Case Study:  Theoretical Aspects

Therapeutic Approach

Gestalt Psychotherapy

Gestalt psychotherapy approaches the world of the client from a stance of accepting the client as they are.  That the client is being as they are, in the best possible way, through having adjusted and adapted their life experiences.

“The Gestalt approach rests on the belief that anyone can, if they want to and have sufficient support, learn how to function in life with greater skill and satisfaction” (Parlett and Hemming, 1996, p197)

The Gestalt approach is based on the absolute inseparable unity of bodily experience, language, thought and behaviour (whether or not in awareness).  Clarkson (2000, p20), and Zinker (1978, p162) both identify that the goal of Gestalt therapy is awareness, and awareness is “that an individual is attending to his experience”

“The goal is for the client to become aware of what they are doing, how they are doing it, and how they can change themselves and learn to value and accept themselves” The Sherwood Institute (2004, p1)

Gestalt psychotherapy is a humanistic, holistic model of therapy.  From Perls et al (1951:1984, p257) “We see that meaningful wholes exist throughout nature, in physical and conscious behaviour both, in the body and the mind.”  A holistic approach takes into account the total self, mind and body as one.

Gestalt works with what is in awareness (figural) and what is not (ground).  With this the work is relational.  As a model of therapy Gestalt is phenomenological.

“Phenomenology is a search for understanding based on what is obvious or revealed by the situation rather than the interpretation of the observer” Yontef (1993, p182)

Dialogic

Additionally, my practice as a Gestalt therapist is dialogic, “… the overall relational context in which the uniqueness of each person is valued and direct mutual, and open relations between persons are emphasised, and the fullness and presence of the human spirit is honoured and embraced” Hycner & Jacobs (1995 p4)

“Dialogical psychotherapy is concerned with the client’s whole existence” (Heard, 1993 p8), and is based on the work of Martin Buber, who put forward the concept of ” the I-Thou dialogue, which is the foundation of dialogical psychotherapy” (ibid, p1)

Within an I-Thou relationship the parties express and accept each other as they are, and that in relating to each other fully do so in the present, here and now.  In this way healing comes from the meeting together.

 “People are not people unless they are in relationship with others; no true human can exist without real or fantasied relationships.”  (Erskine et al 1999, p157)

In the space between, and with, two people lies the centre of polarities of connectedness and separateness.  The polarities are I-It and I-Thou.  These are primary attitudes of connectedness (Thou) and separateness (It)  (Hycner and Jacobs, 1995)

Diagnosis

What and Why

A synonym of diagnosis is judgement (2005,Thesaurus.co.uk), and it is in the context of judging that the use of diagnosis in Gestalt Psychotherapy is often resisted; being seen as contrary to the here and now focusing and experiencing of the client.

Yet, “We see that meaningful wholes exist throughout nature, in physical and conscious behaviour both, in the body and the mind.”  Perls et al (1951:1984, p257)

Our mental awareness is predisposed to interpreting that which we perceive.  This quote from Perls is founded in Gestalt psychology research experiments into perception.  “Gestaltists were among the first scientifically orientated theoreticians to posit the notion of an organisational element in perception”  Spinelli (1989, p33) citing Kohler, 1929; Koffka, 1935).

Where meaningful wholes do not - or appear to not - exist we seek to complete this.  Thus instead of a series of dashes the interpretation is of a circle.

This interpretation, is a judgement, is a diagnosis, of what is being perceived.

Diagnosis is about having some understanding with regard to what is presenting.  “Our way of making sense of the world can be said to be an ongoing form of assessment or diagnosis” Joyce & Sills (2001, p57)

Diagnosis: DSM

Fundamentally we each diagnose continuously.  Making a diagnosis needs to fulfil the ethical and philosophical approach of Gestalt psychotherapy.  Also however there is a need to be able to communicate with the medical profession where the Diagnostic and Statistical Manual of Mental Disorders (DSM) is prevalent. In dealing with personality disorders DSMIVTR (2000) makes clear “the pattern of behaviour and inner experiences need to be markedly different from the norms of the culture from which the client comes” when dealing with Axis II, personality disorders.  This, for me, raises the problem in understanding what norms would be applicable and what culture is to apply!

Diagnosis: Self challenge

Key, in all diagnosis, is to maintain an objective stance of self-challenge of the diagnosis.  The focus then stays with the unfolding experience and drama of the client in relationship with the therapist.

The dictum from Louis Pasteur “… chance favours the prepared mind” (Greenberg 1998, Hanard 2004,) encourages us all to have the knowledge of what exists to prepare us for the new.  This, for me, is what diagnosis is about - being aware of possibilities.

With this awareness I am more able to seek appropriate interventions in working with the client; more able to avoid recreating the pattern of responses the client has experienced to date.

Where the medical use of DSMIVTR is categorical in context, there is an alternative in the use of a dimensional context, “more flexible (and therefore more sensitive at the cost of losing the clarity of categorical approaches.) People have degrees of personality disorder which shade imperceptibly down into personality styles and traits which are not so problematic”. Dent-Brown (2001).

Dimensional Perspective

The dimensional approach emphasises the meaning and purpose of symptoms, not only their presence or absence. Greenberg (1998), Benjamin (1996) Johnson (1994).  This provides the link for engaging the medical and Gestalt models.

The prepared mind favours the consideration of traits and styles.  From a Gestalt perspective traits and styles support seeing the client as a whole person; faceted with different behaviours and differentiating styles of presenting.

Gestalt perspective

Gestalt diagnosis is usually referenced to the “Cycle of Gestalt Formation and Destruction”, Clarkson (2000, p32).  Also referred to as the Cycle of Contact

Figure 2 Mackewn, J (1997, p19) Interactive cycle of contact - withdrawal of organism and environment (inspired by Zinker, 1978)

This process of sensation through to withdrawal applies at both a micro and macro level.  In essence I see this process as a fractal; at every level of process the cycle applies.   A healthy process occurs when the individual experiences the contact cycle fully and completely.  Interruption to this cycle indicates a loss of contact for the individual; contact with their environment; in their relation to an other.  Gestalt sees the self as being formed at the contact boundary; where self meets other and thus interruptions to contact interrupts formation of self.  From a dialogic perspective this meeting is between self and other - person or environment.  The formation of self occurs in ‘the between’.

I am not qualified and would, correctly and properly, resist providing a DSM diagnosis in my professional capacity.

Global Assessment of Functioning

(GAF) Scale (DSMIVTR Axis V)

Note: This version of the GAF scale is intended for academic use only.