Author: Chew-Helbig, N.

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

Introduction

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

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

Definition of Compulsive Sexual Behaviour Disorder (ICD-11)

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

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

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

Diagnostic requirements (ICD 11) are as follows:

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

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

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

Variations of Compulsive Sexual Behaviours and Sex Addiction

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

Life Consequences caused by CSBD

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

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

Who are at risk of developing CSBD?

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

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

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

There are gender differences associated with CSBD:

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

How Addiction to the Compulsive Sexual Behaviour Starts

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

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

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

How Addictive Behaviour is Reinforced

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

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

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

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

This is the compulsion cycle.

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

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

Comorbidity with other Psychiatric Disorders

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

Neural Correlates of Compulsive Sexual Behaviours

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

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

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

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

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

This demonstrates the splitting that exists in subjects with CSBD.

Gestalt Therapy for Treatment of Compulsive Sexual Behaviour Disorder

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

Gestalt Awareness Continuum approach and Contact Interruption in CSBD

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

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

The Therapeutic Contact begins before the Beginning.

This is also known as the pre-contact phase.

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

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

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

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

The Paradoxical Theory of Change in the Treatment of CSBD

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

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

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

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

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

Psychopathology is a Phenomenological Process in Gestalt Therapy

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

Psychopathology is process.

Psychopathology relies upon the following:

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


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

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

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

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

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

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

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

Creative Indifference as Central Attitude when working with CSBD

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

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

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

Polarities as depicted in Zinker (1977).

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

Conclusion

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

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

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

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

Case Study of “John”

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

References

Ballester-Arnal, R., Castro-Calvo, J., Giménez-García, C., Gil-Juliá, B., & Gil-Llario, M. D. (2020). Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive behaviors, 107, 106384

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

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

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

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

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

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

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

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

Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … & Irvine, M. (2014). Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one, 9(7), e102419.

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

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

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

Transitioning. This is an important interview.

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

Gestalt Therapy: The Paradoxical Theory of Change

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

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

Beisser (1970)

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

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

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

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

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

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

Reference

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

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

Introducing the Aesthetic Turn in the field of Psychotherapy

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

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

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

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

Read more on Therapeutic Autoethnography

Reference

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

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

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

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

Compulsive Sexual Behaviour Disorder in Psychotherapy

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

Definition of Compulsive Sexual Behaviour Disorder

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

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

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

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

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

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

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

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

Differentiation of Compulsive Sexual Behaviour from Sexual Desires and Libido

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

Neuroscience of Compulsive Sexual Behaviour Disorder

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

Psychotherapeutic Approach to Compulsive Sexual Behaviour Disorder Diagnosis

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

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

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

Gestalt Therapy understanding of CSBD

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

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

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

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

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

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

References

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

Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior: Prefrontal and limbic volume and interactions. Human brain mapping, 38(3), 1182-1190.

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

How does Psychotherapy Work? General Systems Theory and Synchronization

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

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

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

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

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

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

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

Francesetti, 2015

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

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

General systems theory

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

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

The phenomenon of Synchronization

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

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

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

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

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

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

Psychotherapy and General / Dynamic Systems Theory

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

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

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

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

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

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

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

On the lighter side…

Want brief therapy? This is what it looks like…

References

Francesetti, G. (2015). From individual symptoms to psychopathological fields. Towards a field perspective on clinical human suffering. British Gestalt Journal, 24(1), 5-19.

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

Gestalt Therapy Verbatim (Perls, 1969): Book Review

A thousand plastic flowers 
Don’t make a desert bloom 
A thousand empty faces 
Don’t fill an empty room.

Fritz Perls

I enjoy reading this book, written “ad verbatim”, as the title describes. The presentation style gives us an implicit sense of who Perls is and his first-person perspectives as a therapist.

“Gestalt therapy verbatim” is a unique book that gives readers a firsthand look at the ideas and techniques of Gestalt therapy through the words of its founder, Fritz Perls. The verbatim format, in which Perls’ words are recorded exactly as he spoke them during therapy sessions, lectures, and workshops, provides an authentic and engaging look at the development and practice of Gestalt therapy. It can be a valuable resource for those interested in learning about Gestalt therapy or for those who are already familiar with the approach and want to gain a deeper understanding of Perls’ thought and practice.

