Gestalt Therapy Case-Study: From procrastination to recalling a story in a novel

Written by: Nicole Chew-Helbig on 15 June 2017 in Vienna, Austria.

Cite this article as: Chew-Helbig, N. (06/2017), Gestalt Therapy Case-Study: From procrastination to recalling a story in a novel, in The Psychotherapist . Date accessed 08/2019, https://nikhelbig.at/gestalt-therapy-case-study-from-procrastination-to-recalling-a-story-in-a-novel/.

Abstract

This case study is an abstract from a therapeutic work. It is a demonstration how a recall of the client’s favorite novel as a teenager develops into a psychotherapeutic session that is meaningful to the clients identification of himself. This is a technique usually used for working with dreams in Gestalt therapy, in which the client plays the parts (makes projections) of his dream.  In this case it is not the dream, but the novel.

Case study: CL’s Novel

CL works in a publishing company. He reports having problems with procrastination. Although quite successful at his job, he struggles making datelines. He finds himself delaying getting things done till the last minute, which sees himself sitting up till early hours of the morning smoking cigarettes. This is an excerpt of a Gestalt Therapy Session. Throughout this article, the principles of Gestalt Therapy adopted in this session are also explained in this color.

NC: Now can you bring to mind a moment in which the word “procrastination” feels familiar?
CL: (Contemplates…) Yes. I had to write a short article for the company’s blog. It was in morning, I took out the PC, but then I did instead some online shopping.
NC: Stay with the feeling of the moment before you switch to online shopping.

“Staying with the feeling” is an approach in GT where the narrative (which is usually an intellectual process) is embodied into experience.  
CL: I feel anxious.
NC: This familiar to you?… stay with it. Can you remember a time in your childhood when you felt something like this?
CL: In school. It was Math, and I had homework. The teacher wasn’t pleased, I made mistakes I did not understand…

This narrative goes on, and we talked about anxiety about what he considered “small criticism”. This recall of the past is a “free association”. The experienced client knows how to take memories or images that pop up in the moment and vocalize them. Sometimes these associations do not seem to make sense at the moment, but these usually do. 

NC: Stay with this anxiety again… much earlier… maybe at home…
CL: Nothing special, really, I am just having a picture of a dirty bicycle. I was 8 or 9, it is my bicycle. I was supposed to clean it, but I didn’t want to do it.
NC: You had to do it, but you do not want to do it now?

CL had used the present tense, and I felt it is a good thing, so I followed with the present tense. This is a good opportunity to work with past experiences as if it were in the present. Actually this is how we live, with occurrences of our past popping up in the present.

CL: Yes.
NC: What would you rather have done?
CL: Read a book.
NC: Have you a book in mind?
CL: Yes. (mentioned a title of a book).
NC: Where would you go to read this book?
CL: In my bedroom.
NC: How does it feel to be in your bedroom reading this book?
CL: Relaxed, comfortable… safe.

Notice that he said “safe”. It seems to correlate with the “anxiety” behind the procrastination. This is an indication that sitting in the room, and reading that book is a way out of anxiety. At this point I could have gone back to the anxiety, and tried to work on it. My interest of the moment, however, took me to the curiosity about the book (which I will explain later why). This is working in the here-and-now. The therapist is following her own feelings of curiosity, and being present.  This means that we may, at this juncture abandon trying to sort the problem of procrastination. In Gestalt, we work on what is present. The present is always changing. We do not try to force goals into the present or force the client to concentrate or dwell on issues that are not there at the moment.

NC: The title of this book got my interest, I have not heard of it before.
CL: (laughs). It is a very old novel. German novel about German brothers coming back from the 2nd World War, and the Russians came.
NC: You mentioned this book was comforting to you, a 9 year old.
CL: for some reason, yes.

The backstory here is, like many of his generation, CL’s estranged father was a soldier in the German NS. CL himself is a liberal (kind of left-wing writer). This information in background, now got my interest to this book preference CL as a child. The background is very important to the Gestalt therapist because we are interested in the foreground. The foreground is made clearer only when the background is complete. 

NC: Tell me about the book…
CL: (laughs, a little more shakily. He goes to his phone, and searches this book on an online site. Makes some association:)
NC: What comes to mind…
CL: Two scenes. This guy talks to his buddy in prison about the time he was taken from his home by the Russians. He was in the garden of his parent’s home, and his mother had baked a cake. Then they came to take him away. (laughs) He tells his buddy that he wished now that he had taken the cake along with him. The other scene is that he tells his buddy, “now I hope the Americans come, and gets rid of the Russians, so that they can free us”).

