Dialogic Gestalt Therapy

By Gary Yontef

Ref: Yontef, G. (1998). “Dialogic Gestalt Therapy”. In L. Greenberg, G. Lietaer, & J. Watson (Eds.), Handbook of Experiential Psychotherapy. New York: Guilford Publications, pps. 82-102. Posted with permission from Guilford Press.

 

There has been a growing trend in the last two decades for state-of-the-art practice of Gestalt therapy to be guided by a more explicated and consistent understanding of three cornerstones of its integrated theoretical framework: field theory, phenomenology, and dialogue. Field theory provides a way of thinking, phenomenology a way of defining and working with awareness, and dialogue delineates the necessary relationship between therapist and patient. Together they form the foundation of the whole that is Gestalt therapy.

This trend returns to and enhances the basic principles of Gestalt therapy and moves away from the “California model” that popularized Gestalt therapy from the mid-60s through the mid-70s. From the first Gestalt therapy publication (Frederick Perls, Ego, Hunger and Aggression, 1942/1992) there has been a serious intent to create a system of theory and practice that melds creative use of active phenomenological techniques with a therapeutic relationship based on the model of existential dialogue and that moves from a static perspective of history and structure to one that centers on here-and-now process.

The widespread attention received in the popularization phase by dramatic, cathartic, effective techniques, anti-intellectualism, and interpersonal confrontation diverted attention from more solid Gestalt therapy practice and overshadowed the theoretical basis of Gestalt therapy. Solid practice and theory of Gestalt therapy was not only concerned with techniques but more importantly with relationship; not only focused on here-and-now process but also studied individual structure (e.g., diagnosis) and history; not only the individual but also the social/cultural context; not only focused on feelings but also on cognitive processes and philosophy (Perls, Hefferline and Goodman, 1951/1994; Yontef, 1993). This illustrates a principle of Gestalt field theory: Integration of polarities. In Gestalt therapy field theory dichotomies are considered artificial dualisms that are based on partial understanding. A more holistic understanding is sought in which the dualisms are unified into natural polarities, e.g., yin and yang (Perls, 1942/1992).

State-of-the-art practice of Gestalt therapy has been guided by the cornerstone principles discussed above. Knowledge gleaned from this practice has led not only to clarification and refinement of the principles and their application, but an integration of the principles with each other. Experience has led to an increasing emphasis on the importance of the therapist understanding, respecting, and orienting to what the patient actually experiences. This is a form of intimate contact and requires a softer, more accepting, more peaceful way of relating than encounter-group-like confrontation. In the balance between clinical frustration and support, support is now considered more important and necessary than previously believed.

Gestalt therapy has been associated with a focus on process as it unfolds one moment at a time, especially micro-focusing on the observed behavior and emotions of the patient at each moment, making interventions that actively focus and intensify awareness and behavior and often lead to cathartic release. The empty chair and the two-chair experiments, sometimes combined with non-verbal expression of affect, were probably the best known of such techniques. But the list of experiments of active focusing that are used in Gestalt therapy is infinite. A patient biting his lip might be asked to bite harder or say something biting. A patient saying everything is fine and tapping fingers might be asked to tap harder, sometimes leading to pounding gestures that bring previously underground resentment into awareness and expression.

But, the experiments are means of phenomenological exploration and not attempts at cathartic release or behavioral training. Not only are a very wide variety of interventions used, but therapists are invited to be creative about finding or creating other techniques that apply the principles and fit the moment. Gestalt therapy has been called “permission to be creative” (Zinker, 1977).

For example, an experiment was created in working with Amy, a 35 year old woman who frequently focuses on her difficulty in establishing intimate contact with men, but has no idea what she does that interrupts connection. In sessions she looks away whenever there is excitement or increased intensity of contact between us or between her and other group members. Focusing here and now on her averting her eyes is an experiment that helps her experience what she does out of the consulting room much more effectively than abstract discussion. Conceptions and Misconceptions

One style of Gestalt therapy, incorrectly identified by some as the essence of Gestalt therapy, is limited to what is immediately observable and the recognized context narrowed to only include the immediate therapeutic moment. In this approach to Gestalt therapy attention to structure, what in field theoretical terms is considered to be repetitive processes, or to what phenomenologists refer to as invariants, was eschewed in favor of living in the here and now (based on the Principle of Contemporaneity, Lewin, 1936, 1951). This involved relating to the individual at each unique moment. A corollary of this style seems to be an attitude that a therapist’s understanding does not have to include considerations of diagnosis, history, personality type, and culture.

Inferring Gestalt therapy theory and methodology from observations of demonstrations of the California model, rather than investigating the ordinary practice or theory of Gestalt therapy, led many to erroneously assume that the essence of Gestalt therapy is “Gestalt therapy techniques” and that catharsis and breaking down defenses were the aim of the techniques. Unfortunately, when cliches such as “there is nothing but the here and now” were loosely bandied about, or techniques demonstrated without theoretical explication, practitioners were left with a misleading impression of naivete, of simplistic contemporaneity, and the understanding that techniques could be responsibly or effectively used without considerations of relationship and overall methodology and philosophy. At the level of practice, good Gestalt therapists have always centered on what the clinical situation called for and have not adhered to this simplistic view.

Gestalt therapy theory is actually more inclusive, flexible, and clinically astute than its myth and very supportive of creative variation from dogma. The conception of the now is part of complex issues of time and space in field theory and phenomenology, which is far from simplistic or naive (Yontef, 1993). This has been more clearly explicated in the last decade and a half.

For example, it is now clearly held that contemporaneous awareness can support any awareness, even if not physically observed in the room by the therapist at a moment in a session, and that the background can be as broad as the sophistication of the therapist and the patient allows. The exploratory lens alternates between a narrow micro-focus and a wide focus as clinically needed. Although the act of experiencing takes place contemporaneously, the reference of the experience can be past, present, or future — in the room or anywhere in the universe. The perceived “now” can be as narrow as a fraction of a second or as wide as a lifetime. The focus and the width of what is currently perceived of as “now” changes with each moment. It is also true that there are repetitions or invariants, e.g., character structure, that must be included in an insightful awareness of contemporaneous functioning or effective or safe practice of psychotherapy.

