Symptoms of Anxiety and Panic Disorders in the Context of the World We Live in

Anxiety and panic disorders are getting increasingly common among young adults. This is a phenomenon observed and mentioned by mental health professionals who work in Europe, Asia and America. There are several hypothesis to this observation. The logic that resonates most with me is the one by a psychiatrist colleague from Italy, Gianni Francesetti.

Francesetti attributes panic disorder to “an acute attack on solitude (loneliness)”. This actually implies that the symptoms of panic and anxiety attacks, while observed to be affecting an individual person, is in fact contributed by this person’s relationship to the world around him/her. Why? Because we cannot be lonely if we are in contact with some other persons in the environment. Hence to be lonely is to be left in the cold with on one for company.

The word panic is descriptive of the state of being left exposed in the wilderness. It is said to have been derived from the name of the Greek god, Pan. Reading the characteristics of Pan one would derive the keywords, all-encompassing, wilderness, solitude, rejection, stomach-churning cry and death. The word panorama describes the wide open field space. A young animal separated suddenly from its mother and exposed to the cold environment would panic. In its panic it would cry out.

Neuroscientist Panksepp’s lecture explains to us how the panic pathway in the brain is wired up. He also tells us in the video below that the baby animal in panic would be quiet again once it is held warmly. If it were not held, it cries would ultimately stop, and the animal would fall into a state of what looks like depression in humans. The panic system generates loneliness and sadness, and it is observed to be the gateway to depression.

The panic system is related in mammals (including humans) to separation distress and over exposure. Human suffers experience the onset of panic disorder usually as young adults, the age when one leaves the parental home.

Most clients who complain of panic attacks are independent and forward-looking people. Feelings of being exposed or separated are not part of their conscious awareness. These experiences belong to the client as toddlers or babies, and are overwhelming. Many clients manage to uncover this hidden past experience after months of psychotherapy.

Psychotherapy for Anxiety or Panic Attacks – A case study

Clarise, 26 years old, a student who holds also a job as a medical receptionist. She had her first panic attack when she was 20 and had just left her family home and moved to another country, Vienna. She explained that the onset of subsequent panic attacks happen when she is about to leave the family home when she is on holiday there. Strangely, this is also related to her leaving her younger brother, Mike.

Proud of being an independent worker, she came to therapy often talking dryly about happenings at work, talking about panic attacks and medication, and avoiding topics about her relationships. I could perceive her avoiding experiencing her emotions, and her intense fear of going there. Sessions in the first 4 months felt slow. I soon had difficulty remembering her among the other clients.

The slow, almost deadening atmosphere in the sessions soon became clear to me. I felt like I was in conversation with someone who was trying to make herself invisible to me. Yet I felt a longing between us for contact. Clarise came every week for therapy faithfully. I decided on several experiments during the sessions. The most useful of which was very simple: to walk around the room as we spoke. Clarise, while walking, became more animated. It seemed as if in order to make herself invisible, she kept her body still. When she had to walk around, her energy flowed. She appeared then more alive and open to being in conversation with me.

Over time, Clarise was able to talk about her childhood. Keywords were: Unwanted child. Emotionally abusive mother who was devaluing, abandoning, de-validating of her feelings, denying, contradicting. Her mother favors her younger half-brothers. As a child she had to look after the boys. She was also competitive with mother with regard to the brothers. She became overtly responsible for Mike.

Her childhood memories were fragmented, indicating a kind of trauma, perhaps from neglect. Only mother’s feelings of those days could be recalled by Clarise. In the therapy room, it felt to me as if her mother always present. Sometimes I would use the mother’s “presence” as an intervention.

Clarise admits to be constantly yearning for attention. This is a paradox, because of the way she unconsciously makes herself invisible. She admits to flattening her voice to control emotions. Clarise has little body awareness, which she became aware of as we walked around the room.

Gestalt Psychotherapeutic intervention for panic attack symptoms

Clarise’s case shed light on the polarities that emerged during our work.

