By Giovanni Salonia in Gestalt Therapy in Clinical Practice: From Psychopathology to the Aesthetics of Contact (Gestalt Therapy Book Series 2). Gianni Francesetti, Michela Gecele, Jan Roubal, and Leslie Greenberg
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Gestalt Therapy with the Phobic-Obsessive-Compulsive Relational Styles by Giovanni Salonia
Ch 25. Gestalt Therapy with the Phobic-Obsessive-Compulsive Relational Styles. by Giovanni Salonia (Loc: 12,009)
Gestalt Therapy and Psychopathology
Gestalt Therapy reads phobias, obsessions and compulsions as dysfunctional relational styles (Loc: 12,021)
every psychic disturbance reveals and derives from an interruption of the process of approach between organism and environment, (Loc: 12,028)
Missing the contact with the environment stops the growth and produces symptoms: (Loc: 12,030)
interruptions of contact (Loc: 12,058)
are learned in the primary relationship, are manifested in the various relationships, that the organism attempts to set up with the environment (Loc: 12,059)
What Specific Interruption for the Phobic, Obsessive and Compulsive Relational Styles? (Loc: 12,064)
phobias, obsessions and compulsions are disorders which reveal interruptions of the cycle of contact (Loc: 12,068)
when the organism, after being oriented towards the new direction,… begins to be aware of excitation and energy to move towards the environment (action/manipulation phase) (Loc: 12,069)
Interruption in the teething phase (transition from receiving to manipulating) will lead to symptoms of phobic-obsessive-compulsive disorders, (Loc: 12,103)
this developmental picture, phobias, obsessions and compulsions (Loc: 12,106)
have in common terror (unsupported fear) as a response in the body (Loc: 12,107)
3. Phobic Relational Style (Loc: 12,113)
Phobia is described as unmotivated, intense fear of an object or a space unrealistically perceived as dangerous. (Loc: 12,116)
the subject is not afraid of the object itself (Loc: 12,117)
but has a phobia of the sensations that it provokes … the phobia fundamentally concerns the anguish of feeling certain emotions which the body evaluates as insupportable. (Loc: 12,118)
In the phobic relational style the patient feels constrained to avoid contact with specific objects (Loc: 12,123)
or with precise environmental conditions (Loc: 12,124)
this terror has been learned in a relationship in which the patient has not been supported in the emerging of the excitation of her/his body. (Loc: 12,129)
the child connects the unbearable internal sensation with an external object which is easier to control. (Loc: 12,131)
there comes about a circular, interdependent entanglement between the constriction of the outside world (Loc: 12,132)
and the constriction of the subject’s bodily pattern and pattern of relationships. (Loc: 12,133)
that to understand the world of the phobic patient it is necessary to bear in mind that s/he is contextually attracted and terrorized by the phobic object: (Loc: 12,136)
The seriousness of the phobic disorder is connected to the partial or total impairment of the relational, professional and social life. (Loc: 12,139)
Obsessive Relational Style (Loc: 12,180)
thoughts, impulses or images (Loc: 12,182)
presented to the mind unwished for, irrational and uncontrollable by the individual. … function (Loc: 12,183)
to control the energy and the sensations the body begins to be aware of … afraid of because it feels them to be irrepressible drives to destructive actions. (Loc: 12,184)
We start from the awareness that through obsessive thoughts the patient now, dysfunctionally and painfully, cares for her/himself. (Loc: 12,192)
excessive control s/he exercises would be due to the excessive lack of care on the part of the parental figures. (Loc: 12,193)
has not learned intimate spontaneous control, (Loc: 12,195)
keep under control those emotional energies that s/he considers dangerous. (Loc: 12,196)
Fear – which, being unsupported, has become terror – emerges in the child’s body when the motions begin to be felt and drive towards action. (Loc: 12,199)
the child had (Loc: 12,200)
lacked a support in letting her/himself go in the flow of emotions. Now (Loc: 12,201)
does not trust it and desperately tries to keep it under control. (Loc: 12,202)
Obsessive thoughts, although they take various forms, have in common the indecision which expresses (almost makes visible) the interior-relational drama: “Shall I let myself go or not to the emotions in the relationship?”. (Loc: 12,205)
indecisions regard certain fundamental topics: (Loc: 12,206)
security/insecurity (Loc: 12,207)
health (Loc: 12,207)
guilt (Loc: 12,208)
perfection (Loc: 12,208)
Obsessive thoughts are distinguished (Loc: 12,211)
syntonic egos, when the subject understands the reasons for them, feels that they are her/his own (Loc: 12,212)
dystonic egos, felt as extraneous, coming from outside (Loc: 12,213)
5. Compulsive Relational Style (Loc: 12,227)