The therapist must be present-centered with the patient, but his or her map must be broader than a moment. Larger gestalten are essential to here-and-now work, just as the conception of the larger picture must be validated or invalidated in the phenomenological micro-focused work of the moment. The long term needs of the patient may well develop from supporting what emerges at each moment as advocated by Gestalt therapy theory, but how this is done in terms of relationship, technique, and focus must vary according to personality pattern, strengths, weaknesses, and so forth, and this is often not clear enough without consulting an understanding of larger gestalten to make sense out of what is happening in the therapy hour.

Example One: Bob

In this example, simple attention by Bob to his present experience allowed a meaningful story to evolve and a relationship to develop, gradually broadening his present experience by including awareness of previously unaware affect and processes of avoidance.

Bob was a well dressed, middle aged man who was referred by his wife’s therapist because “he needs something for himself”. He has been a solid and reliable support while his wife has been going through the aftermath of her mother’s death and her own successful recovery from cancer. He is a very articulate professional man who tells his wife’s story very clearly. However, questions such as “What are you experiencing right now?” were answered only with talk about aspects of his wife’s travail without giving any attention to his own feelings. My noting this lack of naming any of his own feelings was shrugged off. He did confirm that he subjectively felt the tension I observed (fidgeting, compression in his fingers, tight breathing, voice that was huskier than his natural voice).

In his second session I continued to share my understanding of what he was experiencing (empathic attunement), asked about his actual experience, and disclosed my observations. His spontaneous stream of consciousness provided sufficient emotional focus that I did not suggest any active focusing experiments other than asking what he felt at the moment. During that session he came to realize and acknowledge that he knew his thoughts but was usually out of touch with his feelings. In the third session tears showed in his eyes as he talked of his sleepless nights caring for his wife, how he loved her, and the pain he felt when he recognized her pain. I was touched, which showed on my face, and while no explicit mention was made of this, he appeared to notice, and his experience of his own sorrow deepened. After he cried and wiped his eyes, I asked “What do you experience now?” He said he felt relieved and noticed his tension had left. For the first time in our work he was not fidgeting, his knuckle

s were not white, his voice more natural. While during most of the first three sessions he talked about his story, the point of phenomenological focus and maximal contact between us were the moments of here-and-now, present-centeredness. He felt his grief, he felt relief, he learned something about his awareness process, and was affected by our engagement — he was the center of someone’s caring rather than his being the caretaker and problem-solver.

Example Two: Tom

In this example, the therapist’s attention to a broader field was needed before the patient could begin either to tell his story or focus on his immediate affective experience. Later, here-and-now focusing led to intensive exploration of childhood abuse.

Tom was also a middle aged man referred by his wife’s therapist. While a straightforward here-and-now focus on affect and armoring worked well with Bob, the same was not true of Tom. Bob was over socialized, talked of the important events in his life, functioned well in his career, had a satisfying and stable marriage, and showed no signs of serious character pathology. Tom on the other hand, chatted amiably about psychological processes in his life, but without meaningful focus on either story or here-and-now process. Gentle efforts to clarify story, current experience, or what he wanted from therapy were not successful in the first session. He canceled his second appointment at the last minute. I wondered about alcohol or drug abuse. Subsequent interactions with the patient and the referring therapist revealed that Tom was an alcoholic whose wife considered him abusive and threatened divorce if he did not get therapy.

Good therapy with Tom required some awareness by the therapist of events outside the therapy hour that Tom avoided bringing into the hour. This started with working on his resentment about being pressured into therapy and his denial of there being any problem. Work eventually included extensive work on his background of being abused as a child by an alcoholic father. While the work was experiential, the background of his life had to be carefully explored. As this background was discussed, the patient began to recognize the depth of his emotional baggage from his childhood. Real progress started when he connected his immediate experience in the therapy hour, especially his reaction to the therapist, with his emotional history.

Summary. While current Gestalt therapy practice focuses on what is being experienced here and now, it is also guided by understanding historical and characterological background factors. These background factors help organize the current field. It is the relationship of what is in immediate awareness and these background factors that makes meaning of what is happening in the therapy hour. This relationship of figure and ground is the gestalt that illuminates what therapy with this person requires, the patient’s needs and strengths, what sequencing and timing is optimal for maximum effect with this patient, and enables the therapist to be aware of particular dangers in therapy with this particular patient. Thus experience at one time and place is made meaningful by the context of background experience, i.e., repetitive, ongoing experiences and patterns occurring in the world prior to and outside of the consulting hour. This is illustrated by work with Margaret, Example 3 below.

Full awareness, and a therapeutic methodology to reach that capacity, requires a blend of the fluidity of here-and-now process (fast moving process) and the predictability of invariant structure (slow moving process). In the fluidity of narrow focusing in the present, both the felt experience of the patient and the structural aspects are clarified. On the other hand, present experience is clarified by the information about structure/invariants that funnels into present-centered exploration. It is only when the therapist integrates this information that intensive experiential work can be safe, sophisticated, relevant, and effective.

Contact and the Dialogic Relationship

The first goal in dialogic Gestalt therapy is to “meet” the patient existentially, to “start where the patient is” and then make contact on as empathic a basis as circumstances allow. From that point all purpose and design are jointly constructed by patient and therapist. The therapist’s prime directive is to contact the patient rather than “fix” or move the patient.

