Gestalt Therapy for Addictive and

Self-Medicating Behaviors
Lecture One–The Need to Change
Philip Brownell
The Need to Change

Part One:
The Nature of Addiction and Self-Medicating Behaviors
 Addiction is
Centrifugal
The constructs of “addiction” and “self-
medicating behaviors” overlap. For some
people and contexts of discussion they
refer to the same thing. On the one
hand a very strict understanding of
addiction requires physiological
dependence upon one or more illegal As life goes round and round, the
drugs (Dimente, 2003), tolerance, and drug of choice–getting it, using it,
withdrawal. On the other, a wider associating with others who use it and
understanding identifies addiction as so forth–becomes central. All other
being anything in which people are activities are spun to the periphery
consumed with behavior that becomes and out of sight. One’s life world
centrifugal in nature, that is, forcing shrinks; it becomes shrink-wrapped
other parts of life to the periphery of around the drug or behavior of
living (Alexander and Schweighofer, choice.
1988).
 Appreciating the
Addictive Field
Addiction and self-medicating are never one-person
processes, as if the problem belongs to the addict alone.
They always involve other people, even though the addict
or self-medicating person remains responsible as the agent
of behavior for whom the use of a substance or the use of
some kind of action serves some purpose. Addiction and
self-medicating behaviors are functional and relational.
 Substance Dependence
Substance dependence is defined as cognitive, behavioral, and physical characteristics showing
that a person continues to use a substance in spite of the fact that that causes a great deal of
difficulty and that three or more of the following can be seen during any given 12 month
period:

(1) Tolerance (the need for increasing quantities of the substance to achieve intoxication or
the desired experience);

(2) Withdrawal (cognitive and physiological behavior change resulting from declining levels
of a given substance in the blood or bodily tissues in people who had maintained heavy
dosage over time);

(3) Compulsive use, either by taking more over a longer period of time than originally
intended and/or continuing to use in spite of a desire to reduce or discontinue using;

(4) So much time is spent in the rituals of obtaining or using the substance that using pushes
to the side other aspects of life, even important social, occupational, or personally
significant people and activities;

(5) In spite of the mounting damage and loss accruing through the use of the substance, the
person in question continues to use. The key element is that even in the face of this
accruing loss, and especially even when the person admits that he or she ought to quit,
and wants to quit, the use continues.
The Need to Change

Part Two:
Just How “Fixed” Can One Get? The Nature of Recovery
 Recovery
Abstinence is simply sobriety, the presence of the absence
of using an addictive substance or engaging in compulsive
self-medicating behaviors. Recovery, however, is a freely
chosen lifestyle characterized by sobriety, health, and
responsible participation in one’s social world; it is the
absence of mood altering substances and the maintenance
of a program designed for growth in the person and
enhancement of the person’s life (Hanley, Ganley, &
Carducci, 2008).
 Stages of Recovery
1. The Detoxification or Stabilization stage of care–usually occurs in an inpatient
setting, is several days in duration, and is focused on ameliorating the
physiological and emotional symptoms that follow recent substance use and
motivating the patient to accept that there is a problem and to learn how to
deal with that problem.
2. The Intermediate stage of care sometimes occurs in a residential setting but
usually in an outpatient setting, is several weeks or months in duration, and
is focused on teaching the patient new skills to cope with relapse situations
and motivating him or her to develop and maintain lifestyle changes that are
inconsistent with substance use.
3. The Continuing Care stage of treatment is 1 or more years in duration and
focused on relapse prevention through continued support of positive lifestyle
changes and regular monitoring of potential risk factors for return to
substance use.
The Need to Change

