Francesetti: Gestalt Therapy, an Engine of Change.

This lecture was given by Gianni Francesetti in Madrid on 22nd Sept 2023 at the European Association of Gestalt Therapy conference.

This article is a work in progress…. These are my notes and personal reflections on this lecture.

@ 10:30 On the topic of “Boring.“

Francesetti begins by explaining that he has tried to make his speech less “boring”. He then says, “Boring is not so bad, maybe.”

He will mention this phenomenon of boredom — which I find noteworthy due to personal experiences as someone who often gets bored myself and working with clients who feel chronic boredom as a practitioner — later on in this lecture.

Field perspectives in Gestalt therapy: there is a growing interest in the field perspectives in the current psychotherapy universe. This has much to do with current clinical issues. Frank Staemmler (2006) writes about the concept of ‘field’.

What does “Field” mean? Is it different for each person, or is the feel a “common” dimension?

@13:15 The speaker mentions that different people use the term “Field” differently, and even the same author may use different meanings of the word field, that a definition needs to be made. I tend to think that perhaps this is precisely what the term is about. The field is an all-encompassing concept, and all meanings of the word field are valid and useful to psychotherapeutic work.

@13:59 Is the field different for each person or is it a common dimension in a given situation?

The field as organism-environment contact/unity, and the key historical influencers to the concept of field theory in Gestalt psychotherapy.

@ 35:20 What are the clinical issues we are facing today?

Case study

Psychopathology, just like life, is a fractal.

References

Francesetti, G. (2023). Gestalt therapy. An engine of change. Lecture EAGT Conference on 22 Sept 2023. Madrid. retrieved from https://youtu.be/dSIGs2bbwGU?si=cQGEKwFSDBMZFTbo&t=506

Staemmler, F. (2006). A Babylonian Confusion?: On the Uses and Meanings of the Term ‘Field’. British Gestalt Journal, 15(2), 64.

Gestalt Therapy: The Paradoxical Theory of Change

Since its founding, Gestalt therapy has been at odds with the dominant medical and psychiatric paradigm of therapeutic change. In the 1970s and early days of its development, the founders of this therapeutic modality, Fritz & Lore Perls and Paul Goodman crystallized the concept of change in psychotherapy through the work of Arnold Beisser, who named this theory the Paradoxical Theory of Change.

“[T]hat change occurs when one becomes what he is, not when he tries to become what he is not. Change does not take place through a coercive attempt by the individual or by another person to change him, but it does take place if one takes the time and effort to be what he is – to be fully invested in his current positions. By rejecting the role of change agent, we make meaningful and orderly change possible.“

Beisser (1970)

Humanistic and existential approaches to psychotherapy emphasize the movement in the here-and-now in the therapeutic relationship. The therapist does not assume the role of fixer or changer but pays attention to the existential meeting with the client. Attunement to the therapeutic situation enables the client and therapist to study and appreciate the phenomenon of their co-created field, which is the physical and emotional environment. In this environment, suffering (or pathos) is felt, grasped and seen. This process of inquiry into pathos is the essence of psychopathology.

People do not change by trying to be who they are not.

Change does not happen through striving or coercion—the person who abandons attempts to disown parts of themselves and tries to change experiences the shift. Hence the paradox, to change, one first seeks to refrain from jumping into influencing change.

The person seeking change in therapy is in conflict, constantly thinking of moving between what they “should be” and what they think they “are”. This dichotomy of personhood is brought to light experientially in therapy. From staying with the discord, the client finds integration.

The Gestalt therapy process is experiential. We use experiments so that clients can learn with an embodied experience. The embodiment of the experience kicks of a cascade of real, percievable change, where the split parts of the self is actualizes into an evolved version. Perls alludes to this spontaneous change in this passage:

[W]e realize that we cannot deliberately bring about changes in ourselves or in others. This is a very decisive point: Many people dedicate their lives to actualize a concept of what they should be like, rather than to actualize themselves. This difference between self-actualizing and self-image actualizing is very important. Most people only live for their image. Where some people have a self, most people have a void, because they are sobusy projecting themselves as this or that. This is again the curse of the ideal. The curse that you should not be what you are. (Perls, 1969 p.39)

Reference

Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 1(1), 77-80.

Perls, Frederick (Fritz). (1969/1992) Gestalt Therapy Verbatim (p. 93). The Gestalt Journal Press. Kindle Edition

Reich’s Case Examples: Process vs. content in the psychotherapeutic dialogue

Wilhelm Reich, in Character Analysis (1945/1984), illustrates the importance of working on the process of the therapeutic relationship – i.e. what is going on between therapist and client— before jumping into analytical work. Reich points out that neurotic character traits— being symptoms as the result of the failure of the individual to resolve the unconscious conflict between repressed instinctual demands and the ego forces that work against these instinctual demands— need to be worked with first before the client is able to benefit from any analytical work. Reich explains that interpretation is the process of bringing that which is unconscious into consciousness. However, the problem lay in “counter-cathexes”— which can be explained as strict censor of thoughts and desires in the preconscious— that critically selects the thought process of the client, rendering it difficult for the client to freely associate. At the same time, it is the need of the patient’s unconscious to find release for this conflict through contact with the analyst (as it is a need for an individual to contact any other individual or situation). The result is an establishment of a relationship with the therapist that is prompted by love, hate or fear— what is known as transference. This can come in two main forms: 1) positive transference, whereby there is cooperation/compliance by the client due to positive feelings and 2) negative transference, where the treatment is impeded due to ill feelings the client has toward the alliance.

Reich points out that while negative transference is easier to detect – since it works against and irritates the therapist’s intentions— as something to work on, positive transference is as important – or even more important.

Positive transference often gets mistaken for progress until the positive feelings ultimately transform into disappointment. For this reason, it is observed that the tendency of the therapist to begin analyzing every material that the client presents prematurely, to rely on the routine passage of therapy sessions, without considering the effects of transference, is not effective in bringing about a resolution to unconscious conflicts and does not make for a successful healing alliance.

Reich writes, “If the analyst interprets the material in the sequence in which it appears in each case, whether or not the patient is deceiving, using the material as a camouflage, concealing an attitude of hate, laughing up his sleeve, is emotionally blocked, etc., he (the analyst) will be sure to run into hopeless situations. Proceeding in such a way, the analyst is caught in a scheme which is imposed on all cases, without regard to the individual requirements of the case, with respect to the timing and depth of the necessary interpretations” (p. 8). In other words, it is almost impossible for the therapist to distinguish authentic, useful narrated content from, perhaps, words that are used to manipulate the therapeutic situation or relationship, unless the underlying situation of the relationship itself is understood. It could be difficult to be sure of what goes on in a relationship of which one is part. For the therapist, time, together with an attitude of patient, phenomenological observation, allows the therapist to gain experience of being with the client. Setting aside this time helps the therapist to understand what is in between them and the patient.

Reich’s case examples

In the third chapter of Character Analysis entitled On the Technique of Interpretation and of Resistance (p. 21-38), Reich provides snippets of case studies. These examples help us to understand what Reich means by working on what Freud calls the forces of “resistance and transferences” that interfere with the attempt at analysis before jumping into analyzing the content of the client’s narratives— and the “chaotic situation” that can happen when attention to this is not observed. The case examples cited revealed instances where therapy sessions did not help the patient because the therapist failed to notice and observe resistances due to transference— and character— but instead delved into (or attempted to delve into) interpretation right away, without preparing the client – and therapist himself— for the analytical work first. I shall discuss some of the cases, and briefly discuss what kind of questions could have been asked by the therapist in the situations.