CL, has made associations again. This I found to be interesting. The scenes have irony and are a bit funny. Freud in his writings, “Der Witz und seine Beziehung zum Unbewußten” or “Jokes and Their Relation to the Unconscious” , tell us that there is significant repressed unconscious material in jokes. We’ll see how this plays out… 

NC: Could you play out the scene? Try. You are this guy talking to your buddy in prison. Say “I am in the garden of my parents, and my mother had baked a cake…”

Unlike psychoanalysis, where the therapist takes on the task of analyzing the joke for the client, in Gestalt Therapy, the client tells us his/her version of the story. This method is usually used in Dream analysis (or dream work) in Gestalt therapy. The client is invited to take a role in his dream (or in this case, story). His task is to talk in the first person.  By this time, there was actually resistance on the part of the client. There were points in the session when CL started to intellectualizing, either by stepping out of the scene, or to make judgment of the scene, even though he was quite agreeable to doing this experiment of playing the part of the characters in his associations. Playing part in associations and dreams is usually uncomfortable for many people because they feel awkward, or they do not trust what they say or feel in this kind of work. My experience is that the client is seldom ever wrong in this sense.

CL: I am in the garden of my home. My parents are there. Mother has baked a cake.
NC: Tell me about the cake.
CL: Delicious. She baked it often.
NC: then what happened.
CL: Soldiers came to the gate, and took me away. Then I am in the prison talking…
NC: Slow down. What happened as they took you away…
CL: That is not in the book.
NC: They are at the gate, they ask you to come with them.
CL: Yes.
NC: What’s going on.
CL: I feel scared, I suppose.
NC: I can imagine.
CL: In I am not sure if I would ever come back.
NC: Yes. Now, come back here with me. Have you an understanding what is going on with this character in prison as told his buddy that he should have taken the cake along?
CL: He is scared, he wished his mother was there, he’s afraid he would never see her again.
NC: Would you like to work on the next scene?
CL: Sure.
NC: I am in prison and I hope…?
CL: I am in prison, I tell my buddy, I hope that the Americans come soon and drop bombs on the Russians.
NC: What is the purpose of that?
CL: to save us.
NC: From?
CL: We are trapped in prison.
NC: What does it mean to be in prison?

This part took a bit of time. We stayed with it together… Staying with the client’s pause is good point of contact. Contact is a very essential part of Gestalt therapy. It usually comes when the client touches something emotionally significant, and when the therapist is able to give support. 
CL: No freedom… I am in danger… I am guilty… I feel hopeless… I feel helpless…
NC: in prison, no freedom, in danger, guilty…
CL: yes.

The client, in his association, has come to contact with some deep feelings. These are unconscious until now. We can ask “what are you feeling guilty about…?”, but this might lead the client to intellectualizing. The cleaner path is to bring the client back to the present situation, the here-and-now.

NC: Tell me about what’s happening now. You being here with me now, we are talking now…
NC: are you in danger?
CL: no. I am safe.
NC: Guilty?
CL: No… not hopeless nor helpless. (Takes a deep breath.)

Note that this is a condensed version of the dialogue. CL had a bit of difficulty with the associations at first, and this is normal. Why we worked these scenes is because they were freely associated, and my guess was that they had significance. The other clue that this was significant was the resistance of the client along the way of this experiment.

At the end of the dialogue, CL took a really deep breath reflexively. He looked calm, and said “I feel good”. “Fine,” I said, and we ended there.

This short session demonstrated a closing of a gestalt. The client had anxiety-related procrastination issues, and that led to a memory. This memory led to a group of unconscious feelings, which took solace is a kind of joke or wit, or an entitled way of thinking “I hope the Americans bombs the Russians..” These were also not fully owned by the client, since he attributes it to a story book. However, the client was really interested in the experiment, because he realized, too, that there was some kind of association between this story and his relationship to his father. The beauty of Gestalt therapy is that we help the client come to his own meanings and understanding through his experiencing and embodiment of the experience. The therapist’s work here was that of supporting, and not of prying. 

In the following sessions we discussed this dialogue again in relation to CL’s relationship to his parents. There was even clearer understanding to the cultural significance of “jokes” or “making light” in tough situations. Also, there was a discussion about how we deal with anxiety and fear.

The rest of the associations with regards to this dialogue, I’ll leave it to you, the reader.


An Entrepreneur in Therapy: Case study by Kets de Vries

This is a case study excerpt form this featured book, Reflections on Character and Leadership by Manfred Kets de Vries (pp.20).

Cite this article as: Chew-Helbig, N. (06/2017), An Entrepreneur in Therapy: Case study by Kets de Vries, in The Psychotherapist . Date accessed 08/2019, https://nikhelbig.at/an-entrepreneur-in-therapy-case-study-by-kets-de-vries/.

