Kernberg (2008) writes that for the treatment of any case in which antisocial features of the personality disorder (PD) are suspect, the following should be evaluated by the therapist. Such evaluation makes it possible to access his/her ability to rely on the patient’s ability to sustain the therapeutic relationship and also to access the safety of the sessions:
The presence or absence of pathological narcissism.
The extent to which the superego pathology dominates (i.e. which part of the spectrum of the triad).
The intensity of egosytonic aggression and whether it is directed against the self in the form of suicidal/self mutilating behavior, or violent behavior against others / sadistic perversion.
Severity of paranoid tendency.
Stability of the person’s reality testing (ibid. p. 130).
The prognosis for Antisocial PD is not expected to be good in psychotherapy, in particular, if the client has severe aggressive pathologic behavior, and /or if the patient has no social support which the therapist can work with. According to Kernberg, therapists should begin work with client only after gathering the facts surrounding the clients’ coming for therapy, social support, ability to proceed with therapy in safety.
The treatment of malignant narcissistic PD (MNPD) has somewhat better prognosis than APD. A precondition for treatment is also strict control of antisocial behavior, and removal from social environment that facilitates his/her current behavior—e.g. exposure to the street gang.
General Psychotherapeutic Strategies
Kernberg’s suggestions are:
Establishment of solid, unbreakable treatment frame.
Systematic interpretation of psychopathic transference.
Guiding the patient to communicate honestly (if at all possible) about their behavioral problems outside the session.
Combining the above narrative with the developed regressive behaviors experienced during the sessions.
Gradually making it possible to connect the pathological behaviors interpretively into cognitive and affective experiences in the transference.
Highly deceptive clients make this work almost impossible. In such cases family members or other informants may be of help. The therapist should always make it prioritize urgency of intervention: 1. Danger to self/others, 2. Threats of treatment disruption, 3. Dishonesty in communication, 4. Acting outside and inside sessions, and 5. Trivialization of the communication.
Kernberg also states that it is essential to look for affects through verbal and nonverbal communication, nonverbal behavior, and the transference. The content of what the client says is usually a weaker source of affective information than what goes in these realms (ibid. p.140).
Treating Personality Disorders with Gestalt Therapy
Considering Kernberg’s suggestion, I notice the congruence of his method to Gestalt therapy practice:
Gestalt therapy is focussed on the process of the therapeutic dialogue, i.e. non-verbal interaction / body language. Therapist also encourages the client to enact situations that cannot be talked about. Poor functioning personality disorders prevents the individual from communicating with the therapist on a contactful level. As Kernberg notes, there is a tendency for such a client to deceive / idealize and devalue/ play victim or rescuer or persecutor with the therapist. The awareness of the therapist of this phenomena is essential. He /she is most effective when he/she can contain the clients behavior without getting roped into the game.
For this reason, in gestalt work, we focus of body language / tone of voice together with what is said, and we also focus on our (the therapists) own personal reactions. What the therapist tells the client is not analysis, but a descriptive reflection of what the therapists sees hears and senses.
The client benefits from this kind of honest interaction, because he/she too are not going to be caught up in games. In the beginning, there will of course be discomfort and frustration. If the client sticks to the work, there will be progress made.
It is said that the truth will set you free. In psychotherapy patients liberate from the psychological stressors in their lives through uncovering the truths about themselves.
This might sound counterintuitive if we believe that we know everything about ourselves or that we are in total control of the decisions we make. The field of psychology has proven empirically that this is not the case, and psychoanalysis has provided theories about how this is so.
Put briefly, the human person is an integral part of his/her society and culture through which our psychological processes are influenced.
Knowing the truth is coming to terms with this realization. That we become depressed, anxious, angry… etc because we have lost the sense of our of needs. In so doing we turn them into symptoms, so that we do not have to face these needs.
An example would be that of a woman who is depressed and no longer able to enjoy simple things in life. Through therapy she uncovers the truth that her going into depression is a means for her to not face up to an inner rage, for it was safer to lock oneself into a state of depression than to attack another person, especially an abusive childhood caregiver. Realizing the truth of her rage, she is able to talk about it and understand it. In Gestalt therapy, the client is encouraged to express this rage through art, speaking, acting out, writing… etc. When the underlying issue is set free, the depressive symptoms lose their foundation as well.
Therapy in this way is done with the patient being in control of his/her progress. Therapists in general do not advice, coerce or make analysis to tell the clients what the truth is. Clients find this out through dialogue with the therapist. The client has the agency to his/her own truths and healing.
