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chapier 8 Gestalt Theory Melinda Haley Gestalt theory has a rich and varied history. While Fritz Perls is generally credited with being the foremost practitioner of Gestalt counseling and psychotherapy (Bloom, 2009), his method was influenced by the Gestalt psychologists who preceded him, such as Max Wertheimer, Wolfgang Kohler, and Kurt Koffka (Benjafield, 2008). These psychologists laid the psychological groundwork for Perls's application of Gestaltism to counseling and psy- chotherapy (Stoehr, 2009). The difference between Gestalt psychology and Gestalt therapy is that the former is concerned with perception and cognition, whereas the latter focuses on personality, psychopathology, and psychotherapy (Henle, 1978). The word Gestalt is a German term used to define a unique patterning in which the parts are integrated into the perceptual whole (Engelmann, 2008). There are three parts to the definition of a Gestalt, “a thing, its context or environment, and the relationship between them” (Kelly €: Howie, 2007, p. 137), and the term “connotes the structural entity which is both different from and much more than the sum of its parts” (Clarkson, 2004, p. 1). BAREReROOND Frederick (Fritz) Perls Friedrich Saloman Perls was born in 1893, the middle child and only son of middle-class Jewish parents in Berlin. He later anglicized his name, becoming Frederick, although most people called him Fritz (Thompson €: Rudolph, 2000). Perls received a medical degree in 1920 after a brief stint as a medical corpsman during World War 1. He found his war experi- ence brutal in military authoritarianism and racial prejudice. These experiences influenced his humanitarianism but also left him with a deep cynicism about human nature (Seligman £r Reichenberg, 2009). His early training in psychoanalysis took place in Austria and Ger- many, and he became associated with neurologist Kurt Goldstein (Clarkson, 2004). While id, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. erican Counseling Association. All rights reserved. 167 163 THEORIES OF COUNSELING AND PSYCHOTHERAPY working as Goldstein's assistant at Frankfurt's Institute for Brain Injured Soldiers in 1926, Perls became interested in the transforming of Gestalt psychology into Gestalt therapy (Perls, 1969b). When Hitler came to power, Perls and his new wife Lore (Laura) relocated to Johan- nesburg, South Africa (Stoehr, 2009), where they became the first psychologists in that area (Wheeler, 2004). In 1946, Perls immigrated to the United States, and in 1951 he cowrote Gestalt Therapy: Excitement and Growth in the Human Personality (Perls, Hefferline, $e Good- man, 1951). Following the favorable reception of this text, he established several Gestalt institutes throughout the country, the first in New York in 1952. His work at the Esalen Institute in California established him as a prominent practitioner of Gestalt counseling and psychotherapy. Laura Perls Fritz Perls's work was carried on after his death in 1970 by his wife, Laura Perls. It has be- come increasingly clear since her own death in 1990 that Lore (Laura) Posner Perls (b. 1905) contributed significantly to Gestalt counseling and psychotherapy, having studied with Max Wertheimer and gaining recognition as a Gestalt psychologist in her own right (Gaff- ney, 2009). She continued her work long after her husband's death, becoming an influential force in Gestalt therapy and the training of Gestalt therapists until her own death. Paul Goodman Another person who participated in the development of Gestalt therapy is Paul Goodman (Bloom, 2009). When he met Perls in 1949, Goodman was already an accomplished classical scholar, wrote fiction and political criticism, and had been deeply influenced by his studies of Sigmund Freud, Otto Rank, and Wilhelm Reich (Stoehr, 2009). Goodman collaborated with Perls on Gestalt Therapy: Excitement and Growth in the Human Personality (Perls et al, 1951). Although Perls initially received the recognition for this work, many scholars have since come to credit Goodman with writing at least half of the manuscript, specifically the half dealing with the theory of Gestalt therapy (Serlin 8: Shane, 1999). Goodman's role is now seen as one of collaboration with Fritz and Laura Perls, and his own contribution to development of the theory is acknowled ged (Gaffney, 2009). While Fritz Perls is still cred- ited as Gestalt therapy's most boisterous and ardent promoter, there are those who now consider Paul Goodman its chief theoretician (Meier €: Davis, 2009). Phenomenology, Existentialism, Field Theory, Dialogue, and Gestalt Therapy Gestalt psychology was not the only influence that inspired Gestalt therapy. Although the roots of Gestalt therapy can most certainly be found in phenomenology and field theory (Bloom, 2009), there exists within it the influential existentialist writings of Soren Kierke- gaard, Friedrich Nietzsche, Martin Buber, Paul Tillich, and Martin Heidegger; the writings of Aristotle, William James, John Dewey, and Immanuel Kant; and the philosophies of Zen Buddhism and Taoism. In addition, there are also some added basic principles from psychoanalytic theory, humanistic theories, and Reichian body therapy (Reilly €: Jacobus, 2009). The coagulation of all these perspectives placed the focus on improving clients” awareness of their subjective experience. Gestalt therapy does this by facilitating the cli- ent's ability to become authentic and make choices that lead to a meaningful life, while setting in motion the natural process of growth that moves toward integration within self and between self and the environment (Yontef, 2007). i, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. merican Counseling Association. All rights reserved 170 THEORIES OF COUNSELING AND PSYCHOTHERAPY dichotomies and polarities, and foreground and background, to name just a few. There are many constructs associated with Gestalt therapy, and this section provides an over- view of the major ones. Field Theory: Organism and Environment The scientific paradigm forming the basis of the Gestalt therapy perspective is field theory with a view to the organism—environment as a field of activity (Gaffney, 2009). In contrast to a reductionistic, unilinear, cause-and-effect model, field theory focuses on the whole, in which all the elements found within the field are in relationship to and influence one another (Wagner-Moore, 2004). Field theory is based on the principle of interdependence. Phenomenological Field The phenomenological field is the field that is the focus of Gestalt therapy (Reilly é: Jaco- bus, 2009). This field changes according to the individual's focused awareness (Yontef éz Fuhr, 2005). At one