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Psychotherapy today

Gestalt therapyGestalt therapy is an existential and experiential psychotherapy that focuses on the individual’s experience in the present moment, the therapist-client relationship, the environmental and social contexts in which these things take place, and the self-regulating adjustments people make as a result of the overall situation. It emphasizes personal responsibility. Gestalt therapy was co-founded by Fritz Perls, Laura Perls and Paul Goodman in the 1940s–1950s.

Overview of main premises

Edwin Nevis described Gestalt therapy as “…a conceptual and methodological base from which helping professionals can craft their practice” (Nevis, E., 2000, p.3). In the same volume Joel Latner asserted that Gestalt therapy is built around two central ideas: that the most helpful focus of psychology is the experiential present moment and that everyone is caught in webs of relationships; thus, it is only possible to know ourselves against the background of our relation to other things (Latner, 2000). The historical development (see below) of Gestalt therapy shows the influences that have resulted in these two foci. Expanded, they result in the four chief theoretical constructs (see below under the theory and practice section) that comprise Gestalt theory and guide the practice and application of Gestalt therapy.

Gestalt therapy was forged from various influences in the times and lives of the founders: physics, Eastern religion, existential phenomenology, Gestalt psychology, psychoanalysis, theatrical performance, systems and field theory (Mackewn, 1997).

Gestalt therapy rose from its beginnings in the middle of the 20th century to rapid and widespread popularity during the decade of the 1960s and early 1970s. During the 70s and 80s Gestalt therapy training centers spread globally, but they were, for the most part, not aligned with formal academic settings. As the cognitive revolution eclipsed Gestalt therapy in psychology, many came to believe Gestalt was an anachronism. In the hands of Gestalt practitioners, Gestalt therapy became an applied discipline in the fields of psychotherapy, organizational development, social action, and eventually coaching. Until the turn of the century Gestalt therapists disdained the positivism underlying what they perceived to be the concern of research, and so, largely, ignored the need to utilize research to further develop Gestalt therapy theory and support Gestalt therapy practice. That has begun to change.
Gestalt therapy focuses more on process (what is happening) than content (what is being discussed). The emphasis is on what is being done, thought and felt at the moment rather than on what was, might be, could be, or should be.

Gestalt therapy is a method of awareness, by which perceiving, feeling, and acting are understood to be separate from interpreting, explaining and judging using old attitudes. This distinction between direct experience and indirect or secondary interpretation is developed in the process of therapy. The client learns to become aware of what they are doing psychologically and how they can change it. By becoming aware of and transforming their process they develop self acceptance and the ability to experience more in the “now” without so much interference from baggage of the past.

The objective of Gestalt therapy, in addition to helping the client overcome symptoms, is to enable him or her to become more fully and creatively alive and to be free from the blocks and unfinished issues that may diminish optimum satisfaction, fulfillment, and growth. Thus, it falls in the category of humanistic psychotherapies.

Contemporary theory and practice

Gestalt therapy theory rests atop essentially four “load bearing walls:” phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom – Brownell, P. (ed.) (2008), Handbook for Theory, Research, and Practice in Gestalt Therapy, UK: Cambridge Scholars Publishing. Although all these tenets are present in the early formulation and practice of Gestalt therapy, as described in Perls, F. (1969), Ego, Hunger, and Aggression. and in Gestalt Therapy, Excitement and Growth in the Human Personality (Perls, Hefferline, & Goodman, 1951), the early development of Gestalt therapy theory emphasized personal experience and the experiential episodes understood as the “safe emergencies” of experiments; indeed, half of Perls, Hefferline, and Goodman (1951) consists of such stylized experiments. Later, through the influence of such people as Erving and Miriam Polster (Polster & Polster, 1973), a second theoretical emphasis emerged: contact between self and other, and ultimately the dialogical relationship between therapist and client. Later still, field theory emerged as an emphasis (Wheeler, 1991). At various times over the decades since Gestalt therapy first emerged one or more of these tenets, and the associated constructs that go with them, have captured the imagination of those who have continued developing the contemporary theory of Gestalt therapy. Since 1990 the literature focused on Gestalt therapy has flourished, including the development of several professional Gestalt journals. Along the way, Gestalt therapy theory has also been applied in Organizational Development and Coaching work. Thus, currently, Gestalt therapy training institutes often offer programs in both clinical and organization tracks.

