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This article defines and supports the experiential processes of awareness, expression and connection (relation) as significant change agents and goals in the use of psychotherapy with dually diagnosed clients. These eminently human processes-- awareness of self and other, expression and connection--are seen as vital prerequisites for therapeutic treatment as well as desired outcomes of the therapy itself. The contact-withdrawal cycle as utilized in the Existential-Gestalt theoretical model of psychotherapy is explained and offered as a "road map" or series of guideposts for the therapeutic journey. Specific areas of therapeutic concentration are described, as well as how they interface with the phases of the contact-withdrawal cycle. Specific strategies and clinical examples support the importance of an experiential and process orientation in psychotherapy for dually diagnosed consumers.
Fifteen years ago as I entered private practice as a psychotherapist, the treatment world for dually diagnosed (MH/MR) clients was predominantly behavioral. I felt immediately outside of the therapeutic loop, a process therapist in a land of behaviors and consequences. This is not to say that I discounted the importance of behavioral approaches, problem-solving techniques and psychoeducation, but believed that something quite vital to a humanistic therapy was missing. With post-graduate training in an Existential-Gestalt approach to therapy and growth as well as in the creative art therapies, particularly music, I found myself emphasizing emotional awareness and expression of that emotional truth to other human beings. My own personal inclinations as well as the Gestalt model (Clifford Smith, 1989-1991)led me to experience, awareness, expression, and connection as necessary components of any therapy that was to go beneath surface behaviorism to the gestating place of Self-discovery and, ultimately, Other-contact. Handicapped or not, every person must struggle to balance Self-creation and Other-connection. Whether such an approach with this population was at all possible remained the question.
Much has been written during the past three decades regarding the validity of counseling and psychotherapy for dually diagnosed clients. In Mental Health Aspects of Mental Retardation Robert Fletcher (1993, p. 328) writes:
The literature reviews on therapy with mentally retarded persons (Jakab, 1970; Lott, 1970; Sternlicht, 1965; Albini and Dinitz, 1965; Szymanski, 1980) demonstrate that psychotherapy with persons who have mental retardation is both feasible and successful. Furthermore, these reviews do not advocate any particular theore- tical framework; rather, they describe the benefits derived from multiple forms of clinical orientation (Rubin, 1983).
The American Heritage Dictionary (1969) defines process as "a series of actions, changes, or functions that bring about an end or result…ongoing movement; progression…" (p. 1043). In the context of this article, process refers to the central importance of lived experience in its organic and varied forms, rather than exclusively mental and behavioral activity. The internal and interpersonal functions, the ongoing, natural progressions towards health and growth are attended to in such a way that the desired goals occur naturally. Specifically, the experiences of awareness, expression (particularly emotional), and connection (relatedness) will be highlighted as essential to a process orientation in psychotherapy, an approach in which the journey is as important as the destination, and at times is the destination.
Several authors supporting the use of counseling and psychotherapy for dually diagnosed clients indicate the importance of the process aspects of their methodology. Andrew Levitas and Stephen French Gilson, in their description and treatment of the primary and secondary psychosocial deficits in dually diagnosed clients (1993) as well as their application of the separation-individuation scheme to these developmental issues (1994), describe the need for the growth processes involving self-awareness, emotional development and relationship. Similarly, Blotzer and Ruth (1995) suggest that "...we resist pressures to be too goal-oriented" (p.10), while Nehama Baum (1994), in describing the use of sandplay therapy with MH/MR clients, states that in each individual "...there seems to be a force which continuously strives for self-actualization and fulfillment...It puts trust in the process of change..." (p. 256).
Self-awareness and self-revelation--making oneself known--are supported as goals by several authors. Joan Bicknell (1994) writes: `"Before counseling can be effective, the person with disability must want to communicate...and must feel 'good enough' about himself to feel that he can do this" (p. 50). Ruth and Blotzer (1995) state as one of their therapeutic principles: "People with disabilities have complex inner lives, and a useful way of working can evolve from the struggle to understand their experience" (p. 4). Regarding this inner world , they further write: "And we want to be understood in the particularities, affective contexts, and full range of potentials of who we are" (p. 4). Lastly, Levitas and Gilson emphasize the therapist's need to learn to read the cues to the inner life of the client (1989, p. 102).