The book is segmented into two parts – first, an introductory section that describes Gestalt therapy and provides brief background information about its origins and development; and second, three case histories that show how Perls applied his approach during his encounter with the clients named in the case studies.

This is an aged enjoyable book. I have assembled some excerpts here.

Perls on “techniques”

One of the objections I have against anyone calling himself a Gestalt therapist is that he uses technique. A technique is a gimmick. […] We’ve got enough people running around collecting gimmicks, more gimmicks, and abusing them.

Perls adds that Gestalt therapy is not about providing instant cure, instant joy, instant gratification. That works in psychiatry, in addictions, and in today’s world, through the likes of pop-cultured therapy. Gestalt therapy offers all the opportunity for growth, and growth is an organic process. The client has to invest in themselves and grow.

Perls on Anxiety

Anxiety is the gap between the now and the then. If you are in the now, you can’t be anxious, because the excitement flows immediately into ongoing spontaneous activity. If you are in the now, you are creative, you are inventive. If you have your senses ready, if you have your eyes and ears open, like every small child, you find a solution. (p. 23).

He differentiates this from hedonism, where one seek pseudo sensory stimulation. Let us perhaps reflect on how we can relate this concept with the problem of compulsive disorders like sex addiction.

Perls on what happens in the splitting of the self and pathology

You are already coming to the point where you begin to understand what happens in pathology. If some of our thoughts, feelings, are unacceptable to us, we want to disown them. “Me, wanting to kill you?” So we disown the killing thought and say, “That’s not me — that’s a compulsion.” Or we remove the killing, or we repress and become blind to that. There are many of these kinds of ways to remain intact, but always only at the cost of disowning many, many valuable parts of ourselves. The fact that we live only on such a small percentage of our potential is due to the fact that we’re not willing — or society or whatever you want to call it is not willing — to accept myself, yourself, as the organism which you are by birth, constitution, and so on. You do not allow yourself — or you are not allowed to be totally yourself. So your ego boundary shrinks more and more. Your power, your energy, becomes smaller and smaller. Your ability to cope with the world becomes less and less — and more and more rigid, more and more allowed only to cope as your character, as your preconceived pattern, prescribes it. (p.31)

Noteworthy is that this book was written in the 1960s, when the polyvagal theroey concept of introception was not yet discovered. In my practice I do guide the client to separate their ruminating thoughts (that is a bottom-up introception) from conscious thoughts.

Perls’ thoughts on trying to change oneself and others

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

When we reflect on attitudes on mental health today, which modality is most sought after? The modalities that promote self-image actualization, where there is a delusion that we can change ourselves, our thoughts and our relationships, or the ones that are based on the theory of authentic and organic self actualization?

Perls on Growth, the Impasse, and the aim of therapy

[H]ow do we prevent ourselves from maturing? What prevents us from ripening? […] We ask the question, what prevents — or how do you prevent yourself from growing — from going further ahead? […]

My formulation is that maturing is the transcendence from environmental support to self-support. Look upon the unborn baby. It gets all its support from the mother — oxygen, food, warmth, everything. As soon as the baby is born, it has already to do its own breathing. And then we find often the first symptom of what plays a very decisive part in Gestalt therapy. We find the impasse. Please note the word. The impasse is the crucial point in therapy — the crucial point in growth.

The impasse is called by the Russians “the sick point,” a point which the Russians never managed to lick and which other types of psychotherapy so far have not succeeded in licking. The impasse is the position where environmental support or obsolete inner support is not forthcoming and authentic self-support has not yet been achieved. The baby cannot breathe by itself. It doesn’t get the oxygen supply through the placenta anymore. We can’t say that the baby has a choice, because there is no deliberate attempt of thinking out what to do, but the baby either has to die or learn to breathe. There might be some environmental support forthcoming — being slapped, or oxygen might be supplied.The “blue baby” is the prototype of the impasse which we find in every neurosis. (P. 48)

The process of maturation is the transformation from environmental support to self-support, and the aim of therapy is to make the patient not depend upon others, but to make the patient discover from the very first moment that he can do many things, much more than he thinks he can do.

Perls on Character

The more character a person has, the less potential he has. That sounds paradoxical, but a character is a person that is predictable, that has only a number of fixed responses, or as T. S. Eliot said in The Cocktail Party, “You are nothing but a set of obsolete responses.” (P. 53)

Character is a fixed response that we develop in childhood to manipulate the environment, to get our needs met. The basic need is love from the child’s caregivers, and manipulation comes in the form of playing roles that keep the individual immature.

