The therapeutic concepts I present here are not new; they are a snapshot of Fritz Perl's' Gestalt Therapy. However, the revisions I propose here are original, and are the revisions I make as I apply Perl's' Gestalt theories to modern psychotherapeutic practice. Dr. Frederick S. Perl's' Gestalt Therapy is an Expressional Therapy to treat mental illness, as opposed to the popular Cognitive-Behavioral Therapy taught in universities today. Though Gestalt has fallen out of favor in counseling education, I find it still has great merit, for it can be amended to suit the individual client's temperament, as well as to the temperament of the therapist who presents it. This is my attempt at that revision process.
Working with Resistances
Perls advised when there are resistances (avoidances or phobias) in the patient, to go further into them by amplifying them; by dramatizing them, giving voice to the "hidden desires," and allowing their expression. Expression is only a hunger to be heard; we are all hungry in different ways. If the client suffers from anger, magnify the expression of anger in the safety of the therapeutic setting. This can be accomplished utilizing Perl's' Chair Exercise, or through psychodrama, wherein the feared object is given permission to have "its say," such as, "playing rage," or "playing the obsessive" (smoker, eater, drug user, etc.).
Perls taught that to deny expression of such powerful emotions and compulsions causes not their cessation, but it's opposite, exacerbation; anything we resist persists. For example, during psychodrama the compulsive over-eater could be encouraged to finish the sentence, "I eat because... " until she has exhausted her verbal arsenal. This serves the purpose of giving the compulsion an audience. To answer questions "in character" and automatically, without censoring, is to stop suppression and encourage expression. Expression is art, and Gestalt was originally a European art movement which later Perls transformed into a psychotherapeutic movement.
I believe Gestalt done right is art. Today, however, Gestalt Therapy has been reduced to techniques, a therapy which has been downsized, reduced to its simplest form, a development which Perls would have likely found distasteful. What remains of Gestalt Therapy are the dismantled pieces of his originally holistic theory. Gestalt Therapy is an incomplete Gestalt now, which is an oxymoron; it's what Perls preached against. Perls conceived of the world in systems, as he was first trained as a medical physician. His methodology was to work to restore the equilibrium of the organism, not in part, but in the whole. He didn't advise "piece-mealing" his theory, nor "soft-peddling" it. I believe Perls would be disappointed but not surprised that his contributions to psychology have been confined to what he might have described as, "a dog and pony show."
Perl's' vision was an Expressional Therapy, a highly interactive process which is an exchange between clinician and client, at times evoking emotional upheaval in the patient. His methods were not a cup of tea, or a walk in the park with the therapist; instead, his methods were a stiff shot of whiskey and a confrontation with suppressed inner pain. For some, giving expression to the forbidden self, the subjugated, guilt-ridden, better-left-hidden self, is disquieting, distasteful and embarrassing. Shame is encountered, pain is unearthed, and old beliefs which are nasty, negative and shocking to the client come bubbling to the surface.
However, in the aftermath of exploration and catharsis of suppressed feelings and repressed memories, a restoration of the true, unhindered self occurred in Perl's' patients. The truth was bubbling to the surface at last, both in his patients, and as proof that his techniques worked. Gestalt at its finest is an excavation of the soul; unearthing emotions and memories buried in the forgotten field of the unconscious; perhaps filed away in Jung's Collective Unconscious. It is a retrieval method of touching upon what has been carefully buried, to see it afresh, for what it really is, and then to reset the broken bone. It is a reflective, benevolent act, in hopes that the suppressed traumata can be used to heal. This is the Gestalt Therapy that Perls envisioned and applied; the integration of the disowned parts of the personality, so the neurotic is freed of his rigid, relentless compulsions and fear of loving too much.
I offer here a simple revision of some core Gestalt techniques, a therapeutic approach which I would rather call Expression Therapy, as Gestalt has left a bitter taste in some psychological historian's mouths. The first revision I would propose is Perl's' emphasis on the physiological resistances presented during therapy. Interpreting and analyzing non-verbal communication has some merit in the patient who squirms or smiles to cover up, or scratches nervously, for it gives the therapist non-verbal clues with which to draw out unspoken feelings. The client is physiologically compensating for the mental discomfort she naturally experiences while in the "hot seat" of the therapist's chair. To allow this natural discharge of pent-up anxiety is beneficial to the client.
