The British Gestalt Journal 31(1): Writing evocative case studies

Writing evocative case studies: applying autoethnography as a research methodology for the psychotherapist.

Abstract

This is an introduction to the application of autoethnography, a qualitative research method, an aesthetic inquiry into the psychotherapy process. The method engages the practitioner as researcher-autoethnographer who enters a field, which is their client’s therapy process. The aim is to derive insights and deepen the understanding of process, theory and diagnostics from psychotherapy sessions in practice. The therapist creates a reflexive account of their experiences, recording this in their session notes, which are also the field notes and the data. As an autoethnographer, the therapist begins therefrom a process of creative writing. The writing process is reflexive, and aesthetic. Integral to the research method, the act of writing forms a hermeneutic circle where new insights into the phenomenon of therapy happen for the researcher. The writing is created as an art form, usually a story or poetry. The result of this method is a written, evocative, aesthetic representation of the therapy process, based on the phenomenological experience of the practitioner. Demonstrating this method, a single case study of an online Gestalt therapy session of a male client diagnosed with depression and borderline personality disorder is featured in this article. The outcome of this form of aesthetic inquiry is the embodiment of psychotherapy theory through the aesthetic sensibility of the therapist-researcher.

Keywords: autoethnography, psychotherapy case studies, psychotherapy process research, gestalt therapy, aesthetic inquiry

Excerpt

In Gestalt therapy practice, aesthetic sensibility to the atmosphere is instrumental to the therapist, in order that they can attune to the movement of the phenomenological field (Francesetti, 2015). This is where this research methodology aligns with Gestalt therapy practice. Theory of the phenomenological field is central to Gestalt therapy (Parlett, 1991; Staemmler, 2006; Francesetti, 2019; Philippson, 2009; Robine, 2006; Spagnuolo Lobb, 2013) as it is in psychology (Lewin, 1951). Attunement to the aesthetics of the phenomenological field allows therapists to move beyond the mono-personal, third-person attitude of diagnosing the client’s psychopathology using manuals like the DSM (American Psychiatric Association, 2013) and evaluating clients using psychometrics. It goes even beyond the bi-personal, relational attitude of inquiry into the therapeutic alliance (Greenberg, 1986; Clarkson, 2003; Jacobs & Hycner, 2009; BCPSG, 2010). Aesthetic attunement brings the psychotherapeutic process beyond therapist and client, into the atmospheric realm of the phenomenological field of the here-and-now.

Reference

Chew-Helbig, N. (2022a). Writing evocative case studies: applying autoethnography as a research methodology for the psychotherapist. The British Gestalt Journal, 31(1), 35-42.

Find this Journal here: https://www.britishgestaltjournal.com/shop/british-gestalt-journal-311 or request a copy from me.

The change moments in psychotherapeutic practice 

The challenge with humanistic psychotherapy today is to realize the philosophical con­cepts and theory put into practice. How do we see an I-thou moment in a therapy ses­sion? 

My personal conviction in this topic is borne by the fact that I have experienced change moments – as a client of psychotherapy. Over the years, I have also been able to tell if these change moments had a lasting effect, or if they were just cathartic or tempo­rary because of suggestion and coercion. Perception of from the client’s point of view recorded over lifetime (a couple of years), may be essential aspect of psychotherapeutic process research. 

The process of defining the healing I-Thou moments (Buber, 1936) in psychotherapy often gets lost in language. What some call the transcendental phenomenon (which I have in this paper related to an aspect of Clarkson’s framework), is also called “miracle moments” (Santos, 2003), “sacred moments” (Pargament, 2007), and “moments of meeting” (The Boston Change Process Study Group, 2010). 

What is typically experienced in this moment is typically described like this: “Every therapist knows that there are some special moments in psychotherapy. I experi­ence them as “sacred moments” when immediate realities fade into the background, when time seems to stand still, when it feels as if something larger than life is happen­ing. In these moments, I believe, a meeting of souls is taking place. This was one of those times” (p. 6). 

