Presenting a psychotherapy case study about how psychotherapy treatment heals.
The full potential of psychotherapy is healing. The healing work enabled through psychotherapy is holistic. This means that psychotherapeutic healing involves the biological, psychological and social aspect of the patient.
Psychotherapy is a complement to medical treatment
Unlike medical professionals who traditionally focus solely on the body while ignoring the social and mental state of the patient — that is now changing in, thankfully– psychotherapists pay attention to the entire person. Particularly true for chronic diseases like cardio-vascular heart disease, medicine and medical procedures only try to remove the symptoms. Psychotherapy helps the patient to work through stress that resulted in the symptoms in the first place, manage behavior to help maintain lifestyle changes, and work through coping with the depression and trauma of having been diagnosed.
Psychotherapy is a more intensive form of counseling or psychiatry
Psychotherapy is a profession that is often confused with others, like counseling, psychology and even psychiatry. To really briefly describe the essential focus on each field of mental health I would say that counseling works on problems of daily existence, daily functioning at work and play, or problems created from behaviors that do not support daily function. Psychology is a broad field of work that researches human behavior and responses to situations. Psychiatry considers that which is emotional and behavioral to be biological, and deals with these issues with medicine or medical procedures.
The way to explain the gestalt therapy attitude towards healing is with this Chinese idiom:
“When cutting grass, the roots are not pulled out, when spring arrives, the grass grows back.”
We can see this in ourselves and in others. Our emotional problems, issues with relationships, problems with work, health problems tend to show repeating patterns. Sometimes we even see these patterns in our parents or in our children. Oftentimes we try to fix the problems. Often another problem of a similar nature surfaces. This is the metaphorical grass mentioned in the above idiom.
If you do go for psychotherapy, your attitude as a patient is to work towards identifying and removing the roots. It is not always painless, but a therapist who is well versed in the work can walk you through it.
The tool of Psychotherapy is dialogue
The term “talking cure” was coined by a patient of Breuer, Anna O, the first recognized patient of psychotherapy. Talking is not the right word. Rather I would used the word, dialogue. Gestalt psychotherapists like myself work with verbal and non-verbal communication. We can work with persons who do not talk or are not able to.
Psychotherapy works through affects and unconscious activity through dialogue and expression of these thoughts and emotions. The goal is to relief stress from painful emotions, by working through traumatic memories, painful thoughts, and difficult emotional experiences. Through working with the unconscious, awareness is formed and stress is relieved.
Relief of stress from psychotherapeutic treatment and health consequences
The relief of stress creates a change in the neuro-chemical balance in the brain. In turn, the hormonal system is readjusted. This changes and strengthens the immune system and cardio-vascular system. Balance in the immune system reduces risk of cancer and even aids in healing cancer, while reduced stress to the cardio-vascular system reduces blood pressure and heart attack & stroke risk.
Psychotherapy heals the body by causing a readjustment of the neuro-chemicals and hormones in the organs. Patients can feel this effect after an effective session of psychotherapy.
What one gets from Psychotherapy is a holistic benefit: empowerment to build relationships, energy for work, study and play, and inner peace.
What is the consequence of this relief of stress? Let this interview of Bruce Lipton explain to you how relief of stress as a result of dealing with the unconscious leads to physical healing and prevention of serious diseases. Lipton explains how medical problems are influenced by epigenetics rather than genetics. Unlike genetics, which we cannot change, epigenetics describe the expression of genes. Expression of genes is determined by environmental and situational factors that we face in our daily lives.
Lipton explains that belief can determine outcome of treatment of illnesses, and how this translates to the concept that our consciousness affect if we get ill or get cured.
Healing in the psychotherapeutic session
I focus on the emotions and the connected thoughts that arise. The opposite is also important: memories and even fantasies are investigated to examine the underlying emotions. The integration of the person with his/her emotions and thoughts through dialogue and behavioral experimentation in the psychotherapeutic session leads to chemical change in the neurological system of the patient.
This is a case study of a patient who came to therapy because of experiencing stress at his workplace. He was often on sick leave for chronic migraine, hemorrhoids and even un-explainable occasional hearing loss. Close to losing his job, he attends therapy. Only after weeks of treatment, did he realize how he, as a young child, was affected by traumatic situations at kindergarten and later elementary school. His home country was governed by a communist regime during the time of his childhood in the 80s. He had survived his childhood years by forgetting how frightening and lonely the situation was, while secretly hoping that he would be sick so that he could skip school.
This client’s psychotherapy treatment was about working through the trauma. With time, we worked together integrating his memories with awareness of which emotions belonged to the past, and what is no longer needed in the present. One of these was the realization that he no longer needed to “get sick” to skip work. He took breaks, sometimes weeks of non-paid vacation. He learned to regulate his spending, so that he could breathe easy when he took those breaks. Talking about and expressing painful emotions allowed him to release energy that he had bottled up and forgotten all his young life. He became more aware of tension in his body, and started doing yoga. Soon after, he stopped taking medication for migraine. The patient realizes that his path to healing is life-long. Along the way, he was able to find love as well.
The Lasting Effect of Psychotherapy
Unlike taking a pill to regulate emotions, neurological changes brought about by psychotherapy are subtle and lasts the lifetime. With regular sessions, these changes snowball into observable physical improvement. Unlike medication, treatment with psychotherapy does not leave behind negative physical side-effects, as can be seen with antidepressants.
For reasons that Psychotherapy is chemical-free, it is a treatment much needed for children, teens, young adults, and people hoping to be parents.