Part Three:
The Will To Change
 Motivation
Martin & Mackinnon, et al (2011) pointed to a study that
showed people with purpose were more apt to do better in
recovery from cocaine addiction. This purpose, this
motivation to change has largely been studied in
connection with the beginning of treatment (as seen in
motivational interviewing), but there is evidence that the
issue of motivation is important throughout the process of
treatment and needs to find attention so as to foster even
greater long term results (Korcha, Polcin, et al, 2011).
 Motivational Interviewing
In the dynamic of addiction an approach avoidance cycle
develops in which a person approaches the using because
of the pleasure it brings but avoids it also because of the
destruction it brings. Thus, an ambivalence develops
(Fraser & Solovey, 2007), and in gestalt terminology that
means that an impasse has been reached in which the
client is stuck between two ends of a polarity. This is also
the situation in which the much-favored practice of
motivational interviewing (Miller & Rollnick, 2002) takes
place.
 The Impasse
In gestalt therapy an impasse is usually a point in the therapeutic process at which
the patient senses a lack of support, either internal or external, and is stuck between
moving forward into uncharted territory and resisting change, holding to the status
quo–change vs. no change (Yontef, 1993; MacKewn, 1997).
The impasse is the place where the forces with a person “are equally distributed
between the wish to increase awareness and the felt (but often unconscious) need to
block awareness…It is the place where people’s organismic urge to uncover fixed
gestalts and premature denials of their real needs is met by the pressure of fixed
habits and inertia.” (Mackewn, 1997, p. 171)
The gestalt therapist waits on the creative adjustment of the client, not rushing to
rescue. The therapist may choose to support the resistance, thus robbing it of fuel,
but basically, the therapist “hangs out” with the client in the impasse, maintaining a
dialogical relationship, and explores what it’s like for both client and therapist to be
there. Thus, the addition to customary MI from a gestalt perspective would be the
phenomenal exploration of not only the client’s desire to change, but also the
relational support of the client’s resistance–supporting the resistance corresponds to
“rolling with the resistance” from a purely MI perspective; however, it is also a bit
more.
 Motivational Interviewing
• It is a way of resolving the impasse by emphasizing one side
of the ambivalence, and it leads to change.

• MI has been found to enhance treatment outcomes in a

variety of applications by encouraging preparatory speech
that focuses on desire, ability, reason or need and
commitment speech in which the client expresses the intent
to change (Moyers, Martin, et al, 2009).

• Since these arise from the client’s own subjective sense of

being in the world, and are his or her desires and interests,
the dissonance of not pursuing what is in one’s best interest
(literally) helps to dissolve the ambivalence (and so this is
the crux of the theory behind MI).
 Motivational Interviewing
The therapist using Motivational Interviewing, utilizes five
principles, arranged in the acrostic that spells “DARES.”
The therapist Develops discrepancy, Avoids argumentation,
Rolls with resistence, Expresses empathy, and Supports self-
efficacy (Oetzel, 2010). Developing the discrepancy makes
explicit a difference between the status quo and desire for
change, and that creates a cognitive dissonance. Avoiding
arguments requires the therapist to back away from
conflict; it’s related to rolling with resistance, in which the
therapist uses the momentum of the client by guiding,
reflective listening, and affirmations. Expressing empathy
means understanding the client’s experience. Supporting
self-efficacy means the therapist supports the sense of the
client that he or she is capable of acting in his or her best
interests.
Gestalt Therapy for Addictive and
Self-Medicating Behaviors
Lecture Two–Relapse and the Gestalt Approach to Treatment
Philip Brownell
Relapse and the Gestalt
Approach to Treatment
Part One: The Nature of Individual Experience
Typical Cycle of Experience
Addict’s Cycle of Experience
Relapse
Cycle
Relapse and the Gestalt
Approach to Treatment
Part Two: The Importance of Relationship
Co-Dependency

• Loss of Self
• Enmeshment
Co-Dependency
Co-Dependency
 Boundaries
External

Internal
Relapse and the Gestalt
Approach to Treatment
Part Three: The Sense of the Situation
 Context
The social,
physical,
geographical
space in which a
person drinks
or uses affects
the experience
of the person
and can relate
to relapse.
Relapse and the Gestalt
Approach to Treatment
Part Four: The Willingness to Experiment
Gestalt Therapy for Addictive and
Self-Medicating Behaviors
Lecture Three–The Life World and Long Term Recovery
Philip Brownell
The Life World and Long
Term Recovery

Part One:
How To Rebuild the Life World
Relating Horizon to Attitude
to Life World
The Life World and Long
Term Recovery

Part Two:
The Role of Discipline in a Person’s World
The Life World and Long
Term Recovery