Many authors have stressed the importance of emotional awareness and expression. Levitas and Gilson (1989, p. 101) write that the limited emotional reactions of handicapped clients are not intrinsic to mental retardation, much of these limitations being due to conditioning. Hollins, Sinason and Thompson (1994) state the "...need for 'emotional' rather than cognitive intelligence..." in treatment of handicapped clients, and that such therapy must rely on emotional understanding (p. 234).
With respect to the relational aspect of process in therapy itself, most writers reviewed (Prouty, 1976; Fletcher, 1993; Bicknell, 1994; Blotzer and Ruth, 1995; Levitas and Gilson, 1994; Caine and Hatton, 1998) insist on the centrality of the therapeutic relationship, much in the tradition of the client-centered approach of Carl Rogers (Rogers, 1951).
Additionally, several writers stress the need for adaptability and flexibility when immersing oneself in the process of therapeutic change with dually diagnosed clients. Three decades ago, Sternlicht (1965) was already describing very specific techniques that he found useful with clients who were verbally impaired, all of them very experiential processes. Among them were play therapy, creative art therapies, projective techniques and psychodrama. More recently, Anne DesNoyers Hurley (1989) writes of the importance of matching techniques to cognitive and developmental levels, the need for more directive approaches, therapeutic flexibility, as well as family and staff involvement. Levitas and Gilson (1989, p. 71) support the use of play therapy and other methodologies that are effective with children and adolescents when working with impaired clients, all in the service of the therapeutic goal of "...choice consistent with safety". Baum (1994) describes her use of sandplay therapy with this population, concluding that "...the stories of the rich inner life of children and adults with mental retardation can be told and their deep therapeutic process can be clearly noticed" (p. 255). Finally, in describing clinical bias against prescribing psychotherapy other than behavioral treatment for clients with mental disability, Prout and Strohmer (1995) stress the clinician's responsibility to provide the client with ways of communicating thoughts, feelings and concerns as well as employing "expression fostering techniques" (pp. 51-52).
Prouty (1976), however, in examining the necessary conditions for client-centered psychotherapy, began to describe processes or pre-conditions required by any form of counseling or therapy. Prouty reviewed the findings of the Wisconsin Study (1967, Rogers, Gendlin, et al.) which examined the impact of the therapeutic relationship on schizophrenics and schizophrenic retardates. Relationship (1972,Rogers) and experiencing (Gendlin, 1970) were deficient in these clients, thereby making therapeutic contact mostly unachievable since this population was unable to take in or experience the therapist's unconditional positive regard. Prouty (1976) proceeded to posit the need for "pre-therapy" (p. 648), a methodology to facilitate these impaired psychological functions.
In his theory of psychological contact as a necessary condition for psychotherapy and counseling to occur, Prouty (1976, pp. 648-649) described a person's need for contact with self, the world, and the other. He employed various forms of reflection (situational, facial, word-for-word, body and reiterative) to effectively mirror these points of contact to clients, thereby facilitating their own contact functions and subsequent contactful behaviors.
In summary, there have been numerous researchers and clinicians over the past three decades who have supported both the effectiveness of various forms of psychotherapy with the dually diagnosed population as well as the need to re-examine the therapeutic process with these clients. Prouty's work emphasizes the importance of the pre-conditions necessary for any meaningful self- and other-interactions and to creatively find ways to reduce the developmental lags that have led to the absence of such conditions. Other writers focus on the task of stepping beyond the restrictions of one's training in order to employ and, when necessary, create methodologies that will facilitate the therapeutic process beyond the point of psychological contact towards the client's desired goals.
THE GESTALT CONNECTION
The Existential-Gestalt tradition places great emphasis on here-and-now experience, awareness of that experience, and contact (with self, other and the world), processes required for any person--handicapped or not--to create a truly lived life rather than one of robotic requirements and imitation (Polster & Polster, 1974).
An individual is seen as a self-regulating organism (Smith, 1985, p. 11) containing an innate sense of what is needed for healing, health and growth. From time to time a person will become aware of various needs calling for attention in the service of this health-growth process, but among those different needs, one or another will take stage center in our awareness, moving into the foreground of consciousness. In the Gestalt tradition, the need or "want" which dominates this foreground is first attended to since this is what the organism senses as of initial importance. When this need is fulfilled, some other awareness will move into the foreground in a very organic way, calling for focus on a new want or need. When the person takes steps towards meeting a need and achieves satisfaction, s/he is then able to move to the next organismic requirement.
