Transcript for February 16 2018

>> So, Evan, can I start? Okay, well thanks for joining me today on our brown bag, which is called Understanding Traumatic Brain Injury from a Gestalt Approach. So I want to give you a little bit of background in terms of this topic and how I came about basically trying to approach this. This is something I've been kicking around since I've been a doctoral student. And a lot of my clinical experience has been in the area of traumatic brain injury and also different forms of acquired brain injury. And you know, when I first came across Gestalt therapy was when I was a doctoral student. It was a counselling theory class. And my impression was that this theory just really seemed to fig this population. And I think, you know, a lot of the theories we talk about in rehabilitation counselling, they fit different populations better than other populations. So in the area of traumatic brain injury, again I really thought that this seemed to fit well in a number of different dimensions. And to that point, I actually wrote a paper on it for one of my seminar classes. I sent it to a journal, got rejected. And you know, I held on to it. I thought, "I still kind of believe in this theory." You know, this theory is connected to traumatic brain injury.

And I just never really did anything with it further until about a year and a half ago. I thought I should take this up again and start to work on this. So I've been doing some background reading, some updating of the content of this article. And you know, basically trying to move forward with really seeing how conceptually the theory fits this population and you know, trying to express that in terms of an article. I am going to be presenting this topic at an upcoming National Counselling and Rehabilitation Conference in Anaheim. And this brown bag is good practice to kind of start thinking about ways to explain this and you know, maybe start thinking about ways to kind of revise some of the ways I'm trying approach this topic. So I want to see how many people we've got online. Andrea, I know you're online. And for anyone else who joins, you can unmute your audio any time you want to jump in and basically say anything. Because I think, you know, this is a topic that's interesting to talk about, kind of get different perspectives on. And again, from my point of view, that would be good practice for me as I move forward with this topic.

So I talked before about this conceptual fit of the Gestalt therapy to traumatic brain injury. And I think one of the backdrops for kind of looking at theoretical approach to fit a population is that in rehabilitation counselling we often criticize the field for not really having a clear theoretical focus. You know, we kind of do a lot of things without a real clear theoretical basis for this. And I think you know, theory is an important element to have in any kind of counselling approach, interventions we provide and so on, because it gives us a framework to work from, gives us a set of expectations we can try to test to examine. It gives us a means to evaluate the interventions we're trying to advance. So it's an important kind of like I guess foundation for guiding the work we do. And in Gestalt therapy, we talk about this idea of holism. That is like one of the primary things that's going to come through in this approach. So its focus on the holistic needs of humans, as well looking at self-determination are really key in terms of how we try to advance rehabilitation counselling. And I think like even more so beyond kind of a general rehabilitation counselling population, when we look at people with traumatic brain injury, it has even more of a fit.

Because as we go deeper into my presentations today, I'm going to talk about some of the things that Gestalt therapy advances with the nature of psychological maladjustment. Especially in the areas of fragmentation, unfinished business and loss of self-awareness. And you know, in working with this population - as a case manager I worked in supportive living in neuropsychological assessment and doing different support groups. And then my research primarily focuses on the family effects of traumatic brain injury. You know, see these things directly through those contexts. Was there a comment? Yeah, I heard a voice. No? Okay. Again, any time you want to jump in, throw in questions, comments, observations, that's awesome. Okay, so traumatic brain injury, this is something I talk about basically in any kind of publication or presentation I do. I think it is something that we don't talk enough about in rehabilitation counselling. And that's you know, it's problematic because this is such a pervasive disability. There are so many different ways in which we increasingly recognize the issues of traumatic brain injury and how it affects individuals. So I have some data on here. You know, the CDC talks about that in 2013 there were around 25 million emergency room visits attributed to TBI, while we had almost 300,00 hospitalizations resulting from this disability. So if you're hospitalized, it probably means you have you know, some level of loss of consciousness, perhaps brains swelling. Perhaps some kind of altered neurological status. Something that will really, you know, impact you in a variety of ways and perhaps on a lifelong basis.

So that's a lot of people. And we also look at in terms of our veteran population with Operation Iraqi Freedom, Operation Enduring Freedom which is Afghanistan, and Operation New Dawn which is kind of as we've moved out of Iraq in terms of our kind of active military forces. This is sort of like a maintenance force more or less. So those three operations, we as of September 2013, almost 221,000 veterans are in the VA's TBI Veterans Health Registry from their military service. And now also, you know, we talk about this issue of chronic traumatic encephalopathy, which is an issue attributed to concussive and sub-concussive injuries. And I think the number one area where we are really talking about this is in the area of football. And one of the people we have on Zoom today is Andrea Ersuit, or now Folsom. And Andrea was my student assistant last semester and Andrea did a lot of research in terms of locating articles on this topic and you know, has seen I think just how big o fan issue this is. I just kind of point all these things out just to make the point that you know, traumatic brain injury is really front and center as one of I think the key disabilities we have to focus on. But when we look at our training and rehabilitation counselling, like what's required from our accreditation is not something you have to really have much discussion on. So I think a lot of rehabilitation counsellors are coming out of programs around the United States without probably that much preparation background.

Again, kind of talking about the impacts of traumatic brain injury as kind of the context and backdrop to looking at this connection of Gestalt to TBI. We know that there's a lot of unemployment issues with people with TBI. So according to national data, CISCO Center, traumatic brain injury model systems program, if you receive inpatient rehab following TBI, those individuals only demonstrated a 28% employment rate one year post-injury. If we remember one of those previous statistics I mentioned, that we have approximately 300,000 persons hospitalized because of TBI every year, that's a lot of people that are then ultimately unemployed. We also know like in the state VR, vocational rehab systems - so in California we call that the Department of Rehabilitation - only 34.8% of those who had closed cases in fiscal year 2015 achieved an employment outcome. And when we talk about employment outcomes, it could be self-employment. It could be into competitive, integrative employment. There's a number of different categories. But it's something where you have an employment outcome, which is what is desired in this system. So again, a pretty low number, 34.8%. The other thing I think we have to keep in mind is that there are interventions out there that have shown relationship to positive outcomes.