Through working with the psyche, psychotherapy enables the patient to better function in work, play, sex and relationships. As the patient becomes more self aware, he/she also becomes more aware of his/her relationships. He/she ultimately functions better in life. The effect of psychotherapy achieves what one looks for in counseling, with the added benefit somatic healing.
Just as there exists many schools of psychotherapists, there are, of course, different opinions on this subject of healing. The article written reflects my own work.
My work in psychotherapy is about healing through the integration of psyche and body. It is in my foreground every minute I work with a patient. Oftentimes it is not obvious that in our therapeutic conversation, there is an underlying therapeutic process. The phenomenon of a relational gestalt therapy (my school of study) dialogue is mostly felt, tasted and sensed, before it gets intellectually understood.
Subtle is the therapeutic process not?
When we go for therapy, we may experience change from the beginning, or no big change for weeks or months. We may talk about the same things in circles before something happens: an insight, an understanding, a gush of emotions, a relief from tension. When and how we get to this point in the therapy is usually not foreseeable. The process can be described as to be like titration. We make small steps. There is no explosion, but natural, holistic change.
Case Studies of healing process in psychotherapy
Case 1, Mary: I recount a case study of a journalist named Mary (not her real name), who came to therapy because of stress due to conflict with her colleagues. Her goal of therapy was to reduce the stress and panic feelings when she is at work. She feared that she may become too emotionally unstable to go to work because of this. For months, Mary talked about her work environment, the colleagues and tried to understand the incidents that triggered in her deep emotions. She also talked about her work, which she calls “her passion”; to remind women of their rights through feminist writings and stories. More weeks went by, and I began to wonder myself if her process was heading anywhere. I stuck to the process of her work, which with time, saw Mary more comfortable with expressing more difficult emotions, especially feelings of vulnerability. Baby steps. One day, she revealed that she had been sexually assaulted by a group of college mates and that she had kept this incident a secret for 20 years. She was able, after 14 months of therapy, to talk about it in session. Along with this revelation came a flood of feelings: resentment, shame, guilt, vulnerability, frustration, anger, grief, and also thankfulness. At one point, she was even angry at me for having initiated her emotional unravelling. For a couple of weeks, she said that she could not work. She then emerged from this. Mary transformed. She had been afraid of coming to terms with a painful past. In so doing, she re-lived her inner feelings of resentment, frustration and anger towards others and herself in her workplace and even in her writings. While these feelings helped her to write powerful articles, it also caused her to build walls between herself and the society in which she is in contact with. The conflicts left her stressed out and panicky at work. She was helpless against the emotional turmoil. Working through her traumatic experience, she unleashed the source of these painful feelings. Through this process, Mary was awarded choice. She could tap on these feelings as motivation to write and guide others. She is, however, not bounded to these feelings anymore. She finds inner-calm — which she said “had always been there”, but she did not realize it– in her social context. With time, she was able to build more allies. Panic feelings were soon of the past. Mary’s healing came about in little steps.
Case 2, Sunil: Sunil (not his real name), was a foreign student from India. He has chronic pain and problems with his digestive system, which doctors have diagnosed as Irritable Bowel Syndrome. He knows that his physical symptoms are related to “stress”(actually compulsive intrusive thoughts and actions) and sleeplessness. Sunil grew up experiencing family violence. With therapy, Sunil learned to notice his emotions and how past memories of childhood affects him today. He learned to observe the triggers in his everyday environment. He learned how to notice and accept his triggered self. Sunil learned to engage the support of his loved ones by explaining to them what was going on in him, and what he needed. With time and help from others, Sunil’s episodes reduced in duration and intensity. Sunil learned in therapy to be conscious of changes in his body when he got triggered. He was guided to find out what his body needed to calm down from its hyper-aroused state. Sunil’s healing process involved dealing with somatic reactions to triggers, and working through past hurts. Within months, Sunil’s digestive system stabilized. He also slept better. Sunil’s healing process was a holistic one.
So what is healing to me in the psychotherapeutic sense?
Mary and Sunil’s healing was a journey towards self-awareness and growth. The time, energy (and, not to forget, money) spent in therapy rewarded them with freedom from unconsciously re-living traumatic pasts.
Healing in psychotherapy takes place when the patient is able to grow and transform through insight and experiencing (and sharing) of feelings. This healing provides the individual with choice. This concept of healing is unlike that of conventional thought of “healing diseases”, which strive to remove the disease. In psychotherapy, mental and emotional issues are not to be judged as bad and removed; but understood. Depression, anxiety, PTSD and personality disorders aren’t “diseases to be cured”. These are opportunities for personal growth.
The healing –in a way described in this article– achieved in psychotherapy, is permanent. What Mary has gained will be with her for life, and she will continue to grow with it.
Psychosomatic Disorder: Overeating associated with other psychological disturbances
Overeating is considered a behavioral disorder that is attributable to psychological disturbances. This behavior has its physiological consequences. Obesity, which is measured by a body mass index [BMI ≥ 25], is all but a consequence of this behavior. Depending on genetic factors, some people who develop overeating behavior disorder may not become obese. Other physical problems, however, eventually afflict long-term overeaters. This include metabolic syndrome, a chronic disease suffered by millions worldwide which result in morbidity and mortality. Despite much attention put into the worldwide “obesity epidemic” the problem of over-nutrition is difficult to grasp. This is attributed to the fact that the cause of the problem is multifactorial, with environmental and psychosocial influences in play (Agras, 2005).
Different Subtypes of Eating Disorders
Eating disorders are grouped together in the ICD 10 and DSM-V system. This include Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Unlike AN and BN, together with other forms of Eating Disorder Not Otherwise Specified (EDNOS), overeating is a disorder associated with over-nutrition and has the opposite effect. The sufferer does not compensate for the habit by doing activities like purging in order to lose the calories consumed. As opposed to these eating disorders it is not clear if the root of over-nutrition is psychological or physical, i.e. if obesity, and other affects of over-nutrition is a cause of overeating or vice versa or both ways (ibid. p. VII).
