The Person-Centered Journal, Volume 4, Fall, 1997
Printed
in the
TOWARDS INTEGRATING PERSON
CENTERED AND GESTALT THERAPIES
In the
now famous tape of Gloria in Three approaches to psychotherapy (Shostrom
(1964), Gloria reports at the end of the session that a combination of
Rogers and Perls would be ideal for her. Although
subsequently she kept in contact with
Similar
to most approaches to psychotherapy, person centered therapy and gestalt therapy
have sought to maintain their separate identities. In a
directory of gestalt training courses, O'Hara (1984) found a complete absence of
one which combined gestalt therapy with the person centered approach.
Yet in describing their practice, the majority of gestalt therapists
listed more than one type of therapy. Furthermore papers
(O'Leary(1993), O'Leary(1997)) in the major gestalt journals have examined the
use or similarity of key concepts in the two approaches while Stanley and Cooker
(1976) considered how the core conditions of the person centered approach could
strengthen gestalt techniques. However they used the core
conditions as outlined by Carkhuff (1969a,b) rather than those used by
In one of the main books on the person centered approach entitled Client centered therapy and the person centered approach, O'Hara (1984) claimed that a holistic way of thinking would allow the integration of the two approaches since it would consider both intrinsic and relational factors. A previous publication by Cochrane and Holloway(1974) focused on similarities between the two therapies stressing their common approach to the nature of the person, their process orientation to therapy, their goals and their similarity in definition of maladjustment. They further held that the therapeutic process was in the hands of the client and that the techniques of gestalt therapy can be employed in the process of person centered therapy. However, O'Hara considered their contribution was a merger rather than a synthesis.
But what precisely constitutes a synthesis or a merger? Thesaurus definitions overlap: blend and combination are given for both words but there are other different words given for one but not for the other. For example synthesis includes as parallels creation and formation while merger is equated with amalgamation and convergence. O'Hara (1984) by emphasizing the need for a synthesis is pointing to the necessity for a new formation. A true synthesis will require the identification of what is in common in the two approaches, what may be in common but is obscured by different names and the creation of new combinations through the process of inclusion of elements of both.
14
The person centered approach and gestalt therapy consider the how and what of behavior rather than the why. They pay attention to historical reality insofar as it effects the present but prefer to stress functional laws of behavior. Viewing clients in this manner rather than in a pathological way moves the emphasis from a medical to a developmental model of the person.
Both approaches grew out of the existential philosophic tradition. They value present subjective experiencing, the therapeutic relationship, personal responsibility and autonomy. From existentialism they derived the emphasis that by paying attention to experiences in the present moment, change will occur. Hence they are phenomenological in their orientation to clients. The freedom of individuals is acknowledged: they are viewed as self determining and creating their own lives. Non-rational experiences are honored and the dominance of rationality is not presumed.
In integrating person centered and gestalt therapy, the underlying assumptions in both approaches need to be congruent with one another. Since both lie within a humanistic orientation they share common assumptions with respect to the nature of the person, the goal of therapy and the therapeutic process. Individuals are viewed as being the ultimate determiners of their own destiny. The language used in this regard differs in the two approaches: person centered therapy speaks of fully functioning individuals who are experiencing the world around them and are self-actualising while the very word gestalt denotes wholeness which emerges from developing awareness. Hence both orientations view individuals as moving towards psychological health if the appropriate conditions exist. Therapy seeks to establish those conditions so that individuals may engage in self exploration.
The
goal of both therapies is seen as individuals becoming more of themselves.
In person centered therapy,
Evidence of this process can be seen in clients moving away from undue
dependence on others, towards self-direction and responsible choosing, towards
openness to life and experience, towards trust of self and others and towards a
greater creativeness in thought, word and action. In gestalt
therapy, the goal is viewed as the integration of polarities which results in
organismic self-regulation. Self regulation can be enhanced
through awareness since clients can accept aspects of themselves which they have
previously denied and can get in touch with unfinished business in their lives.
THE CHANGE PROCESS
The process of therapy in terms of the therapist lays emphasis on the attitudes of the counsellor in person centered therapy, in particular those relating to empathy, congruence and unconditional positive regard, while in gestalt therapy awareness, contact and the dialogical relationship are emphasized.
