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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.

Screen Shot 2017-12-16 at 08.53.32

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. There is more shame and humiliation underlying. This is manifested by anxiety about damage to a kind of grandiose self image. In PTSD symptoms, the anxiety is mainly about survival.

Knowledge of these differences facilitate the psychotherapeutic treatment of the patients, since both types of patients experience the relationship with the therapist differently. This also reflects the difference between event onset trauma in the case of PTSD, and developmental attachment related trauma in the case of complex trauma.

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 07/2019, 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.

Coming off Psychiatric Medications

Taking psychiatric medications is not the same as taking over-the-counter flu medication. When one gets a flu, one simply takes a pill and stops when the symptoms subside. With psychiatric medications, however, this is different. Having started on a course of psychiatric pharmaceuticals for mental health symptoms like depression, anxiety or psychosis, one must follow carefully the directions of the physician, and to consume the right dosage at the prescribed intervals. When the symptoms subside, or when one feels that the meds do not help, the patient should not simply stop taking the medication. He/she should first consult the psychiatrist who would advice the patient on how the dosage can be reduced.

This controlled reduction of psychiatric medication is an important measure of harm reduction. Why harm reduction? Psychiatric drugs are chemicals that alter the balance of one’s brain biochemistry. On consumption of these drugs, the body and brain cells adapt to the drugs. This adaption process does not happen spontaneously, but take weeks. Genes are switched on and off. A hormonal and a neurobiochemical balancing act takes place. When you decide to stop taking the drugs, you’d need to allow time for your balancing neurobiological system to adapt back to life without these medications.

Measures to take before thinking about coming off antidepressants:

  • Find support from the people around you. Going off these meds can be an unpredictable process. One my feel moderate to severe swings of mood, disordered sleep, anxiety and even rage.
  • Plan beforehand to take up some wellness and coping skills. Some of the most effective are body-based activities that require controlled breathing, like weight-training, yoga, swimming, dancing and meditation. Different people have different preferences.
  • Get support from a psychotherapist at least 6 months before you decide to reduce your medication. This will help you resolve internal conflictual issues that triggered the symptoms in the first place.

In the video below, Will Hall, a former psychiatric patient turned psychotherapist and harm reduction educator explains how and why coming off psychiatric drugs need special attention.

Download Will Hall’s free booklet on coming off psychiatric drugs.

How to Contact Me for Psychotherapy in Singapore

Poem: the Sense of an Ending

 The world spun increasingly slow
Days felt like months
Hours felt like days
Minutes felt like hours
Volcanoes spurted their larvae
All together
They wanted me to feel their inner heat
I didn't want to miss it
I felt hot, very very hot
I smoldered, I cringed,
I felt as if I were turning to ash
Instead I turned into glass
Thick glass
I refracted the glow of the molten larvae
The larvae felt like tears
Tears that would have otherwise remained retroflected,
Flowed in hot fury
I am thankful for the heat that changed me
I have turned into a solid, transparent, reflective, smooth, supportive material
This is a gift
As the end drew near
The volcanoes emptied out
Heat turned to warmth
It is now summer
The sense of an ending
There is sadness
It is not grief because there is no loss
Only gain
As the last milliseconds crept by
I felt the here-and-now like never before
How long does the here-and-now last anyway?
3 seconds? 3 milliseconds?
At the very end
As we say our goodbyes for the last time at the door
as we turn to look each other for the last time eye to eye
The here-and-now is eternity.

Nicole Chew-Helbig, Vienna, 26.6.2019


How much should therapists reveal about themselves? What Tronick’s Still Face Experiment teaches us about being Psychotherapists

Many psychotherapists are instructed, from the day they begin training, to abstain from almost any form self revelation to their clients. Different schools of psychotherapy have different ideas about how much therapists should hide their true beings from their clients. These vary in degrees. Some would go all out to clean out their online presence, some deliberately give their offices the blank look to hide their identity, some would go even as far as to work with the client withholding their facial expressions (by sitting behind the client, for example).

Is there reasonable purpose for this?

Some classical Freudians would argue that this is essential. They would shun even the idea of calling the client if he/she did not show up for a session.

I belong to the more humanistic category of psychotherapy, Gestalt Therapy. In our modality, the client and therapist as human beings take part in the psychotherapeutic process. If the therapist does not show up as a real person, it would not be Gestalt therapy.

How do we reconcile the differences in principles between psychotherapy schools with regard to revealing the therapist’s real face to the client?

The answer would have to come from developmental science itself: Tronick’s still face paradigm.