And I mentioned like one of these studies, Mark Tucker and myself, we did an analysis of what's called RSA-911 data which is the Rehabilitation Services Administration collected information over a fiscal year. And so we looked at fiscal year 2015 and we found that you know, if you advanced in your education - let's say if you came into the VR system with a bachelor's degree and you finished with a master's degree, if you went up one level, it had a relationship to being employed ultimately. So there are some things out there that talk about potential interventions and you know, things that seem to work. So let's move on to gestalt therapy. This guy is Fritz Perls. And Andrea, have you ever seen this guy before? Have you ever talked about him in any of your classes? Anybody else on the call, has anybody ever seen this guy before, Fritz Perls? All right, well this guy is the person most associated with Gestalt therapy. And when you look at pictures of Fritz Perls over the years, this is kind of like the Esalen Institute in Big Sur, California version of Fritz Perls in the late 1960's. Long hair, you know, kind of your typical guru of the human encounter movement. But before then, he looked much more conservative in terms of his outlook and appearance. But he's the person most associated with Gestalt therapy. But there have been other people that have been you know, I would say like foundational persons in Gestalt therapy.

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But again, Fritz Perls is the person most associated with Gestalt therapy. And the interesting thing about Perls is that a number of people have criticized him for being kind of flamboyant and in his counselling approach basically trying to meet his own narcissistic needs. And you know, just doing things to just kind of get a reaction out of his clients and maybe amuse himself. So I think that the modern day Gestalt therapist wouldn't look like what Fritz Perls would in a counselling session. To get a sense about how Fritz Perls might look, if you ever do a YouTube search for Gloria and Fritz Perls, I think it was 1965, a real client named Gloria had a counselling session with Albert Ehls, the sub-rational model of behavior therapy. And then Carl Rogers for person-centered therapy, and then Fritz Perls for Gestalt therapy to kind of see the nature of the different ways of doing counselling. But nonetheless, in spite of those criticisms, I think if you read some of his work, it's very interesting. And he really presents I think a different way of looking at counselling. And like a lot of the people who came up in his generation, he was trained in psychoanalysis and that was really thought to be the way of doing counselling. So he really you know, departed in terms of that traditional way of doing counselling.

So what do we assume in Gestalt therapy? And this gets into where I really think it has a really good conceptual fit to traumatic brain injury. In this approach we talk about holism. Self-fulfilment and self-responsibility. And you know, I mentioned in his writing, if you look at Gestalt Therapy Verbatim, which is in the STC library, that was the last book that he wrote, but it became a very popular book to articulate the positions of Gestalt therapy. And then he wrote hunger and aggression are a vision of Freud's theory and method, which he published in 1947. And this is one of these books where he you know, went out on a limb in a sense and criticized like Freud's way of thinking. And at the same time, we have people like Carl Rogers who wrote this book, talking about person-centered therapy. Also he really departed from that traditional way of thinking about therapy, had to be like based in the psychodynamic theory. And this idea of like him kind of being called the founder of Gestalt therapy, he rejected this title. And in his 1969 book Gestalt Therapy Verbatim, he talked about the fact that Gestalt therapy is really about just kind of the human spirit. And it's not - it really can't be attributed to like one person. It's sort of like saying, "I'm God and I'm creating something that is a universal truth for all humans." So he didn't want to take the credit for saying that he was like this person. He said Gestalt is as ancient and old as the world itself. And the only law which is constant is the formula of Gestalts which are whole and completeness.

Gestalt is a German word meaning like a whole, complete concept. So that's the concept we're going to come back to. So again, this focus on holism explains the use of the German word Gestalt which is a meaningful whole, organized configuration. And it is based on something called Gestalt psychology. So Gestalt psychology is not the same exactly as Gestalt therapy, but they're interwoven in a lot of ways. And Gestalt psychologist Kurt Kaffke said that the whole is other than the sum of the parts. That this whole, like this integration of all these elements of the human being, it's more than just like taking different elements of your life, that it's more than just those separate disparate elements. And you know, a lot of the different theories in psychotherapies talks about like a drive, something that really kind of moves our energy forward in any action that we take. In Gestalt therapy, we talk about we are guided by a desire for homeostasis, which refers to a perception that one's needs are satisfied. So we're constantly moving toward that. And in Gestalt therapy, we talk about a figure-ground conceptualization, which means figures are basically those emerging needs that we become aware of. And ground is basically like the environmental, social context in which we live.

So that connection, that figure-ground connection will be different for every person based on the unique context in which they have lived. And you're never like done with homeostasis, because as you meet different needs in your life, new ones will come to your awareness. And you're always going to be kind of growing and moving toward you know, whatever those new goals are in life. In Gestalt therapy, therapists believe that humans naturally grow towards self-actualization, maturity and environmental harmony. And the term we're going to use that is hunger instinct. So that kind of gives you just a little bit of kind of the conceptual, theoretical point of view of this approach. And I mentioned before that in the late 1960's, Perls was very popular in the human encounter movement. Like especially places like the Esalen Institute in Big Sur, California. And you know, I think people at that point really were kind of questioning just you know, the laws of society and you know, things we were taught are right and wrong, our values and so on. They were really questioning that, you know, especially during a time in which there's a lot of disillusionment with the Vietnam War.

