Fritz Perls: Working with Dreams in Gestalt Therapy

Dreams. What are they? For those of us who know already, dreams are the windows to our unconscious. To fall asleep and dream is to let go of our outer world. In doing so, the life of our inner world takes shape. Since our innermost consciousness is in sleep separate from our senses that communicate with the outside world, the life of dreams seem to us mysterious: on the one hand there seem to have meaning in the dreams, and on the other hand the context is an amalgamation of experiences and emotions mixed together, and makes little sense. Most of our dreams are forgotten, and if we try to remember them, we cannot be sure if the memory of the dream is even accurate.

From the 9th Century didactic poem of Titus Lucretius Carus, De Rerum Natura (IV, v. 959),

The unconscious material in dreams are useful and important for psychotherapeutic work. This is especially so when the dream is a recurring one. According to Fritz Perls (1969):

“(T)he most important dreams– the recurrent dreams. (…) If something comes up again and again, it means that a gestalt is not closed. There is a problem which has not been completed and finished and therefore can’t recede into the background.”

Another proof that dreams are the stuff of the unconscious, is the proof that in people who suffer sleep disorders, the problem are the result of the mind not being able to let go of the external world. This is a world of the senses, and of spiraling thoughts.

Dream work in Gestalt Therapy

Sigmund Freud has, in one of his most-read book, The Interpretation of Dreams, gives us an idea of how dreams are interpreted in psychoanalysis (Freud & Strachey, 1964) .

In this article, I focus on the dream work in Gestalt therapy. Gestalt therapy has a tradition of non-interpretation on the part of the therapist. So how does one work with dreams without interpretation? Much of the recorded dream work of Fritz Perls is found in this book, Gestalt Therapy Verbatim. Here are case studies of work conducted by Perls in front of a group. On reading this book alone, some colleagues of mine find Perls’ style brash and some even find it bullying. Before we judge, it is important to ask ourselves if the work that Perls demonstrated served the volunteer. Mostly it has. The members found greater self awareness, and many have experienced a closed gestalt, or an integration of their split parts. Also it is useful to note that Perls’ clients are actually mostly students of therapy themselves, and not “patients” in the true sense of the word.

Below is a video of Perls’ dream work. There is a lot of emotionality that arises from the client herself. Perls as a therapist merely supported her. He does not interpret (or at least that is the intention). What the meaning of the dream really was about is actually not verbalized. The patient derived her own sense of what it meant. She has also experienced the meaning and not only thought about it intellectually.

This non-interpretation is a different attitude from psychoanalysis.  In Gestalt Therapy, the client is asked to play component parts of the dream. They may even play the dream itself. For example, the client says “I am my dream, and I am vague, and I am not there for you to remember me…” or “I am my dream, but I am incomplete.”

In the example below, the lady plays the water, “I am the water…”

This is called projection. It helps the client to feel the part of him/herself that he/she has disowned and has projected onto objects of the dream. Disowned parts of the self are in the unconscious, and integration is the work of therapy.

“Every dream or every story contains all the material we need. The difficulty is to understand the idea of fragmentation. All the different parts are distributed all over the place. A person, for instance who has lost his eyes — who has a hole instead of exes will always find the exes in the environment. He will always feel the world is looking at him.”

Read also: Dreams and Dream Work in Psychotherapy 

References

Freud, S., & Strachey, J. E. (1964). The standard edition of the complete psychological works of Sigmund Freud.

Perls, F. S. (1969). Gestalt therapy verbatim.

How Bobby Mcferrin explains Gestalt Theory with this Act

Bobby McFerrin  is famous for his hit song, “Don’t Worry Be Happy”. In this video, he demonstrates how the crowd intuitively synchronizes to the pentatonic scale. Ferrin says, “What’s interesting to me about that, is, regardless of where I am, anywhere, every audience gets that.”

How can we use this act to explain the Gestalt therapy theory?

    • Closing the Gestalt. The brain of most humans find completion in the pentatonic scale. This is a pattern of notes one would hear when one plays only the black keys on the piano. To the human brain, this note-pattern closes itself in a harmonious way (i.e. it just sound right).  This is how McFerrin is able to rely on the crowd’s intuition to “play” the music.

  • Field Theory. The crowd, the men on stage and the atmosphere make up the field. McFerrin harnesses and motivates to make a unified sound. If, for example, something in the middle of the performance distracts the crowd (for example, an explosion, or if the electricity breaks down) the focus of the crowd would be dissipated, and there would be, instead of a unified presence, chaos.
  • Phenomenology. McFerrin does not push the crowd to play the music like he would push piano keys. This would not be possible. In order to get so many people to sing in the same tune, he has to judge when the right moment is to act (to jump, or to say something or to make a mimic). This sensing of the crowd is the sensing of the phenomenology of the field.
  • Contact. When we can “tune in” to the other, we make contact. Each member in the crowd sings with his own voice and tone. Each is different, but together they are in contact.