Case 1

“A patient who suffered from an inferiority complex and self-consciousness enacted his impotence by adopting an apathetic attitude (“What’s the use?”). Instead of divining the nature of this resistance, clarifying it, and making conscious the deprecatory tendency concealed behind it, I told him again and again that he did not want to cooperate and had no desire to get well. I was not entirely unjustified in this, but the analysis was not successful because I failed to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.” Instead, I allowed myself to be trapped into futile reproaches by my own inability” (ibid. p. 23).

The therapist, frustrated at the client’s perceived non-cooperation failed to acknowledge the process of how the client was unconsciously avoiding the work; by resigning to the belief that there was “no use”. This resignation in itself is the defense mechanism and the ripe material for the work. In trying to fish for cooperation from the client, the therapist missed what was present that could be worked on, as the therapist himself points out: (see above: to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.”). The therapist, when unaware of his own need to get cooperation, was in danger of re-enforcing the resignation and breaking contact with the client. Working on the here-and-now, the therapist in such a situation may ask the following questions that address the client’s resignation, and perhaps his lack of will to even try. These questions may lead the therapist and client to a deeper understanding of phenomena in the alliance itself: “what does it mean for you when you say ‘what’s the use’?”, “what would you imagine could happen if you tried?”, “what would it mean if you tried and failed?”, “I am interested to know if would you like to try for a couple of minutes and see how?” “If not, what can I do/not do to help you work this out?”.

Case 2:

“In still another case, it happened that in a dream during the second week of treatment the incest fantasy appeared quite clearly and the patient himself recognized its true meaning. For a whole year, I heard nothing more about it; consequently, there was no real success. However, I had learned that at times material that is emerging too rapidly has to be suppressed until the ego is strong enough to assimilate it” (ibid. p. 24).
What appears to be material, in this case, a narration of a dream may be a way of resistance from being seen through story-telling. It is an example of a therapist focusing on “content”, which is the dream story, and not noticing the “process” which is the fact that the client is telling the story in the first place. The content is enticing. The process is invisible. Unawares, the therapist missed the resistance because it is embedded in the process of what is being said. It would be helpful to ask the client questions that bring him back to the alliance: “I’m hearing your dream and it is really interesting to me that you are so clear about it, and my instinct is to ask you more about it. I’m just curious, what is it you want me to know from this?” “What is important right now for us to work on with regard to what you just said?” or “What is it like for you to tell me this?” With these questions, the client will have a choice to either work deeper into what is really disturbing him about the dream (if at all), or, he may reveal his need to impress or help the therapist by being unduly cooperative as in positive transference (as will be discussed later).

Case 3:

“A case of erythrophobia failed because I pursued the material which the patient offered in every direction, interpreting it indiscriminately, without first having clearly eliminat- ed the resistances. They eventually appeared, of course, but much too strongly and cha- otically; I had used up my ammunition; my explanations were without effect; it was no longer possible to restore order” (ibid. p. 24).
In this case it is an example of the therapist focusing on content, and unsystemat- ically using this content for analysis. The therapist probably failed to notice the process that was going on, i.e. the fact that there is so much unsystematic work in progress with- in the alliance itself. Possible way to make good the “chaos” is to stop and acknowledge the chaos ensuing. “I notice that we are doing much here and it feels chaotic. I am inter- ested to know what you are experiencing right now.” It may be also useful to check out how not interpreting can help the client. In this case, where a symptom “erythrophobia” is clearly acknowledged, the alliance could be a place for experimentation in the here- and-now— like inviting the client to blush “for a moment”, or what would the client think if he saw the therapist blush— to help the client gain confidence within the alliance.

Case 4:

“Another patient, in the course of three years of analysis, had recalled the primal scene together with all material pertaining to it, but not once had there been any loosening of his affect-paralysis, not once had he accused the analyst of those feelings which- however, emotionless-he harboured toward his father. He was not cured” (ibid. p. 23).
This case is representative of situations whereby the patient seems to have the full acknowledgement of the unconscious material. The therapist is satisfied, but the client is not helped even after 3 years. Reich highlights the importance of the patient embody- ing the experience— feeling the emotions and physical reactions as if reliving the past— rather than simply intellectualizing the recall. Intellectualizing memories, which is easily observed because there is a lot of “talking about” without affect, is really aform of resistance; a way to satisfy the therapeutic process while escaping pain. In ge- stalt therapy, this defense strategy is called “egotism”. Egotism is characterized by the individual stepping out of himself, acting as a spectator or commentator of himself and his relationship with the environment (Clarkson, 2014, p. 65). This is what is happening to the client is this case. This resistance often gets overlooked by therapist because they are sidetracked by “interesting” client narratives. Noticing the interruption is a way to slow down the narratives and show the client that he/she is avoiding something poten- tially difficult to deal with.

Case 5:

“A patient with a number of perversions had been under analysis for eight months, dur- ing which time he had rattled on incessantly and had yielded material from the deepest layers of his unconscious. This material had been continuously interpreted. The more it was interpreted, the more copiously flowed the stream of his associations. Finally, the analysis had to be broken off for external reasons, and the patient came to me… It struck me that the patient uninterruptedly produced unconscious material, that he knew, for instance, how to give an exact description of the most intricate mechanisms of the simple and double Oedipus complex. I asked the patient whether he really believed what he was saying and what he had heard. “Are you kidding!” he exclaimed. “I really have to contain myself not to burst out laughing at all this” (ibid. S.26).

Here, Reich gives another example of a “knowledgeable” and “cooperative” cli- ent whose knowledge and cooperativeness was the resistance itself. Reich explains this behavior to be of narcissistic defense. The therapist is unaware of what Reich describes as “latent resistance”, which he explains are “attitudes on the part of the patient which are not expressed directly and immediately”, but expressed indirectly. The patient’s negative regard towards the therapy (i.e. feelings of doubt, apathy, distrust, etc.) is disguised under the cloak of exceptional docility, or complete cooperation. Reich says that this is “more dangerous” than passive resistance, and the way to handle such situations is to tackle it as it happens, without hesitating to interrupt the flow of communication. Our challenge as therapist is to first notice that such-like phenomena are taking place. It is from this vantage point that Reich emphasizes the topic of character.

Reich’s advice on avoiding “chaotic situations”

Reich tells us that through this process, can we avoid what he terms “chaotic situations” which occurs as the result of:

Premature interpretation and work on unconscious materials, and symbols. Resistance to the therapy itself, when not yet exposed, prevents the patient from assimilating the work. The client ends up “going in circles completely untouched” (p. 26): This phenomenon can be explained as egotism in gestalt therapy. Egotism is a defense strategy whereby the client’s ego distances it- self from the experience, and sees the self from a distance, as if he/she is look at another person. This situation of the client going in circles may help to explain why some clients, though compliant, do not seem to get better.

“Interpretation of the material in the sequence in which it yields itself, without due consideration to the structure of the neurosis and the stratification of the material” (p. 27): The mistake happens in interpretation, because the ma- terial is not worked through in it’s full context, but worked on in unsystemat- ic fragments, leading to loss of meaning.

