Diagnosis of Obsessive-Compulsive Personality from the Gestalt Therapy Perspective

Obsessive Compulsive Personality Disorder explained and treated with Gestalt Therapy method.

The DSM V describes obsessive-compulsive personality disorder (OCPD) as a pervasive pattern of preoccupation with

  • orderliness,
  • perfectionism, and
  • mental and interpersonal control.
obsessive-compulsive treatment

Individuals who present phenomenon of OCPD give up their flexibility of behavior and thought. They become “closed up”, showing lack of openness to the environment around them.

The consequence is that of being in-efficient in doing daily tasks, since the preoccupation is on distracting details, rules and schedules, that leaves the main task undone. The quest for having tasks done perfect also leaves task unfinished. While everything takes longer to complete, there is obsession with work and productivity, leaving little energy left for leisure activities and relationships. Relationships suffer because there is a tendency to be overconscientious, and inflexible about matters of ethics. Many individuals with OCPD tend to have religious or ideological stance, that they hold on to. They may also have a fixed idea of how things should be done, and would not delegate their work to others, unless the others follow his/her way of executing the tasks.  Some persons show tendency to hold on to unnecessary objects.  Similarly there is a tendency to being miserly. A certain feature of this personality style is the display of rigidity and stubbornness. 

OCPD is differentiated from Obsessive Compulsive Disorder (OCD) by the by the presence of true obsessions and compulsions in OCD.

Obsessive Compulsive Personality Disorder Explained with Gestalt Therapy 

Looking at this condition through gestalt therapy lens, we can appreciate the complexity of the treatment process. In seeing the process at each stage and the resistances of the individual towards change, we can follow the clients’s path with more understanding and patience.

At the sensory stimulation phase (the initial phase): one’s own needs are ignored. Habitual behavior and thoughts take the place of present needs.  Feelings that arise in the foreground become interrupted by background noise of routine activity. The patient may find difficulty articulating needs or accessing emotions. Difficult emotions are avoided.  In place of this is the need to continue habitual behavior.

At this phase of treatment, focus on arising emotions is the work. Often the patient is able to recount difficult life situations, but the narration lacks emotional content. The therapist’s job at this point is to support the patient in embodying the denied emotions, instead of blocking them out with compulsive thought. 

At the Orientation phase: There is seeking of external rules. The self has to be perfect, and be right. “I must do it right”. “I must check this…”

There is a sense that being not perfect may lead to loss of love, rejection and helplessness. Control against these feelings are directed towards the external environment.

Experiment with words, making statements and dealing with projections (e.g. other people will judge me if ….) plus dealing with emotions is the work at this stage.

At the Action phase: This is the phase that occurs when the individual is guided to act on behalf of his/her needs rather than acting on his/her impulses. This can bring about anxiety. OCPD actions are acts out of fear of helplessness, and behaves so as to avoid the possibility of situations that leads to helplessness. This means controlling and perfecting the environment, and external self. Ultimately nothing suffices.

Therapy at this phase brings to light the anxiety that arises. There is also projections (attributing thoughts of the self on other people) and retroflections (holding the self back, or blaming the self) that need to be worked through. 

At the Assimilation phase: At this phase, the individual would have tried to change his/her behavior.  This is possible through practicing will-power, or having behavioral-style therapy. However, attempts to change behavior get quickly sabotaged by introjected messages (like “this is wrong”, “it will not work”)  that lead to the individual rationalizing the attempt, denying the point of attempting change, feeling contempt for the effort or try playing down the problem.  This is the reason why in gestalt therapy, we are aware that behavior modification attempts alone does not resolve the issues of OCPD.

At this stage, it would be better to check with the patient about his/her introjects, and feelings of guilt or shame that may arise from taking appropriate action.

At the release phase: Let’s say that the patient has managed to overcome the first four phases, the next tendency would be to hold on to the identification of the self with OCPD. There need would be to not let go of the habitual thoughts and action, to see them as the “right thing to do”. This is a protection mechanism against the grief that can arise from feelings of loss and feelings of loneliness.

At this phase, the patient may seem very sad or look depressed, angry. He/she shows strong emotions. The therapist supports the patient by being present and acknowledging the client’s difficult emotions, and helping him/her work through the mourning process. 

Treatment Focus

The treatment process in Gestalt therapy for OCPD, when done in it thoroughness, with the above phases worked through requires a good amount of patience within the psychotherapeutic alliance. At each phase, difficult emotions need to be acknowledged and processed.

Treatment of symptoms arising from personality disorders take time. Patience is essential for both therapist and patient. Where dealing with loss is concerned, the mourning process is an important, positive step to healing.  

Phenomenology

Physical appearance is usually thin, haggard, not enjoying, gray, tensed.

The emotions include fear, anxiety, loneliness, helplessness, defiance, vulnerability. Initial emotionality may look flat, and restrained.

Psychosomatic reactions may include stomach and gastro pain and symptoms, constipation, circulatory system problems (e.g. myocardial infarction).

