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Bodily retroflections and psychosomatic symptoms

Giuseppe Iaculo

Dialogues
7th European Conference of Gestalt Therapy
September 13-16, 2001 – Stockholm, Sweden
(Mini Lecture)

by Giuseppe Iaculo
Istituto di Gestalt – H.C.C.

Theoretical foundations

It is the aim of this work to introduce the orientation of Gestalt Therapy in its theoretical and methodological approach to the psychosomatic symptomatology and pathologies. In it I essentially refer to the theoretical core of the Gestalt Therapy, or the phenomenological analysis of the contact experience, and to its original elaboration by Frederick Perls and Paul Goodman in their seminal book ‛Gestalt Therapy: Excitement and Growth in the Human Personality“ (Perls et al., 1951-1994). What I consider important to highlight, in brief, is that Gestalt Therapy can be identified as a mainly relational model. That is to say that in the approach to any human experience, and therefore also to the malaise, to the dis-ease, the key is the relational perspective (Salonia, 1992a). From this point of view, the therapist who accepts the client’s call for help, for example, asks himself what the client is doing to meet him, what is his need, what is his deliberateness and how he can help him within the relation that he builds with him.

It could be said, more precisely, that the Gestalt Therapy theoretical system has its foundations in the concept of contact and in the theory of the self, to it closely connected. According to the theory described in ‛Gestalt Therapy“, which is based on the ground of the phenomenological-existential thought, the experience of contact, defined as a process that involves organism and environment, happens in a place, in a point, which has been called ‛contact-boundary“. Where boundary does not mean ‛separation“, but place where the experience happens and the self unfolds. The self loses its characteristic of stable and fixed structure and comes to be identified as a process that exists every time an interaction between organism and environment takes place and hence, at the same time, as a function of the organism/environment field (cfr. Spagnuolo Lobb, 2001).

The ‛processuality“ of the self becomes explicit when the organism mobilizes, compelled by a figure of interest – a prevailing need at that moment – or by the pressing demands of the environment, moves to the contact-boundary in order to meet the environment, to satisfy its need in a temporary merging with it, and then withdrawing and separating from it to assimilate the experience. With reference to this, the self has also been described as ‛the contact-boundary at work“ (Perls et al., 1951-1994, 11). The boundary acts as limit, containment and protection for the organism. It is in this point, as a matter of fact, that organism and environment meet, separate and meet again, it is here that the process of exchange takes place, and it is through the boundary that the organism can establish a specific kind of relation with the environment, which is first of all a relation of growth (Perls et al., 1951-1994, 5). Perls and Goodman state that ‛contact is the awareness of, and behavior toward, the assimilable novelty; and the rejection of the unassimilable novelty“ (ibid., 6). It is trough a continuos and fluent process of assimilation and alienation that the organism grows. The organism in its contact with the environment needs to be able to identify what is good and assimilable, and at the same time, to overcome the obstacles and reject dangers, or ‛alienate“ the unassimilable material.

Having made such preliminary remarks it appears clear how the process of contact must have a creative and dynamic nature in order to be functional. It is extremely important that it never becomes a routine, or something stereotyped, that the organism does not settle down, for example, on a ground of contacts that have a purely conservative aim, since the stability of the ground previously acquired should act as a base to face the novelty and assimilate it. And it is exactly because novelties need to be assimilated that the process of contact cannot be reduced to something passive, they need to be creatively adjusted to what has previously been assimilated. For the authors of the seminal text ‛all contact is creative adjustment of the organism and environment“ (ibid.), to the point that they describe psychology as the science which studies the creative adjustments and they identify the subject of this research with the never-ending alternation of novelty and routine which originates the process of assimilation and growth. Creativity and adjustment are in a relation of polarity, that means they are mutually necessary. One of the aspects that sensibly contributes to make the adjustment creative rather than passive is the ability of the organism to attack and de-construct the environment on one hand, in order to be able to choose what is good, to satisfy the need and keep a functional process of assimilation/alienation alive, and the previously acquired habits related to contact on the other hand. In this theoretical frame the neurotic is seen as a person who, even though has found in the symptom a creative adjustment to face an existential situation of discomfort, still clings to the status quo and cannot find support for the physiologic anxiety that comes with the novelty and the process of de-construction.

The analysis of the contact process between organism and environment is not only one of the most innovative theoretical elaboration of the Gestalt Therapy, it is also what we use in our practice as the methodological core of the therapeutic process. It is exactly what happens at the contact-boundary that is available for our observation and for the possible therapeutic intervention.