I had the benefit of attending a presentation at a Gestalt Associates Los Angeles (GATLA) Summer Residential in Lisbon this year which discussed this very topic of defining these moments of encounter. Entitled, I-thou moments in psychotherapy, the study is the result of meta-analyses of psychotherapeutic literature and interviews with therapists. Hence it was found that these I-thou moments: 

  • are memorable, exists in psychotherapy and appears every now and then.
  • are recognizable, significant events.
  • is based on the quality of dialogue.
  • short lasting (in seconds).
  • is rare.
  • is mutually experienced.
    During these moments 
  • perception gets narrowed.
  • there is an unusual level of understanding and acceptance of the other
  • there is experience of being on the edge of something spiritual.

These moments lead to long term change in the therapy and result in motivation for the client to further therapy work. It strengthens the alliance, and has no negative affects (unlike transference relationship). It is also a qualitatively viewed process, and is often arises from sharing of heavy topics and staying long enough at an oftentimes uncomfortable place. Playing the role “I am the therapist, you are the client” prevents these moments from happening. The challenge in studying these moments is the very fact that in trying to grasp the moment, that moment is lost (Pernicka, 2016).

References

Buber, M. (1936). Ich und Du. Berlin: Schocken.

Pargament, K. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. NY: Guilford Press.

Pernicka, M. (2016, July). I-Thou moments in Psychotherapy. Lisbon, Portugal.

Santos, A. M. (2003). Miracle Moments: The Nature of the Mind’s Power in Relationships and Psychotherapy. iUniverse.

The Boston Change Process Study Group. (2010). Change in psychotherapy. NY: W. W. Norton & Co. .

Empathy and Buber’s I-thou contact

I do not fully agree with Schmid’s implication that empathy is about “try(ing) to understand, as exactly as possible, the accurate meaning of what goes on inside another person in the very moment”. This is the common understanding of empathy, but it actually contradicts the principle of Buber’s (1970) I-Thou contact. “Trying to un­derstand” is a process of someone doing something with an aim to furnish a need in oneself. In this case, it is the need to understand “as exactly as possible”. If a therapist has this kind of goal, his/her goal may become a blockage to contact because he/she is distracted by the need to interpret and the need to establish his/her identification as therapist in the relationship. 

Wouldn’t this amount to using the client to find-out-something-so-that-I-can-do­my-therapist-job? This kind of objectifying the Other in the relationship leaves room for transference and countertransference neurosis. If empathy is as what is generally under­stood as described above, it is then not part of the I-Thou relationship, because the I­Thou relationship excludes objectification. 

The I-Thou contact requires seeing the Other first, and not seeing the other in re­lation to oneself. This movement towards the other first is what Emmanuel Levinas considers the ethical movement (Schmid, 2001). 

Schmid clarifies this disparity later in the article in stating the difference between Roger’s and Buber’s comprehension of the activity of making empathic contact. Be­sides what is mentioned, Rogers also believes that it is necessary “to put one’s own un-derstanding completely apart” if one wants to enter the world of another person empath­ically. Buber, on the other hand believes in the mutuality of the process. 

That which lies beneath the I-thou contact is not empathy but something more than empathy. Buber (1970) uses the word, Umfassung, a phenomenon of embracing, which is “more than empathy”. This process requires the recognition of 2 poles, in en­countering the other “as a partner in a bipolar situation” (p. 178). This implies a dynam­ic relationship of “swinging into” (einschwingen) into the experience of the other and at the same time maintain one’s own reality of the self. It shows a dynamic process of be­ing existentially affected by the other, and including the other person into one’s own existence (Schmid, 2001). 

This is not the same as to “trying to understand someone as exactly as possible”, or to step into someone’s shoes. It is rather about me being me, seeing you, and show­ing you how you affect me— at this present moment. 

This way of relating in the present moment is what Buber calls, personale Vergegenwärtigung. It is an elementary way of relating and means to expose oneself to the presence of the other. This is a personal way of becoming aware of, a way of ac­ceptance instead of perception, a way of acknowledgment instead of knowledge (Schmid, 2001). 

