Gestalt Theory: Treatment

Ongoing Individual Gestalt Therapy

Though Gestalt therapy has gained a reputation to be applied first of all in groups, its basis is in fact personal treatment. You can find some examples in Gestalt Therapy Now publication (Fagan and Shepherd, 1970). Cases descriptions from an annotated bibliography in Simkin is also interesting to study (1979, p. 299).

Gestalt therapy starts when the first encounter and contact takes place. As a rule, evaluation and screening are performed as an element of the continuing relationship more than in a separate phase of diagnostic testing in addition to social history regarding. The information for the evaluation is received by the point of the work start, for instance, by the point of therapeutic encounter. This evaluation comprises the patient's desire and sustain for work within framework of the Gestalt therapy, the connection of client and therapist, the typical professional discriminations of diagnostic and characterological character, resolution upon regularity of sessions, the necessity of adjunctive treatment and medical consultation.

A standard sessions' frequency is weekly (one session a week). Applying the Gestalt methodology, this intensity is sufficient and the result can be regularly achieved at this regularity. Frequently personality therapy is united with workshops, group therapy, combined or family therapy, meditation, movement therapy, biofeedback training. At times clients can have sessions with bigger regularity, but frequently they require time to take in material and more regular sessions can bring to overdependence upon the therapist. The regularity of sessions is determined by such factors as how long the client can go from one session to another without breaking continuity, decompensation, minor types of relapse. So the frequency can be absolutely different and fluctuate 5 sessions per week to one session per 2 weeks. Less frequent sessions evidently reduce intensity up to the point when the client attends a group every week, the therapist remains the same. The frequency of over two times a week is normally not specified, with the exception of psychotics, and is beyond doubt contraindicated with BPD (borderline personality disorders).

Throughout the therapy clients are urged and helped to make a decision. Everything is discussed: exercises, period of process, kinds of adjunctive therapies for use, and other things and though the client makes the choice eventually, the competence and the right decision should be supported by the expert.

Group Models

The duration of Gestalt therapy sessions is different. There are one-hour sessions, more than on hour up to the sessions which are three hours long, therefore the average session lasts for two hours. A usual 2-hour group consists of 10 persons. Gestalt therapists generally experience maximum participation in heterogeneous group, in which the quantity of men and women is balanced. Group member should be screened. Gestalt therapy is proper for any age group, but the usual range in continuing private practice group is from 20 up to 65 years old and the average age is from 30 to 50.

There are Gestalt therapists, who are Perls' followers and they do one-on-one therapy in the setting of the group employing the "hot seat" structure. "In accordance with this method, a person expresses his desire to the therapist to overcome a certain problem. The center of attention is the lengthy interaction then between client and leader of the group ('I and Thou') (Simkin and Levitsky, 1972, p. 240). Episodes of one-on-one type last in average 20 minutes, but can continue from 2 to 45 minutes. In the process of the one-on-one work, all the rest members keep silent. After the work is completed, they share the way they were influenced, what they watched, and in what way their own experiences are alike with the experiences of the client. During the last several years the work of this kind has been developed and began to embrace awareness work without certain problem in the center of attention.

In the beginning of 1960s Perls wrote in his paper:

Recently though, I have removed individual sessions on the whole with the exception of emergency cases. Actually, I am of the opinion that individual therapy is outdated and Gestalt therapy workshops should be instead of it. During workshops I organize at the moment individual work is put together with group work. (1967, p. 306)

This view was not accepted then by the majority of Gestalt therapists, and it is not now acknowledged Gestalt theory and practice.

Some witnesses have illustrated the group work style of Gestalt therapist and individual therapy within the group setting. This declaration is valid for experts introducing Gestalt perception making use of the model without emphasis or having to do with group dynamics or struggle for cohesiveness of the group. Nevertheless, a lot of Gestalt therapists pay special attention to group dynamics.

Bigger employ of the group is undoubtedly within the Gestalt methods and is used more and more in Gestalt therapy (Feder and Ronall, 1980; Enright, 1975; Zinker, 1977). This takes in bigger involvement of group participants when a personality is performing one-on-one work, working over personality themes with all members of the group, with accent on contact in the group, and work with group practice. The diverse degree and kind of structure supplied by the leader of the group can contain prearranged group exercises or not, examining the group's development to its own structure, urging one-on-one work, and so forth. Frequently Gestalt groups start with several exercises to assist members to progress sharing experience "here-and-now".

A regularly applied model is the model which supports enlarged awareness via accent on contact between the participants of the group and one-on-one work within the group (between its members which are persuaded to be active at this stage of work). This provides bigger flexibility and variability.

