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What is Psychosomatics?

What is Psychosomatics?

Psychosomatics is a scholarly discipline of medicine with a rich history. The term psychosomatic was coined in 1818 by Johan Heinroth, and the words psychosomatic medicine is known to be used around 1912; the term being a combination of psychological and body function. Contributing to the development of psychosomatic medicine are the fields of psychoanalysis and psycho-physiologists that work with the mind-body interaction (Levenson, 2005).

As one looks towards the other non-medical and non-therapeutic fields, one also stumbles upon the philosophers like Maurice Merleau-Ponty, who had taken the non-dualistic view that that the ideological separation of mind and body is erroneous. In Phenomenology of Perception originally published in 1945, Merleau-Ponty explains that the body is consciousness, and not separate from the mind: “Bodily experience forces us to acknowledge an imposition of meaning, which is not the work of a universal-constituting consciousness, a meaning which clings to certain contents. My body is the meaningful core which behaves like a general function, and which, nevertheless, exists and is susceptible to disease” (Merleau-Ponty, 2004).

Levenson (2005), in citing three general groups of patients— i.e. “those with comorbid psychiatric and general medical illnesses complicating each other’s management, those with somatoform and functional disorders, and those with psychiatric disorders that are the direct consequence of a primary medical condition or treatment”— gives us an idea of how psychosomatic disorder is considered by the medical profession; that medical and psychological are linked in a way that one is a cause of the other. The perspective of Merleau-Ponty’s writings—and psychotherapists from modalities that are founded on the phenomenological experience— begs to differ from this point-of-view. They consider both medical and psychological ailments are one and the same thing.

A Holistic Point of View

This phenomenological viewpoint marks the movement towards holistic recognition of the connection between what we perceive as mental and physical cause-and-effects of illnesses and the respective treatment of symptoms. This attitude makes psychosomatics stand out from other disciplines of medicine. There is also the implicit recognition that patients suffering from organic diseases recover better with integration of medial and psychological therapy than with just medicine alone.

Historical Concepts of Psychosomatic Medicine

That psychosomatic medicine is considered a new discipline in the medical profession is paradoxical to the history of medicine itself.  Millennia before construct of physics, primitive man understood phenomenologically how his own psyche affected his physical actions, in so doing, attributed the forces of nature to human-like emotional states as well (Alexander, 1962).  This natural sensitivity of human beings to perceive mind and body as inseparable concepts is evident in traditional and folk medicine. Traditional Chinese medicine (TCM) is a good example since it developed independently and possesses written records dating back to 1500 BC (Tseng, 1973).

TCM is based primarily on the idea of correspondence between organism (microcosm) and its environment (macrocosm). Like the “primitive man” idea described by Alexander (1962), this is a belief in the conceptual connection between the body and nature. TCM considers human emotions the “vital air” in the body, which has its equivalence in nature. The body is characterized by its visceral organs. Patients frequently describe their psychiatric problems in terms of organs, like “exercised heart” to give meaning to apprehension, “injured heart” to mean sadness, and “elevated liver fire” to mean agitation and tension (Tseng, 1973). Since psychological problems are deemed somatic and organ-based, ancient Chinese did not separate psychiatric disorders from other medical illness.

Attempts at explanation of natural phenomena is a preoccupation of western civilization, commonly traced to Greek cosmologists of the pre-Socratic era at around 600 BC- 400 BC. Substances like water, air and fire were used – almost metaphorically— to give material foundation for explaining illnesses. Similar ideas were also seen in the medicine of other cultures like those in the Islamic world, Tibet and India (Sabernig, 2016).  This materialist way of understanding disease afflictions can be extrapolated to the modern-day reductionist scientific thinking. The milestone of this idea is popularly traced to Hippocrates in 400 BC, who declared the cause of epilepsy to be material in nature with nothing to do with the “sacred” (Alexander, 1962).

Interestingly enough, when one traces the roots of dynamic psychiatry, one is led to the very concept that Hippocrates disproved in the early days: the idea that demonology has anything to do with the physical condition. In almost every culture, there existed faith healing. Medical anthropologists like Forest E. Clement and Erwin H. Ackerknecht in his early 20th century attempted to systematize primitive medical beliefs and practices. Clement categorized disease theory of the ancient healers into 5 main forms: disease-object intrusion, loss of the soul, spirit intrusion, breach of taboo, and sorcery. For each of these theory there existed corresponding therapeutic methods. These methods included extraction of diseased object, to resort lost soul, exorcism, transference of the foreign spirit to another living being, confession and counter magic.

Ackerknecht showed that the true ancestors of the modern physician are the lay healers, that is, those men to whom the medicine man left the empirical and physical care of the patients), whereas “the medicine man is rather the ancestor of the priest, the physician’s antagonist for centuries” (Ellenberger, 2008, S. 5-48). By taking us through the the era of faith healing to the discovery of the unconscious Ellenberger can help us make sense of how the idea of demonology could have existed as explanation for psychological afflictions during the period of the Dark Ages. The psyche— and consciousness in itself— is, after all, a concept that has been illusive to human awareness, until the 18th Century.

The 20th century saw the movement towards re-integration of this medical field through the development of psychoanalysis and the use of psychotherapeutic methods including hypnosis in dealing with physical healing, as well as the work on the body to aid psychological problems. With the advancement of new technology like neuroscience, we can expect to see the move towards integration and separation of handling of what is deemed psychological and what is deemed somatic issues again and again; this happens as long as mind and body cannot be understood or accepted as one whole which is more than the sum of its parts.  Holism, as with phenomenology, are philosophical foundation in some psychotherapeutic methods that deals with symptoms suffered by individuals in an integrated manner.

 

Categorization of Psychosomatic Disturbances

Given the broad understanding of psychosomatics, one may create categorization of the specific disorders in a number of ways (Mörtl, 2016). In the medical profession, the categorization may be done according to the anatomical location, i.e. the skin, the musculoskeletal, cardiovascular, lymphatic, gastrointestinal genito-urinary, endocrine and nervous systems and specific organ reactions. Another classification system is one based upon the dynamic in which the disorders evolve. They could be:

  • psychological afflictions caused by bodily symptoms, otherwise known as psychophysiologic, psychosomatic or somatoform disorders. These disorders do not present in itself organic causes, which often lead the sufferer to seek multiple medical consultations without result. These symptoms can be observed physiologically on the patient, and a description of the affliction can be made. The nosology— that which describes the underlying psychological causes of the condition— is much more complicated, and would require deeper understanding of the patient’s psychosocial situation as well. This category encompasses an array of somatic syndromes, those which maybe related to mood (affective) disorders, neurotic and stress-related disorders, behavioral syndromes, personality disorders, mental retardation and disorders in psychological development.
  • Physiological problems that cause psychological disturbances, otherwise known as somatopsychic disorders. These disorders have organic causes, and include (but not exclusively) degenerative brain disorders like Dementia, disorders caused by lesions to the brain either caused by disease, damage or dysfunction. The causes of brain dysfunction may be also attributed to intoxication. Symptoms that afflict other parts of the body that also lead to the need for psychological care would be psychosocial influences that affect physical health. These broadly include addictions, poor nutrition and aging. Many physical diseases cause psychological stress, like chronic ailments and terminal conditions. Psychological help is needed to help patients cope with their symptoms, and the consequences of disease.

 

Classification of psychosomatic symptoms

Contemporary textbooks and diagnostic manuals commonly classify psychosomatic disorders as:

  • Somatoform: Physical disturbances caused by somatization of psychological problems. This includes somatoform-autonomous symptoms— like tinnitus, irritable bowel syndrome, and cardiovascular heart disease— non-organic sleep disorder, non-organic sexual disorders, conversion disorder and non-organic migraine.
  • Eating disorders: Behavioral conditions as result of psycho-social problems resulting in Anorexia Nervosa, Bulimia Nervosa and Binge Eating disorder.
  • Potential psychosocial factors in organic disorders in organic disorders like Hypertonia, bronchial Asthma, Colitis Ulcerosa, and Neurodermatitis.
  • Somatopsychic disorders: characterized by psychological symptoms with organic origins like brain lesions, strokes and tumors that cause structural damage and/or biochemical, dysfunction, adversely affecting normal brain activity. This also includes psychological problems in dealing with pain, chronic illnesses, and consequences of surgeries and injuries.

Conclusion

When we consider Merleau-Ponty and the holistic philosophers, it should be a given that the condition of the physical body is one and the same with the mind. In the western world of knowledge politics, this basic wisdom is somewhat put aside in favor of reductionist thinking.  The idea that “psychosomatics” be a discipline rather than a standard form of looking at symptoms is proof of this. The classification in psychosomatic medicine is helpful for practitioners and patients alike to discover which came first— the psychological problems or the physical ones. That, however, cannot really tell much else, since every single client is a unique case study in him/herself in relation to his/her own environment. Non-holistic observing of the client could be the reason that many in the medical and psychotherapeutic professions alike find difficulty working with psychosomatic problems and keeping the clients in therapy.

Development in psychosomatics and psychotherapy may lead to greater arguments among psychotherapy modalities as well as fields of medicine. These studies may also bring the modalities in a common agreement as well. It would be interesting to realize, perhaps, how almost every person suffers from some kind of psychosomatic issue, and how their personality, muscularity, adiposity or aging are linked. The term “psychosomatics” alone conjures a whole philosophical understanding of what it means to have mind and body.

Bibliography

Alexander, F. (1962). The development of psychosomatic medicine. Psychosomatic medicine, 24(1), 13-24.

Ellenberger, H. F. (2008). The discovery of the unconscious: The history and evolution of dynamic psychiatry. Basic Books.

Levenson, J. L. (2005). Textbook of psychosomatic medicine. (J. L. Levenson, Ed.) VA: The American Psychiatric Publishing.

Merleau-Ponty, M. (2004). Maurice Merleau-Ponty: Basic writings. (T. Baldwin, Ed.) NY: Psychology Press.

Tseng, W. S. (1973). The development of psychiatric concepts in traditional medicine. Archives of General Psychiatry, 29, 569-575.

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Freud and Fiction: The Psychological Thinking about Literature

Thought and speech are constituted by language. The medium of our consciousness, also known as our psyche, can be understood from verbal thought, as Lacan says, “the unconscious is structured like a language.”

In this blog, I re-post an interesting lecture “Introduction to Theory of Literature ” by Fry (2009). Fry talks about the essay of Peter Brook, “Freud’s Masterplot: a Model for Narrative”, a chapter in his book, “Reading for Plot, Design and Intention in Narrative“. From this essay the psychological meaning of discourse is developed and discussed.

Brooks on Jakobson and de Man

Plot vs. the Story: The Plot, which Brooks calls, syuzhet  in Russian. The story, fabula, it is the subject matter out of which the plot is made.

Metaphor and Metonymy: 

Metaphor unifies, brings together different ideas, situations.

Metonymy brings things together “by a recognizable gesture toward contiguity but which nevertheless does not make any claim or pretension to unify or establish identity” — without unifying. Metonymy is a figure of speech which a thing or concept is called not by its own name but rather the name of something associated in meaning with that thing or concept.