Categorization in the ICD-10 does not specify or name the condition “Binge Eating Disorder” as in the DSM. Within the ICD-10 there are at least 3 related conditions that could relate to the condition. The closest is F50.9 which is basically Essattaken ohne Erbrechen, F50.4 which if the condition coincides with emotional disturbances. As a consequence, it could also relate to F55, addiction to non-addictive related substances.
General Description and Diagnostic Considerations
Binge Eating Disorder (BED). The behavioral problem of overeating is classified in diagnostic manuals within the category of eating disorders. Only since DSM-V has BED been recognized with its own category. Prior to this, in DSM-IV, BED was relegated to an appendix alongside EDNOS, BED is defined “as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months” (American Psychiatric Publishing, 2013). BED also does not result in compensatory behaviors like purging (Tuschen-Caffier & Schlüssel, 2005). It is separated but intertwined with obesity and is generally known to have emotional underpinnings (Masheb & Grilo, 2006).
It may be useful to note that BED is considered to be a separate condition from the general phenomenon of overeating according to the DSM. In the ICD, there is a condition identified as “overeating associated with other psychological disturbances” (F50.4) a situation of overeating in the presence of emotional stress or setback. Studies have shown that obese individuals with BED differ from individuals who are simply obese (Grilo, 2000).
Obesity is not the only physical consequence of BED, and many sufferers may not show significant signs of adiposity. There exists evidence of risk of metabolic disease arising from the behavior, with a higher percentage of newly diagnosed type 2 diabetics having experienced problems with binge eating compared to other groups who have not that experience. Recurrent binge eating can also make diabetes difficult to control. (Kenardy, Mensch, & Bowen, 1994)
Food Addiction. Could the cause of over-nutrition be the result of addiction to food or certain food ingredients? Is addiction to food, and/or the phenomenon of food craving related to, or contributory to BED? Food craving is known to be a cause of uncontrolled eating, which lead the scientific community to recognize food substances to be potential triggers of addiction, similar to the effect of drug addiction (Pelchat, 2009). Refined foods have been implicated to cause addiction, whereby loss control of intake of such food is a cause of health concern (Ifland, et al., 2009). There are also arguments that unlike drug addiction, what is often food “craving” has a biopsychosocial aspect that is not synonymous with addiction (Rogers & Smit, 2000). In the ICD, depending on severity of dependence to the food substance, we may, arguably, consider the classification under “Abuse of non-dependence producing substances” (F55).
From a biological standpoint, the idea that “non-dependence producing” could be questioned. Long-term chronic over-eating leads to metabolic disorders, which is related to the endocrine system. Insulin resistance caused by constant high levels of glucose and fructose intake results in not only physiological effects on the patient, but also psychological effects. While sugars are not considered directly “psychoactive”, glycemic levels do affect the mental state. Sufferers of metabolic disorders have problems dealing with the homeostasis of blood glucose, and face with uncontrollable craving, hunger and other emotional side effects, like stress and depression (Goebel-Fabbri, et al., 2005). Looking at the situation holistically, one can observe a vicious cycle of uncontrollable behavior resulting in physiological problems that add to more difficulty in managing the behavioral impulses (Vaidya, 2006, S. 76).
Criteria notwithstanding, for this paper, I discuss the phenomena of uncontrollable over-nutrition, since sufferers exists in varying degrees and since as psychotherapists, we may encounter many clients with difficulty controlling their tendencies to over-eat, and need help regardless of whether their symptoms fulfill the criterion stipulated in the manuals or not. As with most eating disorders, that while the symptoms may seem similar amongst patients diagnosed with the same disease, the underlying mental causation for each case is individual-specific. The challenges exist with such clients since there lies not only emotional grounds for the occurring situation, but also physiological causes.
Physical Symptoms vs. Psychological Symptoms
Table 1. lists the differences between the somatic and psychological symptoms of BED and general disorders related to over-nutrition like food addiction.
BED and “Overeating associated with other psychological disturbances”
Over-nutrition, consuming too many calories.
Long term result in Insulin Resistance, Metabolic Syndrome, and complications therefrom (Goebel-Fabbri, et al., 2005, S. 143).
Possible alimentary canal, teeth stomach injury.
Uncontrollable need to consume food. Feeling lack of control over behavior.
Pre-occupation with thoughts of food.
Emotional reaction to condition: anxiety, stress, shame, frustration.
Psychosocial problems, loneliness, loss of normal social activity caused by habit.
Emotional stress caused by illness as a result of over-eating. Comorbidity with mood disorders, high rates of major depression, personality disorders
(Yanovski, Nelson, Dubbert, & Spitzer, 1993).
Vicious cycle of dealing with weight gain and medical problems.
Over-nutrition, consuming too many calories.
Possible toxicity from abused food substance.
Long term result in Insulin Resistance, Metabolic Syndrome and complications therefrom.
Stress caused by weight-loss efforts.
Body image shame.
Table 1 Physical and psychological symptoms
The case study cited here is a self-report by Kimberly, who posts her story online in the form of videos, otherwise known as vlogging. One can access her videos via her in a YouTube Channel @kimberlyuhles1 (Uhles, 2014). I have decided to use this material because the accounts are directly reported by sufferer. Unlike other material we may find, the case studies do not come from first person perspective and are often edited and reworded. I find it more challenging this way, partly because this “client” does not present herself as someone in the victim position, but rather, a survivor of a disease. The sufferer, in her early twenties at the time of recording, seemed to have found a way to cope with her affliction. At the time of writing this paper, Kimberly is 23, and still vlogs regularly on the same channel. With this, one can simulate a situation with a client whose journey still continues.