Part Three:
Your Client’s Body–The Physical Horizon
 The Physical Horizon
Exercise
Nutrition
Sleep
 Benefits of Exercise
Category Benefit
Physical Health Cardio-vascular and physical stamina
Brain Function Lowers risk of dementia and
Alzheier’s disease; associated with
neurogenesis, increases neuronal
survival, increases blood supply to the
brain
Cognitive Improved attention; learning &
memory
Emotional Associated with improved treatment
outcomes for both depression and
anxiety; effective in managing Post
Traumatic Stress Disorder; reduces
stress
Quality of Life Increases a person’s judgment about
well he or she is living based on
physical, social, psychological, and
spiritual domains; facilitates sleep
 Nutrition
People in recovery have been known to have dysfunctional
eating habits that often contribute to excessive weight gain.
Food is sometimes used to self-sooth in the absence of a drug of
choice. A study by Cowan and Devine (2008) revealed three
themes with regard to the use of food at various stages of
recovery: excessive weight gain, meaningful use of food, and
disordered eating with a struggle to eat healthily. People in early
recovery tend to engage in mood and binge eating, using food as
a substitute for the drug and using food to satisfy craving.
People in mid-recovery to late recovery complain about weight
gain and typically make an effort to control their weight. Their
study suggested a relationship between nutrition and general
environment during recovery such that nutrition proved to be a
factor in the recovering addict’s field.
 Sleep
This category is not strictly about sleep. Sleep is the most obvious figure in
speaking about rest, but here I would include the whole topic of rest and
relaxation. Thus, recreation is relevant as well. People can take an interest in
how to relax, in what is called “self-care.” Part of good self-care is learning
how to attend to one’s need for sleep, need for relaxation, and need for re-
invigorating oneself. This can be dedicating oneself to creating the
conditions that would support sleep, taking a walk on the beach, making a
date for oneself at the spa or to get a massage. There are many relaxation
techniques that a client might try out, using the various sense: auditory
DVDs, visual painting and pictures, olfactory scents that evoke a soothing
response from a person’s core. Finally, we come back to the issue of
mindfulness, for that is a great approach to dealing with stress and there is
evidence that stress reduction/processing is the best way to treat insomnia
(Brand, Gerber, Pühse, & Holsboer-Trachsler, 2010).
Gestalt Therapy for Addictive and
Self-Medicating Behaviors
Lecture Four: The Life World and Long Term Recovery (continued)
Philip Brownell
The Life World and Long
Term Recovery (continued)

Part One:
Your Client’s Thought Life–The Cognitive Horizon
 Thinking, Reflection, and
Mindfulness
Thus, the illustration of ruminating is classic gestalt
therapy. To think contemplatively and reflectively is to
chew on whatever is perceived to be interesting,
nourishing, refreshing, and of potential value, and it is to
meditate by bringing it back up again and again to keep
chewing on it until it is completely digested and
assimilated.
 Constructive & Critical
Thinking
Seymour Epstein (1993) described an experiential system that
operates outside of awareness, is associated with emotional
experience, and intuitively organizes experience while directing
behavior. It operates in tandem with a rational system. While the
rational system for processing information operates by rules of
inference and evidence that is linear, analytic, and abstract, the
experiential system operates according to principles that are
holistic, concrete, and associational. The experiential system is
context specific, while the rational is more general. The
experiential system is associated with affect and is adaptational,
based on the feeling of having been in a similar situation at some
other time. The experiential system gives rise to “constructive
thinking” while the rational system gives rise to “rational (or
critical) thinking.”
 Constructive & Critical
Thinking
Lori Katz (2001) spoke of these two systems claiming that
the rational system operates with linear, logical, analytical
and verbal modes of thinking and can rapidly adjust to
changing presentations of information. It is conscious,
deliberate, intellectual and uses abstractions, inferences and
logic.
By contrast, the experiential system is preconscious,
automatic, associative, concrete, primarily nonverbal, affect-
oriented, and holistic. It is responsive not only to direct
experience but also to experience rehearsed in fantasy,
vicarious experience, images, metaphors, and stories…The
experiential system normally changes with repeated
experience, but it can also change from an extremely
emotionally charged since [sic] experience. (p. 187)
 Disciplines
Journaling: write out thoughts, feelings, sensations, doubts–the
whole of your experience as much as you can keep track of it

Self-Reflection and Contemplation; focus on one aspect of your

behavior or thought life and meditate on that.

