Hermeneutic circle of understanding 

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

Reference

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

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

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

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

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

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

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

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

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

Reference

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

Breuer & Freud’s pioneering concept of the psychotherapeutic alliance

Psychotherapy in practice differs from many other areas of medicine, particularly with regard to the patient-therapist relationship.

It has been observed that Breuer’s work documented by Freud paved the way for the less authoritarian attitude of the doctor who knows everything and opened the door to a different kind of therapeutic relationship (Bocian & Staemmler, 2013; Grubrich-Simitis, 1997). Freud wrote in the early days of psychoanalysis of his revered mentor, Jean-Martin Charcot, whose research on Hysteria and its treatment method of hypnosis greatly influenced Freud as a young practitioner, “Charcot, however, did not follow this path towards an explanation of hysteria […].” (Freud & Breuer, 1893). The work of Charcot, notwithstanding, greatly influenced Freud’s transition from neurology to psychopathology (Grubrich-Simitis, 1997, p. 12- 13). Freud acknowledges the contribution of Charcot’s work towards bringing to scientific importance the study of Hysteria, that in having successfully inducing hysterical paralyses in hypnotized patients, Charcot proved that the hysterical paralyses were “the result of ideas which had dominated the patient’s brain at moments of a special disposition” (ibid. p. 13).

Freud’s own studies on Hysteria with Breuer, however, demonstrated the importance of a change in the approach towards the therapeutic relationship in the development of the understanding and healing of a psychological condition. When Freud met Breuer, who became his friend and mentor, Breuer was already in his fifties and was a reputed medical practitioner and experimental physiologist. Breuer had already worked with Bertha Pappenheim, better known as Anna O., in 1880 to 1882, some 3 years before Freud went to study with Charcot. Studies of Hysteria (Breuer & Freud, 1955) were written in 1895, 15 years after the said therapy, and the client by then was known to have been cured of her symptoms. Breuer had, together with his patient— who suffered severe hysterical symptoms and who is often regarded as “highly gifted, and the true discoverer of therapeutic reconstruction”— uncovered the dynamics of mental pathology. Unlike the Charcot school, Breuer used hypnosis “not for the purposes of crude behavioural suggestion but as a route to the memories of pathogenic traumatic experiences that were not accessible to the patient in the waking state” (ibid. p. 21).

Relying on the doctor to carry out treatment while the client remains the passive recipient with the goal of attaining catharsis through hypnotic suggestions, Freud exerts, may not amount to a cure, but a suggestion of a cure. In the case of Breuer’s work with Ms. Pappenheim – in listening with interest to her narratives—the therapist and client were able to investigate the actual events in the client’s life that precipitated the neurotic outcome; this is more than just the knowledge of the existence of psychic disturbance, as Charcot describes it, that is behind the symptoms and desensitizing through hypnotic suggestion. This step of gaining a clear understanding required much more effort, attention and empathy on the part of the practitioner (Freud & Breuer, 1893). Early expert critiques of the Studies of Hysteria reflected Freud’s sentiment of his own work, “[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own (Freud & Breuer, 1895)” (Grubrich-Simitis, 1997, p. 19). With this admittance, we are led to the understanding that procuring a cure requires the abandonment of impersonal scientific learning, but an engagement with the client on a personal level that is different from the conventional attitude of that time, whereby treatment is based on empirical proofs (i.e. what is considered “stamp of science”).

[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own.

Sigmund Freud in Freud & Breuer, 1895

Here we get a glimpse of Freud’s dilemma. He had found a good healing technique, but alas, it did not seem to conform to certain scientific procedures. It is also added that he who “wishes to plumb and describe the mental cannot completely escape the creative writer’s methods of conceiving and describing, however rigorous the will to cool, sober objectivity” (Grubrich-Simitis, 1997, p. 19-20). In many ways, we still find ourselves in a similar situation today, in our discourse on Psychotherapy Science.

That which is more worthwhile to learn from the case of Anna O. is, however, not found in Breuer’s account alone, but that the “psychodrama that took place in Breuer’s treatment, (…), gave Freud raw material for his theories of the Oedipus complex, identification, transference and countertransference, repetition compulsion and acting out (Britton, 2003, p. 8). As if to prove the significance of this first case, Freud (1914) himself reviewed this case 20 years later, pointing out to us to this unique— and often ethically treacherous— aspect of the psychotherapeutic alliance. The word “treachery” is carefully used to emphasize the fact that the danger is insidious and that special attention is necessary to notice and avoid its consequences. In order to investigate a treacherous situation in a relationship, however, we need to understand what lies in it.