Kimberly has two sisters. When she was 9 years old, her father left home for another family. Kimberly reports that he took everything, including material items for their home. As a child, she says she could not understand why her father left. In the process, her mother had to spend time at work, leaving the children to their own devices at home. They ate and did what they liked. Kimberly recounts later on not having the food that she wants to eat at home. Her mother, in effort to control her children’s weight, kept only healthy foods in the house, and disallowing any junk food. Kimberly felt deprived, especially in school watching other children eat whatever they liked (mostly tastier junk food). She also said she felt left out, or the odd one out because of the food she was given for lunch, and that which was not allowed her. She started sneaking to buy junk food herself, which she would eat quickly so that her mother would not catch her eating them. At 12 years old, her mother put her on a weight-loss regime, sending her to a gym even when she was too young to be allowed in that gym. She had to lie about her age to the trainer. When she was caught eating junk food, her mother would punish her with workout. When she turned 17, her realized sense of “freedom” meant that she was free to eat whatever she wanted. Her experience of having her first car was that of having the freedom to eat. Henceforth, she recounted really being addicted to food. She would eat as much as she could while sitting in the car. Her subsequent weight gain (she was reported to weigh about 300lbs) caused depression. She tried to get gastric bypass surgery but could not afford the treatment. She tried unsuccessfully to make herself throw up, but stopped doing it shortly after realizing that it did not help with her weight problem. She reported feelings of depression and self hate.
It seems that Kimberly managed to cope with her situation through her vlogs, which she has done so regularly for almost three years. Much of what she has talked about were her eating disorder, the emotional triggers, and her efforts to self help through diet and exercise. She also likes to give advise to others. Kimberly is also in a long-term relationship, and has recently found out that she is pregnant. She reports her pregnancy to be a happy situation.
From the case presented above, one can appreciate the process that triggered such an eating disorder in a young person. The problems started in childhood and progressed over more than a decade, and is a culmination of situations from which one can hypothesize:
At 7 years old having feelings of loss and betrayal because of father’s leaving.
Feelings of further loss because of mother’s reduced presence at home because of work, and possibly mother’s emotional state.
Probably lack of food in home (because mother was not home) and associating this with loss of parental presence and loss of emotional support.
Stress from mother’s negative reaction, and harsh remedial actions in response to children’s weight gain (probably caused by mother’s own guilt feelings).
Feeling alienated at school. It could have been caused by shame because of parent’s situation, but client associates it with the food she got for lunch.
At 17, she associated freedom with having food. At the same time, realizing she was addicted, then judging her own state of mind.
Stress and depression from dealing with being overweight.
Compensatory measures attempted by client does not fit that of sufferers of Bulimia Nervosa (BN), since the client claimed that she tried it, but found that it did not suit her.
These are intervention questions for client at the present time. The client seems to have coped with her initial situation of over-eating and she has found an outlet for her problems through what Freud considers “sublimation” in the form of vlogs. Exercising is also a compensatory measure (and the voice of her internal mother). I believe that dealing with the client at this point is a more challenging task. The personality of the client is one of an independent person who meets up to personal challenges. She also intellectualizes her inner existence through self-analysis. She has not got counselling, and may may not have had time to deal with experiences that underlie feelings of loss, betrayal and need to be shown love. In a video in the channel where she talked about a breakup with her boyfriend, she repeated that she wasn’t given the love that she wanted even when she knew he loved her (they got back together and are having the baby). My impression from watching the video is that this need for “assured signs of affection” reflects the mistrust felt from earlier abandonment, and could be good direction to take in treatment. I would ask these questions (in italics), and try to get the phenomenological experience of the client. What I would try not to do is to talk about physical symptoms or the over-eating habits that the client is already aware of and is ashamed of, unless the client brings it up.
Questions directly addressing binge eating disorders and the somatic aspects:
Help me understand your relationship to food. How often do you eat? What do you like to eat? Etc.
When you were a child, in what way does food play a role?
Did your family eat together?
When did you realize that you have a “problem” with binge eating? When did it happen, where were you, how did you feel?
You mentioned you got hungry when you were alone, can you help me understand how you felt as you reached for the refrigerator?
When you had your first car, help me understand how it felt to gather the food and eat it.
Imagine yourself in the car, please say what your experience is like.
After the session of eating, please tell me what it was like for you.
What are the physical effects? Do you feel discomfort? Where in your body?
How long did the discomfort last?
What are you feeling about this now as you are telling me this?
Are there long term effects of this habit?
What have you done in efforts to overcome the effects (weight gain)?
How has this affected your relationships/life/work?
What can you imagine you would have done have you did not binge eaten?
The following are questions I would ask considering methods in Gestalt therapy. If the client does not acknowledge binge eating as a problem, or if he/she is convinced that he/she has it under control but still shows signs of dependency issues in relationships, these questions may be a way to help work the client towards the issue:
Congratulations on the baby. Tell me what having this baby means to you? What is it like for you to be a mother? What is it like to hold the baby?
What do you want for your baby? What is your wish? The client may express aspirations for her child, or for her family.
Very nice. Lucky baby. Look for phenomenological expression. On this remark. Is she touched? Eyes moist? Smiling? I wouldn’t ask question but state what I observe. E.g. I notice you were touched/ your eyes are moist/you were smiling when I said this. Then wait for response.
