sexual behaviour despite adverse consequences (e.g., marital conflict due to sexual behaviour, financial or legal consequences, negative impact on health).
    • The person continues to engage in repetitive sexual behaviour even when the individual derives little or no satisfaction from it.
  • The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more).

The patient is not considered to be diagnosed with CSBD if:

  • There is another mental disorder that can better explain the behaviour, e.g. mania, or if the patient’s behaviour is due to drug use or medications.
  • The personal and relational distress experienced is due to moral judgement and societal disapprovements.

Variations of Compulsive Sexual Behaviours and Sex Addiction

There are controversies surrounding labelling behaviours as CSBD and debate over whether the behaviour should be considered a disorder or a moral judgment. Sexual habits become disordered when the relationship to the behaviour becomes a problem to the individual’s life. Compulsive sexual behaviours include dysfunctional pornography use, excessive use of sexual services, chem sex, and sexual acts done indiscriminately with consenting or non-consenting others.

Life Consequences caused by CSBD

Patients who arrive to therapy seeking help to overcome CSBD reveal how seriously their compulsive sexual habits affect their personal lives. They seek therapeutic intervention on their own accord or through the advice or demands from loved ones.

  • Loss of jobs due to porn use at work
  • Legal issues
  • Damaged intimate relationships
  • Negatively affected social standing
  • Diminished libido
  • Sexually transmitted diseases
  • Sexual dysfunction
  • Escort /sex-worker engagement
  • Substance abuse
  • Physiological issues, e.g. insomnia
  • Social isolation, anxiety, depression, self-harming behaviours.

Who are at risk of developing CSBD?

Many individuals with CSBD report having experiences of acting out during pre-adolescence or adolescence, engaging in risky sexual behaviour, masturbation and using explicit material to cope with emotional challenges.

Other factors that have been found to increase the risk of developing CSBD are:

  • Early exposure to sexually explicit material.
  • Early onset of internet use.
  • Childhood sexual abuse.

There are gender differences associated with CSBD:

  • Most clients who report having CSBD are men of all sexual orientations.
  • Women with CSBD usually label themselves as “love addicts”. They are more likely to report having experienced sexual abuse at an early age.

How Addiction to the Compulsive Sexual Behaviour Starts

Hall (2018) categorized broadly the processes in which sexual addictive behaviours are induced in individuals. We can consider that the individual may be influenced through one or more induction processes.

  • Opportunity-induced: with internet pornography accessible with just a mouse click, it becomes the cheapest, lowest-hanging self-soothing treatment choice. Several clients who are addicted to hiring escorts or sex workers report having lived in proximity to brothels and within sex districts as children.
  • The Trauma-induced: children and pre-adolescents discover masturbation as a means of self-soothing and coping with anxiety-triggering home environments.
  • The Attachment-induced: the child learns to cope with loneliness due to percieved neglect or abandonment by primary care-givers by self-gratifying and living in their sexual fantasies. These children are also more likely targets of grooming by sexually-predatory adults.

The psychotherapeutic approach to CSBD treatment needs to be holistic since the source of addictive sexual behaviour is multi-factorial.

How Addictive Behaviour is Reinforced

Psychotherapy with clients dealing with addictions is primarily about getting roadblocks out of the way. These roadblocks impede the client’s ability to break the cycles of addiction. If the client cannot break the cycle, the addiction is reinforced.

Addictive behaviours oscillate between the individual’s need for control or release, in a flip-flop between extreme states of euphoria and despair, avoidance and surrender, self-punishing (guilt) and exhaustion (shame).

Hall (2018) also introduced the six-phase cycle.

The Compulsive Sexual Behaviour Disorder cycle is repetitive, rendering the patient helpless to stop the habit.

This is the compulsion cycle.

There lies in going through this cycle repeatedly, painful feelings of deep-seated guilt and shame. The individual with CSBD is particularly likely to suffer this intensely and alone, keeping the habit out of the scrutiny of others for fear of persecution or being made to halt the habit.

The way out of this psychological pain is for the psyche to form cognitive distortions, like rationalizing, justifying, minimizing the impact, magnifying the need, blaming others and situations for causing them to be addicted, and feeling entitled/deserving of the pleasure, denying the gravity of the behaviour and its potential dangers.

Comorbidity with other Psychiatric Disorders

A recent study in Spain showed that over 90% of CSBD participants met the criteria for at least one Axis I disorder, compared to 66% of non-CSBD participants. CSBD participants were more likely to report an increased prevalence of alcohol dependence (16.2%), alcohol abuse (44%), major depressive disorder (39.7%), bulimia nervosa (5.9%), adjustment disorders (20.6%), and other substances –mainly cannabis and cocaine– abuse or dependence (22.1%). The prevalence of borderline personality disorder was significantly higher in CSBD participants (5.9%). (Ballester-Arnal et al., 2020).