McFerrin says, it works all the time. Yes. The theory of Gestalt Therapy is more than humanistic. It is a theory of phenomenon and contact. The other men on stage says that there is some neuro-biology involved. Yes. There is. This is how the theory of Gestalt therapy functions, through contact leading to physiological change.

On Gestalt Therapy

Gestalt therapy is a modality of psychotherapy which is founded on philosophical principles to guide the practicing therapist towards meeting and supporting the client authentically for who he/she is.  The pillars of Gestalt therapy theory include: the field theory, contact process, phenomenology, and the closing of the gestalt.

The therapeutic aspect of Gestalt therapy happens when the client is able to come into contact with his/her disowned aspects of his/her personality (“the dark side”, some would say). Often these are realities that are too painful or shameful to acknowledge, but are at the same time ever-present in the the life of the person. The effort (usually unconscious) of putting away these disowned parts of the self, utilizes a lot of energy, and is the source of inner conflicts, stress, depression and in severe cases, psychosis.

The Gestalt therapy work is to provide the patient a safe environment to play out, and experience these disowned parts of the self. In the process, the patient learns about these parts, and is given the ability to integrate these parts in their present lives. The net result is a better, less stressful quality of life and also better relationship with others.

How to Ask a Patient about Childhood Trauma History: Dr. Bessel van der Kolk

In this lecture Bessel van der Kolk speaks about his work with patients with childhood trauma. Here is a snippet of this video on how to get from a patient information about his/her trauma history. The topic of childhood trauma is not easy to bring up. Oftentimes the patient doesn’t recall the traumatic event(s). Sometimes these events are not acknowledged as trauma by the patient. Even if someone has encountered trauma and has memory  the event, there may still exist emotional difficulty in relating the event to a professional.

Van der Kolk provides us here with a way of interviewing the client @ 10:20 :

  1. Ask about demographics: where do you live? who lives with you? who does the cooking? who does the dishes? who do you talk to when you come home at night? When you need help/ when you are sick, who can you turn to? when you feel bereft and upset, who do you talk to? These questions give a picture of a person’s interconnectedness.
  2. Ask about the person’s current health (e.g. sleeping patterns).
  3. Family of origin demographics: how about when you were little? who loved you? who was affectionate to you? who saw you as a special little kid? was there anyone in your family who you felt safe with growing up? (*Hear van der Kolk’s comment on this question @ 12:30) who made the rules and enforced rules at home? how did your parents solve their disagreement?
  4. Childhood caretaker and separation.
  5. Other questions @ 31:30 : can we assume that life was good growing up? was anybody in your life a drug addict or alcoholic?

“You really cannot understand anyone with Borderline Personality Disorder unless you understand the terror they grew up in.” Bessel van der Kolk

Childhood trauma and BPD are correlated in findings. 87% of studied subjects with BPD had histories of severe childhood abuse and/or neglect — prior to age 7.  Other personality disorders do not have significant correlations with childhood trauma.

Slide @ 17:05 shows correlation between childhood physical abuse, sexual abuse, neglect and the symptoms of suicide ideas, suicidal attempts, cutting, bingeing and anorexia.

Neglect and ability to feel safe are found to be factors that determine the likelihood in which the patient can feel safe and be helped during therapy.

Full video is here:

Why do we need to find out about traumatic childhood experiences in therapy? Besel van der Kolk explains this @ 44:40, the importance of revisiting the traumatizing events.

@ 45:20 he explains the neuro-biological consequence of trauma.

Otto Kernberg: Transference Analysis in Psychotherapy

This is a summary of Otto Kernberg’s lecture on Transference Analysis.  Transference is an important term in psychodynamic therapies, and even dialogic therapies like Gestalt therapy.

Cite this article as: Chew-Helbig, N. (05/2017), Otto Kernberg: Transference Analysis in Psychotherapy, in The Psychotherapist. Date accessed 02/2019, https://nikhelbig.at/otto-kernberg-transference-analysis-in-psychotherapy/.

 

Transference is defined by Kernberg as: the unconscious repetition in the here-and-now of a dominant pathogenic conflict of the past.

In Psychopathology this pathogenic conflict plays out in the individuals’ present style of relating with others. Kernberg explains the origins of this mode of relating to be from the attachment of an individual to his mother at infancy. Early relationships, environment and the psychosocial world affect the neuro-biological make-up of the individual.