Contact, a crucial concept in Gestalt therapy, refers to “what one is in touch with”. Interpersonal contact is seen as being in contact with self and other. Contact is one of the characteristics of awareness, i.e., one cannot be aware without being in contact with something. However, contact can occur without awareness, e.g., worrying about something without being aware that one is doing so. Another example, a person making a vehement defense of the righteousness of his behavior may actually be in touch with shame and guilt without being fully conscious of it. In this case the emotional energy of the shame and guilt is not allowed to become figural, hence it is relegated to background status. In such a situation the person does not sense or feel the shame and guilt in focal awareness, but nevertheless the shame and guilt energize the behavior. The person is in contact with shame and guilt and aware of something else. In Gestalt therapy these contact and awareness process are explored phenomenologically — the therapist does not tell the patient what he or she “really feels” (interpretation).

Dialogue is a special form of contact in which people are in touch with each other and sharing what they experience without aiming for an outcome, each appreciating the other as a separate source of experience and worthiness, each saying what they mean and meaning what they say. In dialogic contact the meeting is not an instrumental action done in order to reach some other goal, but contact with the other person is an end in and of itself. In a dialogic relationship this contact continues over time.

Much is said in modern Gestalt therapy about dialogue being the basis of good therapy (Hycner, 1985; Hycner & Jacobs, 1995; Jacobs, 1989; Yontef, 1993). It is recognized that “dialogue” in therapy is a modification of the fully mutual “Thou” referred to by Martin Buber. In therapy the attitude is retained, but the dialogue is modified to honor the task and context of therapy.

Dialogue in therapy has the following characteristics:

Inclusion. The therapist simultaneously swings as fully as possible into an approximation of what the patient experiences while maintaining his or her own experience. This brings together fully sensing the patient’s phenomenology as if one were the patient, while maintaining full awareness of self as a different person who cannot feel exactly what the other feels.

Confirmation. In practicing inclusion the therapist makes the patient’s existential existence real by imagining it, making it a shared experience. This confirms the patient by accepting both what is and what could be (potential for growth).

Presence of therapist. The dialogical therapist relates to the patient with open, authentic, and disclosing presence — with discrimination about context, the demands of the therapy situation, the patient’s strength and state, ethical limitations. In my opinion, inclusion, confirmation, and presence work in the therapeutic relationship only when the therapist feels and shows genuine warmth, tenderness, respect, and caring.

Commitment to dialogue. The dialogic therapist surrenders to what emerges between the patient and therapist and to the process of the dialectic formation of new wholes. This differs from the therapist moving the patient to some vision of health and is antithetical to the non-horizontal viewpoint of only the patient changing and the therapist staying the same. In good dialogic therapy, the therapist’s own phenomenology is influenced and changed by the interaction. This is especially important when there is disagreement between therapist and patient, e.g., when the patient is critical of or disappointed with the therapist.

The Paradoxical Theory of Change: Awareness Through Dialogue

The paradox of the paradoxical theory of change: The more one tries to be who one is not, the more one stays the same (Beisser, 1970). Healing is making whole; trying to be who one is not, sets up internal conflict and not wholeness. Real growth is knowing and identifying with one’s self. The more one claims who one is, the more one can grow; on the other hand, the more one disclaims change and tries to stay the same, the less one grows — and even withers and declines as the world around changes. People are not static, but always in transition. At each moment a new figure is always emerging. People grow by identifying with this emerging figure.

The paradoxical theory of change presents the answer to an apparent dilemma: How can therapy be dialogic? Therapy is supposed to help patients improve in some way. Does this not mean moving toward a goal? Goals are something to aim for, but a dialogic relationship is defined as not aiming. Can therapy proceed without goals? How can therapy be dialogic?

The development of a sense of self as being worthy of love and respect, a sense of self that is cohesive, accurate, and self-accepting, is developed in interaction from early childhood on. It is not developed internally separate from the relational events that support and define the self (Perls et al., 1951/1994). In Gestalt therapy theory, the sense of self is relational. There is no “I”, no person, no sense of self, isolated from the interhuman environment. When a child’s emerging figures are met by disinterest or attack, a shame system rather than one of identifying with self is likely (Yontef, 1993, 1996; Lee and Wheeler, 1996).

The Gestalt therapy attitude is that an accurate and loving sense of self can be developed in psychotherapy and that this depends on the quality of contact and relationship and also the potency and pertinence of the awareness work. The dialogic relationship provides the matrix of a relationship with someone who is respected, that accurately understands, respects, and cares about the patient. Nonverbal factors such as tone of voice, intonation, demeanor, and so forth, are very powerful in this regard. When the factors of relationship and technique synchronized, phenomenological awareness work enables a person to have and identify with an accurate sense of self and others.

The phenomenological attitude supports self-identification by accepting the validity of the patient’s subjective experience. Clarification of self and other, identification with self, and acceptance of other is supported in Gestalt therapy by the phenomenological method and dialogic relating. The therapist guides the patient’s work on focused awareness and shares his or her own phenomenological perspectives. The sharing of phenomenological perspectives is a workable definition of dialogue.

The paradoxical theory of change provides a means of doing therapy while not aiming. This attitude of awareness through dialogue and phenomenological focusing and experimentation replaces the aim of changing the person as the main therapeutic orientation and does away with theory-derived interpretation as a main technique. The dialogic therapist operates by receiving the other’s experience respectfully, trying to experience the world as the other experiences it (as closely as possible while still knowing one’s autonomous experience), accepting the other’s experience as equally valid to one’s own, and allowing a mutually influenced change in both points of view to emerge.

It is especially important for the therapist to understand and live out phenomenological and dialogic principles when the patient has a different experience of the therapist than the therapist has of self. A true acceptance of the validity of both phenomenological perspectives enables the experience of both parties to be deepened and widened through the phenomenological exploration.

The Gestalt therapy orientation is to be more fully in touch with the present, including personal awareness and good interpersonal contact. Rather than aiming to be different, to manipulate oneself to reach a content goal, one grows to be different by identifying first with present reality and then with emerging possibilities. This process orientation is quite consistent with principles of dialogue, phenomenology and field theory.

