gestalt therapy case study examples

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Clinical Psychology & Psychotherapy

Gestalt therapy applied: a case study with an inpatient diagnosed with substance use and bipolar disorders, valerie dominitz.

The aim of the present paper is to open the discourse regarding the unmet needs of specific patients, especially those with substance use disorder and/or personality disorder where ‘multimorbidities’, and/or ‘overdiagnosis’ and/or ‘diagnosis overlap’ are frequent. An additional aim is to review the main therapeutic purpose and concepts of Gestalt therapy which might be appropriate in the treatment of these patients often characterized by their difficulties in being aware and in contact in the ‘here and now’. Methods I first start with an overview of Gestalt therapy concepts. Then, I illustrate Gestalt's ‘here and now’ and awareness concepts applied during 18 sessions with an inpatient diagnosed with substance use and bipolar disorders. In addition, the patient had to face an open criminal charge, was regarded as having an antisocial personality disorder and argued suffering from post‐traumatic stress disorder. Results After this two‐month therapy period, the patient entered for the first time a daily rehabilitation program in the community, where he was doing well (this after a few prior hospitalizations). The awareness development in the ‘here and now’ through which different contact styles and cycles of experiences are experienced is a process that allowed the patient to start experiencing contact with himself, his true needs and his environment. This contributed to his well‐being improvement, led and supported his rehabilitation and reinsertion within the society and decrease his relapses, either with drugs or criminal activities.

APA citation

Dominitz, V . (2017). Gestalt therapy applied: A case study with an inpatient diagnosed with substance use and bipolar disorders . Clinical Psychology & Psychotherapy , 24 , 36-47, . https://doi.org/10.1002/cpp.2016

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Gestalt Therapy Applied: A Case Study with an Inpatient Diagnosed with Substance Use and Bipolar Disorders

Affiliation.

• 1 Private Practice, Tel Aviv, Israel.
• PMID: 27098212
• DOI: 10.1002/cpp.2016

Aim: The aim of the present paper is to open the discourse regarding the unmet needs of specific patients, especially those with substance use disorder and/or personality disorder where 'multimorbidities', and/or 'overdiagnosis' and/or 'diagnosis overlap' are frequent. An additional aim is to review the main therapeutic purpose and concepts of Gestalt therapy which might be appropriate in the treatment of these patients often characterized by their difficulties in being aware and in contact in the 'here and now'.

Methods: I first start with an overview of Gestalt therapy concepts. Then, I illustrate Gestalt's 'here and now' and awareness concepts applied during 18 sessions with an inpatient diagnosed with substance use and bipolar disorders. In addition, the patient had to face an open criminal charge, was regarded as having an antisocial personality disorder and argued suffering from post-traumatic stress disorder.

Results: After this two-month therapy period, the patient entered for the first time a daily rehabilitation program in the community, where he was doing well (this after a few prior hospitalizations). The awareness development in the 'here and now' through which different contact styles and cycles of experiences are experienced is a process that allowed the patient to start experiencing contact with himself, his true needs and his environment. This contributed to his well-being improvement, led and supported his rehabilitation and reinsertion within the society and decrease his relapses, either with drugs or criminal activities. Copyright © 2016 John Wiley & Sons, Ltd.

Key practitioner message: People with substance use disorder (where 'multimorbidities', 'overdiagnosis' or 'diagnosis overlap' are frequent), people with personality disorder(s) or people who have difficulties in defining what really disturbs them are the same people who could benefit of GT encouraging awareness and contact development in the 'here and now'. Gestalt therapy should not be regarded as a practitioner's toolbox but as a therapeutic process allowing awareness and I-boundaries development in the 'here and now' through authentic and genuine relationships. The therapist's awareness and contact with themselves and their environment are reflected in the therapist's relaxed but awake and aware state of mind as well as their wise, spontaneous and mindful approach.

Keywords: Awareness; Bipolar Disorder BP; Gestalt Therapy; Personality Disorder PD; Substance Use Disorder SUD; Therapeutic Relationship.

Copyright © 2016 John Wiley & Sons, Ltd.

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A Case for Gestalt Therapy

Author: Jane Barry

Komiko is from a second-generation Asian family. She has lived in Australia all her life, yet her Asian roots are deep. She has been raised according to traditional Asian culture and in addition, she and her family are devout Catholics. Komiko has never questioned her upbringing before, yet now at the age of 26 she is struggling with value conflicts relating to her religion, culture and sex-role expectations and has come to counselling in order to allay some of her confusion.

A précis of the sessions is as follows. For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Komiko had a strict and formal upbringing with her parents and the various Catholic schools that she attended. She was taught to always honour and respect her elders, such as her parents, teachers and priests. Because of this she explains that she has never really felt independent of figures of authority, and has usually acted out the role of a willing child. She states that she seeks the approval of those in authority and whenever she attempts to assert her own will, she experiences guilt and self-doubt.

She has always followed closely the rules and morals of the Catholic Church, through her school and adult life. Komiko has never been married, nor has she had a long-term relationship or experienced sexual intimacy. She states that this is primarily because of the codes she has learned to live by, however there have been times when she has wanted to break away from these. She is interested in living away from her parents and experiencing a relationship out of wedlock, however she is afraid that if she does so, her parents will not accept her decisions.

Although Komiko is frightened to break away from the codes and rules that she has learned, she is seriously considering their validity and realism. She has noticed a change in her own beliefs about morality, and how she no longer accepts her family’s and church’s beliefs without question. She wonders about the importance of her own individual conscience, and following her changing beliefs. The questions she asks herself include: What if I am wrong? Who am I to decide what is moral or immoral? What will I discover if I follow my own path? Will I lose my self-respect or be able to survive the guilt I feel if I don’t follow the teachings of my church and parents?

Generally, Komiko would like to be less dependent, less socially inhibited, less emotionally reserved and be more assertive and able to make important decisions in her life. Instead she finds that she is extremely self-conscious and always considers how she should and should not act. She wonders if she has the strength to act in opposition to what she has learned from her culture, her parents and her church.

Session Content

After drawing out Komiko’s story and beliefs, “C” considers some of the core issues that she is facing. “C” summarises the nature of Komiko’s struggle as follows:

Child roles vs Adult roles:

• Catholic morals vs non-Catholic morals
• Asian influences vs Western influences

Whilst listening to Komiko, “C” considers briefly her own opinions about these conflicts. “C” is a Western, non-Catholic woman and realises her own biases in these arguments may lead her to influence Komiko away from traditional, Asian and Catholic codes of living. “C” also considers that Komiko may be looking to “C” as someone in authority to grant her permission to act more in accordance with her own views.

“C” started with a warm up exercise with Komiko. “C” asked Komiko to summarise the way she was feeling about herself. Komiko stated that she felt self-conscious, weak willed, lacking in assertiveness and dependent. “C” discussed these opinions further with Komiko and asked her questions such as “How are you dependent? Who is responsible for your self-consciousness? What do you take responsibility for?”

Komiko became aware of her passivity through this exercise, and her tendency to allow others to dictate how she should live. “C” then asked Komiko to use the “I take responsibility for.” exercise where she repeated out-loud, all of the current feelings that she was responsible for. “C” then encouraged Komiko to take responsibility for the goals she wanted to achieve.

Komiko said:

• I am responsible for my self-consciousness.
• I am responsible for my dependency.
• I am responsible for my independence.
• I am responsible for my decision making.

“C” added some responsibilities of her own:

• I am responsible for helping you explore your blockages.
• I am responsible for allowing you to make your own choices.
• I will not take responsibility for your decision making.

This exercise allowed “C” and Komiko to examine their roles in the counselling relationship and reinforced that Komiko was responsible for the decision making. Komiko and “C” both were fairly warmed up after this exercise, so “C” encouraged Komiko to perform a dialogue exercise between her assertive self and her unassertive self. “C” explained that this was a chance for both of these sides to talk to each other and air their grievances.

“C” said to Komiko, “In this first chair I want you to position yourself as your assertive self. Your assertive self should talk to your unassertive self in this other chair. “As your assertive self, I want you to sit, speak and act in an assertive manner. You should tell your unassertive side what it is you want to be more assertive about and why.”

As Komiko progressed through this exercise, “C” prompted her to talk about what her assertive side felt and to point out what she didn’t like about her unassertive self. Komiko grew slowly into her role as her assertive self. She experimented with the role of advice giver and decision maker, clarifying the choices that she wanted to make in regards to her life. In particular these included moving out of her parental home and pursuing a relationship.

After this point, Komiko was a little quiet. When prompted to speak, Komiko explained that she feared her parent’s response to these changes. “C” then suggested that Komiko take on her unassertive side. Komiko’s unassertive side defended some of the actions and principles of her traditional upbringing. She explained some of the value that she saw in behaving in accordance with the belief’s of her parents. She wanted to make her own choices, but she wanted her parent’s approval to do so. She was afraid that they would not tolerate her decisions. She explained that some of her parent’s expectations included having supervised dates with young men, living at home until she was married, preferably marrying a Japanese man, wearing skirts and dresses and generally keeping a feminine appearance.

After lengthy discussions with her two sides, Komiko came to realise more clearly the nature of her conflict. Her assertive side wanted to move out of home and be more independent, realising that she may have to live with the disapproval of her parents for a while. Komiko’s unassertive side felt afraid without the support of her family. She thought that maybe she could ease her parents into the idea of her moving out by starting to collect furniture, saving money, looking for suitable apartments and discussing her plans with them.

“C” suggested to Komiko to consider the consequences of moving out on her own, or staying in her parents house. “C” also suggested to Komiko to write a letter to her parents, to tell them of her fears of their disapproval and the consequences this has for her. “C” explained to Komiko that the letter should not be sent, but that she could bring the letter to their next session to discuss its meaning.

In the final part of the session, “C” asked Komiko how she might feel about attempting a more difficult exercise – playing the role of her non-Catholic self, non-traditional self. “C” explained that Komiko was already well acquainted with her Catholic/traditional self and suggested that she experience what it would be like to be her non-Catholic, non-traditional self.

Initially Komiko was hesitant and didn’t understand how she might act as a non-Catholic or non-traditional self. “C” suggested that she think about how she might look, what she might wear, how she might do her hair. Komiko thought that she might wear pants more often, dress in a less feminine style and cut her hair shorter. She practiced walking around the room, as this side of herself, slowly gaining confidence to put a bounce in her step and imagining her hair to be shorter and coloured. She was quite shy about her performance and so “C” joined in also, by mimicking her movements and asking her to describe how she felt about herself.

When seated again, “C” moved on to ask Komiko how she might act on an average day. “C” asked her to imagine her non-Catholic, non-traditional self going to work, doing the shopping or visiting friends. Komiko imagined herself talking avidly to her more assertive friends about making decisions. She discussed the possibility of having her own place to be herself, and how she might plan meals for herself and arrange everything to her own liking. She thought of having friends stay over for weekends and setting up a study room for her work.

Komiko moved on to consider having the freedom to see a male friend from church that she was interested in, without being under the watch of her parents. After this point she was quiet and “C” asked what she was thinking. Komiko said that her Catholic/traditional side was not happy about this, as she was afraid of becoming involved with someone.

“C” prompted Komiko to imagine how her non-Catholic, non-traditional self might approach this problem. Komiko thought that her non-Catholic self probably wouldn’t get involved unless she thought that the relationship could be serious. When asked what being serious meant, Komiko replied that there would be some sort of verbal agreement with her partner and that she would feel in love. She thought that she might see him on weekends and would consider introducing him to her parents.

“C” asked her how her non-Catholic, non-traditional side would feel at this stage. Komiko thought that she might be quite happy, though her Catholic/traditional side feared that her parents might find out earlier, or might not approve of her choice. As the session was near to finishing, “C” asked Komiko to stop playing the role, suggesting that they may work further on these roles in the next session. Komiko sat quietly for some time, reflecting on her role reversal. “C” expressed her admiration of Komiko’s attempts to explore herself and her conflicts. “C” asked her to give herself some feedback on the session.

Komiko felt that she had further explored her motives for change and her fears of change in further detail. She had come to realise her responsibility for both her assertion and lack of it, and had been surprised at the extent of her desire to take more control of her life. She felt that her assertive side had the strength to be independent, whereas earlier, she didn’t think that she had any inner resources to make changes to her life. She hoped to continue the therapy until she became more decided about the decisions she wanted to make.

“C” validated this progress that Komiko had made and suggested that they might continue the next session by exploring some more of the conflict between her catholic/traditional and non-catholic, non-traditional values and to consider the letter that she was to write to her parents.

End of Session

Some points to consider with Gestalt Therapy include:

The assumption of Gestalt therapy is that individuals are responsible for their own growth and behaviour. It is an experiential approach, designed to help people gain more awareness of what they are doing. Gestalt therapy is an active therapy and clients are expected to take part in their own growth.

Most of the techniques of Gestalt therapy are designed to assist people to more fully experience themselves. The therapist should not force clients to partake in experiments if they don’t want to, but in this instance should explore the client’s resistance to the therapy.

Some of the activities and exercises employed by Gestalt therapists include the following:

• I take responsibility for.this is to help someone accept their own personal responsibility for their feelings, actions and their subsequent consequences. This can be useful if the client is blaming others for their problems. By taking responsibility for their problems, the client may be more empowered to change their thinking, actions, and feelings.
• The dialogue exercise…this is a useful experiment to employ if the person is engaged in a struggle of some kind. The client should carry on a conversation between the two parts of themselves that are in conflict. This exercise can help the client to better understand the motives of each side and clarify their experiences.
• I have a secret…this is a technique for exploring secrets and imagining revealing them to others. It allows the client to think about the reactions of others to their secrets and understand the reasons for keeping these secrets. Writing a letter to someone (but not sending it!) may be a way to explore secrets or taboo subjects.
• Reversal technique…if a client is attempting to deny a side of themselves, this technique may be used to help explore the side they wish to cover up. By experiencing themselves as this side, may help them to explore what they are failing to deal with.
• The Rehearsal technique…we rehearse many things inwardly, when we imagine how situations will be. The technique is to rehearse these out-loud by acting out all the things that you might be experiencing inwardly. You might do this when facing something you are afraid of, such as applying for a job, or asking someone for a date.
• The exaggeration exercise…this is designed to draw attention to our body language. The client is to deliberately exaggerate a body movement that they do often, such as frowning or smiling when they feel hurt. The exercise aims to make people more aware of their feelings when they use these particular body movements and gestures.

