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Gestalt Review, 14(1):71-88, 2010

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Gestalt Therapy and Bipolar Disorder

d A A n VA n B A A L E n , M . d .

ABSTRACT
About one in 200 people will suffer from a bipolar episode at some time in their lives. Bipolar disorder is a disorder mostly treated with medication. However, medication alone neither cures the disorder nor prevents relapses. Studies referred to in this article suggest that a combination of medication, psychotherapy, and psychoeducation would improve the course of the illness. Different psychotherapeutic modalities are discussed, as well as psychoeducational treatments. A case description shows how Gestalt therapy can be a relevant psychotherapeutic modality from which clients with a bipolar disorder can benefit. Specific Gestalt therapy interventions are demonstrated and discussed.

Background I began my career as a medical doctor in general practice where, from the start, I struggled with both the potential and the limitations of the medical model. In general practice, patients and doctors are more often than not confronted with multi-causal and complex sufferings. The medical model I had

Isabel Fredericson, Ph.D., served as Action Editor on this article. Daan van Baalen, M.D., has been involved in research as an assistant professor at the Erasmus Universiteit in Rotterdam (EUR), The Netherlands, specializing in the field of chronic diseases and Gestalt therapy. He is a founder of the Norwegian Gestalt Institute and has worked as a therapist, supervisor, and trainer since 1975. He is the principal of the Norwegian Gestalt College and a guest trainer in several European countries. He is a board member of the European Association for Psychotherapy and a former board member of the European Association for Gestalt Therapy.
©2010 Gestalt Intl Study Center

After being in the hospital for a short time she was referred back to me. and later at Norsk Gestaltinstitutt (NGI) in oslo. the only treatment was lithium and/or anticonvulsive drugs. Review of Literature A moving personal and poetic experience described by Kate Redfield Jamison (1995) demonstrates the drama of bipolar disorder: Manic-depression distorts moods and thoughts. The results of our study suggested that there might be significant differences between the psychological history of patients having a spontaneous regression of cancer and other cancer patients.72 GESTALT THERAPY AND BIPoLAR DISoRDER learned had not prepared me well enough for this confrontation. one of which is entitled. She was hospitalized and medicated. and sleepless when I was on holiday. 1998. and too often erodes the desire and will to live. how? In an attempt to answer these questions. The latter is a quantitative study among clinical proven mortally ill patients. hyperactive. In other papers. A client of mine. who survived despite their diagnosis. Norway. 2000). and some of my findings with regard to her case will be compared with the literature reviewed. I recalled from my medical training that a medical diagnosis of bipolar disorder meant having a lifelong mental illness with manic-depressive episodes. an illness that is unique in conferring advantage and pleasure. “Spontaneous Regression of Cancer: A Clinical and Psycho-Social Study” (van Baalen and de Vries. Since then I have been intrigued by the idea of a possible integration of Gestalt therapy and the medical model. yet one that brings in its wake almost unendurable suffering and. yet one that feels psychological in the experience of it. Anne’s case will also be presented and discussed below. . experienced a typical bipolar episode. I was confronted with a medical diagnosis while practicing as a Gestalt therapist. 1987). if so. This work resulted in a number of articles. some of which follows below. incites dreadful behaviors. and without medical treatment. Although I was introduced to Gestalt therapy accidentally. the Netherlands. She became psychotic. I found it a model for dealing with the complexity I was experiencing in my practice. I turned to a review of recent literature on the subject. I put forward a “Gestalt diagnostic system” that could possibly support Gestalt therapists in their work and communication with medically oriented health workers (van Baalen. Consequently. It is an illness that is biological in its origins. Bipolar disorder aroused my interest by accident as well. What was I to do? Continue with Gestalt therapy? And. destroys the basis of rational thought. Anne. A consequence of this interest was research that I did at Erasmus University in Rotterdam (EUR).

