Gestalt Therapy and Rational Emotive Behavioral Therapy: Integrating Existential and Cognitive Psychotherapies by Nina Bingham

Abstract:

This article is a theoretical analysis of Gestalt Therapy and Rational Emotive Behavioral Therapy (REBT). It is a glimpse into the origin, philosophy, interventions, limitations and ethical considerations of the two psychotherapeutic theories. I will also comment briefly on why Gestalt and REBT appeals to me, given the professional counseling environment I work in.

    Of all psychotherapeutic theories I have studied, two appeal to me above the rest: Gestalt Therapy, and Rational Emotive Behavioral Therapy (REBT). Gestalt Therapy is Existential and phenomenological in philosophy, while REBT is considered a Cognitive Therapy. I find that while Gestalt Therapy investigates the broader meaning and purpose of the client’s life and analyzes how the client maintains or loses contact with the therapist, REBT is specifically oriented to examine the automatic thought process, and to identify and reframe cognitive distortions. Employed together, these two therapies can work complimentarily, as Gestalt is a method of promoting self-actualization, while REBT is a practical means of changing self-defeating thought patterns. Next, I will discuss the basic assumptions of Gestalt Therapy, offer examples of commonly used Gestalt techniques which I employ regularly in private practice, and explain how they agree with my counseling philosophy and values.

   
     An adept Gestaltist is a like a client mirror; the client should be able to look and see herself more clearly. During the course of therapy, a Gestalt Therapist will test the client’s contact boundary, and discuss the subject of polarities, asking the client to consider: are his boundaries rigid or loose? Is he isolated or confluent? Does the client polarize issues by catastrophizing, or its opposite: avoiding, denying or ignoring problems? Gestaltists will regularly utilize experiments or Gestalt techniques during therapy, the most renown of these being the “Empty Chair Technique,” where two polarized opinions of the clients are each role played by the client in succession. An example fresh in my mind is a counseling session this week, in which a new divorcee whose husband left her for another woman had never expressed to her ex-husband how his sudden departure and new relationship had left her feeling. She was not able to verbalize even to me how this had impacted her, until I suggested she imagine her ex-husband sitting in the empty chair across from her. This direction gave her focus and courage, and through streaming tears, she was finally able to verbalize how confused, lost, alone, helpless and “in the way” he had made her feel. Due to her ex-husband’s marginalization of her feelings (and his actions), she was able to see the correlation between her current feelings of not being important to others in her life. Gestaltists will also carefully monitor the client for indirect body language which is unconscious expressions of emotion. They may direct the client to exaggerate or repeat body language to give the symbolic gesture a “voice.” During the above interview, I pointed out that the client repeatedly closed her sweater tightly around her neck when discussing how vulnerable her ex-husband’s choices had left her feeling. She admitted, “And I’ve closed up to everybody else in the process.”

    
    From a cultural perspective, Gestalt Therapy may not be the therapy of choice for individuals from collectivist societies who are more private and reflective in nature. Gestalt encourages free outward expression of thoughts and feelings; the client is encouraged to share fears, anger and insecurities. Members of collectivist cultures which might not be accustomed to expressing anger or fear openly could be misjudged by a Gestalt therapist as withholding or resistive, and thus develop a bias against working with individuals from collectivist cultures, unless the counselor is culturally sensitive. If the counselor understands the client’s perspective, she can adapt the therapeutic approach to the client, rather than demanding the client adapt to the approach.