These are just some of the experiments used in Gestalt therapy. You may know of others. Perhaps you might like to think about how you might use these experiments with someone like Komiko.

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Gestalt Therapy Explained: History, Definition and Examples

These terms have become part of the cultural lexicon, yet few know that their roots come from gestalt therapy.

Gestalt therapy is an influential and popular form of therapy that has had an impact on global culture and society. It is an amalgamation of different theories and techniques, compiled and refined over the years by many people, most notably its founder, Fritz Perls.

Although gestalt therapy is often considered a “fringe therapy,” it is applicable in diverse settings, from the clinic to the locker room to the boardroom. Read on for an introduction to this exciting therapy.

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This Article Contains:

Gestalt therapy defined, a brief history: the 3 founders of gestalt therapy, 4 key concepts and principles, the empty chair technique, examples of gestalt therapy, criticisms and limitations, 3 books on the topic, a take-home message.

Gestalt therapy is a bulky concept to define. Let’s start with a definition by Charles Bowman (1998, p. 106), a gestalt therapy scholar and practitioner. We’ll present the full definition and then break down its parts:

Gestalt therapy is a process psychotherapy with the goal of improving one’s contact in community and with the environment in general. This goal is accomplished through aware, spontaneous and authentic dialogue between client and therapist. Awareness of differences and similarities [is] encouraged while interruptions to contact are explored in the present therapeutic relationship.

Let’s break it down into three components:

Gestalt therapy is a process psychotherapy with the goal of improving one’s contact in community and with the environment in general . A process psychotherapy is one that focuses on process over discrete events. This means that gestalt therapists are more interested in the process as a whole, rather than individual events or experiences.

This goal is accomplished through aware, spontaneous and authentic dialogue between client and therapist . Gestalt psychotherapists use a relational, here-and-now framework , meaning that they prioritize the current interactions with the client over history and past experience.

And finally: Awareness of differences and similarities [is] encouraged while interruptions to contact are explored in the present therapeutic relationship . Gestalt therapy draws upon dialectical thinking and polarization to help the client achieve balance, equilibrium, contact, and health. We will explore these concepts in greater depth later in this post.

Gestalt therapy borrows heavily from psychoanalysis , Gestalt psychology, existential philosophy, zen Buddhism, Taoism, and more (Bowman, 2005). It is an amalgamation of different theoretical ideas, packaged for delivery to patients using the traditional psychoanalytic therapy situation, and also includes elements from more fringe elements of psychology, such as psychodrama and role-playing .

It is tempting to buy into the “great man theory” of gestalt therapy and give all of the credit to Fritz Perls; however, the story is more nuanced than this (Bowman, 2005). Gestalt therapy is the result of many people’s contributions. Since this is a brief article, we will focus on three founders: Fritz Perls, Laura Perls, and Paul Goodman.

Gestalt therapy originated in Germany in the 1930s. Fritz and Laura Perls were psychoanalysts in Frankfurt and Berlin. The Perlses’ ideas differed from Freud’s so radically that they broke off and formed their own discipline.

In 1933 they fled Nazi Germany and moved to South Africa, where they formulated much of gestalt therapy. They eventually moved to New York and wrote the book on gestalt therapy with the anarchist writer and gestalt therapist Paul Goodman (Wulf, 1996).

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‘Whole’ + Health + Awareness + Responsibility:

The German word gestalt has no perfect English translation, but a close approximation is “whole.”

Gestalt therapy is based on gestalt psychology, a discipline of experimental psychology founded in Germany in 1912. Gestalt psychologists argued that human beings perceive entire patterns or configurations, not merely individual components.

This is why when we see a group of dots arranged as a triangle, we see a triangle instead of random dots. Our brains organize information into complete configurations, or gestalts (O’Leary, 2013).

Additionally, the individual is thought of as being involved in a constant construction of gestalts, organizing and reorganizing their experience, searching for patterns and a feeling of wholeness. Gestalt therapy associates feeling whole with feeling alive and connected to one’s own unique experience of existence.

Gestalt therapists apply this philosophy of wholeness to their clients. They believe that a human being cannot be understood by generalizing one part of the self to understand the whole person (O’Leary, 2013). For example, the client cannot be understood solely by their diagnosis, or by one interaction, but must be considered the total of all they are.

To understand what it means to be healthy in gestalt therapy, we must first understand the ideas of figure and ground. To illustrate, let’s use an image called the Rubin Vase.

There is a black outline of a vase on the screen, and at first, this is all the viewer notices, but after a moment, the viewer’s attention shifts and they notice the two faces outlined in the white part of the screen, one on either side of the vase.

In the first perception, the black vase is called the figure, and the white faces are called the ground. But the viewer can shift their attention, and through this act, the figure and ground switch, with the white faces becoming the figure, and the black vase the ground.

Gestalt therapists apply this perceptual phenomenon to human experience. Going through the world, we are engaged in a constant process of differentiating figures and grounds. The figure is whatever we are paying attention to, while the ground is whatever is happening in the background. Healthy functioning is the ability to attend flexibly to the figure that is most important at the time (O’Leary, 2013).

Gestalt therapy sees healthy living is a series of creative adjustments (Latner, 1973, p. 54). This means adjusting one’s behavior, naturally and flexibly, to the figure in awareness.

Here is another example of this process: As I am writing, I realize that my lips are dry and my mouth is parched. I get up, pour a glass of water, and then return to my writing. In response to my feeling of thirst, I shift my frame of awareness from my writing, to drinking water, and then back to my writing. The act of drinking water, satisfying my thirst, completes the gestalt, and I am free to return to my work.

In contrast, unhealthy living results when one’s attention flits from one figure to the other without ever achieving wholeness.

An easy example of this can be seen through our relationships with our phones. If we are working on something important and our phone rings, we can make a decision to ignore it for the moment, finish our work, and then call the person back later. If there is a deadline for our project, this may be the healthy choice. But if we allow our attention to be divided each time our phone rings, we may never finish our project.

Healthy living requires the individual to attend flexibly and intentionally to the most crucial figure in their awareness.

3. Awareness

Although we cannot help but live in the present, it is clear to anyone living that we can direct our attention away from it. Gestalt therapists prioritize present moment awareness and the notion that paying attention to the events unfolding in the here-and-now is the way to achieve healthy living.

Awareness allows for the figure/ground differentiation process to work naturally, helping us form gestalts, satisfy our needs, and make sense of our experience (Latner, 1973, p. 72). Awareness is both the goal and the methodology of gestalt therapy (O’Leary, 2013).

Therapists use what is present in the here-and-now, including actions, posture, gesticulations, tone of voice, and how the client relates to them, to inform their work (O’Leary, 2013). The past is thought of as significant insofar as it exists in the present (O’Leary, 2013).

Gestalt therapists focus on helping their clients restore their natural awareness of the present moment by focusing on the here-and-now in the therapy room. Experiences and feelings that have not been fully processed in the past are revisited and worked through in the present, such as with the empty chair technique, explored later in this post.

4. Responsibility

In gestalt therapy, there are two ways of thinking about responsibility. According to Latner (1973, p. 70), we are responsible when we are “ aware of what is happening to us ” and when we “ own up to acts, impulses, and feelings. ” Gestalt therapists help their clients take both kinds of personal responsibility.

When therapy begins, clients do not internalize feelings, emotions, or problems, often externalizing and shifting responsibility for their actions as the fault or consequence of others (O’Leary, 2013). They may be stuck in the past, ruminating on mistakes or regrets about their actions.

When clients are better able to take responsibility for themselves, they come to realize how much they can do for themselves (O’Leary, 2013).

To do this, clients must have an awareness of what is happening to them in the present moment, as well as awareness of their part of the interaction. Increasing this type of awareness, completing past experiences, and encouraging new and flexible behaviors are some of the ways that gestalt therapists help their clients take personal responsibility.

Things that are in our awareness but incomplete are called “ unfinished business .” Because of our natural tendency to make gestalts, unfinished business can be a significant drain of energy, as well as a block on future development (O’Leary, 2013).

The most popular and well-known technique in gestalt therapy, the empty chair technique or empty chair dialogue (ECH), is a method of resolving unfinished business in the therapy room.

Unfinished business is often the result of unexpressed emotion, such as not grieving a loss (O’Leary, 2013), and/or unfulfilled needs, such as unaired grievances in a relationship. The client may have chosen to avoid the unfinished business in the moment, deciding not to rock the boat or to preserve the relationship.

After the fact, these unexpressed feelings may lack a suitable outlet or may continue to be avoided because of shame or fear of being vulnerable. Most people tend to avoid these painful feelings instead of doing what is necessary to change (Perls, 1969).

The empty chair technique is a way of bringing unexpressed emotion and unfulfilled needs into the here-and-now. In ECH, the therapist sets up two chairs for the client, one of which is left empty. The client sits in one chair and imagines the significant other with whom they have unfinished business in the empty chair.

The client is then instructed and helped to say what was left unsaid to the imaginary significant other. Sometimes the client switches chairs and speaks to themselves as though they were the significant other. Through this dialogue, the client’s past emotions are brought into the present. They are then processed and worked through with the therapist.

This technique can be done with either an ongoing relationship or a relationship that has ended. The resolution of the work is to help the client shift their self-perception. Clients undergoing ECH may shift from viewing themselves as weak and victimized to a place of greater self-empowerment. They may see the significant other with greater understanding or hold them accountable for harm (Paivio & Greenberg, 1995).

Gestalt therapy is used in a variety of settings, from the clinic to the corporate boardroom (Leahy & Magerman, 2009). Gestalt institutes exist all over the world, and the approach is practiced in inpatient clinics and private practices in individual and group therapy . Because of this variety of applications, it can take many forms.

In 1965 the American Psychological Association filmed a series called “ Three Approaches to Psychotherapy ,” featuring Fritz Perls (gestalt therapy), Carl Rogers ( person-centered therapy ), and Albert Ellis ( rational emotive behavior therapy ), demonstrating their approaches with a patient named Gloria.

To see what gestalt therapy looks like, you can watch this video of Perls working in real time. In the video, Perls describes his approach, works with Gloria for a brief session, and then debriefs the viewer at the end.

Much of the criticism in the literature focuses on Fritz Perls, the larger-than-life founder of gestalt therapy. Perls had a powerful personality and left a deep personal imprint on the therapy that he developed. Indeed, his own limitations may have limited the therapy.

Perls struggled with interpersonal relationships throughout his life. In turn, the therapy he helped create focused on the ideas of separateness, personal responsibility, and self-support as ideal ways of being (Dolliver, 1981).

One criticism of Perls’s work of spreading gestalt therapy to lay audiences is that he focused on specific techniques that he could demonstrate on film or in live demonstrations.

These demonstrations elevated Perls to guru status and also encouraged practitioners to apply his techniques piece-meal, without understanding the underlying theory of gestalt therapy. This had the overall effect of watering down the method as a whole (Janov, 2005).

Another critique is that Perls’s gestalt therapy focused on helping clients to have “honest interactions” with others. In contrast, he maintained a strict focus on the client’s experience, leaving himself out of the room by avoiding personal questions, turning them back on the client (Dolliver, 1981).

Recent gestalt therapists have revised this aspect, bringing more of themselves into the room and answering their clients’ questions when there could be therapeutic value in doing so.

Perls also emphasized “total experiencing,” yet he de-emphasized the client’s past and kept the focus of the work strictly on the present. He also emphasized “ living as one truly is ,” but in the room, he relied upon reenactment and role-play, which he strictly controlled (Janov, 2005).

Gestalt therapy promotes a specific way of living, and therapists need to be mindful of whether encouraging these behaviors and values in their client is actually in their best interest. By adopting an explicit focus on helping clients “ become who they truly are ,” Perls denied his part in shaping what parts of themselves clients felt free to express in the therapy (Dolliver, 1981).

Gestalt therapists have spent a long time living in Perls’s shadow. New therapists would be better served by learning the theory and practicing without trying to imitate Perls’s style, pushing forward and altering the therapy to make it a better fit for their methods and the needs of their clients.

To practice gestalt therapy effectively and cohesively, rather than as a disconnected set of techniques and quick fixes, it is crucial to have a good understanding of the underlying theory as well as the historical antecedents that it is based on (Bowman, 2005).

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These three books discuss Gestalt Therapy more in-depth.

1. Gestalt Therapy: Excitement and Growth in the Human Personality –  Fritz Perls, Ralph Hefferline, and Paul Goodman

This book, written in 1951, is the original textbook describing gestalt theory and practice. If you are interested in going to the source before examining a more modern perspective, this is the book for you.

Available on Amazon .

2. The Gestalt Therapy Book –  Joel Latner

If you are interested in a brief overview of gestalt therapy, as well as a snapshot of the field in the 1970s, this book is a good choice.

3. Buddhist Psychology & Gestalt Therapy Integrated: Psychotherapy for the 21st Century –  Eva Gold and Steve Zahm

For those interested in the intersection between Buddhism and the gestalt technique, this book will be of particular interest.

Related: 16 Best Therapy Books to Read for Therapists

Gestalt therapy is an exciting and versatile therapy that has evolved over the years. There is a dynamic history behind this therapy, and it should not be discounted by practitioners, coaches, or therapists who are deciding upon their orientation.

Gestalt psychology also has appeal to laypeople who find the gestalt way of life to be in line with their values.

When learning about gestalt therapy, it is essential to maintain a focus on the underlying theory, moving past the charisma of its founder, Fritz Perls. Perls’s work is instructive and vital to understanding the rise of gestalt therapy.