When patients are asked retrospectively what they gained from a period of psychotherapy, their answers frequently feature an increase in their sense of agency: “I learned to trust my feelings and live my life with less guilt,” or “I got better at setting limits on people who were taking advantage of my tendency to comply,” or “I learned to say what I feel and let others know what I want,” or “I resolved the ambivalence that had been paralyzing me,” or “I overcame my addiction” are typical comments (McWilliams 1990 p. 16).
It is a given that a person comes to therapy to seek relief in symptoms psychological stress, relationship tensions and/or physical pain/discomfort not treatable by medicine alone. Usually a patient comes to a therapist to present a problem or a chief complaint after having suffered it for a considerable amount of time, while trying alternative/self-treatments.
It is not unusual that the decision to come for psychotherapy and the meeting of the therapist alone can diminish the symptoms. This is due to the relief the client usually feels after having let go of the need to control his/her own symptoms.
Despite this, psychotherapeutic treatment usually lasts months and often years. This is because as the therapy progresses the client and therapist uncover areas underlying the symptoms that need to be addressed, along the way setting new therapeutic goals. The work of therapy goes beyond the swift removal of disturbances.
Uncovering root causes of symptoms are often painful processes. The client needs to feel safe and trust the therapist enough to go deep into the work. For example a young woman with anorexia comes to terms with her feelings of betrayal and entrapment within a perfectionistic family only after 6 month in treatment. She needed another year to come to terms with inner rage against her care givers in order to overcome feelings of disgust for having food in her stomach.
Other examples include the man who comes for short- term couple therapy to “improve his communication” with his wife turns out to have a secret lover who is rearing his unacknowledged child; or the little boy referred for “acting up” with authorities has a private habit of torturing small animals (McWilliams 1999).
Clients usually need a lot of time in order to have the courage to open up their most painful emotional experiences– first to themselves, than to the therapist. Through the trust built within the therapeutic alliance, can revelations of negative emotions like fears and shame be grasped. Through coming to terms with these feelings of vulnerability can the client learn to master his/her feelings and behavior with understanding, knowing that he/she has choices and has the capacity to reach for resources.
The man who is compulsively unfaithful to his partner wants not just to stop having affairs but to be relieved of his constant preoccupation with fantasies about them. The woman with an eating disorder wants not just to stop vomiting but to get to the point where food is merely food to her, not a repository of desperate temptation and wretched self-loathing. A man or woman who was sexually abused in childhood wants to change internally, subjectively, from feeling like a sexual abuse victim who happens to be a person to a person who happens to have been a sexual abuse victim (Frawley-O’Dea, 1996).
Psychological symptoms (and psychosomatic symptoms as well) are the result of an individual’s survival strategy, otherwise known as creative adjustment to unpleasant experiences usually encountered in childhood. Hence the problems clients come to the therapists with,( e.g eating disorders, panic attacks, depression, relationship problems, addictions… ) are superficial signs (or tip of the iceberg). Looking at the experiences and emotions that lie within to keep these symptoms going is what the therapy is about. It is through uncovering these that the client gets to fully understand the root of his/her symptoms, and gradually find their own resources to relieve themselves of the effects of these symptoms and live better.
The questions “what is psychotherapy for?”, “what is the benefit of psychotherapy to the client?” “what should I expect from seeing a psychotherapist?” can be summarized as questions to seek out the goals of psychotherapy.
Setting Goals are Necessary in Therapy
Psychotherapy research has shown that goal setting on the onset of psychotherapy treatment is instrumental in the outcome of the therapy. This may seem the obvious course of action and “something all therapists and clients do”. However, if we think setting therapy goals is straight-forward, it could be that we are not setting the goals conscientiously enough.
Difference between Psychotherapeutic Diagnosis and Medical Diagnosis
Somewhat like a patient going to a doctor’s office, the client goes to a psychotherapist because he/she is facing discomfort and/or is suffering from symptoms. Unlike the doctor’s patient, the psychotherapeutic client’s symptoms are of a psychological nature. This is where we have to be more conscientious than the doctor.
Each Client is Unique
Psychological pain is multifaceted and is not realistically diagnosed on the spot. Therapists use questionnaires and their own observations as instruments for diagnosis, but we are also aware that what we see in the client is unique to the client. This is largely due to the understanding that psychological suffering has much to do with the client’s environmental situation (social, economic, historical, etc.) as well as the client physical state. Most of these factors cannot be tested using test kits. These get uncovered through therapist-client dialogues in the therapy session.
Goals in Psychotherapy that Benefit Clients
Goals made between client and therapists that go beyond merely “fixing symptoms” do more justice to, and offer more benefits to the client. This is especially important for client who have dependency or non-functioning behavioral issues.