Compulsive actions are actions that the patient feels forced to carry out (Loc: 12,228)
to calm the excessive tension (Loc: 12,229)
5.1. Restraining Compulsive Actions - Clinical Level (Loc: 12,235)
the person carries out gestures which serve to calm the tension (Loc: 12,237)
energy felt is unbearable. (Loc: 12,238)
precise aim of calming the tension which has become unbearable. (Loc: 12,239)
Within the same phenomenological field (restraining those emotions felt to be uncontrollable) (Loc: 12,244)
collocate rituals, tics and stammering. (Loc: 12,245)
Rituals – as we have said – are repetitions of a single codified gesture (e.g., if I don’t count up to three I can’t close the door) (Loc: 12,246)
control an emotion that is felt to be dangerous and uncontrollable. … become a kind of structure which restrains energy and are supported by a magical thought: “If I carry out this gesture I will succeed in controlling my impulses, i.e. nothing bad will happen”. (Loc: 12,248)
It is the opposite of trust in the spontaneity of the organism. (Loc: 12,250)
5.2. Compulsive “Expulsive” Actions - Clinical Level (Loc: 12,271)
expulsive compulsion does not have time and numbers as perimeter and may be prolonged until the subject is exhausted. (Loc: 12,278)
the aim of the compulsive expulsive gesture is the wish to expel from one’s body an experience that has become unbearable, (Loc: 12,280)
every symptom has its own painful logic. (Loc: 12,287)
6. The Work of Therapy with Phobic-Obsessive-Compulsive Relational Styles (Loc: 12,295)
collocate the request for help within the personal or family Life Cycle (Loc: 12,299)
attention should be devoted to the moment at which the subject asks for help (Loc: 12,300)
that is when the disorder, … has become unbearable (Loc: 12,301)
It is said that phobic-obsessive-compulsive patients put the therapist’s patience to the test. (Loc: 12,322)
phobias, obsessions and compulsions are very resistant, repetitive symptoms, … therapy is no simple matter. (Loc: 12,323)
The patient “hangs on” to the symptom, (Loc: 12,324)
The symptom, (Loc: 12,326)
replaces the lack … of the parental figures, (Loc: 12,327)
therapist’s task is to create an atmosphere of trust, (Loc: 12,329)
stays with the patient’s torment … gradually becomes visible to the patient (Loc: 12,330)
it will take a long time (Loc: 12,332)
the terror covers experiences that belong to the patient (Loc: 12,334)
the patients will try to talk about their phobias and obsessions. (Loc: 12,336)
Improvement … can also be measured by how long, in therapy, they talk about other subjects. (Loc: 12,337)
«has lost the contact with the ground of personality and he remains aware only of the symptom» (Perls, Hefferline and Goodman, 1997, p. 359) (Loc: 12,341)
therapist will try to re-establish in the patient the recovery of the background, the relational tissue that the symptom encloses. (Loc: 12,342)
invite the patient to collocate the symptom in a context, (Loc: 12,343)
“hierarchy” of intensity in the course of the day: (Loc: 12,344)
passes from the perception of the disorder as an timeless and “spaceless” event (Loc: 12,344)
to the awareness that the symptom is linked to situations of tension at relational level (Loc: 12,345)
Little by little, in this way, the interruption of contact on to which the symptom has been grafted will emerge. (Loc: 12,346)
In all three of these pathologies, (Loc: 12,352)
the bodily relational experience would be terror: … of feeling energy activated in the body, of action that leads to emotion, of detaching oneself and transgressing. (Loc: 12,353)
freezes the patient (Loc: 12,354)
the obsessive’s body is tense (Loc: 12,355)
the compulsive’s body is agitated. (Loc: 12,356)
6.1. The Phobic Relational Style (Loc: 12,359)
Phobias of contagion … the child was restrained by the obtrusiveness of the parental figure (Loc: 12,361)
The therapist’s task … help the person to understand what specific emotions s/he has difficulty in feeling in her/his skin (Loc: 12,365)
The work of therapy … the definition of the boundaries of the skin, and the recognition of the feared emotions. (Loc: 12,367)
may be useful to explore the catastrophic fantasies (Loc: 12,368)
At the same time, (Loc: 12,370)
attempt to give support to the patient’s body in progressively facing the feared experiences. (Loc: 12,371)
Diffusive and monothematic phobias … refer (Loc: 12,373)
to two different levels of growth: wholeness and fullness. (Loc: 12,374)
Diffusive phobias are serious because they interfere with social life, … while monothematic phobias are marginal in the subject’s life (Loc: 12,375)
approaching the phobic object (even in imagination) … has the aim, (Loc: 12,377)
of making her/him become aware of the bodily and relational experience that the object evokes. (Loc: 12,378)
allows the patient’s body … to become aware of and succeed in containing excitation and the (Loc: 12,380)
energy which s/he is avoiding. (Loc: 12,381)
particularly useful … questions (Loc: 12,382)