If you are interested in practicing gestalt therapy, take the time to learn the story and the theory, and then make it your own.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bowman, C. (1998). Definitions of gestalt therapy: Finding common ground. Gestalt Review , 2 (2), 97–107.
• Bowman, C. E. (2005). The history and development of gestalt therapy. In A. L. Woldt & S. M. Toman (Eds.), Gestalt therapy: History, theory, and practice (pp. 3–20). Thousand Oaks, CA: Sage.
• Dolliver, R. H. (1981). Some limitations in Perls’ gestalt therapy. Psychotherapy: Theory, Research & Practice , 18 (1), 38–45.
• Gold, E., & Zahm, S. (2018).  Buddhist psychology and gestalt therapy integrated: Psychotherapy for the 21st century . Metta Press.
• Janov, A. (2005). Grand delusions: Psychotherapies without feeling. Retrieved from http://primaltherapy.com/GrandDelusions/GD12.htm
• Latner, J. (1973). The Gestalt therapy book: A holistic guide to the theory, principles, and techniques of Gestalt therapy developed by Frederick S. Perls and others. New York, NY: Julian Press.
• Leahy, M., & Magerman, M. (2009). Awareness, immediacy, and intimacy: The experience of coaching as heard in the voices of Gestalt coaches and their clients. International Gestalt Journal , 32 (1), 81–144.
• O’Leary, E. (2013). Key concepts of gestalt therapy and processing. In E. O’Leary (Ed.), Gestalt therapy around the world (pp. 15–36). Malden, MA: John Wiley & Sons.
• Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of experiential therapy using empty-chair dialogue. Journal of Consulting and Clinical Psychology , 63 (3), 419–425.
• Perls, F. S. (1969). Gestalt therapy verbatim . Lafayette, CA: Real People Press.
• Perls. F. S., Hefferline, R., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality . New York, NY: Julian Press.
• Wulf, R. (1996). The historical roots of gestalt therapy. Gestalt Dialogue: Newsletter for the Integrative Gestalt Centre. Christchurch, NZ.

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What our readers think.

Thank you for a hugely informative article. Helped me to draw together the different strands of Gestalt in a coherent way.

As a student of counseling, I saw Perls’ video and was totally turned off to the technique. Then I got a practice client who was emotionally shut down and agonized over the various techniques to use that were in my textbook. I realized the client’s mom (the “figure”) was in the room with us and decided to try Gestalt despite my misgivings. It was incredibly fruitful, driving me to always be in the present with the client and always examine my own blocks to being totally present in the moment with the client. I veered into what appeared to be other methodologies as necessary such as somatic, mindfulness, even CBT, but found that those methodologies were actually already part of Gestalt as I learned more about it. It’s a very flexible and powerful container for addressing a client’s needs and keeping the therapist honest with themselves and growing professionally.

I really liked your summary and references, they helped me explain what I’m thinking about Gestalt to others.

How to answer the question “how are you? ” in gestalt

Obviously the client can answer any way they choose, but seeing as Gestalt Therapy focuses on present-moment experience, they might be encouraged to respond openly and honestly with reference to how they presently feel in their body, thoughts running through their head, etc. These are just a couple examples 🙂

Hope that answers your question.

– Nicole | Community Manager

Great and informative article and the video was very helpful in putting this together.

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In and Out of Sync: an Example of Gestalt Therapy

• Original Article
• Open access
• Published: 22 December 2021
• Volume 31 , pages 75–88, ( 2023 )

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• Ryszard Praszkier   ORCID: orcid.org/0000-0002-5135-5210 1 &
• Andrzej Nowak 1  

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This article emphasizes the importance of synchronization in changing patients’ dysfunctional patterns of thoughts, feelings, and behaviors to functional ones. Furthermore, the concept of synchronization in psychotherapy is delineated herein, showing its feasibility through the free energy principle. Most sync-oriented publications focus on the therapist-patient relationship. In contrast, this article is focusing on the therapeutic process, especially by analyzing how dysfunctional units—both in an individual’s mind, as well as in social relationships—assemble in synchrony and how psychotherapy helps to disassemble and replace them with functional units. As an example, Gestalt psychology and Gestalt psychotherapy are demonstrated through the lenses of synchronization, supported by diverse case studies. Finally, it is concluded that synchronization is opening a gateway to understanding the change dynamics in psychotherapy and, as such, is worth further study.

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Interpersonal Coordination Dynamics in Psychotherapy: A Systematic Review

Travis J. Wiltshire, Johanne Stege Philipsen, … Sune Vork Steffensen

• Synchronization

Avoid common mistakes on your manuscript.

Introduction

There is growing interest in synchronization in relation to the therapeutic process (Koole & Tschacher, 2016 ; Ramseyer & Tschacher, 2011 ; Reich et al., 2014 ; Tschacher et al., 2014 ; Yokotani et al., 2020 ). This is supported by development in the hard- and software monitoring of synchronization in therapy. Footnote 1 However, most publications focus on the therapist-patient relationship. In contrast, this article advances the field by focusing on the therapeutic process, especially by analyzing how dysfunctional units—both in an individual’s mind, as well as in social relationships—assemble in synchrony and how psychotherapy helps to disassemble and replace them with functional units.

Synchronization is the process of the coordination of events in order to operate a system in unison. Elements can achieve selective (cluster) synchronization if they simultaneously become salient in some manner, and this mechanism is likely used to synchronize elements that are instrumental to the achievement of a goal (Nowak et al., 2020 , p. 18).

Synchronization can be described using two different perspectives: at the level of system dynamics and at the level of inter-influence among system elements. Both perspectives represent the binding of dynamics, i.e., the dynamics of one element being dependent on the dynamics of another element (Nowak et al., 2020 , p. 6).

In relation to therapy, incompatible elements may be neglected, disregarded, or repressed, or two conflicting mental structures may be created. In both cases, dysfunctional units are assembled: in the first case, leading to the emergence of aggravating unfinished business—a term used in Gestalt therapy (see: Greenberg & Malcolm, 2002 ; O'Leary & Nieuwstraten 1999 ); in the second case, the persistence of conflicted mental structures in time may lead to neurotic stress (e.g., Andrews et al., 1993 ).

To deal effectively with these problems, it is necessary to disassemble dysfunctional units, thereby setting the stage for a reconfiguration that is more adaptive.

Functional and Dysfunctional Units

A functional unit refers to allowing for the creation of temporary structures in unique configurations that are assembled to perform a specific task (Köhler, 1970 ; Mandler, 1967 ; Nowak et al., 2020 ; Tulving, 1968 ).

Nowak et al. ( 2020 ) proposed that the functioning of a system is made possible because of intermittent synchronization, in which sets of elements are assembled and disassembled over time, as demanded by the present function. The elements comprising a substructure are assembled to create a functional unit, which can be observed at different levels of psychological and social reality, from the human brain to minds, groups, and societies. In this vein, to deal effectively with human problems, it is necessary to disassemble dysfunctional patterns, thus setting the stage for a reconfiguration that is more adaptive.

Free Energy Principle

Energy is perceived as an important issue in psychotherapy (e.g., Feinstein, 2008 ; Gallo, 2004 ). There are three kinds of human energy mentioned in the literature, as follows:

Energy being a result of metabolism. For example, studies have found that mental effort can be measured in terms of increased metabolism in the brain (Benton et al., 1996 ; Fairclough & Houston, 2004 ; Gailliot et al., 2007 ). Brain metabolism, measured by functional magnetic resonance imaging or positron emission tomography, is a physical correlate of mental activity.

Libidinal energy, primarily mentioned in psychoanalysis as psychic energy produced by the libido (Barratt, 2015 ; Jung, 1913 ). For example, Sigmund Freud ( 1900 ) used the term “libidinal energy economy” for the dynamic contradictoriness of repression barriers.

The understanding of energy in this article relates to the harmony of a system associated with synchronization.

Synchronization is a natural state in which self-organizing systems strive for a state of minimum energy, according to the free energy principle; an emergent property of this process is synchronization (Ashby, 1962 ; Friston, 2010 ; Friston et al., 2006 ). This relates to all biological systems, including the brain, individuals, and families. It is instrumental for a child’s successful development (Feldman, 2007 ; Harrist & Waugh, 2002 ) and an adolescent’s successful social adaptation (Barber et al., 2001 ). Some authors posit that synchrony is an emergent property of free energy minimization and, in lieu of this, synchronization is a state of a “resting brain” (Palacios et al., 2019 ).

In groups, synchronization increases the tendency to cooperate and to maintain positive relationships (Tschacher et al., 2014 ; Wiltermuth & Heath, 2009 ), while it decreases the occurrence of conflicts and generates efficiency of task groups (Barsade, 2002 ). On an individual level, individuals tend to like and to have more compassion for those with whom they are synchronized (Hove & Risen, 2009 ; Moritz, 2017 ; Valdesolo & DeSteno, 2011 ), and are also more eager to cooperate with them (Lang et al., 2017 ; Wiltermuth & Heath, 2009 ).

The state of synchronization may be temporary, depending on its usefulness. The elements of a system assemble into functional synchronized units and then disassemble when no longer serviceable (Nowak et al., 2020 ; Ramseyer, 2011 ). This property is especially important when the temporary synchronized unit is dysfunctional, leading to some impairments, e.g., on a neuronal level, such as in epilepsy (Jiruska et al., 2013 ; Lehnertz et al., 2009 ), or on an individual level, e.g., obsessive compulsive disorder (OCD) (Özçoban et al., 2014 ; Tass et al., 2003 ). On a family level, some sequences of mutually reinforced subsequent actions/reactions may occur, thereby forming destructive patterns (Nowak et al., 2020 ; Praszkier, 1992 ).

The Psychotherapeutic Process and Synchronization

Psychotherapy is the use of psychological methods to help a person change and overcome problems in desired ways. It is a collaborative treatment based on the relationship between an individual and a psychologist, grounded in dialog and the provision of a supportive environment that allows the individual to talk openly with someone who is objective, neutral, and nonjudgmental, with the aim of working together to identify and change the thought and behavior patterns that keep the patient from feeling good (Hamlyn, 2007 ; Wampold, 2019 ).

There have been some studies related to synchronization in psychotherapy, though mostly focused on the positive impact of synchronization on the psychotherapist-patient relationship and the way it influences the outcomes of psychotherapy (Koole & Tschacher, 2016 ; Ramseyer & Tschacher, 2008 , 2011 ; Tschacher et al., 1998 , 2014 ). To date, there have been no studies on the change dynamics in relation to synchronization.

Filling this gap, and using the premise of the synchronization concept, the psychotherapeutic process may be seen as focused on disassembling dysfunctional units and thus creating space for the emergence of functional ones.

Some problems (e.g., neuroses) appear when elements assembled on a lower level (e.g., memories from past experiences) create, at a higher level of awareness, new dysfunctional units. These units usually influence an individual’s cognitive structure, impacting one’s ability to understand oneself, to attribute others’ behaviors, and to perceive the relationships between oneself and others.

Perhaps, the best illustration of psychotherapy as a process of disassembling dysfunctional units and providing space for replacing them with new emergent structures in one’s cognition, emotions, and awareness is Gestalt theory and Gestalt therapy.

Gestalt Psychology and Gestalt Psychotherapy

Presented below are the basic concepts of Gestalt psychology and field theory, followed by a delineation of the application of synchronization to Gestalt theory, concluded with a characterization of the principles of Gestalt therapy.

Gestalt Psychology and Field Theory

Kurt Lewin’s original conception of field theory (Lewin, 2004 ) was based on Gestalt psychology (Burnes & Cooke, 2012 ). The basic premise is seeing the situation as a whole (Lewin, 2004 ); in other words, perceiving functional systems instead of single elements. There are several related principles (Deutsch, 1954 ; Parlett & Lee, 2005 ), as follows:

Organization and retroflection: Even small, seemingly irrelevant movements, such as tapping one’s finger on the table, may be significant as a symptom of one or more important mechanisms, e.g., the retroflection of energy. Retroflection occurs when a person turns his/her stored up, mobilized energy back upon himself instead of out into the environment, and tapping may be a signal of a suppressed need for the discharge of retroflected energy.

Contemporaneity: The present time reflects both the past (as it was remembered) and the anticipated future.

Singularity: Each situation is unique and could be seen as a “new opening.”

Changing process: Nothing is fixed and static in an absolute way. For each individual, the field is newly constructed moment by moment; individuals cannot have an identical experience twice.

Possible relevance: No part of the total field can be excluded in advance as irrelevant. Everything in the field is part of the total organization and is potentially meaningful.

The figure–ground construct: In Gestalt psychology, an important concept is the figure–ground theory, which refers to the tendency of a system to simplify a scene into the main object being observed (i.e., the figure) and to educe it from everything else that forms the background (Cherry, 2016 ; Wertheimer & Riezler, 1944 ). When a need appears (e.g., hunger), all related images of food, smells, etc., become figures, and the rest of the reality remains in the background. When hunger is appeased, a new functional unit appears, which is a new Gestalt (and it is Gestalt psychology that first introduced the emergence of functional units; see: Nowak et al., 2020 ), such as admiring the beauty of nature or business challenges, and everything else moves into the background.

Gestalt Theory and Synchronization

This delineated process is synchronous: Gestalts emerge, and after gratification has been removed, space is created for new functional Gestalts, thus forming new functional units. However, in some cases, the existing Gestalt is not fulfilled or gratified, and as such, while new needs become more pressing, it is (semi)moved into the background. The unattained functional unit lingers and retroflects in the background, popping up through some unintended movement (e.g., tapping a finger) or action (e.g., emotions transferred to someone else). This kind of a dysfunctional unit does not integrate and, often unconsciously, shatters synchrony.

An example might be that someone did not tell his father, before he died, that he loved him. This unfulfilled need endures, in the background, throughout the rest of his life, unintentionally influencing various actions. The Gestalt principle of contemporaneity allows the individual to fulfill this need in the present through a dialog with the imagined father sitting on an empty chair (see Gestalt techniques below). In this way, the mental system regains synchrony.

Gestalt Therapy

In Gestalt therapy , the ultimate goal is to achieve a client’s awareness, which includes knowing the environment, taking responsibility for choices, self-knowledge, self-acceptance, and the ability to establish contact with others (Yontef, 1993 ). Awareness is seen here as both the content and the process, both of which progress to deeper levels as the therapy proceeds (Yontef, idem ).

The founder of Gestalt therapy, Fritz Perls, believed that the ultimate goal of psychotherapy is the achievement of a degree of integration that facilitates its own development (Perls, 1992 ). In the language of this article, this means decomposing the dysfunctional configurations in the patient’s awareness and fostering the process of recomposing them into new functional units.

Perls based his approach on the concept of phenomenological experience (Crocker, 1999 ; Latner, 2000 ; Yontef, 1993 ), i.e., on shifting the awareness from interpretations and attributions (i.e., malfunctioning cognitive units) to experiencing the “here and now,” and in this way, decomposing old dysfunctional cognitive units and recomposing them on a new functional level. This process was delineated by Melnick and Nevis ( 2005 ) as follows:

Rather than talking about a critical person (e.g., a parent) from a client’s life, a Gestalt therapist might ask him or her to imagine this person in the present (e.g., as if sitting opposite them on an empty chair), or imagining that the therapist is the parent; in both situations, the patient is asked to talk to that person directly in the present.