“The analysis is embroiled not only because interpretations are pursued in every direction but also because this is done before the cardinal resistance has been worked through” (p. 27): The main problem here is due to the re- sistance not being acknowledged and worked through before interpretation is done. The situation becomes confused when the work is entangled with the relationship to the analyst. The unsystematic interpretation works in a vi- cious circle to affect the transference relationship further.

“The interpretation of the transference resistances is not only unsystematic but also inconsistent“ (p. 27): When there is a lack of acknowledgment of the power of the client’s resistance (and latent transference resistances) to need to conceal resistances. These resistances are also masked behind “ster- ile accomplishments or acute reaction formations” i.e. the client may seem to be cooperative, show signs that there is the change in direction expected, or the client may react to analysis in a way so as to deflect from getting to the authentic unconscious material. Therapists may tend to shy away from developing and following up consistently on these resistances in whatever form, due to their own feelings of discomfort (their own resistances) in dealing with the transference resistances in a consistent manner.

It is from the understanding of the effect of transference, that we may be able to appreciate the challenge of being aware of how the interpersonal feelings in the alliance get in the way of therapeutic work.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Chew-Helbig, N. Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA). URL: https://nikhelbig.at/wp-content/uploads/2019/05/NICOLE-HELBIG-PRINTING-copy.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy.

Psychomatics: Binge Eating Disorder

Psychosomatic Disorder: Overeating associated with other psychological disturbances

Overeating is considered a behavioral disorder that is attributable to psychological disturbances. This behavior has its physiological consequences. Obesity, which is measured by a body mass index [BMI ≥ 25], is all but a consequence of this behavior. Depending on genetic factors, some people who develop overeating behavior disorder may not become obese. Other physical problems, however, eventually afflict long-term overeaters. This include metabolic syndrome, a chronic disease suffered by millions worldwide which result in morbidity and mortality. Despite much attention put into the worldwide “obesity epidemic” the problem of over-nutrition is difficult to grasp. This is attributed to the fact that the cause of the problem is multifactorial, with environmental and psychosocial influences in play (Agras, 2005).

Different Subtypes of Eating Disorders

Eating disorders are grouped together in the ICD 10 and DSM-V system. This include Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Unlike AN and BN, together with other forms of Eating Disorder Not Otherwise Specified (EDNOS), overeating is a disorder associated with over-nutrition and has the opposite effect. The sufferer does not compensate for the habit by doing activities like purging in order to lose the calories consumed. As opposed to these eating disorders it is not clear if the root of over-nutrition is psychological or physical, i.e. if obesity, and other affects of over-nutrition is a cause of overeating or vice versa or both ways (ibid. p. VII).

Categorization in the ICD-10 does not specify or name the condition “Binge Eating Disorder” as in the DSM. Within the ICD-10 there are at least 3 related conditions that could relate to the condition. The closest is F50.9 which is basically Essattaken ohne Erbrechen, F50.4 which if the condition coincides with emotional disturbances. As a consequence, it could also relate to F55, addiction to non-addictive related substances.

General Description and Diagnostic Considerations

Binge Eating Disorder (BED). The behavioral problem of overeating is classified in diagnostic manuals within the category of eating disorders. Only since DSM-V has BED been recognized with its own category. Prior to this, in DSM-IV, BED was relegated to an appendix alongside EDNOS, BED is defined “as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months” (American Psychiatric Publishing, 2013). BED also does not result in compensatory behaviors like purging (Tuschen-Caffier & Schlüssel, 2005). It is separated but intertwined with obesity and is generally known to have emotional underpinnings (Masheb & Grilo, 2006).

It may be useful to note that BED is considered to be a separate condition from the general phenomenon of overeating according to the DSM. In the ICD, there is a condition identified as “overeating associated with other psychological disturbances” (F50.4) a situation of overeating in the presence of emotional stress or setback. Studies have shown that obese individuals with BED differ from individuals who are simply obese (Grilo, 2000).

Obesity is not the only physical consequence of BED, and many sufferers may not show significant signs of adiposity. There exists evidence of risk of metabolic disease arising from the behavior, with a higher percentage of newly diagnosed type 2 diabetics having experienced problems with binge eating compared to other groups who have not that experience. Recurrent binge eating can also make diabetes difficult to control. (Kenardy, Mensch, & Bowen, 1994)

Food Addiction. Could the cause of over-nutrition be the result of addiction to food or certain food ingredients? Is addiction to food, and/or the phenomenon of food craving related to, or contributory to BED? Food craving is known to be a cause of uncontrolled eating, which lead the scientific community to recognize food substances to be potential triggers of addiction, similar to the effect of drug addiction (Pelchat, 2009). Refined foods have been implicated to cause addiction, whereby loss control of intake of such food is a cause of health concern (Ifland, et al., 2009). There are also arguments that unlike drug addiction, what is often food “craving” has a biopsychosocial aspect that is not synonymous with addiction (Rogers & Smit, 2000). In the ICD, depending on severity of dependence to the food substance, we may, arguably, consider the classification under “Abuse of non-dependence producing substances” (F55).

From a biological standpoint, the idea that “non-dependence producing” could be questioned. Long-term chronic over-eating leads to metabolic disorders, which is related to the endocrine system. Insulin resistance caused by constant high levels of glucose and fructose intake results in not only physiological effects on the patient, but also psychological effects. While sugars are not considered directly “psychoactive”, glycemic levels do affect the mental state. Sufferers of metabolic disorders have problems dealing with the homeostasis of blood glucose, and face with uncontrollable craving, hunger and other emotional side effects, like stress and depression (Goebel-Fabbri, et al., 2005). Looking at the situation holistically, one can observe a vicious cycle of uncontrollable behavior resulting in physiological problems that add to more difficulty in managing the behavioral impulses (Vaidya, 2006, S. 76).

Criteria notwithstanding, for this paper, I discuss the phenomena of uncontrollable over-nutrition, since sufferers exists in varying degrees and since as psychotherapists, we may encounter many clients with difficulty controlling their tendencies to over-eat, and need help regardless of whether their symptoms fulfill the criterion stipulated in the manuals or not. As with most eating disorders, that while the symptoms may seem similar amongst patients diagnosed with the same disease, the underlying mental causation for each case is individual-specific. The challenges exist with such clients since there lies not only emotional grounds for the occurring situation, but also physiological causes.

Physical Symptoms vs. Psychological Symptoms

Table 1. lists the differences between the somatic and psychological symptoms of BED and general disorders related to over-nutrition like food addiction.

Condition

Physiological

Psychological

BED and “Overeating associated with other psychological disturbances”

Over-nutrition, consuming too many calories.

Possible Adiposity.

Long term result in Insulin Resistance, Metabolic Syndrome, and complications therefrom (Goebel-Fabbri, et al., 2005, S. 143).

Possible alimentary canal, teeth stomach injury.

Uncontrollable need to consume food. Feeling lack of control over behavior.

Pre-occupation with thoughts of food.

Emotional reaction to condition: anxiety, stress, shame, frustration.

Psychosocial problems, loneliness, loss of normal social activity caused by habit.

Emotional stress caused by illness as a result of over-eating. Comorbidity with mood disorders, high rates of major depression, personality disorders

(Yanovski, Nelson, Dubbert, & Spitzer, 1993).

Vicious cycle of dealing with weight gain and medical problems.

Food Addiction/Craving

Over-nutrition, consuming too many calories.

Possible Adiposity.

Possible toxicity from abused food substance.