References

Bocian, B., & Staemmler, F. M. (2013). Kontakt als erste Wirklichkeit. Zum Verhältnis von Gestalttherapie und Psychoanalyse. EHP-Verlag Andreas Kohlhage.

Breuer, J., & Freud, S. (1955). Fräulein Anna O, Case Histories from Studies on Hysteria. In V. I.-1. In The Standard Edition of the Complete Psychological Works of Sigmund Freud.

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

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Grubrich-Simitis, I. (1997). Early Freud and late Freud. Reading a new studies on hysteria and Moses and monotheism. (P. Slotkin, Trans.) NY: Routledge.

Power Differences in the Psychotherapeutic Alliance

Although there are different nuances within different psychotherapeutic approaches, the difference in attitude towards the client-therapist power difference can be divided into two very broad groups— symmetric and asymmetric following terminology used in Altemeyer (2013):

  1. The symmetric aspects of the relationship: In what is considered the humanistic approaches to psychotherapy, the therapist’s work is to be there as a companion to the client, to work with the client in partnership sans analyzing, judgment and oftentimes “helping”, but instead providing unconditional positive regard towards the client. For this to be achieved, there must exist a coming together of\ two authentic individuals as in Carl Roger’s person-centred psychotherapy approach that is “contact-building and acknowledging quality and empathy— without any techniques, means aims or intentions” (Schmid, 2001, p. 1).
  2. The asymmetric aspects of the relationship: Within psychiatry, and some archaic versions of the psychoanalytic/psychodynamic schools, the therapist is often expected to be the one more empowered to help the client, as a medical doctor would with his/her patient, providing analysis and nurturance, working on the interpretation of transference or dreams and the therapist’s countertransference reactions, and being a guiding figure to the client (Scharf, 2016, p. 50-55). Similarly, in behavioral & cognitive therapies, the client relies on the therapist for instructions, to set agendas, to give structure to the therapy and provide assistance for forming new experiences

Both standpoints are necessary for therapy to work. The therapist is a trained professional and has the theory behind them as tool to help the client through difficulties. Hence the therapist is the doctor and authority – and hence professional authority— with regard to psychotherapy. Concurrently, the healing process brought about through psychotherapy comes from the empathic alliance that the therapist builds into the relationship.

How then, if all approaches are viable, do we resolve these seemingly conflictual ideas of the nature of the psychotherapeutic alliance?

We can get an answer by referring back to the five-relational Clarkson framework, we may see that the asymmetric aspect or the relationship actually belongs to the first three parts of the therapeutic relationship: the working alliance (point 1), the transferential/ countertransferential relationship (point 2), and the reparative/developmentally needed relationship (point 3). The therapist’s role in these aspects of the relationship is clearly defined, and the switching of roles between therapist and client in this regard is inconceivable. The psychotherapeutic relationship must remain, on this level, an asymmetric one since the therapist has the defined role of the one who nurtures, helps the client with analysis and is the one being paid to do the job. The therapist takes on an egalitarian stance when he/she gives attention to the mutual relationship and helps the client to experience his therapeutic observations.

In the relational approaches of psychotherapy, however, the therapist helps the client to focus on the here-and-now and actively reduces the power inclination within the relationship; this with the intent to engage with the client on a more emotional and experiential level (Altemeyer, 2013). From this vantage point, we can see that the fourth and fifth aspect of the alliance— the person-to-person relationship (point 4) and the transpersonal relationship (point 5)— comes into play. With this understanding, we may be able to appreciate how and why all modalities of psychotherapy schools work: because each of the 5 levels of the alliance is (albeit in different measures and emphases) present in the relationships. We may be able to also understand why psychotherapeutic approaches over time evolve from analytical to relational and vice versa. Approaches evolve because therapists, through their experience working with their clients, have realized the need to modify their attitudes dynamically towards the therapeutic alliance in order to be effective in helping their clients.

