Trauma: Symptoms of Dissociation and Treatment

The DSM describes main feature of dissociation as a disruption of memory, consciousness and identity or perception. Dissociation is a protective mechanism. Human beings have at their disposal to survive traumatic events.

Abusive painful experiences and memories are put away into isolated compartments in the mind, and separated from regular memories.

Read also: Traumatic and Non-Traumatic Memories

Dissociation is a way the mind organizes information

Dissociation refers to a compartmentalization of experience: elements of an experience are not integrated into a unitary whole but are stored in isolated fragments (van der Hart et.al., 1998).

Exposed to trauma, the mind splits. The part of the brain that continues with the daily functioning of life (the left brain), and the emotional part of the self that holds the traumatic memories (the right brain) and its survival impulses of the moment of trauma becomes unintegrated with each other. This leaves the person with a split sense of self.

In trauma, the left and right hemispheres of the brain becomes more split and less integrated.

Experiencing a split sense of self can be disturbing. To notice the phenomenon as it happens is to gain agency.

The disruption of integration of the hemispheres of the brain leads to the experience of feeling something and “not making sense” of the feelings. The feelings come in the form of emotions, perceptions or physical pain.

The experience of not making sense of what one feels, can be disturbing. As human beings we need to make meaning and understand things about ourselves to feel safe. When such splitting occurs, the trauma survivor experiences blankness and confusion. This contributes to more insecurity. Oftentimes the need to make meaning results in thoughts that are paranoid in nature, intrusive and/or obsessive.

In therapy, clients are guided to 1. first identify the feelings and sensations that make no sense, 2. accept these feelings without making meaning. 3. observe the nature of thoughts that arise from attempt to make meaning, and 4. allowing these sensations to pass (through relaxation or somatic exercises). Each of these steps are tedious and challenging, needing full attention of both therapist and client. This is also solid mindfulness work. The result is the client gaining of agency of the self.

Splitting leaves the client fragmented into parts of personality. As different times the person’s right brain may trigger experience in him/herself a part that is raging and wants to fight or take revenge, a part that is terrified, a part that is ashamed, a part that is needy and/or a part that wants to run away. When these parts are traumatized, they feel out of control.

The left brain engages the other parts of the person that wants agency. These parts manage daily function, the part that is sociable, and the part that is responsible.

Noticing split-off and traumatized parts

One can notice that splitting has occurred through phenomena like experiencing chronic inability to make decisions, continually relapsing into addictive behavior, having intrusive emotions that seem to arise out of nowhere, intrusive thoughts, shifts in mood or behavior, going numb, getting hyper-aroused, collapsing, feeling suicidal, hearing voices, loss of ability to connect with others, difficulty communicating, withdrawal from society, feelings in the body and somatic symptoms that are not based on medical logic.

There are different severity levels of dissociation

Dissociative symptoms can be severe in some people to a point of rendering them incapacitated. Many individuals, however, experience dissociative symptoms, and are still able function and be successful in life.

Treatment of dissociative symptoms with therapy in functioning individuals is a measure to keep the person healthy and functioning. While we can cope with dissociative symptoms, these symptoms do not disappear on their own. Symptoms get worse with age, and are exacerbated by crises in life. This is why and how some seemingly functioning people experience sudden psychological breakdown.

Signs to look out for in functioning individuals

It is clear that severe dissociative symptoms require professional attention. Less obvious or hidden signs of dissociation are worth noticing: 1. difficulties putting things together, not being able to remember conversations, forgetting appointments, or inability to recount coherently what happened in certain situations, 2. experience of doing things that does not seem to add up, like having sexual relationship with someone one finds unattractive, 3. having unexplained chronic pain or somatic symptoms, 4. chronic experience of stuck in life, 5. experience of identity confusion, 5. experience of self-harming or suicidal thoughts.

Therapy that focusses on mindful observation of these symptoms, its triggers and the trauma underlying lead to successful outcome in providing clients with agency over his/her life.

Bibliography

van der Hart, O., van der Kolk, B. A., & Boon, S. (1998). Treatment of dissociative disorders.

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Psychological Trauma: Types and Symptoms

Psychological trauma is a person’s experience of one or more events that is too overwhelming for the person to emotionally, physically and intellectually react to, and integrate into his/her memory and sense of self. The experience is that of as sense of threat to life, integrity or sanity.

Psychological Trauma is not only PTSD

Traumatic events are varied. It can be one major event (as in the case of PTSD), a series of events or living conditions that persists. In traumatic events the person is vulnerable and loses sense of agency or control. Since vulnerability is the feeling, young children and babies are more prone to being traumatized than healthy adults.

