Geštalt terapija kao mera prevencije u svakodnevnom radu u pedijatrijskoj praksi

Olivera M. Ćirković
Beomed, Belgrade, Serbia

Summary

Gestalt therapy as a humanistic therapy with holistic approach uses techniques that focuses on gaining an awareness of emotions and behaviors in the present rather than in the past, here rather that there. Due to etiology of most commonly health disturbance in everyday paediatrician’s practice psychological reasons is one of commonly mentioned risk factors. This article shows how gestalt therapy can be used as preventive measures and support to everyday paediatrician’s practice. Aim of this work was to implement gestalt therapy in paediatrician’s practice due to achieving completely holistic health care and prevent possible episode of asthma attack, eczema or vomiting or diarrhea as most common symptoms in practice. Beside medical treatment, we practice gestalt therapy together with children and parents. Number of asthma attack episodes decreased same as intensity. This was really considerable in ordinary “stressful” situations that were earlier very significant detail in anamnesis. Same was with vomiting or diarrhea. Picture of gestalt therapy in named situations was one based on a horizontal relationship. Exactly that provided me a holistic approach as paediatrician and therapist. Together with children and parents we explored nuances within relationships (paying careful attention to present experience). Through different cases we realized that important (support) factor for children with asthma, eczema and some gastrointestinal disorders and their recovery is one of parents, mostly mother.

Keywords: gestalt therapy,holistic health, asthma, allergy, eczema, gastrointestinal disorders, quality of life

Sažetak

Od svih priznatih i poznatih terapija, geštalt psihoterapiju možemo pozicionirati u sam vrh svih psihoterapija po svome holističkom pristupu koji se primenjuje u radu sa pacijentima. Na osnovu podataka o etiologiji različitih zdravstvenih tegoba koje se sreću u pedijatrijskoj ordinaciji psihološki faktori jedni su od najčešće spominjanih. Cilj rada je bio da, u skladu sa dostizanjem što potpunijeg holističkog pristupa zdravstvenom zbrinjavanju u pedijatrijskoj praksi, implementiramo geštalt terapiju i na taj način podržimo mere prevencije koje bi umanjile broj asmatičnih napada, ekcema, povraćanja ili proliva (kao najčešćih simptoma u pedijatrijskoj ordinaciji). Individualni rad sa decom i roditeljima je bio osnovni metod implementacije geštalt terapije u pedijatrijskoj ordinaciji. Broj akutnih asmatičnih napada se smanjio, kao i njihova jačina. Ovi rezultati su bili izuzetno značajni u tzv. stresnim situacijama. Slična situacija je bila i sa povraćanjem ili dijarejama. Rad geštalt terapeuta odnosio se na horizontalni odnos. Upravo takav odnos je omogućio holistički pristup kako pedijatra tako i geštalt terapeuta. Zajedno sa decom i roditeljima istraživali smo nijasne u odnosima koje kreiraju. U radu sa različitim pacijentima uvideli smo da važan faktor za decu sa astmom, ekcemom ili nekim gastrointestinalnim problemom, kao i za njihov oporavak, ima uloga jednog od roditelja, najčešće majke.

Ključne reči: geštalt terapija, holističko zdravlje, astma, alergija, ekcem, gastrointestinalne tegobe, kvalitet života

How Gestalt works

Gestalt therapy is built upon two central ideas: that the most helpful focus of psychotherapy is the experiential present moment, and that everyone is caught in webs of relationships; thus, it is only possible to know ourselves against the background of our relationships to others (1).

Gestalt therapy as a humanistic therapy uses techniques that focuses on gaining an awareness of emotions and behaviors in the present rather than in the past, here rather that there.

That is a reason that gestalt therapists use questions such as: "What are you doing (or be aware of) right now? How are you doing it? Where are you right now?” Very important for therapy process is rule that therapist does not interpret experiences for the patient, but therapist and patient, do, work together to help the patient understand him/herself (2). That is a reason that gestalt therapists use to say for themselves that they work “Here and Now, What and How”.

Gestalt therapy begins with the very first contact. There is no separate diagnostic or assessment period. Instead, assessment and screening are done as part of the ongoing relationship between patient and therapist. This assessment includes determining the patient's willingness and support for work using gestalt method (either in individual or group work or constellations), as well as determining the compatibility between the patient and the therapist (3).