If client makes reference to her past experience as a child, e.g. “I do not want my child to bear the same problems,” then ask about it. Otherwise, stick with the moment of happiness with having the baby. Dwelling with the positive makes for good rapport.
If client talks about disappointing childhood, say, tell me, what happened when your father left? What did that mean to you then?
Imagine you were back there, what would you like to say to him? What would you like to ask him? Use empty-chair if client is okay with it, and guide client through experience. One may also continue with discussion on the client’s father, but with focus on what the client feels about him, look for emotional queues on the face and body language.
Tell me, what is your father’s response now? This question one can ask after empty chair or some kind of constellation technique. This is to help client gain insight into the father’s motives/weakness.
So he said this. What do you take from it? Usually client will experience that father’s leaving was not her fault and/or that it is his weakness and/or this is how grown ups behave…etc.
I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
Imagine yourself as the child, and your father just left suddenly. What do you want to say to your mother? Again, empty chair or phenomenological discussion. This is to establish client’s idea of what was going on with mother.
How did you feel being alone at home without her? It is to help client find out Was it fear? Anger? Hunger? What? Then allow the client to take it in.
I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
As an adult, here and now, tell me what you think of this little girl?
I think she’s ……too! Repeat the positive things client says about herself as a child.
Give us one word to describe this session. This is to crystalize the insight, at the same time to put distance again from the past and return to the present.
While many people may face the same kind of childhood trauma, only some children develop, for example, Anorexia Nervosa. Others may do the opposite and become binge eaters and /or become obese. For others, eating disorders do not become a problem, but they develop an array of physiological symptoms as a result of anxieties, phobias and internally directed aggression. Question that arise are: is there ever a psychological problem that does not have somatic implications? Are there ever somatic symptoms that do not affect the psyche? What has personality—what many would agree to be caused by the ego— got to do with the physical attributes of a person? Does personality, then, correlate in some way to the manner of physiological disorders an individual might contract? For that matter, is every individual really unique, and what can personality traits tell us about the motivation behind these disorders?
We may find some good advice from pioneer Gestalt therapist, Erving Polster (1987); he has trained therapists of the modality to see, and value every persons’ life as a novel. This idea may be very helpful, because it puts the therapist on a mindset of valuing the clients’ life as something interesting and worthwhile to investigate. When the therapist is interested in the life of someone, he/she would naturally ask appropriate questions and go beyond the stories he/she tells, or that of his/her doctors. The therapist would be able to work authentically without fear of seeming unprofessional, losing the client to other therapists, making the client angry or other problems we have discussed at class. In dealing with dialogue, I’d often refer to the works of Lynn Jacobs, one of which tackles shame (of both client and therapist) in the therapeutic dialogue (Jacobs, 1995). What one can infer from Jacob’s argument is the possibility that shame (or unrecognized shame) in therapy prevents the therapist and client from getting to the heart of the matter, thus leaving problems to persist and the therapy ineffective. One can only imagine that ineffective therapies, especially encountered by clients dealing with somatic symptoms, can be intolerable and frustrating. This leaves for interesting work and more detailed efforts into psychotherapy process research.
Agras, S. (2005). Preface. In S. Munsch, & C. Belinger (Eds.), Obesity and binge eating disorder (pp. VII-IX). Basel: Karger.
American Psychiatric Publishing. (2013). Feeding and Eating Disorders. Retrieved from American Psychiatric Publishing: http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf
Goebel-Fabbri, A., Musen, G., Sparks, C. R., Greene, J. A., Levenson, J. L., & A.M., J. (2005). Endocrine and Metabolic Disorders. In Textbook of psychosomatic medicine (pp. 495-497). VA: APPI.
Grilo, C. (2000). Binge eating disorder . In F. CG, & B. K. (Eds.), Eating Disorders and Obesity: A Comprehensive Handbook, (2 ed., Vol. 54, pp. 178–182). NY: Guilford Press.
Ifland, J. R., Preuss, H. G., Marcus, M. T., Rourke, K. M., Taylor, W. C., Burau, K., & Manso, G. (2009). Refined food addiction: a classic substance use disorder. . Medical Hypotheses, 72(5), 518-526.
Jacobs, L. (1995). Shame in the therapeutic dialogue. Retrieved 2016, from http://icpla.edu/wp-content/uploads/2013/09/Jacobs-L.-Shame-in-the-Therapeutic-Dialogue.pdf
Kenardy, J., Mensch, M., & Bowen, K. (1994). A comparison of eating behaviors in newly diagnosed NIDDM patients and casematched control subjects. . Diabetes Care , 17, 1197–1199.
Masheb, R. M., & Grilo, C. M. (2006). Emotional eating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder. International Journal of Eating Disorder, 39, 141-146.
Pelchat, M. L. (2009). Food addiction in humans. The Journal of nutrition, 139(3), 620-622.
Polster, E. (1987). Every person’s life is worth a novel. Gestalt Journal Press.
Rogers, P. J., & Smit, H. J. (2000). Food craving and food addiction: a critical review of the evidence from a biopsychosocial perspective. Pharmacology Biochemistry and Behavior, 66(1), 3-14.
Tuschen-Caffier, B., & Schlüssel, C. ( 2005). Binge Eating Disorder: A New Eating Disorder or an Epiphenomenon of Obesity? In M. S, & B. C (Eds.), Obesity and Binge Eating Disorder (Vol. 171, pp. 138-148). Basel: Karger.
Uhles, K. (2014). My story: Why I weighed over 300 lbs. Retrieved from YouTube Video Channel : https://www.youtube.com/user/HOPEANDSMILES/featured
Vaidya, V. (2006). Psychosocial Aspects of Obesity. In V. Vaidya (Ed.), Health and Treatment Strategies in Obesity (Vol. 27, pp. 73–85). Basel, Karger: Adv Psychosom Med.