moment, the focus may be entirely internal, attending to self and its in- terrelated parts. During the next moment, the phenomenological field may shift to a focus on the person in relationship to his or her external environment, which is made up of its own constituent and interacting parts. When the focus is internal, the field is represented by parts of the self, which may be broadly defined as mind and body. Holism Gestalt therapy is holistic rather than reductionistic; itis concerned with the differentiation and interrelationship of the parts that make up the whole rather than on parts in isolation from one another (Hurley, Barrett, r Reet, 2006). In therapy, it means attending to the whole person (mind, body, spirit) rather than just one aspect of the client, such as the cli- ent's symptoms. Differentiation and Contact In Gestalt therapy, a healthy individual is one who can differentiate self while also making contact with others. Contact involves the ability to be fully present, in the moment, and available (Lobb €: Lichtenberg, 2005). In fact, life is described as a constant process of con- tact and separation between a person and those with whom the person is in relationship, such as family members and loved ones, colleagues, and employers. Contact and differ- entiation, and connection and separation, define a goal of Gestalt therapy, which is to help clients become more integrated within themselves and in relationship to others—in other words, to help clients to create differentiated unity. Differentiated unity for the client as a whole person means awareness of thoughts, feelings, and senses (i.e., taste, smell, hearing, touch, sight) or an integration of mind and body (Gaffney, 2009). Confluence When people cannot become differentiated, often what happens is confluence. This is the process whereby a person loses sight of himself or herself by incorporating too much of the environment or others into the self (Pack, 2009). Boundaries For survival, the organism—that is, the individual —must make contact with the environ- ment. The function of the individual's boundaries is to simultaneously be firm enough to differentiate self from others, yet open or permeable enough to make contact with others Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. rued, Capuzzi, David, and Copyright O 2010. Americ: zan Counseling Association. All rights reser GESTALT THEORY ¿77 (Pack, 2009). In this process, the individual assimilates nourishment from the environment and rejects or keeps out that which is not nourishing. Therefore, differentiated contact naturally leads to health and development (Kellogg, 2004). Boundary disturbances occur when boundaries between self and others are overly rigid, creating isolation, or are overly permeable, creating a merger in which differentia- tion of self is lost to confluence with the other (Pack, 2009). An example of a boundary disturbance is retroflection, an internal split within the self in which elements of the self are rejected as “not-self.” In this situation, the individual does to self what is normally done to the environment—that is, differentiating between nourishing and toxic elements in the environment, assimilating the former and rejecting the latter (Lobb €: Lichtenberg, 2005). The individual in this case disowns parts of self. This undermines health and functioning. Introjection occurs when material from the environment is taken in without discrimina- tion concerning its nourishing or toxic qualities (Ginger, 2004). Projection involves taking parts of self and directing them outward onto others (Kellogg, 2004). Some people are unaware of disowned parts of themselves and routinely project them onto others. This in- terferes with selfawareness, coming to terms with these disowned elements of the person, and accepting them. Deflection is the avoidance of contact through diversion (Clarkson, 2004). That is, instead of being direct and genuine in a relationship, the individual may present a disingenuous, false image of himself or herself to others, as a way of avoiding contact. However, deflec- tion also occurs when the individual fails to receive, attend to, or be aware of information coming from the environment. Dichotomies and Polarities In field theory, there is a distinction made between dichotomies and polarities (Brownell, 2009). Dichotomies are unnatural splits in which a field is made up of separate, competing, either-or parts instead of integrated elements in relationship to one another that form a whole (Kellogg, 2004). However, polarities are a natural part of fields. Fields are differenti- ated into polarities—opposite parts that work in tandem or in contrast to one another to help clarify meaning (Crocker €: Philippson, 2005). When integration fails, splits occur. The parts of the person—those elements of mind and body that make the person what he or she is—are experienced as separate, not inte- grated (Hurley et al., 2006). Thus, a mother may dichotomize her capacity to be a caretaker from her ability to care for herself. Yet health is found in integration, in which difference is accepted and various parts of the self work together. Foreground and Background Another principle of Gestalt therapy is that of the foreground and background in a phe- nomenological field. The goal is a well-formed figure standing in contrast to a broader, less-well- defined background (Pack, 2009). The figure is in the forefront of the individu- al's awareness of the phenomenological field at any one time. Problems occur when fore- ground and background are not well formed and clearly distinct from one another. The concept of health according to Gestalt theory defines a situation in which aware- ness accurately represents and brings to the foreground the dominant need of the whole field (Yontef €: Jacobs, 2007). Gestalt therapy also abides by the law of homeostasis (or self- regulation), which is the organism's tendency to seek balance within itself and between itself and its environment (Brownell, 2009). Thus, if the person needs food for energy, he or she becomes hungry, the need for food comes to the foreground, and the person eats. This returns the body to a state of homeostasis in which there is enough food to provide the energy needed for proper functioning. Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. GESTALT THEORY ¿72 is apparent that Gestalt therapy places a high value on autonomy and self- determination. Although Gestalt therapy maintains a “no should” ethic, there is one exception. The ex- ception is the situation. Perls believed that when clients understand the situation they find themselves in and allows it to shape their actions, then they have begun to learn how to cope with life (Yontef £z Jacobs, 2007). I-Thou, What and How, Here and Now A shorthand for Gestalt therapy is reflected in the phrase “I-Thou, what and how, here and now,” which was derived from the philosophical writing of Martin Buber (Brownell, 2003a). The counselor or therapist and the client form an alliance based on self-responsibility and an agreement to strive to be present with each other during their time together. Further- more, the focus of counseling and therapy is the “what and how” of a client's experience in the present, in the moments that the counselor or therapist and the client are together (Pack, 2009). The client and the counselor or therapist explore together through experi- ments that reveal what the client does and how it is done. According to Melnick, Nevis, and Shub (2005), the experiment is one method of teaching the client in which the client can learn. A here-and-now focus on the what and how of the client's internal and external processes increases awareness, which is a necessity for growth and a focus of the experi- ment (Wagner-Moore, 2004). The counselor or therapist is aware of the centrality of the client-counselor /therapist relationship and tends to it by being present, respectful of the client's capacity to heal and grow, and willing to be an authentic person in the therapeutic relationship (Melnick et al., 2005). The client-counselor /therapist relationship is viewed as horizontal, not verti- cal. Thus the two parties seek equality in relation to one another (Clarkson, 2004). In this process, the counselor or therapist may choose, when appropriate, to share his or her own experience in the moment as it helps to facilitate the client's awareness. Direct experience is the tool used to expand awareness, and the focus on the client's pres- ent experience is made deeper and broader as counseling or therapy unfolds. Awareness is viewed as occurring now; it takes place now, although prior events can be the object of present awareness (Yontef €: Fuhr, 2005). Even though the event took place in the past, the focus is on the awareness of it that is taking place in the now, in this moment. Therefore, the present is understood as an ever-moving transition between past and future (Yontef éz Jacobs, 2007). ar aman IIIgIgqgqkk+kzgÍk q Overview This section covers the goals and desired outcomes of Gestalt counseling or therapy, the process of change that leads to client growth, and the specific strategies used in the change process. Goals of Counseling and Psychotherapy According to Tillett (1991), “As creativity and spontaneity are central to Gestalt, and as there is intrinsic antipathy towards the concept of therapy as technique, it can be difficult to reach an acceptable definition of Gestalt therapy” (p. 290). However, practice may be illuminated by examining the goals of Gestalt therapy. According to Tillett, they include the following: e Development and expansion of both physical and emotional awareness are empha- sized. Intellectual insight and interpretation are limited. Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. 17% THEORIES OF COUNSELING AND PSYCHOTHERAPY *e Therelationship between client and therapist is existential and is central to the coun- seling or psychotherapy process. + Conversations between client and counselor or psychotherapist are useful only to the extent that they support enactment and experimentation. *e Change should occur as the result of heightened awareness of the interactional pro- cess between client and counselor/psychotherapist or by the activity and experi- mentation within the counseling or psychotherapy process. (p. 291) Yontef (1995) suggested that Gestaltists are not concerned with a “preset end goal” (p. 273). However, Gestaltists do recommend the particular goal of phenomenological exploration rather than reconditioning of behavior or interpretation of the unconscious (Brownell, 2003a). This goal is valuable in that it places ownership and responsibility di- rectly on the client and facilitates the client's engaging in an inherently natural process of growth. Burley and Freier (2004) suggested that the purpose of Gestalt therapy is the “pro- cess of interruption of the gestalt formation and resolution or destruction process” (p. 322). The Process of Change Understanding the process of change from a Gestalt perspective calls for an appreciation of Perls's goal for the process: The Gestalt approach attempts to understand the existence of any event through the way it comes about, which is to understand becoming by the how, and not the why; through the all- pervasive gestalt formation; through the tension of the unfinished situation (business). (Perls, 1966, cited in Fagan é Shepherd, 1970, p. 361) Specifically, the process of change in Gestalt counseling and psychotherapy consists of identifying and working through a variety of blocks or interferences that prevent the client from achieving a balance. Perls (1969a) described clients who block as follows: (a) those who cannot maintain eye contact, who are unaware of their own movements; (b) those who cannot openly express their needs; and (c) those who use repression, examples of which are insomnia and boredom. Yontef and Fuhr (2005) asserted that change in Gestalt therapy happens through three methodological elements: (a) field process thinking, (b) experiment in phenomenological awareness, and (c) existential dialogic contact and an ongoing relationship between coun- selor and client. According to Levitsky and Perls (1970), the process of change, which is aimed at helping clients become more aware of themselves in the here and now, involves several precepts, including the following; 1. Acontinuum of awareness: Clients focus constantly on the how, what, and where in the body, in contrast to the why (Melnick et al., 2005). 2. Statements rather than questions: Many theorists and practitioners have found the es- tablishment of response-ability to be more helpful and respectful than expecting an- swers to questions (Houston, 2003). 3. Useof the first-person pronoun “1” rather than “it” or “they”: 1f a client says that “people feel angry,” for example, the counselor or therapist asks the client to restate this sen- tence using “I feel angry.” Then the client owns his or her feelings instead of distanc- ing himself or herself from them by saying ”I feel thus and so.” 4. The contact issue of addressing someone directly: Clients are helped to express them- selves, their feelings, thoughts, needs, and concerns as they occur in the moment directly to the counselor or therapist. Talking about or “beating around the bush” is discouraged (Yontef éz Fuhr, 2005). Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. 