Mindful Attention to What Is; practice this by making

appointments with yourself to pay attention to what is going on
around you.

Rational, Critical Analysis (Post-mortem) of Relapse; slow down

the “video” of your last relapse, and write out the story of it; go
over this with your therapist and then take that story home and
rewrite it, trying to add anything that had been left out.
The Life World and Long
Term Recovery (continued)

Part Two:
Your Client’s Emotions–The Affective Horizon
Emotional Self-Regulation
A number of studies have focused on identifying
specific high-risk situations. Extensive evidence from
these studies has shown that negative affect is one of
the most prominent factors associated with relapse to
maladaptive drinking. (Berking, Margraf, & Ebert,
2011)
It would seem that emotional self-regulation is crucial
to successful relapse prevention, and the areas of
emotional intelligence and self-conscious emotions are,
in turn, crucial in considering emotional self-
regulation.
 Disciplines
Increase emotional vocabulary by associating emotional terms with
emotional facial expressions.

Practice feeling statements (as opposed to thinking statements)

Try out various emotional expressions standing in front of a mirror

and notice the feeling inside that is evoked with various visual
countenances

Read books about emotional intelligence

Admit faults while maintaining contact in the midst of shame

experiences (and so developing an increasing capacity to endure
anxiety)

Practice in expressing emotions in various ways using diverse media

The Life World and Long
Term Recovery (continued)

Part Three:
Your Client’s Relationships–The Relational Horizon
 Disciplines
People watch (pick a public place like a bus station or a
shopping mall, then sit down and watch people; develop a
growing capacity to be curious about them)

Practice contact skills such as looking, listening, touching,

talking, moving, smelling, and tasting (Polster & Poster,
1973)

Practice building others up rather than tearing others down

(on the idea that to gain a friend, one must be a friend).
Practice mindful awareness of current surroundings, one’s
own feelings, thoughts, values, and desires

Practice differentiating and boundary setting

The Life World and Long
Term Recovery (continued)

Part Four:
Your Client’s Ultimate Beliefs–The Spiritual Horizon
 Spirituality
Spirituality and religion are important factors in recovery
(Diaz, Horton, McIlveen, Weiner, & Williams, 2011;
Allamani, 2010; Sussman, 2010; Godlaski, 2010; Hagedorn
& Moorhead, 2010; Dodge, Krantz, & Kenny, 2010). They
are major meaning making systems in the lives of most
people, and they are usually factors in the personal
background and cultural context of a person.

The 12 step programs popularized by groups like AA, NA,

and AlAnon are spiritual systems (Hunt, 2010; Schenkeer,
2009). All one has to do is to consider the first three steps
to grasp that fact.
 12 Steps
We admitted we were powerless over our addiction–that our lives had become unmanageable

Came to believe that a Power greater than ourselves could restore us to sanity

Made a decision to turn our will and our lives over to the care of God as we understood God

Made a searching and fearless moral inventory of ourselves

Admitted to God, to ourselves and to another human being the exact nature of our wrongs

Were entirely ready to have God remove all these defects of character

Humbly asked God to remove our shortcomings

Made a list of all persons we had harmed, and became willing to make amends to them all

Made direct amends to such people wherever possible, except when to do so would injure them or others

Continued to take personal inventory and when we were wrong promptly admitted it

Sought through prayer and meditation to improve our conscious contact with God as we understood God,
praying only for knowledge of God's will for us and the power to carry that out

Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and
to practice these principles in all our affairs
 Disciplines
Fast two days each week; just drink water or vegetable juice. See
what happens.
Practice talking to God; combine solitude, in which you get alone
for a period of time periodically, with talking to God about the
real things of life. It’s not about asking God for things; it’s about
sharing yourself authentically with God. Keep a journal of your
experience is like doing this.
Read Mere Christianity, buy C.S. Lewis and write in the margins
of the book your questions, fears, misgivings, doubts, affirmations,
and realizations while doing so.
Read the Gospel of John in a modern translation and ask God to
speak to you through the pages of the book. See what happens.
Find Willard’s book or Foster’s book on spiritual disciplines and
start developing the practice found in them; see if your spiritual
world enlarges.