The experiences of the past, good and bad, thus get activated in the here-and-now, and affect how the individual perceives current situations and how he/she reacts to this situations. How he/she perceives his/her role is also affected by these early experiences.

Negative affects that do not reflect current reality is seen as pathological. These get reinforced through misunderstandings and reaction to and of the environment. These fixated negative reactions become the character and reflect the personality of the individual.

11:00 Kernberg explains that a combination of past experiences (and these are distorted and play out together in the present, not just one event at a time. Although we all transfer our experience of the past to our present, it becomes noteworthy as a personality disorder when this experience was overwhelming to the person, and becomes distorted.

What is done in psychodynamic treatment?

To resolve the pathological conflicts of the past as they get activated in the present.

14:25 By setting up a “normal” situation in the treatment situation. To sit with the patient face to face, and allowing him/her to say whatever comes to mind without feeling in danger of being judged, and to listen attentively to the patient.

Invite the patient to speak openly, support the patient to feel safe in this interaction.

Therapist exhibits technical neutrality. This interaction activates a transference relationship. The therapist can then help the patient interpret this transference reaction to past experience. This is called transference analysis. The adult mind of the patient can then be supported in integrating his/her past experiences with the present situation, leading to normalization of affect in the present.

Significance to psychotherapy…

Paying attention to transference situation, or what we can understand as the relational events that occur between therapist and client in the therapeutic setting in the here-and-now is very important to working with clients because it works directly with the personality of the patient. This is usually the armor that stands in the way of the psychotherapeutic work.  Kernberg’s lecture featured  here is detailed, and he explains how relationship experiences of an individual in infancy has a role in the wiring of the brain. He also explains how with psychotherapy that works with transference, his/her affect incongruence can be “mentalized”, and integrated within the patient.

Borderline Personality Disorder Case Illustration

46:00 Kernberg cites a case study of a patient with borderline personality disorder.

22 years old female, suicidal attempts, overdose of medications and street drugs, frequent hospitalization. 3 previous therapies, unsuccessful. sexual promiscuity,  antisocial and manipulative behavior, violent affect storms, attacking people emotionally.

Treatment started haltingly due to multiple suicidal attempts. Kernberg describes how he experienced her behavior towards him, which were violent and un-compromising. Kernberg explains how he reacted to her firmly, and in my opinion, authentically. He specified what he could tolerate and what he did not.  He however kept focussed on the transference without trying to fix or analyze or advice.

The behavior towards the therapist in this case is what Kernberg describes as the transference. It is how the patient has learnt to behave towards others in a relationship.

What we can take from this, is that patients who have had severe trauma as children do play out their pathological relationships with the therapist. It is up to the therapist to be aware of this patterns of relation of the patient. Sticking to the focus of the transference, and reacting authentically (if you are angry, say so, if you do not accept the abuse, say so, and set limits while being firm and sympathetic).

Kernberg also says that therapist have to look at the treatment in the long term, and although we may be impatient to see change in the patient, we have to be patient.

Important points to protect the frame of treatment

  • safety of the therapist.
  • * use common sense.
  • * be patient in the long run.  session takes months and years.
  • * analysis of what is going on is essential.
  • * tolerance of transference analysis is variable.

Significance of transference in Gestalt Therapy

Gestalt therapists do not use the term transference. This is because of the traditional link this word has to traditional psychoanalysis that Kernberg speaks about.  But the concept of using the interaction of the here-and-now is very much Gestalt therapy. Dialogical Gestalt therapist work with what we call the intersubjective or the in-between. This in-between is the transference. Gestalt Therapist who adopt the strict theory of the method, work with the following processes that is also present in transference analysis:

  • * working in here-and-now, 
  • * attention to the dialogue between therapist and client.
  • * non-judgmental (we call this phenomenological) listening to the client, allowing the client to his freedom of speech.
  • * active listening to the client.
  • * reflecting back to the client how his/her behavior or way of interaction affects the therapist.
  • * supporting the client to understand his current way of relating to his/her past (often pathologic) experiences.
  • * allowing the patient to integrate this phenomena of his/her past into the present.

The dawn of Gestalt therapy was initiated by psychoanalysts like Wilhelm Reich’s “Character Analysis and Sándor Ferenczi. The writings of these men, have already addressed the issue of working with transference as a means of working through character.

References

Kernberg, O. (2016). 29 Otto Kernberg. Youtube.com. Accessed on 05/2017. https://youtu.be/-H9qZBIfjHM

Further Reading:

Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2007). Psychotherapy for borderline personality: Focusing on object relations. American Psychiatric Pub.