A Gestalt therapist might notice something about the non-verbal behavior or tone of voice of the client; then, he or she might have the client explore or exaggerate this non-verbal behavior and fully experience how this reverberates in their emotions.

The Gestalt therapist works with process rather than content, i.e., the “how” rather than the “what.”

Similarly, Gestalt therapy principles were seen by Marcus ( 1979 ) as exploring:

Contact, especially the “here and now” contact with the therapist.

Process, i.e., the flow of the “here and now” behaviors, thoughts, and attributions.

Experimentation, e.g., transforming the patient’s verbal account into role-playing.

These principles translate into very specific techniques, which Yontef ( 1993 ) called “patient focusing:”

Stay with it: Whatever you feel, e.g., being sad, just stay with it, try to explore and deepen the feeling, instead of escaping from it.

Enactment: Change descriptive narration into action; instead of talking about someone, talk to this person (e.g., imagining him or her sitting on an empty chair opposite them).

Exaggerate statements or expressions and connect with associated feelings.

Guided fantasy: The patient closes their eyes and imagines metaphorical situations described by the therapist (e.g., “imagine walking up the hill, finding a dark cave; you are entering the cave—what do you feel?” or “You see a door, come close to it, what are your first thoughts?”).

Body techniques—for integrating body and mind.

Paradoxical techniques, e.g., identifying with both sides of the conflict and speaking from both perspectives (e.g., changing between two chairs, each representing one of the opposing parties).

The Gestalt therapist acts as a “field theory agent:” He/she is not detached from the field, but rather is a part of it (Latner, 2000 ; Parlett & Lee, 2005 ), and carries out mutual “investigation” into how the field and its different parts are organized (Clarkson, 2013 ; Lewin, 2004 ; Parlett & Lee, 2005 ). In lieu of this, the therapist analyzes the existing (“here and now”) functional or nonadaptive units (e.g. some synchronized maladjusted sequences), creating an enabling environment that fosters the process of dissolving old, dysfunctional mental units and replacing them with new ones, based on the perception of reality (especially in the “here and now”). The following cases show therapists “in action.”

From the dynamical point of view, these techniques lead to disenabling of the dysfunctional emotional units and assembling new and functional ones; and in that way—achieving a higher synchrony level.

Examples of Gestalt-Style Interventions

The below cases are abbreviated accounts. The first two are from the Gestalt workshops of Eric Marcus, M.D. carried out in Warsaw in the late 1970s. The third refers to the co-author’s (Praszkier, 1992 ) professional experience as a psychotherapist.

Ann: Discomfort When Focusing on Oneself

In a group session, Ann decided to present her problem. In preparation, she shifted from her comfortable position to an awkward, forward-leaning posture that required muscle tension to be sustained. When she started to talk about her problem, the Gestalt facilitator stopped her and said, “Please don’t move, and fully experience the position you are currently sitting in.” “How does it feel?” he asked.

“I am tense,” Ann responded. The facilitator asked her to relax back into her previous position. Ann sat back, comfortably supported by the back of the chair.

“How do you feel?” asked the facilitator.

“Relaxed,” said Ann.

“Now please sit back in the position you took when you started to present your problem.” Ann again leaned forward to the tense position. The facilitator said, “Ann, please say: ‘When I speak about myself, I must take an uncomfortable position’.”

The group members held their breath as Ann hesitated. Finally, clearly upset, she said in a low voice, “When I speak about myself, I must take an uncomfortable position.” The therapist then asked Ann to repeat this phrase loudly, “When I focus on myself, I must feel uncomfortable!” He asked whether the statement fit her actual feelings.

Ann cried, while the group members remained in total silence, understanding that this was relieving the discharge of previously suppressed emotions. After a while, the Gestalt therapist asked: “When do you feel similar?” Ann responded that this was actually the issue she wanted to raise at the beginning: That with her peers or among her colleagues at work, she always feels tense and stunned, especially when it is her turn to speak up; it even—or especially—happens when she has something important or interesting to say.

This therapeutic experience of enactment and exaggeration solved her problem, as she realized how much she tortured herself whenever focusing on herself or her own ideas. “I will always remember this experience and how I believed that when I speak about myself I must feel uncomfortable.”

The therapist commented that this new experience gave Ann good momentum. At one of the next sessions, Ann volunteered to continue. The therapist asked about her first remembered experience of feeling similar, and this brought back childhood memories. Again, the method was to speak directly to the key people in her life, imagining them sitting across from her—and, in turn, stepping into their shoes to respond to “little Ann.” This inner and often suppressed dialog was enacted at a high-energy level.

In this way, the lingering unfinished and unclosed Gestalts were closed in the “here and now,” in accordance with the contemporaneity principle.

John: Intellectual Shield Covering Anger

John was the most intellectual group member. He talked slowly, weighed his words, and took an unemotional stance. In this way, he was respected, though not very much liked.

During group sessions, John was the last to discuss his problems. When he did speak, he focused on the furthest corner of the ceiling and spoke slowly and without emotion. It came across as a very studied and intellectual account of how he is honest in relationships with people and how this honesty makes others keep him at a distance. At one point, the facilitator interrupted him, “Have you noticed that whenever you talk, you find a spot on the ceiling to talk to? This must be an important place to attract your attention. What is this spot telling you?”.

John looked unnerved and flustered, hesitant to respond. The facilitator continued, “Could you imagine being this spot and talking to John?” John stared at the therapist and then back at the ceiling. Finally, a bit jittery, he started to talk: “I am a neutral spot, I keep your attention so you don’t become emotional; I am your resource to stay balanced.” The facilitator asked John to reply to what the spot on the ceiling told him. John looked even more agitated. “Thank you for being my guardian. Without you…. without you…. I would become furious,” he said in a faltering voice, his hands and legs shaking slightly.

He looked at the therapist, who said, “John, try to be furious then; see what it looks like. Take a pillow and hit the sofa.” John tried. “Harder, John, let all of that anger out of you, and shout out whatever comes to your mind.”

John became furious, hitting the sofa as hard as he could and yelling “I hate you, I hate you.” Finally, he threw the pillow away and, looking a bit confused, sat down. It was the first moment the group saw “the real” John—as per their comments in a feedback session, they witnessed John being natural and being human. Some said that during the lunch break that followed this episode, they wanted to socialize with John, who reacted in a new way, without his usual intellectual shield. After the break, John confirmed that he felt much closer to people.

In one of the next sessions, John came forward, willing to explore where his unwanted anger came from. The therapist asked about his first memories of feeling anger. This apparently raised John’s tension levels. Finally, he said that he remembered being six years old, beset by other children on the playground, especially by the girl he liked the most. At that time, he did not react. He did not even tell his parents, because he was shy to admit that the other children were after him. The therapist asked if there was a specific child he remembered; it was Mary, the girl he actually liked the most. The therapist asked John to imagine Mary sitting on the empty chair in front of him and to talk to her. Through a tense and painful process, John finally opened up and talked to Mary, saying how much he both liked and hated her and that he wanted to hit her in the present moment. The therapist gave John a pillow and prompted him to hit the empty chair and the imaginary Mary. He also told John to speak and shout while hitting the pillow. After this high-energy experience, John became calm and reflective, as well as visibly more relaxed on a physical level.

A Tedious Family

Sessions with this family were prompted by the 16-year-old daughter Juliet’s risk of developing anorexia. In this case, medical support was secured. There were also several preceding individual sessions with the daughter that indicated family communication problems.

During the first few family meetings, the progress gradually slowed to the point that it seemed stuck. The family members communicated in a succinct and formal way, spirited only by Juliet’s problems. Analyzing this case with his colleagues, the therapist noted that there was no real vitality in this family, only routine and tedious patterns. It seemed that the daughter and her younger brother expected more vibrant relationships, and implicitly, that both parents would appreciate such a change as well. In this case, their lack of “fire” was understood as a lack of interest.

The psychotherapist thought that without an occasional burst of joy and “craziness,” relationships usually remain limited to formal patterns, becoming overwhelmingly boring and meaningless. The issue was how to bring into the family some vibrant humor and creativity—a daunting challenge given that “bringing in humor” seemed like an oxymoron (as humor is usually spontaneous). Finally, the idea was to use the Gestalt technique of guided fantasy.

During the next session, the therapist suggested that everybody close their eyes and follow his instructions: “Imagine that your family is sitting at the dinner table. Who sits where? Who says what? Now imagine that the person on your right is doing something really crazy. What is it?”.

There was complete silence. After a while, with their eyes still closed, some of them started to giggle. “Now imagine that the person to your left is doing something really crazy.” The chuckles turned into laughs. The therapist asked the family to open their eyes and to share with one another what they had envisioned. They kept laughing, feeling relaxed and spontaneously talking to one another.

The son imagined their father putting the plate of noodles over his head and the noodles slowly creeping down his face. The father imagined his wife putting her favorite china cat sculpture into a cage. Juliet imagined her brother climbing up onto their wardrobe and loudly reading poems from there (the boy hated poems), and so forth. They could not stop laughing, and continued to share their images. The family left the therapist’s office sharing their ridiculous visions, especially those of the usually formal and humorless father with noodles on his head.

This experience triggered a different communication style at home. The images remained in their memories as “implants,” paving the way to more spontaneous communication. Funny ideas and jokes emerged; they changed their usual patterns, hung out together, went for outdoor treks, etc. This, in a feedback loop, had an influence on Juliet, alleviating her feeling of isolation and lack of acceptance and releasing her tension, thereby eradicating the root causes of her over-fasting.

The curative effects of Gestalt techniques such as enactment, “stay with it,” empty chair dialog, exaggeration, and guided fantasy seem apparent. Ann took her first step by identifying, on the emotional and bodily levels, her previous dysfunctional pattern that merged self-focus with discomfort. The next level of intervention led her to relive her early memories and to explore the circumstances supporting the occurrence of such a conjunction. Her lingering dysfunctional units were dismantled, opening her up to new experiences, i.e., building functional units around self-acceptance and self-reliance.

John was seemingly unwilling to accept the interpretation of him cutting himself off from his emotions and, instead, over-intellectualizing. However, the Gestalt enactment techniques contributed to a non-defensive, emotional way of gaining insight into his process of over-intellectualization that served as a shield, protecting him from his anger, which he was previously hiding from his own cognition. This new insight, together with releasing his emotions in public, gained him attention and was reinforced by positive feedback for being perceived as much more natural and real.

Through the guided fantasy technique, Juliet’s family found a way to change their usual patterns to more vibrant, real, and joyful experiences. The images of family members doing something funny shattered the previous dysfunctional system that was maintaining only formal, a-emotional relationships; also, these images paved the way for a new communication mode that turned into a functional unit, thereby bonding the family.

Previously, the family was paradoxically “bonded” by Juliet’s anorectic problems—the only field where they shared true emotions. The family systems theory indicates that symptoms often play a “positive” role by providing a platform for vibrant communication and, in lieu of this, offering protection from other threats, e.g., family disintegration (Keeney, 1983 ; Praszkier, 1992 ). The new functional unit re-bonded the family, creating a new way of synchronization.

In all those cases, there was demonstrated a process of achieving a new, adaptive synchrony level, through dismantling the dysfunctional emotional and behavioral units and assembling more functional ones.

Fabian Ramseyer and Wolfgang Tschacher from Bern University asserted that synchronization is a pervasive concept relevant to diverse domains in physics, biology, and the social sciences. Are they right in positing that synchrony is also pivotal for psychotherapeutic processes? It seems that it is, considering the growing volume of articles in this field across the last two decades (e.g., Koole & Tschacher, 2016 ; Ramseyer & Tschacher, 2006 ; Reich et al., 2014 ; Yokotani et al., 2020 ).

The premise of synchronization and the assembly and disassembly of dysfunctional units seems cut out for Gestalt therapy: The dysfunctional units of unfinished business (Greenberg & Malcolm, 2002 ; Lubinski & Thompson, 2017 ; O'Leary & Nieuwstraten 1999 ) are being addressed—according to the Gestalt contemporaneity principle—in the present, as they are present in the present.

Other than the Gestalt therapeutic approaches that refer to the essential role of synchronization, e.g., the psychoanalytic concept of separation, individuation has also been analyzed under the premise of synchronization (Moon & Bahn, 2016 ); additionally, family systems therapy has been presented through the lens of synchronization (Nowak et al., 2020 ).

A caveat is that the therapeutic process often is more complicated than in the cases demonstrated in this article. The presented examples were selected as to best portray the issues of synchronization in Gestalt Therapy .

The method used in this article is to delineate the core theoretical concept through case studies. This article is only a first step into deepening our knowledge on the role of synchronization in psychotherapy. The conclusions thus far indicate the value of further study in this direction.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Thanks to Volunteer Editor Paige Vanleer for her important contribution. This article is assigned to the Robert B. Zajonc Institute for Social Studies, University of Warsaw.

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Praszkier, R., Nowak, A. In and Out of Sync: an Example of Gestalt Therapy. Trends in Psychol. 31 , 75–88 (2023). https://doi.org/10.1007/s43076-021-00133-8

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Making Reparation & Mourning as the Road to Mental Healing

We make reparation for our miss-doings. We are humans and we make mistakes. Sometimes it is our negligence that hurt others. Sometimes we are just too weak, too young, too old, too ill, too afraid to do the right thing at a particular time.

Mourning is involved in also other aspects of losses, which does not involve the death of another, but rather the death of one’s sense of self. An example of how this can happen is when one is being diagnosed with a debilitating illness or has become disabled in some way, or has a child/family that is diagnosed as such. Mourning is  also “the reaction related to painful experiences that entail an experience of loss — such as loss of the quality of life, loss of health, loss of previous self-identity, loss of hope, or loss of the container function of the parents. (Barone 2005)”

Owning up to our mistakes/shortfall/incompetencies and taking responsibility for hurt caused is a means of making reparation.

In so doing we also mourn the losses (a broken relationship, a lost trust, a lost opportunity, a metaphorical or real death) as a result of our incapacity to do what was necessary to avoid the unfortunate situation.

Being able to face with the loss / to accept responsibility is the path towards inner-strength. We are able to move on from our human failing. We know that we have the resources in us to get on with life because we are able to overcome a mistake that caused us guilt.