Interpreting the body's movement as therapeutically significant is important collateral information for the therapist, but I believe not crucial. To make it a focal point and draw attention to the client's body language has slight therapeutic merit, but to dwell on it is to cause the patient to feel scrutinized and self-conscious, even more defensive than she already is. I believe non-verbal communication is a secret language for the therapist to read, as an indication of the patient's comfort level, or discomfort. To ask one body part (such as a hand) to "talk" to another body part (the other hand) about its nervous movements may be interesting for the therapist, but you run the risk of the patient feeling intruded-upon or scrutinized. I believe non-verbal communication should not be a focal point in therapy. Rather, it should be used as an adjunct to therapeutic interpretation.
Perls addressed how to manage difficult clients in therapy; these he referred to as "Bear Trappers." He refused to work with these patients unless they readily followed directions by cooperating. As Perls described, they "play along" cooperatively until you touch upon a resistance point, at which time they become triggered and then "lower the boom," or try and trap you, blaming and reproachful towards the therapist. All they can seem to do is to argue, to prove themselves right one more time. Perls would describe these clients as having "no ears," as they are not open to hearing the truth. I find these argumentative personalities to be the paranoiac characters, or those with Paranoid Personality Disorder.
Initially they present as charming, but easily revert to the "Dr. Jekyll-Mr. Hyde" which they really are, when they don't wish to cooperate. The paranoid personality also is, as Freud said about the Narcissist, "His Majesty the Baby." Like the Narcissist, the paranoiac refuses to mature. He throws fits, demanding it be his way, or he will regress to manipulations and "out-smarting" the therapist in a show of egos to prove his superiority. The well-intending therapist then gets caught in a frustrating game of cat and mouse, and the therapist begins to feel "trapped." This game shifts the focus from the problems of the paranoiac to the supposed "ineptness" or "wrong conclusions" of the therapist, which is a diversionary tactic on the part of the paranoiac client, leading to high frustration for both client and clinician. This is why Perls refused to engage with unyielding defenses, and "threw them out" of the "hot seat" during group workshops.
Although I can sympathize with Perl's' frustration in treating Personality Disordered clients who are unrelentingly resistive or argumentative, to refuse to accept them into treatment is to offer these types little hope for recovery. I agree there are clients who present in counseling with the intent of proving the therapist wrong or inept so they can be vindicated in their own minds that nothing is wrong with them in the first place (as they have insisted all along). These difficult cases require firm but gentle approaches which provide direct feedback from the therapist, for to "stroke their ego" is what they are greedy for, but will help them. There should be a balance between dismissing them from the practice, and being a "whipping boy" for them.
The personality disordered person has no eyes. They have dysmorphia, a distorted self-image, or a scotoma; a blind spot, in which they cannot see themselves as others do. Either way, their self-image is distorted. They can neither see themselves as they are, nor do they see the environment as it is. Their sense of reality is warped. Rather than "prove" once again to the paranoiac that they are indeed an "outsider" by throwing them out of the practice and thus confirm their projections, our mission should be to help them develop eyes. It does not matter what I see before me; what matters is what they see in themselves. Personality problems are self-image problems. This laborious process of revealing the truth to the patient requires extraordinary amounts of patience. Like a blind person, you are asking them to see what they have not yet developed the eyes to see. They are at first "groping in the dark," which causes them frustration resulting in anger, which is displaced upon the world (and directed at the therapist).
Working with seriously personality disordered patients is a labor of love; it has to be. If you cannot feel any empathy for their lost-ness, their feelings of betrayal or being the object of persecution (all the while persecuting you), it is better that you do not work with them, for it will require empathy, strong boundaries and patience. To dismiss all "Bear Trappers" from therapy is, I believe, an inability of the therapist, and not conducive to progress for the client. However, to set expectations (boundaries) for the client (in the case of Dialectical Behavioral Therapy, creator Dr. Marsha Linnehan explains to Borderline Personality Disordered patients that they will be dismissed if they miss a certain number of appointments), is healthy and equitable for all.
Boundaries are difficult to understand for personality disordered patients, so by making your clinical expectations clear at the outset is important for a productive working relationship. Paranoiacs want to blame, displace their anger and play the victim role. Clear boundaries allow you to remind them when they have stepped outside of the agreed-upon boundaries (remember, they don't have eyes for themselves). Ignoring their misbehavior or attacks on you will not help them; it will condone and perpetuate those inflammatory behaviors. The "middle-ground" with difficult clients is to make boundary agreements with them at the first acting-out behaviors, and to reinforce those agreements when they reoccur. In this way, through repetition, they learn to self-monitor, or to have eyes, and become increasingly self-aware of their "trapping" tendencies.
