Introducing the Aesthetic Turn in the field of Psychotherapy

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

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

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

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

Read more on Therapeutic Autoethnography

Reference

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

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

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

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

Differentiation between the Healthy Process of Grief and Depression

This information is lifted off the Diagnostic and Statistical Manual of Mental Disorders ( DSM 5). Interestingly, this passage, which I consider to hold very important information, is written as a footnote on page 134 of the Manual.

What is the difference between grief and major depression, anyway?

For one thing, grief is a natural, healthy reaction to loss. It is an emotional response to something that has happened in our lives. We cannot escape encountering losses, and we cannot escape feelings of grief when it happens. Just because one feels terrible in a state of grief, does not mean that one has a mental / psychological disorder.

My reason for highlighting this, is with the hope that in grief, one one learns to find the right kind of self-support: find someone to talk to, try to not be alone, cry, find creative outlet and let time heal the wound (although it may leave the scar).

A potentially detrimental method of avoiding grief is to turn to drugs or narcotics, blame the self/self judgement for feeling bad, or any kind of harming the self or others.

grief and depression psychotherapy — Grief vs. Depression

Here’s what is written in the DSM-5 footnote:

“In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “’joining” the deceased, whereas in a MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.”

Mental Illness: DSM definition of what is mental disorder is and what isn’t

This is the definition of the term “mental disorder” according to the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDI T ION DSM-5 (pg.20):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Mental disorder is a syndrome

The definition describes what mental disorder is. It is a syndrome, which is a group of related symptoms that the individual might encounter. Mental disorders are observable as clinically significant disturbances. This means that if the emotional regulation, behavior or cognitive processes of an individual is not clinically seen as significant, it is not a mental disorder. The mental disorder has to reflect a dysfunction that has underlying causation.

Mental disorders affect daily functioning

A mental disorder is considered as such only when it has consequences to the daily functioning of the individual. This means that even if a person suffers from schizophrenia, if this individual is able to work, live, have relationships and play, he/she does not have a mental disorder.

Distress Caused by Life Situations are Not Mental disorders

Distressing events e.g. death of a loved one, or a divorce can cause emotional /and physical pain. These emotional setbacks that a person faces are unpleasant but is does not mean that the person has a mental disorder.

Socially Deviant Behavior is Not Always the Result of Mental Disorder

Socially deviance is not considered a product of mental disorder unless this behavior is accompanied by a person who has the above-said mental disorder.

Psychotherapy is not only in the business of working with mental disorder.

Psychotherapy is different from psychiatry in the sense that it is not a profession that works only in the face of mental disorder. Even if mental disorder diagnosed, the therapy is focussed on the persons’ emotional state and self support.

Most of my clients are not in my office because of a mental disorder, but because of life events that they need to cope with. Psychotherapy lends the client a space to be heard, to introspect, interact and experiment; so that he/she can realize the choices he/she has to live a stable, functional and even thriving life.

Difference between Hoarding and Normative Collecting Behaviors

Collecting is a part of human nature. The reason for collecting and the type of objects collected is variable and unique to each person.

Normative collectors are specific in what they collect, are organized and mostly functioning.

Types of Collectors

McIntosh & Schmeichel (2004) classify collectors as such:

Passionate collectors, who are obsessive and emotional. They will pay any price for the right item.
Inquisitive collectors, who see collecting as an investment.
The hobbyist, who collects purely for enjoyment.
Expressive collectors, who collect as a statement of who they are. These types suggest some overt motivations for collecting: profit, the emotional thrill of acquisition (intense but short-lived positive affect), pleasure (mild but consistent positive affect), and self expression or aggrandizement

The extent of “passion” put in the collecting activity is varied. In most cases, collecting is healthy and fun. It is when the activity becomes detrimental to the person’s health, relationships and/or finances, when the person feels helpless in controlling his/her collecting activity, that the collecting becomes a “disorder”.

Normative Collecting vs Hoarding

The fundamental difference between hoarding and collecting can be determined from the kind of object that is being collected, the acquisition process, the likelihood of excessive acquisition, the level of organization of the collected objects, the presence of distress, social impairment and occupational impairment issues encountered by the collector (Nordsletten et. al 2013) .

From the table we can appreciate that normative collectors would in general be found to be better off in many life aspects than hoarders.