Polarities to work through are :

  • Powerfulness – Helplessness
  • Fear – Aggression, Anger, Bitterness
  • Control – Chaos
  • Obedience – Defiance, unruliness

Sources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Anger, H. (2018) Gestalt Diagnostics. Private Lecture at the Sigmund Freud University, Vienna. 

3 Approaches to Psychotherapy: A Quick Comparison of the Gloria Tapes

This is a video I made to compare the Gloria sessions with three psychotherapists, Fritz Perls, Carl Rogers and Albert Ellis.

The psychotherapists demonstrate their different psychotherapeutic schools. Perls is a Gestalt therapist, Rogers is a person Centered Therapist and Ellis is a behavioral therapist.

Psychotherapy research of today has shown us that the he personality of the therapist is an essential factor in therapy process.

0:59 When we observe how the client at first moments of meeting the therapists behaves differently in each session, we may be able to understand the phenomenon of this idea.

At 3:37, we look at the body language of the therapist and client. 4:40 Non-verbal communication is sometimes more telling of the interaction.

At 5:50, we compare who spoke more, who had more air-time in the sessions.

To end the video, the representing theme of the Gloria tapes were discussed.

What does “healing” mean in Psychotherapy?

My work in psychotherapy is about healing. It is in my foreground every minute I work with a patient. Oftentimes patients do not realize that in our therapeutic conversation, there is an underlying therapeutic process. This is because the therapeutic dialogue is, a conversation with another person, but different.  The phenomenon of a relational gestalt therapy  (my school of study) dialogue is mostly felt, tasted and sensed, before it gets intellectually understood.

Subtle is the therapeutic process not

When we go for therapy, we may experience no big change for weeks or months. We may talk about the same things in circles before something happens: an insight, an understanding, a gush of emotions, a relief from tension.  When and how we get to this point in the therapy is usually not foreseeable.

Case Study of healing process in psychotherapy

I recount a case study of a journalist named Mary (not her real name), who came to therapy because of stress due to conflict with her colleagues. Her goal of therapy was to reduce the stress and panic feelings when she is at work. She feared that she may become too emotionally unstable to go to work because of this. For months, Mary talked about her work environment, the colleagues and tried to understand the incidents that triggered in her deep emotions. She also talked about her work, which she calls “her passion”; to remind women of their rights through feminist writings and stories. More weeks went by, and I began to wonder myself if her process was heading anywhere. I stuck to the process of her work, which with time, saw Mary more comfortable with expressing more difficult emotions, especially feelings of vulnerability. Baby steps. One day, she revealed that she had been sexually assaulted by a group of college mates and that she had kept this incident a secret for 20 years. She was able, after 14 months of therapy, to talk about it in session.  Along with this revelation came a flood of feelings: resentment, shame, guilt, vulnerability, frustration, anger, grief, and also thankfulness. At one point, she was even angry at me for having initiated her emotional unravelling. For a couple of weeks, she said that she could not work. She, however, recovered from this.

Mary transformed. She had been afraid of coming to terms with a painful past. In so doing, she re-lived her inner feelings of resentment, frustration and anger towards others and herself in her workplace and even in her writings. While these feelings helped her to write powerful articles, it also caused her to build walls between herself and the society in which she is in contact with. The conflicts left her stressed out and panicky at work. She was helpless against the emotional turmoil. Working through of her traumatic experience, she unleashed the source of these painful feelings.  Through this process, Mary was awarded choice. She could tap on these feelings as motivation to write and guide others. She is, however, not bounded to these feelings anymore. She finds inner-calm — which she said “had always been there”, but she did not realize it– in her social context. With time, she was able to build more allies.  Panic feelings were soon past.

So what is healing to me in the psychotherapeutic sense?

Mary’s healing was a journey towards self-awareness and growth. The time, energy (and, not to forget, money) she had spent in therapy rewarded her with freedom from unconsciously re-living a traumatic past.

Healing in psychotherapy takes place when the patient, like Mary, is able to grow and transform through insight and experiencing (and sharing) of feelings. This healing provides the individual with choice. This concept of healing is unlike that of conventional thought of “healing diseases”, which strive to remove the disease. In psychotherapy, mental and emotional issues are not to be judged as bad and removed; but understood. Depression, anxiety, PTSD and personality disorders aren’t “diseases to be cured”. These are opportunities for personal growth.

The healing –in a way described in this article– achieved in psychotherapy, is permanent. What Mary has gained will be with her for life, and she will continue to grow with it.

 

 

Nicotine Addiction: the bio-psycho-social viewpoint of the smoking habit

This article is a reflection on the lecture series on the topic of addiction. The focus here is that of nicotine addiction.

Why Smoking?

Nicotine addiction seems less serious to law enforcers than addiction to other “hard substances” like opioids, for example. However, for the many persons who need to quit the cigarette for health reasons, addiction is an important issue. This short paper addresses some of the different aspects of nicotine addiction that warrant attention. Through this overview, we can appreciate how one “habit” transcends over many fields of science, and how psychotherapy, within these fields that can support cessation.

