Category: Articles on Psychotherapy Practice

Psychotherapy related articles

How does Psychotherapy Work? General Systems Theory and Synchronization

How do we explain the transformative work of psychotherapy? The therapist and client of the psychotherapeutic encounter do not exist in an isolated bubble; both exist integrated with the environment we call the field. The field encompasses the biological, psychological, physical and sociological environment in which the therapist and client are embedded. The psychotherapy situation is in constant flux with the field. Psychotherapy is an open system.

Change in psychotherapy is complex, non-linear, and perceived as organic. The psychotherapy profession has long understood this concept, which differs from the paradigm of the broader field of the medical model of healing that views the patient as a unique entity disconnected from the environment.

The medical model approach considers the patient and their issues unique to the individual, often ignoring the environmental contribution to the patient’s suffering. The patient sees the medical professional and gets treated for their symptoms. Usually, the patient is offered medication to relieve symptoms, and healing is expected to happen spontaneously. Sometimes healing does not occur, but just an alleviation of suffering. Diagnosing and treating the patient this way is the mono-personal approach to therapy.

The figure below illustrates the different dimensions ‘ways of seeing’ psychopathology (suffering and symptoms), treatment and diagnosis in therapy. The relational attitude is adopted by contemporary psychotherapeutic schools, where the study, focus and treatment is experienced in the therapeutic relationship.

Three different attitudes and focus on treatment and diagnosis: 1) the mono–personal attitude where the client and their suffering is attributed to the individual alone disregarding the environment, 2) the relational where the client’s suffering is encountered and treated within the therapeutic relationship, and 3) the field theory, or the aesthetic attitude where the client is treated as a co-creator of the field.

The field theory is unique to Gestalt therapy. Contemporary Gestalt therapists have attuned themselves to investigating psychopathology and therapy even further by looking at the aesthetics of the co-created field.

A Gestalt therapy perspective of psychopathology is necessarily grounded in a field epistemology. The field concept enables us to understand experiential phenomena as being emergent from a dimension that cannot be reduced to the individual, or to the sum of individuals at play. Every relational situation actualises a new, original field. Subjective experience is not the product of a single mind or isolated individual; it is an emergent phenomenon of the actualised field.

Francesetti, 2015

The co-created field encompasses the client and therapist in their bio-psycho-social environment and is unique to the encounter. Read also: Notes on Field Theory in Gestalt Therapy. Field theory renders the therapeutic encounter an open system. Neither is the client treated as an individual nor is the therapeutic situation treated as separate from the outside world. The field theory includes everything relevant to the here-and-now of the therapeutic session. Attunement to the field involves noticing and focusing on the atmosphere of the therapeutic situation. Change is effected through the field. Movement in the field facilitates meaningful psychotherapeutic change and transformation.

As we consider the concept of the co-created field in psychotherapy, we will also realize that psychotherapy is an open, dynamic and complex system.

General systems theory

Notes on how psychotherapy works based on dynamic systems theory or general systems theory.

General Systems theory is an interdisciplinary practice applied to many fields of sciences, including cybernetics and biology. The concept was published in 1934 by Austrian biologist Karl Ludwig von Bertalanffy (1901-1972), who proposed that the classical law of thermodynamics, which applies to closed systems, has limited relevance to open systems (Wikipedia, 2020).

The phenomenon of Synchronization

The videos below demonstrate the phenomenon of synchronization. Unique objects with their own stable pattern, influence the co-created environment, causing their own patterns to change.

Two metronomes are placed on a common base. The metronome on the left is set at 192 beats per minute. The one on the right is set at a slightly lower rate. The metronome pendulums are initially out-of-phase. The two pendulums oscilate in phase due to conservation of momentum and coupling via the base. A true physics masterpiece!

This is another example with the use of several metronomes, each with their own temporal settings. After a while, all metronomes sync together.

This video illustrates the temporal synchronization of metronomes coupled via a common ground plate. This (well-known) phenomenon goes back to the observations of Christiaan Huygens (die Pendeluhr: Horologium oscillarium, 1763). Timeline: 0:00 – Setup and “What’s going to happen?” 0:21 – Synchronization from arbitrary positions 1:04 – Re-synchronization after disturbance

Synchronization happens in biological systems. All biological systems are attracted to the field which guides their growth and movement.

We know a lot of factual information about the starling—its size and voice, where it lives, how it breeds and migrates—but what remains a mystery is how it flies in murmurations, or flocks, without colliding. This short film by Jan van IJken was shot in the Netherlands, and it captures the birds gathering at dusk, just about to start their “performance.” Listen well and you’ll be able to hear how this beautiful phenomenon got its name.

Psychotherapy and General / Dynamic Systems Theory

Psychotherapy is an open complex system, like all biological systems and groups. Open complex systems are self organizing, and creatively adjust to their environment. They dynamically change with time. This change is continuous and non-linear.

Open systems oscillate dynamically and try to find stability. Transformative change involves the process of deconstruction, reorganization and reconstruction. In psychotherapy, pathos or suffering is sensed, grasped, and brought to the surface. The client learns to frustrate old patterns by attempting behaviour change and meeting the therapist at the contact boundary. This process can happen through experimentation and (sometimes accidental) confrontation of transferences.

