Bob and Rita Resnick: Gestalt Couples Therapy

In this video, we learn what couples therapy can look like, what gestalt couples therapy is focussed on. Here is an interview with the Resnicks on their perspective on couples therapy in the psychotherapeutic practice.

Couples Therapy Films – with Rita F. Resnick, Ph.D. and Robert W. Resnick, Ph.D. from GATLA Videos on Vimeo.

Experiential psychotherapy sessions bring lasting effect

I mentioned in the first page of my website that clients can expect motivating, fun and experiential psychotherapy sessions. While it is for most clients the road to therapy is wrought with painful experiences and difficulties, being in therapy is about learning. The learning one gets from gestalt psychotherapy is not the kind of cognitive learning one expects to get at school. Rather, in experiential sessions, one learns procedurally. The experiments and role playing enables the clients to embody new ways of being. This kind of learning takes no effort. This kind of learning is integrated and permanent. The road to this kind of learning is also playful, touching and motivating.

What do Gestalt Therapists do?

Gestalt therapy is an effective an efficacious form of psychotherapy (Roubal, 2016). Gestalt psychotherapy is practiced by certified psychotherapists trained and supervised in the modality. Anyone who is interested in having gestalt therapy as a treatment for psychological and psycho-somatic stress or pain, or for the treatment of systemic issues regarding relationships in families or organizations, should seek a gestalt therapist who is actually trained and licensed as one.

Gestalt therapy is often described as a humanistic and holistic form of therapy. What this means, is that when a client comes to a gestalt therapist, he/she can expect to be met with a trained person who has been treated with gestalt therapy him/herself.  Here I emphasize the person as an instrument of treatment, as opposed to other instruments like medication, techniques, advise or exercises.

Established gestalt therapists have identified observable behaviors  that one can expect of gestalt therapists at work. This is documented within the gestalt therapy fidelity scale, or GTFS (Fogarty et al., 2016).

So, what do Gestalt therapists really do in the session? 

Developing awareness.  It is said that “knowledge is power”.  Awareness, however, takes the client way beyond empowerment. It leads towards self-agency and healing. When a client approaches therapy, he/she is really looking for healing answers. This knowledge is given to the client through newly acquired self-awareness. Gestalt therapy acknowledges awareness as encompassing 1) inner emotions feelings, 2) behavior, speech and actions, and 3) thoughts, judgements,  beliefs.  Developing awareness is not what the therapist does per se. Its intent is, however, central to the work.

Working relationally.   Clients usually come for therapy with a target complaint. This complaint is very valid to the goal of the therapy. It is not unlike going to the doctor with a health complaint. Gestalt therapists, however, handle the complaint differently from doctors.  The therapist pays attention to the client’s interaction with the therapist in the session and the therapist pays attention to his/her own resonance with the client in the session. The therapist has no pre-determined agenda. For example, a client comes in with complaints of insomnia.  The therapist focusses on the client interaction with the therapist in the session. There is no judgement on part of the therapist. She allows the client to freely express himself. She pays attention to the differences between them. She notices how the client talks quickly with flat affect. She notices also how she feels “heavy in the head” as the client speaks. Giving attention to this dialogical interaction, the therapist and client gain awareness of the client’s mode of being in the world. The client learns of the psychological burdens that keeps him up at night.

Working in the here and now. The therapist asks the client about his immediate experience. If the client mentions a disappointing day at work, the therapist would notice his facial expressions and tone of voice as he recounts his experiences.

Phenomenological practice. The therapist would bring these feelings to awareness of the present moment, thereby helping the client to describe and deepen his sense of theses experiences and gain better understanding of the presenting issue.

Working with embodied awareness. The client is encouraged to observe his emotions and bodily sensations.  The therapist may notice the client’s shallow breathing, for example, and mention it.  Through this deep embodied understanding the client is encouraged to try new movements. He realizes that he has choices. 

Observance of the resonance in the relationship. The therapist is sensitive to the context in which the dialogue takes shape. Themes emerge. Emotions emerge. The therapist shares with the client her experience of what emerges. The client is empowered, with this awareness which is otherwise unconscious to him.  He is provided with the new learning of his role in his past, present and future relationships.