Polarities are:

  • Fear vs. Curiosity,
  • Attention yearning vs. Self-hiding
  • Being forgettable vs. Forgetting

“I must be afraid so that mother can feel good about herself.”

“When my boyfriend is not at home, I am not in danger of having a panic attack.”

“I make my breathing shallow to press against my chest, so that I won’t cry here.”

Clarise also exhibited tendency for Self-ISOLATION, even if it were unconscious to her. One of her strategies was to dissociate. To disappear. To forget. She admitted that as a child, it was “Safer to be unseen.” If her mother was at home, she would not be able to predict if she would be treated with kindness or anger.

Clarise realised that she could use illness and lately the panic symptoms to garner support from people around her. “When I’m in dire straits, people will come to me and they won’t harm me.”

Looking at PSYCHOPATHOLOGY from the perspective of the relationship between client and therapist.

In the therapeutic alliance, suffering is not located only within the client, but is an emergent phenomenon. This means that we as therapist can feel, perceive ourselves as being part of the symptom. We are impacted by the symptom.

When I am able to acknowledge how being with this client impacts me– in this case the feeling of stagnating stillness and forgetting– I am able to adjust my being with her. In so doing, the atmosphere changes. In gestalt therapy we acknowledge this the as the field.

3 levels of observing anxiety disorder symptoms based on this case study
Single person LevelDyadic Interaction Level Aesthetic Field Level
“My client has panic attacks.” “I forget the client. I overlook her. She seems to make herself invisible to me.” “There is stillness and monotony in the air. I can hear the clock tick. The room feels empty. I feel tingly. There is a sense of longing.”

Conclusion

What I attempt to present here is a cutting-edge perspective of treating symptoms of panic disorder in a patient in the clearest way possible in a blog. Medication and quick therapies have not managed to effect lasting relief for most patients of anxiety. This is why we, as gestalt therapists, look to the broader field. We look beyond the person. We have found useful to see the client in context of the socio-cultural environment. We use this field during the session. We move ourselves in the field. We allow ourselves to be impacted. In this way we make small adjustments. These work as tender changes within the psyche of the client.

Remembering the hypothesis that panic is an acute attack of loneliness, the work with Clarise revealed it to be so. Although Clarise never admitted that she was lonely, she revealed her natural tendency for self-isolation. In making herself forgettable, it was I who ended up feeling left alone in the therapy room. Noticing this and sensing our longing for contact, I could affect the field around us. When the field changed, the client eventually changed. Clarise learned to cry. This was a relief to her. It was a relief to feel safe and be vulnerable. It was a relief to her that she did not have to go into a state of panic to afford company.

Bibliography

Francesetti, G. (Ed.). (2007). Panic Attacks and Postmodernity. Gestalt therapy between clinical and social perspectives. FrancoAngeli.

Coming off Psychiatric Medications

Taking psychiatric medications is not the same as taking over-the-counter flu medication. When one gets a flu, one simply takes a pill and stops when the symptoms subside. With psychiatric medications, however, this is different. Having started on a course of psychiatric pharmaceuticals for mental health symptoms like depression, anxiety or psychosis, one must follow carefully the directions of the physician, and to consume the right dosage at the prescribed intervals. When the symptoms subside, or when one feels that the meds do not help, the patient should not simply stop taking the medication. He/she should first consult the psychiatrist who would advice the patient on how the dosage can be reduced.

This controlled reduction of psychiatric medication is an important measure of harm reduction. Why harm reduction? Psychiatric drugs are chemicals that alter the balance of one’s brain biochemistry. On consumption of these drugs, the body and brain cells adapt to the drugs. This adaption process does not happen spontaneously, but take weeks. Genes are switched on and off. A hormonal and a neurobiochemical balancing act takes place. When you decide to stop taking the drugs, you’d need to allow time for your balancing neurobiological system to adapt back to life without these medications.