Facing up to one’s role in such losses is not the same as blaming oneself. It is to acknowledge what actually happened, and how one was part of it. To blame oneself is to accuse oneself of something one doesn’t believe one has responsibility for. 

Gestalt Therapy Case Example of Making Reparations

Mr. K, a young man of 23, comes to therapy with impulsive anger issues. He has been incarcerated for assault and battery. Each time he regresses into violent behavior, he regrets it, and feels guilt. However, at the slightest provocation, he bursts into uncontrolled rage.

He has been to behavioral therapy to control his impulses. The treatment did not work and he was sorely frustrated. In jail, he was offered gestalt therapy counseling from an intern–  what looked like fighting fire with paper.

The therapist realized after 4 sessions a pattern in this client. Each session, he earnestly repeated the same story to her. Each time he did so, he revved himself into anger. It was a story of his childhood. His father had a violent nature and would beat his mother. As a child, from his early childhood, he remembers his mother in tears of fear and frustration as she served the family their meals. His older brothers were also later violent towards her and Mr. K.

The work for Mr. K turned out to be one of reparation. This was only possible because he was able to feel sadness and guilt (in the case of violent patients who do not feel this kind of remorse, it might not be possible).

Mr. K. was supported to revisit this childhood scene, and as he was retelling the story, the therapist asked him to hold back his anger and breathe by saying comforting words. She asked him what he experienced watching his mother’s sadness. He said he felt hopeless. He said he was too small and afraid to save her.

The therapist supported the client with helping him formulate these statements: “mother, I am 6 years old, and I am too small and too weak to save you.” and to himself “K, I am sorry, I am 6 years old and I am too small and too afraid to save your mother.”

Both K and the therapist were very touched by the phenomenon in the therapy room. This is the taking of responsibility. It is not self blame, but the recognition that one was simply not humanly able to save the mother.

The next steps came naturally. The therapist guided the client in a mourning process. The loss of a mother that could protect the son. Weeks of therapy was devoted to this process. It included creating art, writing poems.

Incapacity to make reparations and mental pain

There are individuals who have difficulty or have not capacity to accept responsibility. This is a mental state for some people and is part of their personality. In psychoanalytic term, it is a condition of being stuck in the paranoid-schizoid position and not being able to move forward to the more ambivalent depressive (nothing to do with depression) position.

When one is stuck in the paranoid-schizoid position, one suffers deep depression and paranoid anxiety. One’s state of mind is that on seeing the world in black and white and nothing in between. Everything is either very good or very bad. This was Mr. K’s life before his sessions with the therapist. He was had paranoid rage, and was very depressed.

Being so paranoid also leads one to have a need for omnipotence, which one displays through grandiosity or threatening (manic) behavior.

Taking responsibility for one’s own deeds is a lessening of omnipotence. Discovery of the resilience of the good object. Less fear of destroying it.

Manic reparation in the Paranoid-Schzoid position.

Say for example a man who strikes his wife then brings her flowers. Avoidance of acknowledging damage done, his aims to repair the hurt is in such a way that his own feelings of guilt and loss is never experienced. Not acknowledged. His wife is felt as inferior, dependent and contemptible. She is confused by his behavior. He then considers her ungrateful. He blames her for his anger towards her.

In this case his unconscious guilt is not reprieved. The good object, the wife, is “magically repaired”. Instant repair. It is like the instant cure of swallowing pills instead of going through therapy. Of going to sleep so that you do not see.

Emotional tantrum is used also as a quick way of handling problem

How do, for example, some people reveal their contempt? By raising emotionality. This is also see among people who do good deeds, like some social workers and activists?

Freud on Mourning and Melancholia

Freud (1922), in Mourning and Melancholia, writes about the ability to mourn as a means of overcoming loss. The inability to mourn or the absence of the mourning process leads to melancholia, which we understand today as major depression.

Genuine Reparation and Creativity

Genuine reparation is slow, there is no quick fix. It takes consideration of the other person. It takes mourning the damage. It takes getting to experience the guilt, the fear of damaging the good object, the relationship. It also takes creativity.

Renunciation of magic and omnipotence. Allows the object to be free. To accept the separateness of the object. This is how we overcome guilt .

Un-recognized guilt, leads to aggression turned towards the self, which is a condition we know as major depression.

Hence the recognition of a loss and the process going through the mourning process, is essential to recovery and prevention of major depression. Much of the therapeutic process involves in one way or another accompanied mourning of loss.

Bibliography

Barone, K. C. (2005). On the processes of working through loss caused by severe illnesses in childhood: a psychoanalytic approach.  Psychoanalytic Psychotherapy ,  19 (1), 17-34.

Klein, M. (2002).  Love, guilt and reparation: and other works 1921-1945  (Vol. 1). Simon and Schuster.

Freud, S. (1922). Mourning and melancholia.  The Journal of Nervous and Mental Disease ,  56 (5), 543-545.

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How Gestalt Therapy Works

Jodi Clarke, LPC/MHSP is a Licensed Professional Counselor in private practice. She specializes in relationships, anxiety, trauma and grief.

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What Are the Pillars of Gestalt Therapy?

What is an example of gestalt therapy, what is the main goal of gestalt therapy, effectiveness, things to consider, why is gestalt therapy controversial, how to get started.

Gestalt therapy is a form of psychotherapy that focuses on a person's present life rather than delving into their past experiences. This form of therapy stresses the importance of understanding the context of a person’s life when considering the challenges they face. It also involves taking responsibility rather than placing blame.

Gestalt, by definition, refers to the form or shape of something and suggests that the whole is greater than the sum of its parts. There is an emphasis on perception in this particular theory of counseling. Gestalt therapy gives attention to how we place meaning and make sense of our world and our experiences.

Gestalt therapy was developed by Fritz Perls, with the help of his wife at the time, Laura Perls, and introduced in the 1940s as an alternative to more traditional psychoanalysis . Both Fritz and Laura were trained in psychoanalysis and gestalt psychology.

Along with others, such as Paul Goodman, they worked together to develop a style of therapy that was humanistic in nature. In other words, the approach focused on the person and the uniqueness of their experience.

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There are a number of principle ideas that come into play with gestalt therapy, from perception to self-awareness .

Experience Influences Perception

In this  client-centered  approach to therapy, the gestalt therapist understands that no one can be fully objective and that we are influenced by our environment and our experiences. A therapist trained in gestalt therapy holds space for their clients to share their truth, not imposing their judgment and accepting the truth of their clients' experiences.

Since therapists are human as well, it is important for gestalt therapists to consider the influence of their own experiences on what is happening in the session.

Context Matters

When in session, gestalt therapists want to learn about the experience of their clients. It is understood that context matters and the therapists use techniques to help the client become more aware of their experiences, their perceptions, and their responses to events in the here and now.

Rather than specifically targeting the past and asking clients to purposefully bring up old experiences, gestalt therapists operate from a place of understanding that as clients become increasingly aware, they will overcome existing roadblocks. There is no forced work or technique, just holding space for client awareness is key in this approach.

The Present

The main hallmark of gestalt therapy is the focus on the present. In the session, the client and therapist rapport is critical in building trust and safety. As the client shares, a gestalt therapist will help bring the client back to the present if there is a sense they are spending too much time in the past or if their  anxiety  may be speeding them into the future.

An example of keeping a client present in gestalt therapy might include something like asking the client about their facial expression or body language as they process a particular event or experience. In asking about something they are observing in the room, they are helping the client come back to the present and process what is happening for them at that moment.

Working Through Pain

We work very hard to survive painful experiences, and part of this survival may include shutting down our emotional hurt or painful memory of the event. In gestalt therapy, you are offered a space where you don't have to do that hard work anymore.

This isn't to suggest that things will come up quickly, but they don't have to. A gestalt therapist understands that things such as painful memories or events will come to awareness when the client is ready for healing in that area.

Self-Awareness

During gestalt therapy, there may be some experiential exercises that you will do with your therapist. Experiential exercise refers to therapeutic activities done in therapy that can help to  increase awareness  and help with processing. At the heart of gestalt therapy is awareness. As Frederick Salomon Perls put it, "Awareness in itself is healing."

Rather than sitting still and talking, you may be asked to actively participate in something like role play, guided imagery , or the use of props to help communication and understanding. Engaging in experiential exercises can be a wonderful way to open up and share, especially when it is difficult to find words or when you tend to process in a more visual way. Gestalt therapists understand that these exercises help to increase awareness.

Some therapy approaches tend to focus on the therapist as an expert on distress and symptoms. The client has more of a learning role, as the therapist shares their knowledge about what they are experiencing and how to heal.

Within gestalt therapy, the client has space to safely explore their experiences without fear of judgment. In fact, the client is encouraged to not simply talk about their emotions or experiences, but to bring them into the room so they can be processed in real-time with the therapist.

The therapist may guide you using several techniques.

The goal of gestalt therapy is for the client to collaborate with the therapist to increase personal awareness and actively challenge the roadblocks that have been getting in the way of healing.

Words and Language

Attention to language and tone is important in gestalt therapy. As clients learn to accept responsibility, they learn to use language that reflects a sense of personal ownership rather than focusing on others. For example, rather than saying, "If he didn't do that I wouldn't get so mad!" a client might be encouraged to say, "I feel mad when he does that because it makes me feel insignificant and I don't like that."

The use of "I" statements is important in gestalt therapy.

Empty Chair

This is a role-playing exercise that allows a client to imagine and participate in a conversation with another person or another part of themselves. Sitting across from the empty chair, the client enters into a dialogue as if they were speaking with that other person or that other part of themselves.

The empty chair exercise can be very helpful in drawing out important perceptions, meanings, and other information that can help clients become more aware of their emotional experience and how to start healing.

Another example of role-playing might be what is referred to as "top dog and underdog." In this, it is recognized that a client has different parts of self. Similar to the empty chair, the client speaks as both the top dog, which is the more demanding side of their personality and the underdog, which is the more submissive and obedient side of their personality.

The key is to become aware of inner conflicts so that the person can better learn how to integrate these parts of self into a more complete whole.

Body Language

During a session, a gestalt therapist will observe the client's body language and movement such as tapping their foot, wringing their hands, or making a certain facial expression. The therapist is likely to mention their observation of this and ask what is happening for the person at that moment.

Incorporating language, the gestalt therapist may even ask the client to give their foot, hands, or facial expression a voice and speak from that place.

Exaggeration

In addition to giving body language a voice, a gestalt therapist may inquire about the client's body language. If it is difficult for the client to find words to put to what is happening, they may be asked to exaggerate that motion or repeat it several times in a row for a period of time during the session to draw out some of their experience at that moment.

The client and the therapist get a chance to process emotions and how the person might have learned to disconnect their emotional experiences with their physical experiences.

Locating Emotion

During a session, it is common for people to talk about emotion. Talking about emotion is different than experiencing an emotion. As a client talks about emotion, the therapist may ask them where they feel that emotion in their body.

Examples of how a person might describe how they're experiencing emotion in their body include "a pit in my stomach" or "my chest feels tight." Being able to bring the emotional experience to awareness in the body helps the client stay present and process their emotions more effectively.

Creative Arts

Additional activities such as painting, sculpting, and drawing can also be used to help people gain awareness, stay present, and learn how to process the moment. It is generally noted in this style that any technique that can be offered to the client, other than traditional sitting still and talking, can be helpful in allowing them to become more aware of themselves, their experiences, and their process of healing.

What Gestalt Therapy Can Help With

There are a variety of conditions that gestalt therapy may be used to treat, including:

• Low self-efficacy
• Low self-esteem
• Relationship problems

Benefits of Gestalt Therapy

Some of the potential benefits of gestalt therapy include:

• An improved sense of self-control
• Better ability to monitor and regulate mental states
• Better awareness of your needs
• Better tolerance for negative emotions
• Improved communication skills
• Improved mindfulness
• Increased emotional understanding

Staying Present

Gestalt therapy aims for the client to gain greater awareness of their experience of being in the world. Gestalt therapists do not have a goal of changing their clients. In fact, clients are encouraged to focus on becoming more aware of themselves, staying present, and processing things in the here and now.

The collaborative relationship between therapist and client is fundamental to the healing process in gestalt therapy.

Self-Awareness and Growth

It is suggested that the way we learn how to survive experiences, particularly painful experiences, is to create blocks or push things out of awareness so that we can move forward. As effective as it may seem, it can create trouble for us as we become more compartmentalized and fragmented in our sense of self and our experiences.

The very techniques we once used to help ourselves become blocks to self-awareness and growth. Increasing client awareness allows for these blocks to be identified, properly challenged, and moved out of the way so we can find healing and personal growth.

Personal Responsibility

A key goal in gestalt therapy is to give clients the opportunity to own and accept their experiences. In blaming others, we lose our sense of control and become victims of the event or the others involved in the event. Gestalt therapy encourages clients to challenge those old ways of how we may have created meaning about an experience.

Learning how to accept and embrace personal responsibility is a goal of gestalt therapy, allowing clients to gain a greater sense of control in their experiences and to learn how to better regulate their emotions and interactions with the world.

Gestalt Therapy

Reviewed by Psychology Today Staff

Gestalt therapy is an approach to psychotherapy that helps clients focus on the present to understand what is actually happening in their lives at this moment, and how it makes them feel in the moment, rather than what they may assume to be happening based on past experience. Along with person-centered and existential therapy, it is one of the primary forms of humanistic therapy.

The term “gestalt” is derived from a German word that means “whole” or “put together.” Gestalt therapy was developed in the 1940s and 1950s by Fritz Perls, a psychiatrist and psychoanalyst, and his then-wife, psychotherapist Laura Perls, as an alternative to traditional, verbally-focused psychoanalysis . Their foundational premise is that people are best thought of as a whole entities consisting of body, mind, and emotions, and best understood when viewed through their own eyes.

The gestalt philosophy rejects the notion that any one particular trait, episode, or indeed a diagnosis could define a person. Instead, their total self must be explored, discovered, and confronted. As they encounter and gain awareness of other parts of themselves, individuals can take greater responsibility for themselves and hopefully gain a greater sense of what they can do for themselves and others.

Instead of simply talking, clients in gestalt therapy are often encouraged to engage in intellectual and physical experiences that can include role-playing, re-enactment, or artistic exercises like drawing and painting. In this way, clients can learn to become more aware of their thoughts and actions, of how negative thought patterns and behaviors may be blocking their self-awareness and making them unhappy, and how they can change.