Comments:

From my perspective, hoarding and collecting, while both activities involve collecting or accumulating objects, arise from very different needs. Patients from the two groups look and live differently. If the objects of desire among the normative collector is to bring self satisfaction and perhaps aggrandizement, for the hoarder, collecting could be a strategy to hold one’s sense of self in place.

Treat hoarders with empathy

It is this second group of individuals who need more support and empathy from the society. Isolation and mocking (a.k.a reality tv productions on hoarders) do not help the hoarder, but create more anxiety that perpetuate the condition, making life more difficult for the persons. Individual and group psychotherapy is known to help sufferers maintain function in their daily lives.

Bibliography

McIntosh, W. D., & Schmeichel, B. (2004). Collectors and collecting: A social psychological perspective. Leisure Sciences, 26(1), 85-97.

Nordsletten, A. E., de la Cruz, L. F., Billotti, D., & Mataix-Cols, D. (2013). Finders keepers: the features differentiating hoarding disorder from normative collecting. Comprehensive Psychiatry, 54(3), 229-237.

Narrative Impoverishment in Schizophrenia: Lysaker & Lysaker

“Schizophrenia is characterized by the profoundly diminished ability to experience and represent one’s life as an evolving story” (Lysaker & Lysaker 2006). Disorganized communication about facts, affects and thoughts is involved in disability and a cause of anguish, and a sense of self that lacks depth. There is a lostness of the self amidst an evolving life, and a sense of being an object of social control. The narratives are impoverished.

The article cited is interesting because it provides for a model of schizophrenia that allows us an idea about how we can work towards a functioning psychotherapeutic alliance with clients who aren’t able to easily provide a clear narrative or dialogue.

Read about Notes: Bakhtin’s Polyphonic Novel and the Dialogical Self

Since the work of psychotherapy involves also narratives, how and what can be understood in order to overcome the obstacle of the lack of ability in the client to form coherent narratives?

Dialogical Theory of the Self is used to understand the typology of the experience of self in schizophrenia.

Barren, monological and cacophonous narratives in schizophrenia

The authors asked these questions:

How could someone lose a sense of him or herself amidst a life where there was formerly coherence?
When one’s sense of self appears to be perishing, just what is it that seems to be vanishing (Lysaker & Lysaker, 2001)?

The answer to understanding this is the dialogical models of the self as written by Dimaggio et. al, 2003, Hermans 2004, Nietzsche 1966. That our sense and story of ourselves are part of inner dialogues of different self positions.

It is to be assumed that (p. 59) :

(1) narratives in schizophrenia may become impoverished when processes that allow for the shifting hierarchies within the self are compromised, and

(2) that the loss of sense of self may fundamentally involve the experience of the loss of dialogue.

Thus impoverished narratives may be reflections of diminished dialogical processes rather than merely weak stories.

Forms of narrative impoverishment and the sustenance of dialogue in psychotherapy

Lysaker and Lysaker suggests that other than forcing the client into narrating cohesively, more attention should be paid to the here-and-now relationship between client and therapist.

The client who has no stories to tell, has difficulty putting into words or bringing to the mind, events and people from the past experiences. The client can be encouraged to describe his/her experiences in the therapy room and his/her relationship with the therapist. The therapists encourages the client on, by sharing his/her own experiences.

If the relationship can be narrated it seems that other relationships might subsequently be narrated as well – leading ultimately to richer narration of internal feelings and conflicts.

For clients who get stuck in monologues, the therapist can bring the client back to the here-and-now by asking what is being experienced as the stories are being told. The therapist can continually make statements or ask questions that encourage the client to relate his/her narratives to his/her experiences in the present.

(W)ith the monologue it may be more important to begin by understanding the suffering of a self that is dominated by a limited number of themes. This could include empathic reflections about how specific thoughts take control and make it impossible for the client to think of anything else. By reflecting on the weight of a delusional theme on the daily life and social relationships, the therapist may avoid agreement or disagreement with a delusion or obsessive theme while building the relationship.

Only after the contact through empathic listening is made, and the client is able to relate his/her experiences of the narrated themes, the therapy can move into the more cognitive approach of reality checking these themes.

From a dialogical perspective we reason that this cognitively-based process may diminish the power of the dominant self-positions and allow other self-positions to begin to contribute to the conversation.

In the case of the cacophonous narratives, the central methodology is the continual mirroring and reflection of what the client is saying at the present moment. In the midst of the fragmented talk, there are pieces of self positions that, with the therapist’s validation, will take foothold.