The client’s “pathological” situation is an autonomous pattern formation, which the client would like to change. This pattern is, however, a stable pattern that has developed through life experiences and trauma. It is a meaningful pattern, though often dysfunctional that the individual has adapted to since childhood. In psychopathology, some patterns have more severe consequences for the person, like obsessions and compulsions, and anxiety. In less severe states, the individual suffers setbacks in relationships due to personality and unstable attachment styles. This pattern is played out in therapy and felt in the field. The attuned therapist can grasp how the therapy situation impacts them in the co-created field with the client.

In therapy, the client’s pattern is challenged. The challenge brings about resistance. We can say that the old pattern repels this challenge. The client may get used to this challenge and change. This may manifest as the ability for the client to attend therapy as a routine. This initial influence of therapy on the client is the first -order change. Here lies a comfortable synchronization in the field.

Transformation happens at the second-order change. This process takes time. The second-order change is the lasting permanent change of the pathological pattern. Second-order change requires the deep modification of the system’s way of functioning. In Gestalt therapy, this is a phase of change called the impasse. Read also: Gestalt Theory: 5 Phases of Therapeutic Change. When the client can stay in therapy long enough to find themselves in a situation of the impasse, which is often an uncomfortable state, a transformation phenomenon happens. At this stage, there is a re-synchronization, and the new pattern becomes stable. The client experiences a shift.

In trauma therapy, the synchronization that happens in the therapeutic encounter is also a physiological one. The therapist provides the client with a safe space and a centred presence in the therapeutic field. The client who shares the field, like the opposing metronome in the videos above, begins to operate in sync with the therapist.

Therapeutic change and transformation works through synchronization, and this involves the passage of time. Psychotherapy is a powerful resource that offers deep organic change and psychotherapeutic treatment. Shortcuts and quick fixes has never been the premise of psychotherapy.

On the lighter side…

Want brief therapy? This is what it looks like…

References

Francesetti, G. (2015). From individual symptoms to psychopathological fields. Towards a field perspective on clinical human suffering. British Gestalt Journal, 24(1), 5-19.

Ludwig von Bertalanffy. (2022, November 20). In Wikipedia. https://en.wikipedia.org/wiki/Ludwig_von_Bertalanffy

The change moments in psychotherapeutic practice 

The challenge with humanistic psychotherapy today is to realize the philosophical con­cepts and theory put into practice. How do we see an I-thou moment in a therapy ses­sion? 

My personal conviction in this topic is borne by the fact that I have experienced change moments – as a client of psychotherapy. Over the years, I have also been able to tell if these change moments had a lasting effect, or if they were just cathartic or tempo­rary because of suggestion and coercion. Perception of from the client’s point of view recorded over lifetime (a couple of years), may be essential aspect of psychotherapeutic process research. 

The process of defining the healing I-Thou moments (Buber, 1936) in psychotherapy often gets lost in language. What some call the transcendental phenomenon (which I have in this paper related to an aspect of Clarkson’s framework), is also called “miracle moments” (Santos, 2003), “sacred moments” (Pargament, 2007), and “moments of meeting” (The Boston Change Process Study Group, 2010). 

What is typically experienced in this moment is typically described like this: “Every therapist knows that there are some special moments in psychotherapy. I experi­ence them as “sacred moments” when immediate realities fade into the background, when time seems to stand still, when it feels as if something larger than life is happen­ing. In these moments, I believe, a meeting of souls is taking place. This was one of those times” (p. 6). 

I had the benefit of attending a presentation at a Gestalt Associates Los Angeles (GATLA) Summer Residential in Lisbon this year which discussed this very topic of defining these moments of encounter. Entitled, I-thou moments in psychotherapy, the study is the result of meta-analyses of psychotherapeutic literature and interviews with therapists. Hence it was found that these I-thou moments: 

  • are memorable, exists in psychotherapy and appears every now and then.
  • are recognizable, significant events.
  • is based on the quality of dialogue.
  • short lasting (in seconds).
  • is rare.
  • is mutually experienced.
    During these moments 
  • perception gets narrowed.
  • there is an unusual level of understanding and acceptance of the other
  • there is experience of being on the edge of something spiritual.

These moments lead to long term change in the therapy and result in motivation for the client to further therapy work. It strengthens the alliance, and has no negative affects (unlike transference relationship). It is also a qualitatively viewed process, and is often arises from sharing of heavy topics and staying long enough at an oftentimes uncomfortable place. Playing the role “I am the therapist, you are the client” prevents these moments from happening. The challenge in studying these moments is the very fact that in trying to grasp the moment, that moment is lost (Pernicka, 2016).

References

Buber, M. (1936). Ich und Du. Berlin: Schocken.

Pargament, K. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. NY: Guilford Press.

Pernicka, M. (2016, July). I-Thou moments in Psychotherapy. Lisbon, Portugal.

Santos, A. M. (2003). Miracle Moments: The Nature of the Mind’s Power in Relationships and Psychotherapy. iUniverse.

The Boston Change Process Study Group. (2010). Change in psychotherapy. NY: W. W. Norton & Co. .

Empathy and Buber’s I-thou contact

I do not fully agree with Schmid’s implication that empathy is about “try(ing) to understand, as exactly as possible, the accurate meaning of what goes on inside another person in the very moment”. This is the common understanding of empathy, but it actually contradicts the principle of Buber’s (1970) I-Thou contact. “Trying to un­derstand” is a process of someone doing something with an aim to furnish a need in oneself. In this case, it is the need to understand “as exactly as possible”. If a therapist has this kind of goal, his/her goal may become a blockage to contact because he/she is distracted by the need to interpret and the need to establish his/her identification as therapist in the relationship. 