Symptoms of Psychological Trauma

Sufferers of PTSD tend to be more aware that they suffer from trauma than individuals who suffer developmental trauma or complex trauma.

Symptoms of trauma are often experienced as: irritability, depression, numbness, fogginess, lack of concentration, sleeping disorders, nervousness, panic disorder, chronic pain, addictions and addictive behavior, self-harm and suicidality, and eating disorders.

Symptoms of psychological trauma
Diagrammatic Symptoms of trauma

Trauma-focussed psychotherapists would check childhood experiences of individuals with these symptoms for sources of traumatic experiences.

It is not unusual for such clients who are not suffering PTSD but complex or developmental trauma to be baffled at the idea that they are manifesting symptoms of trauma, since these experiences are either forgotten, or because the memories in themselves are not recorded as traumatic.

Traumatic experiences that happen in infancy and early childhood lead to what is termed developmental trauma.

Developmental Trauma

The younger the child, the more dependent they are on their caretakers for survival. Children get traumatized by neglect, separation and abandonment, exposure to domestic violence, parents fighting, witnessing violence, fearful caregiving, threats to them (meant or not), medical crises and accidents, death in the family, especially of parents and siblings.

Developmental trauma are more insidious than adult onset trauma because young children are not able to process the memories of the event(s) fully.

These memories are not integrated into learning experience, and remains out of awareness. As the child develops these memories become physiological and psychological symptoms.

Developmental Trauma presents itself also as generalized symptoms. Patients experience difficulties in areas like : 1) affect dys-regulation, 2) having a deep sense of self devaluation, 3) having difficulties forming relationships, and 4) dissociating from experiences.

“Getting Triggered” in the present as sign trauma

Since memories of traumatic experiences are not adequately integrated, the body remembers the traumatic experiences without the brain understanding what they are about. Such memories of traumatic past experiences are called implicit memories, or memories without language.

Implicit memories are sensed. These are memories of the past. However, in the present, harmless events can happen that are similar in feeling to these traumatic past memories. The body reacts to these harmless present events like it did during the traumatic event. The individual is unaware of the past memory hijacking the present moment and gets triggered.

When the dust settles, the sufferer and those around him/her cannot understand how or why the person over-reacted to the present event in such an exaggerated manner.

We may all be familiar to getting triggered or witnessing someone being triggered. It can be disturbing and sometimes destructive.

Understanding that these triggered states of emotionality, fear or rage are rooted in past traumatic experiences can provide for some relief to all involved, because this condition can be treated with psychotherapy.

Psychotherapeutic Treatment of Psychological Trauma

Psychotherapeutic treatment for trauma is an individual process. The condition of the patient and the extent of trauma first needs to be understood. Since traumatic experiences involve a deep sense of threat to life, the therapist needs to create a safe secure setting for the patient.

Trauma therapy can take months to years, depending on the condition of the patient and the trauma. There are five main phases involved:

  1. The first phase of trauma therapy is to establish security for the patient in the session as well as in the patient’s daily life outside therapy.
  2. The second phase would be to work with the client to build resilience, self support, orientation and self awareness. This phase requires the moment-to moment tracking of sensations and emotions that occur in the body before, during and after triggers.
  3. This third step includes psycho-education in which the client learns the nature of his/her traumatic experiences and how his/her symptoms align with the theory underlining. Though this learning he/she learns to dis-identify from his/her symptoms.
  4. The fourth phase is trauma memory processing. This step is only done when the patient has his/her agency and can see his/her triggers as they happen. EMDR is a technique that can be applied in this this phase.
  5. The fifth phase is about integrating the memories and experiences. The patient learns to move on, make new affirmations and begin to live a life that is more in the present and not held back by the trauma symptoms.

Trauma therapy has its contra-indications. Patients can get re-traumatized if the groundwork of phases 1 and 2 are not adequate. The building of the therapist-client working alliance is thus very important to ensure safe, effective trauma treatment.

A EMDR Methodology for Working with Trauma

EMDR is a form of psychotherapy originally designed for trauma therapy. EMDR provides a here-and-now stimulus as the client recounts his/her traumatic memories. Tapping or eye movements keeps the client in the present and in the observer position. This keeps the client stable, so that he/she can remember stressful experiences without being re-traumatized.

EMDR is very much a relational-therapy application which I find very useful for integrating into my work.

EMDR is founded by Francine Shapiro. Here are 2 lectures of EMDR by Shapiro herself.

