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. 

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.

Gestalt Therapy is about Action and not Simply Talk

If the process of psychoanalysis, as defined by Freud’s Anna O., defined as a “talking cure” (Breuer & Freud, 1893/2009), what about Gestalt therapy?

The curative process of Gestalt therapy is action. Polster and Polster (1974, p.233-284) devote a an entire chapter on their book to the concept of “experimentation” as a therapeutic process. During a gestalt therapy session, the client is encouraged to try out new behaviors, and stay with feelings which he/she would otherwise not dare to (or is not allowed to confront) in daily life.

More than just a “talking cure”, gestalt therapy is like a “doing cure”.  The client talks, but his/her talk is not merely a narration or a “talking about” something. Polster and polster uses the term “aboutism” to describe narration without feeling or action.

“Gestalt therapy tries to restore the connection between aboutism and action. By integrating action into the person’s decision-making process, he is pried loose from the stultifying influence of his aboutist ruminations. (p.234)”

The client has a something to say. The therapist encourages the client to put this narrative into action. The above quote gives us also a sense of how gestalt therapy actually releases a person of a key symptom of depression and anxiety — rumination (Nolen-Hoeksema, 2000). Rumination is experienced as having obsessive circulating thoughts.

By encouraging the client to put talk into action, his/her ruminating thoughts gets translated into physical acts of doing.  These thoughts no longer get trapped in cognition. As the client acts out thoughts he/she experiences some control of these ruminations. The most likely thing to happen in the process is the out pouring of emotion.

Dialogue is Action

Dialogue is talk in action. Every psychotherapeutic dialogue has the potential of being curative, provided that it encourages the client to move away from the cognitive aspect of the talk — i.e. aboutism or talking about– towards acting and feeling the talk.

How can the gestalt therapist put talk further into action?

Through experimentation.

To be experimental is to constantly ask the questions, “what if…” or “what would happen if…” . What if you had the chance to say __ to your mother? What if your father were in this room now? What would happen if you tapped you hands quicker? … etc.

Each action is dealt with in the here-and-now. The follow-up questions would sound like, “what is happening now?”, “where are you at the moment?” “what comes to mind at this moment?”

The therapist is also part of the experiment. When the therapist is able to share his/her own experience at the moment, it can help the client better experience the phenomenon taking place.

Hycner (2009) aptly considers a gestalt therapy session a crucible, a small, self-contained space in which the client gets to experience new ways of being in the world.  A crucible is what is used in experimental chemistry.

 

Bibliography

Breuer, J., & Freud, S. (1893/2009). Studies on hysteria. Hachette UK.

Hycner, R. (2009). Relational Approaches in Gestalt Therapy. NY: Gestalt Press.

Polster, E., & Polster, M. (1974). Gestalt therapy integrated: Contours of theory and practice (Vol. 6). Vintage.

Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511.

 

Levels of Gestalt Therapy Treatment Methods

A client who has just started therapy will experience different kind of session as a client who has been with the therapist for a longer period of time. Similarly, clients who experience psychosis would benefit from different style of therapy than clients who have issues based on neurosis. Then there are clients who seek therapy because they are facing really difficult existential issues in their lives. Their therapy would be experienced differently.

Gestalt therapy is known for its multi-variant techniques. However, what is seen as techniques is not Gestalt therapy. Gestalt therapy is the principles that lie under these techniques, within the dialogue between patient and therapists.

Different people, different needs at different times.

Level 1: Being present for the Client

The basis of all good therapy work is work with empathy, listening and validating. Being present, attentive, authentic and connecting with the client and inviting the client to be in contact. Contact work as such is healing, as it works towards reducing anxiety and loneliness that comes with it. Being present is really about the therapist putting aside prejudices, need to help, self-evaluation, analyzing the client or giving advise.  This is very important fundamental attitude for therapists in the session. It is also the most challenging.

This is also the only way to help clients who are psychologically very fragile and fragmented heal.