Why this case study? 

Kets de Vries gives a very detailed psychoanalytic account of a case study of an entrepreneur he names Nr. X. This case study illustrates how the inner and private life of the leader have significant effect on the performance of the leader. As the leader gets older, it is not unlikely that unresolved inner problems from childhood affect many areas of the individuals life, including his/her relationships and health.

Reason for Seeking Psychotherapy
Client:  Mr. X, a 44 – year – old. Youngest of 6 siblings (2 brothers, 3 sisters). Occupation: Entrepreneur. Family Life: 21 years married but recently separated, 4 children.

Events leading to therapy request:

  • Mr X. had thrown his wife out of the house.
  • her increasing need for more independence had become a bone of contention.
  • He complained about her lack of caring and suspected that she was emotionally involved with a younger man working at the office (she worked in his company).
  • He is strongly annoyed that his children had taken the side of his wife.
  • History of depressive episodes (but not thought of as serious as now).
  • Has now feelings of worthlessness. No life prospects.
  • Fears losing his mind.
  • Problems at work due to wife’s (and young colleague’s) departure.
  • Worries about the company health. Fears of bankruptcy / humiliation as result.
  • Feels paralyzed at work. Not able to function. Feeling painful going to the office.
  • Psychosomatic complaints: nightmares, sleep problems, severe headaches which affects eyesight. Temporary loss of vision. Diarrhea and nausea. Impotence.

Childhood History

Mr. X’s thoughts about his father: a salesman / entrepreneur. Often away from home due to work. Remembered as a boisterous man who laughed a lot and brought him presents from his frequent business trips. Felt that he was his father’s favorite. When he was seven years old, his father became bedridden. Having his father in the house gave the boy the opportunity to spend more time with him. He began to feel close to his father. When he was 98 years old, his father died in a mental institution. This event was to Mr. X shrouded in secrecy. Mr. X is suspicious of the fact that his mother and elder sisters transferred his father to the mental hospital, thinking it was unnecessary and that it caused his death. He had tried a number of times to find out what had really happened, but had not been able to uncover the truth. The whole incident seemed to have been suppressed as a dangerous family secret. Mr. X suspected that his father had committed suicide which, given his family’s religious orientation, would explain the secrecy around the incident.

Mr. X’s recollection about his mother: Described as a very controlling, overprecise, critical woman who constantly worried about money and the future. After the death of his father she struggled maintaining the family also with coping financially. He felt that she saw everything in a
negative light. She never made a positive comment. Nothing he did was
ever good enough. He also described her as a perfectionist. He had never
been able to live up to her standards.

Mr. X’s recollection about his childhood life: Apart from the death of his father,his childhood was described as uneventful and quite happy. He felt proud of the fact that he had been something of a rebel as an adolescent.

Major Issues

  1. Relationships with women:
  2. Attitude to work: He used to be enthusiastic about his company, now feels it is too complicated and wants to give it away. Similar feelings about possessions.
  3. Depression: feeling pessimistic, life is a sacrifice, fear of being alone. Feeling completely deserted due to wife’s departure from his life. According to Mr. X, he once used to have everything. Now things were different; his health had been ruined; his life was in a shambles. He felt worthless. He wondered what had kept him so busy at work in the past.

Personality Issues

“He revealed that throughout his childhood he had been scared of losing control. He was reluctant, for example, to fight with other children for fear that he would lose control and kill someone.

Denial of inner reality and flight into external reality through work had
become a way of life. His defensive structure, however, of escaping into
action — ‘ the manic defense ’ (Klein, 1948) — no longer seemed to work.”

Dramatic mood swings, an all – or – nothing attitude. Very little was needed to push him in one direction or the other.

Repressed Emotions & Inner Reality
Denial of feelings of depression through unrealistic optimism, laughter, humor, frantic activity, and excessive control had always been an important element in maintaining Mr. X ’ s psychic equilibrium.

Attempts to fight his depressive state by eliminating negative thoughts. Turns to self-help books in order to improve ability to repress depressive reality.

This point of a person, and this happens often with people who are functioning and try to excel in aspects of their life through forcing themselves into change. i.e. When I feel hurt/stressed/sad/angry (any “negative” feelings), I try to escape by pushing myself to do better, to think positive. This works, but only very temporary. The breakdown that comes is usually catastrophic and very difficult to overcome. In Gestalt psychotherapy, there the paradoxical theory of change (Biesser, 1970).