• When It's Used
• What to Expect
• How It Works
• What to Look for in a Gestalt Therapist

Gestalt therapy can help clients with issues such as anxiety , depression , low self-esteem , relationship difficulties, and even some physical concerns such as migraines , ulcerative colitis, and back spasms. People who are interested in working on their self-awareness but may not understand the role they play in their own unhappiness and discomfort could be good candidates for gestalt therapy. Gestalt techniques are sometimes used in combination with dance, art, drama, body work, and other therapies.

A gestalt therapist focuses on what is happening in the moment and finding solutions in the present. For example, rather than discuss why something happened to you in the past, the therapist might encourage you to re-enact the moment and discuss how it feels right now—in other words, actually to experience those feelings rather than just talking about them. The therapist may ask questions like, “What’s going on in this moment?” or “How does this make you feel now?”

A gestalt therapist may encourage you to try dream work, guided fantasy , role-playing, and other techniques to help bring past and current struggles to life in the therapeutic setting. As a client becomes more aware of themselves and their senses, they can begin to move past blame and take more responsibility for themselves, accept the consequences of their behavior, and learn to satisfy their own needs while still respecting the needs of others.

As a humanistic therapist, a gestalt therapist strives to remain empathetic and non-judgmental and to be accessible to clients without exuding an air of superiority. While the therapist may not impose their own interpretations on their clients’ experiences, they will listen closely to their words, keenly observe their body language , and guide sessions based on what they hear and see.

For example, the therapist is likely to encourage clients to use “I” statements that focus on their own actions and feelings instead of those of others (“I feel anger when she ignores me” instead of “She makes me mad by ignoring me”) as a way of moving toward taking personal responsibility. And if a client begins dwelling on their past, or fixating on anxiety about the future, the therapist may urge them to come back into the present and explore their emotions in the moment.

Gestalt therapy does not have set guidelines for sessions; therapists are meant to be creative and find approaches that fit each client. But some gestalt exercises are fairly commonly used, including by other types of therapists:

The empty chair. In this exercise, the client sits across from an empty chair, representing a partner, relative, boss, or other person—or in some cases, a part of themselves—and, with the therapist’s encouragement, improvises a dialog with it. (Sometimes the client will go back and forth improvising the roles of both parties.) The goal is to address “unfinished business,” resolving past conflicts or encounters within their own selves by bringing the emotions raised into the present and working through them in the moment. Individuals may find that through this exercise they can access feelings and perceptions in a way that they could not by simply talking about a person, episode, or concern.

Exaggeration. A gestalt therapist will closely observe a client’s gestures and physical responses as they speak—for example, slouching, frowning, or bouncing their leg. In an exercise known as exaggeration, they may ask the client to repeat and exaggerate a given movement to explore the emotions attached to it in the moment and to help them gain a greater general understanding of the connection between their emotions and their bodies.

Through these exercises and other gestalt techniques, individuals may be able to reconnect with feelings they might otherwise ignore or deny, and reconnect those parts of themselves into their whole self.

Gestalt therapy is based on the principle that to alleviate unresolved negative feelings like anger, pain, anxiety, and resentment, those emotions cannot just be discussed, but must be actively expressed in the present. Without that, psychological and physical symptoms can arise.

The Perlses believed that it is not our responsibility to live up to others' expectations, nor should we expect others to live up to ours. In building self-awareness, gestalt therapy aims to help clients better understand themselves and how the choices they make affect their health and their relationships. With this self-knowledge, clients can begin to understand how their emotional and physical selves are connected and develop the confidence to live a fuller life without holding themselves back, and to more effectively face problems when they arise.

Some people may struggle to adapt to the lack of formal structure typical of gestalt therapy sessions; clients may also find the emphasis on the present unhelpful if they feel strongly that they need to explore and resolve issues from their past. Some individuals may not be comfortable with a gestalt therapist’s observations of their body language and emotions, while others may not be able to commit to techniques that feel unnatural, like the empty chair exercise.

If a professional becomes convinced that a client cannot make further progress with gestalt therapy, they may recommend that the individual accept a referral to a therapist with different training or expertise.

Look for a licensed, experienced psychotherapist with a stated gestalt approach toward therapy. There is no formal certification required to practice gestalt therapy but mental health professionals may take continuing education courses and training in gestalt therapy techniques. In addition to finding someone with gestalt experience, look for a therapist or counselor who is especially empathetic and with whom you can feel comfortable discussing personal issues.

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• v.24(3); 2021 Dec 20

Personal therapeutic approach in Gestalt therapists working with clients suffering from medically unexplained psychosomatic symptoms

Contributions: JR and RH contributed mainly with data analysis and with writing the Results and Discussion sections. MC and TR contributed mainly as analysis auditors and with writing the Introduction and Methods sections. All the authors reviewed the whole article.

Treatment specificity and adherence to treatment manuals represent essential components of the medical model in psychotherapy. The model assumes that psychotherapists who work with the same type of clients and who identify with the same theoretical approach work very similarly. This study illustrates the shortcomings of that assumption and explores how therapists’ individuality forms and shapes their unique approaches that resonate with their own personalities, inclinations, and worldviews. Semi-structured interviews with eight Gestalt therapists working with clients who experienced medically unexplained physical symptoms were analysed using the grounded theory method. Considerable differences were found among the therapists within four domains of the personal therapeutic approach, namely Case Conceptualization , Therapeutic Task , Therapist’s Position , and Alternative Strategy . However, regardless of the differences, all the therapists endeavoured, either implicitly or explicitly, to convey to the clients what they considered to be healthy functioning. There is considerable diversity in the way therapists work even when they subscribe to the same psychotherapeutic approach and work with the same type of clients. The exploration of psychotherapists’ usual strategies, as well as the alternative strategies they use when their usual strategies do not work, appears helpful for capturing their personal therapeutic approaches.

Introduction

Psychotherapists tend to develop, either deliberately or unintentionally, individualized approaches that resonate with their personality, inclinations, and worldviews (Fernández-Alvarez, Gómez, & García, 2015 ; Řiháček & Roubal, 2017 ). These personal approaches are created from a blend of one’s theoretical orientation, natural skills and abilities, personal history and experiences, accumulated professional experience, and their own experience in therapy (Maruniaková, Řiháček, & Roubal, 2017 ; Maruniaková & Řiháček, 2018 ). Indeed, it has been shown that the proportion of variance explained by differences among therapists is much higher than the proportion explained by differences among treatments (Baldwin & Imel, 2013 ). Therapists’ individual approaches seem inseparable from their personalities and cannot be fully standardized.

Such a point of view contrasts with the medical model in psychotherapy (Wampold & Imel, 2015 ). Assessing psychotherapists’ adherence to a treatment manual became an integral part of randomized clinical trial methodology (Waltz, Addis, Koerner, & Jacobson, 1993). Technique is regarded as the active ingredient of treatment and, therefore, a group of psychotherapists applying the same therapeutic approach are expected to think and behave in a very homogeneous manner throughout the therapeutic process. Another assumption embedded in the medical model is treatment specificity (Wampold & Imel, 2015 ). Various disorders are assumed to have different causes. Since treatments are expected to specifically address these causes, distinct techniques are prescribed for different disorders and conditions. This also naturally leads to the standardization of treatments and to a demand for psychotherapists to follow these specific guidelines.

In the present study, we challenge the above-described assumptions of the medical model using the concept of a personal therapeutic approach (PTA) (Řiháček & Roubal, 2017 ; Maruniaková, Řiháček, & Roubal, 2017 ; Maruniaková & Řiháček, 2018) as it naturally appears in daily psychotherapy practice. We start from the position of seeing psychotherapy as a primarily interpersonal process in which the technique cannot be separated from the relationship, and the therapist participates in the process with his or her whole personality ( e.g ., Orlinsky & Ronnestad, 2005 ). We are equally critical of the assumption that psychotherapists, if properly trained, are, in fact, interchangeable (Elliott, 1998 ; Orlinsky & Ronnestad, 2005 ).

We also question the concept of treatment specificity for different kinds of mental health problems. Categorical concepts of psychopathology are being revisited and adjusted in favour of more general psychopathology factors (Caspi et al ., 2014 ; Hopwood et al ., 2019 ) and the same therapeutic change mechanisms have been identified across various mental health issues (Wampold, 2015 ). From this point of view, we may expect that change mechanisms targeted by different therapists would be applicable across diagnostic categories, even if they work with a specific group of clients. Consequently, treatment strategies would differ across psychotherapists because they would be influenced by the therapists’ personal preferences rather than the diagnostic category in question.

In the present study, we deliberately chose a setting where a rather uniform approach to treatment would be expected: the psychotherapists were all trained in the same psychotherapy approach (Gestalt therapy), and their clients all had the same kind of clinical symptomatology (medically unexplained somatic symptoms, MUPS). Under these conditions, we explored how therapists’ individuality forms and shapes their own unique psychotherapy approaches.

The term MUPS is being used for a somatic symptom experience that lacks any medical explanation (Brown, 2007 ). These clients, after a series of unsuccessful medical consultations, are often referred to psychotherapy and are considered difficult to treat (Heijmans et al ., 2011 ; Luca, 2011 ). This study is a part of a larger project that included the analysis of clinical strategies used in the treatment of MUPS by psychotherapists of various theoretical orientations. In a previous study, we analysed data from the whole sample (Čevelíček et al ., 2019 ). For the purpose of this study, however, we selected only those for whom Gestalt therapy was their primary theoretical orientation. This approach was chosen simply because it was the most represented one in the sample.

Change mechanisms emphasized in humanistic and experiential psychotherapies for the treatment of MUPS include validating clients’ experience of their somatic symptoms, increasing bodily and emotional awareness and regulation, helping clients understand how their symptoms are grounded in their relational and cognitive patterns, and nonjudgmentally accepting the presence of symptoms while focusing on client resources and abilities, rather than symptoms and deficits (Řiháček & Čevelíček, 2019 ). Several change mechanisms used in Gestalt psychotherapy have received empirical support when examined across different psychotherapeutic approaches. These mechanisms include increasing symptom acceptance, which represents the willingness to experience unwanted emotions, thoughts, and bodily sensations with the ability to act despite symptoms; development of coping strategies that can build on clients’ strengths; instilling positive expectations from the treatment; helping clients engage in pleasurable activities and reducing their fear of symptoms; helping them sense more control over symptoms; and fostering working alliance (Pourová et al ., 2020 ).

In the present study, while keeping both the self-identified psychotherapeutic approach and the target client population constant, we aimed to explore the inter-individual differences in therapists’ PTA. Clients with MUPS are considered difficult to treat and we can therefore expect that a significant portion of cases may be viewed as unsuccessful by the psychotherapists (Heijmans et al ., 2011 ). Therefore, to explore diverse strategies within psychotherapists’ PTAs, we asked them about both successful and unsuccessful cases. This was motivated by the intention to explore the alternative strategies they used when they perceived their usual strategy as unsuccessful. Through a qualitative analysis of interviews with therapists, we sought to answer two complementary research questions. The first one was focused on the uniqueness of each therapist’s personal approach: In what ways do Gestalt therapists differ from each other when working with MUPS clients? The second one, on the other hand, aimed to identify common patterns behind the heterogeneity: What are the common principles that, on a meta-level , govern the functioning of the individualized therapist’s personal approach?

Materials and methods

Participants.

Eight self-identified Czech Gestalt psychotherapists, four males and four females, all Caucasian, aged from 38 to 54 ( M =44.4, SD= 6.0). Their psychotherapy experience ranged from 14 to 28 years ( M =17.9; SD= 4.9), and their specific experience with clients suffering from MUPS ranged from 5 to 19 years ( M =11.8; SD= 4.3). All of them had worked with clients suffering from MUPS for at least 5 years. With regard to their professional background and education, two were psychiatrists and six were psychologists. All the participants had finished graduate-level academic training in their respective professions and then finished a certified psychotherapy training with a minimum of 750 training hours. Most of them had completed additional shorter trainings, two were trained in body-psychotherapy, two in systemic and family therapy, one in hypnosis and CBT, one in relaxation and imagination techniques, one in EFT, and one in supervision.

Gestalt therapy is one of the humanistic psychotherapies and is based on a phenomenological exploration of the processes of experiencing as they emerge in the therapeutic meeting (Francesetti, Alcaro, & Settanni, 2020 ). Gestalt therapy, as an existential and relational approach, focuses on what the client and the therapist experience and how they make meaning of the co-created therapeutic situation. Symptoms, including MUPS, are seen as products of the creative self and display human uniqueness (Perls, Hefferline, & Goodman, 1951 ). Psychopathology represents an originally unique creative adjustment in a difficult situation (Roubal, Francesetti & Gecele, 2017 ). However, once the situation is resolved, the adjustment no longer serves the client’s needs and restricts their ability to have satisfying contact with their environment. In this sense, symptoms can be seen as a plea for a kind of contact that would render the symptoms themselves unnecessary (Sichera, 2001 ), which is explored in the hereand- now relationship with the therapist.

Gestalt therapy, in general, focuses on the mutual bodily processes of affective co-regulation between the client and the therapist (Francesetti, 2019 ; Jacobs & Hycner, 2009 ; Philippson, 2009 ), and also focuses its approach on psychosomatic symptoms (Iaculo, 1997; Kepner, 1993 ; Nemirinskiy, 2013 ). It does not deal with the human body per se but with contact in the body/environment field (Реrls, Hefferline, & Goodman, 1951). Psychosomatic symptoms can be perceived as a retroflected form of contact with the world (Nemirinskiy, 2013 ) which is actualized in the therapy situation, allowing for the exploration of the relational aspects of psychosomatic symptoms. However, Gestalt therapy as a humanistic approach does not primarily focus on the treatment of psychosomatic symptoms. Rather, it aims to support the human growth of the clients in the unique contexts of their lives. Despite the internationally widespread network of practitioners, rich theoretical developments, as well as a growing amount of research literature (Barber, 2006 ; Brownell, 2008 , 2016 ; Strümpfel & Goldman, 2001 ; Roubal et al ., 2016 ; Strümpfel, 2006), specific research on MUPS is vastly missing in the Gestalt therapeutic tradition, and Gestalt therapy relies on studies of other humanistic and experiential approaches.