McWIlliams (1999) writes quite clearly that the goals of psychotherapy extends beyond the disappearance or mitigation of symptoms of psychopathology. It extends also to
* the development of in- sight, an increase in one’s sense of agency,
* the securing or solidifying of a sense of identity,
* an increase in realistically based self-esteem, an
* improvement in the ability to recognize and handle feelings,
* the enhancement of ego strength and self-cohesion,
* an expansion of the capacity to love, to work, and to depend appropriately on others, and
* an increase in the one’s experience of pleasure and serenity.
There is empirical evidence to prove that when these goals are worked on, positive changes happen, including better physical health and greater resistance to stress (p.12).
This article features a study by Binder et. al 2009, Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy.
The findings of this study provides us with some answers to what patients or clients of psychotherapy regard as change in psychotherapy, and how they perceive their experience in therapy which is considered successful for them.
The client’s point of view is very important. Mental states cannot be fully measured, as opposed to physical states. There is no machine, or test kit to measure the mental state of health. A person’s mental wellness is witnessed through his/her ability to function in daily life, and also his/her own perception of how things are.
What is successful psychotherapy or counseling? If a client claims to feel better, we’d ask what they meant. It could mean they feel more relaxed, less stress, less anxiety. They could say that they are able to sleep better, have less physical pain. Or they could feel more energetic– whichever is important to the client at the time.
Methodology of this Study
The qualitative research was conducted using semi-structured, qualitative, in-depth interviews with 10 former psychotherapy patients, recruited through an advertisement in a local newspaper. A descriptive and hermeneutically modified phenomenological approach–i.e. using expert interviewing and not just questionnaires in order to grasp full meaning of what is transpired in conversation –was used to analyze interview transcripts.
What was most important explicitly for the clients in the therapy?
1 Having a relationship to a wise, warm and competent professional.
the client’s feeling of safety within the therapeutic relationship was mention.
the therapist having the right doses of contact with the client, and
the therapist having flexibility in approach to working with the client.
2 Having a relationship with continuity, safety and hope when feeling inner discontinuity.
the continuity, consistency of the therapy.
therapist being with them through difficult emotional experiences.
3 Having beliefs about oneself and one’s relational world corrected.
the patient is able through therapy to reconnect with his/her meaning making, having a look at misconceptions or introjects of which the client was not aware of.
therapists guides the client through his change of the worldview.
4 Creating new meaning and see new connections in life patterns.
the idea of having been helped by having one’s beliefs and belief systems corrected,
help in making new choices, or change in habitual patterns
helps the client see how the his/her present experiences and behavior in reaction to the experiences are rooted in the past experiences, i.e getting clarity and insight.
This study reflects what I see in practice. Good outcomes in psychotherapy happens when the client is able to engage in the sessions with support of the therapist. The route to good outcome varies with individuals and the therapeutic alliance.
Binder, P. E., Holgersen, H., & Nielsen, G. H. (2009). Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy. Counselling and Psychotherapy Research, 9(4), 250-256.
These are summarized findings obtained from this 2008 study by Jennings et. al. entitled Psychotherapy expertise in Singapore: A qualitative investigation. The researcher cited Singapore as a good place for studying psychotherapy due to it cultural diversity relative to its geographical size.
In this study, a group of 9 therapists and/or counselors were selected from a pool based on being seconded by colleagues as “master therapists”. The interviews were conducted with structured questions, and video-taped. These were later analyzed using grounded theory.
Results of the Study
Here are the viewpoints of the master therapists.
Needed personal characteristics that therapists should have:
Empathic : Master therapists spoke of possessing a great empathy for their clients. As one master therapist explained, once the client felt genuinely understood and accepted in whatever circumstances, true change and healing began.
Non-judgmental: This trait can produce a sense of safety for clients.
Respectful: The master therapists were mindful of their impact on clients and the importance of working with clients in a respectful manner. Respect for clients, whoever they are and whatever their issues may be, was a pervasive theme among these master therapists.
Needed developmental influences that therapists should have are:
Experience: The interviewees described a journey, explaining the many elements that created and influenced their path to expertise. When exploring elements of expertise, experience was mentioned frequently as an important factor. One master therapist made the point that there were no quick developmental influences and no guarantee that experience alone leads to expertise.
Self-awareness: The master therapists spoke of how their self-awareness has served them well when conducting therapy. One master described it as recognizing your internal processes when working with clients and being able to be a participant/ observer of interactions with clients.
Humility. The master therapists recognized humility as another important component in the development of expertise. Recognizing one’s limits may serve as a source of motivation and growth. One master therapist described the importance of the humbling process of recognizing and learning from one’s mistakes.
Self-doubt: Despite their experience and reputation, some of the master therapists addressed another issue related to the development of expertise* periodic self-doubt*and how this feeling motivated them to keep growing their clinical skills.
Therapists’ approach to practice:
Balance between support and challenge: Many of the master therapists spoke of the importance of maintaining a balance between support and challenge when working with clients.