776 THEORIES OF COUNSELING AND PSYCHOTHERAPY Perls believed that counseling and psychotherapy were means of enriching life (Dye éz Hackney, 1975). From his perspective, it is clear that well people can get better. Interven- tion strategies suggested in this section are for clients who are fundamentally well but who need assistance in “making it” in a complex world. The aim of Gestalt counseling and psychotherapy is to take advantage of all dimensions of humanness by achieving integra- tion. The goal is to enable a full experiencing of issues or events rather than just a cognitive understanding of them. Given the goals of completeness, wholeness, integration, and fulfillment of the essen- tially healthy but needy individual (in the sense of an incomplete Gestalt), the following intervention strategies may be used (see Table 8.1). I would like the reader to have the opportunity to learn about as many Gestalt experiments as is feasibly possible. Unfortu- nately, the restrictions on this chapter cannot allow for an in-depth discussion on all the Gestalt experiments available to the practitioner. Therefore, a comprehensive table that provides details—albeit brief ones—on several of these experiments has been provided. Brief Intervention Strategies Generally, Gestalt therapy has not been known for its brevity, and it lacks dimensions usu- ally associated with brief interventions, such as quantifiable behavioral goals (James éz Gilliland, 2003). Within a managed care setting, it is difficult for administrators to accept the types of treatment goals set in Gestalt therapy because insight is neither concrete nor measurable, two criteria for treatment planning within the managed care setting (Haley éz Carrier, 2010). The process of change and perceived progress of a client is considered a function of the whole field, which includes the client's motivation, the therapeutic relationship, the clinical setting, and the client's social world (Brownell, 2003b). Therefore, therapy can be a lengthy process and does not lend itself easily to a managed care setting. It should be reiterated here that Gestalt therapy is existential and phenomenological, and therefore the focus is not on facilitating behavioral changes within the client but on helping the client to develop insight and interpersonal awareness. The purpose is for the client to discover, explore, and experience his or her own shape, pattern, and wholeness and to integrate all of his or her separate parts (Clarkson, 2004). As a result of this insight and awareness, the client can achieve lifestyle changes (Burley €: Freier, 2004). However, given that Gestalt therapy is action oriented, it can in some ways be similar to cognitive-behavioral therapies, and therefore brief therapy benefits can be derived (Hous- ton, 2003). There is no one way to conduct Gestalt therapy, and therefore it can be flexible to brief intervention (Brownell € Fleming, 2005). Gestalt therapy is interested in how a cli- ent does the things he or she does and in building self-awareness. This in turn can lead to the client making different choices in his or her life. As Houston (2003) stated it, “The aim of Gestalt Therapy is to awaken or mobilize people enough for them to get on better with their lives than they were managing before coming for help” (p. 3). Houston (2003) advocated for brief Gestalt therapy (BGT), in which the client is active between sessions in applying the insight learned in session. Houston asserted that clients who are psychologically minded, insight oriented, motivated, and able to develop and sustain relationships are the best candidates for BGT. In this manner, BGT can be effective in as little as eight sessions. Clients With Serious Mental Health Issues It is difficult to have a discussion of Gestalt therapy in relation to clients with serious men- tal health issues because Gestalt therapy is holistic; it does not break a person down into separate “pieces” or variables, and, therefore, it is difficult to “classify” clients in the same Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. rued, Capuzzi, David, and Copyright O 2010. Americ: zan Counseling Association. All rights reser GESTALT THEORY 277 Table 8.1. Gestalt Therapy Intervention Strategies Experiment Purpose Technique Location of Feelings To encourage the client to directly experi- ence sensations in the body that are con- nected to his or her current feelings. Confrontation and Enactment To help the client to confront old behav- lors, feelings, or expressions by acting out the various parts, This confrontation of self and then the enactment of dis- owned thoughts, feelings, sensations, or actions allow the client to discover and then reown neglected parts of the self. To help the client to achieve clarity. This is an extension of the confrontation and enactment intervention. It allows the client to become cognizant of how his or her behavior may be affecting others and to gain insight into all pieces of the problem or issue. Empty-Chair or Two-Chair Strategy; also called the “Hot Seat” Making the Rounds To teach the client, through a group thera- py technique, to be a group member and make some form of contact with other group members or practice new ways of being with each group member. To help the client in the present to under- stand what may be going on in the here and now, Because images, fantasies, and dreams are the projections of the person, dreams can be seen as the metaphoric expressions of the content and can reveal certain aspects of the person. The dream is not interpreted or symbolized in Gestalt therapy. The dream is simply re- enacted to bring awareness to the client regarding the different paths of self. Dream Work Unfinished Business To resolve the unresolved feelings that have been left over from interpersonal relationships, most notably feelings of worry, resentment, grief, guilt, or rage. This exercise is designed to bring incom- plete gestalts to closure. To help the client bring clarity out of con- fusion and enable the client to practice change. This intervention seeks to break the client from the habit of playing the prescribed role(s) he or she continues to play within society. To eliminate the client's ability to mini- mize selfexpression such as with the conjunction “but,” asin “I would like to do this, but...,”or“lama good person, but... ” andit prevents the client from disqualifying or taking away validity by adding ambiguity. Rehearsal Minimization Instead of asking the client, “What are you feeling?” the therapist tells the client, “Show me where you are feeling this anxiety, apprehension, or nervousness.” The client is told to “be your hand,” “be your sorrow,” “be your hatred.” This forces the client to own what has been disowned. By identifying with all his or her “parts,” the client