In the clinical practice the Gestalt therapist is interested in the present of the relationship with the client, that is in the contact. The background of the contact, of this time ‛here and now“, is the therapeutic relationship: the whole of the contacts that have previously been between the psychotherapist and his client. The therapeutic relationship, in turn, has its background especially in the vital cycle of the client, his personal history, his peculiar vision of the world and man, but also the therapist’s vital cycle, history, vision of the world and theoretical reference frame. Psychoterapy is considered as an interaction where two different views of life meet. During the therapeutic course the two horizons progressively meet and merge through a circular process to signify his malaise and the therapist will learn to link the uniqueness of the client’s narration with his own reference frame. Within the client/therapist relational dyad experimentation and exchange are essential to ensure that none of the two horizons enslaves the other, because this would mean failure of the therapy (cfr. Salonia, 1992a).

The key to the therapeutic process in Gestalt Therapy is the contact deliberateness. Deliberateness, according to phenomenology, is the structure of meaning of the experience and it is what bridges subject and object, organism and environment. Husserl (1912-28) states phenomenologically the meaning of the self and the world in their intentional relationship. Reality cannot be thought of, if not in relation to the subject, and on the other hand the subject itself cannot be hypothesised and analysed, if not in relation to the real world in which he lives and in which he intentionally projects himself. Deliberateness is always knowledge of something which is the world, therefore the subject projects himself in the world with his own peculiar deliberateness that he expresses more fully through his body. Deliberateness is knowledge but also awareness. It is the possibility to identify oneself as the person who follows that particular direction, who makes those choices rather than others. Deliberateness then concerns both ideas and body, acting, as we will better explore later on, and provides also the sense of time and continuity: ‛I am I and continue being I“.

In Gestalt Therapy the contact deliberateness is considered as the journey the client sets on to try to reach the therapist. The two partners of this special relationship live, structure and deepen the contact between themselves within each session, and from session to session.

Contact is a reality that evolves, it is an experience that structures itself in time in the organism/environment relationship. In every contact there is a before, during and after. In this respect the relationship must be considered as ‛relationship-in-becoming“ (Salonia, 1992a, 12). Perls and Goodman have studied the structure of an event, called contact, carrying out a phenomenological analysis of this experience and of its evolutionary processes, identifying four phases in it: fore-contact, contacting (withits sub-phases of orientation, manipulation, and ‛readiness“ to act), final-contact and post-contact (cfr. Salonia, 1989b for a detailed description of the process phases). In the progression of each contact episode it is possible to identify a specific deliberateness: it initially leads the organism to move towards a completion of its need in the environment, looking in it for orientation, it takes the organism to mobilize in order to make that action become its figure of interest, and then to act through an organized and targeted behaviour, finally it allows to retire, letting the need recede into the background, so to leave space for the emergence of the next figure of interest.

Perls and Goodman besides have pointed out that one can meet and recognise different modalities of interruption of the experiential process called contact. Different problems can therefore be identified according to the phase in which the contact cycle gets interrupted. More clearly, they state that the interruptions of contact happen when excitement gets blocked and, according to the phase in which that happens, the organism performs different modalities of resistance to contact. Excitement gets, in any case, blocked when the organism is without support, both intrapsychic and relational support, and the support the organism needs is specific for each one of the different phases of contact. Within the relational view the Gestalt therapist can look at which point the client interrupts the contact with him, i.e. at which point of the session the organism blocks the flow of the process and behaves dysfunctionally. There are contact dysfunctions that manifest at the beginning of the session, others do in the so called phase of orientation or in the phase of manipulation, there are interruptions that take place in the moment of the full contact or at the moment of separating. The therapist can also pay attention to the moment, or moments of the therapy (beginning, first year, etc.) in which the client shows more difficulties in establishing a contact with him.

Arranging the contact interruptions in a time sequence it is possible to identify the most appropriate therapeutical intervention and hence the most adequate support, that can be offered to the client in that specific contact interruption, in that determinate relational moment (Spagnuolo Lobb, 1992).

The centrality of action

We have previously seen how deliberateness is strictly related both to awareness and ideation and to corporeality and action. Action gives an actual shape to deliberateness and allows the individual to have a view on persons and things which is ‛his own“, the subject has the possibility to choose and address his attention toward an aspect of reality rather than another, knowing that, if he wants to, he can then opt for another direction. In the phase of the contact cycle called manipulation or mobilization, that precedes the phase purely dedicated to action, when a larger differentiation of energy (excitement) takes place, the subject can recognize more clearly what he feels and his need, preparing himself to act; he is able to look at the environment according to his intention, having awareness of what he wants to do and of how he wants to do it. Action refers to the concept of choice and the possibility of actively change the environment, the subject can do what he wants in the world, freely choosing the act he identifies with. The choices that are made serve the purpose of defining the awareness that the individual has of himself, they make him define himself as an existence positioned in time and space and give him the sense of his ‛power“, his capability of changing and manipulating the environment in order to satisfy his need (Husserl, 1912-28). To keep a habit, to repeat a determinate action, strengthens and better defines the sense of identity, it contributes to the process of differentiation: ‛I am a person who generally does this thing“.