energy. is a brain disorder that causes unusual shifts in a person’s mood.J. (p. Rapid cycling tends to develop later in the course of illness and is more common among women than men. Bipolar disorder causes dramatic mood swings – from overly “high” and/or irritable to sad and hopeless. colleagues. 2007. The periods of highs and lows are called episodes of mania and depression. but as many as one third have some residual symptoms. and family that I do. passim. this form of the illness is called Bipolar II Disorder. never develop severe mania but instead experience milder episodes of hypomania that alternate with depression. Some people experience multiple episodes within a single week. emphasis mine) The classic form of the illness. however. or even within a single day. Some people. People with bipolar disorder can lead healthy and productive lives when the illness is treated effectively. the symptoms of bipolar disorder are severe. Without treatment. Epidemiological studies emphasize the need to study this illness further: • two to four new cases occur per 100. Between episodes. 2008). . however. In contrast to the normal ups and downs that everyone goes through. and then back again. Severe changes in energy and behavior go along with these changes in mood. over time. the natural course of bipolar disorder tends to worsen. I am fortunate that I have not died from my illness. and ability to function. which involves recurrent episodes of mania and depression. Episodes of mania and depression typically recur across the life span. and fortunate in having the friends. a person is said to have Rapid-Cycling Bipolar Disorder. is called Bipolar I Disorder.DAAN VAN BAALEN 73 not infrequently. . in most cases. When four or more episodes of illness occur within a 12-month period. fortunate in having received the best medical care available. most people with bipolar disorder are free of symptoms. D. a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. (National Institute of Mental Health. 6) What Is Bipolar Disorder? Bipolar disorder.000 people per year for . But. suicide. often with periods of normal mood in between. proper treatment can help reduce the frequency and severity of episodes and enable people with bipolar disorder to maintain a good quality of life (Miklowitz. . also known as manic-depressive illness.

(2006) . according to Simeonova et al. 2005) The study by Morgan et al. (2006) describe the impact of cognitive-psychoeducational intervention on bipolar patients and their relatives. 2009). Garnham et al. (Drug and Therapeutics Bulletin. (2006). (2005) suggests that the quality-of-life of bipolar patients is compromised due to the disruptive impact of the illness. There was high concordance of bipolar I disorder in a nationwide sample of twins. (2006) show that children of bipolar parents are at increased risk of developing mood disorders and Kessing (2006) shows that age is of some importance. (2004) show in a nation wide twin study (USA) that bipolar disorder tends to run in families. Their results also point to important gaps in health care that may be overcome by ameliorating the access to support services. • peak age at first diagnosis of bipolar disorder is age 25-30. 2007. High creativity and bipolar disorder seem to correlate in families. systematic care was associated with a significantly greater reduction in mean level of mania symptoms. Reinares et al. (2005). Patients with clinically significant mood symptoms at baseline appeared to benefit the most. (2007) state that psychoeducation or psychosocial interventions tend to enhance pharmacotherapy outcomes in bipolar disorder.74 GESTALT THERAPY AND BIPoLAR DISoRDER bipolar affective disorders. Treatment Medications known as “mood stabilizers” are usually prescribed to help control bipolar disorder. a comprehensive treatment program pays off in bipolar mania. What Correlations Can Be Found in the Disorder? Kieseppä et al. • 15-20% of patients with the disorder commit suicide. Bernhard et al. but many patients have affective episodes in adolescence or early adulthood. Prognoses According to Simon et al. Doctors are to apply a combination of pharmacological and psychoeducational treatment for the long-term benefit of these patients. acute depressive and mixed episodes being the periods of greatest danger. Examples are lithium and anticonvulsant drugs (National Institute of Mental Health. Wals et al. • the above means that about one in 200 people will suffer from a hypomanic episode at some time in their lives.