As Clarkson define: “Gestalt practice represents a complete body of theory and technique which appears to use the major tenets of existentialism in the counseling and psychotherapeutic situation”.Clarkson has summarized and updated a number of “fundamentals” of the gestalt approach, including: a dialogic therapeutic relationship, wholeness, the organismic tendency towards self-regulation, authenticity of the psychotherapist, respect for the integrity of defense and the challenge to change, the here-and-now, and the philosophical and ecological fact of response-ability. Gestalt psychotherapy emphasizes the movement towards health (and healthy self-regulation) and as such challenges a strictly 'medical model' view of disease: symptom - diagnosis – “cure” (4).

The founding father of gestalt psychotherapy, Fritz Perls, was very clear about this: “The description of psychological health and disease is a simple one. It is a matter of the identifications and alienations of the self: if a man identifies with his forming self, does not inhibit his own creative excitement and reaching towards the coming solution; and conversely, if he alienates what is not organically his own and therefore cannot be organically interesting, but rather disrupts the figure background, then he is psychologically healthy” (5).

Number of researches and articles were published until today regarding to child development, different pathology and use of gestalt therapy. Gari M. Yontef decline that “all concepts, principles and theoretical discussions presented in the body of gestalt literature available today can be related to child growth and development as well as to child pathology”.Shmuckler and Friedman have connected personality theory and child development through play: “Since play can be regarded as a central developmental process, it provides an important link between understanding healthy development and clinical process”.
The most important fact is that gestalt therapy has holistic approach to the person (patient/client). This is one of most important reason (beside work in “here and now”) that this direction of psychotherapy is used in everyday physicians practice to support different medical treatments (6).

Looking from the side of physicians, the holistic physician will support the patient in confronting the problems beneath the surface that are the cause of the disease from a holistic perspective. The holistic process theory of healing and the related quality of life theories state that the return to the natural state of being is possible whenever the person gets the resources needed for the existential healing (7). The resources needed are “holding” in the dimensions awareness, respect, care, acknowledgment, and acceptance with support and processing in the dimensions feeling, understanding, and letting go of negative attitudes and beliefs. Existential healing is not a local healing of any tissue, but a healing of the wholeness of the person, making him much more resourceful, loving, and knowledgeable of himself, his own needs and wishes. In letting go of negative attitudes and beliefs, the person returns to a more responsible existential position and an improved quality of life. The philosophical change of the person healing is often a change towards preferring difficult problems and challenges, instead of avoiding difficulties in life (7).

Due to etiology, the most of health disturbance in everyday paediatrician’s practice has some psychological base (beside life style, as one of commonly mentioned risk factor). Asthma, allergy, and eczema are believed to have a psychosomatic dimension (7), which can be understood due to the fact that many children and adolescents who have asthma, allergy, or eczema grow out of it. This is very fortunate because many modern-day children suffer from allergies.

Number of medications exist today on pharmaceuticals market and might relieve the children from the worst of these symptoms, but the problems often remain throughout life, as a chronic disease (7).
We often see that the child’s quality of life and health status from the perspective of holistic medicine often is a thermometer for the thriving of the whole family (7). Depending on the phase of development, young children need the confirmation from the society (8).

Main idea for this collaborative (combined) work as paediatrician and gestalt therapist came from McPherson definition of chronically sick children who have some special needs of care: “Children with special health care needs ate those who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” (9).

How we worked

Discussing with parents who were willing to work on personal development, to improve the general quality of life in the family and their relationship with the children, we started with individual work with them and their child, in the same time while children’s treatment went on. I created dual process (parallel process) with children and family, as paediatrician and gestalt therapist.Beside medical treatment, we practice gestalt therapy together with children and parents and in some cases with parents (mostly mothers) individually. We established and implement this way of holistic approach on a weekly basis.

Children also were helped (10, 11) if their parents agreed to do work on personal development, to improve the general quality of life in the family and their relationship with the child. We often see that the child’s quality of life and health status from the perspective of holistic medicine often is a thermometer for the thriving of the whole family (6). Actually, children were perfect (without mistakes) thermometer for the thriving of the whole family, their relationships, boundaries, interpersonal conflicts, etc.

The improvement of the named symptoms is noticed after only a few sessions (5-6) with a paediatrician skilled in using gestalt therapy tools and able to coach the children and parents successfully through a few weeks (8-12) intensive gestalt therapy while children used prescribed medications and did all necessarily diagnostic procedures and checkup controls. According to our data base for purpose of this article we present just health condition generally (without laboratory analyses, quality and quantity of prescribed medications, etc.) Number of asthma attack episodes decreases, same as intensity. Period between two episodes last longer. This fact was very important (for continue therapy) in ordinary “stressful” situations that were earlier most significant risk factor. Similar result we got with vomiting or diarrhea. Number of episodes of named symptoms decreased after a period of 2 months (8 sessions) for a one third.