Being in the world is not enough for the subject to define himself, it is necessary to make choices. Freedom, even if it can arise from the past, is realized in the here and now, in the present, since it is only thanks to action that the individual completes his deliberateness, meets his needs and modifies the environment. To be free in the world is to be free to do something. In acting, obviously every human organism follows some common rules and meets the needs of other he can’t ignore, but he nevertheless acts with a peculiarity, through a modality that is his own, that identifies him. Actions can therefore also have the deep power to change the world of the personal meanings.

In 1951 Perls and Goodman used action to define the self: the self is the act, it is completely identified with acting since it is a system of contacts in function and it exists everywhere a contact is taking place, that is on the contact-boundary between organism and environment. According to the authors of Gestalt Therapy (Perls et al., 1951-1994, 156) the self creates some particular structures with the aim of being able to come to a creative and satisfying adjustment. Paul Goodman, elaborating Perls’ ideas, identified three of these structures and defined them Id, Ego and Personality, after all considering them simply as different aspects of the self. It was Isadore From to change and widen this basic concept, to define the three components of the self not as pure topographic descriptions, but as functions (Id-function, Ego-function and Personality-function), that have the purpose of identifying oneself (Muller, 1993, 12) and that are considered as capabilities of the person to relate to the world (cfr. Spagnuolo Lobb, 2001).

The Id-function of the self informs the self of what the organism needs more immediately, it concerns the background from which the need emerges, therefore it encompasses the body experiences, the environment still indistinctly perceived, the past unfinished businesses and the background of the granted contacts, the still vague feelings, in short everything that enables the organism to direct the next contact toward the environment. The Personality-function informs the self on who it is, is the assumption of what one is and has become and at the same time of what one is not, and it is therefore expressed by the question ‛who am I?“ or ‛what have I become?“, it concerns the experiences of the personal identity, the just lived and past ones, the assimilated story, roles, personality.

The Ego-function of the self concerns the processes of identification and alienation (‛what do I want and what do I not want?“), and it has to be considered as an intentional power to decide, an actively and intentionally acting so that in a specific moment the organism can choose in the contact with the environment what is good and ‛nourishing“ (‛how can I get to what I want? by which means?“), or reject what is undesired, unpleasant or ‛poisonous“. Hence it is this function of the self to identify the action and to give the person the feeling of being active and realizing an intentional completeness.

In the theoretical and methodological framework of the classic Freudian psychoanalysis action and body are not considered, only listening and meaning are central. This orientation has contributed, in the past, to stress the cultural dichotomy mind/body and to increase the tendency to deny the body, to disown it and not to experience it as part of the self. As everybody knows, it was Wilhelm Reich to mark a turning point directing the attention toward the malfunctioning of the whole personality, strongly investing on the somatic language in the formulation of his character theory, and so making the body the central place for the diagnostic evaluation and for the therapeutic intervention (Reich, 1949). Reich was also the first one to lay aside the prohibition to contact the client’s body, sometimes actively acting on it during a session with the aim of attacking resistances.

Perls learned from Reich, being at one time his client and student, various theoretical and methodological principles and was influenced by his interest in the body as aspect of the self where muscular tensions linked to the client’s emotional blocks manifest and can therefore be identified (cfr. Salonia – Spagnuolo, eds., 1988). In spite of this influence and the common holistic viewpoint, Reichian approach and Gestalt Therapy have many important differences (cfr. Kepner, 1993), one of the most important is that while Reich saw resistance and its physical manifestation as defences to be attacked and broken down, in Gestalt Therapy resistance is seen, also in its somatic manifestations, as an expression of the self and a creative solution of the organism in the face of an uncomfortable evolutive situation, an aspect to be made aware and active, so that the person can make alternative choices.

Interest in the body and active acting, in creative expression and in the human organism movement, the attention to how the client moves, to how he gets in contact with his self-body, how he breaths and which posture he assumes, are therefore part of the roots and the methodological foundations of Gestalt Therapy, and even if action belongs to the store of other therapeutic approaches: i.e. of the bodily therapies, of the psychodrama, etc., the Gestalt peculiarity is to place it with coherence within its theoretical system and to use it ‛in the frame of a consistent therapeutic procedure“ (Cavaleri – Lombardo, 1992, 31). Action is considered as part of the whole of the organism, and it is therefore not only consequence of the inner experience, but inner experience itself. In the session the therapist encourages the client to express his need creatively, almost artistically, supports him to go toward a holistic integrated change, believing that the act is not just a simple consequence of the awareness, but it is for understanding ourselves and for learning, in addition to being the realization of the full contact with the environment. ‛In the picture of the Phenomenology and Existentialism the Gestalt Therapy proposes ‛its“ concept of action as the overcoming at the same time of both the pure objectivity and of the pure subjectivity and starting from such conceptualisations, it shows all its ‛repairing“ and therapeutic strength“ (ibid.).