Working with client’s mode of relating. The therapist acknowledges the client’s relationship pattern as these emerge during the session. In gestalt therapy, both therapist and client co-create the space in which they reside. They explore how they impact each other in the relationship.

Adopting a spirit of experimentation. Like in a kaleidoscope, small changes in movements lead to complete change in form of the pattern. The therapy session is like a crucible of life. The client is encouraged to experiment with new ways of being: simple moves within a session like a movement of the hand or uttering a sentence to somebody on an empty chair. The therapist supports the client with these experiments. They explore ways in which he can integrate these experiences in the world outside the therapy session.

The client leaves therapy with new awareness and is armed with choice. In the case of the client who has had insomnia, work with a therapist in the gestalt modality can be effective. The client works on his self as a whole, rather than only with his sleeping problems. The client is not his illness. He is a person who has feelings and relationships. Working on his self-awareness, the client gains agency over himself. In therapy, he experiments with ways of being. He finds answers to questions that affect his life. He gains better understanding of his past, present and future. He gains self-compassion. He learns to let his body rest at night.

Bibliography

Fogarty, M., Bhar, S., Theiler, S., & O’Shea, L. (2016). What do Gestalt therapists do in the clinic? The expert consensus. British Gestalt Journal25(1), 32-41.

Roubal, J. (Ed.). (2016). Towards a research tradition in Gestalt therapy. Cambridge Scholars Publishing.

Contact for gestalt therapy in Singapore or recommendations internationally

Why body-awareness is integral to the psychotherapeutic process

Psychotherapy is healing through the psyche. What is the psyche really? Does it reside in the brain? Not only. However, if it were so, then what is the brain? The brain is an inseparable part of the body. The body is the brain and everything material about a living person. The psyche is affected by the environment in which the individual is exposed to. The body responds and reacts to the environment throughout the life of the person. The environment is the external part of the body. The environment includes the physical as well as the social aspects of the person’s life. Psychotherapeutic practice that integrates work with the body is holistic. Not all psychotherapists work with the body. Those who do, work on the premise that the route to emotional and mental well-being is body-awareness and care.

What are emotions for?

Emotions are actual physiological reactions that tell us how to behave and react to the environment presented to us. Emotions are triggered by our body’s interaction to the present in the environment. Emotions can also be triggered from our imagination, dreams and fantasies. Emotions are necessary for us to live and thrive in our social and physical environment.

Emotions are felt in the body.

When we get anxious, we feel our heart racing and our skin sweating. When angry, we feel heat. When ashamed, we get red in the face. Whether or not we acknowledge these emotions in our minds, the body feels these emotions. People who are not in touch with their emotions often actually do have feelings. They simply “think” that these feelings are not present. Not feeling emotions is a way of protecting oneself from being emotionally hurt and weakened. Just because the mind is not able to acknowledge the emotions, it does not mean that the emotions are not felt. People stop themselves from feeling emotions through actions like tensing muscles, shallow breathing, numbing the sensory organs or storing/losing fat.

A study by Nummenmaa et.al (2014), provides us with interesting graphics of body maps related to different human emotions. About 700 participants were asked to color outlines of bodies in such a way as to describe how their bodies feel in response to stimuli that evoke particular emotions. They were asked to color the bodily regions whose activity they felt increasing or decreasing while viewing each stimulus. The results are represented in this the graphic below. Bright yellow shows high activation, while blue to green shows deactivation of the part of the body when the emotion is perceived.

Bodily topography of basic (Upper) and nonbasic (Lower) emotions associated with words. The body maps show regions whose activation increased (warm colors) or decreased (cool colors) when feeling each emotion.

In psychotherapy, emotions are not only acknowledged as mental states, but also as physical states. The work oscillate between talking and listening to the narratives, feeling the sensations in the body, and identifying the emotions underlying. We work to integrate these different aspects of emotional perception. I sometime describe this as defragmentation; to bring disconnected parts back into an understandable whole. This works for all symptoms presented and especially well for clients who are surviving trauma.