The Social Norms of Smoking Initiation

The habit of cigarette smoking is observed to be most often developed during adolescence. Qualitative studies were thus conducted by Peters, et al. (2005) involving high school students who are smokers, regarding the latter’s beliefs in smoking initiation and nicotine addiction.

Questions posed to the subjects were like, “who was with you the first time you smoked?”, to which the answers were largely peers and family members of the same age-group like cousins. Smokers from both genders regard “curiosity” and “peer pressure” as motivation for starting the habit, while for boys, the added motivation is for “cool / image”.

Other means of modelling and encouragement given to teenagers as motivation for initiation of smoking are:

  • Self medication and coping: “My parents were arguing so I went in her car and saw her cigarettes there, I wanted it to calm me down” and “Because I was having problems at my house and my friend told me if you want to feel better you should start doing it.”
  • Peer Pressure: “Because someone asked me if I have ever done it”, “because he (boyfriend) kept telling me try it, try it” and “because everybody was smoking one at the bus stop.”
  • Curiosity: “We were just curious”, “something to try” or “I was curious to see if it was an effect.”
  • Other Modeling Recurrence: “Because I saw my friends doing it”, and “Because everybody else was doing it, so I wanted one.”

The majority of the subjects revealed that the next time they smoked after the initiation is within 48 hours of the first smoke. This recurrence of smoking crystallizes the behavior into an addiction:

  • Craving/Withdrawal: “I was craving it and I wanted to be with my friends”, “I had to have another cigarette”, “When they are shaking.”

When asked “how long does someone have to smoke before they are hooked?” The first 3 times emerged as the most frequent response from the subjects. Most subjects also say that one pack or less is all it took for them to get hooked on the smoking habit.  This is also the topic of question for Birge, et al. (2017),  “What proportion of people who try one cigarette become daily smokers?”.

At the mention of “being hooked on the habit” or eventually “becoming daily smokers”, it is interesting to also note that it may not necessarily mean that the subjects were actually spontaneous addicted to the substance, nicotine, per se.  This would have only been clearer had the subjects who were just initiated, were induced to try to “quit” after the 2nd, 3rd (and so on) smoke after initiation.

Smoking Regularity and Nicotine Addiction in Adolescence

Selya et al. (2013) worked on the little-known time-varying effects of smoking quantity and nicotine dependence on the regularity of adolescent smoking behavior. The findings indicated that, in adults, smoking quantity and extent of nicotine dependence is significantly related to regularity of smoking during adolescence. Nicotine dependence is found to increase over time as the effects from regularity of smoking decreased with time. This indicates implicitly also that the initial phases of smoking have more significance in causing nicotine addiction.

A Brief Neurobiology of Nicotine Addiction

From the above studies alone, one gets the impression that, for adolescents at least, smoking is an addictive habit from the beginning. What is not so clear is to what extent, and which time frame does the biological effects of nicotine take over the psychological need to light up a cigarette. The students cite mainly psychological factors (e.g. image and peer pressure), rather than physical factors (e.g. pain management) in getting initiated to smoking.

Nicotine molecules target neuronal nicotinic acetylcholine receptor (AChRs) of cells, in particular neurons. Activation of these receptors is involved in a chain reaction that regulates the system related to dopamine (the dopaminergic system). Consuming of Nicotine regularly causes an “up-regulation” of these receptors. This means that the cells are genetically stimulated to produce more or more effective AChRs receptors. This change in biological structure in neuronal cells changes the normal homeostasis of the intercellular environment of the brain. This process of up-regulation is known to be responsible for the initiation of nicotine dependence (Ortells & Arias, 2010).

The motivation for smoking, like other drugs and addictive behaviors, relies on neurons in the brain’s reward system, based in a brain region called the ventral tegmental area (VTA). Obtaining a reward leads to excitation of these neurons and the release of a neurotransmitter, dopamine. Dopamine transmission from the VTA is critical for controlling both rewarding and aversive behaviors.  The degree to which the reward system can be activated is normally tightly controlled by a neurotransmitter called GABA which inhibits excitatory signaling in neurons and keeps the system in balance. Figure one pictorially represents how the main neurotransmitters are held in homeostasis in living cells (in particularly the brain). When a substance like nicotine affects the effects of a neurotransmitter— in this case, Acetycholine— the system would adjust itself to regain balance. Chronic exposure to nicotine leads to the cells adjusting permanently to the imbalances. Such changes are adaptations that occur at a genetic level (since it involves receptors, which are proteins). When the addictive substance is no longer in the system, the imbalance caused by the adaptation would be felt.

Figure 1: (Tretter, 2018)

 

Researchers have also discovered enzymes that disinhibits dopamine neuron action with chronic nicotine exposure (Buczynski, et al., 2016). Pointing further to the biochemical action of nicotine that leads to the addictive phenomenon.