Yanovski, S., Nelson, J., Dubbert, B., & Spitzer, R. (1993). Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry, 150(50), 1472–1479.
This is my critique of a therapy work I witnessed. This is a case study of a 27 year old student, Miriam (not real name, and all details are changed) who attends therapy sessions because she had problems sleeping. After several sessions, she got in touch with the running thoughts that go on in her mind at night.
This is a case I witness during a training session. The names and stories are changed to avoid recognition of the individuals involved. The therapist is a trainer demonstrating his work to a group. Though I was not impressed with his work, this case story is interesting. I shall write my own analysis of the work in blue, and leave you to make your own associations. You may send me your feedback in the comments.
Much of these thoughts brought out in Miriam deep rooted anger. She explains that this anger has been with her her entire life. Miriam had also often mentioned of anger bubbling up and interfering with her activities.
The present theme
A theme brought up in one session of therapy within a group, was that she was angry about being responsible…
“I am angry that I have to be responsible for everything that has to be done at work… I cannot rely on anyone to help me, but they expect me to be there to help them.”
“I cannot just let go and leave the scene like everyone else when there is something to be done. It is a burden. ”
“I am envious of my girl-friends, when they need help, someone is there to help them. I, for example, cannot even find anyone to help me to hang up a picture in my apartment. my girl-friend offered to ask her father to help me. That is not the point. I wish that I had a father like hers. He is always there for her.”
At this point, Miriam showed signs of deep sadness.
As the group session wore on, Miriam offered to work in the middle of the group.
Miriam explained that her birth father, Mark, is someone who was not there for her in her childhood(i.e. this person was not known to her till she was 17). In fact he has only met her after the death of her mother 10 years ago. She longs nevertheless “for him to acknowledge his fatherhood to her. Even though, he actually acknowledged her within his community, friends and family. This is “not about the money ” [Miriam mentions this several times]. “I just want him to accept me as a daughter.”
Miriam explained the difficulties in communicating with Mark. She describes him as “living in his own world”, that their communication is superficial, that the last christmas was disaster when she was with his family, that she is afraid that he would reject her on grounds that he might think she wants more from him than he is willing to give.
The therapist offered the 2-chair (empty chair) method. He asked Miriam if she would like to put her birth father in that chair. The therapist was more concerned that Miriam showed her emotions of anger clearly, but did not clarify the many things Miriam said that sounded (to me, at least) ambiguous.
2 chairs were set in the middle of the room. One was to be for Miriam, the other, her father. Miriam spent the next 5 minutes explaining again the situation with her father, her frustration . Another 5 minutes was spent deciding where to put the chairs.
Miriam explained that she could not face her father directly. She feels unsafe. (I was wondering what her intention was to say this, since her father is not really there. Was it to avoid the work in front of the group? Maybe it was not the right place and time for the work. On hindsight, I am realizing that this is a sign that the issue was bigger that what meets the eye.)
Miriam says she feels better writing him a letter. The therapist and client talk further, with more explanations on how things were, and how frustrated she is. The therapist managed to get Miriam to talk more about where she wants to be positioned in Mark’s life. Miriam explains, and declares further that she wants to be acknowledged.
The therapist then asks Miriam if that is all… Miriam says, yes, everything is clearer, “I was afraid that he would reject me, because thinks it is about money.”
The 2 chair work ended there.
Towards the End of Miriam’s work
The therapist enquired how Miriam felt. She said she felt “more stable”. The therapist then explains further about how important it is to stay in a position and feel the emotions clearly.
Miriam mentions that this is something that has been all along an issue with her and her family. She goes on to say that her late mother was ashamed of having had 4 children from 3 different fathers. That this was known in the family, but never brought into conversation. Her mother, therefore, never made contact with Mark, and never asked him for anything.
The therapist ended the work there. He did not pick up on this new theme.
It is with this statement, that the existential issue Miriam really surfaced.
Comment on the case:
Miriam’s dilemma is touching, and is different from many other cases of a person trying to make contact with a father:An Adult trying to build contact with a father that one has never met as a child is likely to be in a different situation from coming back to contact with a father one knew as a child but lost contact with.
This is not a story about a person longing for contact with a person she had lost because he was someone she had not known. Many questions arise from this, which were overlooked during the work, that we cannot answer now without the client’s input:
What is she really longing for? Recognition, “not money”. What is important about being recognized by this person?
What does achieving this recognition solve?
The person has actually recognized the client (by introducing her as his daughter to the community, as mentioned). What, then is adequate recognition? How would she know when it is adequate?
The client mention at the end of her mother’s shame, and how this reverberated within the family and kept hushed. The questions worth noting here are:
How much of this shame is introjected by the client? To what extent does she identify with this aspect of her mother?
How had the death of her mother affected her need to have a closer relationship with her biological father? (they got to know each other better after her death.)
Since the therapist did not notice the significance, this was not brought to discussion and not worked on.
Comment on the work:
This is an example of a therapist who has overlooked the existential (and hence important) issues because of focussing on technique (wanting to demonstrate 2-chair technique).
Observing this technique , one has to realize that this is not a good demonstration of the 2-chair work. The use of chairs alone does not define the method. Here are the problems with this example:
The client did not get a chance to really “converse” with her father in the empty chair directly. She couldn’t, because she was talking to the therapist all that time, not to her father.
She was not asked to sit in her father’s chair, which is an important part of the 2 chair work. To sit in the seat of the other person, is a learning process in having a different perspective. To sit in the other’s seat is also a way to identify how much of what one thinks (about how the other will react etc.) is the product of one’s own projections. Had she sat on her father’s seat, she may have come to realize how much of her projections were hers, and how much of it is real. She may have also had the insight of being her father and looking at Miriam (to see oneself with the eyes of the other).