On changing every question to a statement

“One fool can ask more questions than a thousand wise men can answer.” All the answers are given. Most questions are simply inventions to torture ourselves and other people. The way to develop our own intelligence is by changing every question into a statement. If you change your question into a statement, the background out of which the question arose opens up, and the possibilities are found by the questioner himself.

[…]Every time you refuse to answer a question, you help the other person to develop his own resources. Learning is nothing but discovery that something is possible. To teach means to show a person that something is possible.

“Why and because are dirty words in Gestalt therapy.” (p. 64)

when we ask why we get an explanation and we will fail to get an understanding.

Perls on Resentment

We see guilt as projected resentment. Whenever you feel guilty, find out what you resent, and the guilt will vanish and you will try to make the other person feel guilty. […]

If you have any difficulties in communication with somebody, look for your resentments. Resentments are among the worst possible unfinished situations — unfinished gestalts. If you resent, you can neither let go nor have it out. Resentment is an emotion of central importance. The resentment is the most important expression of an impasse — of being stuck. If you feel resentment, be able to express your resentment. A resentment unexpressed often is experienced as, or changes into, feelings of guilt. Whenever you feel guilty, find out what you are resenting and express it and make your demands explicit. This alone will help a lot. (p. 68)

Perls goes on to explain how resentment that is articulated, then switched to appreciation is healing.

Perls on Nothingness and the Fertile Void

The whole philosophy of nothingness is very fascinating. In our culture “nothingness” has a different meaning than it has in the Eastern religions. When we say “nothingness,” there is a void, an emptiness, something deathlike. When the Eastern person says “nothingness,” he calls it “no-thingness” — there are no things there. There is only process, happening. Nothingness doesn’t exist for us, in the strictest sense, because nothingness is based on awareness of nothingness, so there is the awareness of nothingness, so there is something there. And we find when we accept and enter this nothingness, the void, then the desert starts to bloom. The empty void becomes alive, is being filled. The sterile void becomes the fertile void. I am getting more and more right on the point of writing quite a bit about the philosophy of nothing. I feel this way, as if I am nothing, just function. “I’ve got plenty of nothing.” Nothing equals real. (pp. 77-78)

The concept of the Fertile Void is critical to the understanding of Gestalt therapy, a topic which is discussed in these pages:

Perls on taking responsibility and blaming

All the so-called traumata which are supposed to be the root of the neurosis are an invention of the patient to save his self-esteem. None of these traumata has ever been proved to exist. I haven’t seen a single case of infantile trauma that wasn’t a falsification. They are all lies to be hung onto in order to justify one’s unwillingness to grow. To be mature means to take responsibility for your life, to be on your own. Psychoanalysis fosters the infantile state by considering that the past is responsible for the illness. The patient isn’t responsible — no, the trauma is responsible, or the Oedipus complex is responsible, and so on. I suggest that you read a beautiful little pocketbook called I Never Promised You a Rose Garden, by Hannah Green. There you see a typical example, how that girl invented this childhood trauma, to have her raison d’etre, her basis to fight the world, her justification for her craziness, her illness. We have got such an idea about the importance of this invented memory, where the whole illness is supposed to be based on this memory. No wonder that all the wild goose chases of the psychoanalyst to find out why I am now like this can never come to an end, can never prove a real opening up of the person himself. (P. 62)

Considering that trauma work is a critical part of therapy, could Perls’ words in the above passage put into question his credibility on the subject of trauma? Well, before the “Harry & Meghan” saga at the turn of this year, 2023, and before “woke-ism” lost its meaning, which is compassion, I might have considered Perls’ opinion here archaic. However, now I understand what he’s saying. Perls warns us in 1969 that we will want to redeem ourselves from our low self-esteem, and the easy way out of true healing from this shame is to lay blame or make excuses for ourselves. Laying blame is relinquishing responsibility, not what trauma work or psychotherapy is about.

The work with trauma, revealing and processing traumatic events in psychotherapy functions to bring to light childhood pain that the client was not previously able to access. In childhood, the individual adapts to suffering out of context. Adaption to suffering ultimately becomes a fixed pattern of being in the world. This pattern is the personality. When the pain of the past is revealed, it can be felt, sensed and shared. In therapy, the therapist witnesses the suffering that is shared. When this happens, there is enlightenment. The client can then fully grasp feelings they have dissociated from in childhood and infancy. Only then can these feelings be relegated to the past. Feelings relegated to the past will less likely interfere with the present and future without awareness.