can become what he or she “truly is” and be able to take responsibility for the self. The client is asked to play one or more roles in addition to his or her own self. The client speaks to the part of each person connected to the problem by moving back and forth between the chairs, This technique can also be used for issues that are internal within the cli- ent by having the client move back and forth among opposing forces and play out all the roles pertinent to the internal conflict, For example, in a conflict mak- ing a decision, the client can role play both the “pro” and the “con” sides of the decision-making conflict. The client is asked to engage each member of the group. For example, this engage- ment may be soliciting feedback from each member or making a statement to each member. This technique asks the client to reenact the dream in the present and to play out the parts of the dream as if itwere hap- pening in the here and now. The client is told to animate the dream and give voice to all the people and parts. This allows the counselor or therapist to help the client come into contact with, own, and accept responsibility for parts of the self that may not be well known or accepted, as every part of the dream represents some aspect of the self. The counselor or therapist helps the client to recognize his or her “stuck” points, The emphasis is on helping the client to recognize and accept what “is” rather than what “could be.” The clientis asked to rehearse new sen- tences or actions that are different from his or her status quo. An example of minimization is when the counselor or therapist removes the cli- ent's use of the word but from his or her expressions by changing it to the word and. Asin, “Lam a good person, but...” to “I ama good person, and...” This removes the ambiguity, which allows the client to be noncommittal. (Continued on next page) Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. GESTALT THEORY 179 Table 8.1. Gestalt Therapy Intervention Strategies (Continued) Experiment Purpose Technique “T Take Responsibility To help clients accept and recognize their 1) Bora “TI Have a Secret” Contact and Withdrawal Can You Stay With This Feeling? feelings and actions, and take responsi- bility for them instead of projecting them onto others. To explore feelings of guilt and shame and identify what attachments the client holds that keep him or her from resolv- ing this conflict. To help the client to understand the polar nature of existence and thatitis okay for these polarities to exist. This helps the client to understand itis okay to with- draw from situations to preserve one's attention, For example, one must rest to have energy. This is a polarity, just as one must periodically withdraw from others to maintain closeness. Just as rest- ing enhances energy, so too does tempo- rary withdrawal enhance closeness. To keep clients from running away from uncomfortable feelings or glossing them over without examination. It prevents the client from avoiding. The counselor or therapist facilitates this by making the statement, “I take respon- sibility for...” and then asks the client to fill in the blank. Typically, the client will make a statement such as, “I am uncomfortable in social situations and I take responsibility for my own feelings of dis-ease.” Thisis a group therapy technique in which group members are encouraged to think of a personal dark secret (but not disclose ¡it to the group) and then imag- ine (project) how others would react to this secret if it were known. The clientis told that when he or she feels like withdrawing from a situation, he or she would close his or her eyes and fantasize about a place where he or she feels secure and safe. When the client feels this safety and security, the client then should open his or her eyes, having rested and enhanced energy, continue on, and reestablish contact. When the client expresses a feeling, mood, or state of mind that is unpleasant or uncomfortable and that he or she tries to discount, dispel, or minimize, the client is then asked to elaborate on the “what” and “how” of his or her feelings. manner as is required by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision [DSM-IV-TR]; American Psychiatric Association; see Lobb, 2003). Gestaltists do not believe in disease but rather in “dis-ease,” and to suggest that disorders are of the mind is inimical to the Gestalt approach. Gestaltists believe disorders are holistic and organismic and that symptoms of dysfunction are not in an individual but rather are in the reality of a person's experience (White, 2009). An individual is seen as someone who is ultimately healthy and striving for balance, health, and growth (Hurley et al., 2006). Gestaltists also view symptoms as an individual's creative adjustment to a difficult situa- tion in his or her life (Lobb €: Lichtenberg, 2005). Gestalt theory relates the development of pathology to the habitual selfinterruption along the contact-withdrawal continuum. Contact-withdrawal is a concept that explains people's interactions with others (Bloom, 2009). People make contact with others from the outside boundary of themselves. Humans strive to be together with others in the world (Pack, 2009). When a person has a bad experience or experiences making contact with oth- ers, then he or she begins to withdraw to protect the self (Lobb, 2003). This self-protection prevents appropriate interaction with others, and therefore interactions that could be clas- sified as pathological result instead. As a result of this hindered progress along the contact-withdrawal cycle, people”s needs are not met and they become inhibited in their awareness and expression. As a conse- quence, they begin to internalize to meet their needs satisfaction. Part of the process of this internalization is that people begin to introject that which they cannot get from themselves and internalize messages given by others that they begin to see as truth. Believing they are bad encourages people's fear of abandonment by others, and they then begin to block their awareness, put up defenses, and retroflect (turn back on the self) to prevent expressing Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. 