Gestaltz therapy integrated in paediatricians practice

The inspiration for implementation of my gestalt approach to sick children and their parents came firstly from a practical concern to set up work with children (and/or their parents) more on the map within the holistic health care. Looking at them, not only as patients with certain medical disturbance who need medications and different diagnostic procedures and later, possible, prolonged treatments, but also as figure with different background, unique environment, the uniqueness of each person's experience, awareness of what is present in the here and now, and creation of shared understanding through dialogue. Inter-reaction between the individual and the environment, and within the individual and the environment was viewed through the so-called ground, the field they created with me led me to stay there (in that field) and look in same. Figure might be anything within the environment or situation that was the focus of attention of that moment. Groundwas the environment or background surrounding the figure. Ground includes all that is within one’s field of perception (physical and emotional), but that is not the focus of attention (but is important to take in consideration). Figures exist within boundariesthat define and separate them from the environment.

My picture of gestalt therapy in named situations was one based on a horizontal relationship. Exactly that provided me a holistic approach as paediatrician and therapist. Together with children and parents we explored nuances within relationships (paying careful attention to present experience).

Two written work were very useful for complete named work, both as paediatrician and therapist. One was article written by Kate Tudor: “Integrating Gestalt in Children’s Groups” where she described gestalt “contact cycle” both as a practical tool for such work as well as a theoretical framework for understanding phases of child development and for integrating other psychotherapeutic approaches (12). Second one was book “Brief Gestalt Therapy” written by Gaie Houston, focusing on brief and time-limited therapies. This book sets out to describe how gestalt therapy can be used to good purpose and with good outcomes, working either with individuals or groups (13).

Mentioning the contact cycle and interruptions of the same we should to be aware that the contemporary model often cited is Clarkson. This “Cycle of Gestalt formation and destruction” is usually known as “contact cycle” or “gestalt cycle”.

The figure 1 illustrates the seven stages of the “gestalt cycle” of experience: sensation, awareness, energy mobilization, action, contact, resolution and withdrawal of attention. Any human experience begins with sensory arousal that is brought about by one or more of the five senses (touch, smell, sight, hearing, and taste).

Gestalt Therapy as Preventive Measure

Figure 1: Cycle of Gestalt formation and destruction (Adapted by «The cycle of Gestalt formation and destruction», Petruska Clarkson, p. 33., 1999.)

This arousal stems from elements in the environment and leads to an awareness of figures. Awareness occurs when figures emerge from sensations. Awareness focuses attention on important elements (figures) within the environment (ground) so that important elements emerge as clearly differentiated figures. Awareness is continuous and ongoing. Energy is the potential or capability to do work. Awareness brings about an awakening of internal energy, which produces the additional strength necessary to bring important background elements into focus (make figural). In the Gestalt sense, energy mobilization refers to the work that takes place in order to produce a clearly differentiated (14).

The same cycle, with the concepts explained in language accessible to children, was suggested by Kate Tudor (this “translation” on children’s language described Kate Tudor cited in above mentioned article):

  • Sensation ~ feel
  • Awareness ~ know
  • Energy mobilization ~ think
  • Action ~ do/act
  • Contact ~ make it
  • Resolution ~ enjoy
  • Withdrawal of attention ~ let go

It is possible to interrupt any phase of named cycle. Place of interruption will define defense mechanisms. The individual is encouraged to become aware of his or her own feelings and behaviors, and their effect upon his environment in the here and now. The way in which he or she interrupts or seeks to avoid contact with the present environment is considered to be a significant factor when recovering from psychological disturbances. By focusing the individual on their self-awareness as part of present reality, new insights can be made into their behavior, and they can engage in self-healing. Some of the contact interruption occur through projection (seeing outside one's self what belongs to one's self), introjection (swallowing whole instead of assimilating, chewing, and digesting), retroflection (directing impulses towards the self that rightly should be directed to the other, as in anger directed toward self-causing depression or psychosomatic symptoms), and confluence (dissolving the self-other boundary and merging with the other). By focusing the individual on how contact-making occurs or is disturbed, new insights can be made and the fluid process of adequate contacting resumed.

Through different cases we realized that important (support) factor for children with asthma, eczema and some (very often) gastrointestinal disorders and their recovery is one of parents (mostly mother). Her/his (mother/father) functionality provide certain, non-prolonged recovery.

Very serious obstacle was to explain and mobilize parents to improve quality of life. It had be done by coaching them creating a schedule of everyday daily activities (different for everyone individually) (15). Children with allergy and asthma, same with gastrointestinal disorders were also supported and helped by their parents who were able to work on personal development, to improve the general quality of life in the family and their relationship with the child.