Gestalt therapy supports jointly constructed process goals. For example, the therapy is oriented toward staying in contact with the here-and-now process of figure formation, i.e., what is important to the patient at each continuing moment. This includes learning to use this process to explore any aspect of life — whether problematic, a matter of positive expansion, or just an object of curiosity. Our experience has been that this leads to deeper emotional connections, insight, and healing.

Meeting the patient where the patient is and helping the patient be in touch with self and other in a manner consistent with the paradoxical theory of change replaces any therapist constructed end goal. Gestalt therapists dialogue about the patient’s feelings, desires, aspirations, values, and situation. The effective therapist contributes a knowledge of how to proceed in sequential steps that do not exceed the patient’s external or self-support and that take into account the structure of the patient’s personality, personal and cultural values. This means helping the patient identify both with what is, as well as with what is emerging, so that the patient can grow without disclaiming or artificially pushing him or herself.

It should be noted that dialogue is a guide for Gestalt therapists and it is not our goal to convince the patient to believe in or behave according to dialogic principles. To aim to move the patient to be dialogic would be a violation of phenomenological and dialogic principles. Therefore, we do not believe that the patient should practice dialogue — but it is a possibility. When the patient experiences the therapist’s dialogic relating and builds support through the relationship and phenomenological experimentation, the patient may move toward being more dialogic. This is a happy outcome, but not one the therapist aims for.

The Phenomenological Method

Phenomenology is a discipline guiding people to stand aside from their usual way of thinking so they can distinguish between what is actually being experienced (perceived and felt) in the current situation and what is residue from the past (Ihde, 1977; Spinelli, 1989). A Gestalt exploration seeks “naive” perception “undebauched by learning” (Wertheimer, 1945, p. 331). The discipline includes methods for discriminating between actual experience and experience clouded by preconceptions, assumptions, filters of what reality is (Ihde, 1977). Data includes what is “subjectively” felt as well as what is “objectively” observed. Actual experience is a phenomenological reality and not a surface manifestation of some other, “real”, meaning, that can be found through the therapist’s interpretation.

This phenomenological discipline of here-and-now exploration is a foundation of most existential thought; and, sharing present experience is an indispensable component of an existential dialogue. In fact dialogue could be defined as shared phenomenology. A therapy that is truly experiential or dialogic must emphasize, clarify, and enhance present experience.

Phenomenological discipline helps the willing patient and therapist move from unrefined subjective experience to a more refined experience. Phenomenological principles are the mainstay of inclusion, empathy, and affect attunement and is essential to experiential therapy. The experience-near reflections that are the most common intervention and means of contact in experiential therapies are based on phenomenological assumptions.

Gestalt therapy extends this shared phenomenological and dialogical approach by teaching the patient how to focus and experiment phenomenologically. This proactive attitude is one potent way for the therapist to be active in dealing with character pathology while maintaining a dialogical and phenomenological attitude. A further extension is the use in sessions of direct, active, experiments that are phenomenological in their intent, design, and execution.

This awareness work focuses on the continuum of the patient’s awareness, and interruptions of this awareness. What is the patient in contact with? What is not allowed into focal awareness? The therapeutic work in the phenomenological frame moves from straightforward awareness to awareness of awareness, and from this to insight (Yontef, 1993). Great emphasis is put on how the patient constructs his or her sense of reality, especially his or her sense of self. This gives an alternative to either attacking defenses or supporting defenses, i.e., being aware of defenses. Experiments help clarify and separate variables. In time, this attitude and skill set become integrated into the patient’s everyday functioning, i.e., phenomenological ascent (Spinelli, 1989; Yontef, 1993).

Summary. Learning to grow by accepting who one is happens in a dialogical relationship. The phenomenological attitude supports dialogue and it is through the dialogic relationship that the clinical phenomenological treatment occurs. In dialogic treatment two persons share their phenomenological perspective and work cooperatively in focusing, understanding, experimenting with new behaviors and discovering experientially.

Integrating Relationship and Technique

Some humanistic psychologists see using active techniques, such as “Gestalt therapy techniques”, as inauthentic and manipulative and therefore inconsistent with a dialogic relationship. I believe this dichotomy to be spurious, naive and unnecessary. Gestalt therapy envisions a relationship that includes but is not limited to empathic reflection and a vision of active methodology that is a cooperative effort at growing through experiential understanding. It does not relate by being an expert who can explain the real meaning behind the surface or by being a change agent who directly modifies patient behavior.

An authentic relationship emphasis can be integrated with an active methodology if the methodology is a phenomenological one. It is the thesis of Gestalt therapy that therapy that is the most effective and safe integrates a certain kind of relating to patients, i.e., dialogic, and a varied and active phenomenological methodology. Many modern experiential psychotherapies, including the Rogerian and the intersubjective self systems, have similar pictures of the therapeutic relationship. Dialogic Gestalt therapy agrees with these therapies that the most central aspect of psychotherapy is the relationship, but Gestalt therapists also believe that active focusing can not only make the therapy more effective, but can also enhance the quality of the therapeutic relationship. The relationship also provides the supporting environment making the active experimentation safe for the patient and it also directs the application of our knowledge and techniques.

Obviously there are a variety of active methodologies, with differing philosophies of therapy and differing stances on relationship. Techniques can be shared among the various methodologies, but the meaning, benefits, and dangers of the techniques are so different in different contexts that they are not equivalent. Using “Gestalt therapy techniques” in another framework may be useful for work in that framework, but it is not Gestalt therapy. Using behavior therapy techniques, e.g., desensitization, can be useful in Gestalt therapy — but it is not and should not be confused with systematic behavior modification.