Integrating the feelings in the body with the emotions and then the thoughts that accompany these sensations are integral to the psychotherapeutic work. In my practice, the emotion-body awareness link is worked on at the beginning of the client’s therapeutic journey. New clients, especially, need assurance that this process is effective.

Bibliography

Nummenmaa, L., Glerean, E., Hari, R., & Hietanen, J. K. (2014). Bodily maps of emotions. Proceedings of the National Academy of Sciences111(2), 646-651. https://www.pnas.org/content/111/2/646

Let this video of an impala being rescued teach us about trauma and trauma treatment in psychotherapy

I watched this video about an amazing rescue of an impala, and cannot help but feel a tremendous sense of wonder for the nature of the nervous system.

This video shows us an animal’s natural response to a traumatic event, being stuck in a situation which is life threatening. Then it comes across rescuers who saved its life.

How is this connected to trauma treatment?

Well, if we observe carefully the behavior of the impala, we may be able to learn something very valuable about treating post-traumatic stress disorder and complex trauma in humans. Let’s take this video as a metaphor: the impala as the client who seeks the help of a professional, the rescuers. The impala is not aware of its traumatic situation. It only knows that it wants to get out of being trapped. Clients too come to therapy seeking help to get out of a “stuck” situation. They have often little awareness of the big picture. In therapy, the therapist and client find out together what the big picture looks like.

When clients come to therapy, there is anxiety. Just like in the video, as the rescuers approach the impala. It becomes more afraid. Client’s wonder, “Can he/she help me?”,” Will I be hurt by this person?”,”Is therapy a waste of my resources?” “What is he/she doing?” “Is he/she judging me?” etc.

The therapist is there for the client exclusively. In the video, the rescuers genuinely want to save the impala. Hence, it is really important that the therapist is there, in the session, only for the client. Realistically, this can only be possible with therapists who genuinely love the work and who are adequately remunerated for it. Reasons why professionals in the helping professions burn out and become ineffective can be attributed to this point: giving is a two-way process, and overt charity is neither kind nor sustainable.

The therapist’s empathy. A genuinely present therapist will put in the effort and strength to be with the client; just like the man who would put his body in the mud for the impala. The therapist would experience what the client is going through. This is how we can understand empathy.

Therapists also need other therapists to support them. That is why we attend workshops, therapy, supervision and inter-vision. In the video, the rescuer does not work alone. When he is stuck in the mud with the animal while his friends are there with the rope to help to pull him out when the need exists.

A part of therapeutic treatment is about doing nothing together. This is a recovery phase for both therapist and client. When the rescuers finally manage to pull the impala onto safe ground, they take time to be with the animal and to give it some comfort by washing it. We can see in the video that the body of the impala is really still at this point.

The stillness seen in the animal’s body is not merely calmness. It is possibly a somatic response to a highly frightening situation. The body shuts down. It fatigues. The work is far from over. Trauma-focussed therapist will not overlook this. Human clients in this state have varied symptom: of being depressed or numb, get panic attacks, lack focus, forget things, feel the need to throw up or cut themselves, feel like they are dying, lose their sense of reality (…the list goes on). The client needs then to physically recover. For this to happen, he/she needs the support of the therapist. In the video, this process seems natural and smooth for the impala. The rescuers pat the animal on its back, pulls it up and encourages it to get up and go. This is the act of bringing the beast back to its senses. The animal gets on its feet, trembles, pants and bolts.

In human beings, this process often does not happen so smoothly. Steven Porges explains why this is so with the polyvagal theory.

Treating clients at this phase involves a sometimes a long-drawn and difficult process of working through the client’s very difficult feelings despair, fear, guilt, grief plus the bodily reactions accompanying it. Human beings are afraid of these reactions in themselves. Such reactions are somatic, and may include panting, trembling, screaming, hitting or pushing, bolting, crying, and sometimes throwing up. We try, most of the time, to allow this energy to come out in tiny steps. Peter Levine calls it “titration”.

Therapists would also encourage clients to do body-focussed activities like yoga, weight-training, dancing or tai-chi to get more in touch with their bodily sensations.

Trauma-focussed therapy, for whom?