Empathy, according to O'Leary and Kelly (1992), may be compared to two tuning forks in the same key: when one is struck the other picks up the sound transmitted by the first while forfeiting
15
nothing of its own basic nature (O'Leary(1993).Writings by O'Leary in the nineties (1993,1997) and gestalt approaches and on equating empathy have focused on empathy in the person centered and gestalt approaches and on equating empathy with healthy confluence. In the 1980's, Tobin (1982) and Yontef and Simkin (1989) chronicled and advocated a shift in gestalt therapy from confrontational techniques to a softer more empathic attitude.
Empathy, O'Leary (1993) held, can be communicated as effectively through the overt recognition of non-verbal behavior as through communication based on verbal behavior. What is importance in an empathic context is the manner in which therapists communicate and their desire to understand their clients. She stated that "the inner experience of the therapist incorporates the verbal, gestural and postural impressions of clients" p. 113 and argued that apparent differences between the two approaches in responding empathetically relate to idiosyncratic modes rather than to fundamental differences. Polster (1995) devoted chapter of his book A population of selves to the topic of empathy in a gestalt therapy context while in 1987 he had viewed the receptive process of the therapist to the client as one of becoming fascinated.
In considering confluence and empathy, O'Leary (1997) suggested that empathy could be conceptualized as comprising of both foreground confluence which centers on the other and the shared emotion and background confluence which holds the distinctness of persons, allows perspective taking and takes the organismic experiencing of the therapist into consideration in the interaction. Hence both therapists and clients are involved in empathy. The empathy of concerns and experiences of clients.
Congruence was equated with realness by Rogers(1990) who described it as
"sparkling", p. 16. He emphasized that
it involves therapists being their true selves, becoming self-accepting and
getting closer and closer to their organismic experience.
Unconditional positive regard was defined by
Although gestalt therapy recognizes that the affective response of therapists vary, it differs most from person centered therapy in that gestalt therapists do not offer unconditionality to clients. In a new integration it would seem desirable to retain unconditionality as an important dimension. Everyday life indicates that individuals flourish when they are with people who accept them unconditionally and allow them to develop their own sense of self. This does not mean that therapists agree with all the behaviors of clients but they do not censure them as persons
16
Integrating Person Centered and Gestalt Therapies
because of these actions. Yet therapists can share negative feelings regarding the actions of clients without threatening their unconditionality. Unconditionality removes the threat of conditionality. In conditional relationships, individuals are cared for because of what they do leaving a doubt that this care will disappear if certain conditions are not met.
While person centered therapy emphasizes the attitudinal conditions which the therapist brings to therapy, gestalt therapy has in recent years spoken of the dialogical relationship which holds many of the qualities of the I-Thou relationship discussed by Buber (1958). Yontef (1993) pointed out that it is based on authenticity "saying what one means and meaning what one says" p.253. Congruence then is at the foundation of the dialogical relationship. The emphasis on the dialogical ensures that this authenticity is not only the particular prerogative of the therapist but also includes the client. Hycner(1985) stated that, in a dialogical approach, process and goals are centered on the relationship between therapist and client and techniques only occur in this context thus reiterating O'Hara's viewpoint. Levitsky and Perls (1970) laid the foundation for the dialogical when they stated "true communication involves both sender and receiver" p.164. A synthesis of both approaches then would bring with it a rich literature on the therapeutic relationship and specific aspects that enhance the quality of that relationship. Most notable among the latter are the core conditions.
The process of change in terms of clients involves becoming closer and closer to their organismic experience in person centered therapy and in developing self support in gestalt therapy. Perls (1969) viewed maturation as moving from environmental support to self-support although Yontef (1993) pointed out that self support was often confused with self sufficiency. However Perls also emphasized the importance of contact which by its very nature implies an interpersonal dimension. The manner in which self support occurs in gestalt therapy has been termed the paradoxical theory of change by Beisser (1972). Change occurs when individuals become what they are rather than when they endeavour to become what they are not. In person centered terminology this means that clients become increasingly more congruent.