Irvin Yalom, in his biography, talks about one of his first clients, Sarah B., the wife of a business tycoon who suffered catatonic schizophrenia, who existed in a frozen state, not able to react to stimuli. Being a new in the profession, he was at a loss for what to do. He decided, during his rounds at the hospital ward, to converse with his non-reacting patient. He spent these 15 or so minutes talking to her about his day, the headlines etc. It was not till new neuroleptics came to existence did Sarah B. was able to move again. When she came around, the author mentioned to her of his multitude of doubts that he was of help to her in all those hours. She answered, “but Dr. Yalom, you were my bread and butter.”

Level 2: Phenomenology and Body Awareness

As the therapy progresses, and depending on the client, more work is done on the awareness of the body. This is not bodywork, but the momentarily focus on tension in the muscles and breathing. This is done in a dialogical way.

The more stable client would get sessions that looks like a play of being present. Looking at the phenomenon of the moment. What is going on, how the interaction feels like in the moment. What comes to mind now, etc. is discussed.

Level 3: Use of Creative Media

The use of creative medium, like art and music is useful at this stage for self reflection and sharing one’s internal structure with the therapist.

Further into the course of therapy, the client gets to work on relationships intra-psychic and external. Gestalt therapy is known for it’s two-chair work.

Level 4: Confrontation and Frustration

Very stable, self-sustaining clients who need therapy for self-awareness, who already have months or years of sessions with the therapist, may appreciate the challenge  that involves frustration of resistances, etc. This is done with all the first three levels intact. Gestalt therapy is never without level 1 !

What is being “frustrated” is the clients tendency to deprive him/herself of his/her need. For example, a client feels loneliness and longs to ask a lady for a date. He  is, however, so fearful of being rejected that he keeps to himself rather than calling her. The therapeutic frustration here is the confrontation of his fear of rejection.

At the end of the day, empathy is the most important aspect of therapy. 

Most therapy with clients do not reach the confrontative stage, and most sessions of gestalt therapy do not involve empty chair work. All clients at all stages of therapy are served best at the first level. It is also the most challenging part of the work.

Integrating Kernberg’s Model of Personality Organization with Gestalt Therapy

Kernberg’s model of personality organization provides us with a helpful visual of how differently experienced psychological symptoms relate with each other. Symptoms of personality disorder are very individual and unique each client. The “severity” of the symptom is phenomena “felt” by other people in the community and the therapist. It is therefore more accurate to base our assessment of the client’s problems on the effect the client’s behavior has on others and therapist, and based on how fixated the client is on this behavioral pattern. It is assumed that the more fixated one is on a mode of behavior, the less one is able to function socially and economically.

Kernberg established 3 main group of personality organization. These are arranged in increasing order of “severity”: 1. the Neurotic Personality Organization (NPO), 2. The Borderline Personality Organization (BPO), and 3. the Psychotic Personality Organization (PPO).

Horizontally, Kernberg also categorizes the symptoms as a spectrum of introvertion and extrovertion. This describes how much the individual with such diagnosis interacts with the other. The more introverted would keep the self in isolation. This would range from shyness to complete fear of being with others (as in severe paranoid PD / schizoid PD). The extrovert range would range from being dependent on the presence of others ( as with the dependent PD) to victimizing others (as in malignant narcissism PD or antisocial PD).

Most severe condition is the psychotic condition.

Kernberg (2008) Model of Personality Organization

When we connect this with Melanie Klien’s (Kernberg is a Kleinian) model, we can see that the BPO represents the condition where an individual is stuck at the paranoid-schizoid phase. The NPO represents the individuals who have developed into the depressive phase. *Note* that the terminology here is very confusing, because “paranoid-schizoid” and “depressive” used in this context has not much to do with the absolute meaning, but rather serves to describe a phase.  Please refer to this article for clarification on this topic.

When we consider Kernberg’s diagram, we may be able to appreciate how if the individual is fixed to the BPO, he/she may be holding on to maintain an intact sense of self. The consequence of not having the symptoms may lead to breakdown and possibly psychosis. As therapists, we must be very aware of this “ability” of the client to support him/herself in this way, even though his/her behavior is hurtful/harmful/not helping. 