Wouldn’t this amount to using the client to find-out-something-so-that-I-can-do­my-therapist-job? This kind of objectifying the Other in the relationship leaves room for transference and countertransference neurosis. If empathy is as what is generally under­stood as described above, it is then not part of the I-Thou relationship, because the I­Thou relationship excludes objectification. 

The I-Thou contact requires seeing the Other first, and not seeing the other in re­lation to oneself. This movement towards the other first is what Emmanuel Levinas considers the ethical movement (Schmid, 2001). 

Schmid clarifies this disparity later in the article in stating the difference between Roger’s and Buber’s comprehension of the activity of making empathic contact. Be­sides what is mentioned, Rogers also believes that it is necessary “to put one’s own un-derstanding completely apart” if one wants to enter the world of another person empath­ically. Buber, on the other hand believes in the mutuality of the process. 

That which lies beneath the I-thou contact is not empathy but something more than empathy. Buber (1970) uses the word, Umfassung, a phenomenon of embracing, which is “more than empathy”. This process requires the recognition of 2 poles, in en­countering the other “as a partner in a bipolar situation” (p. 178). This implies a dynam­ic relationship of “swinging into” (einschwingen) into the experience of the other and at the same time maintain one’s own reality of the self. It shows a dynamic process of be­ing existentially affected by the other, and including the other person into one’s own existence (Schmid, 2001). 

This is not the same as to “trying to understand someone as exactly as possible”, or to step into someone’s shoes. It is rather about me being me, seeing you, and show­ing you how you affect me— at this present moment. 

This way of relating in the present moment is what Buber calls, personale Vergegenwärtigung. It is an elementary way of relating and means to expose oneself to the presence of the other. This is a personal way of becoming aware of, a way of ac­ceptance instead of perception, a way of acknowledgment instead of knowledge (Schmid, 2001). 

The I-Thou relationship is basic existential relationship without the complications of identity and needs. The healing power of this relationship is in the confirming of the other for who he/she is. Buber is quoted to use the word Realphantasie, which indicates that what is happening is that “the Other’s reality is touched” (ibid.). What is experi­enced through this form of relationship is the transpersonal, intersubjective acknowl­edgment of the other, affirming the identity of the other through the presence of the self. Both partners in the relationship attains affirmation of the self. This benefit is mutual, and the relationship is symmetric. What happens in this mutual exchange, Staemmler (2009, p. 96) explains is not a “fusion of horizons”—which happens with just empathy alone— but a widening of each other’s horizons in such a way that that it is integrated with each other’s personal background.

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

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

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.

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.

What’s behind the transforming power of dialogue?

Dialogue is a means of making contact, and it is a form of action that goes beyond ver­bal communication. That which lies intrinsic in an I-Thou contact? Is it a phenomenon we understand as empathy? This phenomenon is in itself a concept that leaves much to be discussed. In the context of this paper I’ll refer to Schmid (2001). This paper entitled Comprehension: the art of not knowing, gives a perspective of Buber’s philosophy in the context of psychotherapy, which is useful for this section of this paper (there are also parts of this paper which I have reservations about, which I will also discuss). Schmid states in the beginning that empathy is an “innate (inter-) personal quality” that reaches “beyond identification and interpretation”. It is the act of allowing oneself to be impressed by the other, while expressing oneself in an authentic way in the presence of the other. 

This way of explaining the empathic in a contact with the other is, whether through verbalized or symbolic communication (i.e. body language, a look in the eye or simply “being there”), empathic contact means to put aside the need to use the other person for any personal gratification at all. This means to be there with the other person without feeling as if one has to interpret the identity of the other or the need to establish one’s own identity in the presence of the other. There is no goal in such a contact but a process of “being there”, being authentically present, as an individual, and inviting the other to be there as well as an authentic person. This contact is at a transpersonal level.

Read also: Empathy and Buber’s I-thou

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

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

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.

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.

Healing through dialogue is an eminently hermeneutical phenome­non indeed

“Healing through dialogue is an eminently hermeneutical phenome­non indeed.”

Gadamer, quoted in Staemmler (2009, p. 65). 

The psychotherapeutic alliance is a dialogue which is action. Through this dialogue, understanding takes place. This understanding comes about through a hermeneutic pro­cess. This process requires the authentic inclusion of the self of the therapist. 

Staemmler goes on to emphasize that in the process of understanding, one needs to be asked to ask authentic questions, bearing in mind the tendency for therapist (per­haps to hide his/her own shame) of not being authentically available to the client by asking pseudo-questions, which includes pre-prepared list of questions or repetitive questions like “how do you feel?” without actual curiosity. Pseudo-questions also in­clude questions that predestine their answers. Authentic questioning requires the bring­ing into the open what is unexpected, with the knowledge that the client has the answer. This means that the therapist needs to be open to listening, and living with the uncer­tainty of the answer that he/she is given. This requires that the therapist relinquishes any control over the client’s answers and meaning-making, and this includes predicting what the client’s answer should be before even asking the question. 

This relinquishing of control in dialogue leads us away from Buber’s “I-it” and towards the “I-Thou” way of relating. Incidentally, this forms the “symmetrical” aspect of the psychotherapeutic alliance as discussed earlier described by Altemeyer, and con­nected to Clarkson’s the person-to-person relationship (point 4) and the transpersonal relationship (point 5). 

