Gestalt Approach to Psychotherapy

The first part of this essay sets out to describe the Gestalt approach to psychotherapy. The second part details how I would incorporate the Gestalt approach into a hypnotherapy session.

Gestalt therapy was first developed by Fritz and Laura Perls in the 1940/50s. Though the Gestalt approach originally developed in the United States, it has spread widely, and there are now Gestalt practitioners all over the world. It can be carried out ‘one-to-one’ with individuals, with couples, in small and large groups, and with families.

Gestalt therapy is very unpredictable, creative and innovative. It uses a range of therapeutic experiments, interventions and interactions.

Gestalt therapy developed from the third psychotherapy force – the humanistic tradition. It is rooted in existentialism and phenomenology. Like humanistic psychotherapy, the Gestalt approach puts the client in the centre of the frame. Each person is viewed as a whole (Body/Mind/Spirit). Gestalt therapy is therefore a holistic approach which embraces all human experiences, perceptions and potential. Each person is seen as a unique individual in a particular life situation who can only be fully understood in relation to that situation as s/he experiences it (phenomenology).

There are 2 major aspects to Gestalt therapy: The Cycle of Awareness and The Five Levels of Neurosis.

Cycle of awareness:

In the Cycle of Awareness the self is the centre and is surrounded by boundaries (as in the diagram below) and then the environment.

Satisfaction

Final Contact

Sensation

Withdrawal

Mobilisation

Action

Awareness

SELF

A healthy boundary would be pliable and a person would have clear sense of who she is.

An unhealthy boundary would be problematic. It could be over permeable and too compliant or too rigid and inflexible for example. Unhealthy functioning ‘blocks’ can occur at each boundary disturbance and interrupt the natural flow of positive energy. Blocks or defense mechanisms include decentisation ( numb ourselves) ; deflection ( denial); introjection ( what ought/should do/ how should feel) ; projection ( onto somebody else) ; retroflection ( bottle up) ; egotism ( over analysing a job) ; confluence ( not being able to let go; losing oneself in a relationship). If this boundary is too pliant or too rigid the person will have problems, for example relationships with external reality may suffer and s/he may have an impaired view of him/herself. When stasis, resistance or rigidity prevents the flow through the cycles of awareness, this results in “unfinished business”.

The unresolved or unfinished business is seen as an obstacle, restricting the person’s ability to function fully. This obstacle is often referred to as ‘dis-ease’ by Gestalt therapists. The therapist would help the client move towards a greater understanding, responsibility and self-awareness to complete this ‘unfinished business’. By ridding themselves of the unfinished business the client will be better able to experience closure and move on with their lives.

Gestalt is recognised for its focus on developing the authentic and through awareness to encourage personal growth and develop potential. We do this by noticing how we are living now and exploring how we may create any fixed patterns of behaviour that leave us feeling dissatisfied, uncomfortable or ill at ease.

In Gestalt therapy the issue requiring completion would be brought to the Here and Now. By encouraging a client to focus on the present helps them channel helpful anxiety into creativity and action rather than on negative issues. Avoiding the use of too little precaution (catastrophic fantasy) or too much precaution (anastrophic fantasy) allows for healthy risk taking.

Noticing what we experience and how we behave in the present creates an opportunity to explore changes in our behaviour and attitudes now. This may enable us to complete previously unresolved experiences and to develop more satisfying ways of expressing ourselves.

Perls believed that the actual awareness of an individual is more trustworthy than an interpretation of any information that a person might provide a therapist with. He believed that the information provided moves between the ‘figure’ and the ‘ ground’ with the figure being the item at the forefront at that particularly time, and the ground being the remainder of the person’s awareness.

The point is we do not see all things equally. At any given moment, some things are ‘figural’, and grab our attention. Then something else stands out for us, and the previous figure recedes into the background. We are continually organising and re-organising our experiences of ourselves and the environment into a series of ‘meaningful wholes’ or gestalts in this way. Identifying this continual organismic figure-ground process was one of the early Gestalt therapists greatest achievements.

Surrounding the boundaries in the Cycle of Awareness is the ‘environment’ . This is linked to another key aspect of Gestalt work – Field (or environment) Theory. Gestalt therapists consider human beings as organisms existing in an environment. In Field Theory we become what we are by how we interact with our field (or environment) and the relationship between our field and our inner world. The person is intimately connected with their environment, and cannot really be separated from it.