   
    I believe my personality style and philosophy aligns most closely with Gestalt Therapy as I am by life philosophy an Existentialist, and believe in the Phenomenological approach to therapy, so Gestalt is an easy fit within that philosophical framework. I enjoy the Gestalt approach because it is therapist-directed, meaning that the therapist is free to introduce various experiments and techniques during the session, if it will enhance the dialogue. Yet, it is grounded in a dialogical approach, wherein the Gestalt therapist invites the client into conversation for the purpose of establishing contact with the client: to see where the client’s contact boundaries are, and understand more completely when the client retreats, and what she responds to. To practice Gestalt effectively, the therapist must be confident and not tentative in her use of techniques and interventions, yet simultaneously use her therapeutic knowledge, skill and intuition in knowing when to introduce interventions into the dialogue, and when to refrain. In Gestalt Therapy, highly therapist-directed, the therapist acts as the "producer" of a stage show, while the actor is like the client. "Acting out conflicts in the present through exaggeration and role reversals...the Gestalt approach is confrontational" (Okun, Kantrowitz, p. 132). By experiments, techniques, and relational dialogics, the therapist works to raise the level of awareness of the ways in which the client is preventing therapeutic contact, feeling of emotions, free expression, and even free bodily movement. "Thus, Gestalt Therapy is experiential (or emphasizes doing and acting out, not just talking), existential (it helps people to make independent choices and be responsible), and experimental (it encourages trying out new expressions of feelings)" (Okun, Kantrowitz, p. 131). Gestalt therapists stay firmly grounded in the present, so when the client "jumps outside" of the therapeutic encounter to reminisce or to make catastrophic the future, the therapist considers this an avoidance of the present, or an escape mechanism. If the client is not aware of what he is avoiding, the therapist will bring it to his attention. By assisting the client in coming into conscious contact with his resistances or with what he avoids, the therapist hopes the client will free himself of various defensive coping mechanisms he has adopted, such as: retroflection, projection, introjection, denial, etc. Gestalt Therapists read both the verbal and non-verbal communications of the client. The second goal of Gestalt (next to self-awareness) is that of maturity. Dr. Fritz Perls said, "Maturity is when the client is able to transform from environmental support to self-support" (Perls, Gestalt Therapy Verbatim, p. 33). Rather than manipulate others to indirectly get what she wants, the successful client learns to make a direct request for what she wants, and to support herself rather than depending upon her environment for support. Also, any unfinished business from the past will cause a retrospective character, so Gestalt Therapists encourage clients to express regrets or resentments from the past, in an effort to "put to rest" old hurts which may be interfering with the clients present functioning. For me, Gestalt Therapy is the right blend of creativity and freedom of methodology. It also affords the opportunity of coaching clients in self-actualization due to its existential focus.

    
    Next I will describe the basic assumptions of Rational Emotive Behavioral Therapy (REBT), and explain why I employ it as an adjunct to Gestalt Therapy. I see great value in Cognitive Therapy for anxiety and depressive disorders. I believe REBT can enable clients who struggle with negative, or fear thoughts, a more structured way to become aware of, question and replace thought patterns that aren't serving them. REBT is a highly structured "thought program" which challenges the client to dispute automatic thoughts, and to replace them with thoughts based in reality. REBT is a strictly cognitive therapy, which means its application is limited to cognitive problems such as occur in anxiety disorders such as Obsessive-Compulsive Disorder (OCD). However, that same narrowness of application makes it powerful as applied to disorders of thought, in that it teaches a systemized method of thought-disputation, reframing of cognitive distortions, and substitution with positive, realistic thought. Without a cognitive-specific intervention like REBT, clients struggling in the grip of anxiety disorders may not find their way out of the maze of distorted thought without such a specific and methodological therapy. Although Gestalt is a fantastic application for the larger issues of existence such as life purpose, meaning and self-actualization, REBT is a relatively simple method to teach the client how to correct cognitive errors. Recently I worked with a client who has been diagnosed with OCD, and I taught him the ABC’s of REBT. Because of the acronyms, he could easily remember the method’s steps, and was reciting it to me before the end of our first appointment. Due to his OCD and Clinical Depression symptoms, this client’s self-esteem had “taken a beating.” There was such relief and excitement in his face when he grasped that there is a cognitive “system,” a “road-map” that he could follow which could help him out of the tangle of his negative thoughts. Used in combination, these two therapies of choice can meet the existential and cognitive needs of clients.