The animal, stuck, finds itself in a panicked state. It’s muscles tense and it tries to fight its way out of the situation. Being really stuck in the mud, all its efforts fail. Its body fatigues. Looking at us human beings, when we find ourselves in a threatening situation, our first impulse is to flee or fight back. In events that cause trauma, this instinct to fight or flee does not lead us anywhere. These traumatic events trap its victims. There is a sense of impending death. Such events can often occur in childhood, as victims of child abuse and neglect are trapped in a life of a child; helpless, vulnerable and dependent on its caregivers. This existence can go on for years.

Many clients come for therapy without the awareness that they are survivors of trauma. As adults, they come to therapy because they encounter symptoms like, depression, suicidality, anxiety, compulsive behavior, rages, emotional dysregulation, feeling numb, fatigued, loss of memory, relationship problems, eating disorders (…the list goes on). These symptoms are now known to be likely somatic reactions to past trauma. Trauma-orientated therapists will pick up on this.

Medication to treat trauma?

Medication stabilizes the body, but it unfortunately does not help the client work through the source of the problem. Medicine does not empower the client with awareness of the self. It does not lead the client towards self-agency. Meds lose their effectiveness with time, when the body adjusts to the chemicals through homeostasis. Imagine the rescuers in the video giving the animal meds, and not doing anything else. The animal will no longer be in distress. It would simply live trapped until it dies.

Conclusion

I hope this article enlightens you the reader on what psychotherapy can look like, and how your symptoms can be perceived and treated.

Psychotherapy, especially therapy that is humanistic, relational and is focussed on empathy, is a great profession because it opens doors for the possibility of healing from the otherwise life-sentence of trauma.

Obesity in adults and its possible link to experiences of childhood abuse

I was researching material on this topic of adult body weight and obesity and its link to adverse childhood experiences, in effort to support my my work with a couple of female clients who have come for therapy to work on their struggles with obesity. These clients are highly functioning individuals, and are relatively successful in life. They are baffled at how they aren’t able to take charge of their eating habits.

A usual practice I follow is to first send the clients for medical examination to exclude extra-ordinary physiological illnesses.

The study below shown as screenshot by Williamson et.al. is just one example of many linking adult obesity to experiences of childhood trauma.

CONCLUSIONS to the study: “Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.”

Binge eating and other addictive behaviors around food have a protective function for the individual. Patients do this to brace themselves against emotional hardships. This behavior actually keeps them stable and functional. It is therefore fully understandable that the eating behavior is borne out of a real need. In adult survivors of childhood trauma, the impulse to eat uncontrollably stems from the need to regulate the nervous system which has been dysregulated by the experiencing of traumatic events.

A client reported that her trigger to binge eat happens the moment she gets home. When she enters the door of her apartment, she’d feel a frantic need to eat whatever is available in the refrigerator, and very quickly. Then she would not stop eating until her stomach starts to hurt. Following that, she’d feel a sense of calmness and guilt. This client has had a childhood history of feeling unsafe in the home. Her father was alcoholic, and her mother was verbally and physically abusive to my client and her siblings. As a child, the act of returning home from school filled her with need for comfort and a dread. This conflict of feelings, she says, returns to her body every time she returns home after a hard days work.

It is possible that one or more of the other clients who come to my office for weight management coaching may be survivors of childhood trauma. I would check with the clients first if they want to explore this. If they do, then the coaching sessions will have to be converted to trauma-focused psychotherapy. Whether or not change the focus of the session is entirely the choice of the client. The client will first have to provide us with informed consent.

Bibliography

Williamson, D. F., Thompson, T. J., Anda, R. F., Dietz, W. H., & Felitti, V. (2002). Body weight and obesity in adults and self-reported abuse in childhood. International journal of obesity26(8), 1075.

Petzold: Short Definitions of Relatedness in Relationship

Relationship

The relationship is an encounter sustained in the long term, a chain of encounters that includes a shared perspective of a shared history and shared present, because there is a free will to live life together in a reliable relationship.

Relationship presupposes the ability to demarcation and touch, conflict and compromise, mutual empathy and shared reality. Relationships are intentional, lasting and reliable. They include the ability to contact and meet.

