Amendt-Lyon: Creative Indifference & Gestalt Psychotherapy

The therapy room has become a multi-dimensional space for creative play and experiments, for novel compositions, mixtures and new combinations. We are part of the equation. A creative elaboration of therapy is for the moment real and the game. One which is limited in time, but which has a lasting effect.

Nancy Amendt-Lyon

In the years post WWII, a German-born jewish psychotherapist & psychiatrist, Friedrich (Frederick) Salomon Perls, with his wife Laure, put together (perhaps gestalt-ed) the foundation of a therapeutic modality now known as Gestalt therapy. They were literally refugees in South Africa at that time. Perls drafted out gestalt therapy philosophy in his first book entitled, Ego, Hunger and Aggression (Perls, 1942/47). In this book, philosopher Salomo Friedländer‘s concept of Creative Indifference”.

Creative Indifference, in Gestalt therapy circles, is also given the terms the Fertile Void and the Zero Point. This is an essential aspect of Gestalt therapy. It is also an abstract concept that deserves attention. Therapists who take the time and space to chew on this concept actually grow as therapists. This is how relevant creative indifference is to our vocation. The very fact that Perls started his first book by explaining Friedländer’s work in its first chapter indicates its relevance.

It is my pleasure, with this blog post, to give highest esteem and admiration for Dr. Amendt-Lyon for this keynote lecture at the Gestalt Conference 2019 in Budapest. I was there, alongside about 800 participants, listening to this lecture. Little did we know at that time that this gathering of international gestalt therapists would precede the unfortunate COVID-19 pandemic that would upend the world we thought then we knew.

Below is a bunch of notes and the transcript of her lecture. I figure that this is necessary, lest the video goes astray.

Transcript (Key notes)

When Fritz Perls wrote Ego, Hunger and Aggression, he stated, “for a long period of my own life, I belong to those who, though interested, could not derive any benefit from the study of academic philosophy and psychology until I came across the writings of Sigmund Freud, who was then still completely outside academic science, and S. Friedländer’s philosophy of creative indifference.”

creative indifference, ego hunger aggression, perls
Ego, Hunger and Aggression, page 13

Perls had several reasons for finding the psychoanalytic system incomplete and faulty. First, for treating psychological facts as if they existed separately from the organism. Second, for using linear association psychology as the foundation for their forward dimensional system, and third, for neglecting an important phenomenon, differentiation.

To correct this third fault, Perls intended to apply differential thinking which is based on Friedländer’s theory of creative indifference.

[…]

Experimenting — A familiar approach to creative indifference and differential thinking

Experimenting allows us as therapists to be learners, to take risks, to bearing, but also humble and clumsy make mistakes and admit them, and especially to be able to attune ourselves to our patients while still remaining in touch with our own perceptions.

From this perspective, an experimental attitude is not only an antidote to narcissism but it also prevents us from producing premature answers to complex questions. It stops us from knowing it all. To me, this is the basis for working creatively. We take into account the patient’s experience as well as the therapist’s, and then we explore the situation they create together.

(A)n experimental attitude is not only an antidote to narcissism but it also prevents us from producing premature answers to complex questions. It stops us from knowing it all.

This makes the field more complex the patient and therapists are interacting each with their own polarities interests motivations experiences and needs.The patients polarities don’t exist in a vacuum. They aren’t the object of an examination, but rather emerge within the context of the therapeutic relationship within a joint situation. This experimental approach turns the therapeutic situation into the kind of fertile void from which the surprising and enriching interplay of polarities can emerge. Novel ways of meaning-making stimulating awareness and connecting to one another are supported. This is the light-footed calibration and balance of all aspects of ourselves in relation to one another being of the field; not digging in our heels in stubborn persistence in isolation and prefabricated assertions.

Embarassment is the boundary state par excellance

Part of the journey toward mutual meaning-making is experimenting with embarrassment. Embarrassment which Laura Pearl’s called the boundary state par excellence in which we have one foot in the familiar and one foot in the unknown; a fine example of balancing and calibrating polar opposites. It’s a little bit the way I feel now not really being able to see you, being mildly blinded but still talking and hoping that you’re staying with me.