About Shapiro’s Way with EMDR

History and research history on EMDR

Commonly administered EMDR Process

EMDR process has a structure. The actual procedure administered is unique to each individual. The therapist, during the session, has to remain focus on the phenomenology of the patient. Keep in mind that simply following the steps alone is not therapy.

1. EMDR therapy begins with a clarification of a trauma-specific case history. The client reveals a traumatic event(s), it’s symptoms and these are to be worked on. The treatment process is also explained to the client.

2. The effectiveness depends on the choice of the outcome situation, and the unveiling of the cause of the traumatic situation.

3. Stabilization of the current situation of the client is important. The client is also prepared internally for the exercise. e.g. the client is asked to use a stop signal if he/she feels too uncomfortable. The client also gets to describe a safe place.  In other words, the client is asked to consider the resources he/she has.

4. Estimation of the degree of severity of the experience. The client is ask to rate the degree of feeling felt at the moment about an event. The client is asked to describe and rate a negative aspect of the event (e.g. feelings of fear or guilt). The client is also asked to describe and rate a positive outcome of the event (e.g. feeling of freedom from guilt).

5. The client is asked to estimate how strong the feelings of stress at the moment is.

6. The client is asked to describe how he/she feels in the body.

7. Pre-processing step: to ask the client to relax and recount the event. Allowing the client to creatively enter into the scene. The therapists begins to lightly tap on the client’s wrists or knees, or guides the client with eye-movements, and encourages the client to describe the situation(s) as they arise to consciousness.

8. The weaving in of the here-and-now situation with past situation.  The client gets to see the traumatic experience as a more mature person (as opposed to a child when he/she suffered a trauma).  The client also gets to view the situation from a vantage point of a safer present.

9. Re-evaluation of the feelings of the traumatic events.

10. Anchoring: the client is asked to recite what he/she has learnt from the experience (the positive experience) as the therapists taps the client’s wrist a little more.

11. Body scan test: to check how the feelings in the body. And to find out what else  that is stressful that is felt in the body.

12. Closing conversation and dialogue: something light hearted, breathing, relaying.

13. Next session, the previous treatment is rated again to see how the treatment is integrated. If the stress is still there, therapy can be repeated, if it is successful, anchoring work can be done.

Sometimes the client does stabilize after the therapeutic work. It is useful to be patient and listen to the patient’s current experience. The goal of the therapy is not to completely resolve every stress in one sitting, but to bring stability week to week, until the client learns to integrate the treatment.

Often the client feels permanent relief of a certain degree of stress.

Own work experience

I decided to use the tapping technique with a client who mentioned a car accident in which she was a driver that happened 20 years before. She is a successful businesswoman in her 50s, and had never mentioned this incident prior. This incident came to light as a result of  a dream recollection.

The client had left a going-away party with some friends, had some drinks. It was also midnight, which was the day of her birthday. As she drove home, she collided with a drunk pedestrian, who got severely injured and died.

During the therapy, the client expressed fear and guilt which she had shut off all the years. She never had a chance to talk about her trauma to anyone and felt lonely.

The tapping allowed the client to see the event as if it were a movie. She could experience the emotions and was able (with hesitation) to vocalize the feelings. Her arms began to sweat.  She began to remember more details of the night after the accident when she went home, and the morning after, how she felt like it was a nightmare, but it was for real.

At the end of the session, the client felt her loneliness, but was relieved about being able to share. Her fear level regarding the event went from a high 10 to 0.  She still processes sadness and guilt about the event, which was later our work-in-progress.

Bibliography

Schubbe, O. (2004). Traumatherapie mit EMDR. Order, 22, 99.

What do Gestalt Therapists do?

Gestalt therapy is an effective an efficacious form of psychotherapy (Roubal, 2016). Gestalt psychotherapy is practiced by certified psychotherapists trained and supervised in the modality. Anyone who is interested in having gestalt therapy as a treatment for psychological and psycho-somatic stress or pain, or for the treatment of systemic issues regarding relationships in families or organizations, should seek a gestalt therapist who is actually trained and licensed as one.

Gestalt therapy is often described as a humanistic and holistic form of therapy. What this means, is that when a client comes to a gestalt therapist, he/she can expect to be met with a trained person who has been treated with gestalt therapy him/herself.  Here I emphasize the person as an instrument of treatment, as opposed to other instruments like medication, techniques, advise or exercises.

Established gestalt therapists have identified observable behaviors  that one can expect of gestalt therapists at work. This is documented within the gestalt therapy fidelity scale, or GTFS (Fogarty et al., 2016).