We were looking at Civil Rights for racial justice, and just a number of areas where people really were questioning kind of everything. So this theory really fit well into that point in time in history. So this approach we have is something called the Gestalt prayer. And it kind of fits like the late-1960's when this came out. But it gets at I think one of the things I've always been attracted to Gestalt therapy, this idea of self-responsibility. And so from a clinical point of view, I think it makes a lot of sense. And in this approach, we would say - or the Gestalt prayer would say, "I do my thing and you do your thing. I am not in this world to live up to your expectations and you are not in this world to live up to mine. You are you, and I am I. And if by chance we find each other, it's beautiful; if not, it can't be helped." You know, a little hokey, but I think it kind of gets at again what we're trying to really advance in this approach. All right. So now let's move on to talking about traumatic brain injury from a Gestalt point of view. And I mentioned at the start of the presentation that in rehabilitation counselling, one of the problems we have is that we have a lack of a theoretical approach to a lot of the things we do.

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You know, I think like if you - for all the students and graduates I have on the call today - you know, think back to like when you did your practicum, your clinical training. It's probably not very often that your sites would say that what you're going to provide in terms of intervention is based on like a particular theoretical model that we are using to guide our practice. It's probably going to be more based on like, "These are the rules of the federal government, like [inaudible]." Or just that this is kind of how we've always done things. Really not a clear theoretical perspective. So benefit of using theory to guide practice is providing like a type of explanation, sensitivity to various client situations. So in this case, when we work with individuals with TBI, and let's say you know, maybe if you don't have a lot of experience with this population, having a clear theoretical sense about what is important for this group, like what really can be challenging to this population, both for the people with this disability and for their family members. It gives you that framework to be able to kind of think about your assessment process, your interventions, and just general level of empathy and sensitivity to what they may be presenting to you.

These models - and the examples I have on here, these are all from different populations or for different kinds of rehabilitation types of considerations. So you see on here probably some names you recognize. Hampton, Guillermo, Tucker and Nichols. So Dr. Hampton and then Dr. Clairmont who works at the Interwork Institute, and we all know Dr. Tucker. And then Taylor Nichols who's a graduate of the RCP. They talked about this idea of cultural humility as like a framework to guide your practice. You need to be aware to effectively kind of train yourself to be sensitive to different client needs related to diversity, related to considerations. But just like one example, another one, Bishop, Shepherd and Stentock's 2007 article talked about a conceptual framework for working with individuals with MS. So that's kind of the way I'm thinking about this particular article, is looking at Gestalt therapy as providing a conceptual framework for working with this population. We often use conceptual frameworks when we don't lay out a good sense about how to work with the group. We don't really know much about them. It's a group that maybe lacks professional focus and consensus. And in this context, Gestlat therapy is offered as a means of establishing a framework to address the psychological, emotional, familial needs that really go unmet in rehabilitation counselling.

And as I said earlier, from an accreditation point of view, you know, it's not really required that you have much training on traumatic brain injury. I think it's very possible you might be getting out of a program like HMR's or different programs around the US and not really having a lot of background in terms of really knowing how to work with this group. So that's kind of this overall purpose. That's what I'm really trying to get across in the article, and it's been kind of difficult at times to really articulate that, but that's what I've been trying to work on. So when we think about TBI, people with this injury can have a lot of negative psychological outcomes, which can be chronic. And as I go through this, I want to be really clear that we're not talking about every individual who's affected by traumatic brain injury. There's a lot of people with traumatic brain injury who are very much able to reach like a positive quality of life, positive healthy psychological wellbeing. They're able to find like a new sense of identity for their lives. But there's other individuals who I would say like are stuck in a sense, or are not able to move forward. And that might result in things like anxiety and depression, perceived negative quality of life.

And in this approach, in terms of applying Gestalt therapy, we could try to really help individuals address the factors that block their ability to live holistic lives, move toward a sense of homeostasis. You know, that sense of always moving toward having your needs met. Self-actualization, and then taking responsibility for the direction of your life. And the things I'm going to talk about next are fragmentation, unfinished business and lack of self-awareness. And in Gestalt therapy, regardless of the population we're working with, that is what a Gestalt therapist would say are going to be like the things that really kind of present a problem for individuals. Just you know, in any kind of walk of life. And so let's talk about teach of those three different areas. And I just want to pause for a second. I want to see if anyone has any questions, any comments before I move on. And you can unmute so you can talk right into your computer or your phone.

>> Hi, Chuck. Can you hear me?

>> Yeah.

>> Oh good. I don't know what I'm doing. This is Jen.

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>> Hi, Jen.

>> I'm a lot older than the rest of you. You have to give me time. Well, I think what you're talking about obviously is evident and absolutely that you're right that we don't get a chance as counsellors to really look at people that have TBI's the same way that we're encouraged as far as mental health or physical disabilities that are much more I guess recognized. But there seems to be so much I would think that's co-occurring with the TBI thing, that the Gestalt makes sense. Because that's how we have to look at people in order to try to help them to self-actualize, to see themselves be able to move forward. That wherever they're at is where they're at, and therefore this is a whole person to move forward. So I mean, I'm just agreeing with what you're saying.

>> Yeah. And I would guess, Jen, in your work - you know, in your work with veterans you probably have seen a lot of individuals with TBI.

>> For sure. And there's so many co-occurring things going on. When I read medical reports, you know - and I get people after the fact that they've been through the majority of their IEP already for vocational rehabilitation. I see that a lot of the time that the counsellors in-house don't really recognize what the realistic expectations can be for someone moving forward with that as part of their disability status. They expect things to be much more cut and dried. You finish this, now you should be on to this. And that's really not the case.

>> Yeah.

>> Especially if they've only had a short-term amount of you know, their benefit paid for for their education. You know, the expectation is you're coming right out of your education. If you're going to work, and why aren't you being successful at that? And it's not reasonable a lot of the time. There needs to be more time built into those programs. But as we said, you know, Veterans Affairs has more of an opportunity or gives more of an opportunity than a lot of the other providers as far as benefit goes.

>> Yeah, great point.

>> That's my two cents.