Unfolding through Therapy

As Mr. X worked his way through therapy he was able to admit to himself several things that was repressed:

  • that his childhood was not so happy as he made it out to be. He realized his urge to think positive and believe positive (unlike how he sees his mother, as a pessimist). He realized how he was treated “like a baby” (which also means not being respected, and made to feel small), feelings of envy of his brother for the role of he man of the house.
  • He remembers using complaints of physical ailments to get attention, and being sensitive to children crying.
  • Was able to acknowledge his father’s darker side. That his father had beaten his children, stifle his behavior, strict rule enforcing.
  • His Oedipal memories.
  • His identification with his father’s tendency to be fake, hiding feelings.
  • He was able to grieve his father’s passing (which he had not the change to due to secrecy)
  • He comes to terms with his anger towards his mother, and also (as a child) feared that his other would die. He had fantasies that he might kill his mother when sleepwalking. His feeling of being unwanted by her, and wanting to prove to her that he was “worth it” to have as a child, and to admire him.
  • All emotions of aggression, guilt, grieve that accompanied these unfoldings.

Relationship with Women
Given the kind of relationship Mr. X had with his mother, it came
as no surprise that he perceived women as dangerous, over-controlling,
not really to be trusted.

Mr. X would divide women into two split categories, the easy and the proper. He had always been fascinated by prostitutes (and still was), but the fascination was accompanied by fear. Prostitutes were tempting but they could also be infected with diseases. He recalled an incident when he visited a prostitute. He felt that he had not treated her like other men. He had not taken advantage of her; he had gained her admiration.

As a young adult he had had many short relationships with women, treating them rather callously, usually dropping them when they became too clingy. He disliked feeling ‘ choked. ’

Dreams and Projections

He felt threatened by women. His dreams illustrated the role women played in his inner life. In many of his dreams, phallic women, portrayed as women with guns, would appear and lie on top of him, having intercourse while putting him in a passive position. He would wake up, frightened, feeling smothered. In other dreams, however, women would admire him from a distance. He described one dream in which he was persecuted by a number of large bees who kept striking at him. They were almost impossible to brush off. He associated this imagery with all the women he had dealt with in this life. Women could cling and sting, but also give honey. They could repel but also give pleasure. Gradually, however, dreams emerged in which he became more assertive with women, not taking such a passive role. Most importantly, in these dreams the degree of anxiety he had previously experienced was missing.

Being in Control
Starting and managing an enterprise had multiple meanings to Mr. X. It signified much more than a means of making a living. He had found out early in life, while employed by a German company, that working for others was too stifling.

These are projections, and much is known to be related to projections he has of his mother being controlling and having secretly done away with his father. Again identification with the father, being the victim of another’s control.

To be independent, to be in control, meant to be free from mother. His inability to work for other people (who would tell him what to do) made him decide to start on his own as his father had done before him. That was the only way to get some power, and no longer be subjected to the whims of others.

Transference of control and being controlled was reported to exist in therapy sessions.

What becomes apparent is his entrepreneurial mindset and work style slowly made sense to him, as his way of dealing with past traumas. It is his way of closing gestalts, and finishing unfinished business. This unfortunately leaves the real unfinished business open, and the only way that a person can live in inner peace is to work constantly. It is like filling water in a pot full of holes.   

Mr. X also worked through other personality traits that developed as a result of being himself, basically. He was able to realize his meed for admiration, tendency for grandiose and depressive moods (bipolar disorder, perhaps), competitiveness, self-defeating behaviors,.

With the newly owned awareness and re-experiencing of past traumas, and the re-integration of his repressed emotions, Mr. X was reported to have slowly managed to get back to work, work with less stress, welcome his wife back into his life. 

The process in which the patient manages to make positive changes to his life is through sitting through and experiencing what is there. What is in his real memories, his real childhood experiences. This is only possible with the accompaniment of a therapist, who is trained to support the client through the process. This process is very tedious and painful. The client has spent almost all his life trying to make changes by pushing his un-bearable realities to the unconscious. To not feel, to forget.

This is what it the paradoxical theory of change is about. When we try to elicit changes, in Mr. X case, when he tries to think positive, push himself to success, and try to do everything he can to overcome painful experiences, all he has achieved is a mountain of disappointments and stress. It is only through not changing. in just sitting in therapy and looking at all these childhood experiences, did his life really begin to change.

References

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

Klein, M. (1948). A contribution to the theory of anxiety and guilt. The International Journal of Psycho-Analysis, 29, 114.

Kets de Vries, M. (2009). Reflections on character and leadership.

Psychoanalysis and Segantini Art

The art with the theme of the “mother” or good and evil mothers by 19th Century painter, Giovanni Segantini, enlivens us to the concept of the good and bad internalized mother in psychoanalysis.