Measures to take before thinking about coming off antidepressants:

  • Find support from the people around you. Going off these meds can be an unpredictable process. One my feel moderate to severe swings of mood, disordered sleep, anxiety and even rage.
  • Plan beforehand to take up some wellness and coping skills. Some of the most effective are body-based activities that require controlled breathing, like weight-training, yoga, swimming, dancing and meditation. Different people have different preferences.
  • Get support from a psychotherapist at least 6 months before you decide to reduce your medication. This will help you resolve internal conflictual issues that triggered the symptoms in the first place.

In the video below, Will Hall, a former psychiatric patient turned psychotherapist and harm reduction educator explains how and why coming off psychiatric drugs need special attention.

Download Will Hall’s free booklet on coming off psychiatric drugs.

How to Contact Me for Psychotherapy in Singapore

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

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

Is there reasonable purpose for this?

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

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

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

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

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

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

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

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

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

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

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

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

Going through Crisis, Dealing with Crisis

This article discusses what is means to experience crisis and dealing with crisis. The word, “crisis” has its Greek origin, krinein, which means, “to judge”. In Chinese, the word for crisis is 危機– the first word 危 means danger and the second word 機 means opportunity.  This indicates that to be in crisis is to be in a state of having the possibility to make choices. This requires evaluation and re-evaluation of what used to be, or what we have been used to.

dealing with crisis

To be in crisis, is to experience a loss or a possibility of a loss of something that was important, that had a meaning in your life. The loss can be something that is tangible, like the loss of a loved one or loss of health, or something spiritual / mental, like loss of trust in someone/something.

Dealing with crisis is a process of creatively adapting to the crisis situation.

 The Change Process in Dealing with Crisis

The loss usually translates into very meaningful changes for the person in crisis.

It is possible that such changes are impetus for growth; though that is not always the case. Experience of crisis can be extremely disturbing and anxiety provoking. When we go through crisis, there is also the feeling of being very alone in it.

Types of Crises

A crisis may be the result of loss of one’s previous identity or role. The loss of (or the expected loss of) a significant person, often changes how the individual sees him/herself in his/her world.  The loss of health or a body part impacts likewise.

Crises occur with the natural course of life: puberty, leaving home, emigrating, having a child, getting divorced or approaching middle-age. These are some events in life in which people find themselves leaving familiar territory and having to make choices.

Getting Help in Times of Crisis

Help, to a person in crisis, is not a matter of giving advice or providing treatment. The best form of help comes in the supporting of the person through this difficult time of change.

Time is a main and stable resource. Stressful experiences occur when we expect a quick way out of the difficult feelings. Effective help comes in the form of one who is patient enough to be present with the person in crisis till he/she can fully integrate with the losses, and can come to terms with his/her new way of being.

This is also the “paradoxical theory of change” adopted by gestalt therapists.

Dealing with Crisis with Someone’s Help

If you are going through crisis yourself, find others who are able to provide you with the support to integrate the new meaning into your life. You can help them to help you, by telling them what you need and what you don’t need.

If you, for example, do not find the advice/consolation of well-meaning friends useful, say to them (if you can muster it), “I need you just to be with me, we do not have to find solutions right now.” Find someone to speak with about your difficult feelings of anxiety, guilt, sadness, grief, etc.

Certainly, getting professional support from a therapist or counsellor is also a good option.

How emotional writing can improve your mood — and health

I am inspired by the many special people with whom I have learnt this to be true; of the healing benefits of writing about life’s experiences expressively.

“Am besten gefällt mir noch, dass ich das, was ich denke und fühle, wenigstens aufschreiben kann, sonst werde ich komplett ersticken. ”  Anne Frank 1944

Translated as: “The nicest part is being able to write down all my thoughts and feelings, otherwise I’d absolutely suffocate.”

Research like those by Pennebaker et. al. in the 1980s have shown that groups of people who have been asked to write expressively about difficult times of their lives 15-20 minutes a day for 5 consecutive days benefitted more from the control group (who were asked to write  about superficial themes) in these areas (Horn et. al 2011):

  • they needed fewer doctor’s visits.
  • they had better immune parameters
  • less medical symptoms
  • less depressive and anxiety symptoms
  • experience overall better sense of wellness.