“What changes in your body on seeing the object? … What parts do you feel are closing? (Loc: 12,383)
If you feel my closeness and my support, what part of your body relaxes and opens up?”. (Loc: 12,384)
Other questions open up the relational dimension: “How would you be different in your life if you didn’t have a phobia? (Loc: 12,385)
how and what would you change in your relationships at … home, at work, … with me your therapist?” … “What would happen if you could not avoid the encounter with the phobic object?” (Loc: 12,386)
serves to explore the fantasies of catastrophe, … also to … make the patient make contact with potentialities (Loc: 12,387)
some Gestalt techniques and experiments. (Loc: 12,389)
the metaphor of approaching the phobic object with a “magic wand”, (Loc: 12,390)
it is a case of re-establishing in the patient faith in her/himself through her/his trusting the therapist. (Loc: 12,391)
Often, it is precisely in the description of the phobic object (“intrusive, disgusting, slimy”) that the patient expresses the experiences s/he is afraid of. (Loc: 12,393)
Working on the phobias allows the organism to feel the emotions that drive it to encounter the other and to experience the spontaneity and fullness of the encounter (Loc: 12,394)
6.2. The Obsessive Relational Style (Loc: 12,413)
bear in mind certain preconditions (Loc: 12,416)
a) obsessive thoughts replace the parental figures and are a way … the subject, (Loc: 12,417)
tries to look after her/himself; … b) the excess of control (Loc: 12,418)
is an attempt to compensate for a serious lack of parental support; (Loc: 12,419)
c) obsessive thoughts express the subject’s indecisiveness: (Loc: 12,420)
attraction towards certain experiences … on the other is terrified by them; (Loc: 12,421)
d) the interruption of contact which brings obsessive thoughts happens in the phase in which the Organism feels emotions that drive towards action; (Loc: 12,422)
e) the (active) emotions that drive towards action are basically aggressiveness and sexuality, (Loc: 12,423)
lead the subject to move towards the other. (Loc: 12,424)
connect the symptom first with current, concrete situations of life (Loc: 12,428)
then, … with the therapeutic relationship. … for the obsessive style … bringing to the contact boundary the emotions of which the subject is terrified (Loc: 12,429)
because these are interruptions of action. … proposing physical exercises which make the subject feel the bodily energy rising, reaching a peak and descending. (Loc: 12,430)
the patient has not suppressed aggressiveness but has avoided feeling it out of fear, … it is necessary to be very careful not to give the patient the picture of a person to be struck (Loc: 12,436)
Something else which proves useful is emitting a sound which comes from the depths and gradually reaches its peak. (Loc: 12,438)
the patient’s body gradually learns to entrust itself to the energy and to risk expressing it. (Loc: 12,440)
in all physical exercises there be progress in the form of crescendo, peak, plateau: (Loc: 12,441)
physical exercise is designed (Loc: 12,443)
for the obsessive … to relax the body and make trial contact by training the body. (Loc: 12,444)
when the patient asks the therapist for unbearable certainties: “Can you guarantee that… (Loc: 12,446)
It is clearly not a cognitive problem. (Loc: 12,449)
only from the certainty of a parental relationship that one learns to tolerate the inevitable uncertainties of life, (Loc: 12,450)
the reassuring style that the parental figures … the therapist must find (invent) a sentence that is reassuring at a “parental” level of certainty (neither false nor technical), (Loc: 12,451)
serves to build a reassuring relationship of support and trust. … trying to convince the patient of the illogical nature (Loc: 12,453)
is counterproductive because it provokes further irritations, (Loc: 12,454)
6.3. The Compulsive Relational Style (Loc: 12,459)
6.3.1. Compulsions of Restraint (Loc: 12,461)
Compulsions of restraint, (Loc: 12,463)
reveal that as emotions become more intense, the patient is increasingly afraid that s/he will be unable to control them. (Loc: 12,463)
serves to … increase control so that emotions perceived as destructive will not emerge from hiding. (Loc: 12,464)
For example, checking over and over … is a relational gesture, both insofar as it expresses the uneasiness of someone who has been assigned a responsibility greater than her/his possibilities, and (Loc: 12,465)
the fear that a negative emotion may come out (Loc: 12,467)
Gestalt Therapy works not on behaviors but on relational experiences. (Loc: 12,472)
6.3.2. Expulsive Compulsions (Loc: 12,474)
therapy is devoted in prevalence to the personality-function (Loc: 12,476)
how does the subject experience feeling a particular emotion? How does s/he assimilate it? “Who” does s/he become after experiencing this emotion? (Loc: 12,477)
In expulsive obsessions (Loc: 12,478)
carry out certain gestures whose aim is to expel the experiences the body has felt. (Loc: 12,479)
