How much should therapists reveal about themselves? What Tronick’s Still Face Experiment teaches us about being Psychotherapists

Many psychotherapists are instructed, from the day they begin training, to abstain from almost any form self revelation to their clients. Different schools of psychotherapy have different ideas about how much therapists should hide their true beings from their clients. These vary in degrees. Some would go all out to clean out their online presence, some deliberately give their offices the blank look to hide their identity, some would go even as far as to work with the client withholding their facial expressions (by sitting behind the client, for example).

Is there reasonable purpose for this?

Some classical Freudians would argue that this is essential. They would shun even the idea of calling the client if he/she did not show up for a session.

I belong to the more humanistic category of psychotherapy, Gestalt Therapy. In our modality, the client and therapist as human beings take part in the psychotherapeutic process. If the therapist does not show up as a real person, it would not be Gestalt therapy.

How do we reconcile the differences in principles between psychotherapy schools with regard to revealing the therapist’s real face to the client?

The answer would have to come from developmental science itself: Tronick’s still face paradigm.

The still face paradigm was demonstrated by Edward Tronick et al. in 1978. This experiment is explained in the video below: https://youtu.be/vmE3NfB_HhE

The experiment involves having a mother play with the baby. We can see how baby and mother interact. The mother is then instructed to turn her face away. When she turns her face back to the child, she withholds her natural impulse to react to the child, and keeps her face emotionless. The baby reacts to the mother’s still face with painful despair. The mother later releases herself from withholding her facial expressions and the baby come back to life.

More modern-day scientific findings are proving that the practice of humanistic psychotherapies like gestalt therapy is congruent to supplying clients with the healing process. This experiment is one of them.

Clients suffering from panic disorder, depression, anxiety, OCD and trauma come to therapy to seek solace and inner peace. Can we imagine how it feels to meet a blank faced therapist in treatment? From the experiment, we can see how the mother’s blank face is the cause of anxiety in the baby. In gestalt therapy we believe in authentic verbal and non-verbal communication. Just like the mother with an expressive face, the therapist’s full presence is a source of solace. The client feels seen and her being is validated. He regains his lost sense of self. She finds her footing on solid ground.

Therapist trying to be the superior, in control and still faced, seem almost inhuman, especially in the presence of clients who are emotional and suffering. The dead face, in my opinion, is traumatizing.

Authentic presence when being with the other has a calming effect on the other person. This is how our nervous system normally functions from the day we are born.

On this topic, I am not advocating being exhibitionistic. I do not believe that therapists should be opinionated or take up too much space from the client. I do, however, believe in real human presence.

Psychopathology is not disease. It is suffering that emerges in the relationship between people. The suffering comes largely from chronic and acute loneliness. Loneliness can only be cured with being with the client in his/her darkest moments.

What do Gestalt Therapists do?

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

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

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

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

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

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

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

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

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

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

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

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

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

Bibliography

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

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

Contact for gestalt therapy in Singapore or recommendations internationally

Why body-awareness is integral to the psychotherapeutic process

Psychotherapy is healing through the psyche. What is the psyche really? Does it reside in the brain? Not only. However, if it were so, then what is the brain? The brain is an inseparable part of the body. The body is the brain and everything material about a living person. The psyche is affected by the environment in which the individual is exposed to. The body responds and reacts to the environment throughout the life of the person. The environment is the external part of the body. The environment includes the physical as well as the social aspects of the person’s life. Psychotherapeutic practice that integrates work with the body is holistic. Not all psychotherapists work with the body. Those who do, work on the premise that the route to emotional and mental well-being is body-awareness and care.

What are emotions for?

Emotions are actual physiological reactions that tell us how to behave and react to the environment presented to us. Emotions are triggered by our body’s interaction to the present in the environment. Emotions can also be triggered from our imagination, dreams and fantasies. Emotions are necessary for us to live and thrive in our social and physical environment.

Emotions are felt in the body.

When we get anxious, we feel our heart racing and our skin sweating. When angry, we feel heat. When ashamed, we get red in the face. Whether or not we acknowledge these emotions in our minds, the body feels these emotions. People who are not in touch with their emotions often actually do have feelings. They simply “think” that these feelings are not present. Not feeling emotions is a way of protecting oneself from being emotionally hurt and weakened. Just because the mind is not able to acknowledge the emotions, it does not mean that the emotions are not felt. People stop themselves from feeling emotions through actions like tensing muscles, shallow breathing, numbing the sensory organs or storing/losing fat.