By way of example, as I sit writing this article, my full attention is on the computer screen, as I attend to the need to meet a deadline and the desire to contribute something of worth to dually diagnosed treatment. I become aware of an ache in my lower back and my concentration suffers because a new want is activated. I adjust the pillows, satisfy the new want, and concentration on the article once again comes to the foreground. I then experience a grumbling in my stomach. This new awareness in the foreground keeps me from focusing on the article, because organism is saying, "Hungry!" I then realize it is almost 8:00 A.M., and I have been writing since 6:30. I go to the kitchen, eat a piece of fruit, satisfying a bodily need, and then find the writing at the center of my concentration once again.
This process of moving from awareness of wants and needs, to action/interaction and then to satisfaction is basic to human existence, and provides an extremely helpful map in the therapeutic attempt to help clients identify wants, discover what gets in the way of satisfying them, and finally to support them in reaching these goals. This overall process is conceptualized in what has been called the contact-satisfaction (or contact-withdrawal) cycle as described by both Joseph Zinker (1977) and Edward Smith (1985). A full contact-withdrawal episode (Smith, 1985, p. 36 accompanying diagram) begins with general awareness of self, other, and world, specifically of wants and needs, moves through emotional awareness and expression (motivation) to action/ interaction (with self and /or world, other), culminating in organismic satisfaction and a natural movement towards the next contact episode.
Life would be simple and wonderful if the contact cycles of our daily lives were allowed to organically move towards their natural point of resolution. Interruptions, however, occur at different points along the way. Awareness of self, other and the world is dulled, prevented or , as with dually diagnosed clients, developmentally unavailable. Blocks can also arise with respect to awareness and acceptance of the emotions that arise to move a person from a want to taking the action/interaction necessary to fulfill that want. Stuckness can occur in the action/interaction phase which prevents us from doing what is necessary to reach satisfaction. This group of interruptions can be due to fear, shame or simply the absence of knowledge and skills required to act. Finally, a person can become immobilized at the point of satisfaction, either not allowing it or refusing to let go of it.
A brief example follows of how the awareness of this cycle can be clinically useful. Mary C., a dually diagnosed client in her mid-twenties entered the session room, and when asked how she was doing, replied automatically, "Fine!" Body language, voice tone, lack of eye contact seemed to indicate that something in her inner world was not "fine". My task as therapist was to read the cues, follow them and to hopefully guide the client into a greater awareness of what was calling for attention. Knowing that Mary was quite musical, I had placed various instruments around the room, and when I suggested she start to play the instrument that she most felt like that day, she chose the guiro ( a grating, percussive instrument), and began to scrape it more and more intensely. This did not seem "fine" at all, so I inquired, "What's happening, Mary?" She responded with: "Mad!!" This was followed by, "Mommy and Dad went away!" And then came the tears.
In terms of the contact-withdrawal cycle, Mary had not been able to allow the awareness of what was most important that morning--her anger and grief over the vacation her parents took without her. A supportive and expressive context helped her connect with this and then to proceed to feelings which moved into expression (anger/guiro and sadness/tears). Interruptions of this natural process, noted more readily with hindsight, had to do with both (1) behavioral programs that were teaching her to manage her inappropriate anger without learning how to be aware of and express anger when necessary, and (2) the very human fear of feeling the loss of being left behind once again.
The Existential-Gestalt tradition, as well as the creative art therapies, additionally emphasizes experience-in-the-now, a tremendous advantage in working with clients whose ability to abstract and generalize is impaired and who often need to develop more of an awareness of direct experience. There is a learning that benefits us all when, instead of talking about or thinking about something (not to diminish the value of these processes), we directly experience it, whether the "it" be something internal to us, between us and another, or between us and the world. Fritz Perls, the founder of Gestalt therapy, referred to this as preferring experience to "aboutism", i.e., talking and thinking about. The Gestalt experiment during a session becomes the vehicle that connects experience and action to "aboutism" and insight. Erving and Miriam Polster (1974) write:
The experiment in gestalt therapy is an attempt to counter the aboutist deadlock by bringing the individual's action system right into the room. Through experiment the individual is mobilized to confront the emergencies of his life by playing out his aborted feelings and actions in relative safety. A safe emergency is thus created where venturesome exploration can be supported. (p. 234)
With this background and with a desire to establish more awareness, expression, connection and satisfaction in dually diagnosed clients, I began the process of stumbling my way into methods and answers to some questions and learning how to deal with the unanswerables and occasional powerlessness of others. It seemed to me that therapeutic approaches with dually diagnosed clients that focused primarily on behaviors and problem-solving seemed to move directly to the action/interaction phase, often without awareness, emotional clarity and relatedness. I became convinced that the addition of therapeutic attention to client awareness of wants/needs (both internal and external) and to the emotions that point to these wants and motivate the person towards satisfaction would enable clients to participate in the full cycle of human existence, transforming conditioned behaviors into authentic and choiceful human actions.