>> Great point. Thank you. All right, so we're going to talk about - I'm going to characterize this as like the three prongs of Gestalt therapy that I think apply to people with traumatic brain injury. And the first is this idea of fragmentation. So in general, you know, we live often in extremes or polarities, where we're in one category versus the other. You know, as I go through this, you can think about how this might apply to your own lives. I certainly can you know for myself as well. We may see ourselves as good or bad, good or evil, strengths versus weakness, totally masculine or totally feminine. You know, it's very easy for us to think in these polarities. And from a Gestalt therapist point of view, they would say that's not a healthy way of living, that we wat to move toward that sense of holism, that sense of balance. And that for a lot of these different things, we have dimensions of all these different characteristics that are part of who we are. So you know, in looking at this part of the theory, you know, it has struck me as whether this really seems like it applies well to people with traumatic brain injury.

Where we see that people with TBI can lose function and abilities that prior to the injury were part of their identity, very key to establishing their self-identity and for satisfying their life needs. And then if they lose that ability, there might be this kind of you know, like a feeling of being lost. Like how do I find a way to re-establish a different identity? Or I think it's too often we see people want to go back to exactly what that identity was prior to the injury. And maybe not realizing I have to kind of make some changes to look at something else. That's a very difficult thing for people to encounter. The onset of TBI can change how people associate with family members and friends. That you know, I mentioned before that one of my areas of research, or really the primary area of research is looking at family caregiving after traumatic brain injury. And we see that individuals can have to kind of redefine the way they relate to parents, to partners and spouses, to children, to siblings, to extended family. And instead of viewing the person with TBI in a pre-injury manner, the person with the TBI may be primarily viewed as a care recipient. And one of the issues here - and this is going to come up later. I'm going to talk about this later in terms of Gestalt-informed interventions.

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This kind of sense of dependency is reinforced by a reality that families may have to provide most of the care and support on a long-term basis because of the lack of a really good long-term care service for people with TBI in the United States. And it's really kind of a mixed bag. I mean, you might go to some states where there are more long-term supports, more programs, more funding. But other states have like absolutely nothing. And you know, if that's the case, you know, you're going to turn to your family. And because of that dynamic, you know, we get into this time of relationship where instead of you know, you being my spouse, I'm going to view you as the person I'm going to meet your care needs. And really, you know, it's going to change the nature of that relationship. And again, other types of relationships can also be kind of viewed that way. Issues of dependence for the person can be reinforced by the way the family members provide their caregiving roles. So this second bullet point is we sometimes have an issue where families can become overly involved. You know, they go way beyond like what they may need to really do. And sometimes that's a desire because they want the person to immediately get back to who they were previous to the injury. And so when we talk about like awareness, awareness is for the person with the brain injury to kind of know how their life has changed.

Awareness is also for the family members to really recognize, you know, your family member has really changed in some really significant ways and we have to kind of deal with that or recognize that. And there may be a difficulty for the family caregiver to come to that realization. We also see this last bullet point, family caregivers sometimes believe they now have the chance basically to reverse pre-injury problems that they didn't feel that they could address prior to the injury. So like substance abuse is one of the ones you might see for this fairly often. It could be some other kind of behavior, something that you know, the family was always frustrated by, but now they feel that because the person's in a more dependent relationship to the family, the family feels that now they have more power to intervene. So all these kind of dynamics you know, really change the way that the family is interacting with that individual, and again reinforce that fragmented perspective that I'm only going to identify with who I was prior to the injury. Or now I'm only going to view myself as a care recipient and not view myself as like a worker, as a spouse, a partner, as a parent. You know, those kind of identities may really be pushed to the side. Another like major prong in Gestalt therapy is we talk about unfinished business. And that's a term you probably have heard just in day to day discussion. You know, it's one of those kind of Gestalt terms that has permeated through the rest of society. So unfinished business is sort of like what we think it is.

It's this sense of unresolved problems and unmet needs. And persons not in touch with themselves who lack important coping skills can feel overwhelmed by the increasing amount of unfinished business in their lives. So again, I think if we think about this for our own lives, for a general population, this is something we can identify with. You know, we sometimes will have just things that, "Boy, I wish I would have done this. I would have tried a new career. I would have taken some kind of risk, or I should have asked somebody out." You know, all these things. We kind of always think, "Boy, I should have taken some action." Or it could be just some kind of lingering goal they have that has never really been met yet. In a way, like this paper I'm working on on this topic is sort of like a type of unfinished business. So it's always been my goal to articulate my views on the connection of Gestalt therapy to TBI, and I haven't been able to do that yet successfully in terms of a journal article. So that is my own form of unfinished business. And when we think about people with TBI, they could have unfulfilled goals as well as unresolved difficulties and problems that existed at the time of the injury.

So things like substance abuse, that's another one that comes to mind. That might have been a real problem for the person previous to the injury. And it still remains an issue and can even be worse now. But there might be like relationship issues that were never resolved, employment and career goals that were never resolved. But they are still kind of lingering around for that person. And the challenge might be, with the TBI, you know, depending on how the person's been affected with memory or with executive functioning or whatever the area might be, it might be more difficult in a sense to try to reach you know, that pre-injury goal, that pre-injury unfinished business that they had. So this quote from Miller - Miller is a psychologist, and in 1993 talked about his experience doing psychotherapy with persons with TBI. And I think his view here kind of articulates well this issue of unfinished business. And he said, "A relatively stable job and family routines, as well as their general cognitive compensatory skills may have allowed them to keep those problems under control. But when the brain injury undercuts their cognitive abilities, the underlying psychiatric disorders or behavior disturbances emerge in an unrestrained fashion." So those things that they could have kept under the surface in a way, they no longer have that ability to do this.