Neural Correlates of Compulsive Sexual Behaviours

Voon et al. (2014) provide a study of the neurobiology of CSBD in this article.

Through fMRI brain imaging comparison studies of CSBD and healthy subjects, they were able to draw the following confirmation and conclusions:

  • That the neural circuits that govern the reward processing in compulsive sexual behaviour and substance dependency overlap.
  • That the CSBD group, compared to healthy individuals, had higher “desire” but similar “liking” scores when exposed to explicit sexual material.
  • Exposure to sexually explicit cues in CSB compared to non-CSB subjects was associated with activation of the dorsal anterior cingulate, ventral striatum and amygdala.
  • Functional connectivity of the dorsal anterior cingulate-ventral striatum-amygdala network was associated with subjective sexual desire (but not liking) to a greater degree in CSB than non-CSB subjects.

In CSBD subjects, there is evidence of a dissociation between desire (or wanting) and liking towards sexually explicit material. This split is a consistent phenomenon associated with drug addictions.

“Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy the biological craving in the brain” and is not correlated with high sex drive (Hall, 2018, p. 7). The motivation for such behaviour is to dissociate oneself from reality and the painful feelings that are present in it.

This demonstrates the splitting that exists in subjects with CSBD.

Gestalt Therapy for Treatment of Compulsive Sexual Behaviour Disorder

Considering the conditions and phenomena around CSBD, Gestalt therapy is arguably a model psychotherapeutic method for treating CSBD. Gestalt therapy, more evident than other modalities, directly addresses intra-psychic splitting mentioned in the above section. Therapeutic work revolves around integration. Integrative Gestalt therapists adopt a holistic approach when working with clients.

Gestalt Awareness Continuum approach and Contact Interruption in CSBD

Dissociation points us to realise the impact of trauma, particularly childhood trauma, on clients.

In Gestalt Therapy, we stay in contact with the client by being attentive to the interruptions in the contact cycle. This therapeutic philosophy is more effective than trying to get the client out of or breaking the compulsion cycle. This is the way to therapeutic change, even though the client who is desperate to break the cycle may not appreciate this.

The Therapeutic Contact begins before the Beginning.

This is also known as the pre-contact phase.

Clients approaching us for therapy may or may not pose CSBD as a presenting issue. There are possible reasons for this:

  • There are more pressing issues that are at the forefront of their minds,
  • The client is in denial that the habit causes dysfunction,
  • The shame of revealing the habit.
  • Fear of persecution.

As therapists, we can be alert to the possibility of CSBD being presented to us later in therapy, which happens when the client feels secure enough in the therapeutic alliance.

The first meeting is very important even though its significance is often overlooked or overshadowed by intake matters. This is the point when the therapist encounters the field of the client. It is like the moment we touch a bucket of cold water. The moment before our organism adjusts to the differences. In this pre-contact phase, we sense the client’s existence most acutely as foreign to ours. The fertile void lies amidst this differentiation.

The Paradoxical Theory of Change in the Treatment of CSBD

We acknowledge the sense of urgency when clients approach psychotherapy to “fix” their addictions. The therapist often feels drawn to this strife. Our first instinct is to yearn for a solution, knowing that diving to “solve the problem” is not the solution. Beisser’s (1970) Paradoxical Theory of Change, a cornerstone of Gestalt therapy theory, becomes an invaluable resource. Biesser adds, (b)y rejecting the role of change agent, we make meaningful and orderly change possible.”

This does not mean therapists do not care if the client overcomes the addiction. We do, as that is the working contract. It means that therapists do not position themselves as the “maker of change”.

The client overcomes an addiction, and in this case CSBD, in a therapeutic change process of self-actualization. Self-actualization is the holistic embodied shift a person experiences almost unconsciously, sometimes spontaneously. This phenomenon happens with clients in therapy for a period of time. Perls explains that we cannot make ourselves self-actualize as it is not an active process:

[W]e realize that we cannot deliberately bring about changes in ourselves or in others. This is a very decisive point: Many people dedicate their lives to actualize a concept of what they should be like, rather than to actualize themselves. This difference between self-actualizing and self-image actualizing is very important. Most people only live for their image. Where some people have a self, most people have a void, because they are so busy projecting themselves as this or that. This is again the curse of the ideal. The curse that you should not be what you are. (Perls, 1969 p.39)

As Gestalt therapists, we are aware of this change process. Our work is to support change through working with the client. The client self-actualizes within the field of the therapeutic relationship. Changes in the field actualize the field, bringing about change to the individuals within it.

