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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
Gestalt Therapy & Bariatric Patients:
A Confluence of Dental Aggression
And The Relational Turn
Charlie Bowman, MS, LCSW, LMFT, LCAC
December 6, 2014
Chelsea Studios
New York, NY
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
1. How I came to this work:
a. [SLIDE 2] – “Case Study” – Lifelong issues with food/weight led me to bariatric
surgery, which we will talk about, and to the realization afterwards that eating
food and relationships with food and others are dependent variables.
A
revelation to many morbidly obese people and me.
i. You can access my manuscript and this presentation at the web address
on this slide. The manuscript is a guide for pre- and post-surgery bariatric
patients and it also includes my own journey, or “case study.” People
considering or completing surgery find it very helpful.
ii. I have been developing ideas and an approach to work with people
having weight loss surgery
and
it
has
primed
my
thinking
about gestalt theory – about the "alimentary model" and aggression, and
about the relational model and food addiction. I am working towards an
integration of these “dependent variables.”
2. What I propose for today:
a. I want to intersperse the presentation with experiments and discussions as we
move along. Let’s interact together and I’ll be responsible for getting to what I
think is most interesting for us today.
b. I want to walk away with fresh understandings about eating, relationships, and
the bifurcation of the alimentary and relational models within gestalt therapy.
c. We will do a number of experiments with the bag of grapes today. Before we
start, I want to ask you to keep focused on the relationship between you and the
grapes, and how the different suggested experiments change or do not change
that relationship and your experience of the grapes.
d. Participation is your choice and some of my instructions may be “hard to
swallow.” You steer your own ship!
Next Page
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
e. Let’s start by considering our social gathering and the food we have been eating.
Here’s what PHG has to say about food and eating in Volume II (Introjection) (p.
434): “Physical food, properly digested and assimilated, becomes part of the
organism, but food which “rests heavy on the stomach” is an introject.” Here’s
the experiment they recommend (p. 436): “Concentrate eating without reading or
thinking. Simply address yourself to your food. Meals for us have become social
occasions for the most part” … and earlier in the passage they suggest the term
social to mean “being willing to introject norms, codes and institutions that are
foreign to man’s healthy interests and needs, and in the process to lose genuine
community and to experience joy” (p. 434-435).
i. (Small groups or large discussion): Recall and share with us your
experience of socializing with the food you had.
Were you aware of
eating? Feel it in your throat or stomach? Taste, smell and feel the food?
ii. Now, let’s eat 2 or 3 grapes silently, alone, quiet, and eyes shut. See if
you notice the grape all along the alimentary canal. What did you notice?
How did the grape change?
How did you change?
How was this
experience different than the social experience with food before we
started?
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
3. GT has followed a similar path over time to the path of recovery followed by the bariatric
patient, specifically in the movement from an “alimentary model” to a “relational model.”
i. I see them both as dependent variables. They are dependent upon each
other – nothing makes sense without relationship as background; and,
relationships make no sense without biology.
1. In GT theory, the contributions of a biological model make us
unique, broad in scope and assimilable.
2. In bariatric recovery, the alimentary model is the building block that
is
pre-requisite
for
reestablishing
supportive
and
nurturing
relationships.
3. GT is, hands-down, the most applicable form of therapy for this
population. This is true because of
a. Our focus on digestion as an explanation for functioning
b. The further development of the concept of introjection
c. Understanding
creative
adjustment
versus
“defense
mechanism” or “resistance” in working with this easily
shamed population
d. The relational turn in our practice – precisely the turn needed
for ongoing health in recovery.
4. We are all familiar with the concept of dental aggression. To simplify it, eating and
digesting are treated as metaphors for what we do with every dimension of experience.
Here’s how Zelda put it in her paper, “Gestalt Therapists Look at Aggression”:
a. “In Ego, Hunger and Aggression, Perls reconfigures instinctual theory.
He
questions sexuality as the organizing instinctual force of individual, organismic
life, separates the alimentary functions (oral and anal) form the reproductive
function, and presents a model with phases based on food and growth driven by
hunger.”
Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
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b. Taylor Stoehr writes in Here, Now, Next: “Perls four main categories of impaired
ego-functions – introjection, projection, retroflection and confluence – were all
based on his alimentary model of organism/environment relations, various ways
in which the identification/alienation function at the contact boundary could go
wrong.”
c. [SLIDE 3] Let’s discuss this passage from the Introductory note to the 1971
edition of PHG in small groups, with a spokesperson, for maybe 10 minutes. My
interest is in your opinions.
i. Small groups. Somebody read the quotation on the screen. Select a
spokesperson.
ii. Check-in with spokespersons
d. Before we move on, this quote from Stephen Perls about eating: Stephen Perls
(from his “Reflections” at the 15th Gestalt Journal Conference: “Seldom did all
four members of our family ever eat together. I remember eating alone and
sometimes with my sister, Renate.”
