IS GESTALT THERAPY "CHEMOTHERAPY" WITHOUT KNOWING IT ?

IS GESTALT THERAPY "CHEMOTHERAPY" WITHOUT KNOWING IT ?

Serge GINGER

Psychotherapists are often focused on psychological and psychosocial feelings and events, while most of our thoughts, feelings and behaviour are also conditioned by neurophysiologi- cal modifications and modifying them, day and night, in a kind of permanent systemic interre- lations.

This short article reminds some basic knowledge about brain functioning, neurotransmitters, Psychobiology of dreams, heredity, etc. and underlines the importance of such updated knowledge for every psychotherapist, and especially if he/she works with emotions and a body involvement.

Some simple examples are quoted of the implication of this weaving between body and mind, in an ordinary Gestalt Therapy session.

I would like to point out the practical and theoretical value, for us Gestalt Therapists, of keep- ing up to date with contemporary research in neuroscience. Indeed this research has, in just a few years, revolutionized our conceptions of the human psyche and today provides solid sci- entific foundations for the methods that Gestalt Therapy was already recommending intui- tively, several decades ago.

Today, the most recent work done in neuroscience makes it possible to better understand the phenomena which occur: any psychotherapy — as well as any learning, by the way — di- rectly affects our brain circuits, modifying the internal biochemistry of the brain as well as the production of hormones and neurotransmitters (dopamine and serotonin, adrenaline and noradrenaline, testosterone and endorphins, etc.). This is particularly true for psychotherapies involving work on the body or the emotions — such as Gestalt Therapy.

I’m often questioned by colleagues, especially by psychoanalysts, who don't take Gestalt Therapy seriously. In general, they know nothing about Gestalt Therapy theory, and are only aware of one or two "tricks.” However, they are forced to recognize the rapid — and lasting, sometimes spectacular progress of some of their former patients, some that they had treated, sometimes unsuccessfully, for many years (one third of our clients at the Paris School of Ge- stalt have previously undergone 5 to 15 years of psychoanalysis).

How can we explain to these colleagues, in a convincing way, these profound successes? A rapid look at the brain's psychoneurological processes seems to me to provide some clear and simple hypotheses. In this short paper, I will of course, limit myself to a general survey, illus- trated by a few summary examples, my sole objective being to whet your appetite for knowl- edge and leave you with some food for thought... The following information is a personal synthesis of about 120 books and the same amount of Journals, in French and English (around 40 000 pages)

Medicine and psychotherapy

We have just entered a third phase of the "peaceful coexistence" of medicine and psychother- apy:

In the beginning, psycho-therapy and chemotherapy (drug treatment) were seen as being op- posed, and most traditional psychiatrists smiled condescendingly at the claims of psychoana- lysts and psychotherapists, considering their methods "fashionable mundane pastimes": they only trusted drugs that had been properly tested in laboratories.

After the antibiotic revolution in infectious diseases, came the "neuroleptic revolution" in mental health care: a series of psychotropic molecules were developed which acted directly on the brain and modified behaviour (tranquilizers, antidepressants, stimulants, anti-

psychotics, etc.). In 1952, Henri Laborit introduced Chlorpromazine (Largactil)— which made it possible to gradually eliminate the strait jacket in psychiatric hospitals (it was re- placed by what was called, with some exaggeration, the "chemical strait jacket".) We know that since then, France holds the dismal world record for use of psychotropic drugs: Temesta (Lorazepam) has become the "aspirin of the psyche" and one and a half million French people today use Prozac (Fluoxetine). These new drugs, however effective they are, are not without harmful side effects (drowsiness, loss off initiative, memory loss and libido loss... or even suicide).

ln the second phase, psychotherapy and chemotherapy were associated: psychotherapy made it possible to prolong and extend the effects of medical treatment, while gradually the dosage was reduce. Conversely, chemotherapy made it possible to introduce a psychological ap- proach to treatment, relieving too strong anxiety or removing delirium.

