Working With A Symptom In A Gestalt Approach

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

The psychosomatic approach is based on the idea of the connection between the body and the psyche. The existence of this kind of connection was known for a very long time. Ancient Greek philosophers have already written about this, discussing the nature of the disease. Socrates says that there is no bodily illness apart from the soul. Plato echoes him, asserting that there are no separate diseases of the body and diseases of the soul. Both believe that illness and suffering are the consequences of wrong thinking. The true cause of illness and suffering is always a thought, a false thought. The body itself cannot get sick - it is just a screen, a projection of consciousness. Therefore, there is no point in patching the screen. Illness is just an expression, a form of a "problem." This is only the opportunity that life takes advantage of to tell us that something is amiss, that we are not who we really are. These arguments of the ancient philosophers contain important ideas of the concept of man as a single integral system, which are currently being revived in the paradigm of the holistic approach, to which, as we know, Gestalt therapy also belongs.

In modern traditional medicine, the idea of a connection between the psyche and the body is presented in the allocation of a separate kind of disease - psychosomatic. These are disorders due to a psychological cause, but with a somatic manifestation. The circle of these diseases initially included seven nosological forms: bronchial asthma, hypertension, angina pectoris, duodenal ulcer, ulcerative colitis, neurodermatitis, polyarthritis. Currently, there are already much more of them. In addition, in the international classification of mental diseases ICD-10, somatoform disorders (axis F45) are distinguished, the very name of which suggests that they are somatic in form of manifestation, but psychological in origin. These include: somatized disorder, hypochondriacal disorder and a number of somatoform autonomic dysfunctions - heart and cardiovascular system, gastrointestinal tract, respiratory system, genitourinary system, etc. As can be seen from the text, both psychosomatic and somatoform disorders are psychological in origin but somatic on presentation of complaints. Their most important distinctive feature is that somatoform disorders are functional, which makes it possible to work with them psychotherapeutically, while psychosomatic disorders have organic changes on the part of organs and medical methods are used to treat them. We will not separate these disorders, taking into account the general nature of their origin - psychogenic, which gives us the opportunity to work with both of them to use psychotherapy. In addition, we will not use a formal division of these disorders according to the nosological principle, but will talk about their specific manifestations, considering these manifestations as psychosomatic symptoms. Thus, in the text we will call a psychosomatic symptom only one that has a psychogenic nature.

In the tradition of the Gestalt approach, the following ideas about the psychosomatic symptom have developed:

A symptom is a stopped emotion. Unmanifest emotion becomes destructive at the bodily level.

The symptom is a consequence of prolonged emotional stress of low intensity. The symptom transforms the situation from acute to chronic.

A symptom is a converted form of contact, an organizing factor in the "organism-environment" field. Any symptom was once a creative adaptation, later turning into a stereotypical, limiting pattern.

A symptom is a fusion of retroflection and somatic projection of alienated experiences onto a specific part of the body.

When dealing with a symptom, the Gestalt therapist adopts the following strategies:

- Holism - ideas about the integrity and interdependence of a) mental and somatic b) organism and environment;

- Phenomenology - referring to the world of the client's internal phenomena, his subjective feelings about his problems and difficulties, allowing him to look at them through the eyes of the client, to refer to the so-called internal picture of the disease.

- Experiment - active research and transformation of the existing ways of interaction of the client with the environment in order to obtain a new unique experience.

In the views on the formation of a psychosomatic symptom within the framework of the Gestalt approach, much attention is paid to emotions: the inability to isolate and identify emotions and the inability to express them, to react. Consequently, the universal start of the pathogenetic process is the rejection of the experience. (O. V. Nemerinsky)

Normally, the process of a person's interaction with the figures of the external world that are significant for him is carried out in the following sequence: sensation - emotion (feeling) - object of feeling - response. For example, "I'm angry with this and that." As you know, most often the basis for the formation of a psychosomatic symptom is the prohibition on aggression.

In the event of a violation of the creative adaptation with the environment, an interruption occurs in one of the links of the above chain:

1. Sensation - insensitivity to bodily manifestations;

2. Emotion - lack of feelings (alexithymia);

3. The object of feeling - the absence of an object for expressing feelings (introjects, prohibitions. "You can't get angry with …")

4. Reacting - the inability to react with a feeling (introjects, prohibitions, trauma. "You can not show anger …").

In my opinion, the breakpoint in this chain - "sensation - feeling - object of feeling - response" - is diagnostically significant, since it determines the strategy of working with a symptom.