Another way of understanding the “I-It” form of understanding is “to claim to understanding the other better than she or he understands herself or himself”. Looking closely this can also be seen as an abuse of professional power “disguised as benevo­lence” (ibid. p. 91-92). The consequence to such behavior to the profession is the dis­trust caused by fear of the client from being misinterpreted and misjudged. 

That which happens in an authentic I-thou dialogue is a mutual exchange. This happens in the “between”. Gadamer, in agreement with Buber: “The dialogue has trans­forming power. When a dialogue succeeds, something remains for us and in us, which has changed us” (ibid. p. 93). “Dialogue that succeeds”, is no ordinary dialogue, but that which is inclusive of the self and the other. Converse to the ‘I-It’ way of relating, it exists, as Carl Roger’s is noted to have explained, “without any techniques, means, aims or intentions” (Schmid, 2001). This kind of dialogue is what Buber terms the ‘I-Thou’. This is the dialogue with transforming power. 

This is the transformative contact which many schools in psychotherapy strive to establish in the therapeutic hour. I use the word ‘strive’ to give meaning to the elusive nature of such a healing contact, and the powerful benefits in the event when such con­tact happens.

What’s behind the transforming power of dialogue ?

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

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

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.

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.

Unconscious feelings and countertransference within the Therapeutic Alliance 

To illustrate how a therapist’s emotions towards client, though brought to awareness and allowed to be revealed, can also be mistaken for authentic reaction to the client’s process, a mentor of mine, in a private lecture on experiences of unconscious effects on a therapist in therapy sessions, narrated a rather simple story he entitled, Chanel No. 5: the client, a middle-aged woman had come to therapy to work on very traumatic and emotionally tragic experiences in her life. The therapist found himself deeply moved by her experiences, and would find himself in tears each time she entered his practice. He questioned his emotionality towards the client only weeks later because he, like many would have, assumed that he was naturally moved by the client’s plight. He subsequent­ly noticed the client’s perfume as she entered the office and asked her what she was wearing. ”Chanel No. 5”, she replied, which was the same perfume his beloved mother had worn for most part of her life. 

In the story, the client instilled emotions in the therapist in which the therapist was unaware of. This gets interpreted somewhat inaccurately at first until the therapist was able to come to a self-awareness. This kind of experience faced by therapists is termed by Freud in a 7 June 1909 letter to Carl Jung, as countertransference, to which Freud explains, “(s)uch experiences, though painful, are necessary and hard to avoid. (…) (W)e need to dominate ‘countertransference’, which is after all a permanent prob­lem for us; they teach us to displace our own affects to best advantage. They are a ‘blessing in disguise’” (Freud, 1909). The unconscious nature of countertransference makes it difficult for the analyst to differentiate between the analyst’s own unresolved difficulties and emotional reactions and impressions that come to the the therapist’s consciousness that are activated by the projective identification of the client. 

While unlike Freud and Klein who considered strong countertransference feelings to have negative affect on analysis and something analysts should work on by gaining more insight into themselves instead, many analysts like Bion have found usefulness in the phenomena. Therapists of the intersubjective and relational schools share counter­transference that they have (and are aware of) as a means to bring authentic contact to the alliance. 

Awareness of therapist’s countertransference is supportive to the therapeutic process 

Countertransference, with awareness, supports rather than interferes with the therapist’s work. Freud’s mention of the need to “dominate” countertransference, can be taken as a call to be aware of dealing with the emotions within the alliance rather than rejecting them and becoming emotionally detached. Heinmann (1950, p. 81) considers this use of countertransference as “one of the most important tools for his/her work. The analyst’s counter-transference is an instrument of research into the patient’s unconscious” as a means of bringing to consciousness of the client what he/she does (consciously or un­consciously) to “get under the analyst’s skin”. How can the awareness of countertrans­ference experienced by the therapist be an advantage to the therapeutic alliance?

“(T)he analysis of the transference, i.e., that part of it which deals with the breaking down of the resistances, constitutes the most im­portant piece of analytic work.”

Wilhelm Reich, 1945/1984, p. 5

The answer is explained by Racker (1953) who acknowledged that the therapist may react emotionally to a patient’s enactments or behavior or personality, but he/she is not prevented from “identifying him/(her)self intellectually with his/(her) defense mecha­nisms and object images”. When the therapist is aware of his/her own emotional reac­tion, this countertransference is actually instrumental into “bringing to his notice a psy­chological fact about the patient” for the feelings helps the therapist to detect the pres­ence of the client’s psychological games. Even though the countertransference feelings are neurotic, the therapist who is aware of this is able to react with understanding. For this understanding to be possible, Racker adds, the therapist has to first analyze and overcome his/her own situation and be able to identify him/herself with the patient’s ego. Within the therapeutic alliance and hour, the patient reenacts and recreates situa­tions that are recurrent in his/her daily situations. These undisclosed and undetected activities, is an unconscious means of avoiding the therapeutic process, and thus “prompted by a desire to retain a defensive organization and probably to recruit the ana­lyst into its personnel” (Britton, 2003, p. 77). In order for the impasse to be broken and the “enactments” to discontinue and therapeutic work can progress, Britton suggests that “until the enactment is recognized and described, the belief system that lies behind it cannot be disclosed, but, at the same time, until the patient’s beliefs that drive it are disclosed the enactment will continue” (Mawson, 2011, p. 4-15). 