The symmetric aspect of the relationship is important to consider– i.e. the person-to-person aspect (point no.4) and the transpersonal relationship (point no.5)— and to show that this symmetric therapist-client relationship is unique to psychotherapy and different from other healing or counselling professions. In most schools of psychotherapy, we are expected to reach into the intersubjective aspect of the relationship, which will be explained in this paper (Chew-Helbig, 2019) as the implicit material (i.e. what is between the lines and not necessarily said), whereas in counselling the focus is on the explicit material (i.e. what is being openly discussed). The symmetric aspect of the relationship is the part of the alliance that brings about enduring change in psychotherapy.

Read in this post about this part of the alliance that is actually the foundation of Freud’s work— that which Freud, through Breuer, discovered and proved to be the way to actually cure what is actually a psychosomatic condition known as Hysteria. Further discussions will move deeper into the whys and hows of what this unique aspect of the relationship actually does to alleviate the patient’s symptoms.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Altemeyer, M. (2013). Die Wiederentdeckung der Beziehung: Ein Paradigmenwechsel im Psychoanalyitschen Gegenwartsdiskurs. In B. Bocian, & F.-M. Staemmler (Eds.), Kontakt als erste Wirklichkeit. Zum Verhältnis von Gestalttherapie und Psychoanalyse (Kindle ed.).

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Chew-Helbig, N. Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA). URL: https://nikhelbig.at/wp-content/uploads/2019/05/NICOLE-HELBIG-PRINTING-copy.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Scharf, R. (2016). Theories of psychotherapy and Counseling. Concepts and cases. (6th Edition ed.). MA, USA: Cengage Learning.

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

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Reich’s Case Examples: Process vs. content in the psychotherapeutic dialogue

Wilhelm Reich, in Character Analysis (1945/1984), illustrates the importance of working on the process of the therapeutic relationship – i.e. what is going on between therapist and client— before jumping into analytical work. Reich points out that neurotic character traits— being symptoms as the result of the failure of the individual to resolve the unconscious conflict between repressed instinctual demands and the ego forces that work against these instinctual demands— need to be worked with first before the client is able to benefit from any analytical work. Reich explains that interpretation is the process of bringing that which is unconscious into consciousness. However, the problem lay in “counter-cathexes”— which can be explained as strict censor of thoughts and desires in the preconscious— that critically selects the thought process of the client, rendering it difficult for the client to freely associate. At the same time, it is the need of the patient’s unconscious to find release for this conflict through contact with the analyst (as it is a need for an individual to contact any other individual or situation). The result is an establishment of a relationship with the therapist that is prompted by love, hate or fear— what is known as transference. This can come in two main forms: 1) positive transference, whereby there is cooperation/compliance by the client due to positive feelings and 2) negative transference, where the treatment is impeded due to ill feelings the client has toward the alliance.

Reich points out that while negative transference is easier to detect – since it works against and irritates the therapist’s intentions— as something to work on, positive transference is as important – or even more important.

Positive transference often gets mistaken for progress until the positive feelings ultimately transform into disappointment. For this reason, it is observed that the tendency of the therapist to begin analyzing every material that the client presents prematurely, to rely on the routine passage of therapy sessions, without considering the effects of transference, is not effective in bringing about a resolution to unconscious conflicts and does not make for a successful healing alliance.

Reich writes, “If the analyst interprets the material in the sequence in which it appears in each case, whether or not the patient is deceiving, using the material as a camouflage, concealing an attitude of hate, laughing up his sleeve, is emotionally blocked, etc., he (the analyst) will be sure to run into hopeless situations. Proceeding in such a way, the analyst is caught in a scheme which is imposed on all cases, without regard to the individual requirements of the case, with respect to the timing and depth of the necessary interpretations” (p. 8). In other words, it is almost impossible for the therapist to distinguish authentic, useful narrated content from, perhaps, words that are used to manipulate the therapeutic situation or relationship, unless the underlying situation of the relationship itself is understood. It could be difficult to be sure of what goes on in a relationship of which one is part. For the therapist, time, together with an attitude of patient, phenomenological observation, allows the therapist to gain experience of being with the client. Setting aside this time helps the therapist to understand what is in between them and the patient.