Flexible therapeutic stance. The master therapists described a flexible approach in their work with Psychotherapy clients. If client variables required them to adapt their style, they did. One theory does not fit all.
Empowerment/strength-based approach: A number of master therapists spoke about their clients’ internal resources and how the therapist’s task was to reinforce these strengths and bring them to bear in dealing with the problem at hand.
Primacy of the therapeutic alliance: Many of the master therapists acknowledged the importance of the therapeutic relationship. The impact of the relationship varied from a necessary condition in the therapeutic process to the relationship being the actual source of healing.
Comfortable addressing spirituality: Beyond observance of any particular religion, many master therapists spoke of a broad personal spiritual mind-set, which primarily functioned as a backdrop when working with clients but also included some therapists privately praying for clients.
Embraces working within a multicultural context: A number of master therapists spoke of the importance of cultural awareness in their work and the challenges of adapting Western therapeutic approaches to Eastern values and systems.
On on-going professional growth:
Professional development practices: Professional development, a key factor in developing and maintaining expertise, was not limited to conferences, literature, or textbooks. One master therapist believed that therapists should extend beyond their areas of practice to broaden development.
Benefits of teaching/training others: Now highly regarded and seasoned, the master therapists have much to offer other therapists. Many of the master therapists viewed teaching and training as an opportunity to hone their own skills and to reflect upon their practice.
Challenges to professional development in Singapore. During the interviews, master therapists identified several ‘‘professional growth edges’’ in the Singapore psychotherapy profession. For instance, a training need recognized by several therapists was that of basic counseling skills. One master therapist explained that basic counseling skills are not natural for many Singaporean trainees.
Comments on the Study and it’s Results
As a Singaporean therapist with training in Austria, it appears that what the master therapists highlight regarding personal characteristics, development and education of therapists are not so different in Singapore than in Europe.
There is one difference that stands out for me, and that is of the need of the Singapore-based therapist to address spirituality. Although it is also important in Europe, the emphasis in this article gives me the impression that is more important and challenging in Singapore.
What is somewhat disappointing about the results is that (and it was articulate also in the article) is that the Master therapists shared very little of their own emotional experiences. The researchers attributed it to the cultural background of the therapist. As someone doing qualitative research myself, I am of the opinion the it is the job of the researchers to lead the subjects to provide this information.
It could be that the shortfall in this study is the interviewers own discomfort in checking with the interviewees on more personal levels.
As a whole, I do agree that Singapore is good ground for psychotherapy research.
Jennings, L., D’Rozario, V., Goh, M., Sovereign, A., Brogger, M., & Skovholt, T. (2008). Psychotherapy expertise in Singapore: A qualitative investigation. Psychotherapy research, 18(5), 508-522.
Projective Identification is one of the primitive defensive operations that goes together with splitting and primitive idealization and omnipotent control.
It is a primitive form of projection of attributing to others what one cannot tolerate in oneself. It is characterized by combination of attributing to somebody else what the person is experiencing but cannot tolerate. While they are still capable of maintaining empathy of what they experience but cannot tolerate. There is also a tendency to induce behavior in the other in effort to control the other person to absolve themselves.
Basically it is an insidious method of inciting emotions, which one cannot come to terms with in oneself, in another person. This as a means to control the other person.
A possible example of such an occurrence is someone who is insecure and envious of another. This person creates situations whereby he/she incites envy and/or competition in the other person.
It could also someone controlling a group. A manager may have a paranoid ideas of the team being disloyal to him, begins to behave in ways to incite feelings of mistrust between the members of the company.
Extra Notes (see Video attached) on Child abuse and projective identification:
Identification of the aggressor : being a ghost to chase the ghost away, stockholm syndrom (Anna Freud’s). Ferenczi’s idea of identification with the aggressor: The abused child behaves in the way the abuser wants to protect himself from the abuser, by appeasing and complying.
The child introjects the abuser’s feelings: he feels both innocent and guilty. There is a clash of feelings. The abuser, to make himself feel less guilty induces the guilt on the child victim. The parent / abuser projects the impart feelings (also known as projective identification, a term Melanie Klein coined later on) on the child. He induces guilt on the child. The child introjects the shame and feels guilty.
The client should be allowed to express their criticism on the therapist, or they will turn on themselves. These negative feelings are not just negative transference. When the clients can voice their critic in therapy, it is a breakthrough. It is a break from the childhood pattern.
You may wonder what is the significance of knowing this: is my spouse / boss / colleague / friend / sibling someone who happens to be alexithymic? Someone who has literally no feelings?
We are not all the same. In fact we are often blind to the people we live with, to their personality and character traits, because we live within our own personality biases. Without psychotherapeutic work, we are often not aware of the fact that we see and feel the world differently from the people around us. That we also have a tendency to assume that the other person understands us and vice versa.