A lot of time was spent on arranging the chairs. This lead to a intellectualized discussion on how scary it is, how frustrating it is, how things used to be… there was much talking about, but the emotion had left the client. The likely cause of this was because the client was not ready to get into the exercise. In the end, the client wiggled her way out of it anyway. Rightfully so, since we know that it is not the actual issue.
There was a lot of mention of emotion, but the expression of emotion got weak. The therapist showed also no emotion, though he looked earnest and attentive. When there is not emotional energy, the work is not possible. This is a pity, because the client started with lots of emotion, but lost it at the chair arrangement part.
What I have learnt from this experience is…
not to take for granted anything that is said by the client, especially if it was something said “in passing”… especially if the client mentions the parents/family in the context of shame.
never to forget the existential nature of issues that tend to repeat themselves (i.e. in this case, complaints about work, and anger)….
when emotions feel deeper than the story, look closer, spend more time.
don’t get distracted by methods…
notice when emotional energy is lost in the middle of the talk. You have lost the client to intellectualization. Even if the client is “talking about” emotion, it is then only talk. This happened during the session.
In my opinion, techniques like the empty chair, or art therapy, or behavioral therapy serve only to create an environment to build contact. These techniques are means to an end. That end is the I-thou contact between client and therapist. Fancy techniques do not heal, only contact heals.
This case study can be found in the preface of the book, On Being Normal and Other Disorders by Paul Vergaehe.
This is a good example of how delinquent behavior can sometimes be a symptom of very understandable everyday circumstances. In this case, what we see as a behavioral problem in a teenager, has much to do with his family situation, and his personality development.
The client is a 15 year old male who is in consultation for having been arrested for car theft.
Symptoms: The client steals only “Mercedes” cars. In the driver’s seat, he drives aimlessly around, then leaves the car in a particular part of the country. He leaves the cars unharmed. He then hitchhikes back home.
Diagnosis: The client is the only child, whose parents are undergoing marital crisis. The mother is from a privileged background, and the father is from working class background who worked himself up the social ladder. The parents fell in love with the other’s differences. Now they reproach each other for it. The father works himself to death and retreats from confrontation. The mother has found another lover. And somewhat coincidentally, the town where the client leaves the car, is where the mother was born and is where her name still holds prestige.
From this case presentation, one can see that the symptom is not the isolated symptom of the client. This case displays the symptom of the family. The child has taken on the job of glueing the family together. When this looks like a hopeless scenario, he acts unconsciously in a symbolic way to communicate this his distress.From a psychoanalytic perspective one would say that his behavior provides an answer to the desire of the Other, that is, his parents, with the proviso, however, that the boy himself is not, or is only barely aware of it. “The unconscious is the discourse of the Other” (Lacan). Systemic theory would say that the boy shoulders the symptoms of his family. A cognitive behavioral approach would see his behavior as learned, which leads us to the following question: From whom does one learn what, and why? (p.5)
Gestalt Therapy Perspective on this Case-study
This are my comments using Gestalt therapy theory:
Gestalt therapy theory would say that the client exists and acts in a field. This field encompasses the family — the family’s present, past and future combined– it includes also the society in which the client lives in, the client’s character development / education and influences.
In this case, the client has lost his self in this field, and is only able to cope in a reactive unconscious manner. This is an example of his creative adjustment to a situation that had gone out of hand for him. The client does things systematically with a certain degree of passion, but lost contact with his conscience and self-preservation instinct. i.e. he was doing something that potentially subjected himself (and others) to harm.
The therapy process is one that would have to deal with the client’s sense of who he is and defining his present needs. Gestalt therapy works in the here & now. The client is guided to experience his present existence, in order to experience his present needs. This is what was evidently “missing”, by studying his symptoms.
Psychoanalysis of the situation points to this: that the boy reacts unconsciously as a distress reaction to his parents’ potential separation. The client is, however, already 15 years old. In reality, the separation of the parents does not pose a life-threat to the patient, although this was the client’s experience when he was a dependent baby.
This situation describes the client’s dilemma: there is unfinished businesses (open gestalts) experienced by the client as a young child, that is not settled. It could be something like: “I am dependent on my parents/ it is dangerous to me if they separate…” What the story really is, has to be uncovered by the client during therapy.
The second part of the therapy has to involve experiencing the needs of the present, as mentioned earlier.
Whatever approach one takes, a common factor emerges: the diagnosis cannot be limited just to the boy. The impact of the Other is fundamental. This is the first major difference between medical diagnostics and psychodiagnostics: clinical psychodiagnostics cannot be restricted to the individual. Psychic identity, with its potential psychopathology and aberrant behaviors, must be conceived in such a way that it grants the other a place equally important as the individual’s. (p.5)
Verhaeghe, P. (2008). On being normal and other disorders: A manual for clinical psychodiagnostics. Karnac Books. P. 4.
Reparation allows us to live out loud. When I can apologize, I have less inhibition. According to Melanie Klein, Reparation is a basis of creativity… to restore the loss. Capable of recovery.
We make reparation for our miss-doings. We are humans and we make mistakes. Sometimes it is our negligence that hurt others. Sometimes we are just too weak, too young, too old, too ill, too afraid to do the right thing at a particular time.