Nicotine Effect on Metabolism

The negative side-effect of smoking caused by tar and “smoke pollution” (figure 2) that causes lung damage is well known and quite easily grasped. However, the effects of nicotine in itself on the biological system – especially on the metabolic system— is relatively not well understood by the general public.  This has likely given rise to the misconception that chewing nicotine or smoking nicotine vapors are the answer to countering the negative health effects of smoking.  In fact consuming nicotine only adds to the metabolic issues in the body.

 

Figure 2 (Ambrose & Barua, 2004)

The effects of cigarette smoking on metabolism is illustrated through a recent Japanese study by Kang, et al. (2009). Fasting blood insulin, glucose and lipid levels were measured in 2 groups of women. One group consisted of regular smokers and the other non-smokers.  Fasting levels of these substances are indicative of the efficiency of the metabolic system. During fasting, insulin levels and glucose levels in the blood should ideally be low. Since there is no food entering the body during fasting, one would expect that glucose that had entered the blood from the previous meal to is already removed from the blood stream. The hormone, Insulin, is produced by the Islets of Langerhan cells of the pancreas immediately during food consumption to signal to the other cells in the body that glucose released into the blood from digested food needs to be quickly removed from the blood.  High levels of glucose concentration in the blood is toxic to the body, and this process of insulin release is a form of homeostasis. During insulin release, fat cells convert glucose to fat, muscle cells convert glucose to glycogen, and cells stop releasing glucose (gluconeogenesis) into the blood stream. After a period of time, the blood glucose level is supposed to be lowered, and Insulin levels in the blood will drop to safe levels (Eckel, Grundy, & Zimmet, 2005).

 

As with the above study by Kang et al., when comparing the blood profiles of the group of cigarette smokers with the group of non-smokers, the results showed significantly higher mean Insulin and blood glucose levels while lower mean high-density lipoprotein (fats molecules) in smokers as compared with non-smokers.  This indicates that nicotine affects the functionality of Insulin by making this hormone inefficient in reducing the glucose levels in the blood. With nicotine, fat cells do not respond as effectively to insulin by storing fat, muscle cells do not respond as effectively to storing glycogen, and cells do not respond to Insulin as effectively to inhibit gluconeogenesis.  So blood glucose after meals take longer time to return to safe levels, causing more Insulin to be pumped into the blood. This conditions mimics that of type 2 diabetes or metabolic disorder.

 

There are many papers that have highlighted the link between smoking and cardiovascular-related illnesses. The above study is an example that explains to us that nicotine affects blood glucose regulation and the function of insulin.  Impaired blood- glucose regulation is related to a pre-diabetic condition also known as insulin resistance.

 

Weight Gain and Smoking Cessation

 

A better-known cause of insulin resistance is not smoking, but high carbohydrates and/or alcohol in the diet coupled with sedentary lifestyle. However, cessation of smoking leads to a “similar” phenomenon of gaining weight. This phenomenon is unpleasant, and it is a signal that nicotine consumption messes up the function of insulin in glucose metabolism.

 

Figure 3 is an illustration from a paper by Nogueiras et al. (2015) that examines the biochemical link between insulin resistance and nicotine use.  If more attention is paid to educating the general public (and doctors) on metabolism, the medical field can perhaps help people with smoking cessation.

 

During cessation, nicotine is suddenly “deprived” in the system, fat cells no longer become insulin resistant (which is a good thing). Fat cells start to “hear” the insulin signals, and mop up the glucose from the blood (also a good thing). Since there is excess insulin in the blood, blood sugar levels become very low and fat cells begin to hold on to the fat (which causes one to put on weight).

 

It could be, that one possible way out of this situation is to maintain a very controlled diet that does not cause more insulin to be released in blood. Since Insulin is mainly triggered when sugars enter the blood stream, it might just be that a very low intake of carbohydrates may be the answer. With time, the body would cope by producing less insulin. Less insulin means that the fat cells do not absorb more sugars but actually start to burn off the fat.  This is how the biochemical aspect of metabolism becomes paradoxical and really interesting, but this is a big subject in itself.

 

Figure 3 (Nogueiras, Diéguez, & López, 2015)

Conclusion

Smoking addiction begins with the initiation at mainly adolescence, which opens up a whole potential field of education, and psycho-social influences. There is also biochemistry. Biochemistry is many-factorial and complex. There is the harmful effects of tar and other chemicals other than nicotine.

 

Nicotine, being known as the addictive substance is significant to the field of neurochemistry and pharmacology.  What is interesting and important is nicotine on metabolism.   This could be relevant in psychotherapy, since it involves lifestyle and effects of hyperinsulinemia or a diabetic-like situation. Hyperinsulinemia is incidentally linked to as well to depression (Löwe, Hochlehnert, & Nikendei, 2006) (Vogelzangs & Penninx, 2007).

 

For psychotherapists, this is a common addiction of functioning (and also paying) clients. Knowledge of the different aspects of this addiction lends itself to a multifaceted way of providing therapeutic support.

 

 

Bibliography

Ambrose, J. A., & Barua, R. S. (2004). The pathophysiology of cigarette smoking and cardiovascular disease: an update. . Journal of the American college of cardiology., 43(10), 1731-1737.