The Two Mothers : Depicting the idealized image of mother. Good and nurturing.
The Evil Mother: the seductress tied to a tree with baby at her breast.

According to scholars like Don Carveth, this idea of the bad mother was blindsided by Sigmund Freud, who was thought to have idealized his relationship with his own mother, and hence could not bring himself to the realization of the bad mother concept.

The Punishment of Luxury: the narcissistic in the mother who is preoccupied with pleasure, abandoning mother.

It was Melanie Klein, who under the mentorship of Karl Abraham, who managed to bring this concept of the two mothers to psychoanalysis.

It was believed that the artist Sagentini lost his mother as a child. He felt guilty with the idea that he was a cause of her death. He was brought up by relatives after his father left him with them. This means that he lost also his father. Sagentini suffered mood swings, which Abraham attributes to the repression of the image of the bad mother (the mother complex). Sagentini’s traumas are not reducible to the Oedipus complex. He was nevertheless susceptible to revenge on the (internalized) mother (and the abandoning/vain…etc. mother) who abandoned him, and he depicts them in his painting.

Abraham points out that excessive hatred/hostility to the mother can be replaced by exaggerated by the opposite: the love of the mother, putting mothers on the pedestal (as in the case with Freud). Sagentini lived with depressive guilt (of having hate for mother turned against himself), and in a way made reparation by depicting the mother & child in his art.

Art is a reparative creative way of healing, and an essential to being healthy. Reparation of one’s internal objects (e.g. internal mother). When one repairs internal objects one can feel whole again and no longer broken. This is the central theme in Kleinian Theory.

The internalized mother is important in the lives of humans. It is the relationship to this internalized mother that we are able to feel protected in this world. In time of trauma, and existentially frightening setback, it is this relationship that gets broken.

 

Jane Tangney: the Difference between Shame and Guilt

Shame and guilt are uniquely human emotions. These are emotions that does not exist in infants up to a certain age. In other words, shame and guilt are emotions learnt, and this learning coincides with the infant’s discovery of the self, when the infant becomes self conscious.

In the lecture below, June Tangney explains the results of her research in this area.

What is the difference between shame and guilt?

According to Tangney, shame comes with the awareness of (or the judgement of) the self as having done (or being) something wrong or unacceptable. Guilt is related to the judgment of the deed (ones behavior) that one has committed.

Shame is also extremely painful relative to guilt. Shame is a feeling of being defective, a sense of being small, exposed, powerless. Shame can last for short or long periods of time. When one feels shame, one tends to want to isolate themselves.

Guilt is different. It comes with remorse, and people who feel guilt are typically drawn to taking reparative action, rather than isolating themselves.

Link between Guilt and Empathy

Empathy is a state of feeling the other’s feelings, and it brings us to altruism.

@ 24:00 Guilt and empathy are connected. Tangney’s team of researchers have found correlation between propensity for the feeling of guilt and people’s ability to step into somebody’s shoes (to be empathic). Meanwhile the other more self-absorbed, pseudo-empathic responses are related to shame.

When a person talks about a shame related feeling in a situation, there is less concern for the other and more focus on the self. When the feeling is that of guilt, the concern is for the other’s feelings.

Shame, Anger and Aggression

The research also found that proneness to shame also related to proneness to anger and aggression. People who are prone to shame, also tend to manage their aggression in a more un-constructive way.

Shame in Family Conflicts

There is therefore correlation with studies of shame in family conflicts and domestic violence.

People prone to guilt are more likely to live a more “moral” life.

Shame and Guilt are not Equally “Moral” Emotions

On the condition that we do not mis-interpret shame with guilt, the findings show that guilt feelings do not cost the person psychologically (as otherwise thought). This means that so long as we do not judge ourselves, but judge the deeds instead, we are in a better situation to cope with the psychological aspect of having done something deemed as inappropriate.

Proneness to shame, on the other hand has been linked to vulnerabilities to depression, anxiety, eating disorder etc.

This also brings to attention how society treats incarcerated people.

Adapting to a more Guilt-Prone style and less Shame-Prone style

Research showed no real inter-generational link in shame and guilt proneness.

Longitudinal studies show that teenagers that are in the guilt proneness fare overall better than  their shame-prone peers.

 

Fritz Perls: Working with Dreams in Gestalt Therapy

Dreams. What are they? For those of us who know already, dreams are the windows to our unconscious. To fall asleep and dream is to let go of our outer world. In doing so, the life of our inner world takes shape. Since our innermost consciousness is in sleep separate from our senses that communicate with the outside world, the life of dreams seem to us mysterious: on the one hand there seem to have meaning in the dreams, and on the other hand the context is an amalgamation of experiences and emotions mixed together, and makes little sense. Most of our dreams are forgotten, and if we try to remember them, we cannot be sure if the memory of the dream is even accurate.