As you know, therapy begins with diagnosis. Technically, in the case of a psychosomatic symptom, this means searching for the interrupted link and restoring the normal functioning of the entire chain. Introjection (I can't, I'm afraid I have no right) and retroflection (turning against oneself) act as interruption mechanisms. The reaction of emotions becomes impossible and their energy chooses its own body (projection onto the organ) as an object of reaction. There is no contact with a real object. Feeling 1) does not fulfill the function of contact 2) destroys its own body, accumulating, expressed in bodily tension, pain. Over time, this method of contact becomes habitual, stereotyped, and the pain from acute to chronic. This is how psychosomatic illness arises.

An important feature of the psychosomatic symptom is the impossibility situation described in the literature, in which two opposite tendencies block each other and the person is paralyzed. As a result, the symptom turns out to be a kind of saving valve that allows the unexpressed energy to be channeled. Most often, in my work, I had to face the existence of such emotions as guilt and anger at the same time. The simultaneous existence of these emotions does not allow any of them to be fully manifested. Feelings of guilt cannot be intensely experienced because of feelings of anger, while the manifestation of anger is blocked by feelings of guilt. This is the “clinch” situation, in which the only possible way out is the emergence of a psychosomatic symptom. This does not happen in the case when we are dealing not with a psychosomatic client, but with a neurotic or borderline client, where one of the poles will be clearly represented, while the other is blocked. In particular, a client with a neurotic organization will express a pole of guilt, a borderline - aggression.

Since a symptom is a fusion of introjection, retroflection and somatic projection, then working with it consists in bringing it to the border of contact and working with these mechanisms of interrupting contact.

The task of therapy in this case will be to create an opportunity for unfolding retroflection and bringing the action to completion, at least symbolically.

Here we can distinguish the following phases of work:

1. Awareness of sensations. (What is this sensation, where is it localized? For example, holding your breath …)

2. Awareness of the pent-up feeling. (What feeling does this sensation contain? For example, "holding my breath, I feel fear …").

3. Awareness of the addressee of the feeling. (To whom is this feeling directed? For example, "this is my feeling for …", "I feel it when …").

4. Awareness of the introject, the prohibition (How exactly does the client stop himself? What violates spontaneity, how aware of the prohibition? For example, “What happens if you express this?”).

5. Response (Initially, at least mentally. "What would I like to do, say?").

6. Awareness of yourself with this feeling. ("What happened to you when you said that?", "How do you feel about that?")

The working scheme used in the Gestalt approach - "sensation - feeling - object of feeling - response", in my opinion, explains the division of all psychogenic disorders into psychosomatic and neurotic ones used in modern medical systematics. It is in the first case that we can talk about psychosomatic symptoms, where problems at the bodily level act as targets. In the second case, we are dealing with symptomatology of the neurotic level, to a greater extent affecting the vegetative and mental spheres. In particular, for disorders of the psychosomatic level, an interruption in the first and second links of the chain under consideration - "sensation - feeling" will be typical. And here it becomes clear why such a phenomenon as alexithymia is characteristic of psychosomatic disorders (but not neurotic ones). Alexithymia, as you know, is the inability of the patient to find words to express feelings. And here it is not a small vocabulary, but a weak differentiation of emotions (see Bowen's concept of differentiation), which actually leads to this kind of insensitivity. And if for somatoform disorders, sensitivity to sensations is still possible, and in some cases even hypersensitivity to them (for example, for hypochondriacal disorder), then for the disorders of the psychosomatic circle itself, inaccessibility for this is already characteristic. In medicine, and in life, examples of such insensitivity to bodily signals are quite typical, when the patient, until he was admitted to the hospital with a serious problem (for example, a heart attack or a perforated ulcer), had no complaints about his health. As for the range of neurotic disorders, it is known that they are not characterized by alexithymia. In this case, the failure occurs in the section "object of feeling - response." Here, the client's difficulties arise not in the absence of feelings, but in the impossibility of detecting the vector of their direction and addressing them.

Considering the above about a psychosomatic symptom, the following algorithm for working with it can be presented:

1. A clear indication of the symptom most often manifested in complaints of pain, dysfunction of specific organs and systems.

2. Awareness of the identity of personality and symptom (idea of integrity): "The symptom is me …". Here the transformation of a partial projection into a total projection takes place by means of identification with the symptom. In this case, the client manifests and experiences the projected qualities, desires, and feelings.

3. Bringing a symptom to the border of contact, a text on behalf of a symptom: "I am a headache …" (idea of phenomenology): "Tell, draw, show your symptom …". As soon as the symptom reaches the border of contact, it ceases to be static and begins to move.

4. Analysis of the symptom as a message:

a) what needs and experiences are "frozen" in this symptom? To whom are these words addressed?

b) Why this symptom. What does he keep from, from what actions, experiences does he save? A symptom in gestalt therapy is considered as a way of self-regulation, a special form of contact. Most often it is an indirect, “racketeering” way of satisfying a need.

5) Searching for another, direct, more effective way to satisfy the need (idea of the experiment).

6) Assimilation, life test.