But today we are entering a third phase: no longer opposition, nor mere complementarity, but now the identity of a dual process. Some psychotherapies are, it has been seen, "chemother- apy without knowing it". They bring about neurophysiological and biochemical modifica- tions, which are both rapid and lasting. As if a "natural pump" had been re-primed. The ma- jor advantage of this new phase is that drugs are strictly adapted to the individual and sponta- neously regulated every second by the organism... sometimes to the nearest thousand mil-

lionth of a milligram, just like our organism constantly monitors the level of blood sugar, iron, zinc (without which we would have no sense of smell), vitamins.

In fact, the administration of external medication could never claim to adapt to the subtle and permanent variations in the balance of hormone levels of every person. Every meal, but also every emotion, modifies this balance. Remember, for example, that passing a competitive ex-

amination can instantly double the level of testosterone in the blood, while an orgasm mul- tiplies by four the level of endorphins. Two blood tests, before and after five minutes of positive visualization, show an average increase of 53 % of the immune system!

So what arc the effects of a Gestalt session, with bodily enactment and emotional mobilization?

Gestalt Therapy, and in particular any modality with body involvement, could be thought of as "right brain therapy", reinstating intuitive synthesis functions and non-verbal language (fa- cial and bodily expression, artistic expression). We could also talk about "limbic therapy," thus returning to their rightful place life's six fundamental emotions: joy and sadness, anger and affection, desire and -fear, while not forgetting that the complex structures of the limbic

system control both the memory and the emotions:

An experience can be better memorized if a sufficient amount of emotion is aroused. (Simi- larly, a photocopier needs to be warmed up, before an image or a text can be recorded).

We learn better when we experience pleasure, desire or fear than when we are indiffert. Ge- stalt strategy aims to mobilize the client's deep emotion, so that the work done is permanently "engrammed" (recorded), thanks to a transformation (putting into form, or "Gestaltung") of the molecular structure. This is enhanced by a modification of the internal environment (ac- tion of neurotransmitters) which, in turn, affects the electric action potential of the cell and its membrane, allowing the opening up of new paths for nerve impulses.

Neurotransmitters

At each synapse, the electric nerve impulse is transformed into a chemical message through the secretion of neurotransmitters by miniscule vesicles. These neurotransmitters give an emo- tional "coloring" to all information thus transmitted. Today more than 70 of these neurotrans- mitters have been identified. Thus, for example, all kinds of desire (hunger, thirst, sex) and all kinds of pleasure (even artistic or intellectual) are correlated to three neurotransmitters:

• dopamine, associated with the tension of desire; • noradrenaline, associated with the excitement of pleasure; • endorphins, which bring about well-being and rest.

The same testosterone controls not only aggression, but also sexual desire (even for women). These two basic life instincts (survival of the individual, and survival of the species) are closely linked (they are placed alongside one another in the hypothalamus, separated only by the pleasure control area). In Gestalt Therapy, this proximity can be used, for instance, to de- velop failing sexuality, through playful aggression.

So Gestalt therapy mobilizes, in particular, the hypothalamic areas (expression of needs, here and now) and the frontal and pre-frontal lobes (integrative holistic approach, and assuming responsibility when making choices). In this way, it keeps these fragile areas of the brain ac- tive, thus preserving the brain’s youth and vitality, since in contrast to inert matter, living matter only wears out if it is not used. Unused neurons become oxidized, and quite literally covered with patches of something we could call "rust".

Similarly, and contrary to a widespread view, the growth of dendrites is not slowed down by aging... but by idleness! Nothing speeds up aging more than a retirement with no substitute activities! A baby that is not stimulated in the cradle will sit up at 21 months and not walk till it is three years old. In a hospital room, patients lying with a window open to the outside world, get well more quickly. In an enriched environment, rats live 50 % longer. In more general terms, change and chaos stimulate life (Prigogine).

The interactions are circular (in a feedback effect). Thus, vigilance stimulates the production of dopamine which, in turn, maintains or increases vigilance. “L'appétit vient en mangeant”, as we say in French, “appetite comes with eating”: hunger stimulates appetite — which stimu- lates hunger. Success produces testosterone, which favors assertiveness, competitiveness and decision-making — which themselves lead to renewed success.

These neurotransmitters function in antagonistic pairs. (This reminds us of the classic Gestalt theme of polarities). For example, the mobilizing, invigorating effect of dopamine, the neuro- transmitter of awareness, contact and desire, is countered by the calming and organizing effect of serotonin, the neurotransmitter of satiety, of regulation and mood organization. (Vincent, 1986).