Fritz Perls (1951) explains:

“No individual is self-sufficient; the individual can exist only in an environmental field. The individual is inevitably, at every moment, a part of some field. His behaviour is a function of the total field, which includes both him and his environment” (Perls, 1951, p151)

A physical environment of-course could include air to breathe, a chair to support your body etc. It would also contain many more physical factors, and just as many psychological ones (I am feeling a little sad today), and socio-

cultural ones (I am a white middle-class female). Sometimes, it is matter or energy that is exchanged, for example eating and breathing. But often it is information, for example looking at the clock. The energy or information continually passes to and from across the boundary between “me” and “my environment”. As we grow we encounter necessary frustrations, and learn that we must primarily utilise our own resources to overcome these. Later we learn how to manipulate our environment including other people to achieve the same ends. To achieve ‘organismic balance’ we must therefore learn from our environment to support our solid base of self-help. Gestalt therapy goals involve attaining a shift from dependence on environment to self-support, in order to resolve presenting problems and live more authentic lives. (Parlett and Hemming, 1996, p 205).

Gestalt therapists make use of questions and words. A Gestalt therapist would encourage a client to replace statements like “I can’t…” by ” I am choosing not to…” (Parlett and Hemming, 1996, p209).) The use of the word ‘should’ would particularly be highlighted as an introjection. Often others (particularly parents) introject pieces of information into us, which are retained (Parlett and Hemming, 1996, p200). Limiting introjections can lead to neuroticism by perpetuating life-limiting patterns. (Nelson-Jones, 2000, p157). Introjected ‘wisdom’ may prevent us from experiencing and learning first hand (interrupting contact with ourselves or others), and this may lead to adult neuroticism by perpetuating life-limiting doctrines.

Introjection is one of the four inter-related mechanisms of contact boundary disturbance.:

Introjection. Inappropriate ownership of information that is not compatible with “Self”

Projection. Inappropriate disownership of part of self by displacing onto others or the environment unacceptable to self-image

Confluence. Unawareness of appropriate boundaries between self and others, creating loss of identity.

Retroflection. A tendency to direct negative feelings internally rather than direct them to others or the environment. (Nelson -Jones, 2000, p 157 -9).

These together with egotism, deflection and desensitisation (Clarkson, 1992, p 45) can be conceptualised as defence mechanisms.

Another important aspect of Gestalt therapy and linked to the above is the five layers of neurosis as in the diagram below.

Cliché layer

Role layer

Impasse layer

Implosive layer

Explosive

Authentic layer

Cliché layer: Engaging in superficial rituals.

Role layer (or Eric Berne/Sigmund Freud layer): Engaging in counter-productive games.

Impasse: Avoiding of suffering, especially frustration.

Implosive layer: Fear of death or a feeling of not being alive.

The explosion: cathartic releases of energy and emotion connecting the person to their authentic self. (Nelson-Jones, 2000, p160)

By working their way through the layers the person can reach their true, authentic self. There are 4 types of explosion: Anger, Grief, Orgasm, Joy.

Perpetuation of neurosis arises because people are unwilling to go beyond ‘impasse’. One principal purpose of Gestalt therapy is to address this issue.

There are many techniques used by Gestalt therapist. Perhaps the most well known of all is the empty chair or two chairs. When using this technique a client would for example, project their representation of somebody, something or even part of themselves into the empty chair and then a dialogue would take place between the representation in the empty chair and the client. Inner conflicts can then be realised, expressed and released. The client is then able to feel a greater awareness and responsibility for the difficulty they had and is better able to make choices to help resolve the issue behind the unfinished business and move on in a more positive way.

This can be use used in pain management and chronic disease states, as well as for emotional pain or conflict. Gestalt “Empty chair” technique may be employed to resolve unfinished business (Battino and South, 2006 p 500); some authors believe, most powerfully, when delivered in reasonably deep trance (Battino and South, 2006., p145). This may also be very appropriate where the client needs cathartic release and is unable to confront the source of his/her anger for practical or social reasons, for example where such release towards a manager at work may lead to dismissal.