Alexithymia is not uncommon. It is assumed that about 10% of the population is alexithymic. With awareness through psychotherapy, one may get to realize that one is or had been living with persons who are unable to identify and describe emotions in the self. This condition is seen as dysfunctional because it leaves the person un-empathic, and the people around the sufferers often get hurt.
Alexithyma proves to be prominent in a number of clinical disorders (e.g., somatoform disorders, panic disorders, depression with dominance of vital and somatic symptoms, posttraumatic stress disorder [PTSD], and eating disorders). Extent of Alexithymia is also significant to outcome in the treatment of these disorders.
Psychological questionnaires used to measure Alexithymia include: Observer Alexithymia Scale (Haviland et.al, 2001) and the the Bermond-Vorst Alexithymia Questionnaire (Vorst et.al, 2001).
Haviland, M. G., Warren, W. L., Riggs, M. L., & Gallacher, M. (2001). Psychometric properties of the Observer Alexithymia Scale in a clinical sample. Journal of Personality Assessment, 77(1), 176-186.
Helmes, E., McNeill, P. D., Holden, R. R., & Jackson, C. (2008). The construct of alexithymia: Associations with defense mechanisms. Journal of clinical psychology, 64(3), 318-331.
Vorst, H. C., & Bermond, B. (2001). Validity and reliability of the Bermond–Vorst alexithymia questionnaire. Personality and individual differences, 30(3), 413-434.
Quiz: How to Identify Alexithymia in a Person
Note: this is a basic quiz and not to be used as diagnosis of yourself or the other person. If you suspect that the condition affects your psycho-social functioning, please consult a mental health professional.
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Written by: Nicole Chew-Helbig on 15 June 2017 in Vienna, Austria.
This case study is an abstract from a therapeutic work. It is a demonstration how a recall of the client’s favorite novel as a teenager develops into a psychotherapeutic session that is meaningful to the clients identification of himself. This is a technique usually used for working with dreams in Gestalt therapy, in which the client plays the parts (makes projections) of his dream. In this case it is not the dream, but the novel.
Case study: CL’s Novel
CL works in a publishing company. He reports having problems with procrastination. Although quite successful at his job, he struggles making datelines. He finds himself delaying getting things done till the last minute, which sees himself sitting up till early hours of the morning smoking cigarettes. This is an excerpt of a Gestalt Therapy Session. Throughout this article, the principles of Gestalt Therapy adopted in this session are also explained in this color.
NC: Now can you bring to mind a moment in which the word “procrastination” feels familiar?
CL: (Contemplates…) Yes. I had to write a short article for the company’s blog. It was in morning, I took out the PC, but then I did instead some online shopping.
NC: Stay with the feeling of the moment before you switch to online shopping.
“Staying with the feeling” is an approach in GT where the narrative (which is usually an intellectual process) is embodied into experience.
CL: I feel anxious.
NC: This familiar to you?… stay with it. Can you remember a time in your childhood when you felt something like this?
CL: In school. It was Math, and I had homework. The teacher wasn’t pleased, I made mistakes I did not understand…
This narrative goes on, and we talked about anxiety about what he considered “small criticism”. This recall of the past is a “free association”. The experienced client knows how to take memories or images that pop up in the moment and vocalize them. Sometimes these associations do not seem to make sense at the moment, but these usually do.
NC: Stay with this anxiety again… much earlier… maybe at home…
CL: Nothing special, really, I am just having a picture of a dirty bicycle. I was 8 or 9, it is my bicycle. I was supposed to clean it, but I didn’t want to do it.
NC: You had to do it, but you do not want to do it now?
CL had used the present tense, and I felt it is a good thing, so I followed with the present tense. This is a good opportunity to work with past experiences as if it were in the present. Actually this is how we live, with occurrences of our past popping up in the present.
NC: What would you rather have done?
CL: Read a book.
NC: Have you a book in mind?
CL: Yes. (mentioned a title of a book).
NC: Where would you go to read this book?
CL: In my bedroom.
NC: How does it feel to be in your bedroom reading this book?
CL: Relaxed, comfortable… safe.
Notice that he said “safe”. It seems to correlate with the “anxiety” behind the procrastination. This is an indication that sitting in the room, and reading that book is a way out of anxiety. At this point I could have gone back to the anxiety, and tried to work on it. My interest of the moment, however, took me to the curiosity about the book (which I will explain later why). This is working in the here-and-now. The therapist is following her own feelings of curiosity, and being present. This means that we may, at this juncture abandon trying to sort the problem of procrastination. In Gestalt, we work on what is present. The present is always changing. We do not try to force goals into the present or force the client to concentrate or dwell on issues that are not there at the moment.