The I-Thou relationship is basic existential relationship without the complications of identity and needs. The healing power of this relationship is in the confirming of the other for who he/she is. Buber is quoted to use the word Realphantasie, which indicates that what is happening is that “the Other’s reality is touched” (ibid.). What is experi­enced through this form of relationship is the transpersonal, intersubjective acknowl­edgment of the other, affirming the identity of the other through the presence of the self. Both partners in the relationship attains affirmation of the self. This benefit is mutual, and the relationship is symmetric. What happens in this mutual exchange, Staemmler (2009, p. 96) explains is not a “fusion of horizons”—which happens with just empathy alone— but a widening of each other’s horizons in such a way that that it is integrated with each other’s personal background.

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury. 

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

What’s behind the transforming power of dialogue?

Dialogue is a means of making contact, and it is a form of action that goes beyond ver­bal communication. That which lies intrinsic in an I-Thou contact? Is it a phenomenon we understand as empathy? This phenomenon is in itself a concept that leaves much to be discussed. In the context of this paper I’ll refer to Schmid (2001). This paper entitled Comprehension: the art of not knowing, gives a perspective of Buber’s philosophy in the context of psychotherapy, which is useful for this section of this paper (there are also parts of this paper which I have reservations about, which I will also discuss). Schmid states in the beginning that empathy is an “innate (inter-) personal quality” that reaches “beyond identification and interpretation”. It is the act of allowing oneself to be impressed by the other, while expressing oneself in an authentic way in the presence of the other. 

This way of explaining the empathic in a contact with the other is, whether through verbalized or symbolic communication (i.e. body language, a look in the eye or simply “being there”), empathic contact means to put aside the need to use the other person for any personal gratification at all. This means to be there with the other person without feeling as if one has to interpret the identity of the other or the need to establish one’s own identity in the presence of the other. There is no goal in such a contact but a process of “being there”, being authentically present, as an individual, and inviting the other to be there as well as an authentic person. This contact is at a transpersonal level.

Read also: Empathy and Buber’s I-thou

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury. 

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

Healing through dialogue is an eminently hermeneutical phenome­non indeed

“Healing through dialogue is an eminently hermeneutical phenome­non indeed.”

Gadamer, quoted in Staemmler (2009, p. 65). 

The psychotherapeutic alliance is a dialogue which is action. Through this dialogue, understanding takes place. This understanding comes about through a hermeneutic pro­cess. This process requires the authentic inclusion of the self of the therapist. 

Staemmler goes on to emphasize that in the process of understanding, one needs to be asked to ask authentic questions, bearing in mind the tendency for therapist (per­haps to hide his/her own shame) of not being authentically available to the client by asking pseudo-questions, which includes pre-prepared list of questions or repetitive questions like “how do you feel?” without actual curiosity. Pseudo-questions also in­clude questions that predestine their answers. Authentic questioning requires the bring­ing into the open what is unexpected, with the knowledge that the client has the answer. This means that the therapist needs to be open to listening, and living with the uncer­tainty of the answer that he/she is given. This requires that the therapist relinquishes any control over the client’s answers and meaning-making, and this includes predicting what the client’s answer should be before even asking the question. 

This relinquishing of control in dialogue leads us away from Buber’s “I-it” and towards the “I-Thou” way of relating. Incidentally, this forms the “symmetrical” aspect of the psychotherapeutic alliance as discussed earlier described by Altemeyer, and con­nected to Clarkson’s the person-to-person relationship (point 4) and the transpersonal relationship (point 5). 

Another way of understanding the “I-It” form of understanding is “to claim to understanding the other better than she or he understands herself or himself”. Looking closely this can also be seen as an abuse of professional power “disguised as benevo­lence” (ibid. p. 91-92). The consequence to such behavior to the profession is the dis­trust caused by fear of the client from being misinterpreted and misjudged. 