For instance, an active methodology for therapeutic exploration can use body awareness in the service of systematic behavior modification, while it can be used in a phenomenological therapy such as Gestalt therapy in the service of understanding and growth that emerges out of the experimentation and therapeutic interaction and is not directed according to preset outcome goals. The latter is consistent with the principles of a therapeutic relationship according to existential dialogic principles; the former is not.

Gestalt therapy methodology includes focus on the unguided subjectivity of the patient, the guided subjectivity of the patient, the phenomenologically refined awareness of the patient, actively guided phenomenological experiments, and direct dialogue between therapist and patient. The patient receives reports of the Gestalt therapist’s awareness (observations, affect, association from the therapist’s history, feelings toward the patient, and so forth) and suggestions about new behaviors, for experimentation in or out of sessions.

The experiment involves a mentality of “try something new and see what you experience.” A patient who races from thought to thought, feeling to feeling, getting agitated and anxious might be asked to experiment with putting a period after each sentence and taking a breath. A sexually inhibited patient might receive a suggestion of experimenting with just looking. The patient who splits complex thoughts/feelings into either/or dichotomies might be asked to experiment with combining “I love Joanne and I am scared to death of being with her.”

Example Three: Margaret

In this example, Margaret was a 35 year old woman. In her first session she spoke rapidly, changed topics often. Multiple crises, each with life and death urgency, suddenly became her focus. Her manner and voice registered her sense of panic and urgency. She was having a fight with her neighbor, angry with her boyfriend, fighting with a department store over disputed charges, multiple medical complaints (headaches, tired, stomach pains) for which the physician could not find a clear cause. She had heard that I was a wonderful therapist, unlike her previous therapist. In response to questions about her immediate experience, she reported intense affect — chiefly panic and rage. Empathic reflections were acknowledged, but seemed to have little effect. She was clear that she wanted a “magic pill”, an instant solution from a master therapist, as if this was the only way she could imagine change.

It was clear to me that her process in the session was a micro-example of how she coped with life at the macro level. In each story she brought up, her behavior had the quality of her wanting to be rescued, avoiding rather than confronting difficulty, acting in panic, often making the situation progressively worse. In the work of the session, she did the same. If she was going to be able to do the work of regulating her life, we needed to interrupt this style in therapy sessions long enough for her to be aware of it and through directed focusing build up a reservoir of skills for improved self-regulation and coping with life problems. It was clear that while she very much needed a relationship with an empathic and accepting therapist who felt warmth or affection for her, she also needed an active teaching methodology as well.

As her speech was building up speed in the latter part of the first session, I said, “Try an experiment: “Close your eyes, take three deep, slow breathes, with long exhales.” As she started the experiment, she closed her eyes and breathed rapidly, blowing out the air in a hyperventilating manner that did not release tensions. When she was finally able to do the breathing in the manner I was suggesting, she did slow down, breathing in a normal manner, and talking with less panic.

When she started to rev up again during the session, without contact with me, I looked at her and interrupted her monologue. “Try another experiment. Look right at me and go back to trying the slow breathing pattern.” After I could feel some connection between us for the first time, I asked her what she experienced. “Right now I feel calmer and am glad to be here.” Here the use of active experimentation aided the development of a contactful relationship — and my suggesting the experiments in a soft manner avoided the danger of the interruptions being perceived as antagonistic or combative. The centering activity introduced in the session would later become a tool she could use in her daily life.

That was our beginning. This kind of proactive, guided experiment that built self-support, and supported good contact between us, continued to be a frequent focus for several months. Her regular behavior in life out of the session helped clarify what needed to be done in the session, i.e., she needed to learn how to regulate herself. Sometimes we focused on the moment in the hour, sometimes we focused on the events of the week both because she needed to do so and in order to gain understanding of the parallel processes that were going on in micro in the session and in macro in her regular life.

At the end of the first session, and a second session scheduled, she asked what she should do about these multiple problems — again wanting to be rescued. I neither offered a suggestion to fix or solve the problems nor at the time did I directly interpret or confront this behavior. Instead I reflected to her that I guessed that she felt like she could not handle these problems herself, which she confirmed. I suggested she might like to learn and that we could do this in therapy. She nodded, as if this were a new thought. I suggested that for the moment she practice the centering activities we had been working with during the session as support for her finding the best solutions she could. Obviously, she still wanted and felt she needed more than that, which I acknowledged, but she could accept this answer for the moment. In large part this was due to my interacting at this point with firmness and clarity, but without giving her a verbal or nonverbal judgmental message.

Understanding borderline process helped me to react to Margaret in a way that would establish good contact and focus the awareness work in a sequence she could grow with. My picture of her ongoing process was clarified by her continued hypomanic build-up in reaction to simple empathic reflections, but rapidly improved functioning in response to the more proactive, actively engaged, experimental interventions. Her expectation that she be rescued at the end of the session was further clarification. Subsequent work confirmed that her self-interruption, failure to center herself, picturing herself as helpless, and expecting to be rescued was a regular part of her functioning. This changed in small but definite stages until the structure of her functioning was more self-supportive.

Therapy beyond that point focused on rather severe childhood intrusion and abandonment experiences that could be dealt with in a healing way now that her self-support had been improved and our relationship deepened. In her family any autonomy, independence, or competence resulted in attack and/or abandonment; the price of any semblance of nurturance was being merged with mother as a pitiful, incompetent child. Before some therapeutic consolidation of self-processes, focusing on her intense, primitive affect and the historical experience creating it, would have been more regressive than her self-support. At the beginning she did not have the ability to experience the regressive processes in the context of growth, healing, and insight, but likely would have regressed into helplessness, being overwhelmed by affect, demanding rescue, increasing crises between sessions. There would also have been a strong chance of suicidal despair, or rageful acting out.

Summary. Learning to grow by accepting who one is happens in a dialogic relationship. The phenomenological attitude supports dialogue and it is through the dialogic relationship that the clinical phenomenological treatment occurs. In dialogic treatment two persons share their phenomenological perspective and work cooperatively in focusing, understanding, experimenting with new behaviors and discovering experientially.