Reich’s case examples

In the third chapter of Character Analysis entitled On the Technique of Interpretation and of Resistance (p. 21-38), Reich provides snippets of case studies. These examples help us to understand what Reich means by working on what Freud calls the forces of “resistance and transferences” that interfere with the attempt at analysis before jumping into analyzing the content of the client’s narratives— and the “chaotic situation” that can happen when attention to this is not observed. The case examples cited revealed instances where therapy sessions did not help the patient because the therapist failed to notice and observe resistances due to transference— and character— but instead delved into (or attempted to delve into) interpretation right away, without preparing the client – and therapist himself— for the analytical work first. I shall discuss some of the cases, and briefly discuss what kind of questions could have been asked by the therapist in the situations.

Case 1

“A patient who suffered from an inferiority complex and self-consciousness enacted his impotence by adopting an apathetic attitude (“What’s the use?”). Instead of divining the nature of this resistance, clarifying it, and making conscious the deprecatory tendency concealed behind it, I told him again and again that he did not want to cooperate and had no desire to get well. I was not entirely unjustified in this, but the analysis was not successful because I failed to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.” Instead, I allowed myself to be trapped into futile reproaches by my own inability” (ibid. p. 23).

The therapist, frustrated at the client’s perceived non-cooperation failed to acknowledge the process of how the client was unconsciously avoiding the work; by resigning to the belief that there was “no use”. This resignation in itself is the defense mechanism and the ripe material for the work. In trying to fish for cooperation from the client, the therapist missed what was present that could be worked on, as the therapist himself points out: (see above: to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.”). The therapist, when unaware of his own need to get cooperation, was in danger of re-enforcing the resignation and breaking contact with the client. Working on the here-and-now, the therapist in such a situation may ask the following questions that address the client’s resignation, and perhaps his lack of will to even try. These questions may lead the therapist and client to a deeper understanding of phenomena in the alliance itself: “what does it mean for you when you say ‘what’s the use’?”, “what would you imagine could happen if you tried?”, “what would it mean if you tried and failed?”, “I am interested to know if would you like to try for a couple of minutes and see how?” “If not, what can I do/not do to help you work this out?”.


Case 2:


“In still another case, it happened that in a dream during the second week of treatment the incest fantasy appeared quite clearly and the patient himself recognized its true meaning. For a whole year, I heard nothing more about it; consequently, there was no real success. However, I had learned that at times material that is emerging too rapidly has to be suppressed until the ego is strong enough to assimilate it” (ibid. p. 24).
What appears to be material, in this case, a narration of a dream may be a way of resistance from being seen through story-telling. It is an example of a therapist focusing on “content”, which is the dream story, and not noticing the “process” which is the fact that the client is telling the story in the first place. The content is enticing. The process is invisible. Unawares, the therapist missed the resistance because it is embedded in the process of what is being said. It would be helpful to ask the client questions that bring him back to the alliance: “I’m hearing your dream and it is really interesting to me that you are so clear about it, and my instinct is to ask you more about it. I’m just curious, what is it you want me to know from this?” “What is important right now for us to work on with regard to what you just said?” or “What is it like for you to tell me this?” With these questions, the client will have a choice to either work deeper into what is really disturbing him about the dream (if at all), or, he may reveal his need to impress or help the therapist by being unduly cooperative as in positive transference (as will be discussed later).


Case 3:


“A case of erythrophobia failed because I pursued the material which the patient offered in every direction, interpreting it indiscriminately, without first having clearly eliminat- ed the resistances. They eventually appeared, of course, but much too strongly and cha- otically; I had used up my ammunition; my explanations were without effect; it was no longer possible to restore order” (ibid. p. 24).
In this case it is an example of the therapist focusing on content, and unsystemat- ically using this content for analysis. The therapist probably failed to notice the process that was going on, i.e. the fact that there is so much unsystematic work in progress with- in the alliance itself. Possible way to make good the “chaos” is to stop and acknowledge the chaos ensuing. “I notice that we are doing much here and it feels chaotic. I am inter- ested to know what you are experiencing right now.” It may be also useful to check out how not interpreting can help the client. In this case, where a symptom “erythrophobia” is clearly acknowledged, the alliance could be a place for experimentation in the here- and-now— like inviting the client to blush “for a moment”, or what would the client think if he saw the therapist blush— to help the client gain confidence within the alliance.