Reading Jakobson and de Man, Brooks helps us understand the terms described to us above.  In Brooks’ essay, “Freud’s Masterplot,” the that the framework for argument is psychoanalytic and that the author is draws primarily from the text of Freud’s Beyond the Pleasure Principle.

On Freud

In this essay Brooks takes from Freud is the idea of structure. The idea that the unconscious is structured like a language. Hence in psychoanalysis is considered a “talking cure”, in which the unconscious is revealed via narrating and free association. “Talking cure” was first coined in the case of Anna O.

In terms of creating fictional plots, in terms of the nature of fiction, which is what interests Brooks–well, what does this mean?

Aristotle tells us that a plot has a beginning, a middle and an end. It seems almost logical, but we should consider this … A beginning, of course–well, it has to have a beginning and it has to have an end… but why does it have a middle? What is the function of the middle with respect to a beginning and an end? Why does Aristotle say, that a plot should have a certain magnitude? Why shouldn’t it be shorter? Why shouldn’t it be longer?

What does the middle have to do with the necessary connection with the beginning and the end, in such a way that resolves a kind of logic that makes the story worth being?  How does all this work? Brooks believes that he can understand it in psychoanalytic terms.

From Freud’s  The Interpretation of Dreams, Brook finds the methodological idea that text can be “mechanized”.

The central two mechanisms of the dream work are simultaneously:

  1. Condensation : takes essential symbols of the dream and distills them into a kind of over-determined unit, so that one can see the underlying desires and wishes expressed in a dream, manifest in a particular symbolic unity.
  2. Displacement: essential symbols of the dream, the way a dream attempts to manifest that which it desires, are not  expressed in themselves but are displaced into obscurely related ideas or images or symbols.

Displacement is a detour of understanding. Condensation is a distillation of understanding. SIMULTANEOUSLY.

Jacques Lacan probably noticed that the work in every day discourse, and also in our dreams, and our narratives, can be understood as operating through these two mechanisms, condensation and displacement.

Condensation is metaphorical in nature, and displacement metonymic in nature. Metonymy is delaying, and a “différance of signification”– or deferring to a later time. Metaphor is in trying to bring together meaning “in a statement of identity of the discourse that’s attempting to articulate itself”, bringing together identity, “affirmation of resemblance”.

brooks freud

So we can see how Brooks combines Freud’s structure in the interpretation of dreams, showing its correlation with Jakobson and de Man’s structure of literature.  Brooks is not interested in the psychogenesis of the author, nor the characters.

The text is not there to tell us about the author or the character. The text is alive, to express desire, put in motion. The structure of the text is there to manifest desire. Freud has a particular desire to fulfill a desire for reduced excitation. can be associate the death wish as the reduction of excitation.

Brooks’ Departure from Freudian Criticism

Brook is taking a different angle with his essay by not getting involved in freudian criticism nor does he talk about how freudian ideas are used in literature.  

“I would remind you in passing that although we don’t pause over traditional Freudian criticism in this course, it can indeed be extremely interesting: just for example, Freud’s disciple, Ernest Jones, wrote an influential study of Shakespeare’s Hamlet in which he showed famously that Hamlet has an Oedipus complex. Think about the play. You’ll see that there’s a good deal in what Jones is saying; and in fact, famously in the history of the staging and filming of Shakespeare–as you probably know, Sir Laurence Olivier took the role of Hamlet under the influence of Ernest Jones. In the Olivier production of Hamlet, let’s just say made it painfully clear in his relations with Gertrude that he had an Oedipus complex. Again, there were actual sort of literary texts written directly under the influence of Freud. One thinks of D. H. Lawrence’s Sons and Lovers, for example, in which the central character, Paul Morel, is crippled by an Oedipus complex that he can’t master and the difficulties and complications of the plot are of this kind.”

“Moving closer to the present, an important figure in literary theory, Harold Bloom, can be understood to be developing in his theories of theoretical text, beginning with The Anxiety of Influence, a theory of the author–that is to say, a theory that is based on the relationship between belated poets and their precursors, which is to say a relationship between sons and fathers. So there is a certain pattern in–and of course, I invoke this pattern in arguing that Levi-Strauss‘ version of the Oedipus myth betrays his Oedipus complex in relation to Freud. Plainly, Freudian criticism with these sorts of preoccupations is widespread, continues sometimes to appear, and cannot simply be discounted or ignored as an influence in the development of thinking about literature or of the possibilities of thinking about literature.”

The text is there to express desire, to put in motion, and to make manifest desire or a desire. Brooks says that he has a particular desire in mind.

The structure of the text, or the way in which the text functions is to fulfill a desire for reduced excitation.  This means that the desire which can be associated with the pleasure principle in sexual terms and can be associated with the idea of the death wish that Freud develops in Beyond the Pleasure Principle.

In these ways Brooks understands the structure, the delay, the arabesque, or postponement of the end.

Within the text there involves a kind of coexistence between the possibility through “desire of reducing excitation, being excited, and reducing excitation.”

Dreams and stories don’t just express this desire; they also delay it.

Many of the dreams we have are neither exciting, and are tedious. Fiction, as art, has structure, and is thus precisely designed to create delay to a desired degree but not unduly beyond that degree.

Middle of fiction involve this process of delay, they seem also to revisit un-pleasurable things.  The experiences that constitute the middles have a tendency to un-pleasurable. The middles are not un-interesting, but they are page turners because they reflect un-pleasant episodes… which we seem to be fascinated with.

Why, in other words, return to what isn’t fun, to where it isn’t pleasure, and what can this possibly have to do with the pleasure principle?

Brooks p. 96-97
Brooks p. 96
Brooks p. 96-97
Brooks p. 97
Beyond the Pleasure Principle

In Beyond the Pleasure Principle,  Freud considers the phenomena experienced with trauma victims. Written at the end of the First World War,  many of the contemporary books written in that time dealt with the subject of war experiences: Virginia’s Woolf’s Mrs. Dalloway, that her treatment of Septimus Smith in Mrs. Dalloway is a treatment of a traumatized war victim and Rebecca West, wrote one in particular called The Return of the Soldier, the protagonist of which is also a traumatized war victim. It seemed to be the theme of the period and Freud’s Beyond the Pleasure Principle contributes to this theme.

Brooks himself likes to refer to the text of Beyond the Pleasure Principle as itself a master plot–in other words as having a certain fictive character, like The Return of the Soldier or Mrs. Dalloway.

Freud begins by saying, “The weird thing about these trauma victims whom I have had in my office is that in describing their dreams and even in their various forms of neurotic repetitive behavior, they seem compulsively to repeat the traumatic experience that has put them in the very predicament that brought them to me. In other words, they don’t shy away from it. They don’t in any strict sense repress it. They keep compulsively going back to it. Why is that? How can that possibly be a manifestation of the only kind of drives I had ever thought existed up until the year 1919, namely drives that we can associate in one way or another with pleasure–with the pleasure principle, obviously; with a sort of implicit sociobiological understanding that the protraction of life is all about sexual reproduction and that the displacement or inhibition of the direct drives associated with that take the form of the desire to succeed, the desire to improve oneself, and the desire to become more complex emotionally and all the rest of it? All of this we can associate with the pleasure principle. How does this compulsion to return to the traumatic event in any way correspond to or submit itself to explanation in terms of the pleasure principle?”

“The Aim of All Life is Death”

The compulsion to repeat, manifests itself in adults in various forms of neurotic behavior.  We can think of it in terms of effort at mastery of something, like a rehearsal of the inevitability of death. The trauma of death which awaits and which has been heralded by traumatic events in one’s life, a near escape: for example, in a train accident or whatever the case may be. So Freud in developing his argument eventually comes to think that the compulsion to repeat has something to do with a kind of repeating forward of an event which is in itself unnarratable: the event of death, which is of course that which ultimately looms.

Freud’s argument is that there is somehow in us a compulsion or a desire, a drive, to return–like going home again or going back to the womb to return to that inanimate state. “The aim of all life,” he then says, “is death.”

Brooks says:

We need at present to follow Freud into his closer inquiry concerning the relation between the compulsion to repeat and the instinctual. The answer lies in “a universal attribute of instinct and perhaps of organic life in general,” that “an instinct is an urge inherent in organic life to restore an earlier state of things.“…

This function [of the drives] is concerned “with the most universal endeavor of all living substance–namely to return to the quiescence of the inorganic world.”

But there’s a reason as to why novels are long: “not too long, not too short, but of a certain length–of a certain magnitude, as Aristotle puts it.”

The organism doesn’t just want to die. The organism is not suicidal. That’s a crucial mistake that we make when we first try to come to terms with what Freud means by “the death wish.” The organism wants to die on its own terms, which is why it has an elaborate mechanism of defenses–“the outer cortex,” as Freud is always calling it–attempting to withstand, to process, and to keep at arm’s length the possibility of trauma. You blame yourself as a victim of trauma for not having the sufficient vigilance in your outer cortex to ward it off. Part of the compulsion to repeat is, in a certain sense–part of the hope of mastery in the compulsion to repeat is to keep up the kind of vigilance which you failed to have in the past and therefore fail to ward it off.

According to Freud, the organism wants to evolve toward its dissolution.

So there is this tension in the organism between evolving to its end and being modified prematurely toward an end, a modification which in terms of fiction would mean you wouldn’t have a plot, right? You might have a beginning, but you would have a sudden cutting off that prevented the arabesque of the plot from developing and arising.

Now what Brooks argues following Freud is that to this end, the creating of an atmosphere in which with dignity and integrity… this is where the pleasure principle and the death wish cooperate.

Hence Freud is able to proffer, with a certain bravado, the formulation: “the aim of all life is death.” We are given an evolutionary image of the organism in which the tension created by external influences has forced living substance to “diverge ever more widely from its original course of life and to make ever more complicated détours before reaching its aim of death.” In this view, the self-preservative instincts function to assure that the organism shall follow its own path to death, to ward off any ways of returning to the inorganic which are not imminent to the organism itself. In other words, “the organism wishes to die only in its own fashion.” It must struggle against events (dangers) which would help to achieve its goal too rapidly–by a kind of short-circuit.

… [W]e could say that the repetition compulsion and the death instinct serve the pleasure principle; in a larger sense [though], the pleasure principle, keeping watch on the invasion of stimuli from without and especially from within, seeking their discharge, serves the death instinct, making sure that the organism is permitted to return to quiescence.

Two differing drives coexist in the developing and enriching of the good plot.

The problem in Beyond the Pleasure Principle, is that it’s awfully hard to keep death and sex separate. The reduction of excitation is obviously something that the pleasure principle is all about. The purpose of sex is to reduce excitation, to annul desire. The purpose of death, Freud argues, is to do the same thing.

For example,  the compulsion to repeat nasty episodes, to revisit trauma, and to repeat the un-pleasurable.  It could be called something which is a kind of pleasure and which therefore could be subsumed under the pleasure principle and would obviate the need for a theory of the death drive as Freud develops it in Beyond the Pleasure Principle.

As with the plot: desire emerges or begins as the narratable.