Transference and countertransference is a phenomenon in the therapeutic alli­ance, Racker’s comment— quoted also in Britton (2003, p. 55)— highlights the attitude towards acceptance of this human condition and working with it’s existence in psycho­therapeutic relationship: “The neurotic (obsessive) ideal of objectivity leads to repres­sion and blocking of subjectivity and so to the myth of the … ‘analyst without anxiety or anger’ The other neurotic extreme is that of drowning in countertransference. True objectivity is based upon a form of internal division that enables the analyst to make himself (his own countertransference and subjectivity) the object of his continuous ob­servation and analysis” (Racker H. , 1968, p. 132). Objectivity, in many respects, is the priced commodity in psychotherapy. If the therapist is caught up in countertransference and is unaware of the fact, his/her endeavors to work with the clients in an objective manner would be unproductive. 

Objectivity as a concept itself needs some careful consideration. For this we can turn to Maturana & Varela (1980): “(O)bjective knowledge seems possible and through objective knowledge the universe appears systematic and predictable”. Objective knowledge, according to the authors, seems possible. It is prized for the very fact that it gives the impression of predictability. When things are systematic and predictable, we feel safe. The authors go on to explain: “Yet knowledge as an experience is something personal and private that cannot be transferred.” The explanation for this is that objec­tive knowledge must be created by the listener. The listener understands and the objec-tive knowledge appears to be transferred (p. 5). The therapist therefore needs to be aware of this phenomenon: that the information being shared between him/herself and the client is experienced and mentally processed by both parties. The reality is, howev­er, that the assumption that common understanding is achieved is only apparent. 

The benefit of keeping this in mind to the therapist is that he/she will be constant­ly on guard and self reflective of his role as observer. The therapist as an observer is part of the system (in this case the client) in which he/she is observing. Since he/she communicates with the client and the client communicates back, and the client is also the observer in return. “Anything said is said by an observer” (p. 8). The observer can­not but interact with the system; the observer is also observed. 

The observer, if self-reflective, is also able to observe him/herself. So in the ther­apeutic setting, the therapist has the work of observing two individuals: the client and himself. What is achieved is a hermeneutic and cyclical process of understanding. This is discussed later in the paper. Maturana & Varela explains this as such: “If an organism can generate a communicative description and then interact with its own state of activity that represents this description, generating another such description that orients towards this representation…, the process can in principle be carried on in a potentially infinite recursive manner” (p. 29). 

This back-forth movement of allowing experiences (via emotions) to occur and then stepping away from the self in acknowledgment and understanding of what has arisen. This acknowledgment of “what-is” happening at the moment describes what Gestalt therapy literature describes as the paradoxical theory of change (Beisser, 1970), whereby healing change happens not by forcefully eliciting change itself (in this case, by repression or ignorance), but by understanding and acknowledging what is happen­ing to the self at the moment. Through assimilation of the situation, in the case of a countertransference effect encountered by the therapist, the therapist is able to under­stand what is going on in him/her. The clarity of this self awareness and acceptance empowers the therapist to overcome and make informed choices. Self-awareness has much to do with being in contact with the self, existentially, in the here-and-now. This is a phenomenological attitude in observing what-is in the present in contact with the client, while being conscious of one’s own biases. 

With the awareness of the self as observer, there will also be an awareness that the other person is different; the other person actually processes his/her own objective knowledge. We will be able to appreciate that there is room for questioning and discuss­ing the ‘facts’ and ‘truisms’, and to investigate the differences between the self and the other. Resnick (2016) tells us that it is the differences between two individuals that ini­tiate the contact. Without awareness and acceptance of these differences—as often hap­pens when people operate in confluent relationships— there is no sense of the other person for who he/she is. Confluent relationships result in the feeling of loneliness in the presence of others, because there is a push for consensus and the authentic presence of persons are thereby not felt. In therapy, this kind of relationship happens when client tries to please therapist and therapist tries to help client. Both try to find compliancy without first looking at the differences. The result is often an alliance without real con­tact.

References

Beisser, A. (1970). The paradoxical theory of change. In Gestalt therapy now (pp. 77-80). https://static1.squarespace.com/static/572d003b40261d2ef97e5b0b/t/59d64989bce1767a9d98ebbb/1507215754788/G+Paradoxical+Theory+of+Change.pdf

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

Freud, S. (1909). Letter to Jung. The Freud-Jung Letters. Princeton University Press.

Heimann, P. (1950). On counter-transference. The International Journal of Psychoanalysis.

Maturana, H. R., & Varela, F. J. (1980). Autopoiesis and cognition: The realization of the living. London, England: D. Reidel Publishing.

Mawson, C. (2011). Introduction: Bion today—Thinking in the field. In Bion Today.

Racker, H. (1968). Transference and Countertransference . London: Karnac.

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

Resnick, R. (2016). New Contemporary Gestalt Therapy Demonstration Films. Vimeo.

What lies within the therapist-client alliance in Psychotherapy?

