Note: This is the first article published by Gestalt! written by a Gestalt client and student rather than a fully-trained practitioner. The article below is true to the phenomenological dimension of Gestalt work by providing a direct account of the treatment of the author's own eating and alcohol problems from her own perspective. It provides a statement of the existential dimension in the Gestalt working process.

Abstract

This first-person phenomenological report compares treatment for alcoholism and bulimia in a traditional inpatient program with subsequent individual treatment using Gestalt Therapy. The treatment program assumed authority over the client's experiences with food and alcohol, and employed dietary guidelines, traditional group counseling, and ultimatums to control deviance from the structured program. Afterward the client felt less empowered to change in her behavior than before hospitalization. In hindsight, she realized that the treatment program created a topdog/underdog struggle within her as a result of its coercive components which led, to solidification of resistance and denial. In subsequent Gestalt-based counseling, almost-immediate sobriety and abstinence resulted from the suspension of judgment and the emphasis on self-awareness and self-determination.. She became aware of how she deceived herself and dissembled to others, stopped her self-destructive retroflection, accepted personal responsibility for her actions, and ended her abuse of food and alcohol.

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Sitting cross-legged on the old dark brown shag carpeting, I sipped my rum and fruit drink while reading a small paperback book. Having recently separated from my husband, I lived in a tiny, cockroach-infested apartment in Houston, Texas. While the apartment appeared orderly and clean from the outside, the insect population belied a hidden struggle that was eating away at the integrity of not only the building, but also of the inhabitants. I had no couch, no chairs, no kitchen table, and no desk. My old television, provided by my in-laws, sat upon a single bookshelf, and was the only piece of furniture in my living room.

I finally uncrossed my legs and resituated myself, lying on my stomach with the book opened up to a list of realities experienced by children of alcoholics. I had been raised by parents who didn’t go without a day of drinking, and drunken fights were common. These experiences still haunted me. The book had been recommended by a substance abuse counselor I met while in a six-week program at the Radar Institute, an interdisciplinary treatment program for eating disorders. Radar focused on my food addiction by utilizing behavior modification, dietary instruction, and group and individual counseling sessions, and also addressed alcohol abuse.

While I had presented myself to this in-patient experience as a bulimic and alcoholic in need of recovery, in reality I had attempted the program in an effort to save a rapidly disintegrating marriage. My deepest hope was to convince my husband to stay in a marriage that had been built on drinking camaraderie. Soon after following him from our home in Washington State to Houston, where he had taken a position with NASA, he discovered my bulimia and threatened to file for divorce unless I sought treatment. The final blow came soon after I was discharged from the Radar program, unsteady and not at all “healed,” and voiced my new concern about our drinking history. Soon afterward, faced with a request to address his own alcohol use, he filed for divorce within two weeks and gave me a month to find a new apartment for our daughter and myself.

Distraught over the loss of a marriage, financial security, and help with our child, I found myself in a strange city without family, friends, or supportive resources. Only one person came to mind as a possible ally, and I called her the same day I moved into my new, bug-infested apartment. Melanie James had been the primary counselor during my six-week stay in the locked ward at Radar, and she had offered her number at the time of my release. I hesitated to contact her, as I had returned to bulimia and drinking two days after the program ended. But I was desperate, so despite my shame and embarrassment, I met with her at her home office.

She welcomed me with genuine warmth and respect, and told me we could try a therapeutic approach that would support my own discoveries and decisions. Rather than conveying alarm or judgment when hearing about my relapse with food and my reliance on drinking, she sided with my resistance and supported my ability to decide the matter for myself. She also recommended the book about children of alcoholics mentioned above: It Will Never Happen To Me!

Although many years have passed since then, I still remember her asking me to let my wringing hands tell their story, allowing my “right to drink and misuse food” to assume a voice as I sat in one of two chairs that faced each other, and I remember her clear respect for my process. In contrast to the residential program's imposed authority over my experience, where I felt less able and willing to change in the face of what seemed to be a loss of what little I could call my own, I could sense Melanie’s sincere willingness to let me decide these issues for myself. Feeling no threat from her, I bought the book she recommended book that very day.