What is the unnarratable? The unnarratable is that immersion in our lives such that there is no sense of form or order or structure. Anything is unnarratable if we don’t have a sense of a beginning, a middle, and an end to bring to bear on it. The narratable, in other words, must enter into a structure. So the beginning, which is meditated on by Sartre’s Roquentin in La Nausee and quoted to that effect by Brooks. The narratable begins in this moment of entry into that pattern of desire that launches a fiction. We have speculated on what that desire consists in, and so the narratable becomes a plot and the plot operates through metaphor, which unifies the plot, which shows the remarkable coherence of all of its parts.

In narrative theory there’s no such thing in fiction as irrelevant detail. Nothing is there by accident. The nature of the underlying desire that’s driving the plot forward; but on the other hand, metonymy functions as the principle of delay, the detour, the arabesque, the refusal of closure; the settling upon bad object choice and other unfortunate outcomes, the return of the unpleasurable–all the things that happen in the structure of “middles” in literary plots. The plot finally binds material together, and both metaphor and metonymy are arguably forms of binding. Brooks says:

To speak of “binding” in a literary text is thus to speak of any of the formalizations (which, like binding, may be painful, retarding) that force us to recognize sameness within difference, or the very emergence of a sjužetfrom the material of fabula.

Tony the Tow Truck Revisited

Tony the Tow Truck. I would suggest that in the context of Beyond the Pleasure Principle we could re-title Tony the Tow Truck as The Bumpy Road to Maturity. It certainly has the qualities of a picaresque fiction. It’s on the road, as it were, and the linearity of its plot–the way in which the plot is like beads on a string, which tends to be the case with picaresque fiction, and which by the way is also a metonymic aspect of the fiction–lends the feeling of picturesque to the narrative. Quickly to reread it–I know that you all have it glued to your wrists, but in case you don’t, I’ll reread it:

I am Tony the Tow Truck. I live in a little yellow garage. I help cars that are stuck. I tow them to my garage. I like my job. One day I am stuck. Who will help Tony the Tow Truck? “I cannot help you,” says Neato the Car. “I don’t want to get dirty.” “I cannot help you [see, these are bad object choices, right?],” says Speedy the Car. “I am too busy.” I am very sad. Then a little car pulls up. It is my friend, Bumpy. Bumpy gives me a push. He pushes and pushes [by the way, this text, I think, is very close to its surface a kind of anal-phase parable. In that parable, the hero is not Tony in fact but a character with whom you are familiar if you’re familiar with South Park, and that character is of course the one who says, “He pushes and pushes…”] and I am on my way.” [In any case that is part of the narrative, and then:] “Thank you, Bumpy,” I call back. “You’re welcome,” says Bumpy. Now that’s what I call a friend.

So that’s the text of Tony the Tow Truck. Now we’ve said that it’s picaresque. We can think in terms of repetition, obviously, as the delay that sets in between an origin and an end. We’ve spoken of this in this case as–well, it’s the triadic form of the folk tale that Brooks actually mentions in his essay; but it is, in its dilation of the relationship of beginning and end, a way of reminding us precisely of that relation. He comes from a little yellow garage. The question is, and a question which is perhaps part of the unnarratable, is he going back there? We know he’s on his way, but we don’t know, if we read it in terms of Beyond the Pleasure Principle, whether he’s on his way back to the little yellow garage or whether–and there’s a premonition of this in being stuck, in other words in having broken down–whether he’s on his way to the junkyard.

In either case, the only point is that he will go to either place because the little yellow garage is that from which he came; in either case–little yellow garage or junkyard–he’s going to get there on his own terms, but not as a narcissist and not as the person who begins every sentence in the first part of the story with the word “I,” because you can’t just be an autonomous hero. On your journey, and this is also true of the study of folklore, you need a helper. That’s part of fiction. You need another hero. You need a hero to help you, and having that hero, encountering the other mind as helper, is what obviates the tendency, even in a nice guy like Tony, toward narcissism which is manifest in the “I,” “I,” “I” at the beginning of the story. Notice that then the “I” disappears, not completely but wherever it reappears it’s embedded rather than initial. It is no longer, in other words, that which drives the line in the story. So the arabesque of the plot, as I say, is a matter of encountering bad object choices and overcoming them: neatness, busyness–choices which, by the way, are on the surface temptations. We all want to be neat and busy, don’t we? But somehow or another it’s not enough because the otherness, the mutuality of regard that this story wants to enforce as life–as life properly lived–is not entailed in and of itself in neatness and busyness. Resolution and closure, then, is mature object choice and in a certain sense there, too, it’s a push forward, but we don’t quite know toward what. We have to assume, though, in the context of a reading of this kind that it’s a push toward a state in which the little yellow garage and the unnarratable junkyard are manifest as one and the same thing.

Now as metonymy, the delays we have been talking about, the paratactic structure of the way in which the story is told–all of those, and the elements of repetition, are forms that we recognize as metonymic, but there’s something beyond that at the level of theme. This is a story about cars. This is a story about mechanical objects, some of which move–remember those smiling houses in the background–and some of which are stationary, but they’re all mechanical objects. They’re all structures. In other words, they’re not organic. This is a world understood from a metonymic point of view as that which lacks organicity, and yet at the same time the whole point of the story is thematically metaphoric. It is to assert the common humanity of us all: “That’s what I call a friend.” The whole point of so many children’s stories, animal stories, other stories like this, The Little Engine that Could, and so on is to humanize the world: to render friendly and warm and inviting to the child the entire world, so that Tony is not a tow truck–Tony’s a human being, and he realizes humanity in recognizing the existence of a friend. The unity of the story, in other words, as opposed to its metonymic displacements through the mechanistic, is the triumphant humanization of the mechanistic and the fact that as we read the story, we feel that we are, after all, not in mechanical company but in human company.

That’s the effect of the story and the way it works. In terms of the pleasure principle then, life is best in a human universe and in terms of–well, in terms of Beyond the Pleasure Principle, the whole point of returning to an earlier state, the little yellow garage or junkyard, is to avert the threat that one being stuck will return to that junkyard prematurely or along the wrong path.

What is interesting?

Narratives are interesting. We compulsively repeat the unpleasant, return to the un-pleasurable… why? In order to gain mastery of what might otherwise be a moment of helplessness in the face of traumatic experiences. I am not sure if it is a death-wish as much as a defying of death. It is as if repeating the event is a means of making “banal” that which has caused so much “excitement” in the form of anxiety. 

As in psychotherapy, patients with psychological issues talk away their suffering. How does the talk do this? Talking or narrating, is a form of repeating unpleasant events. It is not the mere talking about something, but talking to someone who is listening. If there are more people listening, the healing effect gets better.

There is also an effect of hearing another person’s narrative on the listener. The listener is touched by the unpleasant narrative of the other. There is a vicarious effect (something to do with our mirror neurons) and our sense for empathy. Hearing another’s narrative, has a spiritual effect on the listener. This is the reason why we are drawn to such stories and narratives, of plots in literature.  NIk

References:

Brooks, P. (1992). Reading for the plot: Design and intention in narrative. Harvard University Press. p. 90. 

Fry, P. (2009). Introduction to Theory of Literature. Lecture retrieved from: https://www.youtube.com/watch?v=GnnWbVvnYIs.

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The Manic Need to Control : Kleinian Theory

These are excerpts on the subjects from notes taken from Carveth’s lecture “Introduction to Kleinian Theory 5”.

Manic defenses are manifested to protect the ego from despair. It is a means of being omnipotent, and is very much belongs to the paranoid-schizoid position as defined by Melanie Klein.

Inability to deal with loss, leads to symptoms, like depression, and behaviors, like rage. This is a sign of a regression into an existence of black-white thinking, in which there are projections made towards the outside world to ward off unbearable feeling. It is attack on psychic reality, in an effort to control the external objects.

Read also : Making Reparation and mourning as the road to mental healing.

Why the need to control, triumph?

These acts defend the self against realization of dependency. It defends against loss. Triumph is needed so that the person defeats the object, so that there is that “I do not have to care for the object”– which is an aggressive and dangerous condition.

This kind of thinking also serves to ward off envy. Hence it is better to come to terms with one’s feelings of envy, so that on can use it constructively, like for self improvement, than to avoid feelings of envy by trying to dominate and destroy the other.

Contempt is there to deny the object’s value …the object is rendered not worthy of guilt. Contempt justifies the abuse and annihilation of the other.

There is also “manic” in the culture we live in. Our culture as we know it, is one that seems to put taboo on tenderness.

Read also : Conformity and Obedience: Slippery Slope to Dehumanization of the Other and Privacy as Personal Control.

Quote from the 18th Century on Control of the Other

Jean Jacques Rousseau (1712–1778) in Social Contract 1762:

“Man is born free; and everywhere he is in chains. One thinks himself the master of others, and still remains a greater slave than they. How did this change come about? I do not know. What can make it legitimate? That question I think I can answer.”

 

Notable notes:

Interesting points (at the last 5 mins of the video) on guilt, control and being omnipotent.

Strategies for dealing with the object related

From Britton’s Sex Death Superego:

  1. The Schizoid withdraws from the object
  2. The borderline colonizes the object
  3. The Hysteric impersonates

From Carveth‘s The Still Small Voice :

  1. The psychotic denies the reality of the
  2. The pervert castrates the object#
  3. The psychopath destroy
  4. The neurotic acknowledge dependence and guilt towards and suffers from the conflicts
  5. The healthy person repairs loves depends on and sacrifices for good object but also prepared to hate the bad object

Bibliography

Carveth, D. (2016) Introduction to Kleinian Theory 5. YouTube Video. Retrieved from https://youtu.be/VxdWHU1wrBY on 12.2017.

 

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Bion: The Function of Myths in Groups

A group is not an aggregate of individuals. It’s a body that has a mental state and creates a phantasy.

The group produces its own mythology. When the group work is focused on primary functioning, in problem solving, this causes the surfacing of anxiety. Myth has function. It acts as mediator from the mother – infant position to society.

From narcissism (living as only me) to socialism (living as part of society). Myth generates reaction and response because it connects the inner worlds of people. Myths can also be changed. Psychomythology.

Myths are used by the mother to explain “facts of life”.  It provides a illusion that answers the questions of the child and solves his/her developmental problems in understanding the self and world around him/her.

Parent-child transferences are re-played by individuals in groups. Family stories are re-told through unconscious acting out in groups.

Myths also occur in “work” & “non-work” transition.

External influences that change the group pose challenges to status quo of the group. This makes the group conscious of itself. Arrival of a new member, e.g., creates this kind of uncertainty and awareness.

This is a fright-flight response*, but with decorum. The new member is instructed then implicitly how to tow the line.

The task of making contact with the emotional life of the group is like the contact between mother and child. Breast mother family group. The chapter in this book describes an interesting case study of a group therapy, in whicha new member enters the group (Garland 2003).

 

 Note

Bion describes the situation that unfolds when the group is left without a leader. The leaderless group is displaced by one of the following: 

baD: Basic Assumption Dependency –> the need for an omnipotent omniscient leader (a kind of God).

baP: Basic Assumption Pairing –> Group members support tactically a  pairing, with a basic assumption that something good is going to come out of it (like a primal scene).

baF: Basic Assumption Fright Flight –> there is need for rational leadership. If the ability to reason fails, the group plunges into anxiety and hatred.There is regression, and a need to hold onto magical thinking. The group finds the man/woman that has marked paranoid tendencies (Carveth, 2017).