The “self” is not a singular, isolated entity, but a function of the person’s life history and experience from living with others through social interactions from which the individual derives their identity (Altemeyer, 2013, loc. 250). The patient brings into the therapy room not only their psycho and soma but rather, their entire intra-psychic relationships integrated. This concept famously relates to Kurt Kofta’s Gestalt Psychology defining dictum, “the whole is more than the sum of its parts”; Arnheim (1961) elaborates “we do not say: the whole is ‘more’ than the sum of the parts; we prefer to assert that the whole is ‘something else’ than the sum of its parts” (p. 91). Kurt Goldstein postulates this holistic concept to a person. He describes an individual as an “organism” that is not an isolated body, but an indivisible whole which dynamically interacts with the physical psycho-social environment (Votsmeier, 1995, p. 5).

We gain a sense of who we are largely through our social interactions, which are relational. When the relationships in this social environment are damaged, the individual experiences symptoms, which can be interpreted in today’s world as psychopathology; which manifests in varying degrees, and is described in the DSM. Conflicts in social relations in turn lead to further social conflicts, social dysfunction and sometimes somatic symptoms. Hence the psychotherapy patient comes into therapy essentially with the purpose of finding a resolution to relational conflicts. These relational conflicts are interpersonal and intra-psychical. In the therapist’s room, these conflicts play out in the relationship between the patient and therapist in which the problematic relationship between the patient and their world unfolds. Transference and countertransference enactments during therapy reveal the relationship patterns of the client. The therapist does not merely talk about these conflicts. They get involved in this relationship to help the client gain the necessary insight from the experience (Altemeyer, 2013).

This is the point whereby the differentiation –though not separation— between Clarkson’s (2003) transferential / countertransferential relationship (point no. 2) and reparative / developmentally relationship (point no. 3) delineates from the person-to-person aspect (point no.4) and the transpersonal relationship (point no. 5)—i.e. the asymmetric relationship versus the “contact” in the relationship. The former is required of the therapist to take notice of the developing transference, like a figure emerging from the background as described by Polster & Polster (1978, p. 28-69).

Bringing the focus of the transference “figure” beyond the reconstruction of life narratives leads the relationship towards the latter levels. Where the transference that occurs within the therapeutic relationship was once considered—in traditional psychoanalysis— a resistance phenomenon against unbearable memories, now memories come under suspicion in the service of the resistance against the transference relationship (Altemeyer, 2013, loc. 260).

Analysis-making is subject to the therapist’s own experience. Wilfred Bion (1984) provides another way of understanding the stratified nature of the therapeutic relationship using the metaphor of a painter painting a landscape. The experience by the painter of the landscape is captured by the painter as a subject onto canvas. While the landscape and canvas are very different things, what is being communicated from the painter to the viewer of the painting is what Bion calls the invariant. “

The original experience, the realization, in the instance of the painter the subject that he paints, and in the instance of the psychoanalyst the experience of analyzing his patient, are transformed by painting in the one and analysis in the other into a painting and a psycho-analytic description respectively. The psychoanalytic interpretation given in the course of an analysis can be seen to belong to this same group of transformations. An interpretation is a transformation; to display the invariants, an experience, felt and described in one way, is described in another.

Wilfred Bion 1984 p. 4

Interpretation, in other words, is the therapist’s act of capturing the experience of their interaction with the client, transforming it into analysis, so as to communicate

back to the client what the therapist understands of this experience. The nature of the invariant that is transformed, Bion adds, depends on what the therapist understands from the experience. How the invariant is transformed depends also on the theory in the therapist uses in order to understand his/her experience. Therapists from different psycho-analytic schools would thus use different invariants— which is not unlike a realist painter and an impressionist painter painting a similar landscape, both presenting different ideas and meanings of the invariants onto canvas.

As the painter’s transformations vary according to the understanding his painting is to convey, so the analyst’s transformation will vary according to the understanding he wishes to convey.

Wilfred Bion, 1984 p. 5

What we can infer from Bion’s analogy is that there are 2 main steps in a psychotherapist’s work:

1. “creation of the invariant”: like the therapist’s sensing of the client,

2. “transformation of the invariant”: like the therapist’s understanding of the client’s

words and communication in analysis. The above also illustrates different steps that happen in the process of the therapist’s work: the first step requires the therapist to sense, and the second requires the therapist to understand and analyze. This, in relation to Clarkson’s relational framework, we may be able to see the correlation between the first part with the person-to-person aspect (point no.4) and the transpersonal relationship (point no.5), and the second part with the transferential / countertransferential relationship (point no. 2) and reparative / developmentally r relationship (point no. 3). On closer look, we may even be able to infer thatanalysis itself is dependent on the transpersonal. In other words, it is the person-to-person and transpersonal— symmetric aspect of the therapeutic alliance— that precedes and determines the quality of the therapeutic analysis. Bion allows us to accept different methods of analysis like a unique style of the therapist in the interpretation and communication of the analytical work. When the different analytic styles and theories used in therapy are seen in the same light as the use of different genres of painting, we may be able to accept the idea that eventually what matters is the quality of the painting, and the emotional engagement of the artist to the subject, and not only the style used.

This being so, what, in psychotherapy, are the elements that determine this quality?

It is fathomable that the quality of the analysis (and the eventual psychotherapeutic intervention) hangs upon the steps that come before the analysis itself. Bion describes the phenomenon that happens before the “creation of the invariant” as the “intuit”. We can perhaps compare this with what we understand as “intuition”. This sensibility comes from meeting with the client’s being and his/her verbal and non-verbal (i.e. the implicit) communication together with the being of the therapist. When we follow Bion’s track, we’ll be able to understand the relevance of this initial intuition and sensibility to the quality of the alliance. The togetherness of the contact is here articulated to be more essential to the psychotherapeutic work and affects the potential for psychotherapeutic change.