At the stage of working with a symptom at the border of contact, the use of drawing techniques is quite effective. Let's consider the possibilities of drawing in working with a symptom.

A drawing is what is on the border of the contact, belongs to both internal and external.

Pluses of drawing:

- the client expresses himself more freely (his fears, ideas, fantasies) ("I'm not an artist");

- the world of feelings is more easily expressed through color, paints than words (this is especially important for alexithymics);

- drawing is less controlled by the mind;

- drawing is an appeal to an earlier experience of expressing oneself. He is more emotional and less organic in social norms than speech;

- this is a process of direct creation, a change in the world here and now;

- this is an action that allows you to realize your desires and feelings in a symbolic form;

- the picture field allows you to create a special space that the patient controls, can change;

- the disease (symptom) is on the border of contact in the form of a metaphorical expression of the problem.

Drawing a disease (symptom) allows you to highlight the figure of the disease, take it out of yourself and explore the background and interaction in which it exists.

Working with a drawing allows the client to operate with a symptom, being aware of and changing it: being drawn, he becomes conscious, understandable. Experience with it contributes to the integration of the client.

The drawing space is what the client projects himself onto when drawing. The elements of the picture are considered as parts of the "I" of a person. Thus, creating a drawing, the client creates a model of his inner world, a model saturated with symbols and images. Working with the images of the drawing, the client works with himself, as it were, and the changes that he makes to the drawing also occur in his inner plan (client). In the process of creating a picture, we project, take something out of ourselves, thus. this is already a work with retroflection, the feeling has already been projected, it has become external, expressed, definite, accessible to analysis, the search for an object to which it is directed.

Here is the same therapeutic scheme: sensation - feeling - object - expression - integration, but the first two links are already represented in the drawing.

As specific techniques for dealing with a symptom using a drawing, the following can be suggested:

Draw your symptom. Identify with him and come up with a story on his behalf. Who is he? For what? What is its use? what feelings does he express? To whom?

- Draw the father and mother in different colors

- Draw yourself in different colors (see what he took from the color of the father and the color of the mother)

- Highlight diseased organs in a different color

- Explore your drawing in pairs (mother is the image of the world, father is the way of action)

- Draw your body (with a simple pencil)

- Draw a map of emotions next to it (in color) - joy, sadness, sexuality …

- place them on the body drawing (where did that come out?)

- Draw your body

- Investigate in pairs what is drawn better, what is worse? (We know our body unevenly. Our organs have different values for us. We take care of something better).

Another important point in working with a symptom is its symbolic meaning. A symptom is a sign, an interpersonal message containing symbolic information. To a greater extent, this approach is characteristic of psychoanalytically oriented therapy. The symptom is viewed as an encrypted symbolic message, both as a mystery and as a solution to the problem. The task of the therapist in this case is to solve this mystery of the symptom. For this, the psychoanalytically oriented therapist uses some theoretical knowledge of the meanings ascribed to the problematic organs and body parts. So, for example, heart disease is associated with unrealized hostility or an unmet need for power control over the situation, peptic ulcer disease is associated with an unacceptable need for self-perception of the need for protection and patronage, etc. … This approach, in my opinion, has one significant drawback, the essence which in the use of universal values based on common human experience, assigned to a specific organ, part of the body. Such versatility often ignores the experience of an individual, personal history of a person. The psychological content of a symptom is, besides everything, subjective. Therefore, the use of wildcards can be justified at the stage of putting forward a hypothesis that requires verification in subsequent work with the client. In practice, I have come across cases that contradict the universally attributed meanings assigned to this or that organ. For example, a symptom such as pain in the jaws due to tightly clenched teeth upon awakening is traditionally interpreted as suppressed aggressiveness. In reality, behind this was the mindset to achieve a result, despite the difficulties and problems, overcoming resistance, literally "clenching his teeth." The true meaning of the symptom became clear only in the context of familiarization with the client's personal history. Thus, the symbolic meaning of a symptom must be supplemented with the principle of contextuality.

How to determine that we are dealing with a psychosomatic client? Here it is necessary to distinguish, on the one hand, somatic pathology and mental, on the other. As for the assumption of a somatic level problem, it is best to offer the client to undergo an examination at a medical institution according to the profile of their complaints. The absence of organic pathology on the part of the problem organ will allow excluding pathology of a somatic nature. Although, in general, the situation of the initial referral to a psychologist, and not to a medical professional, seems to me at the present time fantastic. Before a psychosomatic client comes to you (if ever), he will visit a large number of doctors and medical institutions. And here, in my opinion, the problem of low psychological culture and, consequently, a large field of activity for psychological education is relevant.

In the end, I would like to say that working with a psychosomatic symptom still comes down to working with the whole personality. This is penetration into the client's life from the back door, since such work begins initially "about the symptom", and then all the same you have to work "about life." And this work is never quick.