Putting into handwritten words your negative emotions, is especially useful. The term “negative”, refers to  painful feelings that we normally try to avoid and conceal from others and ourselves. These emotions are not “negative” in the sense that they are bad or wrong. These emotions, like fear, sorrow, panic, shame, envy, anger, grief, loss and sadness, have everything to do with us being human.

Emotions are embodied. This is not commonly acknowledged fact. However, when panic, for example, sets in, we feel it in the body.  This is why the panic attack is paralyzing. It makes us feel vulnerable.

Depression is not an emotion in itself. It involves a bodily action. Emotions are being controlled. Feelings of rage, anger and fear are being surpressed. There is so much energy in this surpression that the physical energy gers sapped out, leaving us weak.

Writing is a uniquely human activity. It is action. It is intellectual, and it is language. Writing expressions of emotions brings to action the emotions that underlie painful memories. Unlike speaking out or physically acting out the emotions, writing has a protective effect: it is a form of expression that is somewhat energetically controllable. The fact that the writer is control of his/her pen is an important factor for individuals who are psychologically fragile, who risk being overwhelmed (or even traumatized) by painful memories.

Since writing is also language, writing helps us to understand these emotions.

“(T)he most important thing for me is to understand. For me, writing is part of this process of understanding. Writing is an integral part of the process of understanding… If others understand in the same way I’ve understood, that gives me a sense of satisfaction… wie ein Heimatsgefühl*” Hannah Arendt 1964  (Gaus & Arendt, 1964).

*a feeling of being at home.

Expressive Writing in Psychotherapy

Personal experiences allow me to understand the usefulness of writing.

I encouraged almost everyone I know to keep journals, write blogs or keep sketchbooks.  There is no need to write in prose or even correct sentences (although many do write impressively). Simplicity is effective. Write everything down, even if there are doubts if the words are real/true/right or belong. Anything written wrong can be cancelled out later, but write first.

In the therapy session itself, difficult experiences or deeply emotional fantasies, dreams and thoughts can be written down.  Sharing between therapist and client during the sessions are potentially contactful moments.

For clients who have difficulty feeling or expressing emotion, this process is especially useful. Keywords are offered to them. These individuals learn first to intellectualize the meanings of the emotional word, then link them to the experience of the events. The possible outcome of which is a gradual encounter of the person with the realm of feelings.

Unlike spoken narratives, the client remains in control of how much he/she wants to write or express.  He/she has time to consider. Everything slows down. This is especially useful for very delicate clients.

Writing has an added dimension. The words do not disappear — unless the paper is destroyed.

Conclusion

Horn et. al. explains the immunological connection with expressive writing. Mentioned in the article presented are also theories behind how this activity can have such impact (p.254-257).

Writing can be part of the therapy session. The process of writing can shared — the client puts down the words while the therapist supports and provides a safe environment.

 

 

Bibliography

Gaus, G., & Arendt, H. (1964). Gespräch mit Hannah Arendt. R. Piper. Retrieved from web: https://www.youtube.com/watch?v=J9SyTEUi6Kw

Horn, A. B., Mehl, M. R., Detters, F., & Schubert, C. (2011). Expressives Schreiben und Immunaktivität: Gesundheitsfördernde Aspekte der Selbst-Öffnung. Psychoneuroimmunologie und Psychotherapie. Stuttgart: Schattauer, 208-227.

 

Panic disorder and loneliness

Panic disorders are sensed as physical symptoms. Often the root cause of these symptoms are not initially known to the person experiencing these attacks . This “not knowing” makes the physical reactions seem unpredictable, spontaneous and frightening. The sufferer is left feeling vulnerable to his/her condition when a panic attack seemingly arises out of nowhere.

