Brief Gestalt Therapy

Gaie Houston

• Publisher: SAGE Publications Ltd
• Year: 2003
• ISBN:
  9781446229729
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

`Anybody with the slightest interest in brief therapy should read this book. Now that the initial controversy over brief therapy has begun to subside it is great to see how brief therapy works in practice. Gaie Houston?s book is part of a series published by SAGE which sets out to do this - and hers is particularly illuminating and accessible.

As she points out Gestalt is better equipped than many mainstream therapies to be applied to situations with extreme time constraints because it is both flexible and it acknowledges the part that can be played by other therapies. But what propels Houston?s book out of the hum drum - or indeed the defensive (or offensive) diatribes about short therapy which have appeared over the past few years - is her vivid accounts of real-life sessions, both one to one and group, which punctuate the text? - Amazon Review

Brief Gestalt Therapy demonstrates how the Gestalt approach can be used effectively in brief interventions with clients. Gestalt?s distinctively integrative nature and emphasis on a highly co-operative working alliance, make it particularly suited to brief work.

The book sets out the basic theory and principles of Gestalt and looks at each phase of the therapeutic process from initial assessment through the beginning and middle stages to the ending of the work. It presents clear, practical strategies for therapists to follow and in particular examines:

} aspects of Gestalt which are especially relevant to brief work

-} the elements of successful therapy

-} ways of improving skills.

Brief Gestalt Therapy includes vignettes and detailed case studies which bring the theory alive. It will contribute much to both existing literature on Gestalt therapy and also brief therapy, and will be invaluable to trainee and practising Gestalt therapists.

1

Overview

This book sets out to describe how Gestalt Therapy can be used to good purpose and with good outcomes, in brief interventions with a broad range of variously distressed people. It is aimed at psychotherapy students, and experienced practitioners from other disciplines, who want to feel confident about integrating some of what is explained here, into their approach.

Lack of money from funding bodies is behind much of the current interest in brief methods. That is likely to be a bad reason for adopting any therapeutic style. However, this bad reason may have led, or be leading, towards good therapy.

More than a few people still wait to be convinced that brief therapy can achieve anything worthwhile. Many practitioners and schools stress the value of long-term, and alongside that, are dubious about brief work. Further research is arguably needed to establish whether it is valid to assume very readily that long-term therapy is necessarily more effective than that lasting only a few weeks. The efficacy of short-term work is well evidenced by Bloom (1992). Talmon (1990) argues, yet more radically, that most people who drop out of therapy even after just one session do so because they feel they have been helped enough already.

For many people, brief, rather than rigidly time-limited therapy, is indeed enough (Roth and Fonagy, 1996). For others, whose distress perhaps dates back furthest and is profound, years rather than weeks are certainly needed for the de-construction of old perceptions, and the learning of a new and at best a more rewarding way of living. Even here, there is evidence that brief intervention can be of use; Fisch and Schlanger (1998) describe such work with alcoholism, paranoia, delusion and severe depression, under the appropriate title, Brief Therapy with Intimidating Cases. Klerman et al. (1984) describe a brief treatment model successful with moderate and severe depression, based on Sullivan’s interpersonal method, analogous to Gestalt dialogic method.

The idea that people can be helped on the road to healing or change through short exposure to therapy is indeed not new.

There is a great deal of fairly subtle data to support the notion that every human being, if he is not too tediously demoralised by a long series of disasters, comes fairly readily to manifest processes which tend to improve his efficiency as a human being, his satisfactions, and his success in living. (Sullivan, 1954: 100)

The development of brief therapy

In the second half of the twentieth century Cognitive Analytic Therapy and other successful brief methods were developed, often with a borrowing of, or coincidence of invention with, Gestalt ways of working (Flegenheimer, 1982).

Then less attention was paid to the topic in some schools until the millennium approached. In recent years, as we have seen, fund-holders dictate the dosage rate of therapy, often a lower one than their own advisers recommend (Department of Health, 2001). Clinicians trained in careful and painstaking long-term work have needed to adapt, in surgeries and EAP schemes, to what can be seen as the high art form of brief therapy. For some this is a difficult challenge, and one that merits having the principles involved in it spelled out with some care.

Which brand is best?

The aim of any therapy is arguably to enable people to understand and befriend themselves and others, or cope, or move on more rewardingly in their lives. The aim of therapists is at best to be effective in promoting that change. If there is to be a fight between orthodoxy and effectiveness, in any approach, my earnest hope is that effectiveness would win. My experience is that orthodoxy more often does. Then not only effectiveness, but the person who sought help, are victims of the fight.

There is at the moment, nevertheless, some movement towards the integration of approaches to psychotherapy in general. An exchange, sometimes overt, and sometimes a quiet poaching, of theory and methods, is happening between many schools of therapy.