T.C., a very personable woman in her thirties with mild retardation, would travel from her facility to be with her family several states away. She would be driven to a local airport, but would have to travel alone from that point on, changing flights in a major airport. Regardless of how often she did this, a similar scenario was played out each time. She would approach the ticket desk, demand help in finding her boarding gate, and would quickly fly into a rage when not personally escorted to where she needed to go.
This is the beginning of a case description to which I will refer from time to time as a way of concretizing the more abstract descriptions of this approach. Experience, awareness, expression and connection are germaine to a process form of therapy and have served as the underpinnings of my work with dually diagnosed clients. These process goals need to be understood as a direction or a path rather than a fixed point. A content focus, by contrast, will place more of an emphasis on outcome, be it the behavioral goal of a client's program or the solution to a problem. Both are needed, but exclusive attention to results may lead to goal completion without the internalized and autonomous experience of how to reach that outcome. It can also frustrate problem solving by ignoring processes-- emotional awareness, for example--that are crucial for clear resolution. T.C. seemed to be capable of anger expression, but the desired outcome (appropriate expression as well as awareness of all feelings at work) was not achieved, because aspects of the overall process were not in place. Her awareness contact with her emotional world was not full or complete. To this point I will return.
Much of the therapeutic activity surrounding these goals have taken place in five areas of concentration: (1) self-awareness, (2) body and breath awareness, (3) emotional awareness and education, (4) expressive language (accessing and expressing feelings), and (5) communication and conflict education.
During the descriptions of these focus areas, parenthesized abbreviations will refer the reader to the phases of the contact-withdrawal cycle described earlier: (PA) primary awareness and sensation of self, other, world (what Prouty describes as pre-therapy), (SA) self-awareness (thoughts, feelings, needs, wants), (EA) emotional awareness, (A) action towards need satisfaction, (IA) interaction with others towards satisfaction, and (S) satisfaction itself. Also highlighted when feasible will be the commonality we all share in moving through this very human cycle, with or without handicap.
As this work with mild to moderate MH/MR clients evolved, particularly during groups focused on communication, assertiveness and conflict resolution, it became clear that self-awareness was the first necessary step on the road to affective expression and connection. Prouty's work (1976) is very helpful at this stage of the process (PA), his reflective techniques forming "...a common method, in so far as they (techniques) center on pre-expressive, pre-verbal and primitive levels of client behavior" ( p. 649). Clients are introduced to the capacity to notice self, other and the world, something non-handicapped persons take for granted.
Another early aspect of awareness is of oneself as separate from (yet related to) other people (PA). Here the word "boundary" becomes an important concept, one which must be made concrete particularly with the MH/MR client. This entails learning through as many sensory modalities as possible. Any object (hoola-hoops, rope) or body movements (gestures, approach/withrawal exercises) that will enable a client to achieve a physical sense of him/herself as separate from others can be effective.
An additional form of self-awareness often lacking in this population is a realization of the difference between what we often refer to as "inside and outside" (SA). "Inside" of me are my feelings, thoughts, images and desires, while "outside" are events, objects of desire or fear, people and things that stimulate the senses. Again the use of sensory-specific objects as well as body awareness (the use of one's "skin line" as a boundary) and identification exercises (Is_________inside or outside of you?") help to develop a sense of this distinction.
T.C. was aware of frustration and anger, but unaware of a deeper experience and feeling that was driving the anger (EA). In this moment, she also seemed to revert to a less differentiated sense of her self, lapsing into a more fused (con-fused) state with airport personnel (SA). Her awareness of self as separate and autonomous dwindled in the face of her not knowing what to do. Without a sufficient sense of self and without emotional clarity she was not able to handle the situation successfully (IA).