and at alleviating the fears of becoming addicted. (2003). examples of psychotherapies and/or psychoeducation in comprehensive programs are: 1. and adaptation of medication. cognitive behaviour should be considered as an adjunctive treatment. 1999).. (2004) advise intervention at an early stage in bipolar disease in order to limit the patients’ abuse of drugs or alcohol. According to Miklowitz et al. According to Baethge et al. 2005): Relapse prevention. using rating scales for assessment. Interpersonal/Social Rhythm (Frank et al.. (2005) describe treatment strategies that could target at minimizing the self-perceived stigma associated with taking psychiatric medication. (2005). (2007) maintain that psychosocial interventions should be part of a treatment package that most patients with bipolar disorder receive. (2006) recommend that bipolar patients abstain from drinking alcohol. Cognitive Therapy (Lam et al.DAAN VAN BAALEN 75 come to a similar conclusion in a study about what really matters to bipolar patients’ caregivers. Fleck et al. These can be effectuated in a number of ways: discussion of compliance with the patient. Psychoeducation (Colom et al.. cognitive behavioral treatment and behavior modification techniques. Swann et al. Goldstein et al. Miklowitz et al. 2003): Group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Fagiolini et al. drug) and psycho-social-educational treatment plans.. Family-Focused Therapy (Miklowitz et al. (2004) justify long-term clinical support based on the high risk of suicide in bipolar disorder.. (2003) conclude in their study that intensive psychosocial . rodrome Detection (Perry et al. (2006) conclude that such comprehensive treatment programs that include psychoeducational pay off in bipolar mania. patients with bipolar disease also have a high risk of drug and alcohol abuse. 2003): Family-focused psychoeducation and pharmacotherapy. This is especially true of young people. Miklowitz et al. Simon et al. teaching patients about the disease.. Scott et al. Almost half of all bipolar patients suffer from alcoholism during their life. (2006) conclude that for stable. 4. 3. lower-risk populations early in their history of bipolar recurrences. 2. Even in the prestigious British Journal of Psychiatry.e. 5. according to Fleck et al. (2006) There is strong support for a combination of medical (i. 1999): Teaching patients with P bipolar disorder to identify early symptoms of relapse and obtain treatment.

2007). out of two hundred persons one will suffer from this disorder. and when psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder (Miklowitz et al.. the effectiveness of other treatments in this naturalistic sample was even lower” (Garnham et al. because bipolar disorder patients can easily be misunderstood and diagnosed as depressive (as I have experienced in my own clinical practice). or even fewer. (2000) is significant. how? – become even more relevant after the above review of the literature. cognitive therapy and psychoeducation for patient and caretaker.76 GESTALT THERAPY AND BIPoLAR DISoRDER treatment as an adjunct to pharmacotherapy is beneficial. I would like to reformulate my original questions into one: How can Gestalt therapy impact the treatment of bipolar disorder? . Based on all the references referring to the beneficial effects of psycho-social-educational treatment.. This strikes me as significant. impact the long-term outcome of bipolar disease. Most studies cited not only emphasize looking and planning for signs of relapse but also include some means of looking at “illness acceptance.. The disorder is seen as a potentially life-long disease. My original questions – what was I to do? continue with Gestalt therapy? and if so. or of developing rapid cycling. Special stress. All five examples of psychotherapy and/or psychoeducation show solid evidence demonstrating their effectiveness. leading to mistreatment with antidepressant medication. Psychotherapy. and medication alone does not prevent new episodes.e. When only onethird. achieve a remission with pharmacotherapy. 2007). life events. of which 15% will commit suicide. Gestalt therapy was not mentioned in the literature reviewed. They have shown that people with bipolar disorder are at risk of switching into mania or hypomania. one of the biological findings of Thase et al. during treatment with antidepressant medication. and discussion of compliance are mentioned as complementary areas for psychotherapy besides medication. nor did I find publications about bipolar disorder in the Gestalt literature. alcohol consumption. original 2003) is another example of psychoeducation not mentioned in the summary given by Miklowitz et al. The Harvard program “treatment contract” (revised 2007. including psychotherapy along with medication. then psychotherapy is in fact indicated. one emphasizes involving the family very directly. i. Striking to read was that “less than one-third of patients treated with lithium achieved remission.” Several place some emphasis on regular rhythms of sleep and activity.

