Abstract
This family therapy model
will examine an experiential, existential and humanistic approach to
psychotherapy; namely, Gestalt Therapy. Topics to be explored include: the philosophy
of both traditional Gestalt Therapy, Relational Gestalt Therapy and Gestalt
Family Therapy. Other topics included are: a contrast of Family-Centered
Therapy (Rogerian) with Gestalt Family Therapy, strength based vs. deficit
based approach, the theory of change and role of the psychotherapist, view of
psychological pathology and health, and cultural considerations. Assessment,
diagnosis and treatment in Gestalt Therapy will be explained. Assessment,
diagnosis and a treatment plan will be applied to a couple who have presented
for couple’s counseling. It will describe the couple’s characteristics,
personalities, individual diagnosis, and dynamics of the relationship.
Gestalt Therapy Philosophy
The
therapeutic concepts I present here are not new; they are a snapshot of Gestalt
Therapy. Gestalt Therapy is an experiential, existential and humanistic psychotherapy
which has lost popularity in counseling education. However, I find it still has
great merit, for it can be amended to suit the individual client's temperament,
as well as to the temperament of the therapist. I believe Gestalt “done right”
is art. Today, however, Gestalt Therapy has been reduced to techniques; a
development which the originator of this therapy, Dr. Fritz Perls, would have found
distasteful. Perls’ methodology was to work to restore the equilibrium of the
organism, not in part, but the whole. He practiced experiential therapy, a
highly interactive process and collaborative exchange between clinician and
client, at times evoking emotional upheaval in the client. However, in the aftermath of exploration and catharsis of
suppressed feelings and memories, a restoration of the true, unhindered personality
occurred in Perl's' patients. Gestalt at its finest is an excavation of the
soul; unearthing emotions and memories buried in the forgotten field of the
unconscious. It is a retrieval method of exploring what has been carefully
hidden away, to reframe old thought patterns, and then to “reset the broken
bone.” This is the Gestalt Therapy that Perls envisioned; the integration of
the disowned parts of the personality. An adept Gestalt therapist will use the
therapeutic tools Perls left behind to excavate the human psyche, but must
adapt them to their own personality, presentation and delivery style. For
today's psychotherapist, an update of the original heavy-handed Gestalt
approach is in order.
Relational Gestalt Therapy
I believe Gestalt Therapy has theoretical merit and can
be revised for today's clients. What has been termed, “Relational Gestalt Therapy,”
(Jacobs, & Hycner, 2008) is a revision of traditional Gestalt Therapy which
places more of an emphasis on developing an egalitarian relationship with the
client. Contemporary Relational Gestalt Therapy is dialogical and
inter-relating, and more relationally-focused than the technique-oriented
Gestalt Therapy of the past. Co-founder of Gestalt Therapy, Dr. Laura Perls said
about the development of Relational Gestalt, “With the gift of hindsight,
Martin Buber’s philosophy of I-Thou seems the perfect antidote to the
narcissistic flavor that infused Perls, Hoffman, and Goodman’s portrayal of the
organism/environment field paradigm” (Hycner, & Jacobs, 1995,
Introduction). Based upon philosopher Martin Buber’s emphasis on the “I-Thou”
relationship (Buber, M., 1958), a new generation of Gestalt Therapists are
practicing warmly and sensitively, seeing dialogics as the ground upon which to
find a cure rather than techniques.
Gestalt Family Therapy vs. Family-Centered Therapy
While a family is a system comprised of
individuals, it is the survival of the family unit which may be threatened when
a family presents in therapy. Marriage and family therapy has traditionally attempted
to emphasize the sum (family unit) over its parts (family members). For
example, in Family-Centered Therapy, also known as Rogerian Family Therapy
(Rogers, 1951), the family system’s needs are emphasized. In contrast, Gestalt
Family Therapy seems to be of the individualistic persuasion. The logic seems
to be that if the individual is happy, as a result, the group will be happier.
Gestalt Therapy emphasizes the individual’s needs within the family context.