Bibliography:

Carveth, D. (2017). THE TRUMP EFFECT: Freud’s and Bion’s Group Psychologies. Youtube video: https://www.youtube.com/watch?v=SdWG8UiAtpE .

Garland, C. (2003). Group Therapy, Myth in the Service of Work. Mawson, C. (Ed.). Bion today. Routledge. p. 298-316.

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Making Reparation & Mourning as the Road to Mental Healing

Reparation allows us to live out loud. When I can apologize, I have less inhibition. According to Melanie Klein, Reparation is a basis of creativity… to restore the loss. Capable of recovery.

We make reparation for our miss-doings. We are humans and we make mistakes. Sometimes it is our negligence that hurt others. Sometimes we are just too weak, too young, too old, too ill, too afraid to do the right thing at a particular time.

Mourning is involved in also other aspects of losses, which does not involve the death of another, but rather the death of one’s sense of self. An example of how this can happen is when one is being diagnosed with a debilitating illness or has become disabled in some way, or has a child/family that is diagnosed as such. Mourning is also “the reaction related to painful experiences that entail an experience of loss — such as loss of the quality of life, loss of health, loss of previous self-identity, loss of hope, or loss of the container function of the parents. (Barone 2005)”

Owning up to our mistakes/shortfall/incompetencies and taking responsibility for hurt caused is a means of making reparation.

In so doing we also mourn the losses (a broken relationship, a lost trust, a lost opportunity, a metaphorical or real death) as a result of our incapacity to do what was necessary to avoid the unfortunate situation.

Being able to face with the loss / to accept responsibility is the path towards inner-strength. We are able to move on from our human failing. We know that we have the resources in us to get on with life because we are able to overcome a mistake that caused us guilt.

Facing up to one’s role in such losses is not the same as blaming oneself. It is to acknowledge what actually happened, and how one was part of it. To blame oneself is to accuse oneself of something one doesn’t believe one has responsibility for. 

Gestalt Therapy Case Example of Making Reparations

Mr. K, a young man of 23, comes to therapy with impulsive anger issues. He has been incarcerated for assault and battery. Each time he regresses into violent behavior, he regrets it, and feels guilt. However, at the slightest provocation, he bursts into uncontrolled rage.

He has been to behavioral therapy to control his impulses. The treatment did not work and he was sorely frustrated. In jail, he was offered gestalt therapy counseling from an intern–  what looked like fighting fire with paper.

The therapist realized after 4 sessions a pattern in this client. Each session, he earnestly repeated the same story to her. Each time he did so, he revved himself into anger. It was a story of his childhood. His father had a violent nature and would beat his mother. As a child, from his early childhood, he remembers his mother in tears of fear and frustration as she served the family their meals. His older brothers were also later violent towards her and Mr. K.

The work for Mr. K turned out to be one of reparation. This was only possible because he was able to feel sadness and guilt (in the case of violent patients who do not feel this kind of remorse, it might not be possible).

Mr. K. was supported to revisit this childhood scene, and as he was retelling the story, the therapist asked him to hold back his anger and breathe by saying comforting words. She asked him what he experienced watching his mother’s sadness. He said he felt hopeless. He said he was too small and afraid to save her.

The therapist supported the client with helping him formulate these statements: “mother, I am 6 years old, and I am too small and too weak to save you.” and to himself “K, I am sorry, I am 6 years old and I am too small and too afraid to save your mother.”

Both K and the therapist were very touched by the phenomenon in the therapy room. This is the taking of responsibility. It is not self blame, but the recognition that one was simply not humanly able to save the mother.

The next steps came naturally. The therapist guided the client in a mourning process. The loss of a mother that could protect the son. Weeks of therapy was devoted to this process. It included creating art, writing poems.

Incapacity to make reparations and mental pain

There are individuals who have difficulty or have not capacity to accept responsibility. This is a mental state for some people and is part of their personality. In psychoanalytic term, it is a condition of being stuck in the paranoid-schizoid position and not being able to move forward to the more ambivalent depressive (nothing to do with depression) position.

When one is stuck in the paranoid-schizoid position, one suffers deep depression and paranoid anxiety. One’s state of mind is that on seeing the world in black and white and nothing in between. Everything is either very good or very bad. This was Mr. K’s life before his sessions with the therapist. He was had paranoid rage, and was very depressed.

Being so paranoid also leads one to have a need for omnipotence, which one displays through grandiosity or threatening (manic) behavior.

Taking responsibility for one’s own deeds is a lessening of omnipotence. Discovery of the resilience of the good object. Less fear of destroying it.

 


Manic reparation in the Paranoid-Schzoid position.

Say for example a man who strikes his wife then brings her flowers. Avoidance of acknowledging damage done, his aims to repair the hurt is in such a way that his own feelings of guilt and loss is never experienced. Not acknowledged. His wife is felt as inferior, dependent and contemptible. She is confused by his behavior. He then considers her ungrateful. He blames her for his anger towards her.

In this case his unconscious guilt is not reprieved. The good object, the wife, is “magically repaired”. Instant repair. It is like the instant cure of swallowing pills instead of going through therapy. Of going to sleep so that you do not see.

Emotional tantrum is used also as a quick way of handling problem

How do, for example, some people reveal their contempt? By raising emotionality. This is also see among people who do good deeds, like some social workers and activists?

Freud on Mourning and Melancholia

Freud (1922), in Mourning and Melancholia, writes about the ability to mourn as a means of overcoming loss. The inability to mourn or the absence of the mourning process leads to melancholia, which we understand today as major depression.

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Genuine Reparation and Creativity

Genuine reparation is slow, there is no quick fix. It takes consideration of the other person. It takes mourning the damage. It takes getting to experience the guilt, the fear of damaging the good object, the relationship. It also takes creativity.

Renunciation of magic and omnipotence. Allows the object to be free. To accept the separateness of the object. This is how we overcome guilt.

Un-recognized guilt, leads to aggression turned towards the self, which is a condition we know as major depression.

Hence the recognition of a loss and the process going through the mourning process, is essential to recovery and prevention of major depression. Much of the therapeutic process involves in one way or another accompanied mourning of loss.

Bibliography

Barone, K. C. (2005). On the processes of working through loss caused by severe illnesses in childhood: a psychoanalytic approach. Psychoanalytic Psychotherapy19(1), 17-34.

Klein, M. (2002). Love, guilt and reparation: and other works 1921-1945 (Vol. 1). Simon and Schuster.

Freud, S. (1922). Mourning and melancholia. The Journal of Nervous and Mental Disease56(5), 543-545.

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The Function of Religion in Mental Health Today

Religion is in the modern “westernized” world today a topic of contention, that sparked off ever since the era of the Radical Enlightenment that began in the 18th Century in Europe. The situation is somewhat reversed in Asia because the religion of Asia was not Christianity till after this era. Since the theme of this website is not focussed on Religion or History, we cannot completely separate these aspects of cultural anthropology from modern life.

Religion founds the value system of the person. In Psychotherapy, we view the person’s wholeness. This includes the patient’s cultural background and religion. Religion is an important factor of life regardless of whether the person admits it to him/herself or not.

This is the focus of this article: to connect religion in mental health, and to mention the similarities and dis-similarities between the mindset of the two institutions– Religion (Christianity, in particular) and Psychotherapy.

Religion and Metaphors

Religion is transmitted by spoken and written word. Some are also depicted through art. There is hardly any religion in this world that is not transmitted through texts. Literature and art are language of metaphors. It is because of the use of metaphors that the meanings and wisdom of the texts can transcend through time.

Metaphors are poetic. These poetry contain truths about human nature and relationships, truth about our existence, our humanness as part of nature, and wisdom (Carveth, 2017). These are valuable messages that we learn through our culture and hand down to our children.

Much of this poetry is also transmitted through art. Visual art and music. This is how we attain the feelings and the essence of the religious influence.

As part of being human, we gain much from being able to absorb the images, poetry and music and make meaning out of them.

Some of these metaphors are considered myths. Myths are the stings that connect people in a group (Bion on Groups).

This is also known in Cultural anthropology as symbolism.

When we use symbols, we are able to grasp profound meanings through the symbols. We do not just look at the symbol as an object for what it is.

For example, a dove may symbolize peace. When taken literally a dove is just a white bird.

 

Religion against Pathological Narcissism

Narcissism is a word that very much belongs to the world of mental health. To the psychotherapist, narcissism is the root of mental and relationship issues. Religion, in its roots, and psychotherapy share, in a way a common goal of weaning man out of narcissism. There is a differentiation between healthy narcissism and unhealthy narcissism. Healthy narcissism is a self-preserving instinct that help us excel and survive in life. In this context, unhealthy narcissism is being referred to. Unhealthy narcissism is a borderline-operated personality structure as defined by Kernberg.

Read also: Kernberg’s Model of Narcissistic Personality Disorder

The intrinsic value system most religions is one of denouncing self grandiosity, entitlement and the exploitation of others. In the beatitudes recited by Jesus, it is written in Matthew 5:1-12:

“Blessed are the poor in spirit,
    for theirs is the kingdom of heaven.
Blessed are those who mourn,
    for they will be comforted.
Blessed are the meek,
    for they will inherit the earth.
Blessed are those who hunger and thirst for righteousness,
    for they will be filled.
Blessed are the merciful,
    for they will be shown mercy.
Blessed are the pure in heart,
    for they will see God.
Blessed are the peacemakers,
    for they will be called children of God.
10 Blessed are those who are persecuted because of righteousness,
    for theirs is the kingdom of heaven.”

In the beatitudes, Jesus lists out the qualities in a person’s character, and this aligns with Kleinian thought: that healing comes with the ability to mourn, accept one’s weakness, reconciliation (accepting others’ guilt and hence one’s own). Read also: The Manic Need to Control : Kleinian Theory

Religion against Idolatory

The grandiose self-image, and all the objects associate with this image (i.e. wealth, intelligence, looks…etc.) are the worshipped idols. The person is fixated on them, and has no time for anyone else. Idolatry is a projection of value on to external objects. It is a means of being a creator of something/someone greater than oneself. Underlying is the need to feel omnipotent, avoiding the shame of being small.

Religion against Self-Omnipotence, Pride and Oppression of Others

The narcissist lives in a state of constant need for omnipotence. No man is omnipotent, because we are vulnerable to the forces of nature. Eventually we get weak and die. The narcissist cannot deal with that and works against this dreadful thought by creating mental scenarios, idealization, demolishing others, envy, ambitions etc. Victimization of other persons by devaluing, discriminating against, bullying, alienating… is a means for the narcissist to deny his or her own vulnerabilities. He/she gets a taste of overcoming these vulnerabilities by annihilating the spirit of other people who he/she perceives to have these qualities.

Religious literature and art do teach us to overcome our self pride and grandiosity, and be kind and empathic to other beings.

Religion against Envy

Also a part of gaining omnipotence is the need to grab what is seen as good in other people. Read more about envy here. Religions tell us to “be thankful”. In many religions there is a kind of celebration of thanksgiving. Psychoanalysis mention too that gratefulness is an antidote for Envy.