It is interesting to note that the contact-withdrawal cycle seems to have its own inherent developmental organization. One moves organismically from one phase to the next, although not always in the same sequence. Completion of a previous phase--knowing what I want, for example--sets the stage for the entrance of emotional activity to support that want. Emotional attention then energizes the organism towards action and satisfaction. Nevertheless, the contact-withdrawal cycle interfaces readily with the different phases of various developmental models. The movement from want to satisfaction can be seen operating as an infant moves from hunger awareness and expression to satisfaction, or as the growing child moves from more concrete levels of experience to abstract operations in making needs known (Piaget's model) (Dougherty & Moran, 1983). It can also be observed on various levels of the separation-individuation process as an adolescent or young MR adult moves from greater levels of attachment towards separation and autonomy (object relations model) (Levitas and Gilson, 1990).
In enhancing all forms of awareness (PA, SA) in a concrete and experiential manner, we are enabling the client to make up for some of the developmental losses in awareness that most of us effortlessly developed in the physical, sensorial events of childhood. Without this awareness it is virtually impossible to achieve much in terms of affective communication, assertiveness or authentic connection. The client is not alone, however, insofar as non-handicapped have their own way of dulling or blocking awareness, often unconscious, culminating in the same outcome: non-contact.
BODY AND BREATH AWARENESS
From the start body and breath sensitivity becomes an essential tool of awareness. Not only does body awareness--what sensations am I noticing in my body, what am I doing with my face, my posture, how am I breathing--enhance a healthy sense of separation from others, but it also provides one with the first line of communication regarding emotions. As will be discussed later in this article, every emotional response is embodied. That is, it will always be experienced in the body, often before anywhere else. Also important is the fact that body awareness and somatic information are concrete and sensorial, making them more accessible to many dually diagnosed clients than are abstract concepts.
Breath awareness and learning how to breathe diaphragmatically are taught early on, not only as a way of becoming aware of where feelings set up in the body (SA), but to develop the skill of breathing through the fight-or-flight mode that arises when angry or anxious (A). Metaphors describing this kind of breathing might be "soft belly", or "blow up like a balloon". Again, even in the use of language, the attempt is made to address the senses via physical imagery.
In therapy sessions upon her return, T.C. would relive the airport scene imagistically and pay attention to her body signals. Although quite capable of asking questions that would get her to her boarding gate, she had not been specifically taught how to cope with such a situation and was not aware of the primary feeling that was being triggered when the airport staff was not available to take her by the hand and lead her to her destination. The question was then posed: "T.C., as you relive that airport scene, approaching the ticket desk, what starts to happen in your body?"
Here one can recognize similarities between the Gestalt methodology and psychodrama's use of role play. This is understandable given the fact that Joseph Moreno's psychodramatic techniques were one of the major influences on Fritz Perls, the founder of Gestalt therapy. Both traditions emphasize the importance of bringing the client's experience into the present time. This technique referred to as "presentification" (Naranjo, 1970) is particularly useful with clients who have difficulty generalizing. To make the airport scene present and concrete (capable of being experienced again) was a great help in T.C.'s work.
Since we did not have other people (as is possible with group therapy) or the physical environment to replicate the airport scene, I invited her to do this imagistically. She closed her eyes and began to imagine the moments leading to the airport blowup. As if it were a video, I encouraged her to slow down the images so that she she could enter the experience ("as if it were happening right now") with greater awareness, particularly of what was happening in her body, because it is in the body where emotional presence and truth can be found. Our minds can and do play games that interrupt the organismic cycle as it moves into feared emotions. Our bodies, however, never lie.
In order to successfully enter this therapeutic experiment, T.C. had needed emotional awareness and education, both needing to be experiential as well as conceptual (SA). The first stage of this area of focus consists of awareness building through reflecting (mirroring facially and verbally the client's affective signals) and modeling (group involvement is very helpful here). The educational component entails a description of emotions as energy in the body that is (a) a response to a thought, belief or perception in need of (b) recognition, expression or motion outward. Clients are taught how to recognize these body sensations (PA), give them a name if possible, e.g., sad, angry (SA), find a way to express them if needed (A, IA), thereby restoring emotional equilibrium (S).