Gestalt Family Therapy (GFT) is a structural therapy in that, “The therapist
works primarily with the nuclear family, and therapy is aimed toward altering
the structure of the interactions between various family members” (Hazelrigg,
Cooper and Borduin, 1987). The philosophy of GFT is to develop each family
member’s awareness of interactional patterns, and encourages the family members
to be increasingly responsible for their own feelings, behavior, and needs. The
role of the therapist in GFT is to provide therapeutic techniques and
experiments which can stimulate positive change. “The family is an intimate
system in which the behaviors of family members are connected in a
complimentary way. Connections among members may be functional or
dysfunctional, depending on the awareness, needs, and behaviors generated
through such family networks” (Lawe and Smith, 1986). Goals of GFT are to
enable family members to “represent themselves genuinely, and to accept and
respect that they are separate and different from each other” (Lawe and Smith,
1986). Other goals include re-establishing contact between family members and
expression of feelings which were suppressed. In Gestalt Therapy, the therapist
works to improve individual family member’s self-awareness, and heighten the
awareness of the impact the client is having on the family system. In each
family member’s quest to meet his needs, the therapist uses techniques and
experiments to assist the members in defining their needs, expressing their
needs, and improving intimate contact with other family members (Lawe and
Smith, 1986). “A general goal for the therapist is to assist members in
removing barriers they use to avoid being intimate” (Zinker, 1981). As is
typical of Gestalt Therapy, GFT explores the following themes: 1) What
feelings, perceptions and awareness do members have towards the family, each
other, and themselves? 2) How do members deny taking responsibility and
manipulate one another to get what they want? 3) What do members expect from
each other? (d) What unresolved conflicts do members have with each other?
Techniques which the Gestalt Family Therapist may use include: having all
members of the family interact, requesting the members speak directly to one
another, to intervene only when the interaction is at an impasse, identifying
the dysfunctional relational patterns, role playing and the Empty Chair
technique. How does the family know when therapy has been successful? “The
resolution of conflict, anxiety and guilt may be seen as a basic goal of Gestalt
Therapy. The more family members can clearly articulate their wants, needs, and
expectations, as well as to understand, accept and support each other, the more
the family is in harmony and balance…positive outcomes of therapy witness the
increase in the family member’s ability to be responsive to the needs of its
members. Members profit from therapy when they can forgive each other and let
go of the past in order to accept and love each other as they are, and not as
they think they “should be” (Lawe and Smith, 1986). Therapy is also seen as
successful when members take responsibility for their role in family
dysfunction, when conflict is resolved and resentments dissolved, and when each
member of the family feels safe to “be themselves” rather than trying to live
up to expectations of one another.
It is easier to see how the two models of therapy contrast rather than compare; differences in the two modalities are stark. The Rogerian humanist model is client-paced and relatively unstructured in format. It allows a wide berth for exploration of family member’s feelings and concerns. Conversely, Gestalt is more structured and therapist-driven. Gestalt employs techniques and experiments which are introduced throughout crucial points in therapy, especially in moments when the member has reached an impasse. An apt metaphor might be to describe Family-Centered Therapy as more democratic, in that it takes into account the family as a whole, seeking to teach more equality and tolerance among family members. In contrast, GFT allows each member freedom of expression, need fulfillment and individualism. Although both therapies are ultimately focused on the well-being of the family unit, Family-Centered Therapy encourages family members to conceptualize themselves as a collectivist unit, while Gestalt Family Therapy conceptualizes the individuals as being a part of a family, while maintaining separateness. In comparing these two therapies, “It may be the case that there are effective components and change mechanisms that are common to various types of family therapy” (Gurman et al, 1986). It seems to me the qualities that the Rogerian model lacks (being therapist-driven and introduction of techniques and experiments) Gestalt Therapy offers. And, the qualities that traditional Gestalt Therapy lacks (such as empathy and conformation of the client) Rogerian Therapy offers. I believe an amalgamation of these two approaches is what is now referred to as, “Relational Gestalt Therapy” (Jacobs, & Hycner, 2008), and is the Gestalt “wave of the future.”
Theory of Change & Role of the Psychotherapist in Gestalt Therapy
From a Gestalt Therapy perspective, "... the aim of
therapy is to make the patient not depend upon others, but to make the patient
discover from the very first moment that he can do many things, much more than
he thinks he can do" (Perls, 1969, p. 29). What the client doesn't know is
that ultimately, she will solve her own problems. Her life must be increasingly
self-directed and self-determined, or else the therapist acts as the
authoritarian dictator, deciding for the client what is best. When working
with resistances, clients must be challenged: "Without frustration there
is no need, no reason to mobilize your resources, to discover that you might be
able to do something on her own, and in order to not be frustrated, which is a
pretty painful experience, the child learns to manipulate the environment"
(Perls, 1969, p. 32). Let's be clear: therapists do not unintentionally seek to
be a source of frustration for a client. However, the therapist must
intentionally frustrate the client's attempts to sabotage herself or the
therapeutic relationship. When the client produces defenses or fabrications of
the truth, challenging the client to re-think their statements or position is
therapeutic. To placate the client is to be no resource at all for learning. By
ignoring the client's cognitive distortions, the therapist is not a teacher
anymore, but has resorted to being a paid listener. "Instead of mobilizing
his own resources, he (the patient) creates dependencies. He invests his energy
in manipulating the environment for support" (Perls, 1969, p. 32). An
adept therapist will neither allow a dependent relationship to develop with the
client, nor will they be manipulated. Once the client has activated her inner strength and resources she will
shift from an external locus of control to an internal locus of control, and
she will need the therapist's guidance less and less. This process of shifting
the locus of control is the therapy;
it is what will motivate the client to change.