If we can stay with our embarrassment, our clumsiness, our awkwardness, then we can make contact with what is different for the other, and as we allow ourselves to stay with this experience the boundary of what is accessible expands. We don’t acknowledge our embarrassment, but rather remain within our familiar structures, then we may have the feeling of security but the the price is costly. We won’t contact the novel, we won’t learn anything new, we won’t grow. If patients are struggling with leaving their comfort zones and reluctant to familiarize themselves with the unknown, I’ll often encourage them to embody their dilemma by standing up and playing around with the boundaries of the carpet in my office. Virtually with one room one foot on the carpet and,On the wooden floor, representing the familiar and the unknown. Standing up moving around physically embodying different stances often affords them better awareness of their inflexible polarities and entices them to try out new more satisfying calibrations.

[…]

What are exactly creative indifference and differential thinking, polarities, Zero point or pre-difference, degrees of differentiation.

In a chapter written by the German Gestalt therapist, Ludwig Frambach called the world of nothingness Salomon Friedlander’s creative indifference that I translated for the book […], Frambach put forth that Friedländer’s basic concepts. Creative indifference and polar differentiation mark the beginnings of Perls reflections on therapy theory. […]

Background of Friedländer’s life.

He was born in 1871 in Golans, which is now Poland. He was a German-Jewish philosopher and satirist. […]

With a good measure of black humor. Friedländer wrote, very absurd and popular. Avanga poetry and prose under the name Mynona, which is the German term for anonymous (anonym), written backwards. It seems that Mynona was Friedländer’s alter ego. His dissertation focused on Schopenhauer and Kant. In 1906, he moved to Berlin where he was very comfortable in expressionist bohemian circles among artists and intellectuals.

In 1933, he fled from the rising Nazi movement to Paris where he was very ill for many years and this ironically prevented him from being deported. He died in Paris in abject poverty in 1946.

As far as I can could determine except for two of his novels, none of his writing has been translated into English. So anything you read in English of his philosophy is been is in German or another language.

In Ego, Hunger and Aggression, Perls mentions that there’s no such thing as objective science, that all observations, including those made by scientists, are impacted by particular interests preconceptions and an attitude, largely unconscious, which proceeds selectively. He emphasizes that human beings are indifferent to and uninterested in what they subjectively experienced to be not differentiated.

“Indifferent” refers to being disinterested without prejudice or preference, impartial, unbiased.

“Indifferent” here refers to being disinterested without prejudice or preference, impartial, unbiased.

I’m using the term indifferent to mean not differentiated, capable of development in more than one direction. Being disinterested underlines the absence of prejudice or selfish interests, whereas being uninterested refers to aloofness. So disinterested and uninterested are not very good synonyms because uninterested rather means “I don’t care. I have no interest at all.”

The Zero point, null or naught, is both a beginning and a center like with positive and negative numbers. Perls finds that it’s natural for human beings to think in opposites.He says differentiation into opposites is an essential quality of our mentality and of life itself. Our systems revolve around the Zero point of normality or health. For example, differentiating into two opposites, such as plus and minus, or pleasure and pain.

The way we think in opposites is important and depends on the context. Opposites Perls says a more closely related to one another than each is related to other concepts, such as black and white within the context of color.

Differential thinking, which is a term that Perls coined is the insight into the working of such systems. We would have no concept for day if we didn’t have night as well.

Perls said instead of awareness sterile indifference would prevail. So in Friedländer’s theory it’s important to distinguish between a fertile void and an infertile one.

Creative indifference and being interested

Creative indifference must be distinguished from uninterested detachment from the “I don’t care” attitude. If we’re to perceive an appreciate a phenomenon, it must be different from something else. And as we try to disentangle thoughts into correlative pairs, the unity of polar differentiation, the middle point, or indifference, remains elusive.