T.C. began to notice that there was activity in her stomach. "What's the movement in your stomach like?" I asked. "It's like butterflies!" And with this classic metaphoric description of embodied fear, T.C. began to discover the fright that her anger was covering. As soon as she was aware of this and could express it, she could then create more appropriate ways of dealing with her fear rather than lashing out at the wrong people. Emotional calm returned, allowing her to think and problem solve more clearly, accomplishing what she was really capable of.
In between the recognition (accessing) and release (expressing) of the feeling, clients also learn to understand the function of the feeling, namely feelings as messengers or signals that things are either "okay or not okay" in response to the thought, perception or belief. After listening to the warning (not okay) or well-being (okay) feeling and checking out the perception to which it is responding, then a decision can be made whether to act/express or not.
In other words, it is important for the client (and staff as well) to understand what the feeling is saying. Sadness, for example, is a response to the perception that I may have lost someone or something, whereas anger is the response to the perception that I may have been violated. The perception needs to be checked out to determine whether or not there has, in fact, been a loss or a violation, but in order to do this the feeling must always be noticed and attended to (SA). The emotion in other words is always doing its job. It is the perception that may or may not be accurate.
T.C. was encouraged to attend to her body signals. "Butterflies" were the embodiment of fear, the emotion that tells us that something may be about to harm us. T.C. needed to recognize, express the fear, and check out the reality of the message attached to it. She began to realize that no one was really violating her (anger) and that there was no real danger to her since she actually knew what to do and the worst that might happen would be missing a plane. Once she did this, the emotional storm abated, clear thinking was restored, and she was able to do what she had been taught to do. Again, the problem was that the behaviors had been taught and much was expected of T.C. by her caregivers, but no one paid attention to the emotional process that accompanied her airport experience.
To summarize the emotional area of focus and to simultaneously recognize the commonality of this process for all persons (handicapped or not), the task to be accomplished has three steps: (1) affective awareness, (2) checking out the message of the feeling, and (3) making the choice (decision point) whether and how to express or whether to take some other action or not. This often takes place in groups, particularly comprised of clients who live and/or work together. Staff members are also schooled in emotional awareness and growth so that they might continue to support the work of their clients as well as take care of themselves.
Expressive language relates mainly to the action/interaction phase of the contact-withdrawal cycle, particularly with regard to communicating needs and feelings. Depending upon the verbal skills of the client, the expression might be a grunt or verbal speech. In either case it is the effort of the organism to move from need awareness, to interaction and satisfaction. It is the therapist's responsibility to provide the expressive tools in order to facilitate this movement and to hone his/her own ability to understand when the expressive repertoire is limited.
Once a feeling has been brought into consciousness through body awareness (SA), there arises a choice point (choice-fulness being a key factor in one's growth toward full aliveness): what shall I do with this emotional energy? To safely navigate these waters when the decision is to go forward and express the feeling, clients learn to use "expressive language" as well as basic communication skills.
Expressive language is any form of communication--be it a word, a sound, a gesture, motion, crying--that allows the aliveness of the feeling to continue as much as possible throughout the expression. It is the difference between someone saying, "I'm sad" without much affective energy, and someone who might cry and describe an "empty hole in my heart". Clients discover expressive--rather than suppressive/repressive--containers in order to both allow the release while making it safe for themselves and others.
It is here that I would caution against seeing catharsis as always desirable, particularly when the understanding of catharsis involves dramatic and externalized forms of emoting. The contact-withdrawal is part of a growth model, and growth demands diversity in one's approach to life's myriad choicepoints. There are occasions when, in fact, one needs external release, yet the release must take place appropriately (when, where and how) and can be as gentle as a few tears or a sigh. Awareness alone can also be curative. Simply knowing that a feeling has been activated and letting oneself have the feeling is, at times, what is necessary as well as sufficient.