Birge, M.,  Duffy, S., Miler, J. A., &  Hajek, P. (2017). What Proportion of People Who Try One Cigarette Become Daily Smokers? A Meta-Analysis of Representative Surveys, . Nicotine & Tobacco Research.

Buczynski, M. W., Herman, M. A., Hsu, K. L., Natividad, L. A., Irimia, C., Polis, I. Y., & Roberto, M. (2016). Diacylglycerol lipase disinhibits VTA dopamine neurons during chronic nicotine exposure. Proceedings of the National Academy of Sciences, 113, pp. 1086-1091.

Eckel, R. H., Grundy, S. M., & Zimmet, P. Z. (2005). The metabolic syndrome. . The lancet, 365, (9468), pp. 1415-1428.

Kang, Y., Imamura, H., Masuda, R., & Noda, Y. (2009). Cigarette Smoking and Blood Insulin, Glucose, and Lipids in Young Japanese Women. . Journal of health science, 55(2), 294-299.

Löwe, B., Hochlehnert, A., & Nikendei, C. (2006). Metabolic syndrome and depression. . Therapeutische Umschau. Revue therapeutique, 63(8), pp. 521-527.

Nogueiras, R., Diéguez, C., & López, M. (2015). Come to where insulin resistance is, come to AMPK country. . Cell metabolism, 21(5), 663-665.

Ortells, M. O., & Arias, H. R. (2010). Molecular mechanisms of nicotine dependence. Journal of Pediatric Biochemistry, 1(2), 75-89.

Peters, R. J., Kelder, S. H., Prokhorov, A. V., Meshack, A., Agurcia, C., Yacoubian, G., & Griffith, J. (2005). Beliefs and social norms about smoking onset and addictions among urban adolescent cigarette smokers. . Journal of psychoactive drugs, 37(4), 449-453.

Selya, A. S., Dierker, L. C., Rose, J. S., Hedeker, D., Tan, X., Li, R., & Mermelstein, R. (2013). Time-varying effects of smoking quantity and nicotine dependence on adolescent smoking regularity. Drug and Alcohol Dependence, 128(3).

Tretter, F. (2018, Feburary). Neuroscience and Genetics. Private lecture at the Sigmund Freud University. Vienna, Austria.

Vogelzangs, N., & Penninx, B. W. (2007). Cortisol and insulin in depression and metabolic syndrome. Psychoneuroendocrinology, 32(7), p. 856.

 

Couples Therapy: Marriage Counseling Approach

What can you expect from your couples therapy or marriage counseling session? In this article I shall endeavor to give you an overview on psychotherapy with couples in my practice.

couples therapy

 

I am influenced by the principles introduced by Bob and Rita Resnick, who together with their faculty of GATLA have been my mentors for many years. I have personally experienced their work by being a model couple at a workshop in Slovenia, 2015.

“Two becomes one, and then there is none.”  Bob Resnick

This quote explains how almost all relationships begin with blissful passion only to evolve with time into something less — often much less.

Falling in love involves meeting a person different from ourselves

Falling in love is about meeting someone, and realizing a “chemistry” with that person. In love, all you want to do is to be with the person to feel his or her presence. There exists interest, curiosity and need. This is a time of exploration and fun. Sometimes it is also a time of anxiety of being with someone new. These emotions make us feel fresh and somewhat alive.

Two becomes One

Passions fade with newness. How come?

As the relationship progresses, two very different people become more and more alike. This seems to be a “natural” process in most intimate relationships. “Successfully” married  (especially elderly) couples, often look and act like each other, oftentimes even being able to read each other’s minds and/or finish each other’s sentences.  For that reason perhaps, we’d think that “two becoming one” is the path to take in relationships.It , after all  recited in most marriage vows.

…then there is none

Resnick argues, however, that when two become one, there’d be none.  The passion arising from the meeting and the curious exploration of two different people is doesn’t exist anymore, when these two different people become the “same person”.

It would then seem like an ideal if both persons in a romantic relationship can stay together as unique individuals, different from each other.

Changing the Other or Changing for the Other

With attachment comes reliance.  There is mutual responsibility attached to serious relationships. We need this kind of mutual responsibility.  Caring mutual responsibility is healthy.

What unfortunately gets mixed up with caring responsibility,  is the idea that we have to give up our needs altogether, or that the other person is expected to give up his/her needs likewise.

With personal needs unmet, both parties begin to make silent demands on the other.  This circle of needs and demands go unnoticed in the undercurrent of the relationship.  There is dissatisfaction as one tries to change him/herself to fit into a relationship role, and there is conflict when one tries to change the other person in to his/her role.

Maintaining a Mutually Nourishing Relationship

To be ourselves and to be with the other. To be for ourselves and to be for the other. To be taken care of by the other and to be take care of the other.   Movement between being for ourselves and being with the other is the premise of a mutually nourishing relationship.

Oftentimes, though, we are not moving, we are really stuck.