Dialogue, for instance, once claimed as particular to Gestalt, is now used in other approaches too. Transference, a concept central to psychoanalytic work, has now entered the thinking of many humanistic schools. What is clear is that Gestalt arguably offers a very clear rationale and philosophy for integration.

Gestalt Therapy is integrative in its nature. Of all brand-name therapies, it may be seen as one highly suited in its holism for use in brief counselling. A Gestalt practitioner is required to stay alive to, and make sense of, all the data she perceives. If she does this honestly and openly, she cannot close her mind to the perceptions of other schools of therapy. In 1951, before Integrative Therapy was generally spoken of, Gestalt Therapy contained the lines:

In this book we candidly accept as powerful approaches a number of different theories and techniques; they are relevant in the total field, and however incompatible they may seem to their several proponents, they must nevertheless be compatible if one allows the synthesis among them to emerge by acceptance and free conflict – for we do not see that the best champions are either stupid or in bad faith, and since we work in the same world, there must somewhere be a creative unity. (Perls et al., 1951: 254)

In terms of both method and theory, then, Gestalt is here seen as a universal or umbrella psychotherapy, which requires the therapist to introduce whatever, in the field of the particular moment created with the particular person, enters her awareness as likely to tend towards effective therapy.

Width of application

Brief therapy is a great test of any method and practitioner. Some schools respond to the hazards of brief intervention by treating only people with particular difficulties, such as phobias or depression. If they do this effectively, it would seem a good idea to think of incorporating their ways of working into other therapies.

There are no standard clients who put themselves forward for short episodes of therapy. A common factor for some will be that they have been referred by a general practitioner. Others will have arrived in the consulting room via an employer scheme. Neither of these factors has very much to do with predicting the sort of distress they are likely to be in.

… It is absurd to think even for a moment of not combating the resistances, of not rousing anxiety, of not showing that a neurotic response does not work, of not reviving the past, of withholding all interpretation and discarding one’s science …. What is the reality of an interview in which one of the partners, the therapist, inhibits his best power, what he knows and therefore evaluates? (Perls et al., 1951: 286)

This bold statement might seem daunting in the demands it implies on the therapist. It might sceptically be seen as an invitation for a kind of anything-goes approach to therapy. Contradictory theory is generally seen as a poor foundation for good psychotherapy, and eclectic methods imply eclectic theory. Coherence of approach is arguably of great importance in providing a rationale for the understanding of everyone involved (From, 1984).

The contribution of Gestalt

The case for brief therapy is in my view unassailable. To understand more of the contribution Gestalt makes here, we need to go back to its origins. The aim of Gestalt Therapy is to awaken or mobilise people enough for them to get on better with their lives than they were managing before coming for help.

What the doctor sets in motion the patient continues on his own. The ‘successful case’ upon discharge is not a ‘cure’ in the sense of being a finished product, but a person who now has tools and equipment to deal with problems as they arise. (Perls et al., 1951: 15)

This book will describe a range of Gestalt responses which seem likely to be of use to the many different people who arrive for brief therapy. The emphasis will be, in the words of Paul’s (1967) dictum, on what treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances. In Gestalt language, explained more fully in the following chapter, this means a respectful attention to context as well as to contact.

In BGT (Brief Gestalt Therapy), the breadth of possible interventions can be as great as the knowledge of the therapist. This knowledge will be tempered by her judgement of what might best serve this person in this context with this difficulty.

This raises an important question. How rigid are the boundaries within which a Gestalt therapist may work? The contemporary answer is there in the early theory. Fritz Perls, perhaps the best-known early writer on the subject, was a trained and practising psychoanalyst. In the course of developing his radically new approach to psychotherapy, he never lost sight of the value of both psychoanalysis and other approaches.

In his preface to the 1945 edition of Ego, Hunger and Aggression, Perls (1992) wrote, with great relevance to now: ‘At present there are many “Psychologies”, and every school is, at least in part, right. But, alas, every school is also righteous’. (p. xiii) He speaks of the need for integration: ‘I have attempted to show that something of this nature can be done, if one throws bridges across the gaps, and I can only hope to stimulate hundreds of other psychologists, psychoanalysts, psychiatrists etc to do the same’. (p. xiii)

The philosopher Karl Popper is clear that the task of scientific enquiry is to work to disprove the accepted truths of the moment. As therapists we deal with the dementingly multivariable, multifactorial, recognisable but not measurable entities that are humans in action and relation. Perhaps this complexity nudges us away from trying to disprove our theories. It is more comfortable to hold on to what seems clear explanation from our teachers and textbooks. Sometimes we grasp an alliterative jingle, or a numbered set of ‘stages’ or issues designed partly to make us feel safe and competent. Or we may fall back on a couple of maxims uttered by a familiar guru, which seem to justify or inform our work.