Example Four: Nancy

This example illustrates the integration of many of the fundamentals of Gestalt therapy that we have been discussing.

Nancy is an attractive 30 year old woman working on an advanced degree in counseling. Her presenting problem is relationships with men and low self-esteem. She wants love and commitment, but only expects abandonment due to her self-perception as being inadequate, boring, loathsome, and unlovable. Her dating history has been with men lacking kindness toward women and fearful of intimacy and commitment.

From the beginning, Nancy reacted very positively to warmth and empathy in the therapeutic relationship, but also constantly scanned for signs of the rejection, abandonment, and betrayal she expected from men. Early in the therapy I was 5 minutes late for her session. Her immediate thought was: “Gary does not want to see me”. She brought her reaction into the session for exploration. I told her that I guessed that while she was alone in the waiting room she felt anxious, a feeling of a great void, worried thinking filling the gap — and that it triggered old thoughts of hers that she was undesirable and other people only tolerate her as a burden. She nodded confirmation. I told her that I was really sorry, regretted being late and triggering all that, and that I actually looked forward to seeing her. She nodded and said that she had sensed that I liked her and she knew that she was being helped by me.

Finally, when the connection with her was reestablishedfollowing my being open, warm, and empathically attuned to her, and also telling her my feelings toward her, I told her that I had characterological difficulty with being on time. That disclosure of mine was the final step needed for her to engage in a deeper exploration of her assumption of rejection and abandonment, leading to work on her current and childhood experience with feeling that significant others thought of her as a burden. She did not need me to be without flaw, did not need more information about my difficulty, she only needed me to be honest, emotionally present, responsive, understanding, and accepting. Supportive, empathic interactions with me were almost always followed by Nancy’s recovery of self-functions and a cohesive sense of self, a sense of self-acceptance, and a deeper self-exploration.

Nancy gets so anxious about both the abandonment she believes is inevitable and possible future incidents of shame and humiliation that she goes into desperate panic. She is ashamed of her anxiety and panic, and of course the shame elicits increased anxiety. She is obviously narcissistically wounded and quite shame oriented. She carries with her a self-image that does not include her positive qualities, such as being bright, sensual, playful, vibrant, loving.

Nancy sees men as powerful, intrusive, and rejecting and herself as lost, lonely, scared, desperate, and empty. She dichotomizes confluence and isolation. As a result, when there is no contact, let alone confluence, she pictures herself alone forever — of course due to her inadequacy. She tells herself that if a particular relationship does not work out, that it is catastrophic and confirms her belief that no man will be interested in her since she is “fat, ugly, and unattractive”. If “he” does not love me, I am unlovable, “I am a bother”. Actual experience that men do find her interesting and attractive does not alter this sense of self.

When she is in a primary relationship, she needs the man to give her inner cohesion, safety, and to heal her feeling of shame and humiliation. When with a man who will not let her feel at all special, such as her current boyfriend (Joe), she asks “What’s wrong with me?” When he does not meet minimal wishes of hers, she believes it is because she wants too much. She has trouble picturing being both nurtured and competent. Nancy can tolerate being alone, and when she is not in a primary relationship, she meets her contact needs with her friends. It is the rejection and abandonment by a man that she finds devastating. Her expectation of betrayal by men goes back to crushing disappointment and betrayal by her older brother and father (discussed below).

In a later session she became aware of her shame, humiliation, and rage that was often retroflected against herself. Her boyfriend, Joe, had treated her badly and verbally attacked her without apparent cause or warning. She felt rageful, wanting to kick and hit him, to hurt him like she had been hurt. She also had a sensation of hurt in her stomach. I suggested she stay with a focus on the sensation without interpreting it. What emerged was her felt sense that the stomach pain was telling her not to act on the wish to hurt him.

I suggested that she imagine Joe was sitting in the empty chair and express her feelings to him either verbally or nonverbally. As is common with patients with a history of narcissistic injury and tendency toward global shame, Nancy had a very negative reaction to enactment techniques such as this. In Nancy’s case, the reluctance does not seem related to an avoidance of the affect or insight that can come from such techniques. She brought significant issues/feelings to explore and she was very responsive to focusing suggestions. She would do mental experiments, did get to real affects, talked with mobilized emotions, explored the background of current experiences, was able to do mental experiments to separate variables, and so forth. So we proceeded by phenomenological focusing without the empty chair.

The following picture emerged:

Joe demonstrates his longstanding avoidance of committed, intimate relationships by moving in and out of relationship with her. He attributes all problems in the relationship to her, including his distancing and exiting. Sometimes at tender moments he cruelly attacks her. He frequently does not follow through with promises and dates, without ever giving her warning, explaining, or apologizing. When he approaches her lovingly, he does not discuss or acknowledge his poor treatment of her. Inevitably he follows the loving connection by either distancing within the relationship or breaking off the relationship again.

In reaction, she feels shame, humiliation, hurt, grief, and rage. Being confluent with his negative judgment, she desperately clings, needing him to change so that her negative self-image is mollified. The relationship reinforces her life script of “knowing” that any man will leave or betray her.

She missed her next session, an unusual event for Nancy. When I saw her the following session, she said we had gotten too close, we had moved into her internal space. When she had thought between sessions about the previous hour and her experiment with giving up her retroflecting defenses, she feared that if she did not go along with my suggestions, she would lose me — she was afraid that I would emotionally kill off our relationship.

As she realized that her experience was more important to me than any technique or program I offered, she stayed with herself directing the anger outward, undoing the retroflection, sounding quite strong. Her therapeutic focusing was self-directed and she did not emotionally lose me. She left feeling safer with me and stronger in the world.

This was an example of the textured interplay between relationship and technique, and between immediacy, past, and future.