The “woke” movement of popular culture today has used the psychotherapeutic process as a Trojan horse for its agenda. Instead of realising suffering and being compassionate to their child-self, the woke seek to redeem themselves of the shame (‘low self-esteem’) from having to suffer childhood helplessness by taking revenge. Revenge is a need for release, to lash out, to whine at the world, to complain and criticise, and it is cathartic. The act of revenge is infantile. The woke person plays the role of victim and perpetrator. In so doing, they fail to mature. They become toddlers in grow-up bodies that can cause destructive revenge. Revenge is violent, and the acts do not heal anyone. Revenge is the transfer of pain from the sufferer to their victims through violence. Violence is the transference of pain that is absent in the perpetrator to the victim. Pain is transferred until it is transformed (Weil, 1952, in this article).

Perls on Group therapy

Basically I am doing a kind of individual therapy in a group setting, but it’s not limited to this; very often a group happening happens to happen. Usually I only interfere if the group happening comes merely to mind-fucking. Most group therapy is nothing but mind-fucking. Ping-pong games, “who’s right?,” opinion exchanges, interpretations, all that crap. If people do this, I interfere. If they are giving their experience, if they are honest in their expression — wonderful. Often the group is very supportive, but if they are merely “helpful,” I cut them out. Helpers are con men, interfering. People have to grow by frustration — by skillful frustration. Otherwise, they have no incentive to develop their own means and ways of coping with the world. But sometimes very beautiful things do happen, and basically there are not too many conflicts, everybody who is in the group participates. Sometimes I have people who don’t say a single word through the whole five-week workshop and they go away and say that they have changed tremendously, that they did their own private therapy work or whatever you want to call it. So anything can happen. As long as you don’t structure it, as long as you work with your intuition, your eyes and ears, then something is bound to happen. (p. 93)

Reference

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

Fritz Perls: What is Gestalt? 1970 Video

The founder of Gestalt therapy, Fritz Perls tells us in his own voice in this gem of a video. What gestalt therapy is. Listen to this, and we can make up our minds as to how relevant this modality of psychotherapy Gestalt therapy is, and has developed till today.

This is what Fritz tells us…

The idea of Gestalt therapy is to change paper people to real people. To make the hollow men of our time come to life and teach him to use his inborn potential. To be a leader without rebelliousness. Having a center without being lopsided.

The social milieu in which we find ourselves, regulated by “should-isms”, by Puritanism where you do your thing whether you like it or not; or by the other extreme, hedonism, “where we live for fun and enjoyment, being turned on anything goes as long as it is nice.”. We become phobic towards pain and suffering.

We avoid and run away from frustration or pain. The result is the lack of growth. [He is not talking about masochism].

The main idea about Gestalt is that Gestalt is about the whole; about being complete. This involves guiding the person to feel, sense and perceive the present (the now), even painful emotions, and allowing the self understand the now and be integrated in the experience.

We ask how. We don’t ask why. Asking ‘how’ helps us to understand. It is in understanding that we can change structure of our life script.

Therapeutic Autoethnography

Doctorate Dissertation 2023

Abstract

Therapeutic Autoethnography is founded on Autoethnography, an emergent field in qualitative research. Therapeutic Autoethnography engages the practitioner as a researcher in the field of the psychotherapy situation. It is a practice-based, practice-driven, practice-informed qualitative research method. It provides an in-depth understanding of what goes on in the diverse naturalistic setting of psychotherapy practice. In Therapeutic Autoethnography, the field being investigated is the therapy situation, which encompasses the individuals attending the session, the therapeutic alliance, and its environment. In the role of researcher, the therapist creates aesthetic accounts of their experiences in the field with their client(s). The writing process is deliberately reflexive and integral to the method. This act of creative writing is a heuristic process where new insights emerge for the researcher. This thesis demonstrates how Autoethnography can be applied as a practical methodology for psychotherapy case study research, especially for explicating the implicit nuances in therapy. 

Keywords: Autoethnography, Therapeutic Autoethnography, psychotherapy research, case study research

academia-Chew-Helbig-Therapeutic-A

Reference

Coming soon