In the field of neuroscience, a part of the brain is acknowledged as having something to do with panic (Solms & Turnbull 2002,  Solms 2015). This part of the brain is also connected to the feelings of loss and depression. It is very common to observe clients who experience depressive episodes, also feel panic. As the course of therapy progresses, feelings of loss emerge .

Changes in life situation can trigger panic attacks. Leaving home, moving to a new country or entering a new marital status, etc. become moments of new learning where trusted supports of the past are no longer available. Unfamiliar ground sets the cycle of feelings of loss of security. Panic attacks seem begin at times when the individual begins to develop a sense of autonomy in life.

Connection between panic attack and loneliness

Francesetti’s  (2013) mention of the link between panic attack and loneliness is noteworthy. He quotes a patient named Marco as saying “panic attack is basically an attack on acute loneliness.”

Reflecting on personal encounters with individuals who struggle with panic attacks…

The client narratives often speak of situations of leaving, being left behind, suffering emotions alone, having had to escape mentally from somewhere. Frequently encountered are narratives of terror feelings experienced by the person as a young child. With the progress of therapy, it often becomes clear how this  episode (and perhaps recurring episodes), gets to be experienced as something suffered alone. The adult client lives with the memories, but cannot make sense of them because he/she could not get the required acknowledgement from others that the event actually occurred.  The isolation and confusion is felt most deeply if the members of the family who were actually part of the scene of terror flatly deny the occurrence or severity of the event(s).

The consequence of such experiences is the embodiment of the fear, disbelief in one’s own experiences, guilt, and a need to distance the self from these feelings.

In therapy the task is to identify the emotions  and wounds associated with these early childhood experiences. These are then worked through together with the client in an experiential and empathic atmosphere. Being authentically present with the client, acknowledging that the events, its severity, containing the emotions that the client is too afraid to encounter, and validating the feelings and thoughts that exist with this event have provides relief.

Panic disorder is one of the most common reasons why people seek psychotherapy.  The decision to seek a remedy in this way is quite likely to be an instinctual one.

Bibliography

Framcesetti, G. (2013). Gestalt therapy perspective on panic disorder. In Francesetti, G., Gecele, M., & Roubal, J. (Eds.) Gestalt therapy in clinical practice: From psychopathology to the aesthetics of contact. Kindle Ed.  position 11673

Solms, M. (2015). The animal within us. Source: Youtube URL https://www.youtube.com/watch?v=JfqVIG9bejU.

Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. Karnac Books.

Surviving the Corporate Work Environment Mentally

I am writing this article on behalf of some young clients who have come to me for coaching over the years.

The beginnings of life as a career person is no easy task. For a young individual in today’s world who’s armed with college education,  plunging into the world of “working adults” can feel more like falling through thin ice on a semi-frozen lake then taking a dive into warm waters.

 

The day you enter the new job, you are faced with the realities of work life as an executive, and the features that come with it:

  1. Office politics: you realize that there are individuals who make the rules, and there are individuals that protect the rules, there are henchmen, rivals, sympathizers and other members of a corporate chess-board. Unlike the chess board, you cannot tell who’s playing what role. This understanding comes to your awareness slowly and sometimes painfully.
  2. Underuse of your abilities: you have spent a small fortune (which you still have to repay) to get yourself educated, and years of preparing yourself for your career, and your work life does not seem to have use for it. You are disillusioned, bored and disappointed with the experience. Deep down you hope, that as you climb the corporate ladder, someone is going to take notice of you abilities and give you a chance to let your expertise be heard.
  3. Overwork: Although you feel a mental under-load, you are overloaded with work. Reports and budgets to create, minutes of meetings to write, sales calls to do, fire-fighting, correspondences, data-collecting, solving problems, responding to complaints, waiting for others to do their part of the job, managing, and datelines datelines datelines.

There are many more challenges faced when a young person begins work in a company, like conforming to corporate culture, work travel, overcoming personal issues. The above 3 factors seem to be the most prevalent and daunting issues that have come to my office.