The still face paradigm was demonstrated by Edward Tronick et al. in 1978. This experiment is explained in the video below: https://youtu.be/vmE3NfB_HhE

The experiment involves having a mother play with the baby. We can see how baby and mother interact. The mother is then instructed to turn her face away. When she turns her face back to the child, she withholds her natural impulse to react to the child, and keeps her face emotionless. The baby reacts to the mother’s still face with painful despair. The mother later releases herself from withholding her facial expressions and the baby come back to life.

More modern-day scientific findings are proving that the practice of humanistic psychotherapies like gestalt therapy is congruent to supplying clients with the healing process. This experiment is one of them.

Clients suffering from panic disorder, depression, anxiety, OCD and trauma come to therapy to seek solace and inner peace. Can we imagine how it feels to meet a blank faced therapist in treatment? From the experiment, we can see how the mother’s blank face is the cause of anxiety in the baby. In gestalt therapy we believe in authentic verbal and non-verbal communication. Just like the mother with an expressive face, the therapist’s full presence is a source of solace. The client feels seen and her being is validated. He regains his lost sense of self. She finds her footing on solid ground.

Therapist trying to be the superior, in control and still faced, seem almost inhuman, especially in the presence of clients who are emotional and suffering. The dead face, in my opinion, is traumatizing.

Authentic presence when being with the other has a calming effect on the other person. This is how our nervous system normally functions from the day we are born.

On this topic, I am not advocating being exhibitionistic. I do not believe that therapists should be opinionated or take up too much space from the client. I do, however, believe in real human presence.

Psychopathology is not disease. It is suffering that emerges in the relationship between people. The suffering comes largely from chronic and acute loneliness. Loneliness can only be cured with being with the client in his/her darkest moments.

What do Gestalt Therapists do?

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

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

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

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

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

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

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

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

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

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

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

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

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

Bibliography

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

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

Why body-awareness is integral to the psychotherapeutic process

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

What are emotions for?

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

Emotions are felt in the body.

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

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

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

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

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

Bibliography

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

Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA)

Abstract

How can we visualize the evolving psychotherapeutic alliance in dialogue? The psychotherapeutic dialogue is an important source of data for psychotherapy outcome and process research. Micro-analyses of dialogical turns within the therapeutic session support the understanding of the therapeutic method. This paper introduces the Helbig Method of Dialogue Analysis. This method is founded upon 4 pillars: 1) that dialogue is implicit action between persons that is supported by explicit verbally uttered content, 2) that the individual’s mode of inter-action within the dialogical dyad reflects the person’s relationship theme or pattern which plays out in the here-and-now, 3) that dialogue is an intersubjective process that leads to the development of new intersubjective configurations, and 4) that the observer-researcher’s phenomenological involvement plays a part in the analytical process. In this study, a 28-minute video-recorded gestalt therapy session is selected. The transcription of the session is coded using the instrument, the Core Conflictual Relationship Theme Leipzig/Ulm. Results obtained from this study are quantified graphical representations of the developing relationship between therapist and client. Simple to operate, scalable and practical, this method is designed for use by therapists and researchers who are interested in tracking, comparing and/or contrasting the developing psychotherapeutic alliance in a single or in multiple psychotherapy sessions.

Keywords: psychotherapy research, dialogue analysis, psychotherapeutic alliance, Core Conflictual Relationship Theme, gestalt therapy.

Download pdf. here.

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The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship

Abstract

This thesis addresses the complicated nature of the psychotherapeutic alliance, by attempting to deconstruct what is already in practice. In piecing out the different aspects of the relationship between psychotherapist and client, and referring back to relevant literature, one can understand better the dynamics that exist within the therapeutic encounter. In the process, one can also see how the different principles of different psychotherapy schools fit into what we understand today as the profession of psychotherapy. Considered a profession, psychotherapy is bound to ethics, within which is the question of competence and accountability. The importance of understanding what really happens in a client-therapist meeting that is unique to psychotherapy, and that which leads to therapeutic change, is emphasized in this paper, with case studies from classical texts and referred back to modern day change-process research.

Keywords: psychotherapeutic alliance, psychotherapeutic relationship, psychotherapeutic change, psychotherapeutic process, psychotherapeutic dialogue, I-Thou.

To download pdf, click here.

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

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

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

How is this connected to trauma treatment?

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

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

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

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

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

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

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

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

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

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

Trauma-focussed therapy, for whom?

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

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

Medication to treat trauma?

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

Conclusion

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

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