We can’t grasp it.

Our focus lies, rather, on the poles than on the indifference.

In this indifference lies the real secret — the creative will, the polarizing one itself, which objectively is absolutely nothing. However, without indifference, there would be no world.

Friedländer says, “yet in this indifference lies the real secret — the creative will, the polarizing one itself, which objectively is absolutely nothing. However, without indifference, there would be no world.”

Indifference, or the naught zero of the difference, is the center of creativity. The original source, the subjective heart of the world, according to Friedländer. External and objective is what can be differentiated into polarities, but the internal part is the indifferent, weighty world of nothingness.

Originally in German, das Weltenschwangerenichts, which means literally, the nothingness that gives birth to worlds.

…The nothingness that gives birth to worlds.

This picture is a Zen calligraphy of the word “mu” which incidentally refers to the same concept of nothingness.

Friedländer emphasizes the lively creative center by referring to it with a multitude of terms ,ego or ego heliocentre, self, being, subject, individual identity, person, mind, soul, absoluteness, the symbol for infinity insistence will or freedom. […] Perls used in writing Ego, Hunger and Aggression, center, zero point, equilibrium, naught, void, pre-difference, holes, balance and so forth.

Friedländer won’t be restricted to one term for what is indescribable and perhaps this joy in circumscribing a definition influence Perls’ diverse descriptions of the concept of self. Because in Perls, Hefferline and Goodman (1951), he refers to it as the artist of life, the function of contacting, the actual transient present, the system of present contacts, and the agent of growth, the complex system of contacts necessary for adjustment in the field.

Creative indifference tends toward creative development.

Friedländer are found indifferentiation to be liberating, for it allowed a person to become centered, able to integrate a variety of experiences and contents, to tolerate ambiguity and ambivalence, and to find what he called, their heart. By embracing a diversity of possible phenomena, we can actively engage in creative production because creative indifference tends toward creative development.

In more simple terms, arising from an indifferent middle point, we can embrace and balance both polar opposites and calibrate our actions, depending on what the situation calls for, demand characteristics of the situation; Gestalt psychologists would say.

Polarities are mutually related, not contradictions

Polarities shouldn’t be treated as mutually exclusive contradictions, but rather as polarly differentiated units of opposites. They are mutually related and can be flexibly centered according to their zero point. Between the polarities there’s a tension, a kind of magnetism an appropriate Gestalt therapy example of this is what we call, present-centeredness.

According to Perls, the present is the ever-moving zero point of the opposite’s past and future. It’s not static, or absolute, but a constant plane with relativity, a balancing, a back-and-forth of meaning-making.

The Field, the Context

Opposites emerge from the pre-different. Differentiation begins at the zero point, and in choosing a zero point, the field is a pivotal factor.

Creative indifference is full of interest, extending towards both sides of the differentiation. It’s by no means identical with the absolute zero point but will always have an aspect of balance. Thus by having the field, the context, we can determine the opposites, and by having the opposites, we can determine the specific field.

[CASE STUDY at timestamp 19:56]

Ludwig Frambach also finds evidence for Friedländer’s differential thinking in such gestalt concepts as as self and middle mode. In Perls, Hefferline and Goodman you’ll read self is spontaneous middle and mode as the ground of action and passion and engaged with its situation as you, I and it. The spontaneous is both active and passive both willing and done to, or better, it is middle in mode, a creative impartiality, a disinterest, not in the sense of being not excited or not creative, for spontaneity is eminently these but as the unity prior and posterior to activity and passivity containing both.

In the English language there hardly exists any middle mode, it doesn’t imply any action on the self such as retroflection. The middle mode means rather that whether the self does or is done to. It refers to the process to itself as a totality. It feels it as its own, and is engaged in it. So perhaps it in the English expression, “to address oneself to”.

The fertile void, the impasse

The fertile void, which Perls seems to often use almost interchangeably with creative indifference, also appears in his five-layer model of neurosis. Following the phony and phobic layer there’s an impasse, a kind of blockade in which former foreground-background differentiation dissolves into chaotic disarray. The fourth layer, resembling a vacuum, is referred to as the death layer, also the fertile void or implosion.