The underlying purpose of the clinical work is to foster reconnection and integration of the organism sensory system with the motor system. When the organism actively orientates itself in the environment, starting from the recognition of its own sensations and from the awareness of its need, mobilizes itself and finally actively acts, its possible to say that somehow the need and the action really end up being a whole. It is then that connection between organism awareness and the active doing is realized at the contact-boundary. As Perls and Goodman write, the root of reality of organism and environment is at the boundary of contact, and it is exactly here that they can be experimented as unified structures (Perls et al., 1951-1994, 3), when, through the realization of the action, ‛awareness, motorresponse, and feeling are given as the same (ibid., 36).

Bodily retroflections

We have seen how, in the phase of the mobilization in the experience of the contact cycle, the organism, after orienting itself in the environment, feels more excitement, it has a fuller awareness of its deliberateness and starts organizing its posture, the muscular districts, to go toward an action that can lead exactly to ‛that“ contact. This phase can sometimes be so short, for example in the habitual reactions, to escape notice. In many cases the phases of formation of the figure of interest, orientation in the environment, of the energy charge in mobilization, and of action happen almost simultaneously. In other situations, in which more complex needs are involved, long term projects, large sequences of actions, it is easier to notice the phenomena involved in the organism mobilization as well as the probable interruptions of the process of preparation to action. Such interruptions can be the result of a perception of lack of environmental support and/or lack of the capability, that the organism should have usually acquired to provide itself with self-support.

To mobilize properly the organism needs to be able to rely on its postural support, on its sense of stability – the grounding so central in Alexander Lowen’s Bionergetics (1975) -, on its capacity of using rhythmic and fluent movements and, overall, on the support provided by a deep and full breathing to the more intense excitement. Breathing ‛is always the start“, Paul Goodman stated (1959-1964), and it is always in some way compromised when we are facing a dysfunction in the experience of organism/environment contact.

In the cases in which there is a lack of ability of the organism to support itself, or the environment is perceived as untrustworthy or unfriendly, if not even destructive of the full expression of the self, the movement that could take the person toward the environment, in order to have an enriching exchange with it, is inhibited or distorted and an action block takes place. The process through which the movement is inhibited and blocked is called retroflection. The person, fearing risk and humiliation, criticism, environment rejection, stops and reverses the energy, recoils on himself the excitement directed to the satisfaction of his need in the environment.

The real world in which we orient ourselves and act is in itself full of obstacles and frustration, we almost in every occasion need to mediate with others’ needs and feel that we have to contain, delay or express in a limited way our need. But if some needs are regularly frustrated or rejected, if the manifestation of the innermost feelings meets a frequent or perennial refusal, we can learn a chronic and unaware way of blocking our body expressions, the movements that could potentially give a full form to the communication of our needs and of our emotional world. Adults often do not allow children to grow spontaneously, following the natural process of differentiation and expression of the self, because of the uneasiness that this can cause in themselves, having themselves in many cases developed the tendency to try to choke back their impulses and emotions (cf. Perls et al, 1994, 344-351).

When, during our evolutive process, we face these environmental conditions, we can develop a marked distrust in reality, learn to reverse the energy direction, that, not moving anymore towards the environment, is retroflexed on ourselves. We can then learn to block our throat and to limit the emission of our voice, of sounds; we can feel unstable and insecure on our feet, maybe because we have a lot of tension in our legs; we become unable to let ourselves go to sadness since we do not support its expression with a full expiration; we get to make our face an expressionless or tense mask; we keep our jaws tightly shut rather then opening them and show our teeth and with them our anger; we can learn to block the harmonious and rhythmic movements of the pelvis, if we cannot support the recognition of our sexual drives and let ourselves go to them in love-making.

The action and the movements chronically blocked, through the body retroflection process, determine a distortion of the bodily life, the development of somatic tensions and inhibition, and hence the emergence of psychosomatic symptoms. James I. Kepner in his book on working with the body in psychotherapy identifies three different forms of body retroflection (Kepner, 1993, 147-8). In referring to them I will briefly illustrate some moments of the story of the therapeutic process with one of my clients.

The first form of retroflection is the literal reversal onto oneself of the action one wants to do to the environment and, as we will see talking about the client in question, many psychosomatic symptoms fall within this category of retroflections.