Nancy continued to feel desperately alone and in need of maternal support to have a positive and cohesive sense of self. As a homework experiment I suggested she meditate with the sentence “Mommy and I are one”. She was receptive to this focused awareness experiment, reporting next session some definite relief from this experiment — although also being aware of mourning the abandonment of her independent self by her mother.

The following material emerged from this.

Nancy was sexually molested by an older brother when she was 3 years old. Her father discovered this when she was four. His stern reaction did not feel emotionally supportive. His exhortation not to repeat the situation felt like blaming her for the event rather than lovingly supporting her right to say no. Her father’s subsequent behavior was never as soft and loving as she had previously experienced it. At four she had been in the throes of Oedipal idealization of her daddy, and it felt like she lost that “good daddy”. In reaction to the chastisement he received and the loss of the sexual relations with Nancy, her brother became distant and unaffectionate. The intimate relationship with neither man was ever truly healed.

Mother taught Nancy that her father was fragile, not to be counted on, easily stressed. Nancy’s feelings were considered too much for men. Later father developed a heart condition and Nancy was told that her emotionality would kill him.

Mother was empathic, but only as long as they were confluent. With differentiation, mother gave her a message that she was bad or selfish. Nancy became compliant with mother, repressed and retroflected her anger, and felt guilty when she did well. Her normal need for autonomy was balanced by a felt need for confluence with mother.

Nancy is caught in a bind between shame and guilt (Yontef, 1993, 1996). If she is independent (e.g., leaving the maternal orb), assertive (especially with brother or father), or sexual, she is bad. On the other hand, if she is dependent, accommodating, or not sexual, she feels shame and inadequacy. She has found it was easier to see herself as unattractive and inadequate than face the guilt of being independent of mother, assertive, vibrant, sexual, and cherished by a man.

Crushing disappointment and a tendency toward inflation or deflation are central issues for Nancy. She has a strong, primitive need for recognition, affection, and acceptance. She has needed a positive reaction from me to feel whole and OK with herself. But, she does not need to be taken care of, takes responsibility for herself, in therapy does not pull for care beyond the therapeutic frame. In fact, sometimes she takes too much responsibility, blaming herself in self-shaming fashion for things that were not her doing. In therapy she needs a positive reaction from me to feel whole and OK and has a positive reaction to empathic interventions that do not ask her to do any “show and tell” experiments.

At first she projected her picture of powerful, intrusive, rejecting men onto me, and in reaction felt shame and envy. She was afraid I would be bored with her, judge her negatively, think her fat and ugly. She was afraid that I would make her vulnerable, and then the power would be mine: I could intrude, hurt her, leave her — at my will. There were obvious issues of safety, trust, and fear of betrayal. If I found her unattractive, it would confirm her self-view. If I found her attractive, she was afraid I would use her sexually.

On the other hand, she was also afraid that her emotions would be too much for me. Her mother’s message that her anger might kill her father colored her contact with me. Nancy reports that father would “slap me with words”, but mom said that father was fragile and that Nancy had to apologize for upsetting him. Anytime Nancy spoke up, mother told her to go to her room and apologize, leaving Nancy feeling that she had to apologize to an abuser and that no one supported her. In her relationship with me she was afraid that merely bringing this up would result in her losing me emotionally.

After exploring this issue, she was late for her next appointment — unusual for her. She talked of being angry, but without focusing it in the room. I asked if she was angry with me. She said she was angry with me for exposing her shame and said she wanted to hide. She was even afraid that I would literally slap her — which had never occurred in either of our lives. She did maintain a sense that this would not occur literally, but the symbolism of it captured her fear of stinging rejection. She realized that she was projecting onto me the way father treated her when he verbally slapped her. At this session it was enough that she could stay in contact with me while sharing these feelings and associations, assimilating the material from the previous few sessions.

As therapy progressed, she came to trust and partially assimilate that I did not find her a bother, I was neither going to be turned off nor be sexual with her, that I was not betraying her, that perhaps she could be lovable. She developed a more accurate appraisal both of her strengths and her contributions to relationship difficulties without being filled with shame. She developed a more accurate sense of her childhood and adult relationships. She broke up permanently with Joe, and increased her ability to see potential difficulties early in dating relationships. She built a sense of confidence in herself, resuming creative activities that she had long ago stopped, and became more assertive and risk taking professionally. Part of the support for all of this was an ability to center herself when intense feelings arose, which included tools learned and practiced in the therapeutic relationship.

Work with Nancy illustrates the advantage of a dialogic relationship in which focused awareness experiments are used with discrimination, and in combining a narrow focus on the immediate with a wider focus on history and other background factors. Nancy grew in the context of a dialogic therapeutic relationship that used an experiential, directed, focused awareness methodology but without enactment techniques such as the empty chair.

Her here-and-now pattern of contact in therapy and in life clarified each other and developed in parallel. Exploration of the larger patterns of her life clarified what was happening immediately in sessions. The reverse was also true, that exploration of the immediate clarified her history and current functioning in the world.

The New Model of Gestalt Therapy

It is my experience that patients and trainees who worked in Gestalt therapy, training, or supervision in the late 60s or 70s and then worked in or observed that framework again in the late 80s and 90s have seen dramatic changes. Both the relationship and the quality of awareness have been much deeper and broader, change has been more profound, there have been fewer side effects such as narcissistic injury, and there has been a more consistent repair as breaches occur in the relationship. There has also been a much more differentiated approach to patients according to their personality style and character structure. Therapists report improved work with their own patients.

As the therapist is clear about what is happening, and also warm and accepting, patients react less to the therapist as an intruder, threat, or someone who abandons them at critical moments. This has made patients feel safer to engage more fully not only with the therapist, but with others in groups, intimate relations, and community. Equally important, patients and trainees have reacted less to the therapist or trainer as a charismatic figure whose power they can only vicariously experience through identification with the idealized, but never claim for themselves, and more as a good person they can relate to horizontally. The capacity of patients to claim their choice, acknowledge alternatives, and take risks in terms of new behavior are better supported with this new attitude.