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That's another dimension of unfinished business. So in addition to you know, the pre-injury difficulties affecting post-injury outcomes, unfulfilled dreams and goals of the person can really be a challenge for the person, especially if it's even extra difficult now for that person to reach that pre-injury goal. And some of the ways you know we see this dimension of unfinished business, you know, it could be reinforced by those around us. By those who are in our families, and also those who are friends and people we work with. So this study, I provide an example. In Leeds, England, they looked at 33 people with TBI who were interviewed about their return to work experiences from 4-6 months post-injury. And the thing that they really talked about was that the people around them, the coworkers, the supervisors, basically expected that they should go right back to who they were in terms of their work performance prior to the TBI. And they didn't recognize that you know, these individuals are really different in some ways and we need to accommodate them. We need to kind of maybe you know, change some of the nature of their job duties to kind of match with their current abilities now. But they weren't getting that kind of support. And I just mentioned the study because it just all the more reinforces this type of unfinished business for the person. And then finally we get to lack of self-awareness, and in Gestalt therapy, this is really kind of the thing that you are trying to always focus on.

Because you know, Perls and other Gestalt therapists would say you know, the issue that humans run into is that they really don't have self-awareness about who they are, what their needs are, what holds them back. And that we often, too often kind of intellectualize our perceptions on life. And so if that comes out in a counselling session, a Gestalt therapist will try to really focus on body language and things the person is saying. Maybe they're not saying those things with their words, but they're saying it in different ways. So Gestalt therapists believe a lack of self-awareness is the central element causing fragmentation, unfinished business and other barriers that we can have in life. And we believe in this approach that we as humans lose touch with how to basically meet our needs due to lack of awareness of how to make contact with and psychologically contact our surrounding environments. So in this approach, we would try to look at the pronouns you use when you talk about things. And you know, sometimes people will talk about you know, why they are depressed. Like why is it that they haven't been able to reach their goals? You hear them kind of talking about - in a general sense that you may use terms like "they", or "They did this to me," or "Society did this to me." You know, things like that where you are talking about this from an external point of view. And in Gestalt therapy, you know, with the idea of responsibility, you have to realize that you are in control of your own life and you have to take responsibility for your own life.

So you're going to change the pronouns that you use in day to day discussion. It's going to be, you know, "I", "my", things where I'm taking control for the direction of my life. And you know, in Gestalt therapy, again the idea is that most people don't have that kind of awareness. We are often out of touch about what it is that we want to do with our lives. And you know, we get all these messages about what we should do. But kind of thinking back to the human encounter movement in the '60's, we think to, "What is it that I really want to do that gets beyond like all those messages I hear from everyone else?" So people with TBI can fail to internalize their new reality. They can deny the enormity of the emotional changes experienced. You might have issues because of lack of self-awareness, with disinhibition, interpersonal problems, overall competency in different domains of life. And the challenge with lack of self-awareness for people with TBI is that it could be like a type of psychological denial. Or it could be from you know the actual region in the brain that controls your sense of self-awareness, could be affected in some ways. And for people with TBI, we talk about existential distress, that you know, this question about, "Who am I now?" Where am I going to go in life? What is my new identity? That can really be a challenge.

And then underlying this distress is a struggle to try to understand what life now means, from potential concerns regarding mortality, isolation and meaninglessness. And you know, Gestalt therapy kind of fits in the domain of therapies like existential therapy or any kind of experiential therapy, where you are really trying to kind of get in touch with these larger kind of life questions. It's different than if you had a focus on like cognitive behavioral therapy or other forms of psychotherapy. You know, it's another reason why I think the Gestalt approach kind of fits well with people with TBI, because you know, you're often trying to address these larger kind of existential meaning of life types of questions as you try to adjust to living with this disability. And also the family members are also having those larger existential types of questions about, you know, what does it now mean to be in a relationship to somebody that has this disability? How do I now kind of redefine the nature of that relationship? So let's talk about interventions from a rehabilitation counselling point of view. And I think this idea of Gestalt therapists focusing attention on personal growth and development, in this approach - and this fits well into the rehab counselling point of view - we are going to focus on the goals and how these things are conceptualized by the client. And it's not going to be directed by me as the therapist or from the counselling.

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So this issue of self-actualization is all the more important, given Perls' belief that most humans fail to develop to their fullest potential. So when you see like 5-15% on this next bullet point, I think he just kind of came up with that. I mean, I don't think he did any kind of like national survey or anything like that. But it's just in his clinical experience, he just kind of realized that most of us do not really actualize to what it is we really could do. And you know, I think it speaks to the power and to the popular nature of this theory. From a counselling point of view, I talked about this before, we're going to talk about words like "I" and "me". I'm going to direct the client to use those rather than using "it", "you", "they" when talking about what is it that they want in life, what is it that they need in life. In regard to the present day orientation, a Gestalt therapist would encourage clients to discuss past, current and anticipated events in terms of how clients right now experience those events. And because you know, we can often intellectualize our perceptions, you're going to focus on nonverbal body language. So let's say like, you know, if a client came in and they were talking about like a relationship with their mother. And as they talk about it, they say like, "I love my mother. We have a great relationship," but you notice the client is getting red in the face or the client clenches her fists. Or there's a lot of - you know, the client may be tapping their foot rapidly. And from a Gestalt point of view, you would point that out to the client. You know, and you would help the client become aware that as you were talking about your mother, you know, you might say, "Did you notice you started clenching your fists?"