Psychopathology is a Phenomenological Process in Gestalt Therapy

Psychopathology is a process. It is not the same as using a diagnostic manual and questionnaires to diagnose a patient and then telling the patient what ailment they suffer from.

Psychopathology is process.

Psychopathology relies upon the following:

  1. Observing while avoiding theoretical explanations, presuppositions and prejudices, confining ourselves to the presenting phenomenon in the therapeutic encounter, and
  2. The attempt to use empathy as a clinical instrument ‘to recreate in the psychopathologist the subjective experience of a patient to obtain a valid and reliable description of his experience.’ (Stanghellini & Fuchs, 2013, p. xviii)


Psychopathology is conceptualised as a process in psychotherapy of bringing to light and making palpable the essence of the suffering of the client. It is through this “en-lightening” or illumination process that therapeutic change can be effected. This process is integral to therapy. It is the therapeutic contract, exists in the therapeutic alliance, and is responsible for therapeutic change.

Gestalt therapy engagement in the phenomenological field persuades the therapist to focus on the process of psychopathology and to perceive the atmosphere of the co-created field of the therapy situation. Through this process, we uncover pathos and painful emotions from trauma while being present with the clients in the here and now. In working with clients with CSBD, this process is crucial for understanding/validating the underlying triggers and suffering the client avoids through addiction.

Shame, Guilt, Despair and Helplessness in the Co-created field

CSBD suffer the pain of shame due to their condition more than any other addicts. Working through shame is fundamental to therapeutic work and is even more crucial when clients struggle with CSBD.

Working with shame in therapy, there needs (Yontef, 1996),

  • Empathic understanding of the patient’s experience with shame
  • Assist the client in understanding this experience fully.
  • Showing warm understanding, acceptance and respect.
  • To heal shame, the therapist must understand shame. The therapist must understand this in the context of the patient.
  • The therapist must be committed to dialogue (Buber, 1970/1936).
  • Hold the client in unconditional positive regard.

Shame is an emotion that holds together the therapeutic alliance when brought into the open. It becomes part of the co-created field. Despair, on the other hand, threatens to break the alliance. This is especially so in work with addictions. Despair is the feeling of resignation and disappointment, especially when relapses happen. Resignation is the sense that there is no hope of resolving the problem, followed by disappointment in the therapy. Recognizing the possibility of despair early in the therapeutic process is helpful.

Creative Indifference as Central Attitude when working with CSBD

Salomo Friedlaender’s “Creative Indifference,” also known as “Schöpferische Indifferenz,” was published in 1918 and is considered a seminal philosophy of Gestalt therapy. Creative Indifference incorporates philosophical values that serve as the bedrock for humanistic psychotherapy approaches like Gestalt therapy:

  • “Creative” = to make something exist out of a void.
  • “Indifference” = to be unbiased, to be present without agenda.
  • Holism = to perceive wholes as more than the sum of parts.
  • Inter-subjectivity = the co-creation of the field.
  • Intentionality (including creative will and decision-making), and
  • Nondualism (emphasising exemption from isolation).
  • The Creative pathos.
  • Creative relatedness.
  • Authentic self.

Read more: Understanding Salomo Friedlaender’s Creative Indifference and The Fertile Void

Polarities as depicted in Zinker (1977).

These values ground the therapist working with CSBD clients. The nature of the pathos in CSBD is compulsivity, guilt and shame, alternating with bouts of despair and helplessness. These feelings exist within the co-created therapeutic field. The therapist will experience these feelings. It is the work of the therapist to willfully attune to the phenomenon of the field and to grasp the feelings that exist in the atmosphere of the therapeutic situation. Creative indifference acknowledges a fertile middle point between polarities (and differences) where contact exists.

Conclusion

CSBD is a complex psychological and physiological challenge to work with clients through in psychotherapy. Shame is an individual’s predominant experience with the disorder, leading many clients to avoid the subject at the beginning of therapy. A contactful therapeutic alliance built on solid footing initiates the treatment process.

The therapeutic change process is organic and progressive. Focussing the work on the abstinence of behaviour alone does not promise a positive outcome of treatment. Therapeutic change depends on the ability of both client and therapist to stay with the process and have the patience and faith to see through cyclical moments of complicated feelings of shame, guilt, and despair. This involves trauma work as well. Feelings of despair usually cause either party in the alliance to give up on the work. The client may despair upon relapse, and the therapist may feel helpless when confluent with the client.