Here the indifference of nothingness, the creative ground can be experienced affording a person the opportunity to readjust a one-sided identification to discover unknown aspects of himself or herself, to experiment with calibrations of extremes, and basically recovery mode.Then the self can be spontaneous in its agency integrating previously rejected or undiscovered aspects of the personality, balancing them appropriately with what a person already accepts and identifies with. This is the emergence of the explosion layer.

[…]

Is working with creative indifference a methodological question an approach that gestalt therapists adopt today?

It’s often the case that people who seek psychotherapeutic help find themselves off balance, out of touch with their emotions, caught in a rut of routine that’s limiting and frustrating… and a person who’s suffering from an urgent problem will most likely not be ready and willing to immediately begin the search for aspects of their perception that have been avoided, overlooked, devaluated or which are potentially shameful. They may say, “This is who I am. This is how I am. I’ll never be able to change.”

Therefore a trusting mutually appreciative therapeutic basis is important before we embark on the adventure of exploring unknown territory. As usual, we’re accompanying our patients, not forcing our insights and interpretations down their throats. We all know that the need to change and grow is often as strong as the need to hold onto our familiar ways of dealing with life.

A part of our task is to stimulate our patients’ curiosity and help them complete the picture between the familiar pole and the unknown one taking the many small steps in between. And this is involves what I often call, “rewinding their film”.

Not being aware of things that might shed light on our situation is one way of avoiding a decision that could bring about change. So with our job to keep the dominant pole in awareness while helping the patient to realize that there’s a polar opposite out there that’s being neglected, and the that these polar opposites are parts of a whole aspect of the same reality. We can help them to realize that restricting themselves to one pole not only keeps them in an unsatisfying situation, but also robs them of the opportunity to test more enjoyable and satisfying ways of being. A part of our task is to stimulate our patients’ curiosity and help them complete the picture between the familiar pole and the unknown one taking the many small steps in between. And this is involves what I often call, “rewinding their film”.

Not knowing for sure, is helpful

To this effect, an indifferent attitude and approach of not knowing for sure is helpful. Not knowing for sure implies that there are countless ways of dealing with a problem not just one. This takes into account the uniqueness of each patient and each therapist and unique this of the way they work together.

Moreover, the rest of the field — the current context — must be considered, such as life circumstances, the social, financial, political situation.

Friedländer’s equilibration of polar opposites certainly influenced pearls work with polarities, as well as the gestalt therapy concept that human beings create their own reality. Equilibriating or centering implies appropriate adjustment to a situation. Balancing the predominant with the neglected aspects, transforming a feudal struggle into productive cooperation. Turning a standoff into enjoyable interplay and enriching recombination.

[…] Instead of rigid and isolated dualities, we have flexible and related polar opposites.

The fertile void is insistent, and it only becomes existent through the will of a person.

If the center, self, zero point or fertile void is indifferent or undifferentiated and everything possibly human is a priori contained in this, then the fertile void can be considered to be an inexhaustible source of energy and possibilities. Friedlander calls this fertile void insistent, and it only becomes existent through the will of a person.

The distance from the zerp point of one’s decision corresponds to a distance from the same zero point in the direction of what this person is avoiding or not embodying. From this perspective, if one’s very essence is considered to be invulnerable, all movements away from the center are seem to be relative differentiations.

Then all the decisions one makes, all the undesirable developments, all the injuries and traumata can be worked through in light of an opposite force that can be accessed. To me, this is a very life affirming position and it’s vital for our work as gestalt therapists and appeals to me on the one hand — but on the other hand, I must admit, that I sometimes feel restricted by Friedländer’s elusive concepts.