Phenomenological method

The goal of a phenomenological exploration is awareness (Yontef, 1993). This exploration works systematically to reduce the effects of bias through repeated observations and inquiry (Yontef, 2005).

The phenomenological method comprises three steps: (1) the rule of epoché, (2) the rule of description, and (3) the rule of horizontalization (Spinelli, 2005). In the rule of epoché one sets aside one’s initial biases and prejudices in order to suspend expectations and assumptions. In the rule of description, one occupies oneself with describing instead of explaining. In the rule of horizontalization one treats each item of description as having equal value or significance. The rule of epoché sets aside any initial theories with regard to what is presented in the meeting between therapist and client. The second rule implies immediate and specific observations, abstaining from interpretations or explanations, especially those formed from the application of a clinical theory superimposed over the circumstances of experience. The third rule avoids any hierarchical assignment of importance such that the data of experience become prioritized and categorized as they are received. A Gestalt therapist utilizing the phenomenological method might find him or herself typically saying something like, “I notice a slight tension at the corners of your mouth when I say that, and I see you shifting on the couch and folding your arms across your chest … and now I see you rolling your eyes back.” All this is not to say that the therapist never makes clinically relevant evaluations, but that he or she, when applying the phenomenological method, temporarily suspends the need for that (Brownell, in press, 2009, 2008).

Dialogical relationship

To create the conditions under which a dialogic moment might occur, the therapist attends to his or her own presence, creates the space for the client to enter in and become present as well (called inclusion), and commits him or herself to the dialogic process, surrendering to what takes place between them as opposed to attempting to control it. In presence, the therapist “shows up” as the whole and authentic person he or she is (Yontef, 1993) instead of assuming a role, false self, or persona. To practice inclusion is to accept however the client chooses to be present, and that may be in a defensive and obnoxious stance as well as an overly sweet but superficially cooperative one. To practice inclusion is to support the presentation of the client, including his or her resistance, not as a gimmick but in full realization that that is how the client is present. Finally, the Gestalt therapist is committed to the process, trusts in that process, and does not attempt to save him or herself from it (Brownell, in press, 2009, 2008)). It should be noted that since Gestalt therapy is an experiential therapy, it is extremely difficult to encapsulate it in the concepts used above, which Perls would probably have referred to as “elephant shit.” From the above description one would be hard put to envision what a Gestalt therapist really does or what a session would look like!

Field-theoretical strategies

“The field” can be considered in two ways. There are ontological dimensions and there are phenomenological dimensions to one’s field. The ontological dimensions are all those physical and environmental contexts in which we live and move. They are the office in which one works, the house in which one lives, the city and country of which one is a citizen, and so forth. The ontological field is the objective reality that supports our physical existence. The phenomenological dimensions are all mental and physical dynamics that contribute to a person’s sense of self, one’s subjective experience, but are not merely elements of the environmental context. This could be the memory of an uncle’s inappropriate affection, one’s color blindness, one’s sense of the social matrix in operation at the office in which one works, and so forth. It is in the way that Gestalt therapists choose to work with field dynamics that makes what they do strategic (Brownell, in press, 2009, 2008)). Gestalt therapy focuses on the character structure; according to Gestalt theory, the character structure is dynamic rather than fixed in nature. To look into ones character structure, the focus would be on the phenomenological dimensions rather than the ontological dimensions.

Experimental freedom

Gestalt therapy has distinguished itself by moving to action, away from mere talk therapy, and is considered an experiential approach (Crocker, 1999). Through experiments, the therapist supports the client’s direct experience of something new instead of the mere talking about the possibility of something new. Indeed, the entire therapeutic relationship could be considered experimental, because at one level it is the provision of corrective, relational experience for many clients, and it is the “safe emergency” that is free to turn this way and that. An experiment can also be conceived of as a teaching method that creates an experience in which a client might learn something as part of their growth (Melnick & Nevis, 2005). Examples: (1) rather than talking about one’s critical father, a Gestalt therapist might ask the patient/client to imagine the parent was present, or that the therapist was the parent, and talk to that parent in this fashion; (2) If a client/patient is struggling with how to be assertive, a Gestalt therapist could either (a) have the patient say some assertive things to members of a therapy group, or (b) give a talk on how one should never be assertive; (3) A Gestalt therapist might notice something about the non-verbal behavior or tone of voice of the client; the therapist might have the client exaggerate the non-verbal behavior and pay attention to his/her experience while doing so; (4) a Gestalt therapist might work with the breathing or posture of the client, and changes in these when the client talks about different content. Through all these means the Gestalt therapist is working with process rather than content, the How rather than the What.