Any psychotherapeutic action in Gestalt Therapy, will contribute to the natural balance of these various internal products. Too much dopamine and you have a cerebral "short-circuit" with excitement close to delirium (schizophrenia); not enough, and you have Parkinson's dis- ease, with slowing down and trembling. Too much serotonin and you have obsessive behav- ior, not enough and you have depression.

When you are losing control of your vehicle, there are two complementary ways of getting it back: you either slow the engine down (you reduce the production of dopamine) or put the brakes on (you increase the production of serotonin). Gestalt therapy sessions act at both these levels, either regulating vigilance and experimenting with a view to obtaining clarifying insight or increased well-being. The art of a therapist consists of pressing the right pedal at the right time, deliberately or intuitively, so as to favor renewed biochemical balance, which is subsequently regulated automatically by natural secretions.

The three "levels" of the brain

Gestalt Therapy interventions usually, follow the bio-logical order (present, past, future) and

not the chrono-logical order (past, present, future): we begin by paying particular attention to what is happening here and now, to the "how" of the relationship (attitudes, postures, sensa- tions and feelings, intonations, etc.); then, we possibly mention the client's past, based on his/her own spontaneously emerging associations; finally, we finish with short-term experi- mentation or projects.

In this we recognize here the three natural "levels" of the brain:

• the deep reptilian brain (diencephalon), which controls homeostasis in the present (balance of needs, temperature, hunger, thirst, etc. ), as well as survival instincts (it continues to func- tion during a coma);

• the intermediate limbic brain, which brings back memories from the past charged with emotion; it integrates conditioned reflexes and learning (from past experiences);

• the superficial cortical brain, which covers and controls all of this: it makes it possible to make choices and take decisions (responsibility and management of the future). During Ge- stalt therapy sessions, we regularly stimulate the faculty to make conscious choices; at all times, the client is invited to make autonomous choices and refusals.

Holistic therapeutic interventions constantly associate reptilian functions (needs), limbic func- tions (emotions and memory) and corticofrontal functions (awareness, experimentation, deci- sion making).

The ego function of the self integrates the needs of the id, with the background of the person- ality.

Heredity and Freedom. Nature and Nurture. Dreams.

Choices are not entirely "free": they are partially conditioned by our personality. Today we are aware of the important role played by hereditary predispositions: the genetic heritage of a newborn baby represents a sum of information that would constitute a library of 3 000 vol- umes, each of 300 pages. The pile would be twenty stories high! (Bourre, 1990). In a way, this is the newborn’s own personal program — which will, or will not be fulfilled.

lt is undeniable that we are born with definite predispositions (size, color of hair or eyes, health, intelligence, gifts for sports, music, drawing, contact; a calm or anxious temperament, optimistic or pessimistic, submissive or aggressive, etc.).

Thus, as the Orientals say, "all is written" (not in the heavens, but in each of my 60 000 bil- lion cells, from the tips of my toes to the hair on my head). The number of possible chromo- some combinations is such that it is mathematically impossible for there to ever be another being the same as me, from the Big Bang to the end of the world (except for identical twins, of course). 

This absolute originality of every living being is another theme that is dear to Gestalt therapists who are wary of any generalization about "normal" development or catego- rization of disorders.

But the fact that all is written does not infringe our freedom of choice, as we can decide not to stick to the text, just like an actor who takes the liberty of improvising. This deliberate con- struction of our own future — built from our available heritage — is one of the main goals of any psychotherapy. In spite of our genes and environment, we remain partly free and responsible:

What matters is not what has been made of me, but what I do myself with what has been made of me. 

(Jean-Paul Sartre)

"All is written....” But how shall we read it? We now know that, in fact, we re-read our pro- visional script every night, during our dreams. (This is the famous hypothesis of Michel Jouvet (1992), "genetic reprogramming").

We re-read it and "annotate" it, integrating into the memory of our species our own personal experiences: this secret "big book" of our lives thus becomes a personal log book or diary, contributing to our individuation. The original text of our genetic heritage is thus readjusted every day, according to our experience and the unique events of our existence: this is Ge- stalt's positive creative adjustment.