lost. her eyes would turn inward. and then suddenly become dark and angry. unable to fulfill her expectations. a hope that the creative processes in her work as an artist could become less demanding. of . and accused surprised me. I soon became aware of wanting to hide the fact that neither art nor Buddhism was “my thing. making me feel lost. I particularly expected to not be good enough. I remember her beautiful large.” I started to feel insufficient. As a teenager (age 16) she had a sexual relationship with an art teacher. She has a daughter born in a former relationship. She had been diagnosed with postnatal depression seven years before entering therapy. “I am not good enough. I became aware of her charisma. and secondly.DAAN VAN BAALEN 77 Case Study At the start of therapy Anne was a divorced woman. I carefully brought up this point in a session. Later in the session. she expressed two issues she wanted to work on: first. She had been attending meditation courses for some years and had heard that Gestalt therapy has roots in Buddhism. depending on Anne’s life situation. good-looking. I was pleasantly surprised when she even showed up. since initially I was not aware of the parallelism between my experience and her description of her creative processes in the atelier. become empty. Whenever we made a new appointment. later more or less frequently. charming woman. living alone. From the beginning of our sessions. be good” were words coming up in me. her interest in Buddhism and the Buddhist view on spiritual development. She described feelings at the onset of a new project as empty and dark: “I will never make it”. Initially. “Produce. not knowing what she wanted. questioning eyes making me feel insufficient. My experience of feeling inadequate. as if accusing me of not being of any help. She knew that one of my former teachers in Gestalt therapy was known to be a practising Buddhist. Having had a general intellectual and philosophic education during my training in medicine and later as a psychotherapist. not knowing what to do.) I experienced Anne as expecting a lot from me concerning Buddhism and art. Anne chose me as her therapist because of her interest in Buddhism. and at the start we saw each other once a week for an hour. whereupon she assured me that what we did was just fine – which. She is educated as an artist and works as such in her own atelier and is rather successful. Her mother was probably suffering from mild depressions (my conclusion). I had no particular skills in art or in Buddhism. She is a tall elegant. without producing any result.” She told me she would often sit for hours in despair in her atelier. a relationship that confused her. When she came into my office for the first time. (My conclusion: depressive episodes. Anne became my client five years ago. and her brother was diagnosed with schizophrenia.

especially not with her partner. her weight increased after her manic episode. you are intriguing. and feeling being part of the universe and knowing. which she practised during her meditation training. visually as well as audibly. with hallucinations. and patience. Values such as non-attachment. who viewed her as psychotic. on her way back from the retreat. along with the psychiatrist. But she was thrown into turmoil of both happiness and doubts. not being good enough. especially with her daughter. and her moods were less expressive than I was used to. a Gestalt therapist. while I was on holiday. Her post-natal depression could have been a misdiagnosed depressive episode of her bipolar disorder (my conclusion). she walked through a forest and saw and heard things she had never seen or heard before. She then continued seeing me. frustrations. she found her present partner. She asked herself why her meditation did not help her to practise her values in her daily life. She felt excited and happy.” In the empty chair she answered as him: “I love you. with a psychotic episode. For example.” As herself. Anne’s interest in Buddhism was another cause of her frustration. and me was that I was not to interfere with the medication. delusions. She described lying on her back one evening. We practised classical work with the empty chair. equanimity. Her diagnosis was Bipolar Disorder I. At the same time. she could not sleep and was frustrated at not being able to share her experience with others in words. our awareness increased and the figure of our work became: expectations. she said: “I am not worth being loved. and exhausted. I would just continue our sessions. This had happened in the summer. once more. She was hospitalized and put on medication (an anticonvulsive drug). and despair. I was unable to believe. regularly seen by a psychiatrist. After ten days she became an outpatient. The doom of her diag- . Because of the medication. Together. Dialogues with her new lover projected into the empty chair diminished her turmoil. who regulated her medication. the psychiatrist. During her sessions with me she started physical training classes. gross behavioural disturbances. She underwent vivid awareness and exquisite sense experiences. “produce and be good” was the figure of our work. upon coming home she experienced herself once more as very impatient and as losing her temper. gave her periods of relaxation in the training hours. she then said: ”Intriguing? No I am difficult to live with!” After six months in therapy with me. where.78 GESTALT THERAPY AND BIPoLAR DISoRDER course. after a year. we slowly began to see parallels between the experience in the sessions and her creative process. The contract between her. she had a manic episode directly after a Zen Buddhist retreat. Gradually. looking at the clear night sky. on the instigation of her partner. she went to see a colleague. Nevertheless. This was an important life event. however.