In my perspective, a contemporary gestalt therapeutic concept of the fertile void is not just about concentrating on a patient’s polarities and calibrating them because this reflects the one person psychology of the past. Contemporary perspective is multidimensional and highly relational. I tend to envision a three-dimensional conglomerate of related parts that can be jointly reconfigured many times over. Rather a sculpture and installation or a group of items placed together, meaningfully then a drawing because the parts need to be movable. So let’s not just limit ourselves to focusing on the calibration of polarities, but also on the additional dimensions of what we as therapists bring into the equation. The relational present of the patient as well, the dimension of time and many other influences on the present situation.

Contemporary perspectives of Gestalt therapists

I’d like to mention the work of several gestalt therapists on who’s concepts are drawn and reflecting on the fertile void Joseph Zinker (1977) on polarities and experiments, Franz Staemmler on cultivated uncertainty, Laura Perls on meaning making and embarrassment, Richard Wallin on Gestalt theoretical principles and Jean-Marie Robine, on intentionality and the situation.

Zinker sketched his notions of a healthy and a pathological self-concept in terms of polar opposites and aware versus unaware experiences. This is a sketch of his of the healthy self-concept where. The aware part is white and shows the the polarities that are accessible to an individual and the shaded area are his blind spots. So the shaded area is rather small.

J. Zinker

The pathological self-concept is here. It shows a rather large shaded area of blind spots things that aren’t accessible. It shows inflexibility and and unawareness.

Despite the fact that many of us today deal with categories of healthy and pathological as being on a much more fluid the spectrum and rather founded on relationally-based aesthetic criteria than individual pathology Zinker’s sketches enable us to understand that embracing contradictions ambivalence and ambiguity and the ability to experience relationships between these internal aspects, help to keep us balanced.

Here he shows that if we stretch the polarities in one direction it automatically stretches also in the other direction.

When Frank Staemmler refers to cultivated uncertainty as an attitude for Gestalt therapists, that reflects the dialogical approach, it implies that we must be aware of our uncertainty regarding our own attribution of meanings to patients. Looking closely, we also find it in what Laura Perls called the three E’s of therapy: existential, experiential and experimental. According to Laura Pearl’s we’re constantly creating out of nothingness psychotherapeutically, artistically, or scientifically with insights and realizations, with the re-configuration of chaos and ugliness into something new and meaningful.

Following the thoughts of Laura Perls and Paul Goodman about aesthetic qualities being inherent to human experience, Michael Vincent Miller (2003), in a beautiful article called Notes on Art and Symptoms, reminds us that Gestalt therapy theory reflects concepts where familiar with in the field of art. Good contact can be seen as an aesthetic activity and these activities demonstrate good form and others beautiful, in the sense of being meaningfully organized and integrated.

It’s precisely the integration of seemingly incompatible and disparate experiences, the ability to deal with the challenges of ambiguity and complexity, the skill of being able to embrace differing perspectives and contradictory alternatives with ease and comfort, that’s our goal and therapy, for they afford us meaning in a sense of being one with ourselves in relation to others. Such ongoing gestalt formation belongs to the essential goals of therapy.

Both art and psychotherapy thus reflect the human tendency to form and transform familiar elements and thus bring about new information to transform one’s own experience in a world in a way that allows for integration by creating something unique and meaningful. Form is given to human experience. It’s precisely the integration of seemingly incompatible and disparate experiences, the ability to deal with the challenges of ambiguity and complexity, the skill of being able to embrace differing perspectives and contradictory alternatives with ease and comfort, that’s our goal and therapy, for they afford us meaning in a sense of being one with ourselves in relation to others. Such ongoing gestalt formation belongs to the essential goals of therapy.

To Laura Perls, we human beings are always involved in the polarities of being unique and being mortal. The first gives us the impression of incredible significance. The second the feeling of fear and frustration and the human condition is a continuous balancing of the tension between these poles.