We can only “be ourselves” if we are aware of who we are. We can only be well taken care off, when we are fully aware of our own needs. We can be for the other only if we are able to listen to what the other person is saying.  Without  awareness, both parties can only rely on guesses, expectations, silent resentment, and conflict.

Couples Therapy Approach

When couples come to the practice, the “client” is the relationship. Relationship functions through communication. Couples therapy will then be centered around communication between two persons in the relationship.

Questions to ask are: How do we perceive our needs? How do we express what we want?  How do we hear the other? How do we react to the other person’s needs? How do we compromise? What do we want the other person to know? How important is the relationship to us? Who are we? …

During therapy, an assortment of themes arise. The focus is on how the couple deals with these themes.  How do they communicate with each other in situations.  The focus is on dialogue.

Each person gets his/her space and voice. The background of each person in the relationship is considered, validated and heard. What has he/she been through? What is he/she going through now? What do both persons want for the future?

Contact me if you have questions regarding Couples Therapy

Reference

Two Become One and Then There Are None: Moving from a Fusion Model to a Connection Model in Couples Therapy from Clinton Power on Vimeo.

 

 

Self Harm & Emotional Pain

Psychotherapy, self harm and emotional pain.

This page features a collection of video lectures on the subject of self harm orNon-Suicidal Self-Injury (NSSI) and it’s connection to emotional pain.  These resources, I hope, will provide some personal and professional answers in dealing with, or appreciating the phenomenon of self harm. The aim of this learning is to bring awareness of what is possible and what is needed to assist others with the same issues. Self harm is a behavior to be respected, because it serves the person. It is also a behavior to be taken seriously, and with compassion.

Willis, J. on “Bullicide”

Willis tells us about the impact of bullying on people who self harm. He also explains with neuroscience that both physical and emotional pain activates the same area of the brain.

Lewis, J. on his personal experience with self harm

Lewis’ sharing of his experiences of self harming may resonate with many people. As in the above video, bullying is known to be a trigger for self harm.  Lewis tells us of the value of loving people who are suffering from emotional pain.

Working with Self Harm in Psychotherapy

Self harm is a clear indication of the need to cope with un-bearable emotional pain. The most important aspect of treating clients who have learnt this coping strategy is to authentically respect the person, what he/she does and feels. The therapy sessions will then deal with the emotional turmoil that underlies the need to self harm. Therapist and client work together to understand the origins of difficult feelings. Reminiscing past experiences in a secure therapeutic environment bring up emotions attached to these experiences. As Lewis explains, it is the cutting that silences the emotions. Therapy brings the voice back to these emotions. This voice is also heard by the therapist who respects the process.

Scapegoating in Groups and Families

Scapegoating is a phenomenon that happens in almost all human groups. A. Colman (video below), begins the above talk by saying that it is the root of evil in humanity. Is he exaggerating this? Or are there truths in his remark?

bullying

What makes a group?

A group is made up of a bunch of individuals (and we are referring to human individuals here), who have to be together because of a certain task or function. A company of workers is a group. There are social groups, church groups, political groups, hobby groups, support groups and the like. Families are also groups.

In my article Bion: The Function of Myths in Groups, I explain that a group is a body that has a mental state and creates a phantasy. The group becomes more than the sum of people that come together to form it. The group has its own dynamics and it is its own organism.

Groups are like organisms, and they strive to keep themselves intact

The group connects the inner worlds of people. Narcissistic tendencies and psychological traumas get played out in groups. Like a living organism, the group strives to keep itself intact.

In order to do so, any form of aggression that naturally and unconsciously arises from the group becomes a threat to the status quo of the group. There is a tendency then for the group to move towards “doing something” to maintain harmony and equilibrium. The individuals then strive to retain their own idea of their “good self” and deny their part in the aggression that threatens the group.

Groups need scapegoats so that the members can disown their responsibility for the group’s destruction

The aggression that is latent in the group becomes disowned by the individuals (who do not want to be blamed for their group’s destruction), and transferred on to an external object of blame. This object of blame is the scapegoat.

Oftentimes the scapegoat is a member of the group. Sometimes it appears in the form of someone from outside the group– people from another culture, immigrants, women, etc.

Scapegoating in Groups

Scapegoating is the most ancient human rituals. It used to come in the form of practices such as child & animal sacrifice, adult sacrifice, witch hunting. Large groups of people can also become scapegoats, as we have witnessed during the Holocaust, Apartheid, and other genocides.

A Scapegoat is a person, subgroup, collective idea … who is made to take the anxious blame for the other people in their place.

The process of scapegoating is done in order for the rest to feel more comfortable, or to be more efficient, and whole.

The scapegoat embodies the transformational, creative and/or destructive potential within the group.

The scapegoat has often creative potential, and is often different from the others in the group. Sometimes this person has the potential to make changes in society.

Scapegoating is victimization of the other

Many who have been young victims of bullying in school or in the family have experienced from a young age, what it is like to be in the position of the scapegoat.

The scapegoat is usually the different / outsider. Not being able to bear the difference. Potential scapegoats are usually people who are racially different.