Notable issues

Self

In field theory, self is a phenomenological concept, and is a comparison with ‘other’. Without other there is no self, and how I experience other is inseparable from how I experience self. The continuity of selfhood (personality functioning) is something achieved rather than something inherent “inside” the person, and has its advantages and disadvantages. At one end of the spectrum, there is not enough self-continuity to be able to make meaningful relationships or to have a workable sense of who I am. In the middle, personality is a loose set of ways of being that work for me, commitments to relationships, work, culture and outlook, always open to change where I need to adapt to new circumstances, or just want to try something new. At the other end, it is a rigid defensive denial of the new and spontaneous. I act in stereotyped ways, and either induct other people to act in particular and fixed ways towards me; or I redefine their actions to fit with the fixed stereotypes.

In Gestalt therapy then, the approach is not the self of the client being helped or healed by the fixed self of the therapist, but the exploration of the co-creation of self and other in the here-and-now of the therapy. There is not the assumption that the client will act in all other circumstances as he or she does in the therapy situation. However, the areas that cause problems will be either the lack of self definition leading to chaotic or psychotic behaviour, or the rigid self definition in some area of functioning that denies spontaneity and makes dealing with particular situations impossible. Both of these show very clearly in the therapy, and can be worked with in the relationship with the therapist.

The experience of the therapist is also very much part of the therapy: since we are co-creating our self-other experiences, the way I experience being with the client is significant information about how the client experiences themselves. The proviso here is that I as therapist am not operating from my own fixed responses, and this is why Gestalt therapists are required to undertake significant therapy of their own during training.
From the perspective of this theory of self, neurosis can be seen as fixed predictability—a fixed Gestalt, and the process of therapy can be seen as facilitating the client to become unpredictable, really, more responsive to what is in the client’s present environment, rather than responding in a stuck way to past introjects or other learning. If the therapist is working from some theory of how the client should end up, this defeats the aim of the therapy.

Change

In what has now become a “classic” of Gestalt therapy literature, Arnold Beisser (1970) described Gestalt’s paradoxical theory of change. The paradox is that the more one attempts to be who one is not, the more one remains the same (Yontef, 2005). Conversely, when people identify with their current experience, the conditions of wholeness and growth support change. Put another way, change comes about as a result of “full acceptance of what is, rather than a striving to be different” (Houston, 2003).

Influences forming Gestalt therapy

Psychotherapy

Psychotherapy is an intentional interpersonal relationship used by trained psychotherapists to aid a client in problems of living. It aims to increase the individual’s well-being. Psychotherapists employ a range of techniques based on experiential relationship building, dialogue, communication and behavior change and that are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family). Psychotherapy may be performed by practitioners with a number of different qualifications, including psychologists, marriage and family therapists, occupational therapists, licensed clinical social workers, counselors, psychiatric nurses, psychoanalysts, and psychiatrists.

Etymology

The word psychotherapy comes from the Ancient Greek words psychē, meaning breath, spirit, or soul and therapeia or therapeuein, to nurse or cure. [1] Its use was first noted around 1890. [2] It is defined as the relief of distress or disability in a one person by another, using an approach based on a particular theory or paradigm, and that the agent performing the therapy has had some form of training in delivering this. It is these latter two points which distinguish psychotherapy from other forms of counseling or caregiving.[3]

Forms

Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Purposeful, theoretically based psychotherapy began in the 19th century with psychoanalysis; since then, scores of other approaches have been developed and continue to be created.
Therapy is generally employed in response to a variety of specific or non-specific manifestations of clinically diagnosable and/or existential crises. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers). However, the term counseling is sometimes used interchangeably with “psychotherapy”.

Whilst some psychotherapeutic interventions are designed to treat the patient employing the medical model, many psychotherapeutic approaches do not adhere to the symptom-based model of “illness/cure”. Some practitioners, such as humanistic therapists, see themselves more in a facilitative/helper role. As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of confidentiality is enshrined in the regulatory psychotherapeutic organizations’ codes of ethical practice.