That which happens in an authentic I-thou dialogue is a mutual exchange. This happens in the “between”. Gadamer, in agreement with Buber: “The dialogue has trans­forming power. When a dialogue succeeds, something remains for us and in us, which has changed us” (ibid. p. 93). “Dialogue that succeeds”, is no ordinary dialogue, but that which is inclusive of the self and the other. Converse to the ‘I-It’ way of relating, it exists, as Carl Roger’s is noted to have explained, “without any techniques, means, aims or intentions” (Schmid, 2001). This kind of dialogue is what Buber terms the ‘I-Thou’. This is the dialogue with transforming power. 

This is the transformative contact which many schools in psychotherapy strive to establish in the therapeutic hour. I use the word ‘strive’ to give meaning to the elusive nature of such a healing contact, and the powerful benefits in the event when such con­tact happens.

What’s behind the transforming power of dialogue ?

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury. 

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

Hermeneutic circle of understanding 

The phenomenological attitude of  putting aside, or bracketing, theories and pre-conceived ideas in favor of un­derstanding the client does not mean the absence of interpreting. It also does not mean that therapists should not have pre-knowledge and theoretical understandings. It is im­possible for anyone, therapists included to not interpret. According to Heidegger, “from the very beginning our essence is to understand and to create comprehensibility.” To interpret and understand is to be human (Staemmler, 2009, p. 65). At the same time, it is through our pre-understandings that we can have any understanding at all. 

For this understanding to be authentic, and not based on blind interpretations of theory, what counts is the attitude towards gaining this understanding. According to Gadamer (Gadamer, 1975/1960), the German word for “understanding” (Verstehen) is also used in the sense of a practical ability (e.g., er versteht nicht zu lesen, “he can’t read”). This is the understanding when one goes beyond simply acquiring scientific knowledge— when one gets well versed in something, like understanding a text, or, in the case of therapy, the client. In efforts to access this kind of understanding, Gadamer writes, one would have “the accomplished understanding (that) constitutes a state of new intellectual freedom” (p. 251). Gadamer likens all such understanding to be ulti­mately self-understanding (sich verstehen). What this means is that understanding in this attitude is a dynamic process of self-involvement. Gadamer explains how when reading words written by someone else for example, the reader projects his/her own meaning for the words as he/she encounters them. As one reads or listens further, one has expectations for what meaning is to come, new meaning then emerges and expecta­tions are revised according to what meaning emerges further. This is the process of un­derstanding the subject matter through self-reflection and reinvestigation of the subject. 

Heidegger (1971), in his writings on what and how art is, says, “What art is should be inferable from the work. What the work of art is we can come to know only from the nature of art” (p. 18). Heidegger adds that in discovering a piece of art, we are lead to a circle of questionings. While we are tempted to avoid this circle, we cannot avoid it if we are to understand that “The artwork is, (…), a thing that is made, but it says something other than the mere thing itself is, allo agforeuei. The work makes pub­lic something other than itself; it manifests something other; it is an allegory. In the work of art something other is brought together with the thing that is made… The work is a symbol” (p. 19). Through this circle of learning and self-reflection, Heidegger de­veloped the concept of the hermeneutic circle. 

Gadamer quotes Heidegger in Being and Time, “(The hermeneutic circle) is not to be reduced to the level of a vicious circle, or even of a circle which is merely tolerat­ed. In the circle is hidden a positive possibility of the most primordial kind of knowing, and we genuinely grasp this possibility only when we have understood that our first, last, and constant task in interpreting is never to allow our fore-having, fore-sight, and fore-conception to be presented to us by fancies and popular conceptions, but rather to make the scientific theme secure by working out these fore-structures in terms of the things themselves” (p. 269). Heidegger defines here the attitude towards authentic inter­pretive understanding. This attitude requires the interpreter to have an awareness of the self, and the prejudices (or fore-having, fore-sight and fore-conception). Gadamer states: “all correct interpretation must be on guard against arbitrary fancies and the limi­tations imposed by imperceptible habits of thought, and it must direct its gaze ‘on the things themselves’.” In the context of psychotherapy, the gaze should be directed on the client and what is happening in the alliance. “For the interpreter to let himself be guided by the things themselves is obviously not a matter of a single, ‘conscientious’ decision, but is ‘the first, last, and constant task’.” In other words, it has to be an attitude towards the understanding process. “For it is necessary to keep one’s gaze fixed on the thing throughout all the constant distractions that originate in the interpreter himself” (p. 269). Gadamer adds that the process of understanding texts— and we can translate this to the verbal and non-verbal communication of the client— involves projection on the part of the interpreter: “He projects a meaning for the text as a whole as soon as some initial meaning emerges in the text.” This projection is necessary in order to make meaning of what emerges— “the initial meaning emerges only because he is reading the text with particular expectations in regard to a certain meaning”. It is the working through of this projection and constantly revising the understanding as new material emerges, “is un­derstanding what is there” (p. 269). It is also worthwhile to note that Gadamer found it important “… to distinguish the true prejudices, by which we understand, from the false ones, by which we misunderstand.” However at the beginning of the Hermeneutic pro­cess it is difficult to tell one from the others (Staemmler, 2009, p. 86).