Recruitment. As an invitation to participate in the research, an email with a short summary of the research goals and the interview description was sent to 71 Czech psychotherapists working with clients suffering from MUPS. We used the following inclusion criteria: i) completed psychotherapy training; ii) at least five years of experience working with clients suffering from MUPS; and iii) willing to talk with researchers about one successful and one unsuccessful case of psychotherapy with clients suffering from MUPS. Thirty-one of them were willing to participate and met the inclusion criteria and eight selfidentified as Gestalt therapists (more details in Cevelicek et al ., 2019). The project was approved by the Research Ethics Committee of Masaryk University (ref. no. EKV- 2017-029-R1).

Data collection. From February to May 2018, two research assistants conducted the interviews. The duration of the interviews ranged from 1.5 to 2 hours. We used a semi-structured interview schedule with each therapist to explore one successful and one unsuccessful psychotherapy case of a client with MUPS. We excluded cases with other serious mental health problems or severe addiction. While no specific time limit was used to exclude cases, participants were instructed to select recent cases so that they could recall the treatment process in detail. The interview schedule covered three themes: i) descriptive information about the client (somatic symptoms; other somatic and mental health problems; age; sex; education; occupation; family situation; and treatment motivation); ii) the client’s understanding of their problems and the psychotherapist’s conceptualization of the client’s problems; and iii) the psychotherapy process in detail (see Appendix for the interview schedule). All interviews were audio-recorded and transcribed for analysis.

There were several reasons for this strategy. First, by focusing on specific cases, we aimed to eschew the psychotherapists’ theorizing about the treatment of MUPS in general and explore their genuine experience. Second, the choice of one successful and one unsuccessful case allowed for the exploration of strategies the psychotherapists used in different scenarios. Third, from an idiographic perspective, this approach should help explore psychotherapists’ styles when working with specific clients and allow for detailed descriptions of those styles.

Data analysis. The data was analysed by the first two authors using grounded theory methodology (Glaser & Strauss, 1967 ; Charmaz, 2006 ). The analysis proceeded in the following steps: i) Using open coding procedures, each interview was analysed by one of the first two authors as a separate case in order to investigate the personal approach of each therapist. The emerging concepts were then provisionally interconnected into a working theoretical model for each case separately. Each of the first two authors analysed a half of the interviews; ii) Each case-specific model was audited and further developed by the other of the first two authors ( i.e ., the one who did not analyze the particular case in Step 1). Then both authors discussed and consolidated each model via a teleconference. Afterwards, the case-specific models were validated by the last two authors; iii) Using the constant comparison method and theoretical coding procedures, the case-specific models were compared to each other, and, within this process, a paradigmatic model was developed to facilitate inter-case comparisons. The paradigmatic model consisted of four domains, namely Case conceptualization; Therapeutic task; Therapist’s position; and Alternative strategy . Each case-specific model was then reformulated using this paradigmatic model to allow for more systematic comparisons among cases. The paradigmatic model was validated by the last two authors; iv) To capture the uniqueness of each case, we strived to develop a title for each that would express its essence in a more holistic manner; v) On a more abstract level, we searched for common patterns across the whole sample related to the functioning of the individualized therapist’s personal approach; vi) Due to the space limitations of this article, we chose four cases that best represented the heterogeneity of the personal therapeutic approaches and present them in the Results section.

Trustworthiness of the results was reinforced by: i) Every case being analysed by two researchers, where one of them conducted the primary analysis and the other served as an auditor; and ii) Using the principle of consensuality (Hill, 2012) as a means of securing the validity of the analytic procedure - at each step of the analysis, findings were personally discussed until a consensus between all four authors was reached that the created concepts were grounded in the data, understandable, and relevant.

As a means for the description of the participants’ PTA, we developed four domains. These domains emerged from the data and included: i) Case conceptualization of how a therapist understands the client’s difficulties; ii) Therapeutic task deduced from the conceptualization; iii) Position from which the therapist approaches their clients; and iv) Alternative strategy used when the main strategy does not work.

We use these domains to structure the vignettes of the therapists. Each vignette is first characterized by a title in the form of a statement paraphrasing the strategy typical for the particular psychotherapist. Due to space limitations, we selected four cases that best represent the heterogeneity of the sample. The therapists’ names used in the Results section are fictional to preserve participant anonymity (see Table 1 for a more schematic depiction of the differences among the four therapists). Some contrasts that may not be apparent from the narrative vignettes are more readily visible in Table 1 . For example, while Magda and Veronika are characterized by a similar approach to Conceptualization (MUPS are associated with unexpressed emotions), they differ considerably in the Task and Position domains: Veronika uses theoretical models to teach the client and offer coping strategies, whilst Magda relies on corrective relational experience provided by an accepting non-expert therapist.

Vincent: I lead the client to change her life

Vincent (Therapist 4) is a 53-year-old male psychiatrist with 19 years of psychotherapy practice.

Case conceptualization. According to Vincent, symptoms signalize that the client is not living a healthy lifestyle. MUPS are caused by the client being over-whelmed by the number of tasks imposed upon him, which is also related to his personal perfectionist nature and his inability to perceive the existential dimension of life. MUPS are caused specifically by existential anxiety, which the client is unaware of and which he manages in a dysfunctional way oriented only to ‘material criteria’:

Summary of working strategies characterizing personal therapeutic approach.

MUPS, medically unexplained somatic symptoms.

In this case, the most primitive issues mattered: to be as rich as possible so the family has a good life. Nothing was really important; the meaning of life or the universe were not of any interest to him. So maybe this is why he had pain in his back and belly (...) He experienced great stress and, in fact, existential anxiety which he was not aware of… (...) For such a person, financial safety is never enough, he repeatedly succumbs to anxiety, because the reason for it lies somewhere else.

Being goal-oriented cannot provide an answer to existential anxiety, the cause of MUPS. Therefore, it is important to understand the client’s existential values and to direct him towards a lifestyle that allows for their fulfilment.

Therapeutic task. The task of psychotherapy is to understand what change in lifestyle is being indicated by the somatic symptoms. Vincent offers a psychological perspective on MUPS and assesses whether the client can ‘accept’ this perspective. The client needs to ‘get caught up’ in therapy and ‘start working on it himself’. He needs to ‘be ready to change his life and himself’. Vincent aims to help the client ‘broaden his awareness’: ‘Draw attention to what the patient experiences, such as somatic symptoms (...). Broadening of awareness, increasing self-support, increasing competencies in the sense that he himself can decide more about his life.’

Therapist’s position. Symptoms have specific causes that need to be addressed in psychotherapy. This causal way of thinking probably reflects Vincent’s medical education and practice. There is a clear hierarchy in the psychotherapeutic relationship. Vincent takes responsibility for the client, especially at the beginning of therapy. From the position of a kind and respectful authority, Vincent legitimizes the client’s troubling experiences: ‘This was probably important for her. (...) That, unlike her, I did not see what was happening to her as something horrible. (...) She simply got scared. (...) She just needed some support and (...) she needed to hear that nothing truly horrible was happening, and that it would be all right again.’

Alternative strategy. Depending on the nature of the achieved change, Vincent distinguishes between ‘relief’ and ‘recovery’: ‘He left with at least some small relief from his symptoms, but this is not a successful therapy for me. Success would be if he would recognize how he is creating the symptoms himself and what they tell him, and if he started to change his life accordingly.’ When it is not possible to achieve the desired change in therapy, Vincent respects this as the actual limit of the client: ‘He could sense that it would lead to some changes which (...) he would not like.’ In such cases, Vincent turns to the medical approach: he educates the client and offers him medications and herbs. He calms the client and relies on the ‘magic of the physician’s reassurance’: ‘She was afraid she would not be able to walk normally again. I told her that was nonsense and that she will be alright. So, I used my role of a physician.’

Magda: I cradle the client patiently

Magda (Therapist 7) is a 54-year-old female clinical psychologist with 28 years of psychotherapy practice.

Case conceptualization. Magda understands the symptoms as an expression of ‘frozen emotional processes’’ that the client is unaware of. They are connected to situations in which actual emotions could not be experienced or expressed: ‘Either great sorrow and loss or often some anger or hurt or trauma that could not be expressed. (...) So, it stays with the person and expresses itself through the body.’ Through focusing consciously on experiencing a somatic symptom in relation to a certain demanding situation, therapy ‘brings to life what was numbed’. Magda recognizes a sequence of processes leading to MUPS: The client who experienced anger with her husband turned it against herself, which then led to the development of MUPS. In therapy, Magda works in the opposite direction, starting from the end: By deepening the awareness associated with MUPS, the client re-experienced aggression, accepted the reality of her relationship with her husband, re-experienced sorrow, and in a safe therapeutic environment, she allowed herself to express her emotions. The MUPS often remain, but the client ‘is dealing with them in a much more realistic way’ in the broader context of her life conditions.

Therapeutic task. Magda focuses on creating a supportive therapeutic relationship. Experiencing the therapist’s support leads to building the client’s self-support, which, in turn, leads to change. The change comes with a modified approach to one’s own body. Until now, the body was ‘causing trouble’. Magda’s task is to help the client find kindness in relation to her body, to experience it and understand it. The client ‘would like her body to function, [she perceives her body] as an object, as a computer. (...) So, [she needs] to become kinder [to herself].’ Magda challenges the client’s somatic explanation of MUPS using an explorative and confrontative approach pointing to obvious contradictions between the client’s explanation and observable behavior here and now in the therapy situation. Magda helps the client understand the dynamics of emotional processes related to MUPS in everyday situations.

Therapist’s position. Magda takes the ‘not-knowing approach’, respecting that somatic symptoms are initially understandable neither for the client, nor for the therapist:

I did not understand that at all. (...) I hear how the clients understand it [the medical explanation]. (...) I need to wait a longer time until some information starts to make some kind sense to me, what it could be about. Simply, I need to be patient.

Magda must not approach the client from an expert position. Such a non-expert approach, which differs from that experienced with medical doctors, provides the client with a corrective experience. Only then can the client be ready to accept the psychological explanation of MUPS. Magda patiently trusts the slow, self-healing process of therapy and respects ‘the wisdom of resistances’ and respects client’s limited capacity, which stops the client from making excessively large changes: ‘Whenever she would fully realize fully in a given moment that she would have to do something [very radical in her relationship with her husband], then a part of her inner dialogue would stop her [as if she would say to herself:] wait, maybe it [MUPS] is just a somatic issue anyway.’

Alternative strategy. When the change cannot be achieved through her basic strategy, Magda does not change her approach, she just intensifies her original strategy: ‘it is simply necessary to be even more patient’. Magda needs to conceal her frustration from the client, especially at the beginning of the therapy. The therapist’s task is to accept her own helplessness regarding MUPS and wait with respect and curiosity. Supporting the creation of a safe and trusting therapeutic relationship is crucial because even if the client is unable to make a visible change, the therapy works on the level of the ‘emotional field’, the shared here-and-now. In this implicit way, Magda can support emotional change in the client through a corrective relational experience.

Irena: I let the client learn from a strong woman

Irena (Therapist 6) is a 42-year-old female psychologist with 18 years of psychotherapy practice.

Case conceptualization. According to Irena, the client needs to learn to physically sense her body. Then she can more sensitively monitor her bodily experiences in difficult life situations and consider her physical symptoms in a broader relational context, ‘so that she becomes aware of the situation before the physical pain comes.’ Irena attributes a symbolic meaning to MUPS: ‘My first hypothesis certainly was that when the patient brought up pain in the pelvis (...), then it was some sexual or female issue.’ Irena tries to convey this understanding to the client: ‘Her skin started to hurt so that she would be protected against intimacy. (...) I told her that.’

Therapeutic task. Irena’s task is to redirect the client back to her feelings, to ‘go deep’ to ‘get to inner values’. The basic method is to build sensitivity to feelings that are experienced bodily: ‘I repeatedly turned her back to her feelings, to experiencing her body, simply to monitor what was changing.’ In addition, Irena believes that clients needlessly limit their understanding of their situation by focusing solely on their actual problems. Instead, Irena strives to ‘broaden the context for understanding’ and actively directs the client’s attention to resources that are available to them in demanding situations: ‘I constantly try to somehow remind her of her resources, inner or outer ones, which are at her disposal. So, I repeat this to her again and again.’

Therapist’s position. Irena takes the position of an expert, who – from a professional distance – assesses both the difficulties and the resources of the client: ‘With some clients (...), it is clear to me from the beginning who has the resources and who does not. Then I set my therapeutic goals accordingly.’ Irena ‘leads’ the client to become aware of her emotions and demands that the client ‘work hard between the sessions’. She advises the client in a kind way, from her position as a strong, yet authentic female authority: ‘Sometimes I say: ‘(...) you need to exaggerate [emotional expression] a few times to learn how to deal with it.’ At the same time, I say: ‘your husband will definitely survive it.’’ Irena leads the client from a power position: ‘When it is needed, I pull her. I do not motivate her; I simply say directly what needs to be done’. However, her authority is a very humane one, she uses herself as a model for explaining how MUPS work: ‘[I told her:] ‘Where I would scream, you experience it bodily’… And we made fun of that (...) [because] laughing strengthens the therapeutic alliance. (...) I sit there and laugh and say: ‘I am so proud of you!’’ Irena is clearly personally involved: ‘I invested quite some effort in her and I still do. I love her, I care for her.’

Alternative strategy. When the above-mentioned strategy does not work, Irena resigns from pursuing change by searching for insights. She stops trying to produce changes directly and resorts to using techniques and consultancy: ‘Mostly relaxation and imagination, these are a kind of rescue’. She directs the client: ‘I do not motivate her, I rather tell her directly that she needs to keep visiting the rehabilitation practitioner regularly.’ She also offers specific ideas for solving the client’s problems, ‘because she lacked the potential for discovering it herself.’ Irena offers simple human support and an opportunity to share: ‘The client does not have the resources for change, so I am a surrogate friend to her […] so that she is not totally alone in it.’ Irena lets herself ‘be used (...) as a kind of anxiolytic’; she even perceives her position as ‘a statefunded emotional prostitute’.

Veronika: I teach the client to use emotions properly

Veronika (Therapist 8) is a 41-year-old female psychologist with 17 years of psychotherapy practice.