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.).

Arnheim, R. (1961). Gestalten. Yesterday and Today. In M. Henle (Ed.), Documents of Gestalt Psychology (p. 91). LA: University of California Press.

Bion, W. R. (1984). Transformations. Karnac Books.

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.

Polster, E., & Polster, M. (1978). Gestalt Therapy Integrated. Contours of Theory and Practice. NY: Vintage Books.

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

Contact & inter-subjectivity: the definition of the self in the therapeutic relationship

“The patient’s unconscious and repressed desires and fears are constantly seeking release or, more precisely, contact with real persons and situations.” (Reich, 1945/1984, p. 5) This relational contact between individuals, as well as the therapist and client, is a common reciprocating mutual co-influence on each other. Whereby one person’s existence is realized only in the presence and perception of each other and the self in the interaction. This togetherness contributes to a co-creation of common meaning-making; a product which is more than the sum of two individuals put together. This personal contact between persons is an inter-subjective event. To further displace Descartes’ dictum, “cogito ergo sum,” the concept of inter-subjectivity maintains instead the notion of “I am seen, therefore I am”. Buber (1936, p. 261) puts it shortly in quote, “Der Mensch wird am Du zum Ich”, which implies the other is a part of the self.

I am seen, therefore I am.

Martin Buber, 1936, p. 261

Self-identity is determined by the internalized relationship of the self with others, which in turn is the relationship between different (sometimes split) aspects of the self. As Kierkegaard (1941/1849) explains, “The self is a relation which relates itself to its own self, or it is that in the relation [which accounts for it] that the relation relates itself to its own self; the self is not the relation but [consists in the fact] that the relation relates itself to its own self.” To further reiterate that this process of self-relating is a continuous dynamic process and not a static one, “Man is a synthesis of the infinite and the finite, of the temporal and the eternal, of freedom and necessity, in short it is a synthesis. A synthesis is a relation between two factors. So regarded, man is not yet a self” (p. 9). Self identity is thus a continual self relation in relation to others. This process, however, involves a mutual recognition of the other, distinguishing oneself from the other, to acknowledge the other as an other self. Self identity, in other words, is implicit in relating of the self to the socio-cultural environment. This dimension of inter-subjectivity in contact is experiential, and considered in psychotherapeutic schools an essential part of the therapeutic hour (Staemmler, 2013).

The origins of an individual’s self-concept and its relation to Inter-subjectivity is elaborated by development psychologists. Trevarthen (1993) writes, “The core of every human consciousness appears to be an immediate, unrational, unverbalized, conceptless, totally atheoretical potential for rapport of the self with another’s mind (p. 121).” The infant’s “primitive state of mind” is inherently aware of human presence and ready to follow and communicate with human mental states. This pre-learning stage is prelinguistic— non-intellectual and primarily emotional— and is a “delicate and immediate with-the-other awareness.” From birth there exists this human self-awareness which is a “manifestation of mind in a person who is capable of being a companion and confidant to the responses of the other, at an emotional level.” This sets the stage for—and precedes— an eagerness and motivation for learning shared meanings with the community in his/her cultural setting (p. 122). Cultural learning (at about 9 months of age) involves the development of self-perception: the child learns to make meaning out of objects, and see themself in the eyes of another person – usually the adult (Tomasello, 1993). Through the child’s interaction with their caregivers, they develop a sense of self-identity which is dependent on how the other perceives them and relates to the meaning of worldly objects according to the other’s perception of these objects. Kernberg (1976) and Kohut (1984) have hypothesized the development of infants’ sense of self is important clinically because it determines certain forms of adult psychopathology (Pipp, 1993).

In adults, the preverbal self is independent of cultural influences, and hence symbolic mediation. It is this aspect of the self that when reached for in the psychotherapeutic alliance, gets through to the transpersonal relationship. This dyadic system within the alliance holds more information and is far more complex than what exists in the consciousness of each individual (i.e. therapist and client) in the alliance (Tronick, 1998).

Vygotsky is noted by Staemmler (2013) to have been one of the first psychologists to develop the idea of the intersubjective relationship as a groundwork for the development and change process, as opposed to the assumption of change as an individual process alone. The intersubjective relationship, that which exists “in-between” during the meeting of persons, is the process to the change. The client benefits from the essence of the contact in the relationship; even more so than the content of the narratives during therapy itself.

Watzlawick et al. (2011) point out the impossibility of not communicating. As human beings, we cannot not communicate; even when we try to defer speaking or reacting to another person. It is also hypothesized that, in the case of psychopathological conditions like schizophrenia, where the client’s strategy is not to say anything, perhaps to avoid communication, in doing so, however, he/she unwittingly communicate. Interaction between individuals ultimately exists in communication. “Communication implies a commitment and thereby defines a relationship(…) Communication not only conveys information but at the same time it imposes behavior” (p. 51).