trying flat breathing even more. consciously and carefully exaggerating my body position. she called it “yielding into the floor. once more. Her partner.” I dared to ask her to experiment and said: “Can you experiment with your “upness. and your eyebrows?” After experimenting on her own for a while Anne answered: “I am not sure. she could not see his care for her in his insistence. Her breathing was flat. Anne said: “I feel calmer today in this session. hanging in my chair. As I became aware. your eyebrows are up. she felt depressed and lonely in her atelier and could not stand being there. As a medical doctor trained in psychiatry. I noticed something different in her body and facial expression. informed by the psychiatrist. However. I am aware that your shoulders are up. I saw no cure. as I saw Anne walking into my office. I feel sort of up. which loomed over our sessions and over her private and professional life. I felt inadequate.” my mood went up as well.” After some time. as her awareness went “up. nor ask her to experiment with her body posture and breathing. I forgot to think as a Gestalt therapist and was caught in the medical model. as I called it. my awareness of emotional flatness kept growing and became figural. where I did not see possibilities for recovery. I did not see the possible parallelism between our relationship and her diagnosis. What had been a relatively good place for her now brought agony. your shoulders. as well as the idea of life-long medication.” by searching for “up-and-downness” in your breath. I invited her to find an exercise with me where she could experiment with sinking down. the risk of another episode and. Parallel with this experiment.” She lay down.” Not being satisfied with her answer. this time not because of the challenge the client had been. The doom. She said: “It feels . she answered: “Yes. and I am afraid I will become manic again. Again. and you breath is high in your chest. but because of the limitations of the medical model. During a session I experimented with myself. understandably insisted on her continuing the medication. Awareness of this situation came gradually: first how my body felt bent down. only life long medication for a chronic disease and no good reason for continuing Gestalt therapy. for I was afraid that she would only hear criticism. I noticed that Anne’s eyes were looking down. letting herself sink into the floor. Anne thought that his fear of another manic episode was the cause of their emotional discussions.” The next session. and finally how an hour felt long. and her body posture was collapsed. on the advice of the psychiatrist. then how my breathing became superficial. I did not dare mention this. the banning of meditation retreats. and to my pleasant surprise. and I feel loosening up and enthusiastic. I stated: “Anne. Her work as an artist became difficult too. I did not see that “we” were depressed after a manic episode and emotionally flattened by medication. made me feel that we had come to a deadlock.DAAN VAN BAALEN 79 nosis loomed over our relationship.

reported. but once I do.” Inspired by this effect. I move a little from down to up. going down on purpose makes me less afraid of going down. Remembering that Anne in fact often wore black.” Then she said: “Yes. black sweater. when you are down?” The next session she reported: “Yes I can. as she was hiding her face behind her long. however sometimes with a colourful streak. She lost a little of her initial fear of another manic episode. I can regulate my down mood to go up. black shoes and stockings.” I answered: “Yes. and said: “I can regulate my mood with this as well.” She experimented more. and afraid of becoming depressed. Remarkable. I can go down when I’m up. my mood indeed goes up.” We experimented further with what could bring her down. After a while she reported: “Interesting. only during a period when she once more became sleepless did she use the same anticonvulsive drug for a week to restore her sleep rhythm (as suggested by the psychiatrist). Anne and I continued working together. one remarkable episode worth mentioning was when Anne invited me to see some of her artwork in a park close to my office. it gives me a feeling of mastering my moods. Anne draped the shawl around her shoulders and walked around a little feeling the shawl. curling in the sand. Anne carefully started to use make-up. I asked her if we could experiment with colours. though I really have to pull myself together to do so. and discussed our findings with up and down. which she had never used before. Anne enthusiastically reported the same effect. When I want to. Colourful dressing helps. I don’t have the energy for clothes and just put on what is there. She was at the same time still medicated and under her psychiatrist’s supervision. I gave her a colourful shawl and waited to see what happened. Could you also experiment with what makes you go up. then started to move slowly and elegantly through the office. Anne was interested in these exercises and went on experimenting at home.” She continued: “often in the morning when I am down. dark hair. The next session she reported that she could keep herself down to a certain degree when she felt too high up. A few weeks later though Anne said: “Now I am down. we then also experimented with going even more up when she felt up. She reported: “Strange.” The following period Anne and I experimented. the way I had done earlier with myself. and I am aware that I can regulate myself more to go down. Together they decided to reduce gradually and eventually stop the medication. Even her facial expression was dark. and other issues came up. I’m aware that you often wear black. We then experimented with going even further down when she felt down. since Anne .” I took some time for my awareness to build up and saw that Anne was dressed only in black: black skirt. so does physical exercise such as walking. I can do this. doing some dance movements.80 GESTALT THERAPY AND BIPoLAR DISoRDER as if I’m lying on a beach.