Bringing Gestalt Therapy into the 21st Century
The last point I will elaborate on regards the use of Gestalt Therapy into the 21st Century, and revising it so that it is more user-friendly for the modern practitioner. We must see Gestalt Therapy in the historical context in which it was developed. Dr. Perls was a German-born psychiatrist who fled Nazi Germany for South Africa, where another cultural upheaval was occurring. He came to prominence in America in the 1960's when there was an anti-establishment, civil war raging: students were revolting, the sexual revolution was happening, drugs were rampant, and young adults were demanding change. The slogan of the day was, "Turn on and tune out." Perls was listening to this outcry from America's youth for genuineness, creativity and most importantly, self-expression. Gestalt Therapy, an expressional therapy, was Perl's answer. His oft repeated phrase, "Loose your mind and come to your senses" was his way of saying, stop justifying, explaining and intellectualizing, and instead, experience yourself. In other words, let's get real. Fritz was about as direct and honest about his opinions as Dr. Laura Schlesinger!
While American culture has changed from a volitile revolution state to the information age, certain human needs remain remarkably stable. Gestalt Therapy can still answer those fundamental psychological human needs. An adept Gestalt Therapist will use the therapeutic tools Perls left behind, to excavate the human psyche, but must adapt them to their own personality, presentation and delivery style. Perls was an irascible character; a strong, determined, stubborn and sometimes inflexible product of three wars. He could not suffer "crybabies" who demanded patience, restraint or large dishes of empathy. He voiced his enthusiasm to work with students who were "open systems" only. To the "closed systems" he asked that they only return if they would work cooperatively with him.
For today's therapist, an update of the heavy-handed Gestalt approach is in order. A healthy dose of humanistic, Rogerian "unconditional positive regard" can temper the Gestalt approach, making it palpable for today's clients, making it the "spice" in the therapeutic "mix." Cognitive-behavioral therapy is the mainstay of universities because it appeals to a wide swatch of clients, is generally non-offensive, and has been empirically effective over time. My fervent hope is that the field of psychotherapeutics will not completely "bury" Gestalt Therapy because its creator was considered difficult to work with. Freud was a highly inflexible and neurotic character; however, we are indebted to him as the father of modern psychology, as he contributed more good than not to the field. We mustn't "throw the baby out with the bathwater" with Gestalt Therapy. I believe Perls contributed a theory and approach to psychotherapeutics that not only has merit, but can and should be re-evaluated for today's clients.
We live in a world where intellect and information is prized, and awareness of our feelings, sensibilities and sensitivities have been dulled. In Anti-Social Personalities, responsibility has been extinguished all together. There is a need, a great need, to again, "Loose our minds and come to our senses." Perls preached of sensory integration, which means being in such organismic balance that we are able to fully experience instead of intellectualizing our environment. To intellectualize is not to feel. To not feel is to deny our senses (both inner and outer). His philosophy of using our raw experience of the "now" moment is a popular New-Age theme; in this, Perls was ahead of his time in promoting that phenomenological, present-oriented approach. Perls knew something about today because his yesterdays were a nightmare. He found solace in discovering the present moment. He found a generation who were demanding change and new approaches, so he decried retrospective theories (Freud's psychoanalysis), while also denouncing future-oriented theories (Adler). He made a gift of what was left: taking full responsibility for our behavior in the present, resulting in a phenomenological and existential theory. Thus, he interpreted flight into the past or future as resistance.
For multiple reasons, Expressional Psychotherapy is a valid means of reacquainting our technologically-focused world with their actual experience of living. If we are freed to express our true thoughts and feelings instead of searching endlessly for the causes of traumata (as is the case in psychoanalysis), and if we can develop ears and eyes (self-awareness) enough to see our patterns of dysfunction, then we stand a chance of transformational change. Perls never said the process of therapy would be easy. He began his seminal work, "Gestalt Therapy Verbatim," with these ominous words:
"To suffer one's death and to be reborn is not easy."
I hope to see a resurgence of Gestalt's expressional therapy. For it to be "reborn again" may take some reconstruction work, but I believe it's worth it.