Gestalt Therapy is not amenable to formulae, to being manualised in the way that earns plaudits from certain kinds of academic researchers.

The following is a list of the underlying assumptions that characterise Gestalt Therapy, and which, seen as a cluster, an organised whole, distinguish it from others:

1. Gestalt formation

The German word gestalt translates roughly to mean pattern, form, or organisation. In this context a gestalt is a field of data, organised by the need of the person experiencing it, into a figure or foreground, and a context or background. In a crude example, someone just setting up house is likely suddenly to notice the furniture shops he has often passed before unknowingly. They have become foreground or figure for him in a gestalt formation or organising of his way of perceiving what is there. One therapeutic consequence of this assumption about how people organise perception, has strong diagnostic implications. It is a move away from very bounded notions of causality. It stresses that all our experience is formed by a web of interdependent factors. Even this description is insufficient, since it reifies, or makes things, out of what are in reality dynamic flowing experience. The uniqueness of any one person’s way of experiencing is valued in this therapy, over and above categorical description.

2. Organisation of the field of perception

Another assumption alongside all the above, is of the dynamic nature of gestalt formation. A central understanding in Gestalt Therapy is that the dominant need organises the field of perception of the client.

In other words, people are constantly changing, in terms of their perception, as well as more obviously in their context. This change can be related to a cycle of experience that at best will lead to a resolution or new laying to rest of whatever was figural, and the learning it led to.

Malan was among the first proponents of brief therapy to stress the value of focus on one issue. This in Gestalt theory would be seen as the dominant need. His descriptions of how he works are analogous to the Gestalt approach of staying alert to contact, to just what goes on between therapist and client, and using that as the diagnostic tool. Such overlaps between Gestalt and other methods and theories is a reassurance, perhaps, that there are not vast numbers of good ideas in the world. Those that exist are likely to be used, perhaps dressed in slightly different uniforms, by many schools that can show successful therapeutic outcomes. (Curwen et al., 2000: 3–4, writing about CBT, have many overlaps with BGT.)

3. Holism rather than categories

Rather than list anxiety, depression and so forth as conditions that might be helped by brief therapy, in Gestalt terms it is more congenial to say that many people are well served by it. Most neurotic conditions are subject to the spirit of the times. Hysteria has lost its league-table position as a manifestation of distress. Neurasthenia is seldom spoken of now, though even in 1951 Perls still made mention of it. It is strongly arguable that looking at the neurotic manifestation as figure is a distortion of the field. The co-morbidities, the social conditions, all that which adds up to this person now seems the proper figure to address. Gestalt places more emphasis on the individual as a field phenomenon, than on diagnostic categories.

A footnote to this critique of over-dependence on categorical thinking is to use another Gestalt notion, that of polarities, to point out that in English we have invented few balancing constructs to the pathological ones so often mentioned in current writing on the topic. There is not a clear term to denote the opposite of neurosis. In psychotherapeutic theory, there are few specific categories to describe the different forms of wellbeing that the soul, the psyche, may enjoy, even when there is distress in other areas. I use this observation as another argument against thinking in terms of categorical, rather than in personal, subjective and intersubjective description.

The larger aspect of wholism, or holism, that is respected in Gestalt is described in its own jargon as the indivisibility of organism and environment. In something nearer English, this means that nothing, or no one, is truly separable from context. This concept, described at greater length in the next chapter, is perhaps quantitatively rather than qualitatively different from the assumptions in other schools of therapy. It is given great weight in Gestalt.

4. Co-operation

The problem of psychotherapy is to enlist the patient’s powers of creative adjustment without forcing it into the stereotype of the therapist’s scientific conception. (Perls et al., 1951: 281)

The therapist may know more about Gestalt, or dialogue, or desirable conditions in therapy, than does the client or group. The people who come for treatment are world authorities on their own perception, have enough health and coping ability, whatever their distress, to have got them this far in their lives and motivated them to seek help. In Gestalt there is stress on recognising the contribution of all parties to the process of therapy. It is...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• 1 Overview
• 2 The Gestalt Approach: Theory Related to Brief Intervention
• 3 The Assessment
• Appendix A Examples of questionnaires that may be adapted for use before the first meeting of therapist and client
• 4 The Beginning
• Appendix B Contract between therapist and third party
• 5 The Middle
• 6 The Ending
• 7 A BGT Individual Case Study
• 8 The Brief Gestalt Therapy Group
• Appendix C Examples of ready-made group experiments
• 9 A BGT Group Case Study
• 10 Evidence, Authority and Now in BGT
• References
• Index