at an exhibition of her work.” By being him in the empty chair. We dealt with the issue by using a classical projection exercise. I had come with a feeling of expectation. where she could also answer as the room. She told me that she had tried several times to clear away the mess and create a sort of order. She still had problems working there. Her atelier was cold. leave me alone.” I did meet her partner. his perspective certainly upset Anne. Whenever the couple had a conflict. Remarkable also. Whether he was right or wrong. never succeeding. He obviously felt insecure after Anne’s last manic episode. Recently. her partner wanted her to continue. We went for a walk together to visit her work in the park. I suggested that she have a dialogue with the room. saying: “I am not ill. and there she did not suffer in the way she had in her own atelier: she did not feel alone or empty or dark. however.DAAN VAN BAALEN 81 had only once shown me a little piece of her work. “We are good enough. She received a grant and a commission for a co-product with a colleague. he used her illness to explain their disagreement and ensuing strong emotions. which immediately disappeared after seeing boxes and cupboards full of stuff. This insight calmed her down. We gave up the discussion when her partner refused. he saw it as a reason for continuing the medication. tables with large heaps of materials. without excessively going “up or down” or being caught in “produce and be good. We both seemed able to endure the tension of intimacy created by the exposure of her artwork and the walk. because I had never asked her to show me anything. Anne and I made an appointment to visit her own atelier. Anne and her colleague worked in a prestigious atelier offered by the local community. I told her: “ I am not surprised that you can’t work here.” She experienced their meetings as meaningful.” and afraid of not being able to comment on her work without her feeling critiqued. certainly for fear of being caught with her in the figure “produce and be good. Anne wanted to stop. inviting individuals to her atelier to create an artpiece together. “the empty chair. Room: “I am cold and do not want to be filled up with more than I already have here. and their relationship slightly improved.” Anne also started to experiment with co-artwork. done by a colleague. she found that her partner was afraid of new episodes and wanted to protect her. “Maybe we will make it”. and I was overwhelmed by the disorder everywhere she could work. The relationship between Anne and her partner became strained because of different opinions about Anne’s medication. probably as a test to see how I would react.” .” She was surprised and relieved that I as a visitor immediately understood that she could not work there in its present state. she appeared to enjoy both our walk (which I enjoyed as well) and my pleasant surprise when I saw her work. Anne and I discussed the option of couple therapy.