Case 4:


“Another patient, in the course of three years of analysis, had recalled the primal scene together with all material pertaining to it, but not once had there been any loosening of his affect-paralysis, not once had he accused the analyst of those feelings which- however, emotionless-he harboured toward his father. He was not cured” (ibid. p. 23).
This case is representative of situations whereby the patient seems to have the full acknowledgement of the unconscious material. The therapist is satisfied, but the client is not helped even after 3 years. Reich highlights the importance of the patient embody- ing the experience— feeling the emotions and physical reactions as if reliving the past— rather than simply intellectualizing the recall. Intellectualizing memories, which is easily observed because there is a lot of “talking about” without affect, is really aform of resistance; a way to satisfy the therapeutic process while escaping pain. In ge- stalt therapy, this defense strategy is called “egotism”. Egotism is characterized by the individual stepping out of himself, acting as a spectator or commentator of himself and his relationship with the environment (Clarkson, 2014, p. 65). This is what is happening to the client is this case. This resistance often gets overlooked by therapist because they are sidetracked by “interesting” client narratives. Noticing the interruption is a way to slow down the narratives and show the client that he/she is avoiding something poten- tially difficult to deal with.


Case 5:


“A patient with a number of perversions had been under analysis for eight months, dur- ing which time he had rattled on incessantly and had yielded material from the deepest layers of his unconscious. This material had been continuously interpreted. The more it was interpreted, the more copiously flowed the stream of his associations. Finally, the analysis had to be broken off for external reasons, and the patient came to me… It struck me that the patient uninterruptedly produced unconscious material, that he knew, for instance, how to give an exact description of the most intricate mechanisms of the simple and double Oedipus complex. I asked the patient whether he really believed what he was saying and what he had heard. “Are you kidding!” he exclaimed. “I really have to contain myself not to burst out laughing at all this” (ibid. S.26).

Here, Reich gives another example of a “knowledgeable” and “cooperative” cli- ent whose knowledge and cooperativeness was the resistance itself. Reich explains this behavior to be of narcissistic defense. The therapist is unaware of what Reich describes as “latent resistance”, which he explains are “attitudes on the part of the patient which are not expressed directly and immediately”, but expressed indirectly. The patient’s negative regard towards the therapy (i.e. feelings of doubt, apathy, distrust, etc.) is disguised under the cloak of exceptional docility, or complete cooperation. Reich says that this is “more dangerous” than passive resistance, and the way to handle such situations is to tackle it as it happens, without hesitating to interrupt the flow of communication. Our challenge as therapist is to first notice that such-like phenomena are taking place. It is from this vantage point that Reich emphasizes the topic of character.

Reich’s advice on avoiding “chaotic situations”


Reich tells us that through this process, can we avoid what he terms “chaotic situations” which occurs as the result of:

Premature interpretation and work on unconscious materials, and symbols. Resistance to the therapy itself, when not yet exposed, prevents the patient from assimilating the work. The client ends up “going in circles completely untouched” (p. 26): This phenomenon can be explained as egotism in gestalt therapy. Egotism is a defense strategy whereby the client’s ego distances it- self from the experience, and sees the self from a distance, as if he/she is look at another person. This situation of the client going in circles may help to explain why some clients, though compliant, do not seem to get better.

“Interpretation of the material in the sequence in which it yields itself, without due consideration to the structure of the neurosis and the stratification of the material” (p. 27): The mistake happens in interpretation, because the ma- terial is not worked through in it’s full context, but worked on in unsystemat- ic fragments, leading to loss of meaning.

“The analysis is embroiled not only because interpretations are pursued in every direction but also because this is done before the cardinal resistance has been worked through” (p. 27): The main problem here is due to the re- sistance not being acknowledged and worked through before interpretation is done. The situation becomes confused when the work is entangled with the relationship to the analyst. The unsystematic interpretation works in a vi- cious circle to affect the transference relationship further.

“The interpretation of the transference resistances is not only unsystematic but also inconsistent“ (p. 27): When there is a lack of acknowledgment of the power of the client’s resistance (and latent transference resistances) to need to conceal resistances. These resistances are also masked behind “ster- ile accomplishments or acute reaction formations” i.e. the client may seem to be cooperative, show signs that there is the change in direction expected, or the client may react to analysis in a way so as to deflect from getting to the authentic unconscious material. Therapists may tend to shy away from developing and following up consistently on these resistances in whatever form, due to their own feelings of discomfort (their own resistances) in dealing with the transference resistances in a consistent manner.