180 THEORIES OF COUNSELING AND PSYCHOTHERAPY their wants or needs and to keep others from leaving them (Lobb ér Lichtenberg, 2005). This is the Gestalt theory of patholo gy. Conversely, normal, healthy behavior occurs when people act and react as total organ- isms—unfragmented, selfregulating, and able to converse along the contact-withdrawal continuum by not selfinterrupting (Lobb ér Lictenberg, 2005). The healthy person con- centrates on one need (the figure) at any present time, delegating other needs to the back- ground. When the need is met, the gestalt closes and is completed, and no business is left unfinished. When the need is unmet, the gestalt remains open and the person accumulates unfinished business (Clarkson, 2004). Research supports that Gestalt therapy works best for overly socialized, restrained, and constricted individuals who intellectualize and have trouble clarifying their feelings (Seligman € Reichenberg, 2009). After having defined the above and stated that Gestalt therapy does not categorize clients according to the DSM-IV-TR criteria, it can also be said that Gestalt therapy has not been limited by the above constraints. In fact, Gestalt therapy has been adapted to be used for a variety of modalities and issues. It has been used in art therapy (Lobb ¿e Amendt-Lyon, 2003), play therapy (Daniels, 2004), educational ther- apy (Garcia, Baker, DeMayo, € Brown, 2005), family and couples therapy (Lynch, Lynch, £r Zinker, 2005), group therapy (Schoenbert, Feder, Frew, €r Gadol, 2005), crisis counsel- ing (O'Connell, 1970), career counseling (Martz, 2001), child and adolescent counseling (Reynolds €: Mortola, 2005; Toman, Bauer, McConville, £ Robertson, 2005), and pasto- ral counseling (Knights, 2002) and has been foundational in many of the touch therapies (Zimmer € Dunning, 1998) as well as eye movement desensitization and reprocessing therapy (Tobin, 2004). Seligman and Reichenberg (2009) stated that Gestalt therapy can be used successfully with the following disorders: mood, anxiety, somatoform, factitious, adjustment, and some personality disorders or personality traits such as avoidant, dependent, narcissistic, histri- onic, and obsessive-compulsive. A literature review demonstrates that Gestalt therapy has been used for a variety of issues, including, but not limited to, alcoholism and substance abuse issues (Clemmens é: Matzko, 2005), autism (Brosnan, Scott, Fox, de Pye, 2004), pho- bias (Imes, 1998), depression (Ellison, Greenberg, Goldman, ér Angus, 2009), sexual abuse (Imes, 1998), psychosomatic complaints (Wolfert €: Cook, 1999), sexual dysfunction and sexuality (Melnick, 2000), body image (Kepner, 2001), issues with self-esteem (Shub, 2000), grief and mourning (Sabar, 2000), developmental issues (Wolfert £r Cook, 1999), workplace enhancement and worker adjustment issues (Kirk, Wood, Burns, Howard, ér Rice, 2001), terminal illness (Strumpfel ¿: Martin, 2004), schizophrenia (Uhlhaas € Silverstein, 2005), posttraumatic stress disorder (Hardie, 2004), geriatric issues (O'Leary € Nieuwstraten, 1999), emotional injury (Greenberg, Warwar, e Malcolm, 2008), bulimia (Denham-Vaughan, 2005), and with special populations such as those who have been institutionalized (e.g., long-term hospitalization and hardcore criminals; Wolfert £r Cook, 1999). It should be noted that caution has been mandated for the use of Gestalt experiments. Although these experiments may seem simple and easy to apply, many are not suitable for all clients, especially those clients who are emotionally fragile, because most of these techniques are very intense. The same cautions are espoused when counselors work with clients who are severely psychotic, severely disturbed, in crisis, or poorly motivated to change (Seligman € Reichenberg, 2009). The skill of the Gestalt counselor or therapist is at issue when working with these types of clients. Improper methods or the inability to work with the client through the trauma, grief, rage, or other intense emotions brought up by these techniques can leave the client in a very vulnerable position. Individuals with more severe issues or disturbances will need long-term intensive counseling or psychotherapy. Although this can be done within the bounds of Gestalt therapy, it must be done with caution and skill. i, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. merican Counseling Association. All rights reserved 18.2 THEORIES OF COUNSELING AND PSYCHOTHERAPY and the counselor or therapist. Dialogue is used to engage clients, not to manipulate or control them. The goal of the Gestalt therapist is to embody authenticity and responsibility in conversations with the client (Daniels, 2004). A third contribution is the emphasis on the counseling or therapy process rather than reliance solely on techniques (Melnick et al., 2005). Beginning practitioners often depend on techniques more than process to help their client. In the application of Gestalt therapy, this creates difficulties because the process of counseling or psychotherapy must accom- modate itself to the personalities and experiences of the counselor or therapist and the client. This often makes it difficult for the novice counselor or therapist to pinpoint an ap- propriate technique to apply to a particular problem. In Gestalt therapy, any activity that contributes to clients” awareness of self, others, and their experience of the larger world is seen as useful. A fourth contribution of Gestalt counseling involves dream work (Clarkson, 2004). The confrontation with “unfinished business” through dream work or other interventions al- lows the practitioner to challenge the client's past in a lively and provocative manner. The purpose of engaging the past is for the client to become aware of and work with concerns, even those from the past, that are a part of present experience and therefore undermine the client's current functioning. A fifth contribution by Gestalt counseling and psychotherapy is its evolutionary shift from constructivism to social constructivism and the acknowledgment that organisms co- create their own reality (Lobb €: Lichtenberg, 2005). People are reactive and cocreate their own truth and reality. Gestalt counseling and therapy has helped the field of counseling evolve over time. Bowman and Nevis (2005) proclaimed that Gestalt therapy has increased a shared therapeutic worldview among practitioners as there “has been movement (a) from deconstructive views of the world toward holistic models of existence; (b) from linear cau- sality toward field theoretical paradigms; and (c) from an individualistic psychology to- ward a dialogical or relational perspective” (p. 5). Finally, in this age of requirements for accountability to those who pay for services, such as third-party payers, the Gestalt approach lends itself well to treating certain diagnoses. According to Seligman and Reichenberg (2009), Gestalt therapy is appropriate for treating certain affective disorders, including anxiety, somatoform, and adjustment disorders, as well as occupational and interpersonal problems, and according to Houston (2003), Gestalt therapy can be effective as a brief therapy to fit the managed care environment. Supporting Research Gestalt therapy focuses on phenomenology and the subjective