Richard Wallen convincingly tied gestalt psychological principles in particular gestalt destructuring and formation to the effect of practice of herself therapy. He suggested ways of interest intervening, that would de-stabilize a blocked unsatisfying life situation and support the patient in reconfiguring the field into a meaningful whole. He gave great attention here to bodily awareness and careful experimentation with perception of and movement. Although he doesn’t speak in terms of fertile voids or polarities, he does focus on deconstructing an imbalanced field and reassembling it beginning fresh to allow a meaningful stop to emerge and this brings me to Jean-Marie Robine profound work on taking shape.

In an article published in 2003 or being focused is his attention on the therapeutic situation and the importance of the unoriginal pre-differentiated phase the vague, confused, diffuse or chaotic phase of four contact before a figure clearly emerges. He states what we call the “social situation” is a structure of possibilities that I create with the other, and which in turn creates us respectively. Clearly the therapeutic situation defines my presence and my intention as a psychotherapist just as it defines the presence and expression of my client.

The concept of the self in gestalt therapy tends to focus on someone’s I am, a narrative identity. Which is one of the possible declensions of the personality mode of the self. A result of experience in a certain situation.

Contrary to gestalt’s temporalized and delocalized way of approaching the concept of self narrative identity tends to be static perceived as a structure or character. It gives us the impression of fixity, suggesting that the self is something permanent or stable. So this need for stability and continuity forecloses access to the novelty of situations and opens us to the repetition of experiences, including the most painful ones. So if a patient has some presuppositions about themselves or us as a therapist, then it prevents this person from sensing in the situation, what’s really going on. They aren’t of the situation. So, this might suit their comfort zone and need for security and certainty, but instead of staying in contact with their immediate sensations and perceptions, however vague, confusing or contradictory, we often tend toward what Robine calls premature differentiation, which is based on a similar premature individuation.

So Robine compels us to linger in this phase of four contact or skillfully return to it with our patients. So we can enable them to access novel aspects of our meeting and to avoid these over-hasty assertions or premature intentionality, because intentionality proceeds, what forms a person’s conscious intent.

We can seek it in the therapeutic situation by expressing how we, as another in the presence of our patient, are mostly impacted by this encounter how we resonate and experience it. We begin with experience with what is sensed and perceived in the moment as opposed to our assumptions of the other.

What I sense and intuit when together with someone helps me to understand what’s in the field. The way I’m affected by a patient gives me information about their intentionality, and how I act on this, can support its differentiation and open the person to new possibilities. Here, now, next tells us that in the present moment there’s an orientation, an imminent direction, an implied future.

Robine talks about the metaphoric construction site, which is reopened by each encounter giving us novelty surprises and touching the unknown. And it appears to me that it’s just this metaphoric construction site –I love that expression — Is the rich source of all possibilities creative indifference.

This view has implications for the effective practice of gestalt therapy. Robine reminds us to attend more carefully to the phase of the process of construction and deconstruction of gestalts. The emergence of figures against the background. As he said at the fertile exit from the void, that according to Perls, defines the zero point, the before and after of every gestalt.

So instead of taking our patients presenting problem, or the figure they decided to work on it face value, it’s our task to introduce a measure of uncertainty or doubt, maybe irritate them. Interventions are called for that enhance the vagueness. They can help to work back to the id of the situation, to an undifferentiated state from which together we can allow gestalt construction and deconstruction to an unfold.

As Robine says, this complexifies intentionality by amplifying confusion. This is one of the gold nuggets in this article, it’s wonderful. So we joined the revisit the elements that contributed to the emerging figure. We disentangle the material, we try to reconnect it, we restructure it, through the presence of another in a way that takes our own situation or present and our presence into account. We afford the patient different information adding complexity and the reorganization. The process of reconstruction allows for novelty and the reorganization of a dysfunctional situation. So this redistributes the excitation. It reorients the direction of meaning. We extend an invitation to play. We play with the situation until work becomes played.