In this manner independent self-positions might be thought to gather strength to the point where they the can again participate in internal conversations.

Relating to Gestalt Therapeutic Process

Taking the psychotherapeutic relationship to the here-and-now is a very strong feature presented in this article. This is also a major principle in gestalt therapy practice. We also get to appreciate how useful gestalt therapy can be for working with clients diagnosed with schizophrenia.

The other aspect mentioned in this article that I find is closely related to gestalt therapy, is that of phenomenology. Although the word is not mentioned, it is implicit when we bring to the awareness the experiences of creating the dialogue, while not getting sucked in by the content of the narratives. The therapist is handed the task of observing what is happening in the session, and not only focussed on what is being said.

Like most humanistic therapies, unconditional positive regard is the foundation of the work, which requires time and also patience.

Bibliography

Lysaker, P. H., & Lysaker, J. T. (2006). A typology of narrative impoverishment in schizophrenia: Implications for understanding the processes of establishing and sustaining dialogue in individual psychotherapy. Counselling Psychology Quarterly, 19(01), 57-68.

Psychomatics: Binge Eating Disorder

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.

Condition

Physiological

Psychological

BED and “Overeating associated with other psychological disturbances”

Over-nutrition, consuming too many calories.

Possible Adiposity.

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.

Food Addiction/Craving

Over-nutrition, consuming too many calories.

Possible Adiposity.

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.

Yo-yo dieting.

Table 1 Physical and psychological symptoms

Case Study

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.

Family History

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.

Current Situation

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.

Clinical Practice

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.

Intervention Questions

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.

Conclusion

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.

Bibliography

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.

What is Psychosomatics?

Psychosomatics is a scholarly discipline of medicine with a rich history. The term psychosomatic was coined in 1818 by Johan Heinroth, and the words psychosomatic medicine is known to be used around 1912; the term being a combination of psychological and body function. Contributing to the development of psychosomatic medicine are the fields of psychoanalysis and psycho-physiologists that work with the mind-body interaction (Levenson, 2005).

As one looks towards the other non-medical and non-therapeutic fields, one also stumbles upon the philosophers like Maurice Merleau-Ponty, who had taken the non-dualistic view that that the ideological separation of mind and body is erroneous. In Phenomenology of Perception originally published in 1945, Merleau-Ponty explains that the body is consciousness, and not separate from the mind: “Bodily experience forces us to acknowledge an imposition of meaning, which is not the work of a universal-constituting consciousness, a meaning which clings to certain contents. My body is the meaningful core which behaves like a general function, and which, nevertheless, exists and is susceptible to disease” (Merleau-Ponty, 2004).

Levenson (2005), in citing three general groups of patients— i.e. “those with comorbid psychiatric and general medical illnesses complicating each other’s management, those with somatoform and functional disorders, and those with psychiatric disorders that are the direct consequence of a primary medical condition or treatment”— gives us an idea of how psychosomatic disorder is considered by the medical profession; that medical and psychological are linked in a way that one is a cause of the other. The perspective of Merleau-Ponty’s writings—and psychotherapists from modalities that are founded on the phenomenological experience— begs to differ from this point-of-view. They consider both medical and psychological ailments are one and the same thing.

A Holistic Point of View

This phenomenological viewpoint marks the movement towards holistic recognition of the connection between what we perceive as mental and physical cause-and-effects of illnesses and the respective treatment of symptoms. This attitude makes psychosomatics stand out from other disciplines of medicine. There is also the implicit recognition that patients suffering from organic diseases recover better with integration of medial and psychological therapy than with just medicine alone.

Historical Concepts of Psychosomatic Medicine

That psychosomatic medicine is considered a new discipline in the medical profession is paradoxical to the history of medicine itself. Millennia before construct of physics, primitive man understood phenomenologically how his own psyche affected his physical actions, in so doing, attributed the forces of nature to human-like emotional states as well (Alexander, 1962). This natural sensitivity of human beings to perceive mind and body as inseparable concepts is evident in traditional and folk medicine. Traditional Chinese medicine (TCM) is a good example since it developed independently and possesses written records dating back to 1500 BC (Tseng, 1973).