References

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury.

Heidegger, M. (1971). Poetry, language, thought . (A. Hofstadter, Trans.) Harper Perennial.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

A mental health horror story — is there truth to this fiction?

This is a story about the consequence of not understanding the client in the mental health profession. 

It is necessary to emphasize the importance of understanding and the dangers of misunderstanding caused by pre-conceived ideas. Stammler (2009) cited a story written by Gabriel Garcia Márquez (1994), which I find interesting to relate: 

A young woman, whose care breaks down on a country road in the pouring rain and who tries to get a lift to the next telephone. After a long time, the driver of a van picks her up. In the van are a group of sleeping passengers covered with blankets. As she is cold and wet the woman gets a blanket too. 

After a while the van stops. Together with the other passengers she gets out and enters a building. She meets a woman in uniform and tells her she wants to make a phone call. She is ordered to join the other women in the communal dormitory. Sudden­ly awake to the fact that she is in a psychiatric hospital, she tries to escape—to no avail. Her explanations, protests, and attempts to leave the building were unsuccessful; they were answered with force and sedation. The next day she is introduced to the medical director of the hospital. He deals with her in a very friendly and patient manner. She tries to convince him that she has only come to make a phone call and repeatedly de­mands to be permitted to call her husband and inform him of her whereabouts. The doc-tor speaks to her in a fatherly voice saying “Everything in due course”—and finishes the conversation. 

A few weeks later she manages to send a message to her husband. The price is high; she has to give in to the sexual advances of the night nurse. The visit of her hus­band to the hospital from which she expects her liberation begins between him and the medical director. The latter explains to the former the mental disease of the wife. He talks of the states of excitation, vehement outbursts of aggression and fixed ideas (espe­cially the one to make phone calls); further treatments as well as the sympathetic coop­eration of the husband for the sake of a positive course of the disease are strictly indi­cated

After having been informed in this way, the husband sees the wife. He soothes her, encourages her, tells her that she will soon feel better, and promises to come to visit with her on a regular basis. At first she is perplexed; then she starts to rave and to scream like a maniac. On her husbands next visit, she refuses to see him. The doctor says to him calmly, “that is a typical reaction, it will pass” (p. 68). 

This almost true-to-life horror story tells us what can happen to clients who slip into dependency on professionals for solutions, and end up being labelled by their diagnoses and misunderstood. It highlights the problem of non-active listening on the part of the professional who engage themselves in analyzing without consideration for what is real­ly happening with the client. Therapists who are fixated on their pre-conceived theories tend to adopt a one-theory-fits-all, which deprives the client of exploring his/her own meanings. This mirrors what Reich was trying to explain with the case studies discussed above: where the therapist was too busy at doing the job of analysis to see-and-hear the client. In the story above the staff at the psychiatric hospital were so busy at being “pro­fessional” that they lost sight of seeing the client, not realizing that the client was not really meant to have been there. This is compounded by the influence professionals have on the public who hold the professional in often too high regard. This kind of mis­use of professional status breaks the ethical code of doing no harm: “In providing ser­vices… (psychotherapists) bear a heavy social responsibility because their recommen­dations and professional actions may alter the lives of others” (European Association for Psychotherapy, 2002, p. §1.1.a). 