And the idea is to increase self-awareness, because we often are out of touch with how we feel about those things. So you know, just a simple kind of intervention like that where you're pointing out nonverbal behavior that the client's not aware of, could be very illuminating to the client about how they really feel about something. So you're going to do a lot of this in this approach. And then to address Gestalt-related challenges faced by people with TBI and their family. We have a variety of experimental and experiential counselling approaches, where you're trying to build self-awareness. We direct orientation to the present, we address fragmentation, we facilitate a holistic perspective. And one of the ways you could do that is something called the game of unfinished business. So you try to talk about those things that are incomplete in your life. And you talk about them within the context of the counselling session and then you try to hopefully then take that into a real-life context. So in the area of TBI, you might discuss how pre-injury career aspirations can be achieved and then post-injury residual capacities. And here, you know, maybe you would talk about different accommodations that could be used. Maybe talking about a different career, if that pre-injury career is not really possible anymore. You may be talking about different dimensions of that career that the person could still do, but maybe they couldn't do exactly what they did before. But you're trying to really kind of you know, move that discussion forward. And one of the ways we could address unfinished business is called the game of dialogue.

Where you can focus on the roles and responsibilities for future planning, future caregiving planning, and the idea here basically is you facilitate a discussion with different dimensions of the self. So for the person with the TBI, you might have them have the dimension of themselves for what they can't do, or disability-related kinds of things versus what they still have an ability to do. And those two dimensions would talk to each other. You might facilitate a discussion of the independent versus the dependent elements of the self. Living with versus without a disability, coping versus giving up. And in a counselling session, you know, basically you're going to kind of prompt that person to have that discussion. You have to help them kind of get over the fact that this is somewhat unusual. And then you help guide that discussion back and forth. You might suggest like, "You know, what is it you think your other part of yourself would say here?" And then you know, you just really kind of keep prompting that discussion back and forth where it becomes more of a natural thing for that person to do that in the counselling session. So for the person with a TBI, you could engage the client in a discussion about the part of self that requires personal care assistance, with the part of the self that is able to kind of like function. And one of the benefits of this - this gets into fragmentation - is that the person realizes that I'm not 100% defined by the fact that I receive care assistance.

You know, yes, in some ways I do need help maybe getting dressed or with getting you know, other daily needs met. But there's a lot of things that I do independently, and I have to realize that I'm not just 100% a care recipient. For family members, dialectic focus on the part of self that's committed to caregiving, versus the part of self which has needs for relaxation and recreation. So family caregivers sometimes overly focus attention on the injured family member and don't really look at their own needs and their own need for life satisfaction. Because you know, the caregiver might have a perspective of, "I'm going to devote 100% of my life to the care of my family member with TBI." And realize that's not really a healthy way to live. You have you know, also your own needs as a human being. You know, you have to pay attention to that. And long-term, you know, if you have this 100% focus on the person, it's not a healthy relationship with that person with a TBI. And for yourself, you're going to become depressed, you're going to become burned out. You might have a lot of physical problems from that. So you know, you're going to talk about them in a counselling session. And then hopefully by the nature of having those discussions, that will translate into you know, taking that out of the counselling session and the person actually changing like how they relate to that person with the TBI.

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Coping with loss. This approach in Gestalt therapy could be helpful with resolving losses that the person perceives. And you openly talk about it. You know, you help the person say things like what I now can't do, what I'm frustrated by. Because I mentioned before that the people in that person's life may not really be supportive of recognizing that, and they may just want that person to always go back to who they were previous to the injury. So in your counselling session, you are going to really give them a forum to talk about that in a way maybe they haven't before. You could focus on losses related to career, relationships, physical function, cognitive skills, self-identity. And it's not that you just want the person to feel just a perpetual sense of loss, but it's that you have to recognize that person has to work through that before they can productively kind of go forward with what they want to do with their lives. For caregivers, you could address the loss of the person you knew as a spouse or partner, child, parent, sibling.

And again, be able to kind of productively move forward in that relationship. We have to in this approach with the individual with TBI determine, you know, could they really engage in this process? Because Gestalt therapy techniques with a lot of other you know, psychotherapy techniques from other disciplines of psychotherapy, you have to have a certain ability to think introspectively. And you have to be able to retain information from session to session. So Ruff, who is a psychologist, has written a lot about people with TBI and psychotherapy, said that those with severe memory deficits may not be really a good candidate for psychotherapy in general. You know, especially if they have to use declarative memory where they have to recall things that were talked about in previous sessions. So other approaches like behavioral therapy or physical therapy might be more effective interventions in those cases. Framing in this approach - I think one of the things I'm really going to try to get across in my paper

>> Hey Chuck?

>> Yeah?

>> I'm sorry. For that, as I was thinking about it, I think this really would be good even if somebody has a deficit with memory. Because I was thinking about the acquired brain injury program, they teach you to write things down. And that has been one of the most successful things to help people recall things and move forward in their lives.

>> Yeah.

>> I don't know, so I was just thinking that this might be a good addition too. And have them write it down as they go.

>> You know, that's a great idea. I haven't put that in the paper, and I haven't really thought about it that way. But that's something I'm going to include. I think that's a great idea.

>> Okay.

>> Yeah.

>> I also wanted to say something. You know, I was thinking about mental health, the wrap things that we do, where we have people when they're at risk before they have a problem or anticipate something happening again, particularly in addiction or sliding by not taking their meds for mental health. But the Gestalt also sort of fits into that game as well, that it actually is worthwhile, because it really does - it keeps you remembering. Like you said, writing it down as far as the wrap and having things set out. I don't know, somehow that may fit with this too. I don't know.

>> No, that's great.

>> I agree.

>> That's awesome.

>> Yeah. Yeah.

>> Yeah. Yeah, well this brown bag is great. You guys are giving me some new ideas. Yeah, that's awesome. I hadn't thought about a wrap plan also, but I think there's some connection to this approach.

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>> Yeah.