    
    I do not see any cultural barriers in using REBT, except that the practitioner must be aware of the sociological context of the client’s thinking process. For example, in the Latino culture it would not be uncommon for a Latina to struggle with being a highly educated, high-salaried woman if she were seeking a Latino partner. In traditional Latino culture, men are honored as the “bread winners,” and take pride in providing for their families. For a career-oriented woman who is Latina, this could spell difficulties where dating Latinos are concerned. Keeping the client’s cultural specifics clearly in mind while working with their cognitive processes will help to avoid therapist-client misunderstanding.

   
     In the time I have practiced I have come to see one thing very clearly, and it is that the most dynamic force in therapy is not a set of techniques, a theory or even a philosophy of practice. It is, as Buber states: “In the beginning is relation” (Buber, 1958, p. 18). “The I-Thou experience is one of being fully present as one can to another with little self-centered purpose or goal in mind. It is an experience of appreciating the “otherness,” the uniqueness, and the wholeness of another, while at the same time this is reciprocated by the other person. It is a mutual experience” (Hycner, Jacobs, 1995, p. 8). However, I’ve also found that a set of time-tested techniques is helpful in the process of therapy, and having a clear philosophy of practice allows the therapist to structure the session cohesively. Relational Gestalt is a fascinating blend of dialogics and technique, and is well suited to my extroverted personality. I may not have the daring flair of Dr. Perls, but I do enjoy seeing what comes of a spontaneously created experiment, and the results of a technique like the “Empty Chair.” My personality is direct enough to confidently lead clients through an intervention, even if I may not know exactly what the outcome will be. Sometimes I’m unsure about where we will land…but I am working into being comfortable with the uncertainty which is Relational Gestalt Therapy. I’m no longer bound to a set of techniques, because I’m making it a priority to build a relationship with the client before me. I’m learning that the most powerful ingredient in the therapeutic relationship is what we create together, the therapeutic bond. The German world Gestalt is translated to mean, “An integrated whole.” With the emphasis being placed on relationship rather than techniques, I feel Relational Gestalt Therapy is becoming more of an integrated whole than ever before.

    
    Being that top values of mine include autonomy and altruism, flexibility, spontaneity and adventure, being a mental healthcare entrepreneur in private practice appeals to me the most. In order to have a consistently full patient schedule, practicality demands that I become licensed to work within the managed healthcare system, and attract clients who have health insurance. Although accepting health insurance clients will be a welcome source of consistent business, I also realize I will have to limit and tailor my treatment plans and methodology to fit within the Cognitive-Behavioral treatment models which managed care utilizes. I suspect that on the one hand although I will be earning a wage I can be satisfied with, I will trade away a certain amount of creativity and decision-making prowess. While I believe I will adjust to the increased paperwork demands and structure of the managed care system, I hope I don’t lose my sense of curiosity and playfulness which Gestalt Therapy has afforded me. It is my nature to be a human relations scientist; to analyze and report on the difficulties, oddities, sorrows and triumphs of the human condition. I don’t imagine any system of business will be able to so thoroughly bore me that I would ever abandon this profession, which by now has become more like a calling.       

                                                   

Refernces:

Okun, B.F., Kantrowitz, R.E. (2008). Effective Helping: Interviewing and Counseling Techniques. Seventh Edition. BROOKS/COLE CENGAGE Learning.

Perls, Frederick, S. (1947). Ego, Hunger and Aggression: The Beginning of Gestalt Therapy. Vintage Books, a Division of Random House, New York.

Perls, Frederick, S., Hefferline, Ralph., Goodman, Paul. (1951). Gestalt Therapy: Excitement and Growth in the Human Personality. The Gestalt Journal Press, Inc. 

Perls, Frederick, S. (1969). Gestalt Therapy Verbatim. Real People Press, Lafayette, California.

Hycner, Richard, Lynne, Jacobs. (1995). The Healing Relationship in Gestalt Therapy: A Dialogic/Self Psychology Approach. Gestalt Journal Press, Inc., Gouldsboro, ME.

Buber, Martin. (1958). I and thou. New York: Charles Scribner and Sons.