CSBD is a diagnosis categorized only recently in the ICD-11. Having CSBD defined in diagnostics is crucial to recognising and treating the disorder. Clinical diagnosis alone, however, is useless to the therapist. The therapeutic process involves the unearthing of the pathos /or suffering/ trauma that underlie the symptoms. This is the process of psychopathology, which requires sensitivity to uncover and make graspable these feelings, or pathos. Following which, something shifts in the system.

Gestalt therapy engages the phenomenon of the co-created field. This is an ideal philosophy for treatment as it is in the field that the psychopathology in the field comes to the foreground and is witnessed. This works best in the treatment of CSBD, since the behaviour is a dissociative, self-soothing mechanism, which can be “unlocked” only when the client is able to grasp the mental suffering from which they are soothing themselves with the behaviour.

Case Study of “John”

Case study of “Businessman John” 40, was presented in the talk on 4 Mar 23 to DRM (Derimu) Psychological Education, 德瑞姆无形完形俱乐部, China (https://www.deruimu.com/).

References

Ballester-Arnal, R., Castro-Calvo, J., Giménez-García, C., Gil-Juliá, B., & Gil-Llario, M. D. (2020). Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive behaviors107, 106384

Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now1(1), 77-80.

Buber, M. (1936/70). I and Thou. Kindle ed. (W. Kaufman, Trans.) Charles Scribner’s Sons.

Frambach, L. (2015). Philosophie, Mystik, Psychotherapie. Die Bedeutung Salomo
Friedlaenders für die Gestalttherapie. In D. T. L. Frambach (Ed.), Friedlaender /
Mynona und die Gestalttherapie. Das Prinzip “Schöpferische Indifferenz. EHP.

Hall, P. (2018). Understanding and Treating Sex and Pornography Addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them. Routledge.

Lee, R. G., & Wheeler, G. (2013). The voice of shame: Silence and connection in psychotherapy. Gestalt Press.

McKinney, F. (2014). A relational model of therapists’ experience of affect regulation in psychological therapy with female sex addiction (Doctoral dissertation, Middlesex University/Metanoia Institute).

Perls, F. (1969/1992). Gestalt Therapy Verbatim. The Gestalt Journal Press. Kindle Edition. (p. 93)

Stanghellini, G., & Fuchs, T. (2013). One century of Karl Jaspers’ general psychopathology. (G. Stanghellini, & T. T. Fuchs, Eds.) Oxford University Press.

Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … & Irvine, M. (2014). Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one9(7), e102419.

World Health Organization. (2018). International Classification of Diseases, 11th Revision. URL: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054

Yontef, G. (1996) Shame and guilt in Gestalt Therapy. In R. Lee & G. Wheeler (Eds) The Voice of Shame. San Francisco: 390. pp. 370-371.

Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.

Transitioning. This is an important interview.

This is a necessary, informative interview for all involved; candidates who are seeking gender reassignment surgery, their family members, and their therapists. Deal with the underlying psychopathology first. Take no irreversible medical measures till the mental health issue is resolved.

Gestalt Therapy: The Paradoxical Theory of Change

Since its founding, Gestalt therapy has been at odds with the dominant medical and psychiatric paradigm of therapeutic change. In the 1970s and early days of its development, the founders of this therapeutic modality, Fritz & Lore Perls and Paul Goodman crystallized the concept of change in psychotherapy through the work of Arnold Beisser, who named this theory the Paradoxical Theory of Change.

“[T]hat change occurs when one becomes what he is, not when he tries to become what he is not. Change does not take place through a coercive attempt by the individual or by another person to change him, but it does take place if one takes the time and effort to be what he is – to be fully invested in his current positions. By rejecting the role of change agent, we make meaningful and orderly change possible.

Beisser (1970)

Humanistic and existential approaches to psychotherapy emphasize the movement in the here-and-now in the therapeutic relationship. The therapist does not assume the role of fixer or changer but pays attention to the existential meeting with the client. Attunement to the therapeutic situation enables the client and therapist to study and appreciate the phenomenon of their co-created field, which is the physical and emotional environment. In this environment, suffering (or pathos) is felt, grasped and seen. This process of inquiry into pathos is the essence of psychopathology.

People do not change by trying to be who they are not.

Change does not happen through striving or coercion—the person who abandons attempts to disown parts of themselves and tries to change experiences the shift. Hence the paradox, to change, one first seeks to refrain from jumping into influencing change.

The person seeking change in therapy is in conflict, constantly thinking of moving between what they “should be” and what they think they “are”. This dichotomy of personhood is brought to light experientially in therapy. From staying with the discord, the client finds integration.