experience of the client. It is largely existential, experiential, and experimental in nature. These features do not lend themselves well to psychotherapy outcome studies (Strumpfel ¿e Martin, 2004). However, evaluation of client outcomes in Gestalt therapy is idiographic—that is, assumed to be based on individual experiences unique to the subject of evaluation. Although individu- als can be questioned about their unique experience of growth in Gestalt therapy, these reports do not lend themselves well to empirical research and the summation of findings via statistical analyses of group data. Therefore, Gestalt therapy has often been criticized for not having adequate research to support its claims (Burley ér Freier, 2004). However, Clarkson (2004) asserted, “Gestalt is concerned with the quality of practice, of learning, of making sense or meaning of experience—so is qualitative research” (p. 182). Gestalt therapy has been shown to be as effective as any other form of therapy (Crocker £r Philippson, 2005). Current research regarding which therapies are most effective have concluded that common factors, which include the therapeutic relationship and the work- ing alliance, are perhaps the most influential factors and that no one theory or therapy stands above the rest as more efficacious or effective as any other (Brown ér Lent, 2008; Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. rued, Capuzzi, David, and Copyright O 2010. Americ: zan Counseling Association. All rights reser GESTALT THEORY ¿33 Gelso éz Fretz, 2001). Gestalt counseling acknowled ges the powerful role of the therapeutic relationship in the success of therapy, and much time is spent in development of the -Thou relationship and equality between counselor and client. Research shows a great deal of support for the efficacy of Gestalt therapy. In a meta- analysis of 31 clinical studies, Strumpfel and Martin (2004) noted the greatest effect size of Gestalt therapy for affective disturbances, substance dependence disorders, psychoso- matic disturbances, personality disturbances, interpersonal problems, and chronic pain. Strumpfel and Martin stated that even though Gestalt therapy is not symptom oriented, it works as effectively on symptoms as therapies that are more symptom oriented. Limitations One of the limitations related to Gestalt counseling and psychotherapy has little to do with the theory itself but with Perls (Reilly €: Jacobus, 2009). The reliance on the workshop for- mat developed during the 1960s seemed to lead to a reliance on Perls himself as a sort of guru who could answer any problem by demonstrating Gestaltism in a workshop (Stoehr, 2009). Although today's practitioners of Gestalt are gentler and less confrontational, the therapy is still largely associated with the antics of Perls himself (Yontef, 2007). In addition, Perls's work is sometimes seen as a potpourri of various theories—a little Freud, a little Jung, and a lot of the Berlin school—yet Perls seldom credits them for their contributions. Consequently, in her later years and upon reflection, Laura Perls noted that there were as many ways to do Gestalt therapy as there were Gestalt therapists, which further dilutes the practice of the theory (Brownell €z Fleming, 2005). Another limitation of Gestalt therapy is the temptation for novice counselors or thera- pists to use such Gestalt techniques (i.e., processes) as empty chair, top dog-underdog, figure-ground, and locating feelings without sufficient practitioner training. However, these processes alone can be of little value in helping the client. In addition, the intense emotional responses that some Gestalt experiments evoke can be harmful to the client if misused or abused by an inexperienced counselor or therapist (Melnick et al., 2005). Other criticisms stem from counselors who use Gestalt therapy and integrate other techniques into a hybrid form of counseling that does not fit under the Gestalt theoretical umbrella. Sometimes these other techniques clash with Gestalt theory and are ineffectual (Brownell €: Fleming, 2005). Some practitioners believe the client's cognitive process is important in counseling or psychotherapy work, yet many Gestaltists tend to deemphasize cognition, focusing more on feeling (Yontef, 1993). In addition, the holistic nature of Gestalt counseling and psychotherapy and its allowances for therapist creativity in developing treatments fly in the face of today's trend toward specialization in the medical field. Fi- nally, Gestalt therapy does not lend itself well to diagnosis using the DSM-IV-TR (Ameri- can Psychiatric Association, 2000) or behavioral contracting, which limits its applicability in managed care settings (James € Gilliland, 2003). Despite the limitations that may exist in Gestalt counseling and psychotherapy, its ho- listic nature is one of its most appealing features. Contrasted with more empirical scientific approaches, it offers a wide variety of opportunities to facilitate the client's journey toward greater health and development. Summary Chart: Gestalt Theory Human Nature Rooted in existentialism and phenomenology, Gestalt counseling and psychotherapy fo- cuses attention on the holistic nature of humankind. Gestalt counselors and therapists strive to encompass the whole organism and operate from the perspective that human beings have the capacity and strength to grow, to develop, and to become the persons they Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. GESTALT THEORY 1/85 and the “shoulds” that make up his or her life. The client will then make better choices that lead to a better life situation, will develop the ability for growth, and will become more integrated within the self, with others, and between the self and the environment. Through this enhanced awareness of the self, the client will gain self-acceptance and can take re- sponsibility for his or her choices and be in charge of his or her own destiny. The therapy objective for any client is to help the client become response-able and break through his or her stuck points. The therapy is not directive but is experiential and is con- ducted through a conduit of the here and now and through the client-therapist (1-Thou) relationship. The focus is on the process and not the content. Case Conceptualization Maria has experienced a series of disappointments and traumas in the last few years. She has survived an abusive relationship and the abandonment of herself and her children by her husband, she has endured estrangement and disapproval from her family of origin, and she is struggling to parent her children alone. She does not feel she is receiving any support from her family or her employer, and it is clear that she feels alone and hopeless. In other