Religion for Guilt and Reparation

Most religions have concepts of guilt and making reparations. Read about Guilt here. As human beings we often are tempted to do deeds that interfere with the wellbeing of others, and that our conscience tell us is not right. We feel guilt. Sometimes we feel guilt if we cannot fulfill our duties because we are human. Guilt is hence felt when we have humanity and compassion in us.

In pathological narcissism, guilt feelings cannot be felt by the individual. The pathologic narcissist has a mental issue that blocks out guilt feelings and empathy. When no guilt is felt, no reparation can be made.

Reparation is practiced in many religions. We are sorry and make up for it. According to psychoanalysis, reparation is the route to empowerment of the self. When we fall, we repair. We know then that we can overcome our failure and live stronger.

Read also: Making Reparation & Mourning as the Road to Mental Healing

The narcissist who cannot feel guilt and cannot repair becomes more paranoid.

Religion is our source for ethics, aesthetics, anthropology and should ideally be a cure for narcissism.

Religion and Magical Thinking

Religions also include what many may call “magical thinking”. Belief in “facts” we cannot rationalize. These are things that we will never be able to prove exist or doesn’t exists, and things that we leave to faith, because they are ungraspable.

While the wisdom and insights to human existence correlate overall in different religions, it is the content of this magical thinking that differ in different religions. This content that differs sometimes cause conflict between groups of people of different religions.

Julien Offray de la Mettrie
(1709-1751)

When Abuse of Religion cause Suffering

In today’s world, as it was in the days of the Enlightenment, people suffered because of abuse of religion by religious institutions. The ways people suffer because of religion:

  • Being oppressed by religion.
  • Being persecuted due to religion.
  • Being shamed by religion.
  • Being judged by religion.
  • Restriction of freedom /rights by religion. etc.

When this happens, we see the narcissistic side of religious institutions. The very act of omnipotence, grandiosity, pride and envy is enacted by religious institutions, and this causes immense suffering.

Psychoanalytic theory explains this as a phenomenon of the loss of ability of religions to separate the metaphors from the objects. The taking of metaphors literally. Seeing the white bird instead of peace in a dove.

In narcissist, this inability to symbolize is well documented. There is splitting of the psyche in the paranoid-schizoid position, and the person (in this case the institution) sees things in black and white. This split person is devoid of empathy and a sense of being one with humanity. Like a narcissistic person, a narcissistic institution idolizes and is concerned about its grandiose self image. It is against everything the religion it represents is about.

Put under the microscope, no religion is free from narcissism. Not even the so-called New Age or the Atheists!

Conclusion

Psychotherapists would often say that it is highly unlikely for a narcissist, especially a malignant narcissist or psychopath would ever show up for in their practice. It is usually the victims of these narcissists that seek help because of abuse. Pathological narcissism is a cause for suffering and environmental damage. It has been mentioned, that we live in a culture so terrified of tenderness, that we are drawn to pick up narcissistic traits ourselves. This too is the root of much of our mental pain.

Freud was quoted as saying that the cure for mental illness is the cure for narcissism, and in order for that to happen, one must learn to love. Melanie Klein says the antidote to envy is gratitude.

That said, I am not subscribing to adopting an attitude of accepting powerlessness, uselessness or total abandonment one’s rights. This kind of new-age mentality reflects also black-white thinking of the paranoid-schizoid position, and describes masochism, which harms more than it serves. There is, after all a concept of healthy narcissism and healthy use of envy, which serves to preserve the organism (self) and serve the environment (others).

Rather than deciding to be for or against religion, we could figure out for ourselves what works for us as individuals in the realm of spirituality and religion. We may also choose to look around us with unbiased eyes so that we can see what serves the world that we have and what destroys. This is probably our best guide.

 

Bibliography

Carveth, D. (2017). F&B 2017F Religion. Retrieved from https://www.youtube.com/watch?v=oeHOKh1NCqQ

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Kernberg: Working with the Antisocial and Malignant Narcissistic Personality Disorder Spectrum

 

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.

Read also

Symptom Relief in Psychotherapy

Psychotherapy is about Uncovering the Truth of the Self

Former Patients’ Conception of Psychotherapy 

Bibiliography

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

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Mourning and Making Reparation through Art

From a development standpoint, this ability to mourn a loss develops in the infant that has moved on from the paranoid-schizoid position onto the depressive position (remembering that the word depressive here has nothing to do with depression). It is a healthy development.

The more integrated infant who can remember and retain love for the good object even while hating it, will be exposed to new feelings little known in the paranoid-schizoid position : the mourning and pining for the good object felt as lost and destroyed, and guilt, a characteristic depressive experience which arises from the sense that he has lost the good object through his own destructiveness. (p.70)

Together with the ability to mourn is also the ability for feeling loss and guilt. This means also that there is a capacity for love that overcomes hate, and there is less projection of destructiveness on to another. In a infant this ability is a milestone in ego integration. He loses his hallucinations of being omnipotent, and can accept dependency.

Mourning and symbolization through creation of art…

The pain of mourning is experienced, leading to drive toward reparation. These, Segal adds, are the basis of creativity and sublimation (turning negative experiences into creative objects). In other words, creating art in various forms is a means of symbolic reparation of loss.  These reparative activities are done because the individual is able to feel concern and guilt towards the other and the wish “to restore, preserve and give it eternal life”. This is in the interest of the self preservation, “to put together what has been torn asunder”, to reconstruct what has been destroyed, to recreate and to create.

Quote about Vincent Van Gogh. Photo taken from Van Gogh Museum, Amsterdam on Dec 2017.

“After his hospitalization in the asylum in Saint Remy Van Gogh felt like a “broken pitcher” that could never be mended. Even so, in between bouts of mental illness, he worked on steadily and courageously to become an even better artist. Painting and drawing, moreover, gave structure to his days and ensured that he did not fall prey to the loneliness plaguing the other patients.”

Sublimation helps the individual put his destructive impulses into creative work. At this point the genesis of symbol formation can be seen. The ability to symbolize is a very important development in human ego development. It is also a means for us to communicate metaphorically, thus allowing us to create and maintain contact with another person/or with society in an empathic way. Religions, for example, are founded on symbols. The healthy individual can also differentiate the symbol he/she has created from the reality from which the symbols are derived.

The depressive position is never fully worked through. The anxieties pertaining to ambivalence and guilt, as well as situations of loss, which reawaken depressive experiences, are always with us. Good external objects in adult life always symbolize and contain aspects of the primary good object, internal and external, so that any loss in later life re-awakens the anxiety of losing the good internal object and, with this anxiety, all the anxieties experienced originally in the depressive position. If the infant has been able to establish a good internal object relatively securely in the depressive position, situations of depressive anxiety will not lead to illness, but to a fruitful working through, leading to further enrichment and creativity. (p. 80)

The Neuroscience of Symbolization

Neuroscience explains brain activity difference between non-schizophrenic and schizophrenic patients in their ability to symbolize.

Tretter, F. (2017). NEUROSCIENCE AND PSYCHOTHERAPY. Private lecture at the Sigmund Freud University, Vienna Austria.

The above diagram shows a the gamma oscillation image from the brain of a non-schizophrenic person (left) and that of a schizophrenic person (right) when they are showed the black-white image of a face. The gamma oscillation on the right shows more brain activity, which is interpreted as the individual being able to derive a picture of a human face from the black-and-white shapes. The schizophrenic brain shows little activity, implying that the individual does not recognize the image as a face.

 

My Thoughts on Mourning and Gestalt Therapy

Reading this chapter by Segal on the depressive position has inspired me to thing about this subject in relation to gestalt therapy. Mourning brings with it lots of sadness and underlying guilt. In the text above, this guilt is attributed to the imagined destruction of the integrated love object.
If we observe people in mourning, there is always this element of regret. There is also a need to make reparation. This is often symbolic and aesthetic in nature. The whole process of the funeral services is in a way a symbolic way of bidding farewell to the dead. This helps the living to heal psychically.

In patients that have problems with the mourning process (e.g. those who cannot move on, those who could not feel sadness, but rage instead, or those who get chronically depressed) are usually stuck in a situation where they aren’t able to fully experience the loss. This could be because of their personality structure, from which the defense is against painful experiences. There is tremendous fear to go to those dark emotions.

The work of mourning in therapy is the work of reality testing. For the client to come to terms with loss. This reawakens deeper feelings of loss experienced in infancy. It requires reworking of loss in the internal object. This process is needed to regain the ability of the patient to come back to reality, learn to love again and build up confidence again.

In therapy, these are worked through. For this to happen, there needs to be a lot of trust in the psychotherapeutic alliance. The therapist and client would spend hours together uncovering the defenses that hold back the client from mourning. The technique of therapy is client centered, with a lot of focus on the phenomenology (non verbal experiences) in the therapy session.

From this article I also see the link between creativity and mourning. Using art in therapy (not to synonymous with art therapy) is also common practice among Gestalt therapists. Creating art is a reparative measure, and together with therapeutic contact and communication, it facilitates openness to emotions and ultimately the freeing from depression and despair. This is a reinforcement of the technique.

 

Read also:

In  Sagentini’s Art  of the mother, the artist uses his art to sublimate the mourning of the loss of his “good mother”.

 

Bibliography

Segal, H. (2012). Introduction to the work of Melanie Klein. Karnac Books.

Other Sources

Carveth, D. (2016). Introduction to Kleinian Theory 5. Retrieved from: https://www.youtube.com/watch?v=VxdWHU1wrBY&t

 

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CPTSD: Complex Posttraumatic Stress Disorder and Child Abuse

While PTSD is a typical response to a single stressor in adulthood, Complex posttraumatic Stress Disorder ( CPTSD ) is the result of childhood experience of abuse.

 

Complex Posttraumatic Stress Disorder CPTSD occurs in neither ICD nor DSM, but it has been proposed for over two decades (p.190). Adult victims of CPTSD suffer lifelong effects of emotional and physical instability of varying degrees of severity, making them also vulnerable in the face of stressful life situations.

Consequences of CPTSD:

Another name proposed for this disorder is “developmental trauma disorder.” CPTSD compromises an individual’s identity, self-worth, and personality; emotional regulation and self-regulation; and ability to relate to others and engage in intimacy.

Individuals can experience ongoing despair, lack of meaning, and a crisis of spirituality.

 

Children are Victims of CPTSD

While PTSD is an atypical response in traumatized adults, developmental trauma may be a very common (and thus the typical) response in traumatized children. Such trauma often goes unrecognized, is misunderstood or denied, or is misdiagnosed by many who assess and treat children.

Children are, due to their immaturity and helplessness, are more prone to being traumatized than adults.  They are also easy targets for narcissistic abuse.

Types of Abuse in CPTSD

CPTSD is generally associated with a history of chronic neglect, trauma, and abuse over the course of childhood. Neglect in early childhood compromises secure attachment and tends to result in avoidant or resistant/ambivalent attachment—or, most severely, toward the disorganized/disoriented attachment style that leads to significant dissociative pathology.

This neglect sets the stage for trauma in early childhood, which further interferes with normal affective maturation and the verbalization of feelings, leading to anhedonia, alexithymia, and intolerance of affective expression. Children and adolescents are more prone to dissociate than are adults.

Experience of Betrayal

Dissociation is especially linked to betrayal trauma—the neglect that allows for, or passively tolerate, more active trauma.