Long term result in Insulin Resistance, Metabolic Syndrome and complications therefrom.

Stress caused by weight-loss efforts.

Body image shame.

Yo-yo dieting.

Table 1 Physical and psychological symptoms

Case Study

The case study cited here is a self-report by Kimberly, who posts her story online in the form of videos, otherwise known as vlogging. One can access her videos via her in a YouTube Channel @kimberlyuhles1 (Uhles, 2014). I have decided to use this material because the accounts are directly reported by sufferer. Unlike other material we may find, the case studies do not come from first person perspective and are often edited and reworded. I find it more challenging this way, partly because this “client” does not present herself as someone in the victim position, but rather, a survivor of a disease. The sufferer, in her early twenties at the time of recording, seemed to have found a way to cope with her affliction. At the time of writing this paper, Kimberly is 23, and still vlogs regularly on the same channel. With this, one can simulate a situation with a client whose journey still continues.

Family History

Kimberly has two sisters. When she was 9 years old, her father left home for another family. Kimberly reports that he took everything, including material items for their home. As a child, she says she could not understand why her father left. In the process, her mother had to spend time at work, leaving the children to their own devices at home. They ate and did what they liked. Kimberly recounts later on not having the food that she wants to eat at home. Her mother, in effort to control her children’s weight, kept only healthy foods in the house, and disallowing any junk food. Kimberly felt deprived, especially in school watching other children eat whatever they liked (mostly tastier junk food). She also said she felt left out, or the odd one out because of the food she was given for lunch, and that which was not allowed her. She started sneaking to buy junk food herself, which she would eat quickly so that her mother would not catch her eating them. At 12 years old, her mother put her on a weight-loss regime, sending her to a gym even when she was too young to be allowed in that gym. She had to lie about her age to the trainer. When she was caught eating junk food, her mother would punish her with workout. When she turned 17, her realized sense of “freedom” meant that she was free to eat whatever she wanted. Her experience of having her first car was that of having the freedom to eat. Henceforth, she recounted really being addicted to food. She would eat as much as she could while sitting in the car. Her subsequent weight gain (she was reported to weigh about 300lbs) caused depression. She tried to get gastric bypass surgery but could not afford the treatment. She tried unsuccessfully to make herself throw up, but stopped doing it shortly after realizing that it did not help with her weight problem. She reported feelings of depression and self hate.

Current Situation

It seems that Kimberly managed to cope with her situation through her vlogs, which she has done so regularly for almost three years. Much of what she has talked about were her eating disorder, the emotional triggers, and her efforts to self help through diet and exercise. She also likes to give advise to others. Kimberly is also in a long-term relationship, and has recently found out that she is pregnant. She reports her pregnancy to be a happy situation.

Clinical Practice

From the case presented above, one can appreciate the process that triggered such an eating disorder in a young person. The problems started in childhood and progressed over more than a decade, and is a culmination of situations from which one can hypothesize:

At 7 years old having feelings of loss and betrayal because of father’s leaving.

Feelings of further loss because of mother’s reduced presence at home because of work, and possibly mother’s emotional state.

Probably lack of food in home (because mother was not home) and associating this with loss of parental presence and loss of emotional support.
Stress from mother’s negative reaction, and harsh remedial actions in response to children’s weight gain (probably caused by mother’s own guilt feelings).
Feeling alienated at school. It could have been caused by shame because of parent’s situation, but client associates it with the food she got for lunch.
At 17, she associated freedom with having food. At the same time, realizing she was addicted, then judging her own state of mind.
Stress and depression from dealing with being overweight.
Compensatory measures attempted by client does not fit that of sufferers of Bulimia Nervosa (BN), since the client claimed that she tried it, but found that it did not suit her.

Intervention Questions

These are intervention questions for client at the present time. The client seems to have coped with her initial situation of over-eating and she has found an outlet for her problems through what Freud considers “sublimation” in the form of vlogs. Exercising is also a compensatory measure (and the voice of her internal mother). I believe that dealing with the client at this point is a more challenging task. The personality of the client is one of an independent person who meets up to personal challenges. She also intellectualizes her inner existence through self-analysis. She has not got counselling, and may may not have had time to deal with experiences that underlie feelings of loss, betrayal and need to be shown love. In a video in the channel where she talked about a breakup with her boyfriend, she repeated that she wasn’t given the love that she wanted even when she knew he loved her (they got back together and are having the baby). My impression from watching the video is that this need for “assured signs of affection” reflects the mistrust felt from earlier abandonment, and could be good direction to take in treatment. I would ask these questions (in italics), and try to get the phenomenological experience of the client. What I would try not to do is to talk about physical symptoms or the over-eating habits that the client is already aware of and is ashamed of, unless the client brings it up.

Questions directly addressing binge eating disorders and the somatic aspects:

Help me understand your relationship to food. How often do you eat? What do you like to eat? Etc.
When you were a child, in what way does food play a role?
Did your family eat together?
When did you realize that you have a “problem” with binge eating? When did it happen, where were you, how did you feel?
You mentioned you got hungry when you were alone, can you help me understand how you felt as you reached for the refrigerator?
When you had your first car, help me understand how it felt to gather the food and eat it.
Imagine yourself in the car, please say what your experience is like.
After the session of eating, please tell me what it was like for you.
What are the physical effects? Do you feel discomfort? Where in your body?
How long did the discomfort last?
What are you feeling about this now as you are telling me this?
Are there long term effects of this habit?
What have you done in efforts to overcome the effects (weight gain)?
How has this affected your relationships/life/work?
What can you imagine you would have done have you did not binge eaten?

The following are questions I would ask considering methods in Gestalt therapy. If the client does not acknowledge binge eating as a problem, or if he/she is convinced that he/she has it under control but still shows signs of dependency issues in relationships, these questions may be a way to help work the client towards the issue:

Congratulations on the baby. Tell me what having this baby means to you? What is it like for you to be a mother? What is it like to hold the baby?
What do you want for your baby? What is your wish? The client may express aspirations for her child, or for her family.
Very nice. Lucky baby. Look for phenomenological expression. On this remark. Is she touched? Eyes moist? Smiling? I wouldn’t ask question but state what I observe. E.g. I notice you were touched/ your eyes are moist/you were smiling when I said this. Then wait for response.
If client makes reference to her past experience as a child, e.g. “I do not want my child to bear the same problems,” then ask about it. Otherwise, stick with the moment of happiness with having the baby. Dwelling with the positive makes for good rapport.
If client talks about disappointing childhood, say, tell me, what happened when your father left? What did that mean to you then?
Imagine you were back there, what would you like to say to him? What would you like to ask him? Use empty-chair if client is okay with it, and guide client through experience. One may also continue with discussion on the client’s father, but with focus on what the client feels about him, look for emotional queues on the face and body language.
Tell me, what is your father’s response now? This question one can ask after empty chair or some kind of constellation technique. This is to help client gain insight into the father’s motives/weakness.
So he said this. What do you take from it? Usually client will experience that father’s leaving was not her fault and/or that it is his weakness and/or this is how grown ups behave…etc.
I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
Imagine yourself as the child, and your father just left suddenly. What do you want to say to your mother? Again, empty chair or phenomenological discussion. This is to establish client’s idea of what was going on with mother.
How did you feel being alone at home without her? It is to help client find out Was it fear? Anger? Hunger? What? Then allow the client to take it in.
I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
As an adult, here and now, tell me what you think of this little girl?
I think she’s ……too! Repeat the positive things client says about herself as a child.
Give us one word to describe this session. This is to crystalize the insight, at the same time to put distance again from the past and return to the present.