Scapegoat’s Adjustment

In order to survive being scapegoated, the person either turns into the

  • victim /patient (as in children who develop illnesses or develop behavioral problems in school).
  • avenger (someone who takes revenge)
  • the messiah / prophet (someone who saves the group)

09:10 Colman, in the video above provides us with literary examples of some of these scapegoat transformations.

In Families, the child who becomes the Scapegoat is also the Symptom Bearer

Scapegoating happen in almost all families. Most of the time a child in the families bears the brunt of the scapegoating. If the family is relatively harmonious, the scapegoat feels simply like a “black sheep”, and grows up to be an adult who can function well.

In families that are dysfunctional, or in families where mental disorders and/or addictions or illnesses exist, the scapegoat child develops symptoms or syndromes that affect his/her ability to function emotionally as an adult. Some of these scapegoated children develop psychological issues like depression, anxiety, eating disorders. Some also develop the tendency to self harm.

This is usually seen (which I witness in practice) in a families where parents strive to stay together, despite the fact that one or both parents are abusive or psychologically unstable. What would have been a natural course of action, a break up, is avoided by members of the family at all costs. A superficial picture of stability is often seen in these families.

The “only” problem this family seem to have is a problem child — a child who is doing poorly at school, has behavioral problems, has eating disorder, self harms or has other emotional difficulties. When as therapists we see such children, we understand them to be symptom-bearers.

The experience of being a child scapegoat is one of Childhood trauma. There is immense feeling of loneliness because his/her feelings towards the family are negated by their own parents and siblings. These are the children who’d take the blame for their parents’ worries. Many grow up believing that they are flawed. Many introject the blame. Self blame lead to self hatred, self harm and sometimes suicide.

Psychotherapy for Child Symptom Bearers

Usually families bring themselves into therapy because of a “problem” or “sick” child. In successful family therapies, the therapeutic work centers around the relational dynamics between the family members, and not focussed on the “problem child”. Helping the parents and other members become aware of their roles in the family system releases the afflicted child of having to bear the intrinsic problems that exist in the family.

Psychotherapy for Adult sufferers of Scapegoating

One does not always know that one is being made a scapegoat. In the working environment, the scapegoat may simply find work in the office stressful with conflicts.

Sometimes, of course, in the course of therapy the client realizes that he/she was his/her family’s symptom bearer, or that he/she was a scapegoat in a group.

Being a scapegoat brings with it feelings of loneliness. You are being targeted as the cause of problems. Because of this, there’ll also be feelings of having done something wrong, or being flawed. This progresses to self blame. Psychotherapy involves

  • addressing these feelings of loneliness, shame, fear and betrayal
  • re-aligning oneself by being awareness of the group reality,
  • finding oneself again being independent of the group,
  • finding resources outside the group
  • getting support from others

Contact me freely for more information on this topic, or for therapy.

Psychotherapy in Vienna & on Skype

Find out more about:

Therapy in Vienna …. Therapy over Internet

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”.  This indicates that to be in crisis is to be in a state of having 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.

Resnick: Gestalt Therapy Principles in Today’s Context

What is gestalt therapy? Resnick explains gestalt therapy principles in just 30 minutes with this video. Is Gestalt therapy for you? Watch this.

 

“The relationship is not as important as the research shows but what happens in the relationship. When there is an interaction between therapist and client.”

This is the best video resource to understand, ” what is gestalt therapy?”.

 

 

An Introduction To Gestalt Therapy Theory from GATLA Videos on Vimeo.

Ellenberger: THE PATHOGENIC SECRET AND ITS THERAPEUTICS

This 1966 article, The Pathogenic Secret and Its Therapeutics,  by Henri F. Ellenberger may explain why psychotherapists are bounded by strict confidentiality in their work.

Ellenberger highlights what he calls the “pathogenic secret”. This is a secret of what has happened to us, or what we have witnessed first hand, or what we have been told, that is so “heavily-disturbing”, thus unbearable for us to come to terms with.  This is the secret that we keep to ourselves. Sometimes it is a secret that we keep from ourselves, out of our consciousness. Oftentimes belongs to an an event that had occurred in early childhood.

Under certain circumstances, the confession of the pathogenic secret has been known for time in memorial to have healing qualities.

The Concept of the Pathogenic Secret

Pathogenic secret  manifests itself as chronic neurosis resulting in symptoms like “melancholia, neurasthenia, hysteria, or even psychosis”, i.e. what we know today as psychopathology.

“The nature of the pathogenic secret can also differ widely. In certain patients, it is the matter of secret thwarted love or some other suppressed passion, such as jealousy, hatred, or ambition. Sometimes it is a matter of physical illness or infirmity, of which the patient feels ashamed. Frequently the secret is related to some kind of moral offence which can range from petty theft to murder, but frequently also it is of a sexual nature (adultery, incest, abortion, infanticide, etc.). The secret can also be the painful remembrance of some traumatic event, sometimes connected with a secret of another person (for instance a young girl discovering her mother’s adultery).” There is often experience of shame involved in the pathogenic secret.  The type of the pathogenic secret can differ widely, and it’s effect varies with how the individual attaches meaning to it.