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
5. Let’s shift gears and talk about surgical procedures for weight loss, then come back to
therapy.
a. First, who qualifies? [Slide 4].
i. You must meet requirements from the surgeon’s perspective first
1. A BMI over 35 (pass around the BMI Calculator).
2. The patient’s probability of surviving the procedure
3. There are about 30 significant co-morbidities associated with
morbid obesity – so calculating survival isn’t to be taken lightly.
4. General thoracic surgeons won’t tackle many of the patients that
the bariatric surgeon will. These are high-risk surgery candidates!
b. Next comes the behavioral interview by a licensed clinician.
i. Findings of this evaluation can rule-out surgery if the patient demonstrates
1. Suicidality
2. Chemical dependency
3. Active psychosis or psychiatric co-morbidities such as BPD
4. Poor social and family support systems
ii. Recommendations from the interview include:
1. Whether the patient is a poor or good candidate
2. Recommended further assessment or reassessment
3. Recommended interventions and qualifications, if necessary.
a. Conditions that could result in a positive recommendation
with mandatory ongoing therapy include:
i. Mild or moderate binge eating disorder
ii. Low self-efficacy or motivation
iii. Reasonably controlled chronic mental illness
iv.
A history of isolated suicide attempts.
4. I am generally not in the business of refusing the treatment.
a. I have not recommended surgery 5 times out of maybe 100+
evaluations.
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
i. Partly because I am a softie
ii. Partly because I am a gestalt therapist, with the belief
that we can develop the support necessary to be
successful.
iii. Working with awareness and education, I am
interested in the patients own awareness of the
probability of success.
c. There are three common procedures (SLIDES 5 & 6). Roux-en-Y, Lap Banding
and Gastric Sleeve. [review the slides].
i. Bariatric surgery is the only broadly successful treatment for severe
obesity
ii. The mortality rate for the surgery is between 0.14-1.0%
iii. Between 5-30% fail to achieve BMI targets
iv. Look carefully at Slides 5 & 6.
1. These procedures constitute a trauma to the organism
2. Like Goldstein’s brain injured soldiers, we compensate for the
trauma in remarkable ways.
a. Like sections of our intestine learning new functions
b. Like hormone production changes in the gut
3. These patients are providing me with an opportunity to learn more
about the interplay of my beloved alimentary and relational models!
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
6. Now, let’s get back to gestalt therapy and the particular usefulness of the alimentary
model in these early stages both pre- and post-surgery.
a. SLIDE 7 – Why gestalt therapy
i. Both self-regulation of the organism and relational skills (empathy,
connection, dialogue and sensitivity) develop as the patient changes
ii. Lewin’s heuristic formulae expresses how everything changes
1. The patient through surgical manipulation and rapid weight loss
2. The environmental response to the patient-in-the-world
3. Patient’s felt sense of space and existence
a. Smoked glass story
iii. At 18 months to 2 years I define “Relational success = WLS success”
iv. This is a complex process that requires a multi-disciplinary approach
b. SLIDE 8 – Simple beginnings in Therapy
i. Staying present – managing anxiety & anticipation from insurance
approval, surgery prep (major testing) and post-surgery experiences
ii. On-going breathwork supports awareness of body sensation in addition to
oximeter training for surgery
1. Breathing Into Contact, Susan Gregory, “Paul Goodman wrote,
"The first step in therapy is contacting the breathing." And, “Each
of us breathes with a greater or lesser degree of efficient
adjustment to present circumstance.”
2. Teaching diaphragmatic breathing
iii. The alimentary model of gestalt therapy is a perfect starting point:
1. Morbidly obese persons have a propensity to swallow things whole
2. Biting, chewing, spitting are shameful processes for the patient
valuing introjection
3. We will experiment with this in a minute
iv. Ongoing work with inner conflicts uses a traditional approach:
1. Integrating polarity, decisions, self-image and behavior
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
2. Developing each part through two chair work and dialogue
3. Strong rebellion can accompany the process of introjection
a. Behavioral compliance is key to success
b. I tell patients that manuscript that’s available online should
be 1 page and say “Do what you are told!”
i. Leads into the discussion of authority conflict
v. Self-image changes
1. Weekly support necessary to keep looking in the mirror every day
2. Homework includes:
a. Going through old photo albums
b. Learning to solicit feedback
c. Learning to play and re-learning spontaneity
3. Identity crises are common: breathing, grounding & feeling
a. Begins a strong preference for dialogical contacting over the
“originalist” gestalt approach.
b. “We are walking through this together.”
vi. Let’s experiment with the grapes again
a. Swallow one as close to whole as you dare. That might not
clear your stoma with a Roux-en-Y, nor a tight Lap
b. Now, chew the second grape 50 times. Pay attention to your
experience with your eyes closed.
c. Now, chew the third grape 50 times looking around at others.