Various maps have occurred in gestalt therapy to assist the therapist in the development of self support in the client. Perls (cf. O'Leary (1987)) adopted the concept of polarity, already long established in classical times by Heraclitus, in Taoism and in Jungian therapy. Zinker (1978) developed this further proposing the concept of multilarities, each polarity has several related opposites. More recently, Polster (1995) has created a slightly different orientation speaking of the individual being a population of selves.
In person centered therapy, the specific manner of change is viewed as clients becoming closer to their organismic experiencing so that a reorganization of the self occurs. A formerly denied experience, owned by clients and accepted by therapists, brings about this reorganization which results in new behavior. This behavior reflects the process of clients both becoming more of themselves and less of what they are not and of moving away from pleasing others and living up to their expectations.
The nature of maladjustment is viewed similarly in gestalt therapy and the person centered approach. Maladjusted persons do not allow their own experience into awareness. In gestalt therapy mechanisms and layers are identified through which blocking occurs if they are used in an unhealthy manner. The mechanisms consist of introjection (living based on the oughts and shoulds of others), projection (disowning feelings onto others), retroflection (holding feelings in the body), confluence (losing one's sense of self in another person or object) and deflection (turning aside from present experience). The different layers of neurosis proposed by Perls (1975) prevent true contact with their environment: in the cliche layer, people interact in a superficial manner with each other; in the role or game playing layer, individuals use different roles in their interactions; in the impasse, Perls, Hefferline and Goodman (I951) asserted that people give up
17
their own eyes and ears and manipulate others into doing their seeing and hearing for them but no environmental support is forthcoming; in the implosive layer, two equally strong forces struggle against each other resulting in a kind .of paralysis while the explosive layer , the struggle is resolved with authentic feeling emerging.
Maladjustment,
A new integration of gestalt and person centered therapies requires consideration of the questions has research found both approaches to be significant and what particular aspects have been found to be significant. The benefits of both person centered and gestalt therapies were identified by Smith, Glass and Miller (1980). In a meta-analysis of 475 controlled studies of psychotherapy they found that the average person who received either therapy was better off at its conclusion than more than 60% of those who did not receive therapy. In the case of person centered therapy, this finding also held true for neurotic/true phobic clients while the percentage was more than 50% for psychotics. In a study of 111 participants consisting of nine therapy groups and one control group, Braaten (1989) found a therapy effect size of 1.93 for a group comparison of clients and controls. Hence evidence exists for the effectiveness of both groups.
When type of outcome was considered by Smith, Glasser and Miller (1980), individuals suffering from fear or anxiety or having global adjustment issues who received person centered therapy were more than 60% more likely to have improved than similar patients who received no therapy. The highest percentage related to self-esteem . issues with the figure being 85%. When the authors combined studies in both person centered and gestalt therapies into an overall class entitled humanistic therapy, the greatest percentage (99%) was obtained for self-esteem issues. The importance of this finding lies in the fact that the next highest finding was for cognitive behavioral approaches with the percentage in this case being 73%. Thus it is likely that a synthesis of person centered and gestalt therapies will be particularly effective in working with clients with self-esteem issues.
Based on a study by Lambert, Shapiro and Bergin (1986), Duncan and Moynihan (1994) suggested that 40% of the outcome variance can be explained by extratherapeutic change variables, 30% by common factors while therapist techniques and placebo effects account for 15% each. The authors pointed out that the most frequently addressed commonality was the therapeutic relationship (Grencavage and Norcross (1990). Further evidence for the importance of the therapeutic relationship was provided by Blatt et al. (1996). From a comparison of 156 participants who completed therapy with 28 dropouts who did not in the National Institute of Mental Health Treatment of Depression Collaborative Research Program, they concluded that differences in therapeutic outcome are generally not predicted by the type of treatment experienced but rather by the interpersonal relationship. Hence a new synthesis of person centered and gestalt therapy should consider the three factors of the client-therapist relationship, extratherapeutic change variables and techniques. This synthesis would be ideally placed to consider the client - therapist relationship since the person centered approach has always centered its practice on the therapeutic relationship while more recent emphasis in gestalt therapy has moved more and more towards considering this dimension (Hycner(1991), Yonte f(1993)).