Another version of parts integration is the analysis of sub personalities as advocated by John Rowan (Hunter, 2005, p 10), and the Voice Dialogue

approach recommended by Hal and Sidra Stone (Hunter, 2005, p7). In these approaches ego states are labelled as selves or sub-personalities and the therapist facilitates a discussion between selves, revealing their origins and resolving conflicts. Clients may take chairs to assist them in entering roles. This approach does not usually employ formal trance induction and some authors believe it is susceptible to analytical resistance by the client, leading to short lived results. (Hunter, 2005, p7)

Another common Gestalt technique is the topdog/underdog. During the topdog/underdog a client would be asked to consider two parts of their personality. This could be two parts which are in conflict with one another. The client would be encouraged to imagine a dialogue taking part between those two parts. The topdog would represent the introjecting demander, expressed by “should” and “must”, and the underdog, which is a manifestation of resistance. The dialogue helps bridge the divide between the two conflicting parts so that a better understanding and or resolution can become possible. As Clarkson (1989) states:

“resolution, compromise, understanding or permanent divorce

becomes possible” (Clarkson, 1989 p46).

This happens as the client becomes more aware of his/her own feelings, thoughts and behaviour patterns including their internal battles. They are likely to feel a number of negative or resistant feelings along the way, for example feelings of guilt, anger, depression or anxiety. By facing up to this

and becoming more self aware they are then better able to work out what they need to do to make changes and move on with their lives. By no means is this a simple process and like many Gestalt techniques it can take time and can be emotionally painful until awareness and resolution is reached.

Of-course Parts Integration such as those described is used often in hypnotherapy.

Another concept developed by Perls is the Reversal Technique. Using this technique the client would be encouraged to role play the part of them that they find difficult to do / deal with. For example, a nice person would role play at being aggressive.

Bodywork is also used in Gestalt therapy. This involves the client consciously noting experiences in their body, for example if they experience some tension they may note where they feel or sense it in their body or they may notice how their breathing pattern changes. Once the client becomes more aware of the feelings and experiences in their body they can begin to work out with the therapist how to address these feelings with strategies that work for them and this in turn affects the way they feel about situations when these sensations arise. So both unhelpful or negative physical and mental reactions can be reduced.

The therapist would also challenge incongruence between words and body. Perl’s believed that the body and its functions and processes are bigger than the mind and are anterior to the mind.

Gestalt therapy is an experiential therapy so experiments which are often spontaneous and appropriate for the moment are also used. As are many creative techniques such as painting, drawing, music and many more.

A particular creative element of Gestalt is Dreamwork. Unlike Freud, Perls believed that a client would know what their dream means. In Gestalt therapy the client would be asked to describe their dream in the Here and Now. No interpretation is required by the therapist.

The above descriptions of Gestalt techniques should neither be considered exhaustive nor exclusive. Also, there is more to Gestalt therapy than techniques. An important part is the relationship between therapist and client. The therapist and client have a working relationship with each party taking responsibility for their part of the therapeutic whole process. Contemporary Gestalt therapists are less confrontational and more supportive than Perls and his contemporaries, utilising client-centred self disclosure, and offering strategic guidance but avoiding being an ‘expert’, with more equality in the therapeutic relationship than Rogers recognised in Gestalt approaches in 1977. (Nelson,-Jones, 2000 p 163-4) Unlike other therapies such as psychoanalysis, Gestalt relies more on the client’s participation and on observation of the client’s behavioural, physical or emotional reactions or patterns and less on interpretation and analysis. Indeed in Gestalt therapy

the client would be encouraged to take part in activities and tasks which would help with this participation and observation. This can be compared and contrasted with psychoanalytical therapy which would focus more on analysis and interpretation and much less on the client’s participation in activities and tasks.

Gestalt therapy has contributed greatly. The Cycle of Awareness, the 5 Layers of Neurosis; Unfinished Business and use of creative techniques are firmly integrated into many modern day therapeutic interventions.

There are however, some who say that there are limitations also. For example, long term goals may be unclear to some clients as Gestalt focuses mainly on immediacy – the Here and Now. Also, Gestalt therapists advocate a directive role in using techniques, or teaching their clients to use techniques, to “promote rapid change in a way that the patient can experience directly and others can observe clearly” (Heap and Aravind, 1970, p 187) Some clients may not appreciate this direct approach or may find it difficult to take ownership especially at the start. Some clients may not respond to the creative, experimental techniques used also. Clients would benefit from understanding the process from the start. Most importantly, Gestalt therapy is very dependent on a very skilled therapist who clearly understands and is experienced in Gestalt therapy.