In the face of continued betrayal trauma, dissociation is the child’s best life-saving strategy.

The Bystander Parent

Repeated trauma in childhood involves a perpetrator and victim, but also a parent who permits the trauma to occur; is uninvolved, oblivious, and neglectful; or else is paralyzed by fear into inaction. Patient and therapist may find themselves playing any of these roles and their opposites.

Psychotherapeutic Treatment of CPTSD

When a client comes to therapy, it is often not apparent that he/she suffers CPTSD. Adult clients visit therapy for an array of symptoms that include (but not exclusively) depressive, anxiety, obsessive-compulsive, posttraumatic, dissociative, somatoform, eating, sleep-wake, sexual, gender, impulse-control, substance and non-substance dependency disorders and personality disorders.
There is a danger that therapists who are not aware of CPTSD overlook childhood experiences and spend too much focus on the diagnosed symptom.
If the therapist were to treat the trauma of CPTSD itself, this treatment if successful can ameliorate all the symptoms. This requires that the childhood abuse experiences be recounted and worked through.

The Therapeutic Process

It is common that the patient who has CPTSD will not be able to recollect the events of abuse. If he/she did, he/she may not be able to experience the feelings associated with the time. This is because of the dissociation of the child who was in the situation. Freud explains that what the client does not remember, he acts out. It is important for the therapist to be observant to the repeated behavior of the client in the interaction with the therapist.

The trauma and neglect of CPTSD are essentially relational, and so the therapeutic relationship itself becomes the principal vehicle of change. How the therapist feels, thinks, and acts depends on what aspect of the neglect/trauma drama is being played out with the patient (p.191).

Dealing with childhood trauma is a complicated process in therapy. There may a degree of enactment in the transference and this can be confusing. What is really necessary is a sound therapeutic alliance based on trust. Within the transference relationship, the client a therapist experience the client’s enactments and attitudes towards the abusing parent, the bystander parent and the client as victim and perpetrator. For this reason, the therapist has to be alert to the phenomenology and the here-and-now of what unfolds in the therapy sessions.

Bibliography

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 192). The Guilford Press. Kindle Edition.

 

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Differentiating Symptoms of PTSD from Trauma-Associated Narcissistic Symptoms

Individuals suffering PTSD display symptoms that look like that of those suffering from trauma symptoms associated with the narcissistic personality (TANS).

This article by Simon (2002) sheds clear light on distinguishing between the 2 types of patients. The table below is an extract from the article:

If we were to extract the gist of the difference between PTSD and TANS, we may be able to summarize that unlike in PTSD, patients with TANS main “damage” is that of the grandiose image of the self. Hence there is more shame and humiliation, which is manifested by anxiety about damage to this grandiose self image. In PTSD the anxiety about survival itself.  Because of this the TANS patient is more likely to project their blame and rage at another person or persons.

Knowledge of these differences facilitate the psychotherapeutic treatment of the patients, since both types of patients experience the relationship with the therapist differently.

Bibliography

Simon, R. I. (2002). Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harvard Review of Psychiatry10(1), 28-36.

 

 

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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.

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Envy… and Gratitude

Envy is the idealizing of an object outside oneself, with the wish to devour the coveted object. This object is something possessed by another person or persons. The trappings of envy is that one cannot find peace through separation of oneself from the envied object and the envied other. The resultant is hatred and the need to destroy the other.

Envy can also be seen as a projection of goodness into another person, so that one idealizes the other while devaluing oneself, and eventually hating the other. Envy is a painful emotion and is almost not in the awareness of the individual. It is also integral to being human, and hence it exists in every reasonably living functioning person.

Envy vs. Jealousy

Envy is exists in terms of two persons– it involves you and me. I want what you have, because that is what I lack. Jealousy involves a third person. I am not allowing that other person to take you / your attention/ love, etc away from me.

Destructive Envy

If I cannot have what you have I’ll seek to destroy that coveted thing. Sometime this destruction is abstract.

Greed

Greed is a means to extract all the goodness from the other. Greed doesn’t necessarily seek to destroy. Greed is to consume without gratitude. Hence greed never gets satisfied.

Defenses against feelings of envy

Vanity or grandiosity is a defense against envy. To make oneself more superior to overcome envy of another. Self idealization, feeling omnipotent, not needing or depending on others.

Invidiousness, is a means to act so that the other becomes envious of you.  To projective identifying or evoking emotions of envy in the other. The problem this causes the person to fear the envious eye of other.

Spoiling, devaluing, rigid idealization, projection of envy (a superego that attacks and devalues own achievements) are examples of means to counteract feelings of envy.

When envy is strong, even what’s seems as a good object becomes a source of pain.

In normal experience good experience predominates over bad. Pathology aries when bad predominates good internally and externally.

Positive use of Envy

Constructive envy is one that inspires one to work harder to improve oneself. If I am envious of somebody’s abilities, e.g. piano playing, I practice harder. We also witness the energy derived from envy in the masterpieces created by highly creative people.

Gratitude as the Antidote to Envy

Melanie Klein tells us that gratitude is the antidote to envy. To be thankful is to be able to see the glass half full. Gratitude allows one to feel satisfied with what one has achieved or bestowed.

Bibliography

Carveth, D. (2016) Introduction to Kleinian Theory 4. Youtube. https://www.youtube.com/watch?v=bb-L_QXNyQU&t=2s

 

notes;

Pathologically violent projective identification, where the object (ego) is splintered, attacked. Reality is seen as persecutory and hated. When envy is intense, the perception of the good object is as painful as the bad object.

46:00 Psychopathology is  the result of early decision to try to base your life upon evading pain (Bion).  Psychotherapy is the process of turning this around. To help the individual face the pain and move on to more functional existence.

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Psychotherapy is about Uncovering Truths of the Self

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).

Bibliography

McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

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Symptom Relief in Psychotherapy

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.

Bibliography

McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

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What can Psychotherapy do for you?

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).

Bibliography

McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

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Personality vs Personality Disorders

There are the structural features of what we understand to be healthy functional normal personality in contrast to personality disorders.

The normal personality is characterized by:

1. An integrated concept of the self and an integrated concept of significant others.

“An integrated view of one’s self assures the capacity for a realization of one’s desires, capacities, and long-range commitments. An integrated view of significant others guarantees the capacity for an appropriate evaluation of others, empathy, and an emotional investment in others that implies a capacity for mature dependency while maintaining a consistent sense of autonomy (p. 8).”

2. The capacity for affect and impulse control, and capacity for sublimation in work and values.

“Consistency, persistence, and creativity in work as well as in interpersonal relations are also largely derived from normal ego identity, as are the capacity for trust, reciprocity, and commitment to others, also codetermined in significant ways by superego functions (p.8).”

3. Being able to internalize value systems that is stable, de-personified, abstract, individualized, and not excessively dependent on unconscious infantile prohibitions.

“Such a superego structure is reflected in a sense of personal responsibility, a capacity for realistic self-criticism, integrity as well as flexibility in dealing with the ethical aspects of decisionmaking, and a commitment to standards, values, and ideals, and it contributes to such aforementioned ego functions as reciprocity, trust, and investment in depth in relationships with others (p.8).”

4. Ability to manage appropriately libidinal (all of the instinctual energies and desires that are derived from the id) aggressive impulses. Having the capacity to fully express sensual and sexual desires with tenderness to the other, while being able to be emotional connected to the other in a relationship.

“(F)reedom of sexual expression is integrated with ego identity and the ego ideal. A normal personality structure includes the capacity for sublimation of aggressive impulses in the form of self-assertion, for withstanding attacks without excessive reaction, and for reacting protectively and without turning aggression against the self. Again, ego and superego functions contribute to such an equilibrium. (p.9)”

Bibliography

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

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Former patients’ conceptions of successful psychotherapy

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.

Findings

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.

Comments

Psychotherapy is quite unlike medicine. The clients’ or patients’ needs for treatment are very diverse and individual. Even though there is such a thing as diagnostics in psychiatry, we have to understand that these diagnostics are constructs for professionals to communicate the symptom of the client with each other. With psychological issues, the same symptom displayed may does not mean same source or cause of problem. It also does not mean that the clients with same symptoms will benefit from similar treatment.

Why this?

Put simply, it is because the mental state of the individual is the product of the individual’s relationships, culture, physical health, age, economic situation… etc. The psychotherapist sees the client as a whole person, whose experiences and meaning making are important in therapy.

The result of the findings reflect this.

Bibiliography

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 Research9(4), 250-256.

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Jane Tangney: the Difference between Shame and Guilt

Shame and guilt are uniquely human emotions. These are emotions that does not exist in infants up to a certain age. In other words, shame and guilt are emotions learnt, and this learning coincides with the infant’s discovery of the self, when the infant becomes self conscious.

In the lecture below, June Tangney explains the results of her research in this area.

What is the difference between shame and guilt?

According to Tangney, shame comes with the awareness of (or the judgement of) the self as having done (or being) something wrong or unacceptable. Guilt is related to the judgment of the deed (ones behavior) that one has committed.

Shame is also extremely painful relative to guilt. Shame is a feeling of being defective, a sense of being small, exposed, powerless. Shame can last for short or long periods of time. When one feels shame, one tends to want to isolate themselves.

Guilt is different. It comes with remorse, and people who feel guilt are typically drawn to taking reparative action, rather than isolating themselves.

Link between Guilt and Empathy

Empathy is a state of feeling the other’s feelings, and it brings us to altruism.

@ 24:00 Guilt and empathy are connected. Tangney’s team of researchers have found correlation between propensity for the feeling of guilt and people’s ability to step into somebody’s shoes (to be empathic). Meanwhile the other more self-absorbed, pseudo-empathic responses are related to shame.

When a person talks about a shame related feeling in a situation, there is less concern for the other and more focus on the self. When the feeling is that of guilt, the concern is for the other’s feelings.

Shame, Anger and Aggression

The research also found that proneness to shame also related to proneness to anger and aggression. People who are prone to shame, also tend to manage their aggression in a more un-constructive way.

Shame in Family Conflicts

There is therefore correlation with studies of shame in family conflicts and domestic violence.

People prone to guilt are more likely to live a more “moral” life.

Shame and Guilt are not Equally “Moral” Emotions

On the condition that we do not mis-interpret shame with guilt, the findings show that guilt feelings do not cost the person psychologically (as otherwise thought). This means that so long as we do not judge ourselves, but judge the deeds instead, we are in a better situation to cope with the psychological aspect of having done something deemed as inappropriate.

Proneness to shame, on the other hand has been linked to vulnerabilities to depression, anxiety, eating disorder etc.

This also brings to attention how society treats incarcerated people.

Adapting to a more Guilt-Prone style and less Shame-Prone style

Research showed no real inter-generational link in shame and guilt proneness.

Longitudinal studies show that teenagers that are in the guilt proneness fare overall better than  their shame-prone peers.

 

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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.

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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 01/2019, 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.

Is psychotherapy for me?

Ask yourself these questions to decide if you need psychotherapy.

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

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

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

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

Gabor Mate: On Cannabis use, Addictions and Healing with Psychedelics

Understanding cannabis use, it’s effects, addiction and trauma.