Conclusion

While many people may face the same kind of childhood trauma, only some children develop, for example, Anorexia Nervosa. Others may do the opposite and become binge eaters and /or become obese. For others, eating disorders do not become a problem, but they develop an array of physiological symptoms as a result of anxieties, phobias and internally directed aggression. Question that arise are: is there ever a psychological problem that does not have somatic implications? Are there ever somatic symptoms that do not affect the psyche? What has personality—what many would agree to be caused by the ego— got to do with the physical attributes of a person? Does personality, then, correlate in some way to the manner of physiological disorders an individual might contract? For that matter, is every individual really unique, and what can personality traits tell us about the motivation behind these disorders?

We may find some good advice from pioneer Gestalt therapist, Erving Polster (1987); he has trained therapists of the modality to see, and value every persons’ life as a novel. This idea may be very helpful, because it puts the therapist on a mindset of valuing the clients’ life as something interesting and worthwhile to investigate. When the therapist is interested in the life of someone, he/she would naturally ask appropriate questions and go beyond the stories he/she tells, or that of his/her doctors. The therapist would be able to work authentically without fear of seeming unprofessional, losing the client to other therapists, making the client angry or other problems we have discussed at class. In dealing with dialogue, I’d often refer to the works of Lynn Jacobs, one of which tackles shame (of both client and therapist) in the therapeutic dialogue (Jacobs, 1995). What one can infer from Jacob’s argument is the possibility that shame (or unrecognized shame) in therapy prevents the therapist and client from getting to the heart of the matter, thus leaving problems to persist and the therapy ineffective. One can only imagine that ineffective therapies, especially encountered by clients dealing with somatic symptoms, can be intolerable and frustrating. This leaves for interesting work and more detailed efforts into psychotherapy process research.

Bibliography

Agras, S. (2005). Preface. In S. Munsch, & C. Belinger (Eds.), Obesity and binge eating disorder (pp. VII-IX). Basel: Karger.

American Psychiatric Publishing. (2013). Feeding and Eating Disorders. Retrieved from American Psychiatric Publishing: http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf

Goebel-Fabbri, A., Musen, G., Sparks, C. R., Greene, J. A., Levenson, J. L., & A.M., J. (2005). Endocrine and Metabolic Disorders. In Textbook of psychosomatic medicine (pp. 495-497). VA: APPI.

Grilo, C. (2000). Binge eating disorder . In F. CG, & B. K. (Eds.), Eating Disorders and Obesity: A Comprehensive Handbook, (2 ed., Vol. 54, pp. 178–182). NY: Guilford Press.

Ifland, J. R., Preuss, H. G., Marcus, M. T., Rourke, K. M., Taylor, W. C., Burau, K., & Manso, G. (2009). Refined food addiction: a classic substance use disorder. . Medical Hypotheses, 72(5), 518-526.

Jacobs, L. (1995). Shame in the therapeutic dialogue. Retrieved 2016, from http://icpla.edu/wp-content/uploads/2013/09/Jacobs-L.-Shame-in-the-Therapeutic-Dialogue.pdf

Kenardy, J., Mensch, M., & Bowen, K. (1994). A comparison of eating behaviors in newly diagnosed NIDDM patients and casematched control subjects. . Diabetes Care , 17, 1197–1199.

Masheb, R. M., & Grilo, C. M. (2006). Emotional eating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder. International Journal of Eating Disorder, 39, 141-146.

Pelchat, M. L. (2009). Food addiction in humans. The Journal of nutrition, 139(3), 620-622.

Polster, E. (1987). Every person’s life is worth a novel. Gestalt Journal Press.

Rogers, P. J., & Smit, H. J. (2000). Food craving and food addiction: a critical review of the evidence from a biopsychosocial perspective. Pharmacology Biochemistry and Behavior, 66(1), 3-14.

Tuschen-Caffier, B., & Schlüssel, C. ( 2005). Binge Eating Disorder: A New Eating Disorder or an Epiphenomenon of Obesity? In M. S, & B. C (Eds.), Obesity and Binge Eating Disorder (Vol. 171, pp. 138-148). Basel: Karger.

Uhles, K. (2014). My story: Why I weighed over 300 lbs. Retrieved from YouTube Video Channel : https://www.youtube.com/user/HOPEANDSMILES/featured

Vaidya, V. (2006). Psychosocial Aspects of Obesity. In V. Vaidya (Ed.), Health and Treatment Strategies in Obesity (Vol. 27, pp. 73–85). Basel, Karger: Adv Psychosom Med.

Yanovski, S., Nelson, J., Dubbert, B., & Spitzer, R. (1993). Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry, 150(50), 1472–1479.

Case Study: Longing for Acceptance from Birth Father

This is my critique of a therapy work I witnessed. This is a case study of a 27 year old student, Miriam (not real name, and all details are changed) who attends therapy sessions because she had problems sleeping. After several sessions, she got in touch with the running thoughts that go on in her mind at night.

This is a case I witness during a training session. The names and stories are changed to avoid recognition of the individuals involved. The therapist is a trainer demonstrating his work to a group. Though I was not impressed with his work, this case story is interesting. I shall write my own analysis of the work in blue, and leave you to make your own associations. You may send me your feedback in the comments.

Much of these thoughts brought out in Miriam deep rooted anger. She explains that this anger has been with her her entire life. Miriam had also often mentioned of anger bubbling up and interfering with her activities.

The present theme

A theme brought up in one session of therapy within a group, was that she was angry about being responsible…

“I am angry that I have to be responsible for everything that has to be done at work… I cannot rely on anyone to help me, but they expect me to be there to help them.”

“I cannot just let go and leave the scene like everyone else when there is something to be done. It is a burden. ”

“I am envious of my girl-friends, when they need help, someone is there to help them. I, for example, cannot even find anyone to help me to hang up a picture in my apartment. my girl-friend offered to ask her father to help me. That is not the point. I wish that I had a father like hers. He is always there for her.”

At this point, Miriam showed signs of deep sadness.

Miriam’s work

As the group session wore on, Miriam offered to work in the middle of the group.

Miriam explained that her birth father, Mark, is someone who was not there for her in her childhood(i.e. this person was not known to her till she was 17). In fact he has only met her after the death of her mother 10 years ago. She longs nevertheless “for him to acknowledge his fatherhood to her. Even though, he actually acknowledged her within his community, friends and family. This is “not about the money ” [Miriam mentions this several times]. “I just want him to accept me as a daughter.”

Miriam explained the difficulties in communicating with Mark. She describes him as “living in his own world”, that their communication is superficial, that the last christmas was disaster when she was with his family, that she is afraid that he would reject her on grounds that he might think she wants more from him than he is willing to give.

The therapist offered the 2-chair (empty chair) method. He asked Miriam if she would like to put her birth father in that chair. The therapist was more concerned that Miriam showed her emotions of anger clearly, but did not clarify the many things Miriam said that sounded (to me, at least) ambiguous.

2 chairs were set in the middle of the room. One was to be for Miriam, the other, her father. Miriam spent the next 5 minutes explaining again the situation with her father, her frustration . Another 5 minutes was spent deciding where to put the chairs.