The Contact Cycle in Gestalt Therapy

In Gestalt therapy we talk about contact. Contact is a means of a organism (a person) getting in touch with his/her needs and being able to get his/her needs fulfilled. This is not unlike Marslow’s concept of the hierarchy of needs. Needs not met will end up in the individual being weakened or even harmed as a result of accumulated stress. A very simple example: if a person’s body is lacking in nutrients, the person needs food. If he does not get this food, he suffers. Needs are always present. We have to be able to first realize the needs. In Gestalt therapy, the work of the therapist, for example, is to help the client uncover his needs of the moment, how he denies his needs by numbing himself from the sensation of the need, how he attributes the needs to someone else by projecting the needs and how he is not able to feel satisfied once the need is met.

Below is my sketch of the contact cycle in gestalt therapy. It is complicated, but there are simpler diagrams on the net or in books.

When the need is recognized, acted upon and assimilated, the gestalt is closed. The client is relieved of a stressful condition (that may have pervaded his life).

Shame at the Pre-contact Phase: When we look at the contact cycle, we can see that the hinderance to pre-contact is desensitization. The client does not know about this need. Oftentimes this is attributed to shame: when it is too shameful to even tell oneself that one has this need. Many people do not feel shame also for this reason. They anesthetize themselves from the sensation.

Anxiety at the Action Phase: The next part of the cycle is when one feels a need but acts inappropriately so as not to be able to fulfill the need. This is a miss-action normally caused by projecting what one feels or needs to others. For example when one is completely angry at another, he/she instead thinks that the other is hostile. Oftentimes the projection is brought about by anxiety or a dreaded fear of acting accordingly, but instead act by splitting this action from the self onto the environment.

Guilt at the Assimilation Phase: At the end of the phase, problems arise when the person is not able to assimilate what he/she has felt and done. This is probably the problem with overeating (this a simple example): the person is hungry, eats, but cannot feel nourished. In the realm of personality disorder, it is often the problem of the individual not being able to recognized his deeds, and avoids the feeling by not being able to feel a sensation of satisfaction (lustfulness). There would be continued hunger for whatever the need may be.  In serious cases (perhaps antisocial PD) if one has committed a crime, one is not able to sense guilt or remorse.

Gestalt Therapy and Kernberg’s Personality Model

In the figure below, I try to fit the 2 models together. This is of course, like all models and classifications, a way of conceptualizing, and not fixed truism. One would be well served to look at all graphical representation of psychic phenomena as as spectrum rather than as in discreet boxes and lines.

Personalities “stuck” in the avoidance of guilt end of the contact cycle, for example is caricaturized by the cold-blooded malignant narcissist or sociopath. When we look closely at all other personality fixations we can also see avoidance of guilt. Ultimately, this is all related to context.

Connecting these concepts can be useful to the gestalt therapists who use the contact cycle as means of understanding the mental processes of the client. It also helps us to access what difficult emotions underlie the personality structure of the client. Work with personality disorder is extremely complex because it deals with contact, not only with the environment, but also with the therapist’s personality.

I hope this idea is useful.

Bibliography

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

Illustration: The Dialogical Self and Contact Cycle

Polster and Polster (1973, p. 176) in their book Gestalt therapy integrated explains the syntax of the contact episode as moving through eight stages:

  1. the emergence of a need;
  2. the attempt to play out the need;
  3. the mobilization of the internal struggle;
  4. statement of theme incorporating the need and the resistance;
  5. the arrival at the impasse;
  6. the climatic experience;
  7. the illumination;
  8. the acknowledgment.

This cycle may last for only a minute, or it may play out for months and years. When the circle is not complete, there exists an incomplete gestalt, or unfinished business. In therapy the client is supported to complete pressing needs that are open. The closure of the cycle can bring about catharsis.

This sketch describes the dialogical self in contact with the environment and the resistances that denies the self from experiencing the environment, thus denying the needs of the self. Included are also the introjects that arise from past traumatic experiences and creative adjustments that ensues when these resistances are in play.