Workshop Style

Gestalt therapy and Gestalt training is carried out in workshops, with the schedule for a fixed period, and some of them last only one day. Workshops during the weekend may continue to 20 and even more hours. The durability of workshops varies from one week to some months. A usual weekend workshop participants are a Gestalt therapist and a group of 12 - 16 people. When periods are longer (one week to one month), more than 20 individuals can be observed by one therapist. Regularly with participation of over 16 people, co-therapists are engaged as well.

As workshops are limited in duration and many hours are offered to the participants, the motivation to "work" is usually high. From time to time regulations are set for every participant to give an opportunity to work in turn. Sometimes the rules are avoided. Therefore much depends upon the desire, boldness and strength, some group members for this reason may obtain intense therapeutic consideration during a workshop.

Even though some workshops are prearranged with established groups, the majority of them gather clients for whom this is a new experience. Like in continuing groups, the perfect practice is to screen clients prior to the workshop. An unscreened workshop needs a knowledgeable clinician who dealt with serious pathology and vigilant security for probably susceptible group participants. Confrontive or fascinating Gestalt styles are for the most part likely to worsen mental illness, which may have some group members (Lieberman et al., 1973).

Other Treatment Modalities

Gestalt family therapy use was elaborated comprehensively by Walter Kempler (1973, pp. 251-86). The fullest description of Kempler's work is published in the publication Principles of Gestalt Family Therapy (1974).

The use of Gestalt therapy takes place in temporary crisis interference (O'Connell, 1970), as an accessory treatment for visual problems (1970, Rosanes-Berret), for awareness education of mental health specialists (Enright, 1970), of kids with behavior difficulties (Lederman, 1970), to educate day-care institutions staff (Ennis and Mitchell, 1970), to instruct teachers and the rest on creativity (Brown, 1970), work with a dying individual (Zinker and Fink, 1966), and in organization progress (Herman, 1972).

Management

The management of the case by a Gestalt therapist is a practical subject and determined by the aim of supporting the interpersonal connection. Appointments are generally made on the phone by the therapist. The interior of the office characterizes the personality of the therapist and his style and is not intentionally neutral. The design of the office and its furnishing is aimed to provide comfort and to keep away from a traditional 'desk or table' type separating two sides. In general the physical layout gives space for movement and experiments. The therapist is dressed in informal way as a rule and his manners should be also not official.

Fees arrangement depends upon the individual, here there is no definite Gestalt style, but straightforwardness. The question of fees are discussed straightforwardly with the client and generally gathered by the therapist.

Clearness of boundaries is emphasized, with 2 sides in charge of the current assignment. Therapy work begins from the very first moment. The session is not accompanied with the therapist's notes as it is in the way of establishing the contact. The therapist should do it after the session, if necessary. He is responsible for safeguarding comments, tape and video-recordings and the rest clinical material. The therapist establishes payment conditions, cancellation policy, et cetera. Disobedience and protests are openly discussed. The choice is made with the therapist and both parties keep agreements. The therapist organizes the office to guard it from intrusion, and protects the office every way possible.

The assessment process takes place as part of the psychotherapy and is made by both sides. Some reflections engaged in the process of evaluation consists of coming to a decision upon person or group therapy, assessing the therapist's ability to make a considerate relationship based on credit, and allowing the client choose an adequate example if the therapist suits the patient as well as the chosen therapy.

Problems coming into view in the relationship are openly discussed, in the form of managing the definite problem and examining characterological styles of life or relationship development that would be productive for the client to explore. The requirements, desires and direct experience of two sides lead to the examination always and to salvation of problems.

Case Example

Peg visited at first workshop of Gestalt training. She tried to learn to overcome anger to her husband, who killed himself. After his demise she had to raise their children alone and started a career as she had to support her family financially. She was a bit less than 40 then.

With substantial bravery and activity, Peg managed to arrange a crisis clinic supported by a famous service organization in the big city in Southern California where she lived. Peg was a member of the group of 11 people who took part in a Gestalt therapy training film with Simkin (1969). Here is the excerpt from the Gestalt training film, In the Now:

Peg: I have the same ...returning dream. I'm standing near Camp Pendleton on the ground and an open, countryside, which is rising and falling, just in front of me. I see broad and dirty roads, which are crisscrossing there. Hills come after valleys and valleys after hills....there is an army tank to my right, - marine tanks which have big tracks... there are a lot of them they are closed well and rolling in a line over the valleys and hills, they are closed up. Standing near the road I have a plate with Tollhouse cookies. They are hot and are on the platter -- I see tanks coming one by one. I watch them and they move past me. When I look to my right I notice black shoes, a pair of shoes. They are shiny, and run along among the tank treads as it goes on the hill. When they are just in front of me...the person bends down, the tank moves on, when the person approaches me, I see that this is the best friend of my husband. Every time I wake up at this place. At all times I bring my dream to end...and I started to laugh. But it is no longer fun!