Miriam explained that she could not face her father directly. She feels unsafe. (I was wondering what her intention was to say this, since her father is not really there. Was it to avoid the work in front of the group? Maybe it was not the right place and time for the work. On hindsight, I am realizing that this is a sign that the issue was bigger that what meets the eye.)

Miriam says she feels better writing him a letter. The therapist and client talk further, with more explanations on how things were, and how frustrated she is. The therapist managed to get Miriam to talk more about where she wants to be positioned in Mark’s life. Miriam explains, and declares further that she wants to be acknowledged.

The therapist then asks Miriam if that is all… Miriam says, yes, everything is clearer, “I was afraid that he would reject me, because thinks it is about money.”

The 2 chair work ended there.

Towards the End of Miriam’s work

The therapist enquired how Miriam felt. She said she felt “more stable”. The therapist then explains further about how important it is to stay in a position and feel the emotions clearly.

Miriam mentions that this is something that has been all along an issue with her and her family. She goes on to say that her late mother was ashamed of having had 4 children from 3 different fathers. That this was known in the family, but never brought into conversation. Her mother, therefore, never made contact with Mark, and never asked him for anything.

The therapist ended the work there. He did not pick up on this new theme.

It is with this statement, that the existential issue Miriam really surfaced.

Comment on the case:

Miriam’s dilemma is touching, and is different from many other cases of a person trying to make contact with a father: An Adult trying to build contact with a father that one has never met as a child is likely to be in a different situation from coming back to contact with a father one knew as a child but lost contact with.

This is not a story about a person longing for contact with a person she had lost because he was someone she had not known. Many questions arise from this, which were overlooked during the work, that we cannot answer now without the client’s input:

What is she really longing for? Recognition, “not money”. What is important about being recognized by this person?
What does achieving this recognition solve?
The person has actually recognized the client (by introducing her as his daughter to the community, as mentioned). What, then is adequate recognition? How would she know when it is adequate?

The client mention at the end of her mother’s shame, and how this reverberated within the family and kept hushed. The questions worth noting here are:

How much of this shame is introjected by the client? To what extent does she identify with this aspect of her mother?
How had the death of her mother affected her need to have a closer relationship with her biological father? (they got to know each other better after her death.)

Since the therapist did not notice the significance, this was not brought to discussion and not worked on.

Comment on the work:

This is an example of a therapist who has overlooked the existential (and hence important) issues because of focussing on technique (wanting to demonstrate 2-chair technique).

Observing this technique , one has to realize that this is not a good demonstration of the 2-chair work. The use of chairs alone does not define the method. Here are the problems with this example:

The client did not get a chance to really “converse” with her father in the empty chair directly. She couldn’t, because she was talking to the therapist all that time, not to her father.
She was not asked to sit in her father’s chair, which is an important part of the 2 chair work. To sit in the seat of the other person, is a learning process in having a different perspective. To sit in the other’s seat is also a way to identify how much of what one thinks (about how the other will react etc.) is the product of one’s own projections. Had she sat on her father’s seat, she may have come to realize how much of her projections were hers, and how much of it is real. She may have also had the insight of being her father and looking at Miriam (to see oneself with the eyes of the other).
A lot of time was spent on arranging the chairs. This lead to a intellectualized discussion on how scary it is, how frustrating it is, how things used to be… there was much talking about, but the emotion had left the client. The likely cause of this was because the client was not ready to get into the exercise. In the end, the client wiggled her way out of it anyway. Rightfully so, since we know that it is not the actual issue.
There was a lot of mention of emotion, but the expression of emotion got weak. The therapist showed also no emotion, though he looked earnest and attentive. When there is not emotional energy, the work is not possible. This is a pity, because the client started with lots of emotion, but lost it at the chair arrangement part.

What I have learnt from this experience is…

not to take for granted anything that is said by the client, especially if it was something said “in passing”… especially if the client mentions the parents/family in the context of shame.
never to forget the existential nature of issues that tend to repeat themselves (i.e. in this case, complaints about work, and anger)….
when emotions feel deeper than the story, look closer, spend more time.
don’t get distracted by methods…
notice when emotional energy is lost in the middle of the talk. You have lost the client to intellectualization. Even if the client is “talking about” emotion, it is then only talk. This happened during the session.

In my opinion, techniques like the empty chair, or art therapy, or behavioral therapy serve only to create an environment to build contact. These techniques are means to an end. That end is the I-thou contact between client and therapist. Fancy techniques do not heal, only contact heals.

Case Study: A Car Thief and his Parents

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

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

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

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

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

Comments:

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

Gestalt Therapy Perspective on this Case-study

This are my comments using Gestalt therapy theory:

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

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

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

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

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

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

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

Bibiliography

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

Gestalt Therapy Case-Study: From procrastination to recalling a story in a novel

Written by: Nicole Chew-Helbig on 15 June 2017 in Vienna, Austria. [cite]

Abstract

This case study is an abstract from a therapeutic work. It is a demonstration how a recall of the client’s favorite novel as a teenager develops into a psychotherapeutic session that is meaningful to the clients identification of himself. This is a technique usually used for working with dreams in Gestalt therapy, in which the client plays the parts (makes projections) of his dream. In this case it is not the dream, but the novel.

Case study: CL’s Novel

CL works in a publishing company. He reports having problems with procrastination. Although quite successful at his job, he struggles making datelines. He finds himself delaying getting things done till the last minute, which sees himself sitting up till early hours of the morning smoking cigarettes. This is an excerpt of a Gestalt Therapy Session. Throughout this article, the principles of Gestalt Therapy adopted in this session are also explained in this color.

NC: Now can you bring to mind a moment in which the word “procrastination” feels familiar?
CL: (Contemplates…) Yes. I had to write a short article for the company’s blog. It was in morning, I took out the PC, but then I did instead some online shopping.
NC: Stay with the feeling of the moment before you switch to online shopping.

“Staying with the feeling” is an approach in GT where the narrative (which is usually an intellectual process) is embodied into experience.
CL: I feel anxious.
NC: This familiar to you?… stay with it. Can you remember a time in your childhood when you felt something like this?
CL: In school. It was Math, and I had homework. The teacher wasn’t pleased, I made mistakes I did not understand…

This narrative goes on, and we talked about anxiety about what he considered “small criticism”. This recall of the past is a “free association”. The experienced client knows how to take memories or images that pop up in the moment and vocalize them. Sometimes these associations do not seem to make sense at the moment, but these usually do.

NC: Stay with this anxiety again… much earlier… maybe at home…
CL: Nothing special, really, I am just having a picture of a dirty bicycle. I was 8 or 9, it is my bicycle. I was supposed to clean it, but I didn’t want to do it.
NC: You had to do it, but you do not want to do it now?

CL had used the present tense, and I felt it is a good thing, so I followed with the present tense. This is a good opportunity to work with past experiences as if it were in the present. Actually this is how we live, with occurrences of our past popping up in the present.

CL: Yes.
NC: What would you rather have done?
CL: Read a book.
NC: Have you a book in mind?
CL: Yes. (mentioned a title of a book).
NC: Where would you go to read this book?
CL: In my bedroom.
NC: How does it feel to be in your bedroom reading this book?
CL: Relaxed, comfortable… safe.