Healing Power of the Confession

Working with confessions is not a new concept. It is observed within ancient healing practices. Confessions of sins or taboos have been documented as healing methods in ancient civilizations in places like Mexico and Mesopotamia.

In the Roman Catholic religion, confessions are practiced, as a form of the self reconciling with the social world.  In Catholicism, confessions are sealed in secrecy to the point that under no circumstances is the confession revealed.  Once absolved from sins revealed in the confession, the confession is free from his/her sin.

In the Protestant religion, the concept of “Seelsorge” or “cure of souls” as the result of being in the presence of another in a dialogue that can be an exchange and containing of a secret.

The Pathogenic Secret in Literature

Ellenberger also cites examples of the destructiveness of the pathogenic secret and it the healing effect of the secret’s revelation in literature like Nathaniel Hawthorne’s The Scarlet Letter, Jeremias Gotthelf’s Wie Anne Babi Jowager haushaltet und es ihm mit den Doktorn ergeht,  Ibsen’s The Lady from the Sea,  Marcel Prévost’s L’Automne d’une Femme (The Autumn of a Woman),  Heinrich Jung-Stilling’s Theobald oder die Schwarmer.

The Pathogenic Secret in Criminology

Then there is the confessions of the pathogenic secret in criminology. The author cites 19th century literature,  Philosophie Pénale, published in 1880 by Gabriel Tarde, documenting the effect that the confession of the crime has on the person who committed it.

A problem which seems to have attracted less attention is that of the long range effects of the burden of the secret upon the criminal, should his crime not be discovered. It would seem that the secret exerts a permanent and profoundly disturbing effect on certain criminals.”

Another literature cited was that of Austrian criminologist, Hanns Gross, in his textbook of criminal psychology in 1898.

C. G. Jung (12) tells the story of a woman, unknown to him, who came to hisoffice, refusing to divulge her name, and told him how twenty years earlier she had poisoned her best friend in order to marry her husband. But the husband died soon after she married him, the daughter of this marriage disappeared in turn; even animals turned away from her so that she could no longer ride horses nor own dogs and finally she fell into an unspeakable loneliness; this was the reason why she felt that she must make a professional man share the knowledge of her crime. Jung never saw that woman again and wondered what happened to her. Actually the long-range disturbances caused by a secret of that kind in the mind of an undetected criminal are one of the least-known chapters of criminology.

Hypnosis & Pre-psychotherapy

The notion of the burdening secret became known to magnetists very soon after the discovery by Puységur of the state of “magnetic sleep”, now known as hypnosis.

Moritz Benedikt (1835-1920) in the late 19th Century was already able to explain how symptoms like hysteria was cured with revelation of a pathogenic secret in the individual’s “second life” and thus “inner life”.

Freud’s Psychoanalysis  and Psychotherapy Today

Freud’s earliest publications illustrate the curative process of revealing of innermost difficult-to-bear secret to a trustworthy professional in a therapeutic dialogue, or “talking cure”.  In psychotherapy, this pathogenic secret is something in the unconscious that is revealed in the course of therapy. This revelation is the curative change that occurs in therapy.

With the further development of psychoanalysis, the concept of the pathogenic secret became gradually absorbed into the wider frame of reference of traumatic reminiscences and of repression, and later in the concept of neurotic guilt feelings.

Psychotherapy Law of Confidentiality

It is law in Europe that psychotherapists are committed to confidentiality in their work with clients. This means that whatever the client tells his/her therapist is bounded to confidentiality. The therapist has duty and also the right to maintain this secrecy. The therapist cannot be forced or tricked by anybody– regardless of power or authority– to reveal information given to him/her by his/her client.

This professional code of conduct (in German) for psychotherapists in Austria can be downloaded here:  Berufskodex für Psychotherapeutinnen und Psychotherapeuten

The only consideration to break confidentiality is when  it concerns the welfare of children and if lives are at risk. Even so, the therapist would consult their counsel of psychotherapists for advice and support.

Being trained in Austria, I am not sure at this point if this rule is applicable to other parts of the world. However, in this article, I would like to highlight the importance of confidentiality for the effectiveness of psychotherapy itself. The wish is that there is a worldwide recognition of the special role of psychotherapy as a profession, and respect for the autonomy of psychotherapists in keeping confidential the material obtained from their clients. As a therapist in Austria, I am committed by the license and by the law to keep all information of my clients secure. Documents are locked up, and information are encrypted so that no client information is compromised. When doing research or case studies, the information that is provided is altered in such a way that no person can be remotely identified in the work. All this is monitored by ethics commissions and peer groups.

This code of the psychotherapeutic profession, it’s protection by law of the therapists and clients, in countries like Austria, creates an environment safe for people to use psychotherapy as a means of healing.

Bibliography

Ellenberger, H. F. (1966). The pathogenic secret and its therapeutics. Journal of the History of the Behavioral Sciences2(1), 29-42.