Dissociation   is known to be another contact interruption strategy. The person who is dissociated avoids contact with the stimuli, by retreating in his/her mind. This is a strategy of children who feel trapped in a situation,  but it  can also be something we do, like daydreaming  while pretending to be attentive in school..

contact cycle, gestalt therapy
The dialogical self in Gestalt Therapy, Contact Cycle illustrated

Adapted from :
Clarkson, P., & Cavicchia, S. (2013). Gestalt counselling in action. Sage.

Fritz Perls: Quotes on Therapy in Groups

Fritz Perls on his work with groups:

“Basically I am doing a kind of individual therapy in a group setting, but it is not limited to this; very often a group happening happens to happen.”

group therapy

… on mind-fucking:

“Usually I interfere if the group happening comes merely to mind-fucking (…) ping-pong game, (…) opinion exchanges, interpretations, all that crap.”

to Perls, a group is wonderful if:

“If they are giving their experience, if they ae honest in their expression…”

Perls on helpfulness in groups:

“Often the group is very supportive, but if they are merely “helpful,” I cut them out. Helpers are con men, interfering.”

Basically, to Perls, the group should be a supportive place for people to share their experiences, and to take in each other’s experiences. Being helpful by giving advice, intellectualizing (or mind-fucking), is not being supportive, but actually blocks the other person from developing new means to deal with the world.

This snippet is cited from this book (introduction to dreamwork seminar):

Case Study: A Car Thief and his Parents

This case study can be found in the preface of the book, On Being Normal and Other Disorders by Paul Vergaehe.

This is a good example of how delinquent behavior can sometimes be a symptom of very understandable everyday circumstances. In this case, what we see as a behavioral problem in a teenager, has much to do with his family situation, and his personality development. 

The client is a 15 year old male who is in consultation for having been arrested for car theft.

Symptoms: The client steals only “Mercedes” cars. In the driver’s seat, he drives aimlessly around, then leaves the car in a particular part of the country. He leaves the cars unharmed. He then hitchhikes back home.

Diagnosis: The client is the only child, whose parents are undergoing marital crisis. The mother is from a privileged background, and the father is from working class background who worked himself up the social ladder. The parents fell in love with the other’s differences. Now they reproach each other for it. The father works himself to death and retreats from confrontation. The mother has found another lover. And somewhat coincidentally, the town where the client leaves the car, is where the mother was born and is where her name still holds prestige.

Comments:

From this case presentation, one can see that the symptom is not the isolated symptom of the client. This case displays the symptom of the family. The child has taken on the job of glueing the family together. When this looks like a hopeless scenario, he acts unconsciously in a symbolic way to communicate this his distress.From a psychoanalytic perspective one would say that his behavior provides an answer to the desire of the Other, that is, his parents, with the proviso, however, that the boy himself is not, or is only barely aware of it. “The unconscious is the discourse of the Other” (Lacan). Systemic theory would say that the boy shoulders the symptoms of his family. A cognitive behavioral approach would see his behavior as learned, which leads us to the following question: From whom does one learn what, and why? (p.5)

 

Gestalt Therapy Perspective on this Case-study

This are my comments using Gestalt therapy theory:

Gestalt therapy theory would say that the client exists and acts in a field.  This field encompasses the family — the family’s present, past and future combined– it includes also the society in which the client lives in, the client’s character development / education and influences.

In this case, the client has lost his self in this field, and is only able to cope in a reactive unconscious manner. This is an example of his creative adjustment to a situation that had gone out of hand for him. The client does things systematically with a certain degree of passion, but lost contact with his conscience and self-preservation instinct. i.e. he was doing something that potentially subjected himself (and others) to harm.

The therapy process is one that would have to deal with the client’s sense of who he is and defining his present needs. Gestalt therapy works in the here & now. The client is guided to experience his present existence, in order to experience his present needs. This is what was evidently “missing”, by studying his symptoms.

Psychoanalysis of the situation points to this: that the boy reacts unconsciously as a distress reaction to his parents’ potential separation. The client is, however, already 15 years old. In reality, the separation of the parents does not pose a life-threat to the patient, although this was the client’s experience when he was a dependent baby.

This situation describes the client’s dilemma: there is unfinished businesses (open gestalts) experienced by the client as a young child, that is not settled. It could be something like: “I am dependent on my parents/ it is dangerous to me if they separate…” What the story really is, has to be uncovered by the client during therapy.