Antonio was, when he came to see me, a nearly 35 years old man who looked completely emaciated. The only thing about him that still looked alive were his big dark eyes, standing out on his pale haggard and lifeless face. He had come to see me for a series of psychosomatic symptoms, among which an oesophagitis, a spastic colonopathy, periodic abdominal pain and queasiness which had all contributed to lead him to a drastic reduction of the quality and quantity of the food he had. One of the first difficulties which Antonio became aware of, in the beginning of his therapy with me, was to be unable to say no to those who made excessive and pressing demands or did not recognise and appreciate the efforts he had already made and kept on putting demanding expectations on him. The retroflection of his need to assert himself, and of his anger for not feeling respected, found its somatic correlate in the compression of his abdominal and gastric musculature, and in the withdrawal of energy from his shoulders and arms. He compressed and literally attacked himself rather than allowing himself to actively express his aggressiveness outside, he blocked the movements that could allow him to ‛push away“ others or to keep them at the right distance, making himself passive and weak. The act of compressing himself, kept outside of his awareness, had kept on functioning as a physical symptom.

Antonio’s more purely alimentary symptom to almost totally give up food had a complex meaning, it also had, among others, the potential meaning of a refusal, rebellion and free choice, that could not be expressed in a functional way, and it also manifested at the same time, his loss of touch with the most elementary physiological sensations related to the need of food. Eating disorders are based on the dysfunctional contact process of introjection (Spagnuolo Lobb, 1985). This interruption appears within the experience of the contact cycle in the cases in which the organism has incorporated ‛objects“ belonging to the environment (introjects), so that, in the moment in which the need has already been symbolised, it has been given a name, these previous learnings prevent or distort awareness and the possibility to adequately orient oneself in the environment. The human being is not able to be centred on his need, he is scared of going into the emptiness (the perceptive opposite of the need), and therefore clings to what others have told him of his need. One gives up his free choice and uncritically clings to the information that have not been chewed, digested and assimilated, but swallowed whole. In that sense the introjective relationship with food – passively swallowing or uncritically and generalised refusing – is the opposite of the healthy dental de-construction (cfr. Perls, 1942/45/69), or of the capacity to start from the sensations of hunger, to choose, taste, chew and finally assimilate food.

The retroflection of Antonio’s aggression stratified, as it later became clearer, on prohibitions and rigid introjections, like the conviction to be able ‛to hurt“ the addressee of his emotion. His rejection of food also represented a more generalized rejection of a reality and a family environment of origin perceived as not welcoming and ‛poisoning“, his attempt to start ‛spitting out“ the introjects, since he was unable to de-construct and digest them. It was also the objectification of his rigid opposition, developed for his lack of basis on which he could build a healthy process of alienation of the undesired environmental elements. On the other hand, also his part that manifested opposition, sometimes violent and therefore passive, had to do with an introjective modality, his mother had often told him: ‛you are good, but if someone annoys you, you go wild“ and he acritically adhered to this stereotyped perception of his character. This aspect offers an opportunity to clarify that the prevalence of a certain type of contact interruption does not necessarily rule out the others identified by Perls and Goodman – confluence, introjection, projection, retroflection and egotism (cfr. Perls et al, 1994, 243) – nor does it exclude that the same body retroflections can stratify on other forms of contact interruption, as introjecting, that as we have seen consists in putting acritically a part of the environment into the organism, or projecting, that on the contrary can be seen as placing a part of the organism in the environment. In the latter case the individual, in contact with a more intense excitement, feels too small and fragile to be able to contain it, does not identify with what he feels and shifts his attention to the environment, and it is on it that he places his sensations and his experiences, so much that he could even become an obsessive investigator of what happens to others or outside anyway. There are situations, finally, in which one can meet also a stratification of various retroflections. Antonio retroflected his aggression, which came from having felt hurt and disappointed, from not having met a ‛good nourishment“, but for the same reason he also retroflected his earlier need to rely on the environment.

The second form of retroflective behaviour happens when the movement directed towards the environment is physically inhibited as soon as it starts. The movement is not turned on oneself, but ‛countered by equal muscular force in the opposing muscle groups“ (Kepner, 1993, 148). In these cases the blocked action manifests itself as tension and immobility in the muscular groups involved. Antonio’s body still kept, although to a small extent, a memory of a vitality and energy that you could guess had once been strong in him. It happened, for example, that he would light up when he talked of women and of his desire for them. It was then possible to perceive in him a touch of revitalisation: his shoulder would broaden a little, his lips would part in a sly smile, his eyes would become brighter and his back would bend a little to let his pelvis come forward. Then everything would be blocked, frozen: contact with pleasant sensations in his body was for him a source of fear, since everything that was life and pleasure had not been encouraged and supported. He could only start having small, timid tastes of life. This led us, much later, in his therapy to work on his extreme difficulty in taking the ‛good“, especially when it could be perceived as potential in the relation with me, on his anguish of the possibility of being even destroyed if he would let pleasant sensations enter his body, for example the warmth I could transmit to him gently touching his chest while he breathed. During the first two years of his therapy it would often happen that a session in which he had let go to the contact with vital and energizing sensations would be followed by a worsening of the symptom and his tendency to focus on his body in a negative way.