NC: The title of this book got my interest, I have not heard of it before.
CL: (laughs). It is a very old novel. German novel about German brothers coming back from the 2nd World War, and the Russians came.
NC: You mentioned this book was comforting to you, a 9 year old.
CL: for some reason, yes.
The backstory here is, like many of his generation, CL’s estranged father was a soldier in the German NS. CL himself is a liberal (kind of left-wing writer). This information in background, now got my interest to this book preference CL as a child. The background is very important to the Gestalt therapist because we are interested in the foreground. The foreground is made clearer only when the background is complete.
NC: Tell me about the book…
CL: (laughs, a little more shakily. He goes to his phone, and searches this book on an online site. Makes some association:)
NC: What comes to mind…
CL: Two scenes. This guy talks to his buddy in prison about the time he was taken from his home by the Russians. He was in the garden of his parent’s home, and his mother had baked a cake. Then they came to take him away. (laughs) He tells his buddy that he wished now that he had taken the cake along with him. The other scene is that he tells his buddy, “now I hope the Americans come, and gets rid of the Russians, so that they can free us”).
CL, has made associations again. This I found to be interesting. The scenes have irony and are a bit funny. Freud in his writings, “Der Witz und seine Beziehung zum Unbewußten” or “Jokes and Their Relation to the Unconscious” , tell us that there is significant repressed unconscious material in jokes. We’ll see how this plays out…
NC: Could you play out the scene? Try. You are this guy talking to your buddy in prison. Say “I am in the garden of my parents, and my mother had baked a cake…”
Unlike psychoanalysis, where the therapist takes on the task of analyzing the joke for the client, in Gestalt Therapy, the client tells us his/her version of the story. This method is usually used in Dream analysis (or dream work) in Gestalt therapy. The client is invited to take a role in his dream (or in this case, story). His task is to talk in the first person. By this time, there was actually resistance on the part of the client. There were points in the session when CL started to intellectualizing, either by stepping out of the scene, or to make judgment of the scene, even though he was quite agreeable to doing this experiment of playing the part of the characters in his associations. Playing part in associations and dreams is usually uncomfortable for many people because they feel awkward, or they do not trust what they say or feel in this kind of work. My experience is that the client is seldom ever wrong in this sense.
CL: I am in the garden of my home. My parents are there. Mother has baked a cake.
NC: Tell me about the cake.
CL: Delicious. She baked it often.
NC: then what happened.
CL: Soldiers came to the gate, and took me away. Then I am in the prison talking…
NC: Slow down. What happened as they took you away…
CL: That is not in the book.
NC: They are at the gate, they ask you to come with them.
NC: What’s going on.
CL: I feel scared, I suppose.
NC: I can imagine.
CL: In I am not sure if I would ever come back.
NC: Yes. Now, come back here with me. Have you an understanding what is going on with this character in prison as told his buddy that he should have taken the cake along?
CL: He is scared, he wished his mother was there, he’s afraid he would never see her again.
NC: Would you like to work on the next scene?
NC: I am in prison and I hope…?
CL: I am in prison, I tell my buddy, I hope that the Americans come soon and drop bombs on the Russians.
NC: What is the purpose of that?
CL: to save us.
CL: We are trapped in prison.
NC: What does it mean to be in prison?
This part took a bit of time. We stayed with it together… Staying with the client’s pause is good point of contact. Contact is a very essential part of Gestalt therapy. It usually comes when the client touches something emotionally significant, and when the therapist is able to give support.
CL: No freedom… I am in danger… I am guilty… I feel hopeless… I feel helpless…
NC: in prison, no freedom, in danger, guilty…
The client, in his association, has come to contact with some deep feelings. These are unconscious until now. We can ask “what are you feeling guilty about…?”, but this might lead the client to intellectualizing. The cleaner path is to bring the client back to the present situation, the here-and-now.
NC: Tell me about what’s happening now. You being here with me now, we are talking now…
NC: are you in danger?
CL: no. I am safe.
CL: No… not hopeless nor helpless. (Takes a deep breath.)
Note that this is a condensed version of the dialogue. CL had a bit of difficulty with the associations at first, and this is normal. Why we worked these scenes is because they were freely associated, and my guess was that they had significance. The other clue that this was significant was the resistance of the client along the way of this experiment.
At the end of the dialogue, CL took a really deep breath reflexively. He looked calm, and said “I feel good”. “Fine,” I said, and we ended there.