The second part of the therapy has to involve experiencing the needs of the present, as mentioned earlier.

 

Whatever approach one takes, a common factor emerges: the diagnosis cannot be limited just to the boy. The impact of the Other is fundamental. This is the first major difference between medical diagnostics and psychodiagnostics: clinical psychodiagnostics cannot be restricted to the individual. Psychic identity, with its potential psychopathology and aberrant behaviors, must be conceived in such a way that it grants the other a place equally important as the individual’s. (p.5)

 

Bibiliography

Verhaeghe, P. (2008). On being normal and other disorders: A manual for clinical psychodiagnostics. Karnac Books. P. 4.

Gestalt Theory: 5 Phases of Therapeutic Change

This five phases of change is also termed as five levels of neurosis. Whatever the terminology, it describes a process by which a client goes through when lasting and cathartic change happens.

 

There are several terminologies for these phases, however for this article we shall use the terms:  Fixation, Differentiation, Diffusion, Vacuum (impasse) and Integration.

Phase 1: Fixation (Cliche Role-playing)

At this level what is noticed in the client is a stiffness, being stuck in ideas / conclusions / habits / patterns, feeling trapped, in other words desperation.  The reason for therapy usually describes this condition. The client is stuck in roles, routines that do not serve him. It causes stress and conflicts in his daily life. The client is often also not aware of this point of what he really needs, because these needs are forgotten or relegated to the unconscious. This feeling of “stuckness” in repeating patterns has become part of his way of life and he cannot imagine things being different. He is however affected negatively by it at the present time.

An example :

Mr D addresses his problem of having long term relationships with women. He says that after a while he gets bored with them and wants to move on. He feels empty and lonely, and expresses this to his therapist.

During therapy a picture of the stagnation in the client’s life is formed. There is now awareness about this. The client can decide if and how he would like to proceed.

Phase 2: Differentiation

With the experiencing of the needs (as in the above case), or the feelings of anxiety, avoidance impulses. The client’s attention to the present moment is distracted by memories of the past or hopes for the future. He escapes into chains of thought, ideas and gets into debates and intellectualization.

This roundabout thoughts and decision making is a sign of unfinished business, which the client cannot complete and there is too much anxiety / anxiety of pain involved for the client to face up to the unfinished situation.

At this point, the therapist’s work is to support the client to stay in the moment. Providing a secure environment to face the anxiety — to relive conflicts, the tension between what he/she needs, emotions, impulses to move forward and its resistance, the blockages to act.

When the client is able to see his polarities, he can come to terms with taking responsibility for which direction he decides to move towards.

Mr D’s talk with his therapist has led Mr D to the knowledge of himself– that he is able to share only superficial parts of himself to the other person. In turn, he gets to know only superficial parts of the other. This superficiality is colorless and gets boring very quickly. When this happens, his impulse is to leave the present relationship for another. 

Screen Shot 2017-11-08 at 11.12.09

Phase 3: Diffusion

This is a phase of acceptance. Acceptance of the Situation without avoidance of the issues. The existing situation is no longer working for the client, but alternatives are elusive to him/her. Usually when clients decide to have therapy, they are open to this phase. It is the phase of acceptance. The client accepts his/her responsibility for his/her situation, and realizes that he/she has the resource to work through the situation. This usually happens after an alliance with therapist is grounded.

Mr. D realizes that it is not that the girl(s) are boring, or that he is more interesting. He takes the viewpoint that since this is his experience with every relationship he faces (even non-romantic relationships), something in his way of connecting with others, has something to do with his own psychic defenses. 

Phase 4: Vacuum

At this stage, the client experiences confusion (not knowing how to react). It would be counter-productive at this phase for the therapist to step in and provide analysis of the situation– even if the answers are glaringly clear. The therapist is advised to wait, and allow the client to assimilate this rather uncomfortable phase. Any solutions-orientated premature direction provided by the therapist would compromise the clients’ healing process. Such intervention by the therapist could lead the client to be fixated on the opposite pole of the problem.