in expulsive compulsions her/his anguish is not calmed but (Loc: 12,480)
seems to be increased little by little as the gesture is repeated and ends only because the subject is exhausted. … therapeutic intervention (Loc: 12,481)
restructuring the bodily and cognitive evaluation of those emotions. … body of the compulsive expulsive should be calmed because it experiences agitation, (Loc: 12,483)
begin to distinguish the various levels of experience: (Loc: 12,484)
how s/he feels … how the emotion is perceived by her/his organism (pleasant or unpleasant, interesting or uninteresting) (Loc: 12,485)
how s/he evaluates the experience and on the basis of what criterion. … The interruption happened when the organism received from the environment a definitely negative evaluation of the experience (Loc: 12,486)
(“How could you say that? How could you feel these emotions?” etc.). (Loc: 12,487)
One theme, therefore, which will certainly emerge will be the feeling of guilt, (Loc: 12,488)
necessary to explore both the bodily correlative (what part of the body feels tense when s/he feels guilty) and the cognitive pattern of feeling guilty (what model of being-there-with s/he has learnt). (Loc: 12,489)
compulsive behaviour is reinforced precisely by the fact that it obtains the situation of remaining with the others not in developmental terms but in terms that are regressive both for the individual and for the others. (Loc: 12,493)
Trust in the therapist will allow the patient to go through the anguish of separating her/himself in gratitude but also in pain, discovering an unexplored faith in her/himself and in the person being left. (Loc: 12,495)
7. Towards the Fullness and Uniqueness of the Encounter (Loc: 12,498)
phobias, obsessions and compulsions are disorders that arise exactly at the moment when the organism is preparing to become unique in feeling the energetic excitation of the emotions. (Loc: 12,500)
two phobias that run through the life of the human being: … the phobia of belonging typical of the narcissist (Loc: 12,503)
the phobia of separation on the part of those who feel frightened by the emergence from the confluence of the “we” (and so are afraid of living). (Loc: 12,504)
in the phobic, obsessive and compulsive relational styles, (Loc: 12,505)
becoming unique in bodily excitation provokes first fear of death and then fear of life. … Not having experienced the specific support of the “we” creates the terror of separation and that of affirming oneself: (Loc: 12,506)
the patients, … indecision, fluctuate between the fear of death and the fear of life in the search for a support, a body that will welcome them and let them go. (Loc: 12,507)
It may be added, thinking about phobic, obsessive and compulsive patients, that only someone who is (has been) given a big warm hug can feel and handle her/his own uniqueness! And s/he can hug the other… because s/he is not afraid of dying and of living. (Loc: 12,510)
Comment by Hans Peter Dreitzel (Loc: 12,513)
The author … seems to be a psychoanalyst disguised as a Gestalt therapist. (Loc: 12,516)
the most basic of Gestalt concepts. “Disturbances” or “dysfunctional relational styles” are to be understood as difficulties of “entering into a nourishing contact”. (Loc: 12,520)
the author does not apply his own claim with regard to the importance of the stages of the contact process. (Loc: 12,532)
he relies on Freud’s oral and anal stages of childhood development. (Loc: 12,533)
to my knowledge psychological research has not been able to find any support for this psychoanalytical theory. (Loc: 12,534)
Usually in clinical psychology phobias are considered to be special cases of anxiety neuroses. (Loc: 12,538)
to see them categorized as belonging in the same basket as the compulsive disturbances. (Loc: 12,539)
makes sense only within the orthodox Freudian conceptual framework the author prefers. … the choice of the word “terror” for the emotion the child experiences when the mother feels uncomfortable seems to me somewhat exaggerated. (Loc: 12,540)
In conclusion I should like to point out very briefly an alternative (Loc: 12,547)
a) Phobias are special cases of the anxiety neurotic process, (Loc: 12,549)
The basic introject … is that being aggressive (critical) to the mother is to lose her love and appreciation. (Loc: 12,550)
a creative solution would be to focus this fear on some known object the nature of which has biographical but not psychological (Loc: 12,551)
b) The compulsive-obsessive … basis is the introjected (hence unaware) idea that there is a single correct or right procedure for every act in life. (Loc: 12,554)
this introject denies the ambiguities and the spontaneity of life, (Loc: 12,555)
leads to constant fear of doing something wrong, resulting in guilt feelings. (Loc: 12,556)
c) In contrast compulsive behavior and compulsive thoughts are (Loc: 12,557)
reaction formations, … function of which is to repress anxiety of excitement from awareness. (Loc: 12,558))