It is mostly during our dreams that we fix our memories, especially those which are emotion- ally charged (important experiences, positive or negative, of our lives or our therapy). Thus a rat, if deprived of dreams, loses a large part of its learning faculties. The same is often true for patients who undergo long periods of treatment with neuroleptic or antidepressant drugs — which reduce, or even eliminate, dreaming time. Prolonged deprivation of dreaming seems, incidentally, to favor the appearance of compensatory delirium of an aggressive or sexual nature, as well as bulimic tendencies (Picat, 1984).

This work goes on unconsciously at night, but it is prepared and continued during the day. This constant updating of our "program"—the integration of our experiences and the freely assumed responsibility for our own life plan — is indeed one of the objectives of Gestalt therapy.

We now know that we — like all matter — have three states: waking, sleeping and dreaming. The latter being as different from sleeping as it is to being awake: two-thirds of the right brain are mobilized (Jouvet, 1992), that is, the hypothalamus (needs), the limbic brain (emotions and memory), the cortical (images) and the frontal levels (synthesis, projects, visions), while the communication with the left brain (rational verbal analysis and logical criticism) is cut

off.

Thus, dreams seem to fulfil at least two opposed, but complementary, functions:

• they seem to be the “umbilical cord” of the species (Picat, 1984) — which gives us the

nourishment of our origins and enhances survival functions (aggression and sexuality); they also act as a "rampart against culture" (because our education tends to fight against these two natural instincts); 

• but they also seem to be a crucial individuation factor (that which makes me different from the next person), by taking into account my original experience (Jouvet, 1992); they would thus guarantee the integration of my individual memory into our collective memory

In this way, dreams coulds have the essential function of synthesizing the innate and the ac- quired. If this hypothesis were to be confirmed by research currently underway, it would con- firm that during dreams, the contents of our long term memory are permanently "engrammed" (written into the brain’s structures). In this case, if we wanted to avoid being "marked" by a psychological trauma, we could "erase" it before it was recorded, that is, before the next dream period, just as it is possible to erase instantly a message on the screen of a computer, before saving it permanently in the central memory of the hard disc.

We have successfully tested this hypothesis of mine on several occasions. An emergency psychotherapy session (i. e. before the first night), which makes it possible to de-dramatize a traumatic event by expressing the associate emotion seems, in fact, to soften the psy- chological blow (immediate ex-pression through an emotional debriefing avoids a lasting im- pression in the deep structures of the brain): the victims subsequently talk about this painful event with "reasonable" emotion, almost as if they had witnessed the scene as a "stranger" (Ginger, 1987).

The two hemispheres

The right hemisphere of the brain develops before the left hemisphere, while a baby is still in the womb. It is the center of global intuition, of synthesis, it is the "artistic" brain — which perceives things and situations immediately, without analyzing them, or even being able to name them. Our Western culture has attributed too much value to the left side of the brain, the center for speech, logical analysis and science, calling it the "dominant side" (As we know the nerve fibers cross over as they pass through the medulla: thus the left cortex controls the right hand. In part, this is the reason it is perceived as being dominant: the left side is linked to the majority right hand.)

In reality our deep, meaningful decisions are more often than not dictated by the right side (choice of a partner, of a religion, a politic party, a professional or leisure activity, etc.) and only rationalized afterwards by justifications from the left brain.

Gestalt therapy reacts against Western "cultural hemiplegia" (Ginger, 1987) by reinstating the functions of the right brain, which incidentally, enjoys privileged links with the limbic brain. The right hemisphere values that which is qualitative and subjective, and associated with the phenomenological — Face, body, movement in space, music, poetry, dreams. This is in con- trast to the left hemisphere’s connection with that which is quantitative and objective, associ- ated with behaviorism. The right side values emotions, desires, and the environmental context in a circular systemic approach in which all elements are interdependent. Meanwhile, the left brain controls, as we have seen, the objective scientific or numbered data, verbal language, the contents of the sentences rather than the mood of the conversation, the "text", not the "con- text", in a linear, time-based Cartesian approach.