Encounter

The encounter is a reciprocal empathic meeting of different persons in the here-and-now. The meeting in which there is contact, results in an inter-subjective an exchange, that is healing.

Contact

Contact is described as a meeting of separate and concretely different individuals. The perception and bodily experiences of the person and the environment are separate. The person is able to distinguish the difference between the inner and outer world, and is able to establish, through contact, identity.

Confluence

Confluence is a form of human co-existence that is unrestricted. It is characteristic of the coexistence of the embryo and its mother.
There is no differentiation in perception of the individual persons in a confluent relationship. In adults, the fusion experiences can be that of the positive pleasurable or negative non-pleasurable kind (Petzold 1993, Volume III, p. 1066).

Attachment / Bonding

Attachment is the result of the decision to restrict ones freedom in favor of a freely chosen bonding. To endow an existing relationship with the quality of inviolability through loyalty, devotion, and willingness to suffer .

Dependency

Dependence is a bondage at the expense of personal freedom, which is structurally predefined as a natural “attachment” in children, or it is attachment-based socially meaningful behavior, for example, in the case of adults in need of care in the immediate vicinity of social relationships and networks. But it can also have pathological qualities such as neurotic dependencies, addiction-specific co-dependencies, collusions.

Bondage

Bondage involves massive, pathological dependence still exceeding qualities, because fundamental rights and rights violating restrictions of freedom, mental and real deprivation of liberty, when the enslavement occurs (often on a sexual level in pimp prostitution, sadomasochistic dependencies or on an economic basis in debt slavery, blackmail, etc.).

Source

Renz, H., & Petzold, H. G. (2006). Therapeutische Beziehungen–Formen „differentieller Relationalität “in der integrativen und psychodynamisch-konflikttherapeutischen Behandlung von Suchtkranken. Bei www.​ FPI-Publikationen.​ de/​ materialien.​ htm–POLYLOGE: Materialien aus der Europäischen Akademie für Psychosoziale Gesundheit13, 2006.

Endings: Termination of therapy

Psychotherapy is a life-long, ongoing process for the client. The client feels the effect of therapy long after the sessions are over. It is a fact, that at some point, the therapist and client will part ways. Notwithstanding sudden disability or death of either party, the process of termination is a very important part of the client’s therapy.

Norcross, in the interview below, explains the process succinctly. Like him, I would consider termination a form of “graduation” for both therapist and client. The client attains new learnings about the self, and the therapist achieves an abundance of professional knowledge.

Norcross state the following steps for good termination:

  1. Proper preparation for termination.
  2. Reflection on the gains and consolidation of the gains.
  3. Processing of feelings about the therapists and client.
  4. Discussion on future functioning .
  5. Generalization of skills, etc. achieved.
  6. Anticipation of future growth.

 

Norcross reminds us that termination may not mean ending of the relationship. In fact the therapeutic relationship does not change. Termination or graduation means that a phase of the work is ended. It is not uncommon for clients to resume therapy with the same therapist when they reach a new phase, and when they feel that they need to reconnect with the previous therapist.

My experience is that when time is allowed for the process of termination, the process goes more in-depth. As a consequence, the client gains far more insight from the consolidation of learnings, and is able to take home a valuable resource that lasts a lifetime.

Is psychotherapy for me?

Ask yourself these questions to decide if you need psychotherapy.

This article is for the people have landed on this site looking for psychotherapy, and are wondering if psychotherapy is what they need right now.

Here are some questions (in no particular order) to ask yourselves. If one or more of your answers is a “yes”, it is probably a good idea for you to speak to a psychotherapist.