words, she feels stuck and is at an impasse in her life. Maria has also introjected and internalized toxic material from her environment through the negativity of her family and other important individuals in her life. Therefore, she has not been able to differentiate herself from significant others” views or goals for her. This has led to confluence, which has contributed to her problems. In addition, Maria is not currently experiencing any support through a genuine, trusting relationship, and thus her growth has been hindered and she has experienced a negative view of self. Consequently, she has become out of sync with herself, her culture, and her view of the world, and she has lost contact with important others and has withdrawn from her children, her friends, her family, and even herself. Treatment Plan Creative and spontaneous intervention is the method of the experienced Gestalt counselor or therapist. The major goal of Gestalt counseling or psychotherapy, toward which inter- ventions aim, is autonomy and growth of the client through increased awareness. Accord- ing to Yontef (1995), this can be micromwvareness—awareness of a particular content area and awareness of the awareness process. Through heightened awareness, clients can know what they are choosing to do and can ultimately accept responsibility for these actions. They can also discover available choices and alternatives they may not have recognized due to limited self-awareness. To help facilitate client awareness and growth, the practitioner does the following; + He or she identifies themes or presenting problems that are central to the client's self- organization. + He or she conceptualizes the issues and concerns of the client that will guide the sequence, timing, and methods of the counseling or psychotherapy process. + He or she establishes and maintains a safe and professional environment. e Heor she provides an atmosphere that invites contact between client and counselor or therapist and encourages interaction. Specifically, in the case of Maria, it will be very important to establish contact with her through a genuine, trusting relationship in which she can feel safe and supported and can explore her emotion regarding the hurt and pain she carries within. When a person is Capuzzi, David, and Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. Copyright O 2010. American Counseling Association. All rights reserved. 186 THEORIES OF COUNSELING AND PSYCHOTHERAPY supported through a genuine and trusting relationship, that person can grow in a posi- tive direction and can gain a positive sense of self. Empathic understanding through the dialogue between counselor and client is seen as an important part of this change process. One goal for Maria is to help her develop awareness of her emotions and her own needs, goals, and priorities as separate from those around her. Once Maria can accurately know herself and know her own wants and needs as separate from those of others, she can dif- ferentiate herself from her environment. She will become aware of how the choices she has made for herself have constricted her life and growth potential. This will enable her to make decisions for herself that will be healthy and contribute to her positive growth. Toward this end, it is important to keep Maria present in the here-and-now exploration of her feelings, beliefs, and values as she relates her experiences to her therapist. Maria will need help in exploring the unfinished business of her divorce and family situation and in purging unexpressed emotions. In this manner, she will gain insight and can truly work through her unfinished business in a productive manner. This may help alleviate her bad dreams and provide better sleep for her. It is also important for the counselor to view Maria as capable and response-able to empower her to help her learn to be self-directing and self-actualizing. One caveat here would be to proceed within the boundaries of Maria's culture, but it may be important to help her explore her culture and help her own it rather than have it be an introjected part of her environment. Maria has the response-ability to choose what she values and discover for herself which parts of her culture is congruent with her core, true self. This, too, will also help Maria become more integrated and differentiated, and she will gain valuable self- knowled ge. One way of doing this is to help Maria explore the “shoulds” in her life to gain a deeper understanding of where these come from, which are helpful, and which are those that contribute to her feelings of depression and sense of “stuckness.” Experiments In collaboration with the client, Gestalt counselors and therapists design experiments that will bring about greater self knowledge and insight. This will allow the client to com- plete unfinished business by bringing the situation from the past and “into the right now” whereby the client can use words, actions, or fantasy to complete the unfinished event (Melnick et al., 2005). Some of the experiments that could facilitate the goals outlined above for Maria are listed below. There are many experiments that could be used in the case of Maria, but space prohibits using more than one or two for this section. The following is an attempt to give the reader insight into how these experiments might be used and how they might enhance Maria's awareness. Empty-Chair Technique This technique can be used to help Maria express her feelings and understand her beliefs regarding her divorce and help her deal with the unfinished business that continues to plague her surrounding this event. The counselor or therapist will ask Maria her permis- sion to proceed with the experiment. With her approval, the counselor or therapist will have Maria sit in one chair with another empty chair directly across from her. The coun- selor or therapist then has Maria speak both her part and the part of her husband. This will allow Maria the opportunity not only to express her repressed and avoided feelings but also to express what Maria imagines her husband would say to her in response. This experiment takes the emotion out of the safety of referring to it in the past and brings itinto the present where it can be worked through. Through the empty chair, Maria can speak di- rectly to her husband and tell him of her anger and sense of betrayal and abandonment. In this way, Maria can complete her unfinished business with her husband and gain valuable Gross, Douglas R., eds. Counseling and Psychotherapy : Theories and Interventions (5). Alexandria, US: American Counseling Association, 2010. ProQuest ebrary. Web. 22 November 2016. rued, Capuzzi, David, and Copyright O 2010. Americ: zan Counseling Association. All rights reser 