Gabor answers questions regarding the use of Marijuana (Cannabis). He discusses addictions to some drugs, and how these are relative to the effects of legalized narcotics like tobacco, alcohol and prescription drugs.

Important point he made is on the effects of drugs on developing brains of young children and adolescents, putting a spotlight on prescription of drugs to children.

As a therapist, I fully appreciate his emphasis on psychological trauma as the root cause of addictive behavior. He tells us that the medical profession should be more aware of trauma.

Maté: Denial of own emotional needs and its connection to chronic illness

Do unto yourself, what you would do for others.

This lecture is presented in this site because it is a good argument for going to psychotherapy sessions that involve working through emotions and childhood traumatic experiences.

Gabor Maté’s message is an important one. As I write this reflection article, I am myself experiencing being in a situation which is teaching me an important lesson: I am forced to take a 5-day unexpected break from a hectic schedule which I had created for myself. I had an accident. I fell from a deep flight of stairs, and escaped with injuries that could have been much worse. Sitting at home nursing a swollen brow and black-eye, I am reflecting on how, for the last couple of months, I had wanted this time off but did not have courage to put appointments aside. I did not want to disappoint other people.

This accident was no accident, but a warning. A therapist myself, I knew what was going on in me, but I really thought that the rest could wait. Wrong I was.

It is so easy to fall into the trap of self denial, because we are programmed to be so. Maté’s lecture, “When the body says no — caring for ourselves while caring for others”, hits the nail in the head.

On premature aging due to stress of taking care of others

2:30 DNA studies show aging in people who live under stress.

Preoccupation for the needs of others, while neglecting the self as a risk factor for chronic illness.

4:20 A story of the personality of a woman who has breast cancer. How she worries about her husband’s emotional state rather than dealing with her own illness.

5:31 He reads obituaries of people who died too soon, to illustrate the self-sacrificial and self-denying behavior of people who have died from chronic illnesses.

Dealing with Anger

7:50 The dangers of suppression and repression of healthy anger leads to autoimmune disease and cancer, while going into rages, which is the polar extreme leads to heart disease.

The healthy way to deal with anger is to notice it, accept the feeling and talk to someone who is willing to listen about your anger feelings. Healthy way to deal with anger is crucial to health.

9:55 Mate describes a study from Australia of married women. Those that were unhappy in their marriages and could articulate them were better off physically than those who suppressed their unhappiness. The issue was not about happiness of the marriage but the ability to express the anger underlying.

Hanging on to roles society imposes on you, trying to please everybody, while forgetting to take care of your health can cause deterioration of health and death.

We cannot separate mind from the body.

14:05 Mate explains to us about chronic illness and the current medical attitude towards these illnesses.

We cannot separate the individual from the environment

16:11 We are shaped by the environment. Environment is not only physical, but also the psycho-social environment. This means that the environment includes the people we live amongst.

To illustrate this, he cites studies where children whose parents are stressed are more likely to get asthma in polluted environment and other illnesses. This is known to be directly as a result of stress since asthma drugs are stress hormones themselves.

We cannot separate ourselves from the mental states of others in our society.

Talking about anger to someone is important reliever of stress

19:10 Studies of breast cancer patients in Australia found that having a stressor in life AND being socially isolated made the subjects 9x more likely to have cancer. Mate explains that connection with another person, talking to others about feelings of anger is instrumental to maintaining healthy life.

Stress from anger is not only mental, stress is also felt in the body. In short term, stress hormones help to escape, long term stress causes chronic ailments.

Amyotrophic lateral sclerosis (ALS)

23:20 Maté explains the possible cause of ALS .

ALS is a neurological motor neuron disease, which strikes usually healthy people, and is fatal. Mate found these patients to have a personality tendency of denying their negative feelings, denying the experience of the self, while having the overwhelming need to always be there for others-

27:03 He talks about the story and personality of Lou Gehrig. Gehrig’s name is the name for ALS. His personality of selfless ambition and helpfulness is typical of what Mate considers a personality that is typical of patients wit ALS. Lou Gehrig had childhood trauma from growing up a child of an alcoholic.

These are caused by unconscious patterns. Not the fault of the patient’s themselves.

Unconscious self-denying behavior is learnt from infanthood.

19:30 Mate tells us his own story of how unconscious factors affect how he too has a tendency of self denial while trying to protect his mother.

Infants pick up on the stress of the mother and other caregivers. Infants learn to suppress their own pain in order to maintain a relationship with its care-giver. This infantile suppression becomes a memory that is recorded by and stored in the body. It is called trauma.

Making oneself lovable is done by suppressing feelings and denying own needs.

Mind and body are inseparable.

Personality patterns are learnt from infanthood. These patterns translate into physical illness.

36:00 Newborn need to establish these patterns to maintain attachment to adults.

Emotional centers of the brain are attached to the hormone system, and nervous system are connected to the immune system. These systems are connected.

38:40 Mate explains the phenomenon of “gut feeling.

How and why we give up our authentic selves as children

Children read and respond to gut feelings intuitively. Children are born with ability to intuit body language of adults accurately. As we get older, we begin to suppress this gut feelings, and rely on intellect.

41:40 There are 2 great needs of children. One is attachment to the care-giving adults. The other need is to be authentic. This is a need in order to function as an individual human being. In situations where we, as children have to sacrifice our authentic self, because this authentic self endangers the attachment to our parents, leads us to a pattern of having lost touch with our needs and feelings.

Our problem as adults is that we still stick to this need for attachment.

42:48 The Heart-brain Connection predictive activity.

Hence our emotional states is connected to our physical health.

Healthy anger is about knowing your boundaries and expressing it

44:45 Mate demonstrates what boundaries are and how boundaries can be breeched. He explains that healthy anger is necessary for us to communicate to the other that our boundaries have been crossed and to back off.

Immune system is linked to our emotions

The role of our emotions is boundary integrity. To keep out what is unhealthy, and let in what us enriching. The job of the immune system has similar roles.

Autoimmune disease is a way of the body attacking itself.

To prevent illness or overcome illness, we need to exert who we are and to say, “no”.

Saying “no” may trigger fears about attachment, but we have to remember that we are adults.

If you are caring for others, you must demand support also for yourself.  Ask yourself and reflect on this question: in what situations in your life is it difficult for you to say, “no”.

How a therapist can tell the progress of the patient

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

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

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

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

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

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

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

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

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

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

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

Young & Lester: Gestalt Therapy Approaches to Crisis Intervention with Suicidal Patients

This article explains the use of Gestalt Therapy for crisis intervention with patients who are suicidal. The article by Young & Lester (2001) , provides for good information on the topic. I shall list the following points presented by the authors.

Gestalt therapy is an ideal method for dealing with crisis situations. This is because of the methods focus on the here-and-now and being present for the patient. Working with suicidal patients in crisis, being empathic and listening is everything. Accounts from patients in dire situations are filled with expressions of loneliness and helplessness. Hence being with someone who is actively listening without judgement is precious.

Read also : suicide crisis intervention: working with …

Steps involved in working with patients who are dangerously suicidal involve:

  1. Acknowledge of the suicidal ideation. To offer a listening ear and accepting that the client is in distress and has in mind to take his/her own life.
  2. Exploration of the suicide plan. This means talking openly with the patient about details of his/her ideas of the suicide wish.
  3. Exploring feelings of anger and sadness underlying. When we work through these feelings more emotions are discovered, and these include helplessness, shame and hopelessness.
  4. Bringing to the patient’s awareness that a part of him/her still wants to live. Brining to light this ambivalence is an important step that could radically diminish the wish for suicide.
  5. Giving voice to the patients psychological struggle. Giving a listening ear to the patient’s psychological difficulties frees the person of the guilt of having these painful thoughts and feelings.
  6. Understanding of major issues. With his/her sharing of the issues, both therapist and client get insight and understanding of what is happening to the patient.
  7. Addressing their underlying loneliness. The therapist’s witnessing without judgement alleviates the loneliness felt by the patient of living with the struggles.
  8. Clarity in their responses to feeling questions. The therapist guides the client to get in touch with feelings.
  9. Awareness of how the patient is repressing emotions.
  10. Experiencing repressed emotions. These emotions are very difficult and oftentimes painful. When these are expressed, the distress is followed by relief.
  11. Grounding. As the emotions subside, grounding is the act of bringing the client into the here-and-now in the interaction with the therapist.
  12. Acknowledgement of relief. The relief felt from expressing these emotions and grounding is given some attention so that the patient is able to take in the phenomenon.
  13. Self acceptance and understanding. Therapist and client spend some time expressing gratitude for what they have experienced together.
  14. Exploring options for the future.
  15. No-suicide contracts. The patient promises to not attempting suicide through signing a contract with the therapist.

Read more: Suicide crisis intervention: working with people who are in danger of taking their own lives.

Bibliography

Young, Lin & Lester, David. (2001). Gestalt Therapy Approaches to Crisis Intervention With Suicidal Clients. Brief Treatment and Crisis Intervention. 1. 10.1093/brief-treatment/1.1.65.

Suicide Crisis Intervention : Working with People who are in Danger of Taking their Own Lives

This is an article for persons who need to work with and help suicidal individuals.

I am putting together notes from seminars attended and literature read on the topic of working with people who are imminently suicidal. I hope that the information is useful.

Unless one is familiar, or has come to terms with one’s own thoughts of suicide, one cannot really put him/herself in the shoes of a person in the situation of wanting to kill him/herself. The below video of a talk by Kevin Briggs is a good introduction of how to talk to suicidal people.

How to spot a person who is in danger of suicide

Often when a person is determined to take his/her own life, he/she is alone. Being able to spot a person (family member, acquaintance, friends or other loved ones) in a pre-suicidal situation is life saving.

Pre-Suicidal Syndrome

Ringel (1953) writes that pre-suicidal syndrome is characterized by:

  • Narrowing of the ability to act
  • Narrowing of the emotions
  • Narrowing of the perception
  • Narrowing of the relationship capacity
  • Narrowing of the seeing value (or positivity) in the world
  • Increase of the self-directed aggression
  • Increase of the imposing suicidal fantasies

Other signs of Suicidality

  • Feelings of helplessness and hopelessness
  • Feelings of being offended / hurt
  • Unbearable mental pain
  • Guilt
  • Desire to impress or punish others by suicide
  • Long-lasting sleep disorders
  • Affective and aggression congestion
  • Lack of resources
  • Poor impulse control

Some Observable Signs that a Person is Seriously Contemplating Suicide :

  • there is persistent suicidal thoughts.
  • there is no distancing from the suicide ideas.
  • the person has a suicidal plan — take appropriate action when weapons or medicines are easily accessible or if the plan involves the patient going to a place no one can find them.
  • the person sends out recognizable farewell signals such as letters, giving away objects, cleaning up unfinished businesses, creating orderliness.

Send the Person to the Hospital if…

Call the ambulance when, the person in danger:

  • clearly announces suicide
  • is not believable
  • is not conversant
  • denies intention to commit suicide, however, the external circumstances clearly indicate intent to commit suicide (severe previous attempted suicide in case of continuing stress situation, depression with hopelessness, concrete suicide preparation, details of relatives).