Main concept for successful work was the only possible base that the essence of human life is contact. Contact is where one person meets another person, or meets the outside world. Every organism is capable of effective and fulfilling contact with others in their environment and pursues ways of having contact with others so that the organism can survive and grow to maturity. All contact is creative and dynamic. If contact is not interfered with by what Perls-Goodman called disturbances of the contact boundary, the individual can grow, through assimilation of new experiences.

In our combined therapy, the parents and children were encouraged to experience their own feelings and behaviors in the here and now. Together we tried to recognize the way contact was interrupted. The way in which parents (or children) interrupt contact with the present environment is considered to be a significant factor in creating and maintaining dysfunctional patterns of behavior. Cure of the contact interruptions (work on) would provide healthy relationship between parents and children, and that should provide positive psychological effects (acknowledgment, awareness, respect, care, and acceptance), good health conditions (less chronicity, less acute attack episodes, less comorbidity, less complications) and better life style. There is completely holistic health care (mind, body, spirit). This is a place to count on gestalt therapy as preventive measure in everyday paediatrician’s practice. This way of work, paediatrician and gestalt therapist in collaboration, could provide help and support, both children and parents on multidimensional level (physical, social, emotional, kindergarten or school or work).

As professionals, doing our own mission (we are trained for) we might expect quality work improvement if, without any boundaries, corporate and work together as multidisciplinary team (paediatricians, gestalt therapists, psychologists, nurses). This is not a small task, but can be done over time.

Acknowledgments:

The author thank to Dr Lidija Pecotić, EAGT, ECP, (founder of Gestalt Studio Belgrade) on demonstrated enthusiasm, support, patience and transferred knowledge and skills. Many thanks to Marija Stefanović, EAGT, ECP,for project assistance, time we spent in the supervision of patients, support this idea saw the light of day and being implemented in the daily work in the paediatrician’s practice.

References

  1. Latner J. The Theory of Gestalt Therapy, in Gestalt therapy: Perspectives and Applications. Cambridge, MA: Gestalt Press; 2000.
  2. Polster E. Every Person's Life is Worth a Novel. New York: Norton; 1987.
  3. Hausner S. Čak i po cijenu života, Sistemske konstelacije u radu s oboljelima. Zagreb: Pistacio d.o.o.; 2015.
  4. Yontef, G. Resent Trends in Gestalt Therapy in United States and What We Need to Learn from Them. The British Gestalt Journal 1, 1991; 5-20
  5. Perls FS, Hefferline RF, Goodman P. Gestalt Therapy: Excitement and Growth in the Human Personality. New York: Bantam; 1973.
  6. Ginger S. Geštalt terapija: umetnost kontakta. Beograd: Psihopolis; 2010. p.83-111.
  7. Ventegodt S, Morad M, Merrick J. Clinical Holistic Medicine: Developing from Asthma, Allergy, and Eczema. TheScientificWorldJOURNAL 4. 2004; 936–942
  8. Hercigonja KD. Ethical Dilemas in Children and Adolescents Looking from the Viewpoint of Changing families and Society. Proceedings of the 1st International and Interdisciplinary Congress – Contemporaneity, Ethics, Awareness, Psychotherapy. 2015 Sept. 18-20; Zagreb, Hrvatska. Beograd: Srpsko udruženje za geštalt psihoterapiju; 2015
  9. Jackson AP, Vessey J, Schapiro N. Primary Care of the Child with the Chronic Condition. 5 th ed. St. Luis: Mosby Elsevier Inc.; 2010.
  10. Ventegodt S, Morad M, Vardi G, Merrick J. Clinical holistic medicine: holistic treatment of children. TheScientificWorldJOURNAL 4. 2004; 581–588
  11. Bomon H. Duša kao dimenzija iskustva. Zagreb: Intronaut; 2014. p.76-88
  12. Tudor K. Integrating Gestalt in Children’s Groups. The British Gestalt Journal 1. 1991; 21-28
  13. Houston G. Brief Gestalt Therapy. London: SAGE Publications Ltd; 2003.
  14. Pecotić L. Awareness and Contemporaneity: Information, technology, Communication. Proceedings of the 1st International and Interdisciplinary Congress – Contemporaneity, Ethics, Awareness, Psychotherapy. 2015 Sept. 18-20; Zagreb, Hrvatska. Beograd: Srpsko udruženje za geštalt psihoterapiju; 2015.
  15. Joyce P, Sills C. Skills in Gestalt, Counseling & Psychotherapy. 3rd ed. London: SAGE Publications Ltd; 2014.