Enabling possibilities

Therefore our interventions are aimed at enabling possibilities. We collectively disconnect deconstruct de-autonomized we reshuffle and then we reconstruct. We stand by our patients during upheaval and temporary chaos. We contain confusion and seeming incompatibilities. We assist the new configuration of figure and background we maintain mobility and flexibility. Our task is not a matter of substituting dysfunctional connections with new more appropriate ones. But it’s much more matter of introducing mobility in such a way that nation’s experience can modify if you can modulate its available and accessible materials into creative configurations themselves, unceasingly renewed. As an old saying goes, “if you give someone a fish then he has food for one day, but if you teach him how to fish then they’ll have food for lifetime”.

Our patients’ difficulties in living their symptoms and suffering can be seen as the production of figures from the available materials in their backgrounds, it’s a process of gestaltung, of taking shape giving form to something. So we’re engaged in the structuring of the situation. Often we’ll have to interrupt a patient’s prepared narrative or insist on rewinding the film so that we can benefit from the possibilities of an undifferentiated starting point and continuously engaged in the aesthetic creation of meaningful forms.

It’s this undifferentiated location, this vague phase of fore contact, that I relate to creative indifference, it’s the deep well of all possibilities the metaphoric construction site. So my perspective can be summed up as a decidedly relational multidimensional approach our tasks are to intervene in such a way that the rigid patterns of our patients can be softened, their age-old assumptions are reassessed as to their appropriateness to the current situation over hasty narratives are slowed down and explored step by step. A prefabricated solution to a problem is put on hold and the focus is placed on collaborative meaning-making based on aesthetic experiences.

Accordingly the original situation and materials from which these figures emerge can be jointly perceived, experienced, reconnected in a novel way, thanks to the sensory experience, immediate emotional reaction and insights of the therapist within the therapeutic situation.

Typical interventions to this effect are:

“I feel as if you’re giving me the answer to a question I haven’t posed yet.” “Let’s rewind the film to the beginning and proceed slowly.” “Tell me more about what you were experiencing before you came to this conclusion.” “How else could we perceive this situation?” “What might we have overlooked?” “Describe your bodily sensations and impulses.” “Do any images arise?” ” What do you smell or taste?” “Who or what might have played a role when this difficulty first arose?” “What’s the opposite of your fearing powerless and being at your partner’s mercy?” “My breathing becomes shallow as I listen to you.” “I feel angry when I hear what you’re telling me.” “I start to feel hypnotized when I listen to you talking without interruption.” “I feel out of touch with you when you talk about yourself in terms of clinical diagnosis.”

Clearly this implies that we’re not working solely with a patient’s polarities, but also with what emerges is figural from the context of our experiences, with our immediate sensory and emotional reactions, our fantasies, with our reflections on the therapeutic relationship and dynamics.

The therapy room has become a multi-dimensional space for creative play and experiments, for novel compositions mixtures and new combinations. We are part of the equation. A creative elaboration of therapy is for the moment real and the game. One which is limited in time, but which has a lasting effect.

We have extended an invitation to play. As psychotherapist we can assume that if people have learned one-sided view of themselves and others, they can also learn to balance these misperceptions or premature assertions. At times we’re like good parents. We’re attentive to their needs. We offer them a safe space to explore what might feel threatening and encourage them to restructure and reconnect their interpersonal fields. We encourage them to take stock of their current assumptions and models of the world, to test novel ways of construing and discover what’s appropriate to their life here-and-now with a view to what comes next. Thank you for your attention.

creative indifference, gestalt therapy
Creative Indifference & Gestalt therapy. These are my notes on this lecture.

Bibliography

Ament-Lyon, N. (2019). How can a void be fertile? EAGT Gestalt Conference 2019, Budapest, Hungary. https://www.youtube.com/watch?v=kXMw7h5WWds

Miller, M. V. (2003). The aesthetics of commitment: What gestalt therapists can learn from Cezanne and Miles Davis. In Creative License (pp. 153-161). Springer, Vienna.

Perls, F. (1942, 1947). Ego, Hunger and Aggression  ISBN 0-939266-18-0

Perls, F., Hefferline, G., & Goodman, P. (1951). Gestalt therapy. New York64(7), 19-313.

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

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.

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.