Ideally the therapist relates with firm and clear boundaries, focuses on how the patient behaves and what the patient experiences, acknowledges context, admits his or her own flaws, weaknesses, fallibility, and mistakes. Any particular experiment is suggested as only one of many ways of exploring whatever is the object of study, and the patient’s help in directing the work is invited. Patients are carefully trained to treat therapist statements about them as hypotheses that they can and should correct or disconfirm to the extent that they perceive them as inaccurate.

When patients interrupt, resist, and pull back from staying in contact with their own feelings, the modern approach is gently, insistently, and respectfully making clear the interruption, and that the interruption has an important function that needs explication. The attitude and demeanor of the therapist is crucial. If it turns out that the therapist has a role in triggering the interruption, this too needs to be clearly acknowledged. The inadvertent triggering of an interruption may happen through the therapist inadvertently posing a question in a manner encouraging speculation rather than description of actual experience, coldness or harshness which might trigger shame, or by the therapist’s failure to understand accurately the patient’s experience (Yontef, 1996, in press).

One of the regular activities in Gestalt therapy is to suggest and encourage the patient to try new behaviors as an experiment. This encourages patients to get data on their own reactions to new behaviors, how they go about it, what is experienced in the new behavior, what resistances come up, what unfinished business from earlier period of life emerge from the background as a result of the new activity, and so forth. For example, in working with Amy, the woman mentioned earlier who wanted a relationship with a man and averted her eyes in the therapy sessions, I suggested an experiment of just looking at men.

New behavior in the session included “staying with” (maintaining focus on an experience that emerges as long as it continues to operate), mental/fantasy/imagination experiments, empty chair and two chair experiments, physical experiments (breathing changes, movement, expressive experiments, sensory focus, and so forth). “Staying with” is a direction or suggestion by the therapist when observing an emotion emerging into awareness and the patient is encouraged not to interrupt or interpret the feeling, to keep sensory and mental focus on the feeling, to allow the feeling to change, transform, complete itself without conscious intervention or direction by the patient. These can often be used in coordination with “homework” assignments.

Summary Discussion

Working with the immediacy of the processes emerging at each moment is in polar integration with focus on historical and repetitive characterological patterns. When the here-and-now work is informed by the larger gestalten, it is safer and more effective. The knowledge of Margaret’s borderline personality organization supported an interaction in which boundary skills were built and the dangers of treatment with borderlines avoided. Knowing Nancy’s history of betrayal and abuse sharpened my emotional response to her. At the same time, observing and exploring Nancy’s reaction in the therapeutic relationship clarified the sense of self she brought into her romantic relationships.

Working with tools of phenomenological experimentation is in polar integration with relating dialogically. The dialogical relationship is in itself a phenomenological experiment, one that makes it safe to do other work with focused awareness, experiment, and learn how to explore one’s life experientially. The tools of phenomenological experimentation help clarify exactly what is happening in the therapeutic relationship, thus strengthening it. When Nancy started thinking and feeling that I did not want to see her, clarification required 1) my empathic response and disclosure of something about my feelings of caring, regret, and my characterological difficulty with being on time, and, 2) narrow lens focusing on her continuum of awareness led to awareness of factors in her history that she was projecting onto me. This enabled her to restore her sense of being valued by me. Effective experiential therapy works with here-and-now process and with larger gestalten of history and characterological structure; and, works with a relationship focus as well as active, directed focusing of awareness.

References

Beisser, A. (1970). The paradoxical theory of change. In J. Fagan & I. Shepherd (Eds.). Gestalt Therapy Now. New York: Harper. (pp 77-80).

Hycner, R. (1985). Dialogical Gestalt therapy: An initial proposal. The Gestalt Journal, 8, 1 (Spring 1985), 23-49.

Hycner, R. & Jacobs, L. (1995). The Healing Relationship in Gestalt Therapy: A Dialogic/Self Psychology Approach. Highland, New York: The Gestalt Journal Press.

Ihde, D. (1977). Experimental Phenomenology: An Introduction. Albany: State University of New York.

Jacobs, L. (1989). Dialogue in Gestalt theory and therapy. The Gestalt Journal, 12, 1 (Spring 1989), 25-67.

Lee, E. and Wheeler, G. (Eds.). The Voice of Shame: Silence and Connection in Psychotherapy. San Francisco: Jossey-Bass.

Lewin, K. (1936). Principles of Topological Psychology. New York: McGraw.

Lewin, K. (1951). Field Theory in Social Science; Selected Theoretical Papers. D. Cartwright (Ed.). New York: Harper.

Perls, F. (1942/1992). Ego, Hunger and Aggression. Highland. New York: The Gestalt Journal Press. Original version: (1942). Durban, South Africa: Knox Publishing Company.

Perls, F., (1951/1994). Hefferline, R., and Goodman, P. Highland, New York: The Gestalt Journal Press.

Spinelli, E. (1989). The Interpreted World. Newbury Park, CA: Sage Publications.

Wertheimer, M. (1945). Productive Thinking. New York: Harper and Brothers.

Yontef, G. (1993). Awareness Dialogue and Process: Essays on Gestalt Therapy. Highland, NY: The Gestalt Journal Press.

Yontef, G. (1995). Gestalt therapy. in A. Gurman and S. Messer (Eds.). Essential Psychotherapies. New York: Guilford.

Yontef, G. (1996). Shame and guilt in Gestalt therapy: Theory and Practice. in R. Lee and G. Wheeler (Eds.). The Voice of Shame: Silence and Connection in Psychotherapy. San Francisco: Jossey-Bass.

Yontef, G. (in press). Relationship and Sense of Self in Gestalt Therapy Training. The Gestalt Journal.

Zinker, J. (1977). Creative Process in Gestalt Therapy. New York: Brunner/Mazel.