Jim: You are right. What is that you are you doing now?

Peg: I am making an effort to stop chattering.

Jim: What's your protest?

Peg: This feeling of nervousness and horror I have is not something I like.

Jim: What do you visualize?

Peg: I visualize ridicule.

Jim: Ok. Begin ridiculing.

Peg: Peg, you're absurd. You are large and lazy. You are ridiculous like a comic. You pretend as if you are grown up but this is not so. Those who look at you know that there is a child inside, pretending that you are a woman of 39 and...it's a ludicrous mask. You are 39 and do not have your own business. An absurd age like you are. Being employed you don't have any notion how to succeed. You think that your grand plans will be carried out by themselves, you are not smart enough to make it, so you will be laughed at.

Jim: Ok, it is time to look at people who are laughing at you.

Peg: I'm afraid to. [she is obeying and doing it slowly] They seem to be serious.

Jim: Whom are you speaking about then?

Peg: I think... just my vision... my...

Jim: Who devised that?

Peg: I did.

Jim: Who are those people laughing?

Peg: Yes. This is so I... I'm actually laughing at things which are not amusing. This is so incompetent. [makes a pause]

Jim: What good qualities do you have?

Peg: I'm kind to people. I do not judge. I can keep my house well. I'm an excellent needlewoman, I can bake well...

Jim: Perhaps you'll become an excellent wife.

Peg: And I did.

Jim: Perhaps it will happen again.

Peg: I am unaware of it.

Jim: Say it. "I have doubts that I will become an excellent wife once more."

Peg: I have doubts that I will become an excellent wife once more.

Jim: Inform every man in this room about it.

Peg: I have doubts that I will become an excellent wife once more... [says it again and again - 5 times]

Jim: What are your feelings?

Peg: I am surprised. It just seemed to me so.

Jim: That's it.

Jim: What are your feelings right at the moment?

Peg: Pleasure and satisfaction. I feel fine.

Though "ticket of admission" Peg had was a vision only, it was in the basis of her nervousness and doubts. It seemed to her that she was ridiculed. This dream worked like a vehicle for beginning and, as is often the case, the work brought to unexpected result.

This was the weekend Gestalt training workshop and film was made at that time, later Peg really got acquainted with a man and began to date. They were attracted to each other and eventually married.

A second example of Gestalt phychotherapy is selected from a book to demonstrate certain techniques (Simkin, 1976, pp. 103-18). It is a reduced record of a workshop, where 6 volunteers were present. The session in the morning comprised a film and a lecture-demonstration.

Jim: I would like to begin with saying to you where I am. I would like you to know what I feel now, about my current experience. This looks rather artificial for me, there are lights with cameras around and the public too. I am breathless and loaded with the technical stuff and equipment, and so on, and I am more inclined to running away from the cameras and lights to be in touch with only you. [asks the names of the group members and says his name]

I am thinking that everybody here saw the film as well as the demonstration, and I would prefer to work with you when you are ready to do it. I'll repeat our agreement or contract. The core of the agreement in Gestalt perception is to share where you are, what you are feeling at definite moment, and, in case you are able to, to remain in the awareness, to say what you are concentrating on, what is your awareness now.

* * * * *

I would like to begin first with letting you declare who you are and what you are expecting.

Tom: At this moment I feel tension, for the most part not because of the equipment around me because I am often in such surrounding. This is strange for me to be in a situation of this kind. This morning I felt uneasy for the reason that I didn't see many things here the way you are, and I feel hostility because of it. At present I admit you more as a person.

Jim: I'm looking at your foot at the moment. This is interesting for me if you are able to make your foot speak.

Tom: To make my foot speak? Do you mean to say about the feelings of my foot? What would it say?

Jim: Just go on that, as if you are your own foot.

Tom: I don't get it.

Jim: When you informed me about hostility feeling in the morning, you kicked your leg energetically and I suppose that some kick is still coming from time to time.

Tom: Uh, yes. I assume perhaps I still make some kick, but that does not seem to me that that's something inappropriate now.

* * * * * *

Lavonne: I feel tension at the moment.

Jim: With whom are you speaking, Lavonne?

Lavonne: I remembered this morning, This was a feeling of hostility. I still have a little of it.

Jim: I know that you try to keep away from meeting my eyes.

Lavonne: This is so, you seem arrogant for me.

Jim: You are right.

Lavonne: It is as if I might fight with you.

Jim: Quite right.

Lavonne: I keep away from the eye contact and it is like keeping away from the fight. I have no notion how to solve the problem.

Jim: Would you be willing to tell me what your objections are to my arrogance?

Lavonne: This does not calm me down. In case I have a trouble and I discuss it with you and you're so proud, so I become arrogant as well.