In its pages I found a new way to understand my thoughts, reactions, and feelings. As I lay on the brown shag run and took another sip of my drink, which contained the better part of a fifth of rum, I turned to the page about children who lived with alcoholic parents. Suddenly the thought crossed my mind that as long as I drank, my daughter could not be spared the pain I had experienced. Regardless of how I might try to protect her from the inconsistencies, abandonment, and abuse from a drinking parent, I was choosing to harm her as long as I chose to drink or practice bulimia.

At this point, another thought shattered my long-entrenched ambivalence. For the first time I truly understood that I could not take one sip of one drink without engaging in an entire night of drinking. I knew all too well that had not been able to make it through a 24-hour period without touching a bottle for some time. Suddenly, filled with a new and vivid sense of awareness and responsibility, I closed the book, stood up, I snatched up my drink and carried it into the kitchen. Filled with an intense anger that marked the climactic end of a long inner conflict, I poured it down the sink, along with the rest of the new bottle of rum. Within the next few minutes, I tore through my cabinets and refrigerator, and disposed of every bottle of alcohol in the house. Never before had I done this. My usual custom during momentary episodes of remorse and repentance was to place the bottles in the garbage with great care, so I could retrieve them the next morning if I changed my mind about sobriety, which I invariably did.

But that day something shifted in my thinking and self-perception. What did Melanie James do that primed my willingness to reconsider my dilemma? How did she melt my resistance to self-awareness? I sat down to reflect. After six weeks in the residential treatment program, I had returned to my eating and drinking disorders without any enhancement of my sense of personal strength. Following six weeks of ultimatums, dietary guidelines, and statements that I was insane and that they were the authorities of my experience, I returned home feeling unsteady and less empowered than before the hospitalization. Ironically, while my "savior" earned most of her daily bread as a counselor at the in-patient treatment program, in her private practice, she employed an approach based on the work of Fritz Perls and ignored many of the tenets employed in the residential treatment program.

Treating alcoholics or bulimics is a challenge to even the most seasoned professional, as the outcome is never certain. During my years within 12-step programs, I have seen utter hopelessness and self-destruction transformed into new levels of self-awareness and volition. I have also known veterans in the program who, following years of strict adherence to the dictates of recovery, resumed drinking or bulimia with devastating consequences. Somehow, focused on either past or future failures or accomplishments, these people lost awareness of the moment.

Encouraging emotional, somatic, and cognitive awareness can inspire or preserve recovery not only in settings like my private counseling, but can also be introduced within a formalized, structured programs. Many people approach recovery with ambivalence, a sense of personal powerlessness, and a deep reliance on food or alcohol as a means of coping. Faced with the loss of family, employment, housing, and self-respect, they may enter treatment facilities as a last resort. From my experience, and that of Melanie James, the goal of sobriety or abstinence is not enough. Any awareness-based treatment must begin with easing the patient’s resistances and helping them increase sensory awareness. This awareness is essential in overriding automatic behaviors. “The more aware one is of critical body cues – hints that an automatic response to particular triggers is about to begin or is already in progress – the more power one has to override automatic responses.” (Brown-Miller, 1993, p. 24)

Regardless of why an individual seeks help for an addiction, he or she can benefit from an approach that fosters love, dignity, and humanity. My 6-week stay in the inpatient program was so disheartening above all because as the underlying foundation of therapy was an externally imposed host of “shoulds” that offered structure but no inner awareness of my emotional, physical, and spiritual reality. While their advertised premise is, “It’s not your fault,” their approach, at least 18 years ago when I was a patient, grew into a topdog/underdog struggle as various counselors became coercive agents who solidified my denial, resistance, and rebellion as they insisted upon immediate cessation of the addictive behavior. By insisting on perfect compliance with the therapeutic program, the program itself became an ally of my "internal oppressor," a barrier to self-discovery in any deeper sense, and an extension of my inner conflict.