From the 9th Century didactic poem of Titus Lucretius Carus, De Rerum Natura (IV, v. 959),

The unconscious material in dreams are useful and important for psychotherapeutic work. This is especially so when the dream is a recurring one. According to Fritz Perls (1969):

“(T)he most important dreams– the recurrent dreams. (…) If something comes up again and again, it means that a gestalt is not closed. There is a problem which has not been completed and finished and therefore can’t recede into the background.”

Another proof that dreams are the stuff of the unconscious, is the proof that in people who suffer sleep disorders, the problem are the result of the mind not being able to let go of the external world. This is a world of the senses, and of spiraling thoughts.

Dream work in Gestalt Therapy

Sigmund Freud has, in one of his most-read book, The Interpretation of Dreams, gives us an idea of how dreams are interpreted in psychoanalysis (Freud & Strachey, 1964) .

In this article, I focus on the dream work in Gestalt therapy. Gestalt therapy has a tradition of non-interpretation on the part of the therapist. So how does one work with dreams without interpretation? Much of the recorded dream work of Fritz Perls is found in this book, Gestalt Therapy Verbatim. Here are case studies of work conducted by Perls in front of a group. On reading this book alone, some colleagues of mine find Perls’ style brash and some even find it bullying. Before we judge, it is important to ask ourselves if the work that Perls demonstrated served the volunteer. Mostly it has. The members found greater self awareness, and many have experienced a closed gestalt, or an integration of their split parts. Also it is useful to note that Perls’ clients are actually mostly students of therapy themselves, and not “patients” in the true sense of the word.

Below is a video of Perls’ dream work. There is a lot of emotionality that arises from the client herself. Perls as a therapist merely supported her. He does not interpret (or at least that is the intention). What the meaning of the dream really was about is actually not verbalized. The patient derived her own sense of what it meant. She has also experienced the meaning and not only thought about it intellectually.

This non-interpretation is a different attitude from psychoanalysis.  In Gestalt Therapy, the client is asked to play component parts of the dream. They may even play the dream itself. For example, the client says “I am my dream, and I am vague, and I am not there for you to remember me…” or “I am my dream, but I am incomplete.”

In the example below, the lady plays the water, “I am the water…”

This is called projection. It helps the client to feel the part of him/herself that he/she has disowned and has projected onto objects of the dream. Disowned parts of the self are in the unconscious, and integration is the work of therapy.

“Every dream or every story contains all the material we need. The difficulty is to understand the idea of fragmentation. All the different parts are distributed all over the place. A person, for instance who has lost his eyes — who has a hole instead of exes will always find the exes in the environment. He will always feel the world is looking at him.”

Read also: Dreams and Dream Work in Psychotherapy 

References

Freud, S., & Strachey, J. E. (1964). The standard edition of the complete psychological works of Sigmund Freud.

Perls, F. S. (1969). Gestalt therapy verbatim.

How Bobby Mcferrin explains Gestalt Theory with this Act

Bobby McFerrin  is famous for his hit song, “Don’t Worry Be Happy”. In this video, he demonstrates how the crowd intuitively synchronizes to the pentatonic scale. Ferrin says, “What’s interesting to me about that, is, regardless of where I am, anywhere, every audience gets that.”

How can we use this act to explain the Gestalt therapy theory?

    • Closing the Gestalt. The brain of most humans find completion in the pentatonic scale. This is a pattern of notes one would hear when one plays only the black keys on the piano. To the human brain, this note-pattern closes itself in a harmonious way (i.e. it just sound right).  This is how McFerrin is able to rely on the crowd’s intuition to “play” the music.

  • Field Theory. The crowd, the men on stage and the atmosphere make up the field. McFerrin harnesses and motivates to make a unified sound. If, for example, something in the middle of the performance distracts the crowd (for example, an explosion, or if the electricity breaks down) the focus of the crowd would be dissipated, and there would be, instead of a unified presence, chaos.
  • Phenomenology. McFerrin does not push the crowd to play the music like he would push piano keys. This would not be possible. In order to get so many people to sing in the same tune, he has to judge when the right moment is to act (to jump, or to say something or to make a mimic). This sensing of the crowd is the sensing of the phenomenology of the field.
  • Contact. When we can “tune in” to the other, we make contact. Each member in the crowd sings with his own voice and tone. Each is different, but together they are in contact.

McFerrin says, it works all the time. Yes. The theory of Gestalt Therapy is more than humanistic. It is a theory of phenomenon and contact. The other men on stage says that there is some neuro-biology involved. Yes. There is. This is how the theory of Gestalt therapy functions, through contact leading to physiological change.