So, what do Gestalt therapists really do in the session? 

Developing awareness.  It is said that “knowledge is power”.  Awareness, however, takes the client way beyond empowerment. It leads towards self-agency and healing. When a client approaches therapy, he/she is really looking for healing answers. This knowledge is given to the client through newly acquired self-awareness. Gestalt therapy acknowledges awareness as encompassing 1) inner emotions feelings, 2) behavior, speech and actions, and 3) thoughts, judgements,  beliefs.  Developing awareness is not what the therapist does per se. Its intent is, however, central to the work.

Working relationally.   Clients usually come for therapy with a target complaint. This complaint is very valid to the goal of the therapy. It is not unlike going to the doctor with a health complaint. Gestalt therapists, however, handle the complaint differently from doctors.  The therapist pays attention to the client’s interaction with the therapist in the session and the therapist pays attention to his/her own resonance with the client in the session. The therapist has no pre-determined agenda. For example, a client comes in with complaints of insomnia.  The therapist focusses on the client interaction with the therapist in the session. There is no judgement on part of the therapist. She allows the client to freely express himself. She pays attention to the differences between them. She notices how the client talks quickly with flat affect. She notices also how she feels “heavy in the head” as the client speaks. Giving attention to this dialogical interaction, the therapist and client gain awareness of the client’s mode of being in the world. The client learns of the psychological burdens that keeps him up at night.

Working in the here and now. The therapist asks the client about his immediate experience. If the client mentions a disappointing day at work, the therapist would notice his facial expressions and tone of voice as he recounts his experiences.

Phenomenological practice. The therapist would bring these feelings to awareness of the present moment, thereby helping the client to describe and deepen his sense of theses experiences and gain better understanding of the presenting issue.

Working with embodied awareness. The client is encouraged to observe his emotions and bodily sensations.  The therapist may notice the client’s shallow breathing, for example, and mention it.  Through this deep embodied understanding the client is encouraged to try new movements. He realizes that he has choices. 

Observance of the resonance in the relationship. The therapist is sensitive to the context in which the dialogue takes shape. Themes emerge. Emotions emerge. The therapist shares with the client her experience of what emerges. The client is empowered, with this awareness which is otherwise unconscious to him.  He is provided with the new learning of his role in his past, present and future relationships.

Working with client’s mode of relating. The therapist acknowledges the client’s relationship pattern as these emerge during the session. In gestalt therapy, both therapist and client co-create the space in which they reside. They explore how they impact each other in the relationship.

Adopting a spirit of experimentation. Like in a kaleidoscope, small changes in movements lead to complete change in form of the pattern. The therapy session is like a crucible of life. The client is encouraged to experiment with new ways of being: simple moves within a session like a movement of the hand or uttering a sentence to somebody on an empty chair. The therapist supports the client with these experiments. They explore ways in which he can integrate these experiences in the world outside the therapy session.

The client leaves therapy with new awareness and is armed with choice. In the case of the client who has had insomnia, work with a therapist in the gestalt modality can be effective. The client works on his self as a whole, rather than only with his sleeping problems. The client is not his illness. He is a person who has feelings and relationships. Working on his self-awareness, the client gains agency over himself. In therapy, he experiments with ways of being. He finds answers to questions that affect his life. He gains better understanding of his past, present and future. He gains self-compassion. He learns to let his body rest at night.

Bibliography

Fogarty, M., Bhar, S., Theiler, S., & O’Shea, L. (2016). What do Gestalt therapists do in the clinic? The expert consensus. British Gestalt Journal25(1), 32-41.

Roubal, J. (Ed.). (2016). Towards a research tradition in Gestalt therapy. Cambridge Scholars Publishing.

Contact for gestalt therapy in Singapore or recommendations internationally

Couples Therapy: Helping children cope with parents’ separation and divorce

Children do suffer much when parents separate or divorce. Read how couples therapy can help reduce the emotional stress and confusion in children who have to face their parents separation.

Children are wired to be ultra-sensitive to changes in their parents’ relationship.

Some children are so tuned-in that they pick up unhappiness within the couple long before the couple even acknowledge the gravity of their problems. How do we know this?

Family therapists have long understood — through working with parents and their children — how children’s developing symptoms can emerge out of anxiety over their parent’s state of mind or relationship. This is a known phenomenon from the field of the family system.

Secure parental bonds are important to children.