Expressive, rather than repressive, containers (Smith, 1989-1991) take many forms. A simple exhale after breathing into a feeling or allowing a sound to accompany the outbreath are often very simple, yet effective, strategies for release. Words can carry forth emotional life, but care has to be taken to avoid abstractions and talking about the feeling, rather than staying in the experience of it. "I'm angry" can be an accurate statement, yet without contact with much emotional energy. Allowing emotional life into the same words by engaging breath and voice or using experiential language--"I feel like I've got a volcano inside!"--can keep the emotion alive (A, IA) until it comes to a place of natural rest (S). Even yelling and screaming can be taught as a choice, an appropriate expression in the therapy session, either openly or into a pillow. The overall therapeutic question in the service of growthful satisfaction becomes: How can the aliveness of this emotion reach a safe and constructive resolution?
Occasionally, the emotional expression phase of the contact-withdrawal cycle is interrupted and comes to a halt due to the power of learned inhibitions or the stockpiling of feelings that cannot be sufficiently expressed through ordinary channels. Satisfaction can then be encouraged through repetition or intensification of the emotional expression. In such cases, methods and equipment (batacas, pillows, drums) that work to enhance or enlarge expression are all used in order to give voice to experiences and emotions when expressive capacity is limited or when physical voice or body cannot safely contain them. In addition to breath, voice and tears, clients are often introduced to body posturing and movement to express larger feelings. Anger work, for example, might be encouraged with questions such as "What do your arms want to do? How about your legs and feet?" Happiness and joy are also very important feelings to acknowledge. "How do you sit or stand when you're this happy? How would you move around the room? How would the drum sound?"
One must be cautious, however, of contraindications. These methods are not recommended (1) if the client has not learned how to tolerate strong affect or close down the feelings when leaving the session, (2) if the client does not have a support network in between sessions when these feelings may arise again, and (3) if the client is not able to distinguish between what is appropriate in session and outside of sessions.
Expressive arts--music, art, dance--can be invaluable in providing expressive alternatives (McNiff, 1981). Music (Boxill, 1985; Bruscia, 1987) is extremely effective, particularly in the expressive phase of the cycle. In addition to drumming and the playing of percussive instruments, composing songs that express affect or choosing and singing familiar songs that relate to internal realities expand the ability to move from emotional awareness to expression. Drawing (an extensive art therapy bibliography can be found in Landgarten,1987) as well as telling stories in the third person (projective) can stimulate awareness of feelings (SA) and provide safe release when a client is not comfortable directly addressing reactions to parents, authority figures or painful life events (IA). Sand trays (Kalff, 1986; Baum, 1990) and play therapy (Hellendoorn, 1990) are likewise very useful in this regard. Use can also be made of the Gestalt "experiment" to allow clients to express themselves to symbolic representations of others or to discover/explore and then practice (role play) a skill for an actual life encounter (A, IA). The experiment is a way for a client to become more self aware, to connect the internal experience with outer reality and to come into contact with new possibilities. The Polsters write:
The gestalt experiment is used to expand the range of the individual....A safe emergency is created, one which fosters the development of self-support for new experiences. Actions which were previously alien and resisted can become acceptable expressions and lead to new possibilities. (1973, p.112)
The experiment, often in conjunction with a Transactional Analysis explanation of Parent-Adult-Child roles (Corey, 1982), is also helpful in developing an awareness of inner conflict or impasse between how a client wishes to behave in the present and how that same client is conditioned to act due to past experience. Transactional Analysis as developed by Eric Berne describes three different ego states that are easily recognized by most people because of the universality and relative lack of conceptual. The parent role refers to the state in which we find ourselves criticizing and blaming. The adult position is the mature and balanced "grownup", while the child state can either be the "wounded or hurt" child or, more positively, the free/spontaneous child. When interactions with others become unclear, conflictual, or painful, we are often in either a critical parent or hurt child state. Dually diagnosed clients typically slip into the hurt child mode in the face of real or perceived critical caregivers. Awareness of these states and the emotional, cognitive, and behavioral patterns that accompany them can be very effective in moving from passive and aggressive to more assertive responses. Again, awareness is central to this process.
As mentioned previously, these are processes moving towards internal congruency and satisfaction that all of us share. It is simply more transparent in a dually diagnosed client.
COMMUNICATION AND CONFLICT EDUCATION
Deep breathing and affirmations, as well as the tape of a song we had written together--the "Happiness of All Feelings"-- became her allies in acknowledging and checking out her fears, reminding her of what was real or imagined. In further sessions, T.C. used self-talk, skills and the audio tape of her song while role playing possible scenarios at the air- port, all the while paying attention to emotional signals and learning to tell me about them. Her progress was significant, permitting her to take the trips with no further outbursts and with the ability to handle emotional eruptions as they took place. Having made her internal responses known to herself and others, she was able to achieve the goal everyone knew she was capable of mastering.