18
Integrating Person Centered and Gestalt Therapies
Of the core conditions of the therapeutic relationship, empathy has obtained the most research support. Using cognitive or cognitive-behavioural interventions for depressed patients, Persons and Bums (1985) found that the reports of 17 patients of therapists' warmth and empathy were related to degree of improvement while Burns & Nole- Hoeksema (1992) found that measures of empathy as rated by 185 patients were positively associated with outcome. Rogers (1980) outlined the following major research findings with respect to empathy: the ideal therapist is, first of all, empathic; empathy early in the relationship predicts later success; empathy is offered freely by the therapist; both more experienced therapists and more integrated therapists are likely to be more empathic; therapists are likely to be more empathic than helpful friends although they often fall short clients are better judges of the degree of empathy than are therapists and perceive more empathy when therapy is successful; empathy can be learned from empathic persons; empathy is correlated with self-exploration and process movement; intellectual brilliance or diagnostic skill are unrelated to empathy.
In a longitudinal investigation of 123 Irish adolescents receiving person centered therapy extending over one year, O'Leary (1986) found that of the four therapist offered conditions of empathy, congruence, level of regard and unconditionality, empathy was the most significant. The first research evidence for empathy in a gestalt therapy context has emerged recently in a study by O'Leary et al. (1997).
Research support for the other three core conditions is not as substantial. According to Bozarth (1997), they have not been adequately studied as attitudinal qualities. However O'Leary et al. (1997) study of group therapy did show that trainee therapists experienced greater levels of congruence, level of regard and unconditionality than did a control group although this difference did not occur in another study of the same duration which used a more structured approach. Hence the more structured exercises sometimes used in gestalt therapy are not desirable in a new synthesis. Unlike experiments which emerge from and are rooted in the current experiencing of clients, exercises generally arise from what therapists perceive as best for the group. In a new synthesis, only exercises which evolve from the current experiencing of clients and fit with the frame of reference of clients should be used.
Extratherapeutic factors, Bozarth (1997) pointed out, relate to the internal and external resources of clients. Gestalt therapy from the very beginning has emphasized both of these resources. Perls focused on internal resources believing that individuals became self-supporting as they attend more and more to the inner self. The importance of external resources was indicated by the attention which Perls, Hefferline and Goodman (1951) gave to contact. It was Polster and Polster (1973) however who 1developed the idea of contact stressing seven contact functions(the five senses, speech and movement) and five contact boundaries (body, value, familiarity, expressive and exposure) which can be used to enhance intrapersonal, interpersonal and international contact. More recently, O'Leary (1995) has spoken of self support and interdependence thus emphasizing the balance necessary between internal and external resources in healthy living.
Within the literature on the person centered approach, internal resources are also viewed in terms of the achievement of self-direction and free responsible choice. As therapy proceeds, clients become aware that they can hide behind others or dare to be themselves. This openness to subjective experiencing is accompanied by an openness to all aspects of the external environment. Speaking of person centered therapy, O'Leary (1986) stated that effective counselling could be measured by the degree to which clients become aware of all aspects of their self-experience, the extent to which they accept this experience and the degree to which they are able to expand self-acceptance into acceptance of others. Combining both therapies offers a broader range of focus for clients to develop both internal and external resources.
19
Considering research studies in gestalt therapy, O'Leary's (1995) review provide from among its findings four conclusions that are particularly relevant to a possible synthesis of person centered and gestalt therapy: gestalt therapy increases the self actualization of college students; the two chair technique leads to greater depth of experiencing and increased awareness on the part of clients than does empathic reflection in producing change of felt conflict and target behaviors; the use of awareness is encouraged and gestalt therapists value a safe, trusting environment.
Since the goal of the person centered approach is self-actualization and research evidence exists for its attainment in gestalt therapy, its retention among the goals of a synthesis is desirable. Although there has been a tendency not to include the empty chair in recent developments in gestalt therapy, this practice would appear to be premature given that it is the only one of the gestalt techniques which has been substantiated by research.