A study by Nummenmaa et.al (2014), provides us with interesting graphics of body maps related to different human emotions. About 700 participants were asked to color outlines of bodies in such a way as to describe how their bodies feel in response to stimuli that evoke particular emotions. They were asked to color the bodily regions whose activity they felt increasing or decreasing while viewing each stimulus. The results are represented in this the graphic below. Bright yellow shows high activation, while blue to green shows deactivation of the part of the body when the emotion is perceived.

Bodily topography of basic (Upper) and nonbasic (Lower) emotions associated with words. The body maps show regions whose activation increased (warm colors) or decreased (cool colors) when feeling each emotion.

In psychotherapy, emotions are not only acknowledged as mental states, but also as physical states. The work oscillate between talking and listening to the narratives, feeling the sensations in the body, and identifying the emotions underlying. We work to integrate these different aspects of emotional perception. I sometime describe this as defragmentation; to bring disconnected parts back into an understandable whole. This works for all symptoms presented and especially well for clients who are surviving trauma.

Integrating the feelings in the body with the emotions and then the thoughts that accompany these sensations are integral to the psychotherapeutic work. In my practice, the emotion-body awareness link is worked on at the beginning of the client’s therapeutic journey. New clients, especially, need assurance that this process is effective.

Bibliography

Nummenmaa, L., Glerean, E., Hari, R., & Hietanen, J. K. (2014). Bodily maps of emotions. Proceedings of the National Academy of Sciences111(2), 646-651. https://www.pnas.org/content/111/2/646

Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA)

Abstract

How can we visualize the evolving psychotherapeutic alliance in dialogue? The psychotherapeutic dialogue is an important source of data for psychotherapy outcome and process research. Micro-analyses of dialogical turns within the therapeutic session support the understanding of the therapeutic method. This paper introduces the Helbig Method of Dialogue Analysis. This method is founded upon 4 pillars: 1) that dialogue is implicit action between persons that is supported by explicit verbally uttered content, 2) that the individual’s mode of inter-action within the dialogical dyad reflects the person’s relationship theme or pattern which plays out in the here-and-now, 3) that dialogue is an intersubjective process that leads to the development of new intersubjective configurations, and 4) that the observer-researcher’s phenomenological involvement plays a part in the analytical process. In this study, a 28-minute video-recorded gestalt therapy session is selected. The transcription of the session is coded using the instrument, the Core Conflictual Relationship Theme Leipzig/Ulm. Results obtained from this study are quantified graphical representations of the developing relationship between therapist and client. Simple to operate, scalable and practical, this method is designed for use by therapists and researchers who are interested in tracking, comparing and/or contrasting the developing psychotherapeutic alliance in a single or in multiple psychotherapy sessions.

Keywords: psychotherapy research, dialogue analysis, psychotherapeutic alliance, Core Conflictual Relationship Theme, gestalt therapy.

Download pdf. here.

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The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship

Abstract

This thesis addresses the complicated nature of the psychotherapeutic alliance, by attempting to deconstruct what is already in practice. In piecing out the different aspects of the relationship between psychotherapist and client, and referring back to relevant literature, one can understand better the dynamics that exist within the therapeutic encounter. In the process, one can also see how the different principles of different psychotherapy schools fit into what we understand today as the profession of psychotherapy. Considered a profession, psychotherapy is bound to ethics, within which is the question of competence and accountability. The importance of understanding what really happens in a client-therapist meeting that is unique to psychotherapy, and that which leads to therapeutic change, is emphasized in this paper, with case studies from classical texts and referred back to modern day change-process research.

Keywords: psychotherapeutic alliance, psychotherapeutic relationship, psychotherapeutic change, psychotherapeutic process, psychotherapeutic dialogue, I-Thou.

To download pdf, click here.

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Let this video of an impala being rescued teach us about trauma and trauma treatment in psychotherapy

I watched this video about an amazing rescue of an impala, and cannot help but feel a tremendous sense of wonder for the nature of the nervous system.

This video shows us an animal’s natural response to a traumatic event, being stuck in a situation which is life threatening. Then it comes across rescuers who saved its life.

How is this connected to trauma treatment?

Well, if we observe carefully the behavior of the impala, we may be able to learn something very valuable about treating post-traumatic stress disorder and complex trauma in humans. Let’s take this video as a metaphor: the impala as the client who seeks the help of a professional, the rescuers. The impala is not aware of its traumatic situation. It only knows that it wants to get out of being trapped. Clients too come to therapy seeking help to get out of a “stuck” situation. They have often little awareness of the big picture. In therapy, the therapist and client find out together what the big picture looks like.