Constant unresolved challenges lead to stress and burnout

The consequence of dealing daily with these challenges is work stress. Once we think of the work “stress”, we are no longer talking about needing a coach. What the client really needs is psychotherapy. Stress, after all, is the embodiment of negative emotions.

Stress is about how you, as a human being, somatically interact with the (work) environment in which you have put yourself in.

What most people do in this situation is try to “beef” themselves up. They go for courses on self enhancement, take efforts to socialize in the workplace, work harder and longer, get coaching. This helps to overcome the system that causes the stress, by “taking bulls by the horns”– so to speak.

The feeling of needing to “beef” oneself up is an alarm signal– that despite one’s education and skills, one still feels a lack of self.

My question is, if your body is already stressed, wouldn’t grabbing raging bulls just add to more stress?  This is ikely, and this has lead  many executives towards a situation of ultimate energy depletion.

This phenomenon energy depletion is called a “burnout”.

You love your career, you need your career. So, what can you really do to reduce stress, so that you can keep working?

The answer to this question is not answerable in a few paragraphs.  I can however invite you to see these things in the point of view of a psychotherapist, by asking yourself and answering honestly these questions:

  1. When I am caught in office politics, how do I feel about myself?
  2. When my colleagues say I am underperforming, how do I feel about myself?
  3. The scope of my work is below my intellectual/academic capacity, how do I feel about myself?
  4. My workload is heavy, can I admit to myself it is time to take a break?
  5. I am responsible for the sales figures/growth. How much of this is really within my control? How much of it is highly dependent on external factors (e.g. the market, economy, luck)?
  6. How do I feel about myself when I am not able to accomplish goal which are beyond my control?
  7. Can I admit that things are not entirely up to my control?
  8. I am being judged for goals set by the company, that are actually (realistically) beyond my control. Can I come to terms with this discrepancy?
  9. How can I cope with this discrepancy?
  10. Some colleagues are waiting for me to fail / to judge me / are competitive / deceptive / exploitative. How do I come to this conclusion? what were the signs? Despite all this, what can I do to preserve my sense of self worth?

Some of the above questions are tough questions. Many executives may have the urge to avoid them, and carry on the mantra “it’s no big deal, I can do it.” That’s fine, if it does not lead to a build-up stress.

When clients come for therapy because of burnout (or getting close to it), the answer to some of these questions are painful emotions : feeling of low self worth, disappointment, anxiety, depression and deep rooted shame, and loneliness.

It is better to see this as an opportunity to recover from a state of never-ending struggle with a stressful work environment.  The way one can do this is to re-access one’s relationship with the oneself, and one’s relationship to the job.

Finding resource for relieving work stress:

Think carefully, then of the following questions and statements:

Can you think of  yourself as a person while leaving out your educational and career status?

Complete this sentence. “I would rather go to work at this office, than …” (the answer can be “jobless” / “bored”…)

Tell yourself, “I am (my name). I am working as (my position at this company). I am not merely a (my position at this company).

Things that I am responsible for, but cannot control (e.g. sales figures)… who in the company can really control? Can your superior control the sales figures himself? If a colleague had better sales performance, is it because he/she had better control?

If you’re lagging behind your colleagues (or feel that way), what is the real impact of it to your keeping the job? How can you live with not being the best in the company? What is being the “best” really mean?

What available resources do you have to support yourself at your job:What resources can you get at work? (e.g. friends at work, good relationship with customers/partners). What resources do you have outside work? (e.g. friends, family, hobbies, religion, professional guidances, etc.)

I hope this article provides you with insight into the problems of being a human being of corporate life.  My ultimate message is: You are not your career. Try try try to see the difference.

By the way, this is the same thing I practice. I tell myself, “I am me, I work as a psychotherapist, I am not a psychotherapist.” This gives me a chance to work without judging myself, being stressed out or stressing my clients out. This gives me a chance to forgive myself if I make mistakes. This helps me to work more professionally.

I wish you a successful work life and a good career.