It is from the understanding of the effect of transference, that we may be able to appreciate the challenge of being aware of how the interpersonal feelings in the alliance get in the way of therapeutic work.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Chew-Helbig, N. Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA). URL: https://nikhelbig.at/wp-content/uploads/2019/05/NICOLE-HELBIG-PRINTING-copy.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

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

·

Freud and the here-and-now in the therapeutic alliance

The phenomenon of the present moment often termed the here-and-now is the centre of focus in the practice of other psychotherapeutic schools, and in particular gestalt therapy. Referencing back to Freud, we can see that he makes the distinction between doing analysis and working on the resistance of the client in getting the analysis done. Doing analysis alone deals with past material while working on the resistance deals with the phenomenon of the here-and-now. Doing so is an attempt at tracing the symptom back to the past. Freud explains:

“It may thus be said that the theory of psycho-analysis is an attempt to account for two striking and unexpected facts of observation which emerge whenever an attempt is made to trace the symptoms of a neurotic back to their sources in his past life: the facts of transference and of resistance” (Freud, 1914).

Psychotherapeutic work, at its commencement, is an act of attempt— a process—to investigate. What emerges in during therapy sessions that works against and interferes with this attempt is what we learn to be resistance and transferences. The patient’s unconscious resists analysis. The “resistance” that the therapist encounters during the therapy session, and is considered the point of focus at which to work through the client’s neurotic symptoms.

This resistance is interference within the client to realize an emerging need. Simkin (1973/1990) explains metaphorically that this emerging need is the “figure” that emerges from a “ground”, that, if not realized and met, cannot achieve completion. Unrealized/un-met needs (unclear figures) leave the person with off-centeredness (mangelhafte Zentrierung) and their needs de-differentiated (Entdifferentierung) which become manifest as heightened arousal (Erregungsschwelle), which is lived as the neurotic symptoms (Votsmeier, 1995). The clearer a need is to the client, the more possibility for this need to be met. In therapy, the therapist leads the client towards sharpening this figure, and realizing the need. Needs that aren’t met are also known as unfinished businesses.

The goal of almost all psychotherapy approaches is to work through unfinished businesses, which are situations whereby completion is not achieved resulting in repetitive patterns in behaviour that do not serve the client. Work is done by either bringing awareness to the unfinished situation and/or through saturation/exaggeration by “continuing until you feel fed-up” (Simkin, 1973/1990, p. 87). The resolution comes when completion is achieved, and the figure goes back to the background, allowing other figures to emerge. So that the organism can make contact with the environment.

The process of psychotherapeutic work is initiated by, and consists of, the observation of the interruptions to the work, and not the content of the analysis per se. The resistance to the attempts, when dealt with in the here-and-now, brings about awareness of unresolved situations. This is fodder for therapeutic work.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Freud, S. (1914). On the history of the psycho-analytic movement. In Standard Edition (pp. 2877-2928).

Simkin, J. S. (1973/1990). Gestalt Therapy Mini Lectures. With a new introduction by Ervin Polster. (Kindle ed.). The Gestalt Journal Press.

Votsmeier, A. (1995). Gestalt-Therapie und die „Organismische Theorie “–der EinflußKurt Goldsteins. In Gestalttherapie (Vol. 1(95) , pp. 2-16).

Envy… and Gratitude

Envy is the idealizing of an object outside oneself, with the wish to devour the coveted object. This object is something possessed by another person or persons. The trappings of envy is that one cannot find peace through separation of oneself from the envied object and the envied other. The resultant is hatred and the need to destroy the other.

Envy can also be seen as a projection of goodness into another person, so that one idealizes the other while devaluing oneself, and eventually hating the other. Envy is a painful emotion and is almost not in the awareness of the individual. It is also integral to being human, and hence it exists in every reasonably living functioning person.

Envy vs. Jealousy

Envy is exists in terms of two persons– it involves you and me. I want what you have, because that is what I lack. Jealousy involves a third person. I am not allowing that other person to take you / your attention/ love, etc away from me.

Destructive Envy

If I cannot have what you have I’ll seek to destroy that coveted thing. Sometime this destruction is abstract.

Greed

Greed is a means to extract all the goodness from the other. Greed doesn’t necessarily seek to destroy. Greed is to consume without gratitude. Hence greed never gets satisfied.