When clients come to therapy, there is anxiety. Just like in the video, as the rescuers approach the impala. It becomes more afraid. Client’s wonder, “Can he/she help me?”,” Will I be hurt by this person?”,”Is therapy a waste of my resources?” “What is he/she doing?” “Is he/she judging me?” etc.

The therapist is there for the client exclusively. In the video, the rescuers genuinely want to save the impala. Hence, it is really important that the therapist is there, in the session, only for the client. Realistically, this can only be possible with therapists who genuinely love the work and who are adequately remunerated for it. Reasons why professionals in the helping professions burn out and become ineffective can be attributed to this point: giving is a two-way process, and overt charity is neither kind nor sustainable.

The therapist’s empathy. A genuinely present therapist will put in the effort and strength to be with the client; just like the man who would put his body in the mud for the impala. The therapist would experience what the client is going through. This is how we can understand empathy.

Therapists also need other therapists to support them. That is why we attend workshops, therapy, supervision and inter-vision. In the video, the rescuer does not work alone. When he is stuck in the mud with the animal while his friends are there with the rope to help to pull him out when the need exists.

A part of therapeutic treatment is about doing nothing together. This is a recovery phase for both therapist and client. When the rescuers finally manage to pull the impala onto safe ground, they take time to be with the animal and to give it some comfort by washing it. We can see in the video that the body of the impala is really still at this point.

The stillness seen in the animal’s body is not merely calmness. It is possibly a somatic response to a highly frightening situation. The body shuts down. It fatigues. The work is far from over. Trauma-focussed therapist will not overlook this. Human clients in this state have varied symptom: of being depressed or numb, get panic attacks, lack focus, forget things, feel the need to throw up or cut themselves, feel like they are dying, lose their sense of reality (…the list goes on). The client needs then to physically recover. For this to happen, he/she needs the support of the therapist. In the video, this process seems natural and smooth for the impala. The rescuers pat the animal on its back, pulls it up and encourages it to get up and go. This is the act of bringing the beast back to its senses. The animal gets on its feet, trembles, pants and bolts.

In human beings, this process often does not happen so smoothly. Steven Porges explains why this is so with the polyvagal theory.

Treating clients at this phase involves a sometimes a long-drawn and difficult process of working through the client’s very difficult feelings despair, fear, guilt, grief plus the bodily reactions accompanying it. Human beings are afraid of these reactions in themselves. Such reactions are somatic, and may include panting, trembling, screaming, hitting or pushing, bolting, crying, and sometimes throwing up. We try, most of the time, to allow this energy to come out in tiny steps. Peter Levine calls it “titration”.

Therapists would also encourage clients to do body-focussed activities like yoga, weight-training, dancing or tai-chi to get more in touch with their bodily sensations.

Trauma-focussed therapy, for whom?

The animal, stuck, finds itself in a panicked state. It’s muscles tense and it tries to fight its way out of the situation. Being really stuck in the mud, all its efforts fail. Its body fatigues. Looking at us human beings, when we find ourselves in a threatening situation, our first impulse is to flee or fight back. In events that cause trauma, this instinct to fight or flee does not lead us anywhere. These traumatic events trap its victims. There is a sense of impending death. Such events can often occur in childhood, as victims of child abuse and neglect are trapped in a life of a child; helpless, vulnerable and dependent on its caregivers. This existence can go on for years.

Many clients come for therapy without the awareness that they are survivors of trauma. As adults, they come to therapy because they encounter symptoms like, depression, suicidality, anxiety, compulsive behavior, rages, emotional dysregulation, feeling numb, fatigued, loss of memory, relationship problems, eating disorders (…the list goes on). These symptoms are now known to be likely somatic reactions to past trauma. Trauma-orientated therapists will pick up on this.

Medication to treat trauma?

Medication stabilizes the body, but it unfortunately does not help the client work through the source of the problem. Medicine does not empower the client with awareness of the self. It does not lead the client towards self-agency. Meds lose their effectiveness with time, when the body adjusts to the chemicals through homeostasis. Imagine the rescuers in the video giving the animal meds, and not doing anything else. The animal will no longer be in distress. It would simply live trapped until it dies.

Conclusion

I hope this article enlightens you the reader on what psychotherapy can look like, and how your symptoms can be perceived and treated.

Psychotherapy, especially therapy that is humanistic, relational and is focussed on empathy, is a great profession because it opens doors for the possibility of healing from the otherwise life-sentence of trauma.