Notice that he said “safe”. It seems to correlate with the “anxiety” behind the procrastination. This is an indication that sitting in the room, and reading that book is a way out of anxiety. At this point I could have gone back to the anxiety, and tried to work on it. My interest of the moment, however, took me to the curiosity about the book (which I will explain later why). This is working in the here-and-now. The therapist is following her own feelings of curiosity, and being present. This means that we may, at this juncture abandon trying to sort the problem of procrastination. In Gestalt, we work on what is present. The present is always changing. We do not try to force goals into the present or force the client to concentrate or dwell on issues that are not there at the moment.

NC: The title of this book got my interest, I have not heard of it before.
CL: (laughs). It is a very old novel. German novel about German brothers coming back from the 2nd World War, and the Russians came.
NC: You mentioned this book was comforting to you, a 9 year old.
CL: for some reason, yes.

The backstory here is, like many of his generation, CL’s estranged father was a soldier in the German NS. CL himself is a liberal (kind of left-wing writer). This information in background, now got my interest to this book preference CL as a child. The background is very important to the Gestalt therapist because we are interested in the foreground. The foreground is made clearer only when the background is complete.

NC: Tell me about the book…
CL: (laughs, a little more shakily. He goes to his phone, and searches this book on an online site. Makes some association:)
NC: What comes to mind…
CL: Two scenes. This guy talks to his buddy in prison about the time he was taken from his home by the Russians. He was in the garden of his parent’s home, and his mother had baked a cake. Then they came to take him away. (laughs) He tells his buddy that he wished now that he had taken the cake along with him. The other scene is that he tells his buddy, “now I hope the Americans come, and gets rid of the Russians, so that they can free us”).

CL, has made associations again. This I found to be interesting. The scenes have irony and are a bit funny. Freud in his writings, “Der Witz und seine Beziehung zum Unbewußten” or “Jokes and Their Relation to the Unconscious” , tell us that there is significant repressed unconscious material in jokes. We’ll see how this plays out…

NC: Could you play out the scene? Try. You are this guy talking to your buddy in prison. Say “I am in the garden of my parents, and my mother had baked a cake…”

Unlike psychoanalysis, where the therapist takes on the task of analyzing the joke for the client, in Gestalt Therapy, the client tells us his/her version of the story. This method is usually used in Dream analysis (or dream work) in Gestalt therapy. The client is invited to take a role in his dream (or in this case, story). His task is to talk in the first person. By this time, there was actually resistance on the part of the client. There were points in the session when CL started to intellectualizing, either by stepping out of the scene, or to make judgment of the scene, even though he was quite agreeable to doing this experiment of playing the part of the characters in his associations. Playing part in associations and dreams is usually uncomfortable for many people because they feel awkward, or they do not trust what they say or feel in this kind of work. My experience is that the client is seldom ever wrong in this sense.

CL: I am in the garden of my home. My parents are there. Mother has baked a cake.
NC: Tell me about the cake.
CL: Delicious. She baked it often.
NC: then what happened.
CL: Soldiers came to the gate, and took me away. Then I am in the prison talking…
NC: Slow down. What happened as they took you away…
CL: That is not in the book.
NC: They are at the gate, they ask you to come with them.
CL: Yes.
NC: What’s going on.
CL: I feel scared, I suppose.
NC: I can imagine.
CL: In I am not sure if I would ever come back.
NC: Yes. Now, come back here with me. Have you an understanding what is going on with this character in prison as told his buddy that he should have taken the cake along?
CL: He is scared, he wished his mother was there, he’s afraid he would never see her again.
NC: Would you like to work on the next scene?
CL: Sure.
NC: I am in prison and I hope…?
CL: I am in prison, I tell my buddy, I hope that the Americans come soon and drop bombs on the Russians.
NC: What is the purpose of that?
CL: to save us.
NC: From?
CL: We are trapped in prison.
NC: What does it mean to be in prison?

This part took a bit of time. We stayed with it together… Staying with the client’s pause is good point of contact. Contact is a very essential part of Gestalt therapy. It usually comes when the client touches something emotionally significant, and when the therapist is able to give support.
CL: No freedom… I am in danger… I am guilty… I feel hopeless… I feel helpless…
NC: in prison, no freedom, in danger, guilty…
CL: yes.

The client, in his association, has come to contact with some deep feelings. These are unconscious until now. We can ask “what are you feeling guilty about…?”, but this might lead the client to intellectualizing. The cleaner path is to bring the client back to the present situation, the here-and-now.

NC: Tell me about what’s happening now. You being here with me now, we are talking now…
NC: are you in danger?
CL: no. I am safe.
NC: Guilty?
CL: No… not hopeless nor helpless. (Takes a deep breath.)

Note that this is a condensed version of the dialogue. CL had a bit of difficulty with the associations at first, and this is normal. Why we worked these scenes is because they were freely associated, and my guess was that they had significance. The other clue that this was significant was the resistance of the client along the way of this experiment.

At the end of the dialogue, CL took a really deep breath reflexively. He looked calm, and said “I feel good”. “Fine,” I said, and we ended there.

This short session demonstrated a closing of a gestalt. The client had anxiety-related procrastination issues, and that led to a memory. This memory led to a group of unconscious feelings, which took solace is a kind of joke or wit, or an entitled way of thinking “I hope the Americans bombs the Russians..” These were also not fully owned by the client, since he attributes it to a story book. However, the client was really interested in the experiment, because he realized, too, that there was some kind of association between this story and his relationship to his father. The beauty of Gestalt therapy is that we help the client come to his own meanings and understanding through his experiencing and embodiment of the experience. The therapist’s work here was that of supporting, and not of prying.

In the following sessions we discussed this dialogue again in relation to CL’s relationship to his parents. There was even clearer understanding to the cultural significance of “jokes” or “making light” in tough situations. Also, there was a discussion about how we deal with anxiety and fear.

The rest of the associations with regards to this dialogue, I’ll leave it to you, the reader.

An Entrepreneur in Therapy: Case study by Kets de Vries

This is a case study excerpt form this featured book, Reflections on Character and Leadership by Manfred Kets de Vries (pp.20).

[cite]

Why this case study?

Kets de Vries gives a very detailed psychoanalytic account of a case study of an entrepreneur he names Nr. X. This case study illustrates how the inner and private life of the leader have significant effect on the performance of the leader. As the leader gets older, it is not unlikely that unresolved inner problems from childhood affect many areas of the individuals life, including his/her relationships and health.

Reason for Seeking Psychotherapy
Client: Mr. X, a 44 – year – old. Youngest of 6 siblings (2 brothers, 3 sisters). Occupation: Entrepreneur. Family Life: 21 years married but recently separated, 4 children.

Events leading to therapy request:

Mr X. had thrown his wife out of the house.
her increasing need for more independence had become a bone of contention.
He complained about her lack of caring and suspected that she was emotionally involved with a younger man working at the office (she worked in his company).
He is strongly annoyed that his children had taken the side of his wife.
History of depressive episodes (but not thought of as serious as now).
Has now feelings of worthlessness. No life prospects.
Fears losing his mind.
Problems at work due to wife’s (and young colleague’s) departure.
Worries about the company health. Fears of bankruptcy / humiliation as result.
Feels paralyzed at work. Not able to function. Feeling painful going to the office.
Psychosomatic complaints: nightmares, sleep problems, severe headaches which affects eyesight. Temporary loss of vision. Diarrhea and nausea. Impotence.