Thus, those approaches like Gestalt Therapy (but also rebirth, bio-energetic analysis, pri- mal therapy, etc ) which use body or emotional mediation link the two sides of the brain more than verbal approaches such as psychoanalysis, transactional analysis, neuro-linguistic pro- gramming (NLP), etc. — if, of course, ample time is left for verbalization. This usually takes place after the body or emotional movement. In traditional therapies, verbal expression generally precedes the emotions and induces them. Putting things into words is essential, not for the short-term effectiveness of the therapy sequence, but for subsequent access to the traces of the experience in the brain. The words act as a key, or "entry code", but are not in themselves sufficient to open up new paths — unless they are accompanied by deep emotion (linked, for example, to a strong transference on the therapist).

Sex and the brain

Before ending these few reflections on our two hemispheres, it is important to note a wide- spread error perpetuated by the non-scientific press: many imagine that the right hemisphere is dominant in women, as they are considered to be more emotional. In fact, men get easily carried away, and frequently succumb to passion. Men are more emotional, but they hardly express their emotions. It is an uncontested fact that the right hemisphere is more developed in men — especially due to the effect of the male hormone, testosterone.

This explains why, statistically, men are more gifted in general for spatial orientation (me- chanics, expeditions,...), while women have a more developed left hemisphere, which facili- tates speech and time orientation, and they have more links between both hemispheres. The most plausible explanation is evolution: prehistoric men went off to hunt, silently following the spoor of their prey, while women stayed at home, in the cave, to ensure the rhythms of breast feeding, and family cohesion, via language.

From kindergarten, girls speak in average four times as much as boys. They have a 12-month lead on boys the same age at 6 years old, and are 18 months in advance at 9. The average length of a telephone call is 20 minutes for (French) women, and only 6 minutes for men. Also, women have developed their senses of hearing and smell: their hearing is twice as keen, and six times as many women have perfect pitch. Their sense of smell is twice as sensitive (more still at certain points in the menstrual cycle). Feelings have their own odors: desire, sadness, anger... or schizophrenia. Our vomeronasal organ (VNO), our sense organ for pheromones, influences our unconscious limbic brain without any conscious cortical informa- tion. We are unconsciously sensitive to a thousand million millionth of a gram of musk, i. e. one single molecule.

Testosterone has many effects: reaction speed, visual perception, attention, muscular devel- opment, domination instinct, conquest, etc.: it prepares men for hunting and fighting. Men are thus genetically programmed for competition (which means that the better male ensures the species' descendants) while women are programmed for cooperation and sharing (for chil- dren).

By way of a conclusion

Over the last fifteen years or so, I have been very interested in research in the field of neuro- science, and I have read more than a hundred books and numerous scientific reviews on the subject. How has this research gradually modified my day-to-day work as a Gestalt therapist?

I would like to answer this first with the aid of some simple examples:

• The clearly recollected trace of an experience, either in the daily life or in the framework of a therapy session, implies a "limbic opening up" to emotion; otherwise, the recording of the experience remains superficial and of short duration; therefore, I encourage entering into emotion.

• Since I have understood that all movement in space reactivates the right hemisphere — which is directly linked to the emotional limbic layers — I have no hesitation in having a cli- ent stand up and move around the room, making physical contact with objects, with myself, or with other clients (in the case of a group session).

• Another example: doing a drawing, standing up in front of a paperboard mobilizes the whole body and the right brain (synthetic and emotional), while the same drawing done sitting in a chair on a normal sheet of paper activates the left brain (analytical and rational), since it re- produces a physical situation with scholarly connotations. If the drawing done standing up is done in front of a group, the emotion is amplified even more and the result will be recorded deeply and lastingly.

• So, I often associate group therapy with individual work, as group therapy makes it easier to experience a wide range of personal and social situations — encouraging emotional expres- sion in the here-and-now of the session, as well as various forms of physical contact (ranging from therapeutic tenderness to aggression).

• The physiological interferences — linked to their anatomical proximity in the hypothalamus, between the zones controlling aggression, sexuality and pleasure — mean that often, I either combine or substitute these three emotions during a single session. Sexuality, aggression and creativity are linked, among other things, to the production of testosterone, the "conquest hormone" (in women, as well as in men).

• Women need intimacy to enjoy sexuality. Men need sexuality to enjoy intimacy. When a woman shares a problem, she needs mostly to be listened at, while a man tries to find a solu- tion through action. Such genetic trends must be honored during each therapeutic session.