The younger and more vulnerable the child, the more important to them are the parental bonds. Stable bonds mean safety. When there is a threat to this stability, children get anxious. This anxiety can amount to panic. From the experience of working with adult clients, I have learnt how even older children in their late teens get affected by their parent’s separation.

Children face anxiety and panic when parents separate

“What will happen to my home?”,”who will take care of me?”,”will mommy or daddy leave me?” These questions speak the language of a child’s fears of being abandoned and left exposed to the environment. The resultant “symptom” is anxiety and panic.

Children blame themselves for their parents’ divorce

Older children and teenagers develop an added strategy to withstand this kind of anxiety. They blame themselves. Blaming is a way of assigning power to the object of blame. If being abandoned makes one feel vulnerable, the way to overcome vulnerability is to assign power to the self. The unconscious tendency is to assign blame to the self for what has happened.

There is a tendency for children to blame themselves for their parents’ marriage breakdown.

In their adult years, children of parents in conflict can bear symptoms such as depression, mood swings and anxiety. Many have difficulty with intimate relationships themselves and some even adopt self- harming behaviors. Psychotherapy sessions in my practice has uncovered oftentimes this link.

What can divorcing parents do to minimize harm to their children?

Be open and reassuring with your children. Even very small children can grasp parental conflict. This does not mean that you should fight in front of the children. To be open about conflict is to acknowledge that there is one, without explaining why, or who is at fault.

Be careful not to use the child to take sides.

Reassure the children that their parents love them, no matter what happens. Reassure them that they are good children.

Engage a professional whom the child can regularly talk to. This could be a counselor or psychotherapist.

Engage a marriage counselor or couple’s therapist to help you and your spouse separate with mutual understanding and respect. Psychotherapists provide the supportive environment for the couple to deal with the emotional pain that arises from the separation process. This relieves the child from being the incidental bearer of this pain.

The last point is worth taking seriously. We know that causing pain to our children is the last thing we want happen in the separation process. Unfortunately, without professional support, the unconscious takes over. In high conflict and stressful situations like divorce, people become unaware of themselves and oblivious to what happens.

Envy… and Gratitude

Envy is the idealizing of an object outside oneself, with the wish to devour the coveted object. This object is something possessed by another person or persons. The trappings of envy is that one cannot find peace through separation of oneself from the envied object and the envied other. The resultant is hatred and the need to destroy the other.

Envy can also be seen as a projection of goodness into another person, so that one idealizes the other while devaluing oneself, and eventually hating the other. Envy is a painful emotion and is almost not in the awareness of the individual. It is also integral to being human, and hence it exists in every reasonably living functioning person.

Envy vs. Jealousy

Envy is exists in terms of two persons– it involves you and me. I want what you have, because that is what I lack. Jealousy involves a third person. I am not allowing that other person to take you / your attention/ love, etc away from me.

Destructive Envy

If I cannot have what you have I’ll seek to destroy that coveted thing. Sometime this destruction is abstract.

Greed

Greed is a means to extract all the goodness from the other. Greed doesn’t necessarily seek to destroy. Greed is to consume without gratitude. Hence greed never gets satisfied.

Defenses against feelings of envy

Vanity or grandiosity is a defense against envy. To make oneself more superior to overcome envy of another. Self idealization, feeling omnipotent, not needing or depending on others.

Invidiousness, is a means to act so that the other becomes envious of you.  To projective identifying or evoking emotions of envy in the other. The problem this causes the person to fear the envious eye of other.

Spoiling, devaluing, rigid idealization, projection of envy (a superego that attacks and devalues own achievements) are examples of means to counteract feelings of envy.

When envy is strong, even what’s seems as a good object becomes a source of pain.

In normal experience good experience predominates over bad. Pathology aries when bad predominates good internally and externally.

Positive use of Envy

Constructive envy is one that inspires one to work harder to improve oneself. If I am envious of somebody’s abilities, e.g. piano playing, I practice harder. We also witness the energy derived from envy in the masterpieces created by highly creative people.

Gratitude as the Antidote to Envy

Melanie Klein tells us that gratitude is the antidote to envy. To be thankful is to be able to see the glass half full. Gratitude allows one to feel satisfied with what one has achieved or bestowed.

Bibliography

Carveth, D. (2016) Introduction to Kleinian Theory 4. Youtube. https://www.youtube.com/watch?v=bb-L_QXNyQU&t=2s

 

notes;

Pathologically violent projective identification, where the object (ego) is splintered, attacked. Reality is seen as persecutory and hated. When envy is intense, the perception of the good object is as painful as the bad object.