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., … & Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. The British Journal of Psychiatry, 196(5), 389-395.

Yeomans, F. E., Levy, K. N., & Caligor, E. (2013). Transference-focused psychotherapy. Psychotherapy, 50(3), 449.

Kabat-Zinn Quote on Responsibility of Parents

This is a excerpt from an article, Can attachment theory explain our relationships?

Kabat-Zinn: The meaning of being a parent is that you take responsibility for your child’s life until they can take responsibility for their own life. That’s it!

Me: That’s a lot.

Kabat-Zinn: True, and it doesn’t mean you can’t get help. Turns out how you are as a parent makes a huge difference in the neural development of your child for the first four or five years.

Me: That is so frightening.

Kabat-Zinn: All that’s required, though, is connection. That’s all.

Me: But I want to be separate from my child; I don’t want to be connected all the time.

Kabat-Zinn: I see. Well, everything has consequences. How old is your child?

Me: Four and a half.

Kabat-Zinn: Well, I gotta say, I have very strong feelings about that kind of thing. She didn’t ask to be born.  

Who is Psychotherapy for?

Notice that this question starts not with the “what” but with the “who”. How psychotherapy works is unlike in other medical fields, in which the doctor does the healing “work” while the patient lies restfully and tries to recuperate from his symptoms. In psychotherapy the therapists functions to support the patient in his/her efforts to alleviate his/her own symptoms.

The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.

This means that the patient’s input is essential to the outcome. It is the skill of the therapist to lead the patient to this engagement. There are many techniques that can be employed, and hence many kind of therapies. However these methods are essentially means to guide the patient towards the motivation and awareness of him/herself. The ultimate work happens when there is contact between the client to him/herself and to the therapist. This contact takes effort on the part of the therapist to nurture, and when it happens, the patient feels a “shift” in his/herself. This shift is an indication the something internal has changed.

This may sound abstract, and it is. Psychotherapy is a craft and a skill learned. To be a psychotherapeutic client with successful outcome is also learnt. The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.

That is the goal of therapy: to relieve psychological or somatic symptoms through dialogue and contact. A patient suffering debilitating panic attacks, for example, slowly learns the psychological process and childhood experiences behind these attacks. The therapist supports him/her into contacting his/her unconscious activity and past emotions and unmet needs. In receiving this contact, the therapist works with the client through these experiences. The client is then able to make meaning of these experiences and learns to find resources to deal with pending situations.

So, who is psychotherapy for? It is for anyone who needs clarity in his/her life. He/she does not need to be “sick” or “dysfunctional” to start therapy. In actuality, it is better (and also cost-effective) to enter therapy as a healthy, stressed out, panicky individual, than to wait till the stress becomes too overwhelming.

 

How do we classify mental diseases?

There are 2 main classifications standards that are used today in the western world to diagnose psychopathological symptoms.

In the field psychotherapy, the concept of diagnostics is controversial. The reason being that unlike some physical problems, psychological issues are individual. For example, there is no one single cause of borderline personality disorder (BPD), but an array of situations that occur in the patient’s life that leads up to the symptoms. Diagnosing the symptoms are also complex, since each patient has his/her own way of dealing with the psychological trauma that leads to the condition. However putting labels onto observable psychological and behavioral conditions are necessary for professional to communicate with administrative bodies like psychiatrists, insurance companies, the courts, etc.

The ICD-10 by the World Health Organization (WHO)

The ICD-1o is also known as the International Statistical Classification of Diseases. It is the most recognized diagnostic classification system in the medical profession, and is provided by the WHO.

In the ICD-10 classification of mental disorders (or psychopathology) is categorized in Chapter F. Click here to have a complete online list of the ICD-10 classification of mental disorders.

This chapter contains the following blocks:
  • F00-F09Organic, including symptomatic, mental disorders
  • F10-F19Mental and behavioural disorders due to psychoactive substance use
  • F20-F29Schizophrenia, schizotypal and delusional disorders
  • F30-F39Mood [affective] disorders
  • F40-F48Neurotic, stress-related and somatoform disorders
  • F50-F59Behavioural syndromes associated with physiological disturbances and physical factors
  • F60-F69Disorders of adult personality and behaviour
  • F70-F79Mental retardation
  • F80-F89Disorders of psychological development
  • F90-F98Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
  • F99-F99Unspecified mental disorder

ICD-11 is due to be out in 2018.

The DSM-5 by the American Psychiatric Association (APA)

DSM-5 is the short form for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

 The DSM-5 was published in May 2013.