TCM is based primarily on the idea of correspondence between organism (microcosm) and its environment (macrocosm). Like the “primitive man” idea described by Alexander (1962), this is a belief in the conceptual connection between the body and nature. TCM considers human emotions the “vital air” in the body, which has its equivalence in nature. The body is characterized by its visceral organs. Patients frequently describe their psychiatric problems in terms of organs, like “exercised heart” to give meaning to apprehension, “injured heart” to mean sadness, and “elevated liver fire” to mean agitation and tension (Tseng, 1973). Since psychological problems are deemed somatic and organ-based, ancient Chinese did not separate psychiatric disorders from other medical illness.

Attempts at explanation of natural phenomena is a preoccupation of western civilization, commonly traced to Greek cosmologists of the pre-Socratic era at around 600 BC- 400 BC. Substances like water, air and fire were used – almost metaphorically— to give material foundation for explaining illnesses. Similar ideas were also seen in the medicine of other cultures like those in the Islamic world, Tibet and India (Sabernig, 2016). This materialist way of understanding disease afflictions can be extrapolated to the modern-day reductionist scientific thinking. The milestone of this idea is popularly traced to Hippocrates in 400 BC, who declared the cause of epilepsy to be material in nature with nothing to do with the “sacred” (Alexander, 1962).

Interestingly enough, when one traces the roots of dynamic psychiatry, one is led to the very concept that Hippocrates disproved in the early days: the idea that demonology has anything to do with the physical condition. In almost every culture, there existed faith healing. Medical anthropologists like Forest E. Clement and Erwin H. Ackerknecht in his early 20^th century attempted to systematize primitive medical beliefs and practices. Clement categorized disease theory of the ancient healers into 5 main forms: disease-object intrusion, loss of the soul, spirit intrusion, breach of taboo, and sorcery. For each of these theory there existed corresponding therapeutic methods. These methods included extraction of diseased object, to resort lost soul, exorcism, transference of the foreign spirit to another living being, confession and counter magic.

Ackerknecht showed that the true ancestors of the modern physician are the lay healers, that is, those men to whom the medicine man left the empirical and physical care of the patients), whereas “the medicine man is rather the ancestor of the priest, the physician’s antagonist for centuries” (Ellenberger, 2008, S. 5-48). By taking us through the the era of faith healing to the discovery of the unconscious Ellenberger can help us make sense of how the idea of demonology could have existed as explanation for psychological afflictions during the period of the Dark Ages. The psyche— and consciousness in itself— is, after all, a concept that has been illusive to human awareness, until the 18^th Century.

The 20^th century saw the movement towards re-integration of this medical field through the development of psychoanalysis and the use of psychotherapeutic methods including hypnosis in dealing with physical healing, as well as the work on the body to aid psychological problems. With the advancement of new technology like neuroscience, we can expect to see the move towards integration and separation of handling of what is deemed psychological and what is deemed somatic issues again and again; this happens as long as mind and body cannot be understood or accepted as one whole which is more than the sum of its parts. Holism, as with phenomenology, are philosophical foundation in some psychotherapeutic methods that deals with symptoms suffered by individuals in an integrated manner.

Categorization of Psychosomatic Disturbances

Given the broad understanding of psychosomatics, one may create categorization of the specific disorders in a number of ways (Mörtl, 2016). In the medical profession, the categorization may be done according to the anatomical location, i.e. the skin, the musculoskeletal, cardiovascular, lymphatic, gastrointestinal genito-urinary, endocrine and nervous systems and specific organ reactions. Another classification system is one based upon the dynamic in which the disorders evolve. They could be:

psychological afflictions caused by bodily symptoms, otherwise known as psychophysiologic, psychosomatic or somatoform disorders. These disorders do not present in itself organic causes, which often lead the sufferer to seek multiple medical consultations without result. These symptoms can be observed physiologically on the patient, and a description of the affliction can be made. The nosology— that which describes the underlying psychological causes of the condition— is much more complicated, and would require deeper understanding of the patient’s psychosocial situation as well. This category encompasses an array of somatic syndromes, those which maybe related to mood (affective) disorders, neurotic and stress-related disorders, behavioral syndromes, personality disorders, mental retardation and disorders in psychological development.
Physiological problems that cause psychological disturbances, otherwise known as somatopsychic disorders. These disorders have organic causes, and include (but not exclusively) degenerative brain disorders like Dementia, disorders caused by lesions to the brain either caused by disease, damage or dysfunction. The causes of brain dysfunction may be also attributed to intoxication. Symptoms that afflict other parts of the body that also lead to the need for psychological care would be psychosocial influences that affect physical health. These broadly include addictions, poor nutrition and aging. Many physical diseases cause psychological stress, like chronic ailments and terminal conditions. Psychological help is needed to help patients cope with their symptoms, and the consequences of disease.