46:00 Psychopathology is  the result of early decision to try to base your life upon evading pain (Bion).  Psychotherapy is the process of turning this around. To help the individual face the pain and move on to more functional existence.

Bob and Rita Resnick: Gestalt Couples Therapy

In this video, we learn what couples therapy can look like, what gestalt couples therapy is focussed on. Here is an interview with the Resnicks on their perspective on couples therapy in the psychotherapeutic practice.

Couples Therapy Films – with Rita F. Resnick, Ph.D. and Robert W. Resnick, Ph.D. from GATLA Videos on Vimeo.

How Psychotherapy Works

How does psychotherapy work? What is the difference between psychotherapy, psychiatry and CBT?

Here is useful information for those interested in engaging a psychotherapist.

Transcript of this video:

Psychiatry, CBT and Psychotherapy

When one is in a bad place in one’s head the modern world offers three main sources of help: Psychiatric meditation, CBT and psychotherapy. Each one of these advantages and drawbacks. Medication can be exemplary in a crisis that points when the mind is so under siege from fear, anxiety or despair that thinking things through cannot be an option. Correctly administered without requiring any conscious cooperation from us, pills play around with our brain chemistry in a way that helps us get through to the next day and the one after we may get very sleepy, a bit nauseous or rather foggy in the process, but at least we’re still around, more or less. Then there is cognitive behavioral therapy or CBT. Normally administered by psychologists and psychiatrists in six to ten hour-long sessions which teaches techniques for arguing rationally with and with any luck at points controlling the ghoulish certainties thrown up by our internal persecutors: paranoia, low self-esteem, shame and panic.

Lastly, there is psychotherapy, which from a distance looks like it has only drawbacks. Psychotherapy has a very hard time showing its efficacy and scientific trials and it has to plead that its results too singular neatly to fit the models offered by statisticians. Also, it takes up a large amount of time demanding perhaps two sessions a week for a couple of years and it’s therefore by far the most expensive option on the menu. 

Finally, psychotherapy requires active engagement from its patients and sustained emotional effort. One can’t simply allow chemistry to do the work and yet psychotherapy is a hugely effective choice which properly alleviates pain not by magic or chance, but for three solidly founded reasons.

Our unconscious feelings become conscious with psychotherapy

A founding idea of psychotherapy is that we get mentally unwell have a breakdown or develop phobias because we are not sufficiently aware of the difficulties we’ve been through.  Somewhere in the past we’ve endured certain situations that were so troubling or sad, they outstripped our rational faculties and had to be pushed out of day-to-day awareness. For example, we can’t remember the real dynamics of our relationship with a parent. We can’t see what we do every time someone tries to get close to us.  Nor trace the origins of our self-sabotage or panic around sex. Victims of our unconscious, we cannot grasp what we long for or a terrified by. In such cases, we cannot be healed simply through rational discussion, as proponents of CBT implicitly proposed, because we can’t fathom what is powering our distress in the first place. 

Psychotherapy is a tool for correcting our self-ignorance in the most profound ways. It provides us with a space in which we can in safety say whatever comes into our heads. The therapist won’t be disgusted or surprised or bored. They’ve seen everything already. In their company we can feel acceptable and our secrets sympathetically unpacked as a result crucial ideas and feelings bubble up from the unconscious and are healed through exposure interpretation and contextualization we cry about incidents we didn’t even know before the session.  The ghosts of the past are seen in daylight and a laid to rest.

The importance of working with one’s transference relationships in psychotherapy

There’s a second reason why psychotherapy can work so well. Transference. Transference is a technical term that describes the way once therapy develops a patient will start to behave towards the therapist in ways that echo aspects of their most important and most traumatic past relationships. A patient with a punitive parent might for example develop a strong feeling that the therapist must find them revolting or boring a patient who needed to keep a depressed parent cheerful when they were small might feel compelled to put up a jokey facade whenever dangerously sad topics come into view. We transfer like this outside therapy all the time but there what we’re doing doesn’t get noticed or properly dealt with. Psychotherapy is a controlled experiment that can teach us to observe what we’re up to, to understand where our impulses come from and then adjust our behavior in less unfortunate directions . A therapist might gently ask a patient why they’re so convinced they must be disgusting or they might lead them to see how they use of jokey sarcasm is covering up underlying sadness and terror. The patient thereby starts to spot the distortions in their expectations set up by their history and develops less self-defeating ways of interacting with people in their lives going forward

Psychotherapy provides “the first good relationship”.