There are times when the action/interaction phase of the contact-withdrawal cycle is interrupted by the lack of knowledge or skills needed to transfer what was learned in session to the client's day to day world. T.C. needed to practice the awareness, self-soothing and communication skills in simulated situations (role play and visualization) before she was ready to try it in vivo.
To help achieve this carryover and help the client through action/interaction to ongoing life satisfaction, skills for communication and conflict resolution (IA) are taught to both staff and clients due to the fact that in daily living, one usually has to express needs and emotional truth verbally rather than reaching for a drum or sandtray. Attention is first given, however, to the earlier phases of the contact-withdrawal cycle, namely to various forms of awareness, rather than trying to impose new "training" before any awareness is in place. T.C. had been taking part in group therapy with four of her peers just before Christmas several years ago. All the group members were quite upset at the facility's new director who was changing the format of the annual Christmas program, much to their dislike. They agreed that it would be important to approach the director as a group and express their concerns. I could very easily have taught them how to do this, but first several weeks had to be spent becoming aware of all of their reactions and emotions, as well how they might feel when sitting in the director's office. With this kind of awareness, they avoided being caught off guard emotionally and were able to make themselves known to the director with clarity and maturity.
It is also important to note that in any therapy, particularly with the dually diagnosed population, the therapist is always operating on a continuum between being directive and supporting the client's initiative. The more handicapped a client is, the more need there is for directiveness. Yet, the more that awareness and choice play a part in the new behaviors, the more distinctly human the act becomes.
The curriculum consists of awareness development, attitude changes, developing a positive stance towards conflict, listening and communication skills. The awareness, attitudes and skills involved are required in all healthy and successful human exchange. Affective awareness and expression, in particular, serve clients as they deal with daily interactions and conflicts, creating more authentic connection, particularly during times of loss or adjustment.
Finally, there is a small percentage of clients who can become aware of unfinished emotional business from the past (unresolved previous conflict) by bringing it concretely into the present. This work often has not been successful due to the difficulties in generalizing and abstracting common to dually diagnosed clients. When it has been successful, it has been with clients either with mild handicaps or of borderline intelligence. The use of presentification methods is effective, even if the client does not completely understand past-to-present transference. If the expression of feelings about a past event (reactions to the memory of abusive or critical parents, for example) can be facilitated, the internal stockpile of emotions will be lessened, reducing the risk of projecting these feelings onto present caregivers. There then exists the possibility of completing these events rather than transferring them onto contemporary situations, oftentimes damaging what is already a fragile and tenuous interpersonal network.
This article has intended to demonstrate not only the validity of psychotherapy and counseling for dually diagnosed clients, but also to support an eclectic approach which attends to the processes of awareness, expression and connection as well as to behaviors and cognitions. The Existential-Gestalt model of psychotherapy and growth, particularly as expressed in the contact-withdrawal cycle, offers a framework for enriching present approaches to the psychotherapeutic treatment of this population. Descriptions have been presented of attempts to apply Prouty's "pre-therapy" techniques, the contact-withdrawal cycle, as well as creative art therapy approaches to the treatment of dually diagnosed consumers in the five areas of general awareness, body and breath awareness, emotional awareness and education, expressive language, and communication and conflict education. Finally, throughout the article the reader's attention is drawn to the fact that the human processes of awareness, expression and connection with which dually diagnosed persons struggle are really common to us all.
"What makes us different?" is a question easily answered when considering the clients entrusted to our care. "What makes us the same?" is perhaps a bit more unsettling. Dually diagnosed persons and caregivers all exist on a continuum, fluctuating between Self-directing and being directed, between Self-support and other-support. We all struggle on the same tightrope between remaining a mystery even to ourselves and becoming known.
Likewise, in all therapy--be it for those handicapped or not--there is a place for the deeply human process of becoming the Self--the unique and personal expression of our presence in the world that gives birth to behavior. This process requires awareness and choice, and the greater the extent to which we guide ourselves and our clients into both of these dimensions of authentic living, the more truly human our lives become. We come to know ourselves, and, in so doing, run the glorious risk of becoming known to others.
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