On Gestalt Therapy

Gestalt therapy is a modality of psychotherapy which is founded on philosophical principles to guide the practicing therapist towards meeting and supporting the client authentically for who he/she is.  The pillars of Gestalt therapy theory include: the field theory, contact process, phenomenology, and the closing of the gestalt.

The therapeutic aspect of Gestalt therapy happens when the client is able to come into contact with his/her disowned aspects of his/her personality (“the dark side”, some would say). Often these are realities that are too painful or shameful to acknowledge, but are at the same time ever-present in the the life of the person. The effort (usually unconscious) of putting away these disowned parts of the self, utilizes a lot of energy, and is the source of inner conflicts, stress, depression and in severe cases, psychosis.

The Gestalt therapy work is to provide the patient a safe environment to play out, and experience these disowned parts of the self. In the process, the patient learns about these parts, and is given the ability to integrate these parts in their present lives. The net result is a better, less stressful quality of life and also better relationship with others.

How to Ask a Patient about Childhood Trauma History: Dr. Bessel van der Kolk

In this lecture Bessel van der Kolk speaks about his work with patients with childhood trauma. Here is a snippet of this video on how to get from a patient information about his/her trauma history. The topic of childhood trauma is not easy to bring up. Oftentimes the patient doesn’t recall the traumatic event(s). Sometimes these events are not acknowledged as trauma by the patient. Even if someone has encountered trauma and has memory  the event, there may still exist emotional difficulty in relating the event to a professional.

Van der Kolk provides us here with a way of interviewing the client @ 10:20 :

  1. Ask about demographics: where do you live? who lives with you? who does the cooking? who does the dishes? who do you talk to when you come home at night? When you need help/ when you are sick, who can you turn to? when you feel bereft and upset, who do you talk to? These questions give a picture of a person’s interconnectedness.
  2. Ask about the person’s current health (e.g. sleeping patterns).
  3. Family of origin demographics: how about when you were little? who loved you? who was affectionate to you? who saw you as a special little kid? was there anyone in your family who you felt safe with growing up? (*Hear van der Kolk’s comment on this question @ 12:30) who made the rules and enforced rules at home? how did your parents solve their disagreement?
  4. Childhood caretaker and separation.
  5. Other questions @ 31:30 : can we assume that life was good growing up? was anybody in your life a drug addict or alcoholic?

“You really cannot understand anyone with Borderline Personality Disorder unless you understand the terror they grew up in.” Bessel van der Kolk

Childhood trauma and BPD are correlated in findings. 87% of studied subjects with BPD had histories of severe childhood abuse and/or neglect — prior to age 7.  Other personality disorders do not have significant correlations with childhood trauma.

Slide @ 17:05 shows correlation between childhood physical abuse, sexual abuse, neglect and the symptoms of suicide ideas, suicidal attempts, cutting, bingeing and anorexia.

Neglect and ability to feel safe are found to be factors that determine the likelihood in which the patient can feel safe and be helped during therapy.

Full video is here:

Why do we need to find out about traumatic childhood experiences in therapy? Besel van der Kolk explains this @ 44:40, the importance of revisiting the traumatizing events.

@ 45:20 he explains the neuro-biological consequence of trauma.

Otto Kernberg: Transference Analysis in Psychotherapy

This is a summary of Otto Kernberg’s lecture on Transference Analysis.  Transference is an important term in psychodynamic therapies, and even dialogic therapies like Gestalt therapy.

Cite this article as: Chew-Helbig, N. (05/2017), Otto Kernberg: Transference Analysis in Psychotherapy, in The Psychotherapist . Date accessed 08/2019, https://nikhelbig.at/otto-kernberg-transference-analysis-in-psychotherapy/.

 

Transference is defined by Kernberg as: the unconscious repetition in the here-and-now of a dominant pathogenic conflict of the past.

In Psychopathology this pathogenic conflict plays out in the individuals’ present style of relating with others. Kernberg explains the origins of this mode of relating to be from the attachment of an individual to his mother at infancy. Early relationships, environment and the psychosocial world affect the neuro-biological make-up of the individual.

The experiences of the past, good and bad, thus get activated in the here-and-now, and affect how the individual perceives current situations and how he/she reacts to this situations. How he/she perceives his/her role is also affected by these early experiences.

Negative affects that do not reflect current reality is seen as pathological. These get reinforced through misunderstandings and reaction to and of the environment. These fixated negative reactions become the character and reflect the personality of the individual.