The Gestalt therapy process is experiential. We use experiments so that clients can learn with an embodied experience. The embodiment of the experience kicks of a cascade of real, percievable change, where the split parts of the self is actualizes into an evolved version. Perls alludes to this spontaneous change in this passage:

[W]e realize that we cannot deliberately bring about changes in ourselves or in others. This is a very decisive point: Many people dedicate their lives to actualize a concept of what they should be like, rather than to actualize themselves. This difference between self-actualizing and self-image actualizing is very important. Most people only live for their image. Where some people have a self, most people have a void, because they are sobusy projecting themselves as this or that. This is again the curse of the ideal. The curse that you should not be what you are. (Perls, 1969 p.39)

Reference

Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now1(1), 77-80.

Perls, Frederick (Fritz). (1969/1992) Gestalt Therapy Verbatim (p. 93). The Gestalt Journal Press. Kindle Edition

Introducing the Aesthetic Turn in the field of Psychotherapy

Aesthetic knowledge (also known as tacit knowledge) attained through our lived and sensory experiences. Interest in aesthetics in psychotherapy practice and research is borne out of the search for an alternate method of knowing and knowledge processing. The transmission of aesthetic knowledge has created interest in the qualitative research field for art-based research methodologies like Autoethnography, which I have adapted for the inquiry into the psychotherapeutic process. The turn towards aesthetic knowledge helps us fill in knowledge gaps left behind by decades of positivistic thinking that had dominated research and, inadvertently, training. Postmodernists are more interested in conveying knowledge and overcoming problems of representation and form or the poetics of knowledge-making. Aesthetic inquiry finds value in all field-based, cultural and sociological research, including psychotherapy and organisational development. Aesthetics relates to the study and attunement of the researcher to the atmosphere of the environment, images and perceptions, artefacts, ideas, symbols and culture of the investigated field.

Descartes believed in the power of detached intellectual thinking, but Vico (1744/1948) and Baumgarten (1750/1936) disagreed. They argued that knowledge is more about feelings than cognitions. Vico believed that we create meaning through our senses, and called this “poetic wisdom.” Baumgarten believed that logic studies intellectual knowledge, while aesthetics studies sensory knowledge. This type of knowledge is directly experienced through our five senses. Nietzsche and other philosophers later agreed that aesthetic knowledge is not only a separate way of knowing, but that other forms of knowledge depend on it. Aesthetic knowledge offers new insights and awareness, even though it can’t always be put into words. It’s an embodied, sensory knowing that is often contrasted with intellectual knowing.

The word aesthetics is derived from Greek aisthētikos, which means ‘perceptible things’ and from aisthēta, which means ‘to perceive’. Aesthetic evaluation is a pre-reflexive and preverbal process of sensing the atmosphere of a situation. The atmosphere, the atmos, the exhalation of vapour and the globe is a meteorological term denoting the gas surrounding the planet we constantly touch. The emotions or reactions from interacting with the atmosphere are not personal or internal but shared in a boundless space where the perceiver participates. Atmospheres are inter-subjective and holistic feelings poured out into a certain lived environment (Giffero, 2010/2014, p. 6). Philosopher Schmitz (2003) considers feelings as atmospheres, not subjective moods projected outwards, but affect that fills up the spatial situation with which the individual perceiver gets involved and identifies the self. “‘My sadness’, in fact, implies ‘not that I possess it, Hold it or perform it’, but only that ‘it hits me, regards me, touches me in the flesh’ (Schmitz, 2003, p. 181). The concept of the atmosphere is ambiguous and loses meaning when one tries to put it into words. Atmospheres are hard to define and must be experienced to be understood. Perceiving the atmosphere means capturing a feeling in the surrounding space and being moved by something beyond what can be proven. The atmosphere is a shared space that is difficult to pin down but is integral to how we connect with others and the environment.

Aesthetic sensing and knowledge are implicit in psychotherapy practice and training, even though this fundamental fact is not well represented in psychotherapy Embracing aesthetics in psychotherapy expands our ability to fully grasp the suffering of our clients, which is the essential process of psychopathology. Being attuned to psychopathology establishes a connection between therapist and client crucial for therapeutic change. This approach allows therapists to move beyond the traditional psychiatric diagnosis of disorders, which often views clients as isolated individuals with symptoms. This narrow perspective can be limiting and problematic in practice. Instead, diagnosing through aesthetics encourages therapists to consider the client’s subjective experience and to view them as a whole person. Each person brings their perspective to the therapeutic encounter, and the relationship between therapist and client creates a unique field of interaction. Using the term phenomenology, as proposed by Karl Jaspers, emphasizes the importance of the client’s subjective experience in understanding their pathology. This approach de-objectifies the client and highlights how informed diagnosis and psychopathology are integral to the therapeutic encounter, underlying the rift between practice and research that has plagued the field for decades.