Psychotherapy systems

There are several main broad systems of psychotherapy:

  • Psychoanalytic – the first practice to be called a psychotherapy. It encourages the verbalization of all the patient’s thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the unconscious conflicts which are causing the patient’s symptoms and character problems.
  • Cognitive behavioral – generally seeks by different methods to identify and transcend maladaptive cognitions, appraisal, beliefs and reactions with the aim of influencing destructive negative emotions and problematic dysfunctional behaviors.
  • Psychodynamic – is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension. Although it has its roots in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis.
  • Existential – is based on the existential belief that human beings are alone in the world. This aloneness leads to feelings of meaninglessness which can be overcome only by creating one’s own values and meanings.
  • Humanistic – emerged in reaction to both behaviorism and psychoanalysis and is therefore known as the Third Force in the development of psychology. It is explicitly concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximise potential, ‘the self-actualing tendency’. The task of Humanistic therapy is to create a relational environment where this tendency might flourish.
  • Brief – “Brief therapy” is an umbrella term for a variety of approaches to psychotherapy. It differs from other schools of therapy in that it emphasizes (1) a focus on a specific problem and (2) direct intervention. It is solution-based rather than problem-oriented. It is less concerned with how a problem arose than with the current factors sustaining it and preventing change.
  • Systemic – seeks to address people not at an individual level, as is often the focus of other forms of therapy, but as people in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy & marriage counseling).
  • Transpersonal – Addresses the client in the context of a spiritual understanding of consciousness.
    There are hundreds of psychotherapeutic approaches or schools of thought. By 1980 there were more than 250, [4]. By 1996 there were more than 450, [5]). The development of new and hybrid approaches continues around the wide variety of theoretical backgrounds. Many practitioners use several approaches in their work and alter their approach based on client need.

History
In an informal sense, psychotherapy can be said to have been practiced through the ages, as individuals received psychological counsel and reassurance from others. Purposeful, theoretically-based psychotherapy was probably first developed in the Middle East during the 9th century by the Persian physician and psychological thinker, Rhazes, who was at one time the chief physician of the Baghdad hospital. In the West, however, serious mental disorders were generally treated as demonic or medical conditions requiring punishment and confinement until the advent of moral treatment approaches in the 18th Century. This brought about a focus on the possibility of psychosocial intervention – including reasoning, moral encouragement and group activities – to rehabilitate the “insane”.

Psychoanalysis was perhaps the first specific school of psychotherapy, developed by Sigmund Freud and others through the early 1900s. Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis, and theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference and analysis of the id, ego and superego were developed.

Many theorists, including Anna Freud, Alfred Adler, Carl Jung, Karen Horney, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut, built upon Freud’s fundamental ideas and often formed their own differentiating systems of psychotherapy. These were all later categorized as psychodynamic, meaning anything that involved the psyche’s conscious/unconscious influence on external relationships and the self. Sessions tended to number into the hundreds over several years.

Behaviorism developed in the 1920s, and behavior modification as a therapy became popularized in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eysenck in Britain, and John B. Watson and B.F. Skinner in the United States. Behavioral therapy approaches relied on principles of operant conditioning, classical conditioning and social learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used for phobias, as well as other disorders. Some therapeutic approaches developed out of the European school of existential philosophy. Concerned mainly with the individual’s ability to develop and preserve a sense of meaning and purpose throughout life, major contributors to the field (e.g., Irvin Yalom, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy van Deurzen) attempted to create therapies sensitive to common ‘life crises’ springing from the essential bleakness of human self-awareness, previously accessible only through the complex writings of existential philosophers (e.g., Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, Friedrich Nietzsche). The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic enquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based on existentialism and the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into mainstream focus. Rogers’s primary requirement is that the client should be in receipt of three core ‘conditions’ from their counsellor or therapist: unconditional positive regard, also sometimes described as ‘prizing’ the person or valuing the humanity of an individual, congruence [authenticity/genuineness/transparency], and empathic understanding. The aim in using the ‘core conditions’ is to facilitate therapeutic change within a non-directive relationship conducive to enhancing the client’s psychological well being. This type of interaction enables the client to fully experience and express themselves. Others developed the approach, like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication, and Eric Berne, founder of Transactional Analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today. Self-help groups and books became widespread.