Notice your experience.
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
c. Three distinct periods in the bariatric process – pre-surgery, Surgery and postsurgery:
i. Joke: I was going to call these periods pre-surgery, surgery and finalsurgery, or post-surgery but those designations were already taken!
ii. Pre-Surgery
a. Insurance pre-approval is a grueling process for many
b. Managing anxiety pending approval
c. Decision making pre-surgery
i. Choosing hospital, surgeon, procedure
iii. Surgery
a. “If you live through it…” – understanding the risk
b. Processing support – asking for help
c. Celebrating success!
iv. Early post-surgery [READ SLIDE 9]
1. Internal Support (breathing, body awareness, chewing)
2. External Support (support groups, medical support, social support)
3. Grieving loss of food/binges
4. Setting realistic expectations
v. Late post-surgery [SLIDE 10]
1. Teaching a phenomenological means of meeting the world
2. Addiction transfer is a major issue
a. Substance Abuse – ETOH has a new kick!
b. Spending and sexual acting out/addiction
3. Coping with Vulnerability
a. Paradox of being more visible though taking less space
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
b. Gradual
awareness/anger
at
prejudice
of
weight
discrimination
c. Positive outcomes can feel like grief
4. Managing transitions:
a. Partner jealousy – some estimates are double divorce rate
b. Job changes are also estimated much greater than average
5. Managing disappointment:
a. Suboptimal weight loss (target reached in 2 years)
b. Loose skin
6. The development of a relational approach builds strong support
a. For owning and processing feelings of vulnerability as you
lose the protective blanket of weight
b. Realize that weight was a support for safety
c. Work through anxieties that embodiement awakens, that
contact creates and risk entails.
vi. Summary: I like Bob Resnick’s distinction homeostasis and Homeorhesus
1. Homeorhesus: (Gk.) “similar” and “flow”;
2. Homeostasis: (Gk.) “similar” and “standing still”)
3. Finding the “new flow” in metabolism, relationships, proprioception
and movement
Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
12
7. Shifting gears to back to the relational turn in gestalt therapy …
a. Experiment: With a partner, mindfully eat several grapes and discuss how it
feels as you take them in, what you experience in your body, how eating together
makes a difference, and how the experience is different than eating the two
grapes silently and alone. Any comments?
b. [SLIDE 11] The Relational Turn - 45°, 90° or 180°?
i. Leanne O’Shea’s 2011 address to the World Congress for Psychotherapy
was titled, “Relational is the 'new black'.” She identified these 'relational
competencies':
1. Embodied awareness
2. Hermeneutic enquiry
3. Dialogical contacting
4. Affect tolerance
5. Emotional courage
6. The ability to tolerate complexity; and,
7. An emergent ethics of the 'other'.
c. Stephen Mitchell, Founder of “Relational Psychoanalysis”, coined the phrase
“relational turn” in the year 2000
i. He argued that drive theories and relational theories are conceptually
incompatible.
d. Dan’s 2011 review of Hycner & Jacobs book identified ,“Relationalists” and
“Originalists.”
i. They are shaped by different normative images
ii. They form different worldviews
iii. He states the following: “Throughout the wider relational Gestalt therapy
literature, there is consistent disparagement and aggressive rejection of
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Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
the individualist model of the purportedly dominant Gestalt therapy
paradigm.”
1. Note:
Dan prefers the term “ethicists,” since attention to
relationship is a function of the discovery of ethical subjectivity.
e. Like we did with the alimentary model. Let’s discuss these in small groups, with a
spokesperson, for maybe 10 minutes.
i. Someone read the slide
1. Is it a turn you welcomed?
2. How do you see these developments against the backdrop of the
alimentary model?
3. Do you agree with Mitchell that the theories are incompatible?
4. Do you agree with Dan that they are different worldviews?
5. Do you believe it is all there in PHG?
ii. Spokesperson reports
8. SLIDE 12: Support & Therapy Over Time
a. Makes the clearest case for an integrated alimentary and relational approach:
i. Explain the 18 months – 2 year “grace” period
ii. Alimentary model supports the medical model through surgery
1. Literally relearning how to eat, chew, experience food
iii. Relational model provides support for field changes post-weight loss
1. Literally relearning how to live an embodied, contactful, life full of
available support.
b. The methodology in therapy moves from one that highlights experiment, directed
awareness, homework – O/E thinking on the part of the therapist – to dialogical
contacting, embodied awareness, and attunement or empathy.
i. These are replacements for the original creative adjustment – the
refrigerator!
Charlie Bowman
NYIGT OUTLINE
GT with Bariatric Patients
9. SLIDE 13: Multidisciplinary integration
a. Must be willing to work collaboratively
10. SLIDE 14: Resources
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