Childhood History

Mr. X’s thoughts about his father: a salesman / entrepreneur. Often away from home due to work. Remembered as a boisterous man who laughed a lot and brought him presents from his frequent business trips. Felt that he was his father’s favorite. When he was seven years old, his father became bedridden. Having his father in the house gave the boy the opportunity to spend more time with him. He began to feel close to his father. When he was 98 years old, his father died in a mental institution. This event was to Mr. X shrouded in secrecy. Mr. X is suspicious of the fact that his mother and elder sisters transferred his father to the mental hospital, thinking it was unnecessary and that it caused his death. He had tried a number of times to find out what had really happened, but had not been able to uncover the truth. The whole incident seemed to have been suppressed as a dangerous family secret. Mr. X suspected that his father had committed suicide which, given his family’s religious orientation, would explain the secrecy around the incident.

Mr. X’s recollection about his mother: Described as a very controlling, overprecise, critical woman who constantly worried about money and the future. After the death of his father she struggled maintaining the family also with coping financially. He felt that she saw everything in a
negative light. She never made a positive comment. Nothing he did was
ever good enough. He also described her as a perfectionist. He had never
been able to live up to her standards.

Mr. X’s recollection about his childhood life: Apart from the death of his father,his childhood was described as uneventful and quite happy. He felt proud of the fact that he had been something of a rebel as an adolescent.

Major Issues

Relationships with women:
Attitude to work: He used to be enthusiastic about his company, now feels it is too complicated and wants to give it away. Similar feelings about possessions.
Depression: feeling pessimistic, life is a sacrifice, fear of being alone. Feeling completely deserted due to wife’s departure from his life. According to Mr. X, he once used to have everything. Now things were different; his health had been ruined; his life was in a shambles. He felt worthless. He wondered what had kept him so busy at work in the past.

Personality Issues

“He revealed that throughout his childhood he had been scared of losing control. He was reluctant, for example, to fight with other children for fear that he would lose control and kill someone.

Denial of inner reality and flight into external reality through work had
become a way of life. His defensive structure, however, of escaping into
action — ‘ the manic defense ’ (Klein, 1948) — no longer seemed to work.”

Dramatic mood swings, an all – or – nothing attitude. Very little was needed to push him in one direction or the other.

Repressed Emotions & Inner Reality
Denial of feelings of depression through unrealistic optimism, laughter, humor, frantic activity, and excessive control had always been an important element in maintaining Mr. X ’ s psychic equilibrium.

Attempts to fight his depressive state by eliminating negative thoughts. Turns to self-help books in order to improve ability to repress depressive reality.

This point of a person, and this happens often with people who are functioning and try to excel in aspects of their life through forcing themselves into change. i.e. When I feel hurt/stressed/sad/angry (any “negative” feelings), I try to escape by pushing myself to do better, to think positive. This works, but only very temporary. The breakdown that comes is usually catastrophic and very difficult to overcome. In Gestalt psychotherapy, there the paradoxical theory of change (Biesser, 1970).

Unfolding through Therapy

As Mr. X worked his way through therapy he was able to admit to himself several things that was repressed:

that his childhood was not so happy as he made it out to be. He realized his urge to think positive and believe positive (unlike how he sees his mother, as a pessimist). He realized how he was treated “like a baby” (which also means not being respected, and made to feel small), feelings of envy of his brother for the role of he man of the house.
He remembers using complaints of physical ailments to get attention, and being sensitive to children crying.
Was able to acknowledge his father’s darker side. That his father had beaten his children, stifle his behavior, strict rule enforcing.
His Oedipal memories.
His identification with his father’s tendency to be fake, hiding feelings.
He was able to grieve his father’s passing (which he had not the change to due to secrecy)
He comes to terms with his anger towards his mother, and also (as a child) feared that his other would die. He had fantasies that he might kill his mother when sleepwalking. His feeling of being unwanted by her, and wanting to prove to her that he was “worth it” to have as a child, and to admire him.
All emotions of aggression, guilt, grieve that accompanied these unfoldings.

Relationship with Women
Given the kind of relationship Mr. X had with his mother, it came
as no surprise that he perceived women as dangerous, over-controlling,
not really to be trusted.

Mr. X would divide women into two split categories, the easy and the proper. He had always been fascinated by prostitutes (and still was), but the fascination was accompanied by fear. Prostitutes were tempting but they could also be infected with diseases. He recalled an incident when he visited a prostitute. He felt that he had not treated her like other men. He had not taken advantage of her; he had gained her admiration.

As a young adult he had had many short relationships with women, treating them rather callously, usually dropping them when they became too clingy. He disliked feeling ‘ choked. ’

Dreams and Projections

He felt threatened by women. His dreams illustrated the role women played in his inner life. In many of his dreams, phallic women, portrayed as women with guns, would appear and lie on top of him, having intercourse while putting him in a passive position. He would wake up, frightened, feeling smothered. In other dreams, however, women would admire him from a distance. He described one dream in which he was persecuted by a number of large bees who kept striking at him. They were almost impossible to brush off. He associated this imagery with all the women he had dealt with in this life. Women could cling and sting, but also give honey. They could repel but also give pleasure. Gradually, however, dreams emerged in which he became more assertive with women, not taking such a passive role. Most importantly, in these dreams the degree of anxiety he had previously experienced was missing.

Being in Control
Starting and managing an enterprise had multiple meanings to Mr. X. It signified much more than a means of making a living. He had found out early in life, while employed by a German company, that working for others was too stifling.

These are projections, and much is known to be related to projections he has of his mother being controlling and having secretly done away with his father. Again identification with the father, being the victim of another’s control.

To be independent, to be in control, meant to be free from mother. His inability to work for other people (who would tell him what to do) made him decide to start on his own as his father had done before him. That was the only way to get some power, and no longer be subjected to the whims of others.

Transference of control and being controlled was reported to exist in therapy sessions.

What becomes apparent is his entrepreneurial mindset and work style slowly made sense to him, as his way of dealing with past traumas. It is his way of closing gestalts, and finishing unfinished business. This unfortunately leaves the real unfinished business open, and the only way that a person can live in inner peace is to work constantly. It is like filling water in a pot full of holes.

Mr. X also worked through other personality traits that developed as a result of being himself, basically. He was able to realize his meed for admiration, tendency for grandiose and depressive moods (bipolar disorder, perhaps), competitiveness, self-defeating behaviors,.

With the newly owned awareness and re-experiencing of past traumas, and the re-integration of his repressed emotions, Mr. X was reported to have slowly managed to get back to work, work with less stress, welcome his wife back into his life.

The process in which the patient manages to make positive changes to his life is through sitting through and experiencing what is there. What is in his real memories, his real childhood experiences. This is only possible with the accompaniment of a therapist, who is trained to support the client through the process. This process is very tedious and painful. The client has spent almost all his life trying to make changes by pushing his un-bearable realities to the unconscious. To not feel, to forget.

This is what it the paradoxical theory of change is about. When we try to elicit changes, in Mr. X case, when he tries to think positive, push himself to success, and try to do everything he can to overcome painful experiences, all he has achieved is a mountain of disappointments and stress. It is only through not changing. in just sitting in therapy and looking at all these childhood experiences, did his life really begin to change.

References

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

Klein, M. (1948). A contribution to the theory of anxiety and guilt. The International Journal of Psycho-Analysis, 29, 114.

Kets de Vries, M. (2009). Reflections on character and leadership.