During the 1950s, Albert Ellis originated Rational Emotive Behavior Therapy (REBT). A few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included generally relative short, structured and present-focused therapy aimed at identifying and changing a person’s beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psycho-dynamic or humanistic therapies. Cognitive and behavioral therapy approaches were combined and grouped under the heading and umbrella-term Cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT were oriented towards active/directive collaborative empiricism and mapping, assessing and modifying clients core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A “third wave” of cognitive and behavioral therapies developed, including Acceptance and Commitment Therapy and Dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. Counseling methods developed, including solution-focused therapy and systemic coaching. Postmodern psychotherapies such as Narrative Therapy and coherence therapy did not impose definitions of mental health and illness, but rather saw the goal of therapy as something constructed by the client and therapist in a social context. Systems Therapy also developed, which focuses on family and group dynamics—and Transpersonal psychology, which focuses on the spiritual facet of human experience. Other important orientations developed in the last three decades include Feminist therapy, Brief therapy, Somatic Psychology, Expressive therapy, applied Positive psychology and the Human Givens approach which is building on the best of what has gone before. A survey of over 2,500 US therapists in 2006 revealed the most utilized models of therapy and the ten most influential therapists of the previous quarter-century.[6]

General concerns

Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid clients in reaching their full potential or to cope better with problems of life. Psychotherapists usually receive remuneration in some form in return for their time and skills. This is one way in which the relationship can be distinguished from an altruistic offer of assistance.
Psychotherapists and counsellors often require to create a therapeutic environment referred to as the frame, which is characterised by a free yet secure climate that enables the client to open up. The degree to which client feels related to the therapist may well depend on the methods and approaches used by the therapist or counsellor.

Psychotherapy often includes techniques to increase awareness, for example, or to enable other choices of thought, feeling or action; to increase the sense of well-being and to better manage subjective discomfort or distress. Psychotherapy can be provided on a one-to-one basis or in group therapy. It can occur face to face, over the telephone, or, much less commonly, the Internet. Its time frame may be a matter of weeks or many years. Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining person relationships or meeting personal goals. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with “psychotherapy”.

Psychotherapists employ a range of techniques to influence or persuade the client to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is designed to improve the mental health of a client or patient, or to improve group relationships (as in a family). Most forms of psychotherapy use only spoken conversation, though some also use other forms of communication such as the written word, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.

Psychotherapists are often trained, certified, and licensed, with a range of different certifications and licensing requirements depending on the jurisdiction. Psychotherapy may be undertaken by clinical psychologists,counseling psychologists, social workers, marriage-family therapists, expressive therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines.

Psychiatrists have medical qualifications and may also administer prescription medication. The primary training of a psychiatrist focuses on the biological aspects of mental health conditions, with some training in psychotherapy.

Psychologists have more training in psychological assessment and research and, in addition, in-depth training in psychotherapy. Social workers have specialized training in linking patients to community and institutional resources, in addition to elements of psychological assessment and psychotherapy. Marriage-Family Therapists have specific training and experience working with relationships and family issues. A Licensed Professional Counselor (LPC) generally has special training in career, mental health, school, or rehabilitation counseling to include evaluation and assessments as well as psychotherapy. Many of the wide variety of training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree, or involves multiple certifications attached to one specific degree.

Information taken from Wikipedia, the free encyclopedia

STRASBOURG DECLARATION

ON PSYCHOTHERAPY OF 1990
In accordance with the aims of the World Health Organisation (WHO), the non-discrimination accord valid within the framework of the European Union (EU) and intended for the European Economic Area (EEA), and the principle of freedom of movement of persons and services, the undersigned agree on the following points:

  1. Psychotherapy is an independent scientific discipline, the practice of which represents an independent and free profession.
  2. Training in psychotherapy takes place at an advanced, qualified and scientific level.
  3. The multiplicity of psychotherapeutic methods is assured and guaranteed.
  4. A full psychotherapeutic training covers theory, self-experience, and practice under supervision. Adequate knowledge of various psychotherapeutic processes is acquired.
  5. Access to training is through various preliminary qualifications, in particular human and social sciences.Strasbourg, October 21st, 1990
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