 

 

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:

  1. How could someone lose a sense of him or herself amidst a life where there was formerly coherence?
  2. 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.

 

 

 

Read also : Christopher Bollas on Mental Pain

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 Quarterly19(01), 57-68.

Kernberg: Working with the Antisocial and Malignant Narcissistic Personality Disorder Spectrum

 

Kernberg (2008) writes that for the treatment of any case in which antisocial features of the personality disorder (PD) are suspect, the following should be evaluated by the therapist. Such evaluation makes it possible to access his/her ability to rely on the patient’s ability to sustain the therapeutic relationship and also to access the safety of the sessions:

  • The presence or absence of pathological narcissism.
  • The extent to which the superego pathology dominates (i.e. which part of the spectrum of the triad).
  • The intensity of egosytonic aggression and whether it is directed against the self in the form of suicidal/self mutilating behavior, or violent behavior against others / sadistic perversion.
  • Severity of paranoid tendency.
  • Stability of the person’s reality testing (ibid. p. 130).

The prognosis for Antisocial PD is not expected to be good in psychotherapy, in particular, if the client has severe aggressive pathologic behavior, and /or if the patient has no social support which the therapist can work with. According to Kernberg, therapists should begin work with client only after gathering the facts surrounding the clients’ coming for therapy, social support, ability to proceed with therapy in safety.

The treatment of malignant narcissistic PD (MNPD) has somewhat better prognosis than APD. A precondition for treatment is also strict control of antisocial behavior, and removal from social environment that facilitates his/her current behavior—e.g. exposure to the street gang.

General Psychotherapeutic Strategies

Kernberg’s suggestions are:

  • Establishment of solid, unbreakable treatment frame.
  • Systematic interpretation of psychopathic transference.
  • Guiding the patient to communicate honestly (if at all possible) about their behavioral problems outside the session.
  • Combining the above narrative with the developed regressive behaviors experienced during the sessions.
  • Gradually making it possible to connect the pathological behaviors interpretively into cognitive and affective experiences in the transference.

Highly deceptive clients make this work almost impossible. In such cases family members or other informants may be of help. The therapist should always make it prioritize urgency of intervention:  1. Danger to self/others, 2. Threats of treatment disruption, 3. Dishonesty in communication, 4. Acting outside and inside sessions, and 5. Trivialization of the communication.

Kernberg also states that it is essential to look for affects through verbal and nonverbal communication, nonverbal behavior, and the transference. The content of what the client says is usually a weaker source of affective information than what goes in these realms (ibid. p.140).

Treating Personality Disorders with Gestalt Therapy

Considering Kernberg’s suggestion, I notice the congruence of his method to Gestalt therapy practice:

Gestalt therapy is focussed on the process of the therapeutic dialogue, i.e. non-verbal interaction / body language. Therapist also encourages the client to enact situations that cannot be talked about. Poor functioning personality disorders prevents the individual from communicating with the therapist on a contactful level. As Kernberg notes, there is a tendency for such a client to deceive / idealize and devalue/ play victim or rescuer or persecutor with the therapist. The awareness of the therapist of this phenomena is essential. He /she is most effective when he/she can contain the clients behavior without getting roped into the game.

For this reason, in gestalt work, we focus of body language / tone of voice together with what is said, and we also focus on our (the therapists) own personal reactions. What the therapist tells the client is not analysis, but a descriptive reflection of what the therapists sees hears and senses.

The client benefits from this kind of honest interaction, because he/she too are not going to be caught up in games. In the beginning, there will of course be discomfort and frustration. If the client sticks to the work, there will be progress made.

Read also

Symptom Relief in Psychotherapy

Psychotherapy is about Uncovering the Truth of the Self

Former Patients’ Conception of Psychotherapy 

Bibiliography

Kernberg, O. (2008). Aggressivity, Narcissism, and Self-Destructiveness in the Psychotherapeutic Relationship: New Developments in the Psychopathology and Psychotherapy of Severe Personality Disorders. Yale University Press.

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.