Obesity in adults and its possible link to experiences of childhood abuse

I was researching material on this topic of adult body weight and obesity and its link to adverse childhood experiences, in effort to support my my work with a couple of female clients who have come for therapy to work on their struggles with obesity. These clients are highly functioning individuals, and are relatively successful in life. They are baffled at how they aren’t able to take charge of their eating habits.

A usual practice I follow is to first send the clients for medical examination to exclude extra-ordinary physiological illnesses.

The study below shown as screenshot by Williamson et.al. is just one example of many linking adult obesity to experiences of childhood trauma.

CONCLUSIONS to the study: “Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.”

Binge eating and other addictive behaviors around food have a protective function for the individual. Patients do this to brace themselves against emotional hardships. This behavior actually keeps them stable and functional. It is therefore fully understandable that the eating behavior is borne out of a real need. In adult survivors of childhood trauma, the impulse to eat uncontrollably stems from the need to regulate the nervous system which has been dysregulated by the experiencing of traumatic events.

A client reported that her trigger to binge eat happens the moment she gets home. When she enters the door of her apartment, she’d feel a frantic need to eat whatever is available in the refrigerator, and very quickly. Then she would not stop eating until her stomach starts to hurt. Following that, she’d feel a sense of calmness and guilt. This client has had a childhood history of feeling unsafe in the home. Her father was alcoholic, and her mother was verbally and physically abusive to my client and her siblings. As a child, the act of returning home from school filled her with need for comfort and a dread. This conflict of feelings, she says, returns to her body every time she returns home after a hard days work.

It is possible that one or more of the other clients who come to my office for weight management coaching may be survivors of childhood trauma. I would check with the clients first if they want to explore this. If they do, then the coaching sessions will have to be converted to trauma-focused psychotherapy. Whether or not change the focus of the session is entirely the choice of the client. The client will first have to provide us with informed consent.

Bibliography

Williamson, D. F., Thompson, T. J., Anda, R. F., Dietz, W. H., & Felitti, V. (2002). Body weight and obesity in adults and self-reported abuse in childhood. International journal of obesity26(8), 1075.

Petzold: Short Definitions of Relatedness in Relationship

Relationship

The relationship is an encounter sustained in the long term, a chain of encounters that includes a shared perspective of a shared history and shared present, because there is a free will to live life together in a reliable relationship.

Relationship presupposes the ability to demarcation and touch, conflict and compromise, mutual empathy and shared reality. Relationships are intentional, lasting and reliable. They include the ability to contact and meet.

Encounter

The encounter is a reciprocal empathic meeting of different persons in the here-and-now. The meeting in which there is contact, results in an inter-subjective an exchange, that is healing.

Contact

Contact is described as a meeting of separate and concretely different individuals. The perception and bodily experiences of the person and the environment are separate. The person is able to distinguish the difference between the inner and outer world, and is able to establish, through contact, identity.

Confluence

Confluence is a form of human co-existence that is unrestricted. It is characteristic of the coexistence of the embryo and its mother.
There is no differentiation in perception of the individual persons in a confluent relationship. In adults, the fusion experiences can be that of the positive pleasurable or negative non-pleasurable kind (Petzold 1993, Volume III, p. 1066).

Attachment / Bonding

Attachment is the result of the decision to restrict ones freedom in favor of a freely chosen bonding. To endow an existing relationship with the quality of inviolability through loyalty, devotion, and willingness to suffer .

Dependency

Dependence is a bondage at the expense of personal freedom, which is structurally predefined as a natural “attachment” in children, or it is attachment-based socially meaningful behavior, for example, in the case of adults in need of care in the immediate vicinity of social relationships and networks. But it can also have pathological qualities such as neurotic dependencies, addiction-specific co-dependencies, collusions.

Bondage

Bondage involves massive, pathological dependence still exceeding qualities, because fundamental rights and rights violating restrictions of freedom, mental and real deprivation of liberty, when the enslavement occurs (often on a sexual level in pimp prostitution, sadomasochistic dependencies or on an economic basis in debt slavery, blackmail, etc.).

Source

Renz, H., & Petzold, H. G. (2006). Therapeutische Beziehungen–Formen „differentieller Relationalität “in der integrativen und psychodynamisch-konflikttherapeutischen Behandlung von Suchtkranken. Bei www.​ FPI-Publikationen.​ de/​ materialien.​ htm–POLYLOGE: Materialien aus der Europäischen Akademie für Psychosoziale Gesundheit13, 2006.