Why do such oversights also happen in psychotherapy? Is this what we do on a daily basis in psychiatry? Diagnosing children with ADHD, depression and prescribing psycho pharmaceuticals without first attempting at understanding the pathological field in which the patient resides?

Reich writes of this kind of failure to recognize what is really going on with the client (e.g. transferences), and being too much in need of being complimented (from others and also by the self) : “Un­doubtedly, this can be traced back to our narcissism…” (Reich, 1945/1984, p. 25). Which leads us back to the reality that psychotherapy is about understanding the client and the process of which requires the therapist to first understand themself.

Reference

European Association for Psychotherapy. (2002). Statement of Ethical Principles. Retrieved 2016, from European Association for Psychotherapy: http://www.europsyche.org/contents/13134/statement-of-ethical-principles

Márquez, G. G. (1994). Strange Pilgrims. London: Penguin.

Owen, I. R. (2015). Phenomenology in Action in Psychotherapy.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy. 

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

The Importance of therapist’s Self-awareness & Phenomenological Attitude 

Owen (2015), in Phenomenology in Action in Psychotherapy, explains “Understandings at explicit and implicit levels form worlds with others where there are common objects of attention.” In the therapeutic relationship (as with any relationship), contact is made when there is awareness that what each individual understands of the situation is subjec­tive.

This understanding functions to bring common ground in the relationship. Owen adds that “People have unique personalities and inhabit social contexts and culture, in larger contexts of society and history, through being aware of meaningful cultural ob­jects (although such conscious awareness is influenced by implicit and biological forc­es). Therefore, a special attention is provided for what it means to relate in a context, (…) This includes the consideration of meaning within an attention to the therapeutic relationship in psychotherapy” (p. 2). The therapist, for the maintenance of the alliance, needs to first be conscious of these socio-cultural biases of the therapist’s self towards the phenomena of the on-going present situation in the therapy session.

As discussed in this article, awareness of transference and countertransference forces within the alliance is the tool for the therapist to work through the patient’s resistance, and providing effec­tive psychotherapy. Absence of this awareness on the part of the therapist, renders the therapy process at best non-effective.

Reference

Owen, I. R. (2015). Phenomenology in Action in Psychotherapy.

Unconscious feelings and countertransference within the Therapeutic Alliance 

To illustrate how a therapist’s emotions towards client, though brought to awareness and allowed to be revealed, can also be mistaken for authentic reaction to the client’s process, a mentor of mine, in a private lecture on experiences of unconscious effects on a therapist in therapy sessions, narrated a rather simple story he entitled, Chanel No. 5: the client, a middle-aged woman had come to therapy to work on very traumatic and emotionally tragic experiences in her life. The therapist found himself deeply moved by her experiences, and would find himself in tears each time she entered his practice. He questioned his emotionality towards the client only weeks later because he, like many would have, assumed that he was naturally moved by the client’s plight. He subsequent­ly noticed the client’s perfume as she entered the office and asked her what she was wearing. ”Chanel No. 5”, she replied, which was the same perfume his beloved mother had worn for most part of her life. 

In the story, the client instilled emotions in the therapist in which the therapist was unaware of. This gets interpreted somewhat inaccurately at first until the therapist was able to come to a self-awareness. This kind of experience faced by therapists is termed by Freud in a 7 June 1909 letter to Carl Jung, as countertransference, to which Freud explains, “(s)uch experiences, though painful, are necessary and hard to avoid. (…) (W)e need to dominate ‘countertransference’, which is after all a permanent prob­lem for us; they teach us to displace our own affects to best advantage. They are a ‘blessing in disguise’” (Freud, 1909). The unconscious nature of countertransference makes it difficult for the analyst to differentiate between the analyst’s own unresolved difficulties and emotional reactions and impressions that come to the the therapist’s consciousness that are activated by the projective identification of the client. 