Mourning is involved in also other aspects of losses, which does not involve the death of another, but rather the death of one’s sense of self. An example of how this can happen is when one is being diagnosed with a debilitating illness or has become disabled in some way, or has a child/family that is diagnosed as such. Mourning is also “the reaction related to painful experiences that entail an experience of loss — such as loss of the quality of life, loss of health, loss of previous self-identity, loss of hope, or loss of the container function of the parents. (Barone 2005)”
Owning up to our mistakes/shortfall/incompetencies and taking responsibility for hurt caused is a means of making reparation.
In so doing we also mourn the losses (a broken relationship, a lost trust, a lost opportunity, a metaphorical or real death) as a result of our incapacity to do what was necessary to avoid the unfortunate situation.
Being able to face with the loss / to accept responsibility is the path towards inner-strength. We are able to move on from our human failing. We know that we have the resources in us to get on with life because we are able to overcome a mistake that caused us guilt.
Facing up to one’s role in such losses is not the same as blaming oneself. It is to acknowledge what actually happened, and how one was part of it. To blame oneself is to accuse oneself of something one doesn’t believe one has responsibility for.
Gestalt Therapy Case Example of Making Reparations
Mr. K, a young man of 23, comes to therapy with impulsive anger issues. He has been incarcerated for assault and battery. Each time he regresses into violent behavior, he regrets it, and feels guilt. However, at the slightest provocation, he bursts into uncontrolled rage.
He has been to behavioral therapy to control his impulses. The treatment did not work and he was sorely frustrated. In jail, he was offered gestalt therapy counseling from an intern– what looked like fighting fire with paper.
The therapist realized after 4 sessions a pattern in this client. Each session, he earnestly repeated the same story to her. Each time he did so, he revved himself into anger. It was a story of his childhood. His father had a violent nature and would beat his mother. As a child, from his early childhood, he remembers his mother in tears of fear and frustration as she served the family their meals. His older brothers were also later violent towards her and Mr. K.
The work for Mr. K turned out to be one of reparation. This was only possible because he was able to feel sadness and guilt (in the case of violent patients who do not feel this kind of remorse, it might not be possible).
Mr. K. was supported to revisit this childhood scene, and as he was retelling the story, the therapist asked him to hold back his anger and breathe by saying comforting words. She asked him what he experienced watching his mother’s sadness. He said he felt hopeless. He said he was too small and afraid to save her.
The therapist supported the client with helping him formulate these statements: “mother, I am 6 years old, and I am too small and too weak to save you.” and to himself “K, I am sorry, I am 6 years old and I am too small and too afraid to save your mother.”
Both K and the therapist were very touched by the phenomenon in the therapy room. This is the taking of responsibility. It is not self blame, but the recognition that one was simply not humanly able to save the mother.
The next steps came naturally. The therapist guided the client in a mourning process. The loss of a mother that could protect the son. Weeks of therapy was devoted to this process. It included creating art, writing poems.
Incapacity to make reparations and mental pain
There are individuals who have difficulty or have not capacity to accept responsibility. This is a mental state for some people and is part of their personality. In psychoanalytic term, it is a condition of being stuck in the paranoid-schizoid position and not being able to move forward to the more ambivalent depressive (nothing to do with depression) position.
When one is stuck in the paranoid-schizoid position, one suffers deep depression and paranoid anxiety. One’s state of mind is that on seeing the world in black and white and nothing in between. Everything is either very good or very bad. This was Mr. K’s life before his sessions with the therapist. He was had paranoid rage, and was very depressed.
Being so paranoid also leads one to have a need for omnipotence, which one displays through grandiosity or threatening (manic) behavior.
Taking responsibility for one’s own deeds is a lessening of omnipotence. Discovery of the resilience of the good object. Less fear of destroying it.
Manic reparation in the Paranoid-Schzoid position.
Say for example a man who strikes his wife then brings her flowers. Avoidance of acknowledging damage done, his aims to repair the hurt is in such a way that his own feelings of guilt and loss is never experienced. Not acknowledged. His wife is felt as inferior, dependent and contemptible. She is confused by his behavior. He then considers her ungrateful. He blames her for his anger towards her.
In this case his unconscious guilt is not reprieved. The good object, the wife, is “magically repaired”. Instant repair. It is like the instant cure of swallowing pills instead of going through therapy. Of going to sleep so that you do not see.
Emotional tantrum is used also as a quick way of handling problem
How do, for example, some people reveal their contempt? By raising emotionality. This is also see among people who do good deeds, like some social workers and activists?
Freud on Mourning and Melancholia
Freud (1922), in Mourning and Melancholia, writes about the ability to mourn as a means of overcoming loss. The inability to mourn or the absence of the mourning process leads to melancholia, which we understand today as major depression.
Genuine Reparation and Creativity
Genuine reparation is slow, there is no quick fix. It takes consideration of the other person. It takes mourning the damage. It takes getting to experience the guilt, the fear of damaging the good object, the relationship. It also takes creativity.
Un-recognized guilt, leads to aggression turned towards the self, which is a condition we know as major depression.
Hence the recognition of a loss and the process going through the mourning process, is essential to recovery and prevention of major depression. Much of the therapeutic process involves in one way or another accompanied mourning of loss.
Barone, K. C. (2005). On the processes of working through loss caused by severe illnesses in childhood: a psychoanalytic approach. Psychoanalytic Psychotherapy, 19(1), 17-34.
Klein, M. (2002). Love, guilt and reparation: and other works 1921-1945 (Vol. 1). Simon and Schuster.
Freud, S. (1922). Mourning and melancholia. The Journal of Nervous and Mental Disease, 56(5), 543-545.
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Written by: Nicole Chew-Helbig on 15 June 2017 in Vienna, Austria.
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.
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.
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?
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.
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…
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.
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.
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.
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.
Relationships with women:
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.
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.
“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.
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.