The last of the forms of retroflections could be described as doing to oneself what one would want to receive from the environment, for example to caress ourselves rather than asking somebody to caress us, encourage ourselves when facing a difficult task, rather then asking a friend to do so, and so on. This last retroflective behaviour could be seen as a good form of self-support, a way the subject has of taking care of himself, and in fact in some cases retroflection, as well as the other interruptions of the contact cycle, can be functional. But to do to ourselves what we would expect to receive from outside is generally a characteristic of the individuals that tend to isolate themselves and withdraw, that stop their impulses and movement of opening toward the environment, that renounce to communicate their feelings that foster moving towards, as fondness, affection, desire of intimacy, and therefore strongly limit the possibility to live moments of healthy confluence in the relationship with others. It is a modality of communication that is often met in the ‛narcissistic“ experiential structures (cfr. Iaculo, 1996).

Antonio lived a situation of such an intense deprivation, that it is difficult to say what he did to take care of himself, even if in a retroflective way. He did not perceive himself as self-sufficient at all, but extremely fragile and needy. He surely limited, for the reasons we have seen, all his movements of expansion and opening towards the environment, showing himself often resentful and easily prone to touchiness. This was a clear message for the others and it therefore did not foster their potential attempts to get close to him. This type of hyper-reactivity had become his way of protecting himself from the distressing possibility to be hurt again if he exposed himself, showing his needs, and could be identified as a clear manifestation of how he had withdrawn into himself. Although he had to work for a long time on his anger with me, and on the fact that it had made sense to hate the food he could not have loved, and having in this the chance not to feel blamed, but accepted and understood by me, Antonio became very soon aware of how he had learned to limit his impulses, his desire for closeness and affection, his need to touch and be touched with warmth, and how sad he was for this.

Differently from the client with a ‛narcissistic“ structure, who lives the phobia of introjecting, who has learned to rigidly avoid a position of dependence on the environment, and who believes he should do everything by himself, not to get in touch with his inner emptiness and not to feel little and deprived, he was prone to recognize how the above needs, relative to confluence with the environment, were relevant to him, even though it was extremely difficult for him to show them. He recognized what an intense desire he had to welcome and interiorize positive, ‛good“ and ‛nourishing“ aspects of the environment, even if very often, conditioned by his past experiences, he believed he could not meet any.

We could probably say that the first time he ‛dissolved“ a retroflection, manifesting a need that until then he had blocked, since he did not trust that this could be welcomed, was when he decided to rely on a psychotherapist and that he could spend some money to take care of himself, his first movements that he has not blocked have been the ones to reach my studio.

The specific nature of the clinical intervention in Gestalt Therapy

For psychosomatic medicine, based on the theoretical premises of the classical psychoanalytic model, the patient with psychosomatic symptoms is not able to give them a ‛meaning“, he lives them with a sense of extraneity and as purely organic troubles. In the Freudian view the symptom originates from what has been censored and repressed, and becomes in some way the representative of what has been repressed in front of the ego. The unconscious affects, repressed, related to the repressed contents, have no possibility to reconnect to their environment object of satisfaction and therefore subsist as permanent excitement. The symptom can also, in this sense, be seen as a fragment of the excitement, an emergency solution aimed to release the tension of the ego.

A basic moment in the etiopathogenesis of the symptom is the drive, the instinctual spur that directs the individual toward a particular target. Drives give a dynamic structure and energy to the vital needs, but they become only partially conscious because they collide, during the children’s development, with the social environment resistances and conditionings and with the inner censorial aspects of the super-ego. The sacrifice of the drive satisfaction determines frustration, conflict and contributes to keep permanent the state of excitement, or of an energy that cannot find a satisfactory discharge (Mitscherlich, 1966-67). In this view, mainly ‛economical“, ‛somatization“ becomes expression of a psychic unbearableness, of lack of space for symbolization and cognitive representation. The body therefore becomes the fixed course for the expression of the energetic jam and of the inner conflict.