Defenses against feelings of envy

Vanity or grandiosity is a defense against envy. To make oneself more superior to overcome envy of another. Self idealization, feeling omnipotent, not needing or depending on others.

Invidiousness, is a means to act so that the other becomes envious of you.  To projective identifying or evoking emotions of envy in the other. The problem this causes the person to fear the envious eye of other.

Spoiling, devaluing, rigid idealization, projection of envy (a superego that attacks and devalues own achievements) are examples of means to counteract feelings of envy.

When envy is strong, even what’s seems as a good object becomes a source of pain.

In normal experience good experience predominates over bad. Pathology aries when bad predominates good internally and externally.

Positive use of Envy

Constructive envy is one that inspires one to work harder to improve oneself. If I am envious of somebody’s abilities, e.g. piano playing, I practice harder. We also witness the energy derived from envy in the masterpieces created by highly creative people.

Gratitude as the Antidote to Envy

Melanie Klein tells us that gratitude is the antidote to envy. To be thankful is to be able to see the glass half full. Gratitude allows one to feel satisfied with what one has achieved or bestowed.

Bibliography

Carveth, D. (2016) Introduction to Kleinian Theory 4. Youtube. https://www.youtube.com/watch?v=bb-L_QXNyQU&t=2s

notes;

Pathologically violent projective identification, where the object (ego) is splintered, attacked. Reality is seen as persecutory and hated. When envy is intense, the perception of the good object is as painful as the bad object.

46:00 Psychopathology is  the result of early decision to try to base your life upon evading pain (Bion).  Psychotherapy is the process of turning this around. To help the individual face the pain and move on to more functional existence.

A EMDR Methodology for Working with Trauma

EMDR is a form of psychotherapy originally designed for trauma therapy. EMDR provides a here-and-now stimulus as the client recounts his/her traumatic memories. Tapping or eye movements keeps the client in the present and in the observer position. This keeps the client stable, so that he/she can remember stressful experiences without being re-traumatized.

EMDR is very much a relational-therapy application which I find very useful for integrating into my work.

EMDR is founded by Francine Shapiro. Here are 2 lectures of EMDR by Shapiro herself.

About Shapiro’s Way with EMDR

History and research history on EMDR

Commonly administered EMDR Process

EMDR process has a structure. The actual procedure administered is unique to each individual. The therapist, during the session, has to remain focus on the phenomenology of the patient. Keep in mind that simply following the steps alone is not therapy.

  1. EMDR therapy begins with a clarification of a trauma-specific case history. The client reveals a traumatic event(s), it’s symptoms and these are to be worked on. The treatment process is also explained to the client.

  2. The effectiveness depends on the choice of the outcome situation, and the unveiling of the cause of the traumatic situation.

  3. Stabilization of the current situation of the client is important. The client is also prepared internally for the exercise. e.g. the client is asked to use a stop signal if he/she feels too uncomfortable. The client also gets to describe a safe place.  In other words, the client is asked to consider the resources he/she has.

  4. Estimation of the degree of severity of the experience. The client is ask to rate the degree of feeling felt at the moment about an event. The client is asked to describe and rate a negative aspect of the event (e.g. feelings of fear or guilt). The client is also asked to describe and rate a positive outcome of the event (e.g. feeling of freedom from guilt).

  5. The client is asked to estimate how strong the feelings of stress at the moment is.

  6. The client is asked to describe how he/she feels in the body.

  7. Pre-processing step: to ask the client to relax and recount the event. Allowing the client to creatively enter into the scene. The therapists begins to lightly tap on the client’s wrists or knees, or guides the client with eye-movements, and encourages the client to describe the situation(s) as they arise to consciousness.

  8. The weaving in of the here-and-now situation with past situation.  The client gets to see the traumatic experience as a more mature person (as opposed to a child when he/she suffered a trauma).  The client also gets to view the situation from a vantage point of a safer present.

  9. Re-evaluation of the feelings of the traumatic events.

  10. Anchoring: the client is asked to recite what he/she has learnt from the experience (the positive experience) as the therapists taps the client’s wrist a little more.

  11. Body scan test: to check how the feelings in the body. And to find out what else  that is stressful that is felt in the body.