According to the Gestalt approach to addiction counseling, siding with a person’s resistances changes resistance into assistance. Gestalt therapy assumes the stance of being fully invested in the client’s current position, and supports the view that “change occurs when one becomes what he is, not when he tries to become what he is not.” (Paige, 1975, p. 27) Gestalt therapy makes meaningful and orderly change possible by siding with the client’s resistance and working within the framework of the client’s experiences and beliefs. This was certainly true as I began recovering from alcoholism and bulimia: As I became aware of the structure and function of my drinking (or binging), my behavior began to change immediately.

The keys that allows the client to change are suspension of judgment and encouragement of self-awareness. Within the Gestalt modality, a client who is unwilling to stop drinking is not given an ultimatum of abstinence or rejection. As an alternative, he or she may be offered a mutually agreed upon controlled drinking schedule. While this schedule is often impossible to maintain by an alcoholic, it marks the beginning of an awareness process that can dissolve impasses that are common in traditional therapies, and can helps the person become fully cognizant of what their drinking really means. This process, which includes establishing a realistic estimate of the quality, quantity, circumstances, and financial cost of the drinking behavior, soon directs attention to different aspects of the drinking. In so doing, it supports self-discovery.

When the person begins to see what “solutions” alcohol or food is providing for the problems being coped with, new alternatives can be explored and developed. (Paige, 1975, p. 28) Through the use of group work, working with the flow of awareness, making rounds, using the “hot seat” and the “empty chair,” emphasizing responsibility, and focusing on the “whats” and “hows” instead of the “whys,” a person is led from a position of entrenched habits into a realm of new possibilities.

In my case, at the beginning of treatment, I did not have any alternatives that I knew and trusted would work. A traditional-style coercive attempt to to teach new coping and living skills failed utterly. In contrast, the Gestalt approach helped me to become aware of my self-defeating patterns and to start to take responsibility for my actions and choices.

Fritz Perls recognized and articulated a contributing factor to these self-defeating patterns, commenting that the alcoholic has “drawn a boundary line between himself and the environment--and he draws a neat and clean one right down the middle – but he draws it right down the middle of himself.” (Perls, 1973, p.40) Working with the alcoholic requires a process of self-awareness and integration. The alcoholic actively, yet unconsciously, turns against himself as he would like to turn against the other. To cure an alcoholic, remarked Perls, one must undo his self-destructive retroflection. (in Boylin, 1975, p. 525)

The group is a place where the individual can experience contact as well as the isolation and withdrawal he may have created for himself previously. Within this context, an individual (and other members of the group) can become aware of self-defeating attitudes and actions. One exercise that is useful to the undoing of the retroflection is making rounds, “doing unto others what you do unto yourself.” (Boylin, 1975, p. 531) In this process, the individual who is continually critical of himself or herself may, for example, be fed a critical word, phrase, or gesture to repeat to each member of the group. This expressive technique allows the individual to become more aware of the negative impact of such a statement, and more cognizant of how this statement affects his or her physical, emotional, psychological, and spiritual well-being. The catalytic effect of others “acts as a stimulant to elicit what the continuum of awareness does not elicit spontaneously.” (Naranjo, 1993, p. 83) This externalization of internalized self-criticisms dramatizes their effects.

Gestalt therapy does not attempt to analyze or interpret the person’s behavior or words. Rather, the Gestalt therapist tries to keep the individual in touch with the ways he or she avoids living in the moment and taking responsibility for actions and choices. Where "analysis" of behavior often inspires shame, confusion, and self-pity--and thus continues or even reinforces the rationale for misusing food or alcohol--an emphasis on the “here and now” enhances concrete understanding of the immediate consequences of this maladaptive behavior.