It is evident that this theoretical perspective, rooted in Freudian psychoanalysis, is still strongly intrapsychic, even though it considers how the social factors have a main role in taking the person to unconsciously renounce to the satisfaction of the drive and in determining the somatic conversion of the affects. It sanctions an incurable gap between the social expectations and instances on one side and the individual’s desires on the other. The latter must necessarily renounce something of himself in the process of identification with the social group in order to adjust to it. It is no coincidence that the clinical intervention in this type of approach is mainly aimed, at least in the most orthodox formulation, to an inner decomposition of the conflict, to which it is possible to get through an often very detailed analysis of the most ancient experiences, the interpretation of the unconscious experiences, and finally recognizing and accepting as necessary the sacrifice, to which it is necessary to submit every time one gets to the solution of a conflict.

The energetic and intrapsychic perspective is clear also in more recent contributions of psychosomatic medicine of psychodynamic orientation. The base of the psychosomatic symptom is identified in the emotional repression (for example of an anger that cannot be released) and in a difficulty to solve at the unconscious level the emotional conflict. ‛The problem that does not find resolution at the unconscious level expresses itself on the physical level through a symbolic language“ (Sponzilli, 1999). The task of the therapist is to help the client in the symbolic understanding of his disease and in being able to integrate his new information he has about himself, once it has been acquired.

This therapeutic model underestimates the relevance that, in a ‛healing process“, can have for the client the fact of experimenting within the encounter with the therapist new and different perspectives to interact with the environment and ‛society“. It starts from the idea of the incurable gap individual/social environment, which I have already mentioned, and therefore it refers everything to an inner elaboration of the unconscious conflicts. The recourse to the interpretations technic, besides, can foster in the client the tendency to keep an uncritical and passive position in the face of the external reality and paradoxically puts the therapist in the position of that who reinforces the introjective hyperadaptation to society.

From the hepistemologic perspective finally, this psichosomatic orientation, even if it claims to be holistic, in the sense of considering the unity psyche-soma, reinforces the split mind-body, because it excludes the direct contact with the area of the self which carries the wound – exactly the body -, does not give relevance to acting and experimenting, to movement and body expression, or it merely uses body technics combined, but not theoretically and methodologically integrated, with the cognitive elaboration of the emotional conflict.

I have mentioned in my preliminary remarks that in the theoretical and methodological formulation of Gestalt Therapy it is central a relational perspective in getting close to the discomfort and the symptom that the client brings into therapy. When the client communicates his symptom, that for example can be a psychosomatic symptom, the therapeutic interventions are aimed to a relational phenomenological reading and not to a content reading of this form of communication. The client often has the expectation of having to be helped to discover the ‛truth“ about himself and his behaviours, questions like ‛What does this mean?“ or ‛Why do I do this?“ are frequent, the Gestalt therapist answers these cognitive questions with the offer of a relationship, through and within which the subject can gradually become aware of himself having a broader horizon at his disposal. The work on awareness in Gestalt Therapy is not limited merely to the cognitive aspects, but fosters, in a holistic view, the possibility to understand more totally ourselves and our modality to experience the world. In this sense, it also offers support for an aware reappropriation of one’s emotional world, somatic experiences, ability to act, of what one wants and of how the contact deliberateness is blocked.

The therapist, through the observation of himself and the client as a relational whole, replaces the search for the insight with the search for the experience of contact. ‛Paradoxically, the way in which the patient asks this question shows the perception that he has of himself-in-front-of-the-therapist, his way of entering into contact and putting himself into the relationship“ (Salonia, 1992, 11).

Antonio communicated giving up food all his rejection, fear and distrust that he had learned toward the environment. Such an intense distrust and fear to be hurt to lead him to renounce also an active expression of his feeling of frustration and anger, that he would instead turn against himself. In order to help him to trust him in a first stage I had to support the good reasons he had to hate the world, inviting him to use his eyes to look at me carefully, to observe if I really could receive with respect his first active expression of the emotions he was used to retroflect. To get to this point I started from a phenomenological reading of retroflections as blocked movements I helped him to develop an awareness of the presence of such aspects and a sensory base of them. At first he was not aware of his posture, of how he would sit with his shoulders hunched, of how shallow and held back his breathing was especially in the inspiratory phase, of how he almost did not stand on his backbone and of the strong communicative impact that all this might have on others and, in that specific case, on me. Starting from the awareness of these aspects of the self-body that he had estranged, he then has been able to locate some of the tensions involved in the process of compression of his chest and of his abdomen and therefore in the retroflection of his anger. In order to help him in this purpose I often asked him, among other things, not to talk about his body in an impersonal way (‛I have tension here“, ‛my abdomen is compressed“), but to reappropriate himself of the responsability of what he was doing to himself, pronouncing statements that started with ‛I“ (‛I am compressing and squeezing my abdomen“).