Bearing this connection between relationships and behavior, we can fathom how an alliance, like a psychotherapeutic alliance can support change in behavior in an individual. According to Vygotsky, the individual carries around with him/her his sociocultural interactions regardless of whether he/she is with others or alone. “It is necessary that everything internal in higher forms was external, (…). Any higher mental function necessarily goes through an external stage in its development because it is initially a social function. (…) Any higher mental function was external because it was social at some point before becoming an internal, truly mental function … the composition, genetic structure, and means of action [of higher mental functions]—in a word, their whole nature—is social. Even when we turn to mental processes, their nature remains quasi-social. In their own private sphere, human beings retain the functions of social interaction” (Vygotsky, 1981, p. 162-164). In other words, our social interactions, which are linked to our self-perception, are internalized.

Family therapy in many ways, can be seen as bringing to the external what is already internalized. The focus is on generating dialogues in the social system and also internalized voices. These voices are also known as Bakhtin’s (1984) polyphonic voices. Virginia Satir calls the dialogue of these internalized voices, “the theatre of the inside”, which is unconscious until we realize and accept their existence, and become aware of the conflict that exists between these voices (Satir, 1978/2009). Generating dialogues in therapy means shifting the focus from the content of what is being said in the client’s narrative to the unfolding of emotions that arises as the narratives are told. In therapy, the therapist gets to witness the client’s unfolding and an intersubjective consciousness emerges (Seikkula, 2011). What therefore is mostly needed in the realm of psychological help is not the change of an individual as a person in isolation, but the change in the individual within his/her internalized societal interactions. In a therapeutic setting, the change process occurs in the person-person contact between the client and therapist, to which both parties contribute to. The quality of the contact provides the client with new internalized experiences with another human being, eliciting a shift in prior internalized mental states. The newly internalized experience gained during the therapy hour through transpersonal contact lays the ground for growth and healing long after therapy ends (Staemmler, 2013).

Reference

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

Helbig 2017 Bachelor Thesis Nh S P

Levels in a psychotherapeutic relationship

Clarkson (2003) defines a five-relational framework of the psychotherapeutic relationship. That which seems to be consistent in all approaches in psychotherapy, Clarkson teased out into what seems like five overlapping layers of the psychotherapeutic contact.

These are:

1. The working alliance: This is the aspect of the client-psychotherapist relationship that enables the client and therapist to work together. It is not dependent on the desire of either party to be in this relationship (p. 35-66).

2. The transferential/countertransferential relationship: This describes the facet of the relationship, that is, the experience of wishes and fears transferred onto the relationship, which works to distort the alliance (ibid. p. 67-112).

3. The reparative/developmentally needed relationship: This is the facet of the relationship whereby the therapist provides corrective reparative or replenishing connection or action where previous relationships were deficient, abusive or overprotective (ibid. p. 113-151).

4. The person-to-person relationship: This relationship aspect is the dialogic here-and-now, subject-to-subject relationship, as opposed to an object-subject relationship (ibid. p. 152-186).

5. The transpersonal relationship: Clarkson describes this aspect of the relationship as the timeless facet of the psychotherapeutic relationship, “though difficult to describe, refers to the spiritual dimension or The many levels in a psychotherapeutic relationship”.

This presentation of the psychotherapeutic relationship into these five layers provides insight into the complexity of the psychotherapeutic alliance. Each of the five aspects is crucial to the relationship, and these together bring about the change- a process in therapy. Through the working alliance, the treatment gets initiated, while the codes and contracts act as the foundation for the cure.

References

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

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

Psychotherapy: The Active Ingredient Is The Transpersonal Therapeutic Relationship

Looking at the therapeutic alliance, how does psychotherapy work? This is an excerpt from my thesis (Chew-Helbig, 2017).

The therapeutic relationship is multifaceted. Many authors like Clarkson (2003) have attempted to describe the different aspects of the therapeutic alliance. One may rightfully argue that separating an alliance in this manner is arbitrary. There exists no clear separation between the aspects— the working alliance; the transferential/countertransferential relationship; the reparative/developmentally needed relationship; the person-to-person relationship; the transpersonal relationship. (See https://nikhelbig.at/levels-in-a-psychotherapeutic-relationship/)

These parts exist as a whole and are essential to the psychotherapeutic alliance. It makes for a safe, professional setting in which very sensitive work between people can be done. It is not unlike a surgical room, whereby the environment is set up so that the surgeons can focus and have their instruments at hand and the room is safe from contamination.

These parts put together can also be compared to a pharmaceutical product. If we take a box of medicinal capsules, we’d first see the box with its labels. Inside this box, one may find a paper pamphlet, and there would be bubble pack(s), usually made of plastic and aluminium foil in which the capsules are enclosed. Capsules are made of gelatin and contain powder. A large proportion of this powder is a starch carrier. Mixed into this starch carrier is a microgram of the active ingredient. We can perhaps also see that the different aspects of psychotherapy as the important support for and carrier for the active ingredient in psychotherapy. The question is then, what is the active ingredient?

Like an active ingredient of pharmaceutical medicine, the transpersonal is the most intangible part. It also requires the other parts to package and support its use.

We can also see in pharmaceutics, how the same active ingredient can be packed differently and can look very different. The same ingredient can come in the form of capsules, tablets, syrup, inhalants, injectables etc. These various forms exist so that the active ingredient can be administered to the patient effectively, depending on the need of the patient and the uptake of the drug. In psychotherapy, we could perhaps see that these different forms of administering an active ingredient represent the different modalities of psychotherapy. The active ingredient itself, in all modalities, then could be the same. This is perhaps where psychotherapy research can focus.

References

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

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