unable to fulfill her expectations.e. By so doing. practical test.” I started to feel insufficient.. We see each other now and then. Zinker (1977) elaborated upon these points and came up with the structured Gestalt experiment. an act or operation undertaken in order to discover one unknown principle or effect. you need movers to do the job. you won’t make it alone. my feelings were similar to those Anne had expressed. I know when I am up or down in different situations. 123-155). Anne decided to ask friends to help her “move” stuff out of her atelier. Secondly. I am not good enough. xii). I want to address experimenting as typical of Gestalt therapy. when my experience became so similar to what Anne was experiencing: “I will never make it. proof” (p. (1951) define experiment as: “a trial or special observation made to confirm or disprove something doubtful. I have tried to clean you up. based more on my interest in bipolar disorder than on her need for therapy. Anne felt that she could have more control over her moods. I influenced the Anne-Daan situation. Discussion How Can Gestalt Therapy Impact the Treatment of Bipolar Disorder? First. . which has at least seven distinguishable steps (pp. She said.” The room answered: “You have tried so often. “I am not as much a victim of my moods anymore. establish or illustrate some suggested unknown truth.” After this dialogue. I experimented with these feelings. especial under conditions determined by the experimenter. I influenced its progression by exaggerating my feelings and body position. I experienced an immediate and implicit bodily sense of the Anne-Daan situation.82 GESTALT THERAPY AND BIPoLAR DISoRDER Anne cried and answered: ”I’m so sorry to have put so much into you. my body] implicitly senses the present situation as a whole. as yet undifferentiated from its separate parts” (pp. This an example of what I think Wollants (2007) meant about having deep immersion in the client’s experience: comprehending the client’s behaviour client by perceiving it as she does (p. or to test. and her artistic work did not upset her as before. 86-87). 80. Perls et al. immersing myself in the ongoing experience. Three months later.” Wollants continues. Anne noticed. stating: “Awareness can be defined as the on-going process by which the body [i. consciously trying out my flat breathing even more and carefully exaggerating my body position. emphasis in original). and I can deal with these situations better than before”. Both heightening awareness and feeling part of the situation are typical of Gestalt therapy and open up possibilities beyond diagnosis in the medical sense. we decided to see each other less frequently. and being aware of and becoming a part of it while at the same time keeping my distance from it. saying: “I feel calmer today in this session. I want to discuss the work in the beginning.

experimenting with being up and down. I had been the one with awareness of our situation. She also managed to regulate better her emotional state and felt more capable in the event of new episodes. Experimenting with “up” or “down” and obtaining control over too much of either pole helped Anne lose somewhat her fear of a new manic-depressive episode. the exploration works to reduce the effects of bias through repeated observation and inquiry. p. experimenting with going further down and further up when she felt either up or down. Clearly.DAAN VAN BAALEN 83 Examples of experiments in my work with Anne were two-chair work. Polster and M. Anne and I influenced each other. as discussed by Korb et al. Exaggerating my mood had an effect on her. But I would not call that manipulation or testing boundaries. she experienced it as well. and synthesis as managing to regulate her emotional state and make her more capable in case of new episodes. and visiting her atelier. as Wheeler (1991. the development of the Anne-Daan relationship was an experiment in itself. according to Zwanikken et al.61). they test boundaries and try to change them. Relational Work Bipolar disorder patients have been seen as manipulative.. Anne could also feel the effects of her experiments with awareness. Polster (1973) point out: “Whenever an individual recognizes one aspect of himself. 204). However. which is essential for therapy to occur. Earlier. “I feel calmer today in this session. they come out of a multi-person system.” she said. Moods and affects are not something a person has. According to Melnick et al. Her tendency to become the victim of her moods diminished while being with someone else. lost. the presence of its antithesis. (2005). 103). “Exploration works systematically to reduce the effects of bias through repeated observations and inquiry” (Yontef. (1989. as does Zwanikken. (1990. My moods were not only mine but also Anne’s. 1996. and accused. up as antithesis. In this case.” We not only experimented with “what is” but also exaggerated it. as E. Manic-depressive behaviour functions in a relational system. Later. The bias was her fear of ups and downs. p. is implicit” (p.” The above-mentioned experimenting with “up and down” is also typical of Gestalt therapy. Typical of Gestalt therapy is staying with what “is. or polar quality. 2005 ). I experimented with my own experience. 1998) indicates. “An experiment can also be conceived as a teaching method that creates an experience in which a client may learn something as part of their growth.” as Yontef (2005) explains: “The goal of a phenomenological exploration is awareness. the manic-depressive patient manipulates the experience of others. down can be seen as thesis. By pleasing and denigrating. In the beginning of the therapy when I experienced being inadequate. Anne’s partner’s refusal to go to couples therapy with . Simultaneously.