Furthermore its use is particularly appropriate for clients who suffer from unhealthy confluence and have difficulty in establishing boundaries. What is important is that the use of any technique is subject to the ongoing relationship at any particular moment in time. Techniques emerge from rather than are inserted into the work of clients and this orientation should be included in the proposed synthesis.
Gestalt therapy from its inception has emphasized awareness since Perls (1969) believed that awareness was curative. He viewed it as the change agent within gestalt therapy. O'Leary and O'Sullivan (1997) distinguished between affective, bodily and cognitive awareness: affective awareness involves accentuating present experience and listening to feelings; bodily awareness includes noticing the various sensations occurring in the body while cognitive awareness incorporates understanding how individuals prevent themselves from feeling, thinking and doing.
In the person centered literature, emphasis on clients becoming closer and closer to their organismic experiencing reflects the process of increasing awareness. In this respect the work of Zimring (1995) is worthy of consideration. He explored how having a more subjective or objective internal world affects experience. He distinguished between what he described as the new paradigm where experience occurs in reaction to what the world seems to be at the moment and the old paradigm where the cause of one's emotional problems is not knowing one's feelings. However both paradigms can be usefully integrated since the new paradigm suggests that experience is based on a perceptual-cognitive view of the world while the old model stresses its affective basis. In the latter, the necessity of working through old unfinished feelings is emphasized so that bound emotional energy in the client relating to these feelings may be released. By including both in the new synthesis the perceptual-cognitive approach of the former would be combined with the experiential-affective orientation of the latter allowing an experiential-affective/perceptual-cognitive approach. In a new synthesis, the multidimensional orientation towards awareness suggested by O'Leary and O'Sullivan (1997) would assist in the experiential-orientation dimension of the integrated paradigm.
Emphasizing safety and trust for clients in the therapeutic relationship would allow even greater attention to the internal frame of reference of clients. Maslow (1970) stressed that unless individuals could feel secure in their environment they could not attend to matters such as self-actualization. A new synthesis should deal explicitly with the issue of trust.
CONCLUSION
The present paper has considered how elements from the person centered approach can be united with elements from gestalt therapy to create a new synthesis. Integrating certain concepts in both fields permits a much richer clinical understanding than either would allow on its own.
20
Integrating Person Centered and Gestalt Therapies
Such an integration would combine the relationship emphasis of the person centered approach with the self support and interdependence emphasis of gestalt therapy, a combination which recent research findings indicate can account for 70% of the variance. Such a formation would also appear to hold promise for working with self-esteem issues. This new approach would be neither the green of the person centered approach nor the red of gestalt therapy but a vibrant orange.
REFERENCES
Barrett-Lennard, G. (1962). Dimensions of therapist response as causal factors in therapeutic change. Psychological Monographs, 76, 562.
Beisser,
A. (1972). The paradoxical theory of change. In J. Fagan & I
Shepherd(Eds). Gestalt therapy now.
Blatt,S., Zuroff D.,Quinlan, D. & Pilkonis, P. (1996). interpersonal factors in brief treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 162-17 1.
Bozarth,
J. (1997). The person centered stance.
In C.Feltham (E)Psychotherapies.
Braaten, L.(1989). The effects of person-centered group therapy. Person Centered Review, 4,183-209.
Bozarth,
J. (1997). Playing the probabilities in psychotherapy. Paper
presentation to the Association for the Development of the Person Centered
Approach.
Buber,
M.(1958). I and Thou.
Bums, D. & Nolen-Hoeksema,S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation. Journal of Consulting and Clinical Psychology, 63, 125-132.
Carkhuff,
R. (1969a). Helping and human
relations. Vol. 1. Selection and training.
Carkhuff,
R. (1969b). Helping and
human relations. Vol. 2. Practice and research.
Cochrane, C. & Holloway, A. (1974). Client centered therapy
and gestalt therapy: In search of a merger. In D. Wexler and
L. Rice (eds). Innovations in client
centered therapy.
Duncan, B. & Moynihan, D. (1992). Applying outcome research: Intentional utilization of the client's frame of reference. Psychotherapy, 31, 294-301.