Classification of psychosomatic symptoms

Contemporary textbooks and diagnostic manuals commonly classify psychosomatic disorders as:

Somatoform: Physical disturbances caused by somatization of psychological problems. This includes somatoform-autonomous symptoms— like tinnitus, irritable bowel syndrome, and cardiovascular heart disease— non-organic sleep disorder, non-organic sexual disorders, conversion disorder and non-organic migraine.
Eating disorders: Behavioral conditions as result of psycho-social problems resulting in Anorexia Nervosa, Bulimia Nervosa and Binge Eating disorder.
Potential psychosocial factors in organic disorders in organic disorders like Hypertonia, bronchial Asthma, Colitis Ulcerosa, and Neurodermatitis.
Somatopsychic disorders: characterized by psychological symptoms with organic origins like brain lesions, strokes and tumors that cause structural damage and/or biochemical, dysfunction, adversely affecting normal brain activity. This also includes psychological problems in dealing with pain, chronic illnesses, and consequences of surgeries and injuries.

Conclusion

When we consider Merleau-Ponty and the holistic philosophers, it should be a given that the condition of the physical body is one and the same with the mind. In the western world of knowledge politics, this basic wisdom is somewhat put aside in favor of reductionist thinking. The idea that “psychosomatics” be a discipline rather than a standard form of looking at symptoms is proof of this. The classification in psychosomatic medicine is helpful for practitioners and patients alike to discover which came first— the psychological problems or the physical ones. That, however, cannot really tell much else, since every single client is a unique case study in him/herself in relation to his/her own environment. Non-holistic observing of the client could be the reason that many in the medical and psychotherapeutic professions alike find difficulty working with psychosomatic problems and keeping the clients in therapy.

Development in psychosomatics and psychotherapy may lead to greater arguments among psychotherapy modalities as well as fields of medicine. These studies may also bring the modalities in a common agreement as well. It would be interesting to realize, perhaps, how almost every person suffers from some kind of psychosomatic issue, and how their personality, muscularity, adiposity or aging are linked. The term “psychosomatics” alone conjures a whole philosophical understanding of what it means to have mind and body.

Bibliography

Alexander, F. (1962). The development of psychosomatic medicine. Psychosomatic medicine, 24(1), 13-24.

Ellenberger, H. F. (2008). The discovery of the unconscious: The history and evolution of dynamic psychiatry. Basic Books.

Levenson, J. L. (2005). Textbook of psychosomatic medicine. (J. L. Levenson, Ed.) VA: The American Psychiatric Publishing.

Merleau-Ponty, M. (2004). Maurice Merleau-Ponty: Basic writings. (T. Baldwin, Ed.) NY: Psychology Press.

Tseng, W. S. (1973). The development of psychiatric concepts in traditional medicine. Archives of General Psychiatry, 29, 569-575.

Adjustment Disorders: Causes and Symptoms

The diagnosis of adjustment disorders covers a wide range of maladaptive responses to psychological stress, which could be acute, chronic or repeated. These may be responses to illness, changes to family life, developmental milestones such as puberty, marriage, relocation, changes in employment etc.

Adjustment disorders are often exhibited as (sometimes a combination of) anxious moods, depression, behavioral disturbances, psychosomatic pains and ailments. withdrawal, mental inhibition.

How are Adjustment Disorders Experienced?

Affective states. This varies from individual to individual, depending on the individual’s mental wellbeing and personality. They manifest as anxiety, depression, and conduct change. There may be experiences of apprehensiveness, due to pervasive sense of uncertainty.
Cognitive patterns. The individual with adjustment disorder may be overly preoccupied with what they are facing, or they may defenisvely avoid it.
Somatic States. It depends of how the individual deals with the situation emotionally, adjustment disorder can manifest itself in physical symptoms.
Relationship patterns. Relationship with significant people may be affected due to the stress caused by the disorder. How a person reacts in relationship depends on the individual situation.

How can Adjustment Disorder be Treated?

Individual psychotherapy and/or family therapy is helpful to alleviate the levels of anxiety and stress, by:

Helping the client to uncover the root of the negative affects.
Allowing the client to better cope with the new situation.
If necessary, to help the client take active control of his/her situation (if the situation is negative, e.g. joblessness).
To provide a safe environment for the client to be heard. Hence reducing depression and anxiety caused by loneliness.
For clients who are stable, to help uncover his/her personality structure / childhood experiences that renders him/her vulnerable to the changes.