She enjoyed her craftsmanship in relation to her colleague without being self-critical. who point out that almost half of all bipolar patients suffer from alcoholism. “the insight that ‘the whole determines the parts’ (Perls. Hefferline.84 GESTALT THERAPY AND BIPoLAR DISoRDER her can be seen as an attempt at manipulation. the findings of Goldstein et al.” our Walk to Visit Her Work in the Park According to o’Neill (2008). and mine of not being good enough. Drugs. moved beyond the individual psychology of Anne as artist and her insecurity about being not good enough. “produce and be good. Staemmler (1995). Anne started to experiment with co-artwork. are a reminder for me to consider . reductionist nature of current psychology [and medicine] that sees only the separate nature of the therapist and client contact. 1951. . Alcohol and nutrition I do not know whether drug abuse is involved in this case. The whole determined my experience of pleasant surprise which I became aware of. eventually created change. (2005). Dialogues with him projected onto an empty chair diminished her turmoil around happiness and her doubts about the relationship. (re) establishing relationships with important relatives and colleagues. instead of trying make things change. as result of our relational work. and the art structure. replacing the pat phrase. and not solely with her close family. or at least I.” To exaggerate the situation and to be fully where we were.” Knowing that I was part of the situation made it possible to raise awareness of the situation. in which he would have Anne first imagine her partner and then use the “empty chair. describes a grading process of the dialogue. 21). seemed to have a stabilizing effect.” We. The whole of “Anne-Daan in the park and the art structure” determined the parts. & Goodman. We let ourselves consciously be determined by the whole and expressed what we experienced. . To move beyond this point is to develop an awareness of the ‘self’ of the therapist/client dyad [situation]” (p.p. which suggest that there may be a correlation between high creativity and bipolar disorder. Being an Artist The case of Anne seems to illustrate the findings of Simeonova et al. as she easily had become when working alone on a commission. xi). encourages us as therapists to move beyond the individual. it was a working example of Beisser’s (1970) “paradoxical theory of change. It is possible that. Nevertheless. (2006). Daan. Clearly. The figure formations produced “awareness of emotional flatness and ups and downs. however. Anne.

C. H. All the time. & Strakowski. and we experimented with the “empty chair” (projection work). if much appreciated by me. Department of General Pathology Medical Faculty. C. then the medical theory of this disorder must be reviewed. Substance abuse in first-episode bipolar disorder: Indications for early intervention.DAAN VAN BAALEN 85 that possibility. et al. (1987). à corps retrouvé. is not easy to live with – neither for her. Bipolar Disorders: An International Journal of Psychiatry and neurosciences. Conclusion Gestalt therapy seems to be a modality of psychotherapy from which some clients with a bipolar disorder can benefit. RE fERE nc E S/WORK S cO n Su LT Ed Arndt. M. and to possible reductions in rates of hospitalization or polypharmacy. American Journal of Psychiatry. our approach was relational. 162. (2006). Gestalt Diagnostiek.. 18. we practised being in “middle mode” polarity work and phenomenological exploration. 33-47. Treatment-associated costs must be carefully balanced against the potential gains for patients when it comes to functioning and quality of life. and delaying recurrences. Rotterdam (EUR). J.. Baalen van. Baalen van. However. Anne has had regular therapy sessions but no disorder episodes.. 141-181. In this case. and Gestalt therapy could be the first choice of treatment for some patients. (2000). R. 338–344. we would need more qualitative research focusing on bipolar disorder and Gestalt therapy in order to be able to answer this question. her passion. C. She remains a passionate woman. nor for me. but it is costly. 8. maintaining stability. (1998). For three years (at the time of writing this paper).. Spontaneous regression of cancer. D. Baldessarini. Concurrent tracking of alcohol use and bipolar disorder symptoms.. Baalen van.P. 5. DelBello. Is Anne cured in the medical sense? If her diagnosis of Bipolar I was correct. C. We also worked on the client’s relation to her lover. a clinical and psycho-social study.. Intensive treatment such as Gestalt therapy seems to be effective in hastening recovery from episodes. D. 1008-1010. nor for her intimates. . vijfde jaargang. Tijdschrift voor Gestalttherapie. M . M. D. S. (2005). S. Baethge. Gestalt: Accord perdu. Kaur Khalsa. An important aspect here is the cost-effectiveness of Gestalt therapy interventions. Erasmus Universiteit. her colleagues and her atelier. Gestalt et diagnostic. & de Vries. M. and she has not taken medication for two years.

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