This short session demonstrated a closing of a gestalt. The client had anxiety-related procrastination issues, and that led to a memory. This memory led to a group of unconscious feelings, which took solace is a kind of joke or wit, or an entitled way of thinking “I hope the Americans bombs the Russians..” These were also not fully owned by the client, since he attributes it to a story book. However, the client was really interested in the experiment, because he realized, too, that there was some kind of association between this story and his relationship to his father. The beauty of Gestalt therapy is that we help the client come to his own meanings and understanding through his experiencing and embodiment of the experience. The therapist’s work here was that of supporting, and not of prying.
In the following sessions we discussed this dialogue again in relation to CL’s relationship to his parents. There was even clearer understanding to the cultural significance of “jokes” or “making light” in tough situations. Also, there was a discussion about how we deal with anxiety and fear.
The rest of the associations with regards to this dialogue, I’ll leave it to you, the reader.
Kets de Vries gives a very detailed psychoanalytic account of a case study of an entrepreneur he names Nr. X. This case study illustrates how the inner and private life of the leader have significant effect on the performance of the leader. As the leader gets older, it is not unlikely that unresolved inner problems from childhood affect many areas of the individuals life, including his/her relationships and health.
Reason for Seeking Psychotherapy
Client: Mr. X, a 44 – year – old. Youngest of 6 siblings (2 brothers, 3 sisters). Occupation: Entrepreneur. Family Life: 21 years married but recently separated, 4 children.
Events leading to therapy request:
Mr X. had thrown his wife out of the house.
her increasing need for more independence had become a bone of contention.
He complained about her lack of caring and suspected that she was emotionally involved with a younger man working at the office (she worked in his company).
He is strongly annoyed that his children had taken the side of his wife.
History of depressive episodes (but not thought of as serious as now).
Has now feelings of worthlessness. No life prospects.
Fears losing his mind.
Problems at work due to wife’s (and young colleague’s) departure.
Worries about the company health. Fears of bankruptcy / humiliation as result.
Feels paralyzed at work. Not able to function. Feeling painful going to the office.
Psychosomatic complaints: nightmares, sleep problems, severe headaches which affects eyesight. Temporary loss of vision. Diarrhea and nausea. Impotence.
Mr. X’s thoughts about his father: a salesman / entrepreneur. Often away from home due to work. Remembered as a boisterous man who laughed a lot and brought him presents from his frequent business trips. Felt that he was his father’s favorite. When he was seven years old, his father became bedridden. Having his father in the house gave the boy the opportunity to spend more time with him. He began to feel close to his father. When he was 98 years old, his father died in a mental institution. This event was to Mr. X shrouded in secrecy. Mr. X is suspicious of the fact that his mother and elder sisters transferred his father to the mental hospital, thinking it was unnecessary and that it caused his death. He had tried a number of times to find out what had really happened, but had not been able to uncover the truth. The whole incident seemed to have been suppressed as a dangerous family secret. Mr. X suspected that his father had committed suicide which, given his family’s religious orientation, would explain the secrecy around the incident.
Mr. X’s recollection about his mother: Described as a very controlling, overprecise, critical woman who constantly worried about money and the future. After the death of his father she struggled maintaining the family also with coping financially. He felt that she saw everything in a
negative light. She never made a positive comment. Nothing he did was
ever good enough. He also described her as a perfectionist. He had never
been able to live up to her standards.
Mr. X’s recollection about his childhood life: Apart from the death of his father,his childhood was described as uneventful and quite happy. He felt proud of the fact that he had been something of a rebel as an adolescent.
Relationships with women:
Attitude to work: He used to be enthusiastic about his company, now feels it is too complicated and wants to give it away. Similar feelings about possessions.
Depression: feeling pessimistic, life is a sacrifice, fear of being alone. Feeling completely deserted due to wife’s departure from his life. According to Mr. X, he once used to have everything. Now things were different; his health had been ruined; his life was in a shambles. He felt worthless. He wondered what had kept him so busy at work in the past.
“He revealed that throughout his childhood he had been scared of losing control. He was reluctant, for example, to fight with other children for fear that he would lose control and kill someone.
Denial of inner reality and flight into external reality through work had
become a way of life. His defensive structure, however, of escaping into
action — ‘ the manic defense ’ (Klein, 1948) — no longer seemed to work.”
Dramatic mood swings, an all – or – nothing attitude. Very little was needed to push him in one direction or the other.
Repressed Emotions & Inner Reality
Denial of feelings of depression through unrealistic optimism, laughter, humor, frantic activity, and excessive control had always been an important element in maintaining Mr. X ’ s psychic equilibrium.
Attempts to fight his depressive state by eliminating negative thoughts. Turns to self-help books in order to improve ability to repress depressive reality.
This point of a person, and this happens often with people who are functioning and try to excel in aspects of their life through forcing themselves into change. i.e. When I feel hurt/stressed/sad/angry (any “negative” feelings), I try to escape by pushing myself to do better, to think positive. This works, but only very temporary. The breakdown that comes is usually catastrophic and very difficult to overcome. In Gestalt psychotherapy, there the paradoxical theory of change (Biesser, 1970).