While unlike Freud and Klein who considered strong countertransference feelings to have negative affect on analysis and something analysts should work on by gaining more insight into themselves instead, many analysts like Bion have found usefulness in the phenomena. Therapists of the intersubjective and relational schools share counter­transference that they have (and are aware of) as a means to bring authentic contact to the alliance. 

Awareness of therapist’s countertransference is supportive to the therapeutic process 

Countertransference, with awareness, supports rather than interferes with the therapist’s work. Freud’s mention of the need to “dominate” countertransference, can be taken as a call to be aware of dealing with the emotions within the alliance rather than rejecting them and becoming emotionally detached. Heinmann (1950, p. 81) considers this use of countertransference as “one of the most important tools for his/her work. The analyst’s counter-transference is an instrument of research into the patient’s unconscious” as a means of bringing to consciousness of the client what he/she does (consciously or un­consciously) to “get under the analyst’s skin”. How can the awareness of countertrans­ference experienced by the therapist be an advantage to the therapeutic alliance?

“(T)he analysis of the transference, i.e., that part of it which deals with the breaking down of the resistances, constitutes the most im­portant piece of analytic work.”

Wilhelm Reich, 1945/1984, p. 5

The answer is explained by Racker (1953) who acknowledged that the therapist may react emotionally to a patient’s enactments or behavior or personality, but he/she is not prevented from “identifying him/(her)self intellectually with his/(her) defense mecha­nisms and object images”. When the therapist is aware of his/her own emotional reac­tion, this countertransference is actually instrumental into “bringing to his notice a psy­chological fact about the patient” for the feelings helps the therapist to detect the pres­ence of the client’s psychological games. Even though the countertransference feelings are neurotic, the therapist who is aware of this is able to react with understanding. For this understanding to be possible, Racker adds, the therapist has to first analyze and overcome his/her own situation and be able to identify him/herself with the patient’s ego. Within the therapeutic alliance and hour, the patient reenacts and recreates situa­tions that are recurrent in his/her daily situations. These undisclosed and undetected activities, is an unconscious means of avoiding the therapeutic process, and thus “prompted by a desire to retain a defensive organization and probably to recruit the ana­lyst into its personnel” (Britton, 2003, p. 77). In order for the impasse to be broken and the “enactments” to discontinue and therapeutic work can progress, Britton suggests that “until the enactment is recognized and described, the belief system that lies behind it cannot be disclosed, but, at the same time, until the patient’s beliefs that drive it are disclosed the enactment will continue” (Mawson, 2011, p. 4-15). 

Transference and countertransference is a phenomenon in the therapeutic alli­ance, Racker’s comment— quoted also in Britton (2003, p. 55)— highlights the attitude towards acceptance of this human condition and working with it’s existence in psycho­therapeutic relationship: “The neurotic (obsessive) ideal of objectivity leads to repres­sion and blocking of subjectivity and so to the myth of the … ‘analyst without anxiety or anger’ The other neurotic extreme is that of drowning in countertransference. True objectivity is based upon a form of internal division that enables the analyst to make himself (his own countertransference and subjectivity) the object of his continuous ob­servation and analysis” (Racker H. , 1968, p. 132). Objectivity, in many respects, is the priced commodity in psychotherapy. If the therapist is caught up in countertransference and is unaware of the fact, his/her endeavors to work with the clients in an objective manner would be unproductive. 

Objectivity as a concept itself needs some careful consideration. For this we can turn to Maturana & Varela (1980): “(O)bjective knowledge seems possible and through objective knowledge the universe appears systematic and predictable”. Objective knowledge, according to the authors, seems possible. It is prized for the very fact that it gives the impression of predictability. When things are systematic and predictable, we feel safe. The authors go on to explain: “Yet knowledge as an experience is something personal and private that cannot be transferred.” The explanation for this is that objec­tive knowledge must be created by the listener. The listener understands and the objec-tive knowledge appears to be transferred (p. 5). The therapist therefore needs to be aware of this phenomenon: that the information being shared between him/herself and the client is experienced and mentally processed by both parties. The reality is, howev­er, that the assumption that common understanding is achieved is only apparent. 

