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


Gestalt Therapy and Bipolar Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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