Read more on Therapeutic Autoethnography

Reference

Baumgarten, A. G. (1750/1936). Aesthetica. Bari: Laterza.

Giffero, T. (2010/2014). Atmospheres: Aesthetics of emotional spaces. (S. d. Sanctis, Trans.) Routledge.

Schmitz, H. (2003). Was ist Neue Phänomenologie? Koch: Rostock.

Vico, G. (1744/1948). The New Science of Giambattista Vico. Trans. Bergin, T. G. and Fisch, M. H. Ithaca, NY: Cornell University Press.

Compulsive Sexual Behaviour Disorder in Psychotherapy

Compulsive Sexual Behaviour Disorder (CSBD) is also known as hypersexual disorder, and sexual addiction has been included in the World Health Organization’s International Classification of Diseases (ICD-11) #6C72, which indicates the awareness and perhaps the increased prevalence (current estimate is about 5%, and it could be higher) of this condition in today’s society.

Definition of Compulsive Sexual Behaviour Disorder

Classified as a subset of impulse control disorders, CSBD is described in ICD-11 as: characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

Behaviours associated with CSBD include repetitive sexual behaviour with others or alone, masturbation, the use of sexual services, pornography and cybersex, telephone sex, chemsex and deviant sexual behaviour like voyeurism and taking upskirt pictures, which often gets the sufferer in trouble with law enforcement. The sexual urges are intense, rendering the sufferer helpless at controlling them. The sexual arousal, sexual fantasies and encounters are addictive, taking control of the lives of the person. It is important to note that the behaviours alone do not constitute a problem or an addiction, but the relationship to these behaviours.

Many sufferers report an early onset of impulsive or risky sexual behaviour, beginning during pre-adolescence or adolescence, with a number reporting having stumbled onto and having used porn from an early age. The behaviour often starts off hedonistic, but later on functions as a self-soothing mechanism against mental pain, negative affect, anxiety and depression. The individuals use the high to anaesthetise themselves from feeling negative emotions and emotional pain. The typical porn addict, for example, spends hours online scanning porn sites in an effort to escape reality while keeping themselves in an aroused mental state.

CSBD has consequences for its sufferers and the people close to them. The ramifications range from financial and career failure, breakdown of relationships, sexually transmitted infection and even incarceration. These consequences add to the emotional toll. The shame of having these urges and the potential toll on intimate relationships lead the person to live a parallel secret life, alienating them and crystallising the addiction to the behaviours.

CSBD happens in men and women. While men may report CSBD, women tend to frame the condition as love addiction, often reporting childhood sexual abuse trauma.

Practitioners need to differentiate CSBD from other patients who have feelings of shame and guilt about sexual activity due to moral or religious conditioning, or those who experience fear of consequences resulting from sexual activity. These individuals may inadvertently label themselves inaccurately. It is important for the practitioner to find out if the self-diagnosis is the result of self-judgement, or if there is an impairment.

Some sexual impulses and behaviours are transient. Life transitions and experiences may trigger sexual urges. CSBD should not be diagnosed in individuals who experience only brief episodes of increased sexual activity. One needs to take into account the context in which the person is living before making such a diagnosis.

Practitioners also need to take cultural and religious differences into account when considering this diagnosis.

Differentiation of Compulsive Sexual Behaviour from Sexual Desires and Libido

Patients who suffer CSBD generally complain about suffering sexual dysfunction. We may be able to explain this by considering the dissociative state in which the individual falls into or is on the edge of during the triggers. “Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy biological craving in the brain.” (Hall, 2018) The clients whom I have seen generally encounter sexual dysfunction and low libido.

Neuroscience of Compulsive Sexual Behaviour Disorder

Impulse control disorders as well as addictions appear in brain fMRI scans. In the brains of a sample of individuals who experience CSBD, there appears to be a greater left amygdala grey matter volume and reduced resting state functional connectivity between the left amygdala see and bilateral dorsolateral prefrontal cortex compared to healthy volunteer samples (Schmidt et al, 2017).

Psychotherapeutic Approach to Compulsive Sexual Behaviour Disorder Diagnosis

My therapeutic approach to treating Compulsive Sexual Behaviour Disorder involves a 3-pronged attitude at viewing psychopathology: 

  1. The mono-personal paradigm of diagnosing follows the dominant paradigm of clinical psychotherapy and psychiatry. It views the client’s suffering in isolation and uses third-person descriptive diagnosis and clinical work. This paradigm relies on the client to change independently. The mono-personal approach involves facilitating emotional and sensory awareness, and trauma therapy.
  2. The bi-personal or relational paradigm sees the relationship co-created by the therapist and client, who jointly produce change through their alliance. The therapeutic alliance provides a safe setting for clients to process feelings of shame and guilt experienced.
  3. The field-based paradigm is unique to Gestalt therapy. This paradigm attunes to the atmosphere, sensing the aesthetics of the therapy situation and looking beyond the individuals. Suffering is perceived, and change is co-created. The field-based paradigm requires the therapist to put attention to the “vibe” of the therapeutic alliance. In the atmosphere of the field, the pathos or suffering is felt and brought to the surface.
Figure 1. the three paradigms of psychotherapy and diagnosis

All three paradigms are relevant to the work. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychopathology is the study of the suffering that is the basis of the client’s symptoms. This process is continuing even though a clinical diagnosis has already been made.