  • Your doctor / psychiatrist / teacher or other professional advises you to get therapy.
  • Your loved ones encourage you to seek therapy.
  • You are looking for answers about your inner experience.
  • You are experiencing a difficult milestone in your life: leaving home, getting married or divorced, having a child, being diagnosed with illness, migration, etc.
  • You find yourself in a difficult or abusive relationship at home or at work.
  • You experience physical reactions that you cannot understand: like panic attacks, crying attacks, rage.
  • You are having thoughts that are churning in your mind.
  • You suffer anxiety: social anxiety, phobias, paranoias.
  • You’re not sleeping well: not able to get to sleep, waking up in the middle of the night and not getting back to sleep, not able to wake up, sleeping all day, having nightmares.
  • You have an overwhelming feeling helplessness.
  • You have an overwhelming feeling of guilt. You blame yourself for many things.
  • You harm yourself physically.
  • You have suicidal thoughts and/or plans.
  • You are addicted to substance.
  • You are addicted to a behavior: working, shopping, internet use, porn, sex.
  • You are on antidepressants, anxiolytics or antipsychotic medication, and are thinking of reducing these.
  • You obsess over certain activities. These activities preoccupy your life, affecting your work, and family life– like work, sports, collecting certain things, hoarding things.
  • You have problems eating: obsessive thoughts about eating or not eating, bingeing, throwing up after eating, thoughts of starving yourself, feeling anxious around food, not able to enjoy food or the eating process.
  • You have issues having sex.
  • You suffer pain and aches that your doctors cannot find physical cause of.
  • You are having problems working or studying, and feel like you’re about to burnout.
  • You are socially isolated and / or feel very lonely.
  • You have lost a parent / family member or two for over a year and have not got over the loss.
  • You had had difficult childhood experience of abuse, neglect or abandonment.
  • You have been sexually abused in your life, and have not worked through this experience with anyone.
  • You have difficulty remembering parts of you childhood, and you suspect trauma.
  • You’ve encountered a traumatic event that was threatening to your life or the life of someone else.
  • You cannot feel or identify your emotions.
  • You see, hear of feel things that are not there.
  • You or a loved one suffer chronic physical ailments or disability.
  • You or a loved one have been diagnosed with terminal ailment.
  • Your children are suffering from poor grades, ADHD, stress or are suicidal.

This is not a comprehensive list, although it does cover issues that I deal with in the psychotherapy practice.

How a therapist can tell the progress of the patient

Psychotherapeutic change is observable. Noticing the progress of the client is an important aspect of therapy.

An important aspect in the work of the therapist, is to track patient progress. In my practice, even if I do not mention to the patient, I look for signs at every session.

The healing process in psychotherapy is often a subtle one. Meeting the patient every week, it is possible for the therapist to overlook these changes. Therefore, I give special attention to looking out for the signs.

Importance of looking out for the patient’s progress and change during therapy sessions

It is important for the therapist to be alert to change. Patients are normally oblivious to the subtle changes in their own personality. Left on their own, individuals may start doubting their new sense of being (due to persistent introjects / resistances).

Noticing the client’s change and progress is helpful to him/her. The therapist, in bringing attention to the development of the patient, helps the patient to integrate fully with this new attitude or behavior, through:

  • acknowledgement of the perceived change,
  • appreciation of how the change is impacting the life of the client,
  • understanding of how the change is developing and meaning making,
  • assimilation of the experience, i.e. how it feels to exist with this change.

Some signs of change observable in the patient during the course of therapy.

There are many signs of change. Here is a brief description.

  • Change in how the patient makes eye contact, makes facial expressions.
  • Change in posture, dressing, hairstyle — not the usual change of styling, but when the client comes in, and his/her aura feels different.
  • Change in topics brought up in session — most individuals bring up a kind of focus topic (like work or kids…). I’d notice a change when the topic is suddenly no longer interesting to talk about, or when another becomes figural. Generally, when the topic becomes more about the experiences of the self, it is progress.
  • Change in the client’s emotional vocabulary.
  • Client’s own account of perceiving new feelings or losing anxiety . Especially after holidays, the client reports that certain old feelings of anxiety around the festive season is no longer felt.
  • Client making new decisions. This applies to clients who have difficulty doing so.
  • Client reducing medication (esp, meds that have been long time prescribed), or reports having alleviated physical symptoms.
  • Client reports that children / spouse, etc are “doing better” (usually relationshipwise).

Note that these changes may not mean that the goal of therapy is reached. Change indicates that the therapy is in progress, and the patient can look forward to more enrichment from the sessions.