11:00 Kernberg explains that a combination of past experiences (and these are distorted and play out together in the present, not just one event at a time. Although we all transfer our experience of the past to our present, it becomes noteworthy as a personality disorder when this experience was overwhelming to the person, and becomes distorted.

What is done in psychodynamic treatment?

To resolve the pathological conflicts of the past as they get activated in the present.

14:25 By setting up a “normal” situation in the treatment situation. To sit with the patient face to face, and allowing him/her to say whatever comes to mind without feeling in danger of being judged, and to listen attentively to the patient.

Invite the patient to speak openly, support the patient to feel safe in this interaction.

Therapist exhibits technical neutrality. This interaction activates a transference relationship. The therapist can then help the patient interpret this transference reaction to past experience. This is called transference analysis. The adult mind of the patient can then be supported in integrating his/her past experiences with the present situation, leading to normalization of affect in the present.

Significance to psychotherapy…

Paying attention to transference situation, or what we can understand as the relational events that occur between therapist and client in the therapeutic setting in the here-and-now is very important to working with clients because it works directly with the personality of the patient. This is usually the armor that stands in the way of the psychotherapeutic work.  Kernberg’s lecture featured  here is detailed, and he explains how relationship experiences of an individual in infancy has a role in the wiring of the brain. He also explains how with psychotherapy that works with transference, his/her affect incongruence can be “mentalized”, and integrated within the patient.

Borderline Personality Disorder Case Illustration

46:00 Kernberg cites a case study of a patient with borderline personality disorder.

22 years old female, suicidal attempts, overdose of medications and street drugs, frequent hospitalization. 3 previous therapies, unsuccessful. sexual promiscuity,  antisocial and manipulative behavior, violent affect storms, attacking people emotionally.

Treatment started haltingly due to multiple suicidal attempts. Kernberg describes how he experienced her behavior towards him, which were violent and un-compromising. Kernberg explains how he reacted to her firmly, and in my opinion, authentically. He specified what he could tolerate and what he did not.  He however kept focussed on the transference without trying to fix or analyze or advice.

The behavior towards the therapist in this case is what Kernberg describes as the transference. It is how the patient has learnt to behave towards others in a relationship.

What we can take from this, is that patients who have had severe trauma as children do play out their pathological relationships with the therapist. It is up to the therapist to be aware of this patterns of relation of the patient. Sticking to the focus of the transference, and reacting authentically (if you are angry, say so, if you do not accept the abuse, say so, and set limits while being firm and sympathetic).

Kernberg also says that therapist have to look at the treatment in the long term, and although we may be impatient to see change in the patient, we have to be patient.

Important points to protect the frame of treatment

  • safety of the therapist.
  • * use common sense.
  • * be patient in the long run.  session takes months and years.
  • * analysis of what is going on is essential.
  • * tolerance of transference analysis is variable.

Significance of transference in Gestalt Therapy

Gestalt therapists do not use the term transference. This is because of the traditional link this word has to traditional psychoanalysis that Kernberg speaks about.  But the concept of using the interaction of the here-and-now is very much Gestalt therapy. Dialogical Gestalt therapist work with what we call the intersubjective or the in-between. This in-between is the transference. Gestalt Therapist who adopt the strict theory of the method, work with the following processes that is also present in transference analysis:

  • * working in here-and-now, 
  • * attention to the dialogue between therapist and client.
  • * non-judgmental (we call this phenomenological) listening to the client, allowing the client to his freedom of speech.
  • * active listening to the client.
  • * reflecting back to the client how his/her behavior or way of interaction affects the therapist.
  • * supporting the client to understand his current way of relating to his/her past (often pathologic) experiences.
  • * allowing the patient to integrate this phenomena of his/her past into the present.

The dawn of Gestalt therapy was initiated by psychoanalysts like Wilhelm Reich’s “Character Analysis and Sándor Ferenczi. The writings of these men, have already addressed the issue of working with transference as a means of working through character.

References

Kernberg, O. (2016). 29 Otto Kernberg. Youtube.com. Accessed on 05/2017. https://youtu.be/-H9qZBIfjHM

Further Reading:

Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2007). Psychotherapy for borderline personality: Focusing on object relations. American Psychiatric Pub.

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., … & Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. The British Journal of Psychiatry, 196(5), 389-395.

Yeomans, F. E., Levy, K. N., & Caligor, E. (2013). Transference-focused psychotherapy. Psychotherapy, 50(3), 449.

(German) Gestalttherapie: Zur Praxis der Wiederbelebung des Selbst

Das ist eine Zusammenfassung der letzten 3 Kapitel dieses Buchs, Gestalttherapie: Zur Praxis der Wiederbelebung des Selbst.

In English this book is called Gestalt Therapy: Excitement and Growth in the Human Personality

 

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