Unfolding through Therapy
As Mr. X worked his way through therapy he was able to admit to himself several things that was repressed:
that his childhood was not so happy as he made it out to be. He realized his urge to think positive and believe positive (unlike how he sees his mother, as a pessimist). He realized how he was treated “like a baby” (which also means not being respected, and made to feel small), feelings of envy of his brother for the role of he man of the house.
He remembers using complaints of physical ailments to get attention, and being sensitive to children crying.
Was able to acknowledge his father’s darker side. That his father had beaten his children, stifle his behavior, strict rule enforcing.
His Oedipal memories.
His identification with his father’s tendency to be fake, hiding feelings.
He was able to grieve his father’s passing (which he had not the change to due to secrecy)
He comes to terms with his anger towards his mother, and also (as a child) feared that his other would die. He had fantasies that he might kill his mother when sleepwalking. His feeling of being unwanted by her, and wanting to prove to her that he was “worth it” to have as a child, and to admire him.
All emotions of aggression, guilt, grieve that accompanied these unfoldings.
Relationship with Women
Given the kind of relationship Mr. X had with his mother, it came
as no surprise that he perceived women as dangerous, over-controlling,
not really to be trusted.
Mr. X would divide women into two split categories, the easy and the proper. He had always been fascinated by prostitutes (and still was), but the fascination was accompanied by fear. Prostitutes were tempting but they could also be infected with diseases. He recalled an incident when he visited a prostitute. He felt that he had not treated her like other men. He had not taken advantage of her; he had gained her admiration.
As a young adult he had had many short relationships with women, treating them rather callously, usually dropping them when they became too clingy. He disliked feeling ‘ choked. ’
Dreams and Projections
He felt threatened by women. His dreams illustrated the role women played in his inner life. In many of his dreams, phallic women, portrayed as women with guns, would appear and lie on top of him, having intercourse while putting him in a passive position. He would wake up, frightened, feeling smothered. In other dreams, however, women would admire him from a distance. He described one dream in which he was persecuted by a number of large bees who kept striking at him. They were almost impossible to brush off. He associated this imagery with all the women he had dealt with in this life. Women could cling and sting, but also give honey. They could repel but also give pleasure. Gradually, however, dreams emerged in which he became more assertive with women, not taking such a passive role. Most importantly, in these dreams the degree of anxiety he had previously experienced was missing.
Being in Control
Starting and managing an enterprise had multiple meanings to Mr. X. It signified much more than a means of making a living. He had found out early in life, while employed by a German company, that working for others was too stifling.
These are projections, and much is known to be related to projections he has of his mother being controlling and having secretly done away with his father. Again identification with the father, being the victim of another’s control.
To be independent, to be in control, meant to be free from mother. His inability to work for other people (who would tell him what to do) made him decide to start on his own as his father had done before him. That was the only way to get some power, and no longer be subjected to the whims of others.
Transference of control and being controlled was reported to exist in therapy sessions.
What becomes apparent is his entrepreneurial mindset and work style slowly made sense to him, as his way of dealing with past traumas. It is his way of closing gestalts, and finishing unfinished business. This unfortunately leaves the real unfinished business open, and the only way that a person can live in inner peace is to work constantly. It is like filling water in a pot full of holes.
Mr. X also worked through other personality traits that developed as a result of being himself, basically. He was able to realize his meed for admiration, tendency for grandiose and depressive moods (bipolar disorder, perhaps), competitiveness, self-defeating behaviors,.
With the newly owned awareness and re-experiencing of past traumas, and the re-integration of his repressed emotions, Mr. X was reported to have slowly managed to get back to work, work with less stress, welcome his wife back into his life.
The process in which the patient manages to make positive changes to his life is through sitting through and experiencing what is there. What is in his real memories, his real childhood experiences. This is only possible with the accompaniment of a therapist, who is trained to support the client through the process. This process is very tedious and painful. The client has spent almost all his life trying to make changes by pushing his un-bearable realities to the unconscious. To not feel, to forget.
This is what it the paradoxical theory of change is about. When we try to elicit changes, in Mr. X case, when he tries to think positive, push himself to success, and try to do everything he can to overcome painful experiences, all he has achieved is a mountain of disappointments and stress. It is only through not changing. in just sitting in therapy and looking at all these childhood experiences, did his life really begin to change.
Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 77-80.
Klein, M. (1948). A contribution to the theory of anxiety and guilt. The International Journal of Psycho-Analysis, 29, 114.
Kets de Vries, M. (2009). Reflections on character and leadership.