This exploration of the retroflections in the body process fostered in him, later on, the acquisition of the awareness that he compressed himself through the part of himself that had swallowed the introjects, the duty to take care of others and to be understanding, and that, at the same time, he compressed the active part of himself, the one that desired to rebel and to differentiate itself. The work on his retroflections also facilitated a first active expression of his anger, that he could act out squeezing the arms of the armchair or punching them, and recognizing the fact that his destructive hate and his renunciation to feed himself were instead part of a passive and weak attitude that he had put on in the face of reality, also with a secret hope that he could have been seen and therefore helped. So I set for myself the extremely important task not to excessively reinforce his passive requests for attention, the ones that came through his making himself very weak, his physical pains and somatizations.

While still considering how little he had actually received from the environment, I tried not to stress and reinforce his perception of himself as ‛needy of everything“ and in some occasions I have confronted his defeatist attitude and supported the blocked deliberateness to be active and de-structure reality. Much of the advanced work in his therapy then had to do with helping him to be less scared of life, of the one he could meet in his couple relationship, in sexuality, in the moments of play with his kids, in getting expression of professional esteem, and also of the life he felt in himself – in his self-body – during these experiences of contact with his environment and in the moment he could then assimilate them. When he has started to take his life back, to interiorise a capacity of giving support to his sensations of pleasure and energy, he has had the unexpected surprise that he could receive a recognition, even if a late and limited one, by his old mother of his qualities and merits. He was ready to accept it.

In brief, the peculiarity of Gestalt Therapy is in considering the person as a whole more complex of the sum of its parts: body, thoughts, feelings, fantasies, movements and action. ‛It is the integrated functioning of the various aspects of the whole in time and space that is the person. In this view to treat one aspect of the person exclusively or identify a part as the cause of the problem is to artificially fragment what is in reality a functioning unity“ (Kepner, 1993, 39).

In the theoretical system and therefore in the clinical practice of Gestalt Therapy, the therapist, in helping client to acquire a holistic awareness of himself, avoids to attack his resistances. He can also resistances, since believes them to be a creative solution that patient had to develop, in some phases of his development, perceiving an environment as untrustworthy and not welcoming. He then specifically looks at the physical symptom and to the fact that it is based on a retroflection of the action in the context of the contact that the person creates and has created with the environment. He therefore considers the organism/person always in a close relation with his environment and not only as a psychic structure organised around events and inner conflicts, supports the individual in having a phenomenological experience of his self-body, believing that he must limit himself to accompany the client in following an organismic process aimed to discover his sense of himself and hence also of his corporeity.

The theory of the self in Gestalt Therapy enables one to overcome many dualisms. The self is not considered as an intrapsychic part or structure of the organism, but it is identified as function of the organism/environment field, also when the organism is moved not by an external environmental stimulus but by an inner need. The self is that complex system of contacts that manifests on the boundary of organism/environment interaction, on line of demarcation that does not exclude the environment, but that instead belongs to both, both to the organism and the environment (cfr. Perls et al., 1951-1994, 151). This theoretical conception implies the overcoming of the individual/society dichotomy. In our model the moment of diagnosis and the later one of the proper clinical intervention cannot avoid starting from this epistemological principle and from the assumption that it is not possible to consider an ‛objective reality“ outside, separated from or even in contraposition with the individual, because subject and object are always integrated, involved within a complex field in a continuous process of interaction.
The self besides is a system which is passive and active at the same time, it is by definition involved, attentive and spontaneous, at least when, in non pathological conditions, the Ego-function of the self guides and orientates the process of adaptation of the person, who, following his deliberateness, knows when to act and when to stop. In this sense Gestalt Therapy ‛proposes a (…) concept of action as the overcoming of both the pure objectivity and pure subjectivity and starting from here it shows all its original reparative and therapeutical value“ (Giordano, 1997, 79). Thus it appears clear that another dichotomy to be overcome is the one between spontaneity and deliberateness, spontaneous and deliberate are the same thing, since the spontaneous self knows what it wants.

The Gestalt therapist, in working on retroflections that are at the base of psychosomatic synmptomatology, emphasises awareness of the body and of the blocked actions especially in working on retroflections that are at the base of the psychosomatic symptomatology. He therefore intervenes on the Id-function of the self with the aim of then support the restoration of the Ego-function, or of the capacity of the patient to make choices and to act carrying out his personal deliberateness. He overall identifies the relational encounter that the patient builds with him as the intervention foundation, besides this being a constant key to the reading of the therapeutical process. It is within the therapeutical relationship that, if the client experiences he can feel accepted and can finally allow himself to entrust himself, he will then be able to unfold the blocked contact deliberateness and to gradually overcome the blocks he has put between himself and the environment.

[Translated by Nicoletta Abbate and Giuseppe Iaculo]

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