Strength vs. Deficit-Based Therapy
The goal of Gestalt
Therapy is increased self-efficacy and maturation, the reliance upon one's
inner resources instead of environmental support (Perls, 1969). Initially
though, every client will present at the therapist in a state of impasse. What
seemed "impossible" at the first session is later transformed into
possibility as the client becomes aware of their attempts to manipulate,
sabotage, control and blame themselves and others. The client can then mobilize
her new-found inner strength, and what seemed at first glance to be the
immovable problem has become a steppingstone to a healthier, more successful
life. The impasse has receded and in the foreground is a new vista, ripe with
possibility. Therefore, Gestalt Therapy could be called both a deficit-based and strength-based philosophy. Deficit-based,
in that the client’s dysfunctional patterns will be revealed to them, and
strength-based, because Gestalt Therapy is a humanistic therapy which believes
that all organisms are self-actualizing.
Gestalt Therapy Philosophy of Pathology & Health
Because Gestalt is a humanistic theory, it espouses the
belief that organisms are self-regulating and self-actualizing in nature.
Clients or family systems which are “stuck” at an impasse due to dysfunctional
patterns are considered pathological. Conversely, health is seen as the ability
to release dysfunctional patterns and ways of relating in favor of new
information, i.e., therapist psychoeducation and the family’s feedback. Gestalt
Therapy doesn’t seek to classify mental disorders according to the Diagnostic
and Statistical Manual of Mental Disorders (DSM) (American Psychiatric
Association, 2000) as much as it defines pathology as the inability to regulate
the individual self and successfully adapt to change. Freud labeled defense mechanisms as pathological, so Gestalt
Therapy expounded on a few of Freud’s mechanisms, namely: neurosis, projection
and transference, and introduced the emotional defense mechanisms of:
avoidance, introjection and retroflexion, the polarities of aggression and
self-expression, and how paranoia and projection are interwoven (Perls, 1947).
Gestalt views psychopathology as a failure of the organism to be self-aware;
that an individual or family system may still function, but with a scotoma, or
blind spot (Perls, 1947, p. 236).
Cultural Considerations
From a cultural perspective, Gestalt
Therapy may not be the therapy of choice for individuals from collectivist
cultural groups 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; to “abreact” if they must. Members
of cultures which might not be accustomed to expressing anger or fear openly
could be misjudged by a Gestalt therapist as withholding or resistive, unless
the counselor is culturally sensitive. If the counselor understands the
client’s cultural perspective, she can adapt the therapeutic approach to the
client, rather than demanding the client adapt to the approach.
Gestalt Assessment and Diagnosis
A
married heterosexual couple presents in counseling for couple’s counseling.
They are both in their late forties, Caucasian, and attend a church which
encourages couples to stay together through infidelity. Harry works fulltime as
a salesman, and Marsha works part time as a secretary. Their history as a
married couple is the following: they report having been married for 35 years and
have no children. They are seeking marriage therapy to resolve their marital
discord over a recent extra-marital affair with a woman named Sheila which the
husband, Harry, has been concealing for the past 5 years. Further, this is
Harry’s second affair; his first affair was 25 years ago. In both instances,
the wife, Marsha, discovered Harry’s infidelities. The couple has never sought
therapy before.
Harry seems desperate to keep the marriage intact evidenced by his tearful demeanor, while Marsha is withdrawn and considering separating from Harry. Harry’s affective demeanor is remorseful, yet defensive and angry. He frequently speaks for Marsha, interrupts her, projects blame on her, and makes repeated statements that his wife wants to “control him.” Marsha states her love of Harry, but feels she cannot trust him, and feels she “has to” monitor his whereabouts when at work where Harry met his mistress, because the “other woman” Sheila lives in close proximity to his work. Harry seems to be an extrovert who is high in the personality characteristic of neuroticism, yet low in openness, agreeableness and conscientiousness (O’Keefe, Kelloway, & Francis, 2012). Harry meets the criteria for Narcissistic Personality Disorder (DSM-TR-1V, 2000) while Marsha seems to be an introvert who is high in neuroticism, yet also open, agreeable and conscientious. Marsha has always been mentally healthy, but is lately suffering from circumstantially-induced medium-level depression since she discovered Harry’s affair. Harry further discloses that he was fired from his last job as a retail salesperson for kleptomania. He reports having a history of kleptomania which began in his teens. He describes being “unable” to resist his urges to both steal and “flirt” with women. He denies sexual addiction and substance abuse. Harry admits he feels something is “wrong with him,” but says he has only presented in therapy due to an ultimatum from Marsha. While Harry says he wants to repair the broken trust between himself and Marsha, he frequently becomes angry when confronted with his poor decisions. When Harry is given the opportunity to share his feelings, he escapes sharing his true feelings by claiming he “doesn’t know,” or by evading questions and blaming Marsha. When Harry becomes red in the face and raises his voice to me, I find his demeanor to be hostile and covertly threatening. Yet at the close of each session Harry becomes remorseful and tearful, admitting, “I know I am the problem.”