The third reason why psychotherapy works it is the first good relationship. We are many of us critically damaged by the legacy of past bad relationships. When we were defenseless and small we didn’t have the luxury of experiencing people who were reliable who listened to us who set the right boundaries and helped us to feel legitimate and worthy. However when things go well the therapist is experienced as the first truly supportive and reliable person we’ve yet encountered. They become the “good parent ” we so needed and maybe never had. In their company we can regress the stages of development that went wrong and relive them with a better ending now we can express need we can be properly angry and entirely devastated and they will take it, thereby making good years of pain. 

One good relationship becomes the model for relationships outside the therapy room. Some moderate, intelligent voice becomes part of our own in a dialogue.

We are cured through continuous repeated exposure to sanity and kindness.

Psychotherapy won’t work for everyone. What has to be in the right place in one’s mind? 

One has to stumble on a good therapist and be in a position to give the process due time and care. But all that said with a fair wind psychotherapy also has the chance to be the best thing we ever get around to doing.

Symptoms of Anxiety and Panic Disorders in the Context of the World We Live in

Anxiety and panic disorders are getting increasingly common among young adults. This is a phenomenon observed and mentioned by mental health professionals who work in Europe, Asia and America. There are several hypothesis to this observation. The logic that resonates most with me is the one by a psychiatrist colleague from Italy, Gianni Francesetti.

Francesetti attributes panic disorder to “an acute attack on solitude (loneliness)”. This actually implies that the symptoms of panic and anxiety attacks, while observed to be affecting an individual person, is in fact contributed by this person’s relationship to the world around him/her. Why? Because we cannot be lonely if we are in contact with some other persons in the environment. Hence to be lonely is to be left in the cold with on one for company.

The word panic is descriptive of the state of being left exposed in the wilderness. It is said to have been derived from the name of the Greek god, Pan. Reading the characteristics of Pan one would derive the keywords, all-encompassing, wilderness, solitude, rejection, stomach-churning cry and death. The word panorama describes the wide open field space. A young animal separated suddenly from its mother and exposed to the cold environment would panic. In its panic it would cry out.

Neuroscientist Panksepp’s lecture explains to us how the panic pathway in the brain is wired up. He also tells us in the video below that the baby animal in panic would be quiet again once it is held warmly. If it were not held, it cries would ultimately stop, and the animal would fall into a state of what looks like depression in humans. The panic system generates loneliness and sadness, and it is observed to be the gateway to depression.

The panic system is related in mammals (including humans) to separation distress and over exposure. Human suffers experience the onset of panic disorder usually as young adults, the age when one leaves the parental home.

Most clients who complain of panic attacks are independent and forward-looking people. Feelings of being exposed or separated are not part of their conscious awareness. These experiences belong to the client as toddlers or babies, and are overwhelming. Many clients manage to uncover this hidden past experience after months of psychotherapy.

Psychotherapy for Anxiety or Panic Attacks – A case study

Clarise, 26 years old, a student who holds also a job as a medical receptionist. She had her first panic attack when she was 20 and had just left her family home and moved to another country, Vienna. She explained that the onset of subsequent panic attacks happen when she is about to leave the family home when she is on holiday there. Strangely, this is also related to her leaving her younger brother, Mike.

Proud of being an independent worker, she came to therapy often talking dryly about happenings at work, talking about panic attacks and medication, and avoiding topics about her relationships. I could perceive her avoiding experiencing her emotions, and her intense fear of going there. Sessions in the first 4 months felt slow. I soon had difficulty remembering her among the other clients.

The slow, almost deadening atmosphere in the sessions soon became clear to me. I felt like I was in conversation with someone who was trying to make herself invisible to me. Yet I felt a longing between us for contact. Clarise came every week for therapy faithfully. I decided on several experiments during the sessions. The most useful of which was very simple: to walk around the room as we spoke. Clarise, while walking, became more animated. It seemed as if in order to make herself invisible, she kept her body still. When she had to walk around, her energy flowed. She appeared then more alive and open to being in conversation with me.

Over time, Clarise was able to talk about her childhood. Keywords were: Unwanted child. Emotionally abusive mother who was devaluing, abandoning, de-validating of her feelings, denying, contradicting. Her mother favors her younger half-brothers. As a child she had to look after the boys. She was also competitive with mother with regard to the brothers. She became overtly responsible for Mike.

Her childhood memories were fragmented, indicating a kind of trauma, perhaps from neglect. Only mother’s feelings of those days could be recalled by Clarise. In the therapy room, it felt to me as if her mother always present. Sometimes I would use the mother’s “presence” as an intervention.