How to Act in the Presence of a Person in Danger of Suicide

  • Stay calm, breathe.
  • Try not to be hastily comforting. Comforting is generally not effective.
  • Emphatically empathize instead of admonishing.
  • Concretize rather than generalize. Ask the person specific things, and not talk about hypothetical things.
  • Take the problem mentioned seriously. Do not downplay the problem. Avoid negating the person by using the words “no” and/or “but”. If unsure, say “yes”, “uh huh”.
  • Listen quietly with understanding, instead of judging and commenting.
  • Carefully gather information from the person instead of investigating, questioning, analyzing.
  • Avoid rashness.

Holding a Conversation with a Suicidal Person in Crisis

  • Be understanding to the person in his / her specific situation, especially in the situation that led to suicidal behavior. Ask, “How was that exactly, can you tell me more about it?”
  • Relate to this event. Ask, “That’s a situation where you thought of suicide?”
  • Speak openly when addressing suicidality. “You thinking of ending it all?”, “Can you tell me more about it?”, “I am interested to hear about it.”
  • Talk about the relationship and interaction in the here-and-now between you and him/her. Ask, “How are you feeling with me now, during our conversation?”
  • If you feel touched, or have warm feelings, share this with the person.

Handling Crisis Intervention by Telephone

When someone on the other line of the telephone is in danger of taking their own lives consider the following:

  • Stay calm, breathe.
  • Talk directly about the problem. Encourage him/her to describe the reason for the call. Talk about what concrete help is needed.
  • Discuss what can be done, what realizable help is possible.
  • Invite the person to a face-to-face conversation.
  • Hearing the person out, let him/her talk. Be accepting of what you hear. Respond empathically to sounds of distress. Withhold any judgement, negation (saying “no”, or “but”), blame or preaching.
  • Discuss clearly the next steps about what can be done, if applicable.

Please remember this…

You are in a position to be there for someone in his/her darkest moment. It is a privilege to be there. Be patient and listen with an open heart. Accept what you hear as the other person’s truth. Be present. Focus on your own breathing. If you feel touched, sad or thankful for the contact that you are having, tell it to that person.

Wait for the appropriate time to bring this up…

Acknowledging AMBIVALENCE

Even at moments closest to committing the act of suicide, the person is still ambivalent about his/her death-wish. Verbally acknowledge to this person, that something in him/her still wants to live. 

“Being with you right now, I’m hearing (or feeling, or sensing), that a part of you really wants to live. “

More Notes on Conversation with Suicidal Persons in Crisis

  1. Take every suicide note on the phone seriously A person tired of life is still talking. He/she is still wants to live, otherwise he/she would not be talking to you.
  2. Suicidal behavior is often an attempt of that person to communicate with somebody. It matters not who you are, you are an important listener.
  3. Suicidal remarks must trigger active listening.
  4. People in distress often see black and white. They respond better when you communicate with them clearly, in short, simple language.
  5. The dangerous moments of a suicidal crisis last only a few hours. Do not fear that it would be too much for you to withstand.
  6. If you are someone who is in touch with your own suicidal thoughts and desires, you are more likely to cope with the suicidal aspirations of the other.
  7. Show concern, but do not be afraid of the words and intentions of the other.
  8. Avoid anxious-well-meaning paraphrases. Instead of saying “suicide”, say, “You want to take your life”.
  9. Suicidal callers ambivalently waver between life and death. Talk about this ambivalence and reinforce it. This will help the person to remember that part of him/her still wants to live.
  10. Call the person by the name, in order to develop a personal relationship.
  11. The suicidal person before you has the right to make personal demands and say absurd thing, even though it might get on your nerves.
  12. Talk to the person in the way he/she wants to talk to you. Mirror the person’s kind of talk.
  13. Do not let yourself be drawn into his/her feelings or thoughts of hopelessness. Ask instead about these feelings, and the memories, etc. behind them.
  14. Avoid asking “why” – type of questions. Similarly avoid asking for reasons. These questions are interrogatory.
  15. Encourage mini-actions. “would you like to meet up (if in phone conversation) or “should we have a cigarette?”
  16. Ask about other people who are still important in the person’s life. If there really is nobody, offer yourself as such a person.
  17. Encourage the person to develop fantasies about his/her future, but
  18. do not do it for him/her.
  19. Do not allow his/her conclusions to convince you like “why I have to kill myself “. Turn it around to, “there is still time to do such and such”.
  20. Tell the other how glad you are to talk to him.
  21. Try to reach an agreement that the other before he hurts himself to call you again.
  22. Do not forget, that despite your best efforts, some still would want to exercise their right to take their own lives. Keep this in mind.

Read more: Gestalt therapy approaches to crisis intervention with suicidal patients.

Bibliography

Ringel, E. (1953). Der Selbstmord, Abschluß einer krankhaften psychischen Entwicklung.

Psychotherapy is Healing through the Psyche

Presenting a psychotherapy case study about how psychotherapy treatment heals.

The full potential of psychotherapy is healing. The healing work enabled through psychotherapy is holistic. This means that psychotherapeutic healing involves the biological, psychological and social aspect of the patient.

Psychotherapy is a complement to medical treatment

Unlike medical professionals who traditionally focus solely on the body while ignoring the social and mental state of the patient — that is now changing in, thankfully– psychotherapists pay attention to the entire person. Particularly true for chronic diseases like cardio-vascular heart disease, medicine and medical procedures only try to remove the symptoms. Psychotherapy helps the patient to work through stress that resulted in the symptoms in the first place, manage behavior to help maintain lifestyle changes, and work through coping with the depression and trauma of having been diagnosed.

Studies have been surfacing about the link between stress and chronic diseases. Read this article featuring a lecture by Gabor Maté : Denial of own emotional needs and its connection to chronic illness.

Psychotherapy is a more intensive form of counseling or psychiatry

Psychotherapy is a profession that is often confused with others, like counseling, psychology and even psychiatry. To really briefly describe the essential focus on each field of mental health I would say that counseling works on problems of daily existence, daily functioning at work and play, or problems created from behaviors that do not support daily function. Psychology is a broad field of work that researches human behavior and responses to situations. Psychiatry considers that which is emotional and behavioral to be biological, and deals with these issues with medicine or medical procedures.

The way to explain the gestalt therapy attitude towards healing is with this Chinese idiom:

斬草不除根,春風吹又生

“When cutting grass, the roots are not pulled out, when spring arrives, the grass grows back.”

Chinese idiom

We can see this in ourselves and in others. Our emotional problems, issues with relationships, problems with work, health problems tend to show repeating patterns. Sometimes we even see these patterns in our parents or in our children. Oftentimes we try to fix the problems. Often another problem of a similar nature surfaces. This is the metaphorical grass mentioned in the above idiom.

If you do go for psychotherapy, your attitude as a patient is to work towards identifying and removing the roots. It is not always painless, but a therapist who is well versed in the work can walk you through it.

The tool of Psychotherapy is dialogue

The term “talking cure” was coined by a patient of Breuer, Anna O, the first recognized patient of psychotherapy. Talking is not the right word. Rather I would used the word, dialogue. Gestalt psychotherapists like myself work with verbal and non-verbal communication. We can work with persons who do not talk or are not able to.

Psychotherapy works through affects and unconscious activity through dialogue and expression of these thoughts and emotions. The goal is to relief stress from painful emotions, by working through traumatic memories, painful thoughts, and difficult emotional experiences. Through working with the unconscious, awareness is formed and stress is relieved.

Relief of stress from psychotherapeutic treatment and health consequences

The relief of stress creates a change in the neuro-chemical balance in the brain. In turn, the hormonal system is readjusted. This changes and strengthens the immune system and cardio-vascular system. Balance in the immune system reduces risk of cancer and even aids in healing cancer, while reduced stress to the cardio-vascular system reduces blood pressure and heart attack & stroke risk.

Psychotherapy heals the body by causing a readjustment of the neuro-chemicals and hormones in the organs. Patients can feel this effect after an effective session of psychotherapy.

What one gets from Psychotherapy is a holistic benefit: empowerment to build relationships, energy for work, study and play, and inner peace.

Read also: The Neuroscience of Language Explains How and Why Psychotherapy Cures 

What is the consequence of this relief of stress? Let this interview of Bruce Lipton explain to you how relief of stress as a result of dealing with the unconscious leads to physical healing and prevention of serious diseases. Lipton explains how medical problems are influenced by epigenetics rather than genetics. Unlike genetics, which we cannot change, epigenetics describe the expression of genes. Expression of genes is determined by environmental and situational factors that we face in our daily lives.

Lipton explains that belief can determine outcome of treatment of illnesses, and how this translates to the concept that our consciousness affect if we get ill or get cured.

Healing in the psychotherapeutic session

I focus on the emotions and the connected thoughts that arise. The opposite is also important: memories and even fantasies are investigated to examine the underlying emotions. The integration of the person with his/her emotions and thoughts through dialogue and behavioral experimentation in the psychotherapeutic session leads to chemical change in the neurological system of the patient.

Case study:

This is a case study of a patient who came to therapy because of experiencing stress at his workplace. He was often on sick leave for chronic migraine, hemorrhoids and even un-explainable occasional hearing loss. Close to losing his job, he attends therapy. Only after weeks of treatment, did he realize how he, as a young child, was affected by traumatic situations at kindergarten and later elementary school. His home country was governed by a communist regime during the time of his childhood in the 80s. He had survived his childhood years by forgetting how frightening and lonely the situation was, while secretly hoping that he would be sick so that he could skip school.

This client’s psychotherapy treatment was about working through the trauma. With time, we worked together integrating his memories with awareness of which emotions belonged to the past, and what is no longer needed in the present. One of these was the realization that he no longer needed to “get sick” to skip work. He took breaks, sometimes weeks of non-paid vacation. He learned to regulate his spending, so that he could breathe easy when he took those breaks. Talking about and expressing painful emotions allowed him to release energy that he had bottled up and forgotten all his young life. He became more aware of tension in his body, and started doing yoga. Soon after, he stopped taking medication for migraine. The patient realizes that his path to healing is life-long. Along the way, he was able to find love as well.

The Lasting Effect of Psychotherapy

Unlike taking a pill to regulate emotions, neurological changes brought about by psychotherapy are subtle and lasts the lifetime. With regular sessions, these changes snowball into observable physical improvement. Unlike medication, treatment with psychotherapy does not leave behind negative physical side-effects, as can be seen with antidepressants.

For reasons that Psychotherapy is chemical-free, it is a treatment much needed for children, teens, young adults, and people hoping to be parents.

Through working with the psyche, psychotherapy enables the patient to better function in work, play, sex and relationships. As the patient becomes more self aware, he/she also becomes more aware of his/her relationships. He/she ultimately functions better in life. The effect of psychotherapy achieves what one looks for in counseling, with the added benefit somatic healing.

Just as there exists many schools of psychotherapists, there are, of course, different opinions on this subject of healing. The article written reflects my own work.

Diagnosis of Obsessive-Compulsive Personality from the Gestalt Therapy Perspective

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

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

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

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

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

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

Obsessive Compulsive Personality Disorder Explained with Gestalt Therapy 

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

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

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

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

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

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

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

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

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

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

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

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

Treatment Focus

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

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

Phenomenology

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

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

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

Polarities to work through are :

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

Sources

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

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

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

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

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

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

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

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

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

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