Grencavage, L. & Norcross, J. (1990). Where are the commonalities among the therapeutic common (factors? Professional Psychotherapy Research and Practice, 21, 372-278.
Hycner, R. (1985). Dialogical gestalt therapy. The Gestalt Journal, 8, 23-50.
Hycner, R.(1991). Between person and person: Toward a dialogical psychotherapy. The Gestalt Journal,
Lambert,
M., Shapiro, D. & Bergin, A. (1986). The effectiveness of
psychotherapy. In S. Garfield & A. Bergin.(Eds.)
Handbook of psychotherapy and behavior change. Third
edition.
Levitsky,
A. & Perls, F. (1970). The rules and games of gestalt therapy.
In Fagan, J. & Shepherd, 1. Gestalt therapy now.
Maslow,
A.(1970). Motivation and personality.
O'Hara,
M (1984). Person centered gestalt: Toward a holistic synthesis.
In R.
O'Leary,
E.(1986). The psychology of
counselling. Second printing.
O'Leary, E. (1987). La polarita e la terapia della gestalt. Quaderni di Gestalt, 5, 59-67.
O'Leary, E.(1993). Empathy in the person centered and gestalt approaches. British Gestalt Journal,2, 111-115
O'Leary,
E.(1995). Gestalt therapy: Theory, practice and research.
O'Leary,
E.(1996). Counselling older adults:
Perspectives, approaches and research.
O'Leary, E.(1997). Confluence versus empathy. The Gestalt Journal, (In press)
O'Leary,
E. & Kelly, B.(1992). Personal dialogue.
O'Leary, E. & O'Sullivan, D.(1997). Values and gestalt therapy. British Gestalt Journal, (In press).
O'Leary., Purcell, U., Mc.Sweeney, E., O'Flynn, D., O'Sullivan, K. Barry, N. &
Keane, N. (1997). The
Perls,
F.(1969). Gestalt therapy verbatim.
Perls,
F. (1975). Morality, ego boundary and aggression.
In J. Stevens & B. Stevens(Eds.). Gestalt is.
21
Eleanor O’Leary
Perls, F., Hefferline, R. & Goodman, P. (1951).
Gestalt therapy: Excitement and growth in personality.
Persons, J. & Bums, D. (1985). Mechanism of action of cognitive therapy: Relative contribution of technical and interpersonal intervention. Cognitive Therapy and Research, 9, 539-55 1.
Polster, E. & Polster, M .(1973). Gestalt therapy
integrated: Contours of theory
and practice.
Polster, E. (1987).Every person's life is
worth a novel.
Polster, E. (l995). A
population of selves: A therapeutic exploration of personal diversity.
Rogers, C. (1951). Client
centered therapy.
Rogers, C. (1961). On becoming a person.
Rogers, C. (1965). Client centered therapy: Its
current practice, implications and
theory.
Rogers, C. (1977). Carl Rogers on personal power.
Rogers, C. (1980). A way of being.
Rosenblatt, D. (I 980). The dynamic process of gestalt therapy. Gestalt Journal, 3, 64-68.
Shostrom, E.(1964). Three approaches to
psychotherapy.
Smith, M., Glass, G. & Miller, T.
(1980). The benefits of psychotherapy.
Stanley, C. & Cooker, P. (1977). Gestalt therapy ane the
core conditions of a communication facilitation: A synergistic approach.
In E. Smith. The growing edge of gestalt
therapy).
Thorne. B.(1984). Person-centered
therapy. In W. Dryden. Individual
therapy in
Tobin, S. (1982). Self-disorders, gestalt therapy and self psychology. The Gestalt Journal, 5, 3-44.
Zimring, F.(1995). A new explanation for the beneficial results of client centered therapy: The possibility of a new paradigm. The Person Centered Journal, 2, 36-49.
Zinker, J.(1978). Creative
process in gestalt therapy.
Yontef, G.(1993). Awareness, dialogue and process.
Yontef, G. & Simkin, J. (1989). Gestalt therapy.
In R. Corsini & D. Wedding (Eds.) Current psychotherapies.
Fourth edition.
22