Case conceptualization. Veronika understands symptoms as something caused by restraining emotions, especially aggression: ‘The whole process of her symptoms was based on her holding back her aggression.’ Veronika uses theoretical models to explain to the client how her symptoms are associated with emotions: ‘[I explained to her] how it is and why it is happening this way. (...): ‘This is what is written [as a theory] and it actually seems to me that this principle also applies to your case.’’ In psychotherapy, change occurs when the client learns ‘to experience emotions and to be kind towards herself’.

Therapeutic task. Veronika explains the psychological context and offers a coping strategy. ‘I analysed the situation [with her husband] for her, I was helping her to see his motivations.’ She relies on the theoretical frame that she learned in her psychotherapy training, and she tries to share it with the client: ‘I helped her to understand how her disorder works in relation to her personality from a psychological standpoint. (...) And I offered her a strategy for how to get out of it.’ Veronika demands personal involvement from the client. If the client does not accept the concept suggested to her, the therapist understands it as resistance and tries to eliminate it: ‘I worked with the resistance for a long time, I tried to bring it into the therapy (...), but she always somehow went around it. So I ultimately ended [the therapy] and referred her to a colleague, who she refused, however.’

Therapist’s position. Veronika perceives herself as the initiator of the change. She requires the client to actively take over the responsibility for change: ‘I will not try to persuade someone who is objectively not willing, not trying, and not aiming anywhere.’ Veronika uses her knowledge and skills to teach the client. At the same time, she offers kind patience: ‘I trusted in my knowledge, theoretical background (…). And also in the patience and kindness I felt towards that woman.’

Alternative strategy. Veronika is very clear about her basic strategy, and when it does not work, she feels helpless. In such cases, she at least offers relaxation training. However, she continues to require the client’s active personal involvement in what the therapist is offering to them. If this does not work, Veronika ends the therapy. ‘We really worked on her resistance. (...) [But] she was not even willing to accept the fact that she does not want [to collaborate]. (...) So, as a logical consequence, we ended the therapy.’ At the same time, however, Veronika is respectful to the client as a person, she acknowledges her limitations and does not accuse her of being unable to make a change. She also admits limitations on the side of the therapist and the therapy setting.

General patterns

In the final phase of our analysis, we adopted a more general perspective from which a crucial common pattern could be recognized: All the therapists were trying to convey their fundamental beliefs to their clients. Although the individual beliefs might have differed, we could see how the therapists were trying to pass on to their clients what they considered as healthy functioning. In the successful cases reported by the therapists, the clients seemed to have adopted these fundamental beliefs of their therapists and started to make changes in their lives accordingly.

At the same time, we could see that each of the therapists used their own unique approach to convey their beliefs. The difference was in the relational setting with the client, which varied on the scale between two extreme poles:

EXPERT LEADERSHIP ←→ JOINT EXPLORATION

On one side, there is an explicit position of a directive teacher who knows what is healthy and offers expert leadership: I want to teach the client what I have learned to be useful. On the other hand, there is the position of an exploring companion: Together, we search for a meaningful way of understanding, which will provide the client with guidelines. From this position, the teaching was an implicit dialogical process in which the therapists were ‘seducing’ their clients into adopt the therapists’ beliefs about healthy functioning.

However, the therapists also reflected on unsuccessful cases in which the clients did not accept the therapists’ beliefs on healthy functioning. This point is especially important regarding clients with MUPS who often refuse to accept the psychological aspects of their somatic problems. They also tend to come to psychotherapy with low, or sometimes even negative, expectations after a long series of unsuccessful treatments with different specialists on somatic disorders. For both of these reasons, psychotherapists often reach the limits of their approach when working with MUPS clients.

In such cases, the therapists were pushed to modify the relational setting with the client.

We found that the therapists’ flexibility was very limited in this regard. While on the level of specific therapeutic interventions, the therapists seemed to show high flexibility, on a more general level, they adhered to their favourite collaboration setting. In several cases, they had one more alternative to which they could switch, but no more than that. Accordingly, we distinguished four types of collaboration setting modifications the therapists used in unsuccessful cases:

• Expert leadership was modified to Joint exploration . For example, Irena (I let the client learn from a strong woman) changed the Therapist’s position from that of expert assessment and advice to offering simple human support and an opportunity to share. The Case conceptualization changed from ‘The client needs to understand her physical symptoms in a broader relational context’, to ‘It is important that she is not totally alone in it.’ The Tasks changed accordingly from ‘Turning the client toward her bodily experienced feelings’ to ‘Becoming a substitutional friend for the client’.
• Joint exploration was modified to Expert leadership . For example, Vincent (I lead the client to change her life) changed the Therapist’s position from ‘broadening awareness’ in a safe and trusting therapeutic relationship to educating the client and offering medicines and herbs. The Case conceptualization changed from ‘Symptoms signalize that the client is not living healthily, he is omitting the existential dimension of life’, to ‘Enabling the client to experience at least some small relief from his symptoms’. The Tasks changed accordingly from ‘Raising competencies to decide more about one’s own life by broadening awareness’ to ‘Calming the client down by using the magic of the doctor’s reassurance’.
• Joint exploration was modified to even more intense Joint exploration . For example, Magda (I cradle the client patiently), who patiently trusts the slow selfhealing process in the supportive therapeutic relationship, intensifies this approach by being even more patient, forcing the therapist to process their own frustration. The Case conceptualization (‘Symptoms are an expression of frozen emotional processes’) and the Therapist’s position (Providing the client with a corrective relational experience) remained the same, but the Tasks became less ambitious and demanding (Being even more patient and concealing frustration from the client).
• Expert leadership was modified to even more intense Expert leadership . For example, Veronika (I teach the client to use emotions properly) who, as the initiator of the change, explained the psychological context and offered a coping strategy, stressed this expert Therapist’s position even more and became a relaxation trainer for the client. Case conceptualization (Symptoms as being caused by restraining emotions) remained the same, but the Tasks (Motivating the client to learn a relaxation technique) became less ambitious and more specific.

The way the therapists structure the relational setting with the client, and how they change it in unsuccessful cases, illustrated the personal therapeutic approach not only on the level of working strategies, but also from a more complex point of view. It enabled us to summarize each therapist’s working strategies into one coherent picture.

The present study is the first to explore PTA in Gestalt psychotherapists who reflected on their clinical work with clients suffering from MUPS. The first question of this study was ‘In what ways do Gestalt therapists differ from each other when working with MUPS clients?’ The question assumed that Gestalt psychotherapists would differ substantially in their work, as their PTA would overshadow the fact that they all used the same theoretical model and worked with the same group of clients (Baldwin & Imel, 2013 ; Řiháček & Roubal, 2017 ).

The results of our study show this assumption plausible, as shown by the differences identified among psychotherapists. Our results complement the already existing models of therapist´s individualized approaches (Fernández-Alvarez, Gómez, & García, 2015 ; Řiháček & Roubal, 2017 ) with a new way of capturing the individual difference between therapists by focusing on therapist´s understanding of the client’s difficulties; on a therapist’s task deduced from the conceptualization; on a relational position from which the therapist approaches their clients; and on the alternative strategy used when the treatment did not progress in the desired direction. The psychotherapists’ clinical work represents creative adaptations of the therapeutic style with a specific group of clients, showing an individualized approach that is complementary to the usage of predefined treatment manuals (Wampold & Imel, 2015 ). The need for a flexible use of techniques that aims to find a helpful focus of treatment for clients has been mentioned in other recent studies of professionals who focus on the treatment of people with MUPS (Balabanovic & Hayton, 2019 ; Cevelicek et al ., 2020). These clients are considered difficult to treat (Heijmans et al ., 2011 ; Luca, 2012 ), a position supported by observably mediocre therapeutic results (Kleinstäuber et al ., 2011 ; van Dessel et al ., 2014 ), leaving a high desire to explore different approaches to engage them in treatment. A flexible usage of personal therapeutic styles, similar to the one demonstrated in the present study, might improve psychotherapy outcomes and client engagement, specifically when client characteristics such as psychotherapy preferences, stage of change, reactance level, coping style, and attachment style are accounted for (Norcross & Wampold, 2018). The overview of different personal therapeutic styles that the therapists in our study used in the treatment of clients with MUPS challenges the assumptions of treatment manuals adherence and of treatment specificity (Wampold & Imel, 2015 ), and may serve as an inspiration for other practitioners. However, it is important to note that not just any personal therapeutic style can be presented as effective. A personal style must make use of effective mechanisms of change grounded in a clearly defined theoretical model to be effective.

Since psychotherapists in the studied sample had considerable experience in the treatment of people with MUPS, multiple mechanisms of change were present in their work. For instance, even though the psychotherapists used different positions from which they approached clients in the relational field that unfolded during sessions (Francesetti, 2019 ), both the psychotherapist who used the position of a health-care authority and the therapist who assumed a not-knowing and non-hierarchical position used their positions to legitimize clients’ symptoms and enhance their self-compassion. Similarly, the effective change mechanism of increasing clients’ emotional awareness and regulation (Pourová et al ., 2020 ) was invoked by both the psychotherapist teaching clients emotional management and redirecting clients back to their feelings.

The second question of the present study was ‘What are the common principles that, on a meta-level, govern the functioning of the therapist’s personal approach?’ PTA represents a system with its own inner logic of organization and principles of development according to the core aspects of PTA (Řiháček & Roubal, 2017 ): It is selective in an idiosyncratic way; created from metabolized theories and techniques; responsive to the context of a therapeutic situation and evolves throughout a therapist’s career. In our study, the role of the underlying beliefs was found crucial for each therapist´s PTA. All the psychotherapists applied their views of healthy functioning and the changes they perceived as beneficial across clients and situations rather uniformly. Similarly, when eminent psychotherapists with different theoretical orientations were asked about their usage of beliefs in psychotherapy (Williams & Levitt, 2007 ), they expressed that beliefs governed their emotional reactions to clients and, in turn, the psychotherapists used their emotional reactions to monitor client progress. However, the present study is the first to our knowledge that illustrates how therapists use their beliefs to determine the desired direction of change in clients with MUPS.

Since therapists’ beliefs are intertwined with their perception of a desirable treatment outcome, it is not surprising that they associate clients’ adoption of their beliefs with outcomes (Jadaszewski, 2017 ; Kelly, 1990 ). This is relevant in clients with MUPS who are perceived by professionals as often having views and characteristics that thwart what therapists consider to be healthy and useful in psychotherapy (Balabanovic & Hayton, 2019 ; Heijmans et al ., 2011 ; Luca, 2011 ). The effort to ‘convert’ clients’ beliefs was even more apparent in this study because the psychotherapists perceived clients with MUPS as less open to change. Because suggestion is an effective factor in psychotherapy, ‘converting’ clients’ beliefs about healthy functioning is considered a useful therapeutic strategy (Cuijpers, Reijnders, & Huibers, 2019 ). Indeed, some psychotherapy approaches intentionally aim to change specific beliefs held by clients because they hypothesize dysfunctional beliefs to be the causal or maintaining factors in people suffering from MUPS ( e.g ., Salkovskis et al ., 2016 ). The theoretical and empirical base of therapist’s beliefs about healthy functioning supports their orientation in a complex situation. That said, the need for some flexibility in beliefs about healthy functioning might be an underrepresented theme in treatment and training.

Study limitations

Asking therapists about two of their recent psychotherapies with clients suffering from MUPS, one successful and one unsuccessful, could have influenced the variety of strategies we were able to capture. The therapists might use different positions, tasks, and conceptualizations with different clients. However, the aim of the present study was to capture the therapists’ unique styles from an idiographic perspective, which was still possible within the chosen design. Although the chosen interview process could limit the range of captured strategies, it was successful in capturing the psychotherapists’ beliefs connected to therapeutic success and healthy functioning in clients with MUPS.

We relied on the therapists’ own descriptions of and reflections on their therapeutic work. These may not fully correspond to the therapists’ actual behavior that would be reported by an external observer. While there is research showing that practitioners can accurately recall types of techniques they used (Castonguay et al ., 2017 ), other studies suggest that the reliability of self-report is limited (Santa Ana et al ., 2008 ).

The present study relied on a high degree of analytic inference from the researchers, i.e . it addressed themes that the respondents did not talk about explicitly. For instance, most of them did not explicitly formulate the positions they used in contact with clients. When a high degree of inference is used, data analysis may more often lead to alternative interpretations by different researchers. We attempted to reduce the risk of bias by including multiple researchers in the analysis process and by using the principles of consensuality (Hill, 2012). Admittedly, the results of the study are influenced by our focus on the uniqueness of each therapist’s PTA. Researchers who would endeavour to find commonalities among the therapists in the first place would probably come to different conclusions.

The focus on Gestalt therapists might be perceived as reducing the generalizability of findings for practitioners of other therapeutic orientations. However, we believe that our results point to common factors (Pourová et al ., 2020 ; Řiháček & Čevelíček, 2019) rather than to the specifics of the Gestalt therapeutic approach in clinical practice (Francesetti, Gecele, & Roubal, 2013) and work with psychosomatic clients specifically (Nemirinskiy, 2013 ). We hypothesize that similar variability could be found in other therapeutic orientations. However, this hypothesis must be tested in future studies.

Conclusions and implication for training and practice

The study revealed considerable diversity in the way psychotherapists work, even when they share the same approach and the same type of clients. The specific features of each personal therapeutic approach can be characterized by the particular therapist’s Case conceptualization, Therapeutic task , and the Therapist’s position . However, to understand a therapist’s flexibility, this framework needs to be supplemented with explorations of the alternative strategies a therapist uses when working with an unsuccessful case.

Our finding that the therapists’ unique style of working with clients suffering from MUPS resulted from their beliefs about general healthy functioning has implications for psychotherapy training. Psychotherapy trainees are usually taught specific theories of change that they should apply to clients, and they also tend to adopt their trainers’ beliefs about healthy functioning. In the initial stage of development, trainees tend to apply these theories to clients (Maruniaková, Řiháček, & Roubal, 2017 ; Maruniaková & Řiháček, 2018), later discovering that many clients do not change as expected. Exploring the perspective of implicit theories of change, beliefs, and values, as they translate to interventions, therapeutic relationships, and psychotherapists’ view of treatment success, could help broaden trainees’ concepts of healthy functioning. The flexibility they thus develop might reduce their initial and unnecessary disappointments and protect clients from being pushed into ‘boxes’ into which they cannot fit.

Acknowledgements

The authors thank Jana Vránová and Jana Máchová for their help with data collection.

Funding Statement

Funding: this study was supported by the Czech Science Foundation under Grant GA18-08512S.

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