Ultimately the goal of psychotherapy is to support the client to express his/her adjustment difficulties and fears, so that he/she may find his own resource to cope with the situation.

What is Dissociation?

Meanings for the term “dissociation” continue to evolve. Dissociation was originally seen as a type of hysteria, related to conversion, and distinct from depersonalization. It included amnesia, fugue, certain altered states (e.g., somnambulism), and multiple personality.

Dissociation is a criteria in DSM III for diagnosis of PTSD and ASD, as “flashback or dissociative episodes”. While flashbacks denotes sensing of something there that is not (positive symptoms), dissociative episodes denotes absence of sensing what is there –detachment, reduced awareness, derealization, depersonalization and amnesia (negative symptoms).

In Borderline Personality Disorder, dissociation in DSM-5 is described as “transient, stress-related…severe dissociative symptoms” with depersonalization as example.

3 distinct meanings of dissociative experiences (p.180):

Dissociation of some of one’s mental functions or faculties. The DSM-5 definition: “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). “Negative” dissociative symptoms involve the withdrawal of something, such as dissociation of memory (amnesia), sensation (conversion anesthesia), or affect (emotional blunting). “Positive” dissociative symptoms involve the intrusion of something, such as the sensory reexperiencing of a trauma (flashback), or any other intrusion of affect, knowledge, sensation (in any modality), or behavior (action, unintended vocalization, etc.). Most of these symptoms may occur within a single consciousness.
Depersonalization/derealization. These may be experienced as the withdrawal of the sense of reality. These are also considered as intrusions in the DSM.
Dissociative multiplicity. This is a plurality of consciousness, in which the first two types of dissociation commonly co-occur; thus, there is always the possibility that cases featuring the first two types of dissociation may have covert multiplicity as well. The DSM-5 definition does not really work for multiplicity because once there is more than one self occupying the center of consciousness, there is more than one center of subjective experience and consequently more than one set of symptoms.

Dissociation in Childhood Experience of Abuse

Freud and his colleague Josef Breuer (1895) identified the root of hysteria in women as child sexual abuse, specifically incest. Freud eventually reversed that emphasis to focus on a child’s fantasies of sex instead of the reality of sexual abuse. Other contemporaries—notably Pierre Janet (1889) outside the psychoanalytic movement, and Sandor Ferenczi (1949) within it—retained a focus on the trauma of childhood abuse, positing dissociation rather than repression as the main method a child (and later an adult) uses to cope. They observed that if the trauma were not worked through and resolved at some point, its residual effects would often have a lifelong (and negative) influence across various domains.

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 182). The Guilford Press. Kindle Edition.

Dissociative effects of PTSD

Dissociation is PTSD is not psychosis. The person has a flashback — a momentary out of sync with reality, and reliving an experience in a traumatic past experience.
Dissociation is an altered state of consciousness. Unlike psychosis, the individual is functioning but loose track of time/space, etc. The persons may also have a sense of watching him/herself and not being there.

Dissociative effects from Childhood Neglect

The video above addresses dissociation from own feelings. This happens to children of child abuse from narcissistic parent. Most likely the condition of suffering is not unlike complex PTSD.

Bibliography

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 179). The Guilford Press. Kindle Edition.

Differentiating Symptoms of PTSD from Trauma-Associated Narcissistic Symptoms

Individuals suffering PTSD display symptoms that look like that of those suffering from trauma symptoms associated with the narcissistic personality (TANS).

This article by Simon (2002) sheds clear light on distinguishing between the 2 types of patients. The table below is an extract from the article:

If we were to extract the gist of the difference between PTSD and TANS, we may be able to summarize that unlike in PTSD, patients with TANS main “damage” is that of the grandiose image of the self. There is more shame and humiliation underlying. This is manifested by anxiety about damage to a kind of grandiose self image. In PTSD symptoms, the anxiety is mainly about survival.

Knowledge of these differences facilitate the psychotherapeutic treatment of the patients, since both types of patients experience the relationship with the therapist differently. This also reflects the difference between event onset trauma in the case of PTSD, and developmental attachment related trauma in the case of complex trauma.

Bibliography

Simon, R. I. (2002). Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harvard Review of Psychiatry, 10(1), 28-36.