Gestalt Therapy understanding of CSBD

CSBD and most compulsive behaviours can be explained as contact interruption due to dissociation. Below is a schematic diagram of the awareness cycle:

An explanation of this concept of the contact cycle of awareness can be found in this article.

In CSBD, the interruption seems to happen as a deflection from sensing, just as the trigger of stimulus is about to be sensed. The individual who is not able to tolerate sensing the stimulus dissociates and the awareness is interrupted.

The dissociation triggers hyperarousal which is a physiological reaction that leads to intense stress which leads to a need for release, which is the compulsive behaviour.

Whenever dissociation is identified, we become aware of trauma, in particular childhood trauma, which the client would need to be worked through in therapy. The effect of dissociating can be described in Gestalt therapy terms as the loss of ground, or being on shaky ground where figural experiences fail to form.

At the heart of the treatment of CSBD is ultimately trauma therapy. To support the process, the client is supported through experiments in awareness and accessing core beliefs. The premise of the therapeutic process is to guide the client out of dissociation and facilitate their awareness in the continuum.

References

Hall, P. (2018). Understanding and Treating Sex and Pornography Addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them. Routledge.

Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior: Prefrontal and limbic volume and interactions. Human brain mapping38(3), 1182-1190.

Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.

How does Psychotherapy Work? General Systems Theory and Synchronization

How do we explain the transformative work of psychotherapy? The therapist and client of the psychotherapeutic encounter do not exist in an isolated bubble; both exist integrated with the environment we call the field. The field encompasses the biological, psychological, physical and sociological environment in which the therapist and client are embedded. The psychotherapy situation is in constant flux with the field. Psychotherapy is an open system.

Change in psychotherapy is complex, non-linear, and perceived as organic. The psychotherapy profession has long understood this concept, which differs from the paradigm of the broader field of the medical model of healing that views the patient as a unique entity disconnected from the environment.

The medical model approach considers the patient and their issues unique to the individual, often ignoring the environmental contribution to the patient’s suffering. The patient sees the medical professional and gets treated for their symptoms. Usually, the patient is offered medication to relieve symptoms, and healing is expected to happen spontaneously. Sometimes healing does not occur, but just an alleviation of suffering. Diagnosing and treating the patient this way is the mono-personal approach to therapy.

The figure below illustrates the different dimensions ‘ways of seeing’ psychopathology (suffering and symptoms), treatment and diagnosis in therapy. The relational attitude is adopted by contemporary psychotherapeutic schools, where the study, focus and treatment is experienced in the therapeutic relationship.

Three different attitudes and focus on treatment and diagnosis: 1) the mono–personal attitude where the client and their suffering is attributed to the individual alone disregarding the environment, 2) the relational where the client’s suffering is encountered and treated within the therapeutic relationship, and 3) the field theory, or the aesthetic attitude where the client is treated as a co-creator of the field.

The field theory is unique to Gestalt therapy. Contemporary Gestalt therapists have attuned themselves to investigating psychopathology and therapy even further by looking at the aesthetics of the co-created field.

A Gestalt therapy perspective of psychopathology is necessarily grounded in a field epistemology. The field concept enables us to understand experiential phenomena as being emergent from a dimension that cannot be reduced to the individual, or to the sum of individuals at play. Every relational situation actualises a new, original field. Subjective experience is not the product of a single mind or isolated individual; it is an emergent phenomenon of the actualised field.

Francesetti, 2015

The co-created field encompasses the client and therapist in their bio-psycho-social environment and is unique to the encounter. Read also: Notes on Field Theory in Gestalt Therapy. Field theory renders the therapeutic encounter an open system. Neither is the client treated as an individual nor is the therapeutic situation treated as separate from the outside world. The field theory includes everything relevant to the here-and-now of the therapeutic session. Attunement to the field involves noticing and focusing on the atmosphere of the therapeutic situation. Change is effected through the field. Movement in the field facilitates meaningful psychotherapeutic change and transformation.