Addicts of all kinds, in an effort to deaden themselves against life’s ups and downs, are strangers to many of their own feelings. Dissociating from their true needs and responses, they have a hard time staying with taking responsibility for their behavior and lack of self-control. “Taking the responsibility for themselves rather than placing it on others is sometimes a quite difficult task,” (Bolyin, 1975, p. 528) but it is essential for gaining greater awareness and healing.

Through the dynamics of any addiction, an individual represses, denies and avoids certain feelings, thoughts, attributes, and capabilities that need to be reintegrated into their conscious life in order for recovery to begin. By facilitating new awareness of body posture, vocal tone, and expressive movements – such as through exaggeration of actions or reversal techniques – the individual may become more aware of how they attempt to con themselves and others. By maximizing expressions and allowing for an analysis-free exploration of the individual’s truth (even if it is only true for that moment), the therapist is supporting the individual’s search for authenticity and integration of perceived virtues and vices.

Another expressive technique that can assist in the recovery process of the alcoholic or the bulimic is the principle of reversal. Challenging the individual to shift his or her point of view applies the concept of figure-ground “to the question of self-perception and personality functioning in general.” (Naranjo, 1993, p. 86) This idea of reversing habitual self-perceptions includes challenging physical habits, such as encouraging deep breathing to counter habitual shallow breathing, and word games – substituting the words, “I’m not willing,” or “I’m afraid,” for the overused and habitual reply, “I can’t.”

Seeing themselves suddenly in this clear and realistic light parallels the first step in Alcoholics Anonymous, which states, “We admitted we were powerless over alcohol and our lives had become unmanageable.” (Alcoholics Anonymous, 1976, p. 59)

The next task for the individual is to develop the ability to discriminate what their true wants, needs, and desires are. This is best done within an environment where self-determination and choice are valued. Unlike the program I participated in, where choice was denied me “for my own good,” an existential approach facilitates deeper awareness and volition to integrate new attitudes and perceptions. With alcoholics and bulimics, it is important to assign responsibility not to an outside controlling agent, but to the client, where it belongs. “Gestalt therapy assures the client of responsibility on the grounds that there is no one else available for the job, that each of us is ultimately alone with his or her own needs and desires, and that each of us bears the task of dealing with existence and nonexistence.” (White, 1995, p. 50) This freedom brings liberation from the tyranny of the models of others.


Recognizing that the addictions of alcoholism and bulimia are “free decisions within biological limitations,” (White, 1995, p. 51) they can be viewed as crucial elements to one’s desire for survival and one’s search for meaning. Honoring this adaptive function is the first step to gaining the trust of the person in treatment, and is at the heart of the Gestalt approach. If treatment is successful, it will empower the person's ability to rely on his or her expanded, more integrated sense of self. In turn, this will lead to making more self-affirming and self-nurturing rather than self-destructive, choices.

References:

sAlcoholics Anonymous World Services, Inc. (1976). Alcoholics anonymous: the story of how many thousands of men and women have recovered from alcoholism (3rd ed). New York: Author.

Black, C. (1981). It will never happen to me! New York: Ballentine Books.

Boulet, D., Souliere, M., Sterner, I., & Nadlerr, W. (1992). "Development of a category system of good moments in Gestalt therapy." Psychotherapy, 29(4), 554-563.

Boylin, E. (1975). "Gestalt encounter in the treatment of hospitalized alcoholic patients." American Journal of Psychotherapy, 29(4), 524-534.

Brown-Miller, A. (1993). Gestalt addiction: the addiction-focused group therapy of Dr.Richard Louis Miller. New Jersey: Ablex Publishing Corporation.

Naranjo, C. (1993). Gestalt therapy: the attitude and practice of an atheoretical experientialism. Nevada City: Gateways/IDHHB Publishing.

Paige, P. (1975). "A Gestalt awareness process for working with problem drinkers who do not want to stop drinking." Voices, 11(4), 24-29

Perls, F. (1973). The Gestalt approach & eye witness to therapy. Science and Behavior Books.

White, J. (1995). "A special case for Gestalt ethics: working with the addict." Gestalt Journal, 18(2), 35-54.