• I alternate moments of awareness, stimulation and energizing — which raise the levels of dopamine, with moments of calmness or recapitulation — which stimulate the production of serotonin, regulator of the humor.

• As verbalizing enhances the anchoring and subsequent evocation — not explanation! — of an emotion experienced in the past or in therapy, at the end of a session, I often suggest that the client reformulates verbally, or gives a "title" to his work -— which will later act as a "code" to "open the file again".

• I do not hesitate in being provocative, for example in the form of "paradoxical injunctions" — in order to mobilize the frontal-cortical zones. The frontal lobe is particularly well devel- oped in the human species and allows an adapted decision to be made freely. Without this, a choice cannot freely be made. Any choice consists, in fact, of saying "no" to the rejected so- lutions. Victims of frontal lobe damage function almost automatically: you show them a bot- tle, they drink; they see a bed, they lie down on it; they see a pretty girl, they go up and talk to her.... They have difficulty resisting temptation, since their freedom to do so has been re- moved: they can no longer say "no".

• I frequently use enactment of imaginary, desired or dreaded situations, as I know that for the brain (cortical and limbic), there is no difference between a “real” image (which, in fact, is merely projected onto the various parts of the brain) and an imaginary image (visualized on our inner screens), which triggers off the same neurological processes (hence the effectiveness of visualization and psychotherapy — and the harmfulness of television violence). Thus a fantasy (desire or fear) "acts" on our cellular memory and is engrammed in the same way as an actual experience. (Hence, the frequent problems with false memories of sexual abuse .)

Finally, I have developed two personal hypotheses, deduced from my reading in the psycho- biology of dreams:

• Everyone dreams, for around 100 minutes every night (much more for pregnant women, who double their dream time to accompany the neurogenesis of the fetus — which dreams, at the same time as its mother (Picat, 1984), as of the 7th month of gestation... well before it has been able to repress any desire forbidden by the Super-ego (Freud). Everyone dreams, there- fore, but 8 minutes after the dreaming phase, only 5 % of people remember their dreams when they are woken up. The work of dreams, which Nature mainly planned to take place right in the heart of deep sleep, remains 95 % unconscious. I suggest the hypothesis that when we remember a dream, it is because it was not possible to see it through to the end "normal1y": it has not been fully digested. Hence the idea of working on it as an unfinished business and act- ing out what the end would have been, whether desired or dreaded by the dreamer, "if he had- n't woken up"...

• I have already related the way I will set up “emergency intervention networks” before the first dream period, in order to effect the partial dissolution of a psychological trauma in order to avoid it being fixed in the deep layers of the neurological unconscious.

These brief examples of clinical application of some neuroscientific research fit easily with the Gestalt therapeutic approach.

Right from the beginnings of Gestalt therapy, Perls, Hefferline and Goodman had underlined Man's "animal nature", the importance of the organic unconscious and of physiological ho- meostasis phenomena. For 50 years now, and especially since the considerable advances of the "brain decade" (1980-1990), research has confirmed a little more each day the close links between genetic coding, the transmission of neuronal messages, the subtle biochemistry of the brain, the immune system (based on the distinction between "ego" and "non-ego"), inner ex- periencing and outward behavior.

This research confirms all of the genial intuitions of the pioneers and it is now up to the new generation to continue the work of those who created Gestalt therapy in the light of experi- ence and of science.

Serge GINGER

Clinical psychologist, trainer in Gestalt Therapy, specialized in neurosciences since 20 years, Founder of the Paris School of Gestalt (Ecole Parisienne de Gestalt, or EPG) President of the International Federation of Gestalt Training Organizations (FORGE) Secretary general of the French Umbrella for Psychotherapy (FFdP)

Registrar of the European Association for Psychotherapy (EAP) Author of two bestsellers about Gestalt Therapy, translated into 9 languages:

• GINGER S. et A. (1987). La Gestalt, une thérapie du contact. Paris. Hommes & Groupes. 6th ed. 2000 (510 p)

• GINGER S. (1995). La Gestalt, l’art du contact. Bruxelles. Guide Marabout. 5th edit. 2001 (288 p)