Jim: You reply in kind is what you're stating. Your experience is you react this way.

Lavonne: Yes. Later at this university it seemed to me that I should have been haughty and self-protective always. As I'm black, the reaction of people can be various... people are different ... and I think that I should be ready to answer always...

* * * * * *

Mary: I would like to work on my feelings for my elder son and our struggle but I suppose that this is in fact my struggle.

Jim: Are you able to tell him about it? Call him his name and just say what you think.

Mary: Okay. He is Paul.

Jim: Place Paul on it [moves an empty chair] and tell him about it.

Mary: Paul, there is much confrontation between us. When you independently go out of the drive, I feel hatred. But...

Jim: Wait a little. Repeat it again to Mary. Mary, when you independently go out to the drive, I feel hatred.

Mary: That fits. Mary, when you independently go out of the drive, I feel hatred, because you are bad mother.

Jim: I don't know about your "because."

Mary: No. That's my explanation. When I do yoga I do the same.

Jim: You seem to identify yourself with Paul.

Mary: I do. I am aware of this. I feel envy for his freedom, since he was little and set off to the woods. I was envious of his capability to do it.

Jim: Say Paul about it.

Mary: Paul, at time when you were little, could go away on the whole Saturday without letting me know, I was envious a lot, and I felt upset as I had no opportunity to do it as well.

Jim: You could not do it, or you would not do it?

Mary: I wouldn't though I wished it.

Jim: Well, I get really angry when the person around can afford doing something I want but I can't.

Mary: And I behave this way. I try to remember what I can do and what I will not do. After it I do not do anything. I'm stopping. Tightly planted.

Jim: I would like you to connect with your malice. Place your malice here and talk to Mary's wrecker.

Mary: You are an idiot. Having time and energy for work...which you scatter. You are occupied with numerous things therefore there is always an apology not to fulfill your work, or switch to something different... [makes a pause] You only waste time becoming unhappy and making your life complicated.

Jim: What's happening here? [looks at Mary's hand and points to it]

Mary: I am tight-fisted...this will not do.

Jim: Are you really tight-fisted?

Mary: I suppose I am.

Jim: Okay. There is another part of you - the generous one. Are you able to contact it?

Mary: I am not aware of generous part of myself well.

Jim: Remain tight-fisted just say at that, "Generous self, I do not want to deal with you, I am not aware of you, etc."

Mary: Generous self, I am not aware of you. I consider you try from time to time when you present gifts to people instead of presenting yourself. You refuse an unpleasant lot you could give.

Jim: What took place right now?

Mary: It was a rehearsal. It was not a talk with my generous self. It was a talk with... you mostly. I was keeping back part.

Jim: I have trouble visualizing you like a withholding type of a person. You seemed to me from the very start very energetic and active... and very giving, so it seemed to me.

Mary: I am not aware if I am actually giving. Every now and then I feel like it but my gift is not accepted. And at times I wish to give but I can't. I feel occasionally there was too much I have given already. I shouldn't have given so much.

Jim: Well, just what I'm starting to feel. Some wound. You look wounded - it was in the past. You were wounded during some period when you were vulnerable.

Mary: I'm hurting to some extent.

Jim: It seems for me that you are hurting now, particularly around your eyes.

Mary: I am aware of that, and I don't wish to do that... I have no desire to demonstrate that.

Jim: Okay. Would you wish to block?

Mary: [shutting her eyes] If I do it, I am not able to see you.

Jim: This is right.

Mary: At time I do that, I am not able to see anyone.

Jim: Exactly. At times I block my hurt, no person exists for me and this is my decision.

Mary: I also made this decision.

Jim: It is nice to look at you. You seem so generous now to me.

Mary: You seem generous to me. I think you are generous. You reply to me, I sense that I'm replying to you...

Jim: I'm interested if you can return to Paul for an instant right now. Meet him and examine what takes place.

Mary: Paul, I wish to be generous and warm with you, and I feel this might hurt you if I do so. You are 6 feet tall right now and at times I wish so much to approach to you and to kiss you goodnight or to hug you but I can't do all this any longer.

Jim: You cannot?

Mary: I will not. I will not, because, uh... I've been pushed away.

Jim: You've been wounded.

Mary: Yes, I've been wounded. Paul, I consider it is your own business whether you want to push me away or not, but this does not prevent me from being hurt.

Jim: I like Nietzsche's phrase as far as I remember, when he applied to the sun, saying, that it is none of its business that it shines at him.

Mary: I continue hoping that at 25, Paul, when you go to the Army or whatever... and that at this moment I will have a chance to kiss you good-bye. [makes a pause] I will try not to forget what Nietzsche said to the sun.

Jim: Okay. It was my pleasure to work with you. Thank you.

Mary: Thank you.