Let us now consider some of the Gestalt techniques that can be incorporated into a hypnotherapy session. There are many ways in which the Gestalt approach can be incorporated into a hypnotherapy session. For the purpose of this essay I have prepared a table below to demonstrate how I would do this. In order to illustrate how Gestalt techniques could be used we will assume that the client responds well to the interventions. Clearly in reality case a client may respond to some interventions and not others. In that situation a full evaluation of circumstances and responses would be required and adjustments made along the way.

Gestalt techniques

How incorporated with hypnotherapy

The Here and Now

Bring experiences into the Here and Now through hypnotic trance and then work on them to help resolve.

Two Chairs

This could work wonderfully as part of a hypnotherapy session – either in or out of trance. The client may need to suspend disbelief in order for this to be most effective therefore in trance would work well.

Topdog/underdog

This could be done in or out of trance. For example, ask the client to imagine herself having a conversation with the younger her.

“what would the older, wiser you say now to that younger you”?

This would then end with parts integration, the bringing together of the more positive aspects of both. Thus achieving integration and resolution of the problem.

In Hypnotherapy it is not unusual to utilise strategies to cause the client to, at first, dissociate experience into parts that they recognise, before therapeutically and constructively drawing them into wholeness

Bringing the unconscious into awareness

As hypnotherapists we work all the time with the unconscious mind. Helping a client to be more aware and to bring the unconscious to consciousness is utilised all the time in hypnotherapy.

Role play

This could be built into a hypnotherapy session whilst the client is in trance. For example, I would ask the client to imagine herself as a confident person or to use somebody else’s confidence.

Again parts integration can also be used here to integrate the positive elements of the two persons into one – having the best characteristic of each.

Figures formation

Gestalt’s ‘The figures formation process’ could be used whilst in trance. This asks the questions ‘what is in the foreground? ‘what are you thinking about right now? This could then lead onto the swish method to alter the images and leave the most positive image as the final image.

Turning negative introjections into positive ones.

It would be particularly effective to do this with clients whilst they are in trance, for example it could be incorporated into Ego-Strengthening.

Being bodily aware

This works really well in hypnotherapy.

In Gestalt therapy, therapists bring body awareness into the dialogue, often asking the client to imagine that part of the body talking to them

For example:

‘Think about how you feel when this happens. Where do you feel it? (Answer: stomach) What does your stomach feel like right now? What is your stomach saying now?

In Gestalt a dialogue can be opened between the ‘part’ that is unwell/not functioning and other parts that are deemed to be healthier. In this way the troubled ‘part’ can be integrated into the well part so that it becomes ‘whole’ and healed, or simply accepted and listened to. This would work wonderfully in hypnotherapy.

I may also choose to focus on a part of the body and use it to anchor a more positive stage.

Use of creative experiments

Like Gestalt therapy Hypnotherapy is also a creative process. It is after all the imagination that we are working with more than anything else. For example I would utilise a client’s flair for drawing and ask her to draw a picture to describe how she feels – this could unravel a whole host of possibilities for exploration. As part of the change process she could then be asked to bring this picture back to mind whilst in trance and make it change into the picture she would rather see. This builds on the sense of ownership and accountability “go ahead….create your own new picture” that is also very typically Gestalt. This could then be recalled post-hypnotically.

Clients who have strong powers of visualisation can be more easily guided under a hypnotic trance to participate and engage in experiments.

These are just some examples of Gestalt techniques that I would incorporate into hypnotherapy work. There are many more. Of-course there are some Gestalt techniques which may not blend as well with hypnotherapy and vice -versa. For example, in hypnotherapy we would use regression to take a client back to a situation where as a Gestalt therapist would focus more on the here and now. A Gestalt therapist is also more likely to share their own experiences with a client where as a hypnotherapist is more likely to reserve judgement in relation to this though may self disclose some aspects if considered appropriate.

Personally, I would utilise various psychotherapy techniques and concepts into hypnotherapy work if and when appropriate, including Gestalt, behavioural and client centred approaches. I firmly believe we should make use of all the wonderful psychotherapy approaches available as one integrated approach.

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