Because I suspect that Harry has diagnosis-worthy symptoms, I ask if I can meet with Harry individually for the purpose of clinical assessment, and he agrees. At that appointment, I clinically assess Henry through a self-report of the DSM-TR-1V (2000) and determine he meets the clinical criteria for Narcissistic Personality Disorder, and Impulse Control Disorder Not Otherwise Specified (NOS). I conclude Impulse Control Disorder NOS because Harry meets the criteria, and because of his chronic history of kleptomania. I share the results of the assessment with Harry, and he appears visibly relieved and yet shaken. He wants to disclose his diagnosis to his wife in the next appointment, as he feels this will help her to understand his problems, and perhaps keep her from separating from him.
At the couple’s second appointment, I gather more information from both of them regarding the dynamics of their relationship. Harry discloses that he has a strong sex drive and that while his wife has made a special effort in the past three years to satisfy him sexually, he did not feel “special or important” to Marsha like he did with Sheila. Marsha feels she has tried to do everything she could do to accommodate Harry’s high sex drive, yet admits due to his first affair, she has doubted his trustworthiness and has withdrawn emotionally from Harry. She admits that Harry’s latest suggestion of purchasing a GPS tracking system with which to monitor his whereabouts might be needed, but she suspects he would find a way to evade such a monitoring system. Harry admits to frequently lying to Marsha for “no good reason,” and laughingly agrees that “no GPS system is a match for me.” While I can appreciate Harry’s honesty about his clever deceptiveness, Marsha does not find this amusing; it appears as if Harry is “making light” of her pain, something she has become sadly accustomed to.
Marsha and Harry’s Treatment Plan
The treatment plan I formulate
for Marsha is to improve her self-efficacy and self-confidence, because Harry’s
affairs have taken a toll on her self-esteem and self-worth. For Harry, I will
treat his impulse control problems, evidenced by his chronic kleptomania and
philandering, and I will also seek to improve Harry’s self and other-awareness
which is very low. As a family system, because they have chosen to stay
married, I will work to rebuild their trust in one another through facilitating
a resolution of resentments and regrets, discussion of boundaries and
consequences, and making of new agreements that will keep the marriage intact. I
will seek to equip this couple with skills training in both conflict resolution
skills and inter-personal communication skills, to improve their understanding
of one another, and appreciation for each other.
Gestalt Therapy Intervention &Treatment
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, 1969, 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 because of its existential focus.
Gestaltists may also direct the client to
exaggerate or repeat body language to give the symbolic gesture a “voice.” They
will ask clients to describe dreams, and to play all the parts in the dream,
giving the dream characters and items a “voice.” Gestalt Therapists may ask clients
to repeat phrases for emphasis during therapy which are meaningful, and are not
afraid to lead the client to a catharsis point.
Summary
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, or even a philosophy of practice. As Buber states: “In
the beginning is relation” (Buber, 1958, p. 18). Hycner and Jacobs (1995, p. 8)
state, “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.” 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
Therapy is a fascinating blend of dialogue 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 on 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, that being the therapeutic bond. The German world for
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.
References:
References:
Jacobs, L., Hycner, R. (2008). Relational Approaches in Gestalt
Therapy. Gestalt Press, Santa Cruz, CA
Jacobs, L., Hycner, R. (1995). The Healing Relationship in
Gestalt Therapy: A Dialogic/Self Psychology Approach. Gestalt Journal Press,
Gouldsboro, ME
Buber, M., (1958). I and Thou. New York: Charles Scribner and
Sons. (Original work published 1923)
Rogers, C.R. (1951). Client-centered therapy: Its
current practice, implications and theory: London, Constable
Hazelrigg,
M.D., Cooper, H.M., Borduin, C.M. (1987). Evaluating the effectiveness of
family therapies. An integrated review and analysis. Psychological bulletin,
101 (3), pp. 428- 442.
Law,
C.F., Smith, E.W. (1986). Gestalt processes and family therapy. Individual
Psychology. Journal of Adlerian Theory, Research & Practice, 42(4), pp.
537-544. Integrated review and analysis. Psychological bulletin, 101 (3), pp.
428- 442
Zinker, J. (1981). Lies in intimate
systems. Newsletter, Gestalt Institute of Cleveland, 1,2, 1-4
Gurmin, A.S., Kniskarn, D.P., Pinsof,
W.M. (1986). Research on the process and outcome of marital and
family therapy. Journal of Family
Psychology, Vol. 8, No, 4, p. 390-416. American Psychological