The benefit of keeping this in mind to the therapist is that he/she will be constant­ly on guard and self reflective of his role as observer. The therapist as an observer is part of the system (in this case the client) in which he/she is observing. Since he/she communicates with the client and the client communicates back, and the client is also the observer in return. “Anything said is said by an observer” (p. 8). The observer can­not but interact with the system; the observer is also observed. 

The observer, if self-reflective, is also able to observe him/herself. So in the ther­apeutic setting, the therapist has the work of observing two individuals: the client and himself. What is achieved is a hermeneutic and cyclical process of understanding. This is discussed later in the paper. Maturana & Varela explains this as such: “If an organism can generate a communicative description and then interact with its own state of activity that represents this description, generating another such description that orients towards this representation…, the process can in principle be carried on in a potentially infinite recursive manner” (p. 29). 

This back-forth movement of allowing experiences (via emotions) to occur and then stepping away from the self in acknowledgment and understanding of what has arisen. This acknowledgment of “what-is” happening at the moment describes what Gestalt therapy literature describes as the paradoxical theory of change (Beisser, 1970), whereby healing change happens not by forcefully eliciting change itself (in this case, by repression or ignorance), but by understanding and acknowledging what is happen­ing to the self at the moment. Through assimilation of the situation, in the case of a countertransference effect encountered by the therapist, the therapist is able to under­stand what is going on in him/her. The clarity of this self awareness and acceptance empowers the therapist to overcome and make informed choices. Self-awareness has much to do with being in contact with the self, existentially, in the here-and-now. This is a phenomenological attitude in observing what-is in the present in contact with the client, while being conscious of one’s own biases. 

With the awareness of the self as observer, there will also be an awareness that the other person is different; the other person actually processes his/her own objective knowledge. We will be able to appreciate that there is room for questioning and discuss­ing the ‘facts’ and ‘truisms’, and to investigate the differences between the self and the other. Resnick (2016) tells us that it is the differences between two individuals that ini­tiate the contact. Without awareness and acceptance of these differences—as often hap­pens when people operate in confluent relationships— there is no sense of the other person for who he/she is. Confluent relationships result in the feeling of loneliness in the presence of others, because there is a push for consensus and the authentic presence of persons are thereby not felt. In therapy, this kind of relationship happens when client tries to please therapist and therapist tries to help client. Both try to find compliancy without first looking at the differences. The result is often an alliance without real con­tact.

References

Beisser, A. (1970). The paradoxical theory of change. In Gestalt therapy now (pp. 77-80). https://static1.squarespace.com/static/572d003b40261d2ef97e5b0b/t/59d64989bce1767a9d98ebbb/1507215754788/G+Paradoxical+Theory+of+Change.pdf

Britton, R. (2003). Sex, death, and the superego: Experiences in psychoanalysis. Karnac Books.

Freud, S. (1909). Letter to Jung. The Freud-Jung Letters. Princeton University Press.

Heimann, P. (1950). On counter-transference. The International Journal of Psychoanalysis.

Maturana, H. R., & Varela, F. J. (1980). Autopoiesis and cognition: The realization of the living. London, England: D. Reidel Publishing.

Mawson, C. (2011). Introduction: Bion today—Thinking in the field. In Bion Today.

Racker, H. (1968). Transference and Countertransference . London: Karnac.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy.

Resnick, R. (2016). New Contemporary Gestalt Therapy Demonstration Films. Vimeo.

Naranjo: The Great Composers and the Enneagram

Some years ago the late Claudio Naranjo gave this lecture, and I am glad that it is recorded. Naranjo was a expert personality theorist. We who were taught the enneagrams by him first hand at his seekers after truth retreats were very very lucky.

Naranjo was also a Gestalt therapist trained under Fritz Perls. He applied the enneagrams in therapy. I am only years later able to appreciate Claudio’s invaluable contribution to psychotherapy, when as a therapist myself, I manage to grasp the value of the aesthetics in healing the field in the therapeutic encounter.

Th above video features Claudio playing classical pieces of the great composers so that we can appreciate the nuances in the music created by the men whose personalities shine in their music.