For example, the same client Mr D talks to the therapist who realizes that in their own relationship in the here-and-now, the client avoids deeper communication by answering with the words “”I don’t know” or “I feel bored”. The therapist may have the need to either ignore the “I don’t know” and thereby moving away from the stalemate, or the therapist may “unbore” the session by doing /saying something to fix the situation. This is an example of rescuing the client from the vacuum. 

The client will benefit more if he/she is allowed to endure this momentarily discomfort. Being in a vacuum does not last more than a couple of seconds. The client can be trusted to creatively adjust to the situation and find his/her own solutions. All he/she needs is support to stay in the vacuum long enough for movement to take place.

In this vacuum stage, the client experiences the push and pull of both poles of the problem. He/she feels “stuck in the middle”. The polarities surface from the background of his/her awareness and become clear to him/her.  Through this clarity, the client can make decisions to swing between the poles and not get unconsciously stuck at any extreme. There is freedom of choice.

Phase 5: Integration

A person who is able to stay in the momentary state of emptiness in a vacuum, in confusion, in not knowing which way to turn, eventually reaches an “ah-ha” moment. Fritz Perls (1976) mentions this in his writings often. The problem with us most of the time is that we are afraid of this vacuum. Almost always we bail out by finding solutions, distracting ourselves from the situation, forgetting, being clueless, or deadening our experiences.

In the therapy session, a safe environment is provided for the client to sit into the emptiness long enough to gain valuable “ah-ha” insight / understanding and experiences. The greatest difficulty is abstaining from intellectualizing, and making meaning of what’s going on while in this state of “stuckness”.  This requires the trust of client.

What usually happens is when the client is held by the therapist to stay in position of emptiness, the client does not use his/her old patterns of escaping the problems.  This is an opportunity for the client to reach into past unfinished experiences and experience the needs and feelings involved in these experiences. Here is where enlightenment is achieved.

Mr. D, in sitting with the therapist, and feeling bored, and needing to “flee” the encounter, realizes his anxiety of being seen. He recounts how as a child he was always doted upon by adults, and part of this attention brought also criticism of his emotions, usually negative emotions. He felt lots of expectations on him to be the happy child. 

This is a simple example of how integration of the past experiences to the present takes place. The client sees how his unease with connecting with another person is linked to how he lived as a child.

For the rest of the therapy sessions, Mr. D experiments with being authentic in the presence of the therapist. He is also encouraged to attend group therapy and work through interaction with a group.

Bibliography

Voitsmeier-Röhr, A., Wulf, R. (2017). GestalttherapieErnst Reinhart Verlag: Munich. p. 143-148.

Gestalt Therapy: Paradoxical Theory of Change

We go through life adjusting to situations that we encounter. In some situations we end up using repeating patterns of behaviors and thought processes, which may or may not suit the situation at hand. When our reactions to situations are incongruent to the situations, it is dysfunctional. Dysfunctional reaction leads to problems in relations, stress and different crises.

 

Oftentimes when we are aware of our patterns and try to make changes in our attitudes or behavior — i.e. we go for behavioral therapy, coaching, read self-help books or listen to friends’ or families’ advice — the effort get thwarted. This is because for every action comes an opposing reaction.

Take for example trying to be nice to a neighbor who is irritating to you. You try not to lash out at him/her for weeks until… snap.

Short Case study:

Tackling symptoms alone, without investigating the root causes of the symptoms sometimes makes the life for the individual worse. A client I knew, who was overworking to point of sleeplessness, decided to stop work for a while and went for a meditation workshop. At the workshop he suffered anxiety attacks and needed to leave the workshop. He was later (more) successfully treated after he discovered his motivation for excessive work– to escape his abusive father. This was only possible because the therapist allowed this patient to delve into his need for work, and sat with him through his re-experiencing of being a child of a bullying father figure.

The paradoxical theory of change is thus explained like this: “don’t just do something, sit there.” As gestalt therapists we are trained to be containers of the client’s unpleasant emotions, helping the clients by being with them long enough in these often painful moments, so that they may gain insight, wisdom and resources to find their solutions.

Bibliography

Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 77-80.