Clarise admits to be constantly yearning for attention. This is a paradox, because of the way she unconsciously makes herself invisible. She admits to flattening her voice to control emotions. Clarise has little body awareness, which she became aware of as we walked around the room.

Gestalt Psychotherapeutic intervention for panic attack symptoms

Clarise’s case shed light on the polarities that emerged during our work.

Polarities are:

  • Fear vs. Curiosity,
  • Attention yearning vs. Self-hiding
  • Being forgettable vs. Forgetting

“I must be afraid so that mother can feel good about herself.”

“When my boyfriend is not at home, I am not in danger of having a panic attack.”

“I make my breathing shallow to press against my chest, so that I won’t cry here.”

Clarise also exhibited tendency for Self-ISOLATION, even if it were unconscious to her. One of her strategies was to dissociate. To disappear. To forget. She admitted that as a child, it was “Safer to be unseen.” If her mother was at home, she would not be able to predict if she would be treated with kindness or anger.

Clarise realised that she could use illness and lately the panic symptoms to garner support from people around her. “When I’m in dire straits, people will come to me and they won’t harm me.”

Looking at PSYCHOPATHOLOGY from the perspective of the relationship between client and therapist.

In the therapeutic alliance, suffering is not located only within the client, but is an emergent phenomenon. This means that we as therapist can feel, perceive ourselves as being part of the symptom. We are impacted by the symptom.

When I am able to acknowledge how being with this client impacts me– in this case the feeling of stagnating stillness and forgetting– I am able to adjust my being with her. In so doing, the atmosphere changes. In gestalt therapy we acknowledge this the as the field.

3 levels of observing anxiety disorder symptoms based on this case study
Single person LevelDyadic Interaction Level Aesthetic Field Level
“My client has panic attacks.” “I forget the client. I overlook her. She seems to make herself invisible to me.” “There is stillness and monotony in the air. I can hear the clock tick. The room feels empty. I feel tingly. There is a sense of longing.”

Conclusion

What I attempt to present here is a cutting-edge perspective of treating symptoms of panic disorder in a patient in the clearest way possible in a blog. Medication and quick therapies have not managed to effect lasting relief for most patients of anxiety. This is why we, as gestalt therapists, look to the broader field. We look beyond the person. We have found useful to see the client in context of the socio-cultural environment. We use this field during the session. We move ourselves in the field. We allow ourselves to be impacted. In this way we make small adjustments. These work as tender changes within the psyche of the client.

Remembering the hypothesis that panic is an acute attack of loneliness, the work with Clarise revealed it to be so. Although Clarise never admitted that she was lonely, she revealed her natural tendency for self-isolation. In making herself forgettable, it was I who ended up feeling left alone in the therapy room. Noticing this and sensing our longing for contact, I could affect the field around us. When the field changed, the client eventually changed. Clarise learned to cry. This was a relief to her. It was a relief to feel safe and be vulnerable. It was a relief to her that she did not have to go into a state of panic to afford company.

Bibliography

Francesetti, G. (Ed.). (2007). Panic Attacks and Postmodernity. Gestalt therapy between clinical and social perspectives. FrancoAngeli.

Corporate Counseling: What is the difference between a group and a team?

“A group is any number of individuals who form a recognizable unit, cluster, or aggregation. Teams are specific groups of people with (it is hoped) complementary skills and abilities who join together to collaborate.” Kets de Vries

Within a team are people with different and complementary function. Their unique functions serve the team’s goals. These individuals are highly inter-dependent.   Each team player is also an individual.

The team is considered “merely” group if people are dependent on being in the group, or have to be in this group (as in families), and conform to groupthink. Groups usually form a leadership that decides unilaterally on how the group exists.

Organizations are groups that may or may not be teams. In a team, its members have each a function. This function serve to support the goals of the team.  The collective functionality of all the members of a team is more than the sum of its members. This means that putting the people together alone does not lead to performance unless the potential function of each individual within the group is realized.

Organizations that have healthy functioning teams experience smoother paths towards performance outcomes.

Read also: What motivates people to work and stay in teams?

How do I know if I’m working in a Team?

  • The people you work with have a high degree of interdependence.
  • The group is geared towards a common goal.
  • The members hold themselves accountable for the outcome.
  • The individuals have unique and complementary skills which make them interdependent.
  • Each member and the team as a whole will be affected by the outcome of the work.

Source:

De Vries, M. F. K. (2011). The hedgehog effect: The secrets of building high performance teams. John Wiley & Sons.