>> I think one thing to think about - and I've written a book chapter on Gestalt therapy with my faculty advisor at the University of Wisconsin in my PhD program. We talked a bit about this, but I'm going to really try to stress this in the article, that you know, it's one thing to call yourself - like I'm a Gestalt therapist. Now I wouldn't do that for myself. And I think most of the people that are going to read the article or go to the poster at the conference, I wouldn't want them to think that. It's more - you know, if you actually are a true Gestalt therapist, you have to go through many years of training you know specifically in Gestalt therapy. You have to have you know, specific supervision, clinical experience. You have to really kind of get really deep into this approach. So what I'm talking about is, there's a distinction between practicing as a traditional Gestalt therapist versus using Gestalt-informed philosophy and techniques. And I think there's a lot of counsellors, whether we're in rehabilitation counselling or other forms of counselling, who use elements of Gestalt therapy. Like the empty chair technique, which is something where you would have an empty chair in front of the person and you would invite them to maybe have a discussion with a family member. Or you know, maybe even like people who have been deceased and it's a way to kind of close out some of their feelings towards that person, like some of the unfinished business maybe they still have regarding that relationship.

A lot of counsellors and therapists will use techniques like that. And that's kind of where I'm going with this. And I think one of the things I'm really trying to get across is that the philosophy of Gestalt therapy, you know, the focus on holism, self-responsibility, kind of looking at you know, fragmentation, unfinished business - all those kinds of things are things we could take I think that are useful. And you know, it doesn't require that we become like an advanced, experienced Gestalt therapist. You know, one other thing I want to mention on that, I think one reason maybe while Gestalt therapy has not gotten much attention in rehabilitation counselling is that a lot of our field is really based on evidence-base approaches and having things where you can empirically demonstrate the benefit of a certain kind of intervention. So like if you use solution-focused therapy or if you use like cognitive behavioral approaches especially, there's a lot of empirical data to support that. And let's say if you are a licensed you know, clinical professional counsellor or licensed psychologist, whatever you might be, you know, if you're billing for your services through an insurance company, they're more likely to pay for that - they're more likely to pay for an evidence-based approach. In Gestalt therapy, there really hasn't been a lot of research done on this area.

There is some, but traditionally Gestalt therapists have not really believed in research because they would say that this encounter that you have with a client, it's a very individual type of thing. It's very subjective from the client's point of view. It's a very unique kind of interpsychic type of process that's happening. And how can we really kind of empirically like study that or research that? So I think philosophically, the Gestalt therapists have not done a lot of research. And that probably is why you know, it's not as well known, especially in rehab counselling and other types of counselling approaches. So I do think it fits in rehab psychology, this idea of the I/thou relationship which is egalitarian with the client. You're with the client. You know, it's not like, "I am going to direct you as the client," you know, if I am the professional. It's, "We're going to have an equal relationship." It's a horizontal relationship. And that kind of approach, studies that have looked at the effectiveness of psychotherapy, that this type of approach, this I/thou relationship that we have in Gestalt therapy, that connects well to what research has said that really helps clients with client motivation, ability to work in partnership with a counsellor, to have an effective relationship with a counsellor. Those are all things that are really consistent within this Gestalt approach.

And when we talk about like the use of techniques versus having more of like a philosophy you know that's advanced within Gestalt therapy, Perls talked about not having this reliance on techniques. And he said, "One of the objections I have against anyone calling themselves a Gestalt therapist is that he uses techniques. A technique is a gimmick." You know, I think it's more important about the philosophy of Gestalt therapy than any like one technique you would use. All right, and then the thing I want to finish with is just talking about - this approach I think has a lot of value in looking contextually at the area of TBI. And this author, Coen in 1978, he wrote in - this is in the Journal of Applied Rehabilitation Counselling. He said that Gestalt therapy could be used to change the service system for people. That if we had a more holistic approach to services, one that really values our clients, really respects them, you know, those things that are consistent with the Gestalt approach to counselling, that if we enhance client choice of services, increase accessibility of rehabilitation professionals to the clients, reduce the time in which the individuals need to go through the rehabilitation process. He even talked about things like if your client comes in, you should offer them coffee and donuts and just make them feel really comfortable and honored and respected. That has a lot of weight, a lot of connection to this approach.

And I think in TBI services, that could be extended to looking at our holistic sense of rehabilitation. You know, most of the rehabilitation we provide to this population is in acute care, like in the hospital setting. But long-term community-based services - and I'm sure everyone on the call will be familiar with this - there's just not a lot of good supports you know. And so from a holistic service point of view, we don't really have that. I think another element of this is that we have many professionals working in the field who don't really have a lot of training and knowledge about traumatic brain injury. You know, especially when you get out of the acute care center and you know, you just kind of go to general medical professionals, different healthcare professionals. Most of them are not going to have much background in the area of TBI.

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>> Can I just interject? A lot of the schools that veterans or service members that have diagnoses of a TBI, when they go to school, you know, a post-secondary, they don't get very much support. And they themselves don't realize how it's falling in, that the Gestalt therapy really should be something that's included as part of the understanding when they're providing education to persons that have the diagnosis.

>> That's an excellent point. Yeah. Yeah. So you know, in terms of the future, the things that I'm going to talk about in the recommendations part of this, is I think we can use this idea of a Gestalt connection to TBI to create different types of instruments to look at psychosocial wellbeing and adjustment. You know, especially instruments that are going to focus on fragmentation, lack of self-awareness and unfinished business. I think you know, we can look at more research that looks at different ways of doing Gestalt therapy. How well does it work with people with TBI? I think in terms of how we teach Gestalt therapy, you know, more ways to connect the TBI to the use of Gestalt therapy. And maybe in general, you know, as we look at maybe counselling theories classes or medical aspects of disabilities classes, things like that to connect counselling approaches to different disability populations as a general way of teaching. And then as we talked about, this idea of creating greater care continuity in the TBI system to create like a holistic Gestalt-informed way of providing support to this population. I'll talk about some different ideas with that. So we're at 1:00 but I'm very happy to stay on the call if anybody has any questions or anything anybody wants to kind of throw in as additional ideas. So like you know, the floor is yours right now.