  12. Closing conversation and dialogue: something light hearted, breathing, relaying.

  13. Next session, the previous treatment is rated again to see how the treatment is integrated. If the stress is still there, therapy can be repeated, if it is successful, anchoring work can be done.

Sometimes the client does stabilize after the therapeutic work. It is useful to be patient and listen to the patient’s current experience. The goal of the therapy is not to completely resolve every stress in one sitting, but to bring stability week to week, until the client learns to integrate the treatment.

Often the client feels permanent relief of a certain degree of stress.

Own work experience

I decided to use the tapping technique with a client who mentioned a car accident in which she was a driver that happened 20 years before. She is a successful businesswoman in her 50s, and had never mentioned this incident prior. This incident came to light as a result of  a dream recollection.

The client had left a going-away party with some friends, had some drinks. It was also midnight, which was the day of her birthday. As she drove home, she collided with a drunk pedestrian, who got severely injured and died.

During the therapy, the client expressed fear and guilt which she had shut off all the years. She never had a chance to talk about her trauma to anyone and felt lonely.

The tapping allowed the client to see the event as if it were a movie. She could experience the emotions and was able (with hesitation) to vocalize the feelings. Her arms began to sweat.  She began to remember more details of the night after the accident when she went home, and the morning after, how she felt like it was a nightmare, but it was for real.

At the end of the session, the client felt her loneliness, but was relieved about being able to share. Her fear level regarding the event went from a high 10 to 0.  She still processes sadness and guilt about the event, which was later our work-in-progress.

Bibliography

Schubbe, O. (2004). Traumatherapie mit EMDR. Order, 22, 99.

Couples Therapy: Helping children cope with parents’ separation and divorce

Children do suffer much when parents separate or divorce. Read how couples therapy can help reduce the emotional stress and confusion in children who have to face their parents separation.

Children are wired to be ultra-sensitive to changes in their parents’ relationship.

Some children are so tuned-in that they pick up unhappiness within the couple long before the couple even acknowledge the gravity of their problems. How do we know this?

Family therapists have long understood — through working with parents and their children — how children’s developing symptoms can emerge out of anxiety over their parent’s state of mind or relationship. This is a known phenomenon from the field of the family system.

Secure parental bonds are important to children.

The younger and more vulnerable the child, the more important to them are the parental bonds. Stable bonds mean safety. When there is a threat to this stability, children get anxious. This anxiety can amount to panic. From the experience of working with adult clients, I have learnt how even older children in their late teens get affected by their parent’s separation.

Children face anxiety and panic when parents separate

“What will happen to my home?”,”who will take care of me?”,”will mommy or daddy leave me?” These questions speak the language of a child’s fears of being abandoned and left exposed to the environment. The resultant “symptom” is anxiety and panic.

Children blame themselves for their parents’ divorce

Older children and teenagers develop an added strategy to withstand this kind of anxiety. They blame themselves. Blaming is a way of assigning power to the object of blame. If being abandoned makes one feel vulnerable, the way to overcome vulnerability is to assign power to the self. The unconscious tendency is to assign blame to the self for what has happened.

There is a tendency for children to blame themselves for their parents’ marriage breakdown.

In their adult years, children of parents in conflict can bear symptoms such as depression, mood swings and anxiety. Many have difficulty with intimate relationships themselves and some even adopt self- harming behaviors. Psychotherapy sessions in my practice has uncovered oftentimes this link.

What can divorcing parents do to minimize harm to their children?

Be open and reassuring with your children. Even very small children can grasp parental conflict. This does not mean that you should fight in front of the children. To be open about conflict is to acknowledge that there is one, without explaining why, or who is at fault.

Be careful not to use the child to take sides.

Reassure the children that their parents love them, no matter what happens. Reassure them that they are good children.

Engage a professional whom the child can regularly talk to. This could be a counselor or psychotherapist.

Engage a marriage counselor or couple’s therapist to help you and your spouse separate with mutual understanding and respect. Psychotherapists provide the supportive environment for the couple to deal with the emotional pain that arises from the separation process. This relieves the child from being the incidental bearer of this pain.

The last point is worth taking seriously. We know that causing pain to our children is the last thing we want happen in the separation process. Unfortunately, without professional support, the unconscious takes over. In high conflict and stressful situations like divorce, people become unaware of themselves and oblivious to what happens.