As we consider the concept of the co-created field in psychotherapy, we will also realize that psychotherapy is an open, dynamic and complex system.

General systems theory

Notes on how psychotherapy works based on dynamic systems theory or general systems theory.

General Systems theory is an interdisciplinary practice applied to many fields of sciences, including cybernetics and biology. The concept was published in 1934 by Austrian biologist Karl Ludwig von Bertalanffy (1901-1972), who proposed that the classical law of thermodynamics, which applies to closed systems, has limited relevance to open systems (Wikipedia, 2020).

The phenomenon of Synchronization

The videos below demonstrate the phenomenon of synchronization. Unique objects with their own stable pattern, influence the co-created environment, causing their own patterns to change.

Two metronomes are placed on a common base. The metronome on the left is set at 192 beats per minute. The one on the right is set at a slightly lower rate. The metronome pendulums are initially out-of-phase. The two pendulums oscilate in phase due to conservation of momentum and coupling via the base. A true physics masterpiece!

This is another example with the use of several metronomes, each with their own temporal settings. After a while, all metronomes sync together.

This video illustrates the temporal synchronization of metronomes coupled via a common ground plate. This (well-known) phenomenon goes back to the observations of Christiaan Huygens (die Pendeluhr: Horologium oscillarium, 1763). Timeline: 0:00 – Setup and “What’s going to happen?” 0:21 – Synchronization from arbitrary positions 1:04 – Re-synchronization after disturbance

Synchronization happens in biological systems. All biological systems are attracted to the field which guides their growth and movement.

We know a lot of factual information about the starling—its size and voice, where it lives, how it breeds and migrates—but what remains a mystery is how it flies in murmurations, or flocks, without colliding. This short film by Jan van IJken was shot in the Netherlands, and it captures the birds gathering at dusk, just about to start their “performance.” Listen well and you’ll be able to hear how this beautiful phenomenon got its name.

Psychotherapy and General / Dynamic Systems Theory

Psychotherapy is an open complex system, like all biological systems and groups. Open complex systems are self organizing, and creatively adjust to their environment. They dynamically change with time. This change is continuous and non-linear.

Open systems oscillate dynamically and try to find stability. Transformative change involves the process of deconstruction, reorganization and reconstruction. In psychotherapy, pathos or suffering is sensed, grasped, and brought to the surface. The client learns to frustrate old patterns by attempting behaviour change and meeting the therapist at the contact boundary. This process can happen through experimentation and (sometimes accidental) confrontation of transferences.

The client’s “pathological” situation is an autonomous pattern formation, which the client would like to change. This pattern is, however, a stable pattern that has developed through life experiences and trauma. It is a meaningful pattern, though often dysfunctional that the individual has adapted to since childhood. In psychopathology, some patterns have more severe consequences for the person, like obsessions and compulsions, and anxiety. In less severe states, the individual suffers setbacks in relationships due to personality and unstable attachment styles. This pattern is played out in therapy and felt in the field. The attuned therapist can grasp how the therapy situation impacts them in the co-created field with the client.

In therapy, the client’s pattern is challenged. The challenge brings about resistance. We can say that the old pattern repels this challenge. The client may get used to this challenge and change. This may manifest as the ability for the client to attend therapy as a routine. This initial influence of therapy on the client is the first -order change. Here lies a comfortable synchronization in the field.

Transformation happens at the second-order change. This process takes time. The second-order change is the lasting permanent change of the pathological pattern. Second-order change requires the deep modification of the system’s way of functioning. In Gestalt therapy, this is a phase of change called the impasse. Read also: Gestalt Theory: 5 Phases of Therapeutic Change. When the client can stay in therapy long enough to find themselves in a situation of the impasse, which is often an uncomfortable state, a transformation phenomenon happens. At this stage, there is a re-synchronization, and the new pattern becomes stable. The client experiences a shift.

In trauma therapy, the synchronization that happens in the therapeutic encounter is also a physiological one. The therapist provides the client with a safe space and a centred presence in the therapeutic field. The client who shares the field, like the opposing metronome in the videos above, begins to operate in sync with the therapist.

Therapeutic change and transformation works through synchronization, and this involves the passage of time. Psychotherapy is a powerful resource that offers deep organic change and psychotherapeutic treatment. Shortcuts and quick fixes has never been the premise of psychotherapy.

On the lighter side…

Want brief therapy? This is what it looks like…

References

Francesetti, G. (2015). From individual symptoms to psychopathological fields. Towards a field perspective on clinical human suffering. British Gestalt Journal24(1), 5-19.

Ludwig von Bertalanffy. (2022, November 20). In Wikipedia. https://en.wikipedia.org/wiki/Ludwig_von_Bertalanffy