>> I think anybody that's in job search, whether they have a diagnosis or not, probably could use some information and self-reflection with the help of the counsellor. You know, whether it's myself or anyone else. To be thinking about the I/thou and be able to own it so that when they're able to go in and have a conversation to basically sell themselves to get a job, they'll be able to have a better notion of how to talk about themselves. So that when people come in and would talk to me about their job search, whenever I ask them questions, they almost immediately talk in third-person rather than I/me, I own it.

>> Right.

>> So I think it just would be helpful in general for that portion of our education maybe to be reinforced, that that's what we need to be doing with persons, whatever portion of their benefit that they're using. But particularly, possibly in employment.

>> Yeah. Great point. All right. Anyone else?

>> I really liked what you said about just when you bring them into your office to you know, give them coffee. And honestly, I think it just speaks to treating them as an equal and like you would somebody in business. I mean, everybody's had a life prior to their brain injury. And a lot of times after a brain injury, you know, you feel less than. And so to make sure that somebody realizes that you see them on the same level, I think that helps give a sense of empowerment. And so then providing additional therapy and bringing them to self-awareness is a very empowering tool which will then help them you know, move forward in their life.

>> Yeah. Yeah. Great point. Absolutely. All right.

>> Dr. Dechanef?

>> Yes?

>> I didn't know if you guys could hear me or not. This is Greg. How are you doing?

>> Hey, Greg, how you doing?

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>> Good, thank you. I just was thinking about the time constraints in the recovery process or when people with TBI are being rehabilitated. And these educational programs or training programs during the rehabilitation. I've kind of found with friends of mine that have TBI and my own disability that getting help initially is really frustrating to have to take help. But you very quickly get used to taking help. And when families are over-caring, I think it slows down the rehabilitation process. So how could you use Gestalt therapy with the families to help lessen this?

>> I think there's a lot of applications. You know, this idea kind of being just overinvolved. You know, the idea of creating great self-awareness. You know, that's really going to be like one of the central things you try to do in this approach. It's really making them aware of you know, the fact that they may be really viewing this person kind of in a fragmented way, another Gestalt term. You know, they just only view them as somebody that they take care of. And really kind of getting them to step back a bit and say, "You know, this is also your husband. You know, what about that part of your relationship?" You know, are you able to kind of view that person in that way? And as Tracy was saying, when somebody comes into your office, this is somebody you know who had a whole life and everything you know prior to the brain injury and they continue to have a life after the brain injury. And I think you're reminding the family member that they have to kind of view things in that way, not only as a care recipient. And then part of this awareness is just making them aware of their own needs, and that if you kind of live in this very unidimensional, fragmented way of only providing care and that's your only focus on life, that's going to have a real impact on them and their own wellbeing.

And you know, from a balance, holistic point of view, you have to kind of step back and kind of reexamine that. But this gets into the goals or the things I want to talk about in terms of the kinds of things we need to do to increase the service system, or better improve the service system for people with TBI. Because you know, if you're an overly-involved family caregiver, it may be a reality that there's really nothing else in your area. Maybe you have no other extended family to help out. Maybe there are no programs in your area, and you can kind of understand why somebody would become just overly involved. Because you know, they may not have a lot of help to turn to. So if you have a service system in which you have you know, respite available, you've got different programs available, you've got things where your focus doesn't have to just be caregiving, you're facilitating a way for that person to have a more holistic way of life. And it's not just focused on like them as an individual client, you know, the family caregiver at that point. But you're creating like the context in which they actually could be more holistic and healthy in how they approach life. You know, so there are some caregivers where you can understand why they're overly involved, because there may not be a lot of other options out there.

>> And would you bring in the family with the person? Or would you tend to do it separately? Or would you do it all in one?

>> I think all of that is possible. You know, it kind of depends on the situation. I think some discussion might be easier to have individually with the caregiver. But you know, probably some would be also with both people in the room at the same time. And I think I just would take it on a case by case basis, just what seems to fit better at that point. Yeah.

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>> I wanted to say that I think that particularly in the geriatric population, there really is no real support system for the caregiver, whether it's you know, an acquired brain injury or dementia or whatever is coming on, or a TBI, whatever's going on with that. I think that the caregivers themselves need to be able to have that kind of empty chair therapy to be able to do a better job or to at least be able to compartmentalize for themselves, to be able to provide the care but not have it be that it's so overwhelming. I live with that because I have a spouse who was diagnosed with Alzheimer's, so I understand that.

>> Yeah.

>> Yeah.

>> Yeah, makes a lot of sense for you personally. Yeah.

>> That's so right on. Just speaking to the last eight years, my mom, sister and I took care of my grandma who had rapid onset dementia. And my mom lives up in northern Michigan, the middle of nowhere, and there weren't really any supports. And it was a constant fight and you know, I live back here in California. But when I was there, you know, I saw her constantly having to fight to have you know, to get support for people to come in for a couple hours a day so my mom could finally get rest. So I think having something like that would just, you know, would have been tremendous in helping my mom too.

>> Yeah. Yeah. You know, there's a lot of people out there who can connect in some way personally to these topics we're talking about. You know, caregiving is a very common thing for a lot of our families. So you know, I appreciate you guys sharing your experiences. All right. Well, for those who need CRC credit, what I would recommend you do is contact Crag Winston. Craig is the academic coordinator for the program. Just send Craig an email and just say, "You know, I was on the brown bag today. I need the CRC unit for that." And I'll have Craig email you the evaluation form. You then fill it out and you send it back to Craig and he'll process the CRC unit. But other than that, I really appreciate you guys spending time with me on a Friday afternoon. And it was very helpful for myself for this project. So that's it. All right.

>> Thank you, Chuck.

>> Thank you.

>> Thank you, Dr. Dechenef.

>> Sure.

>> Thank you.

>> Thank you.

>> Thank you.

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