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Gestalt Therapy with Depression

Gestalt Therapy works with Depression

This essay presents working with depression in therapy as informed by Gestalt methodology. It discusses how depression is viewed, diagnosed and worked with according to Gestalt therapy. For the sake of comparative understanding of a different approach to depression as a clinical issue, it provides an analysis of the similarities and differences between Gestalt theory and methodology, and Cognitive Behavioral Therapy theoretical and clinical perspective. Next, it analyses a description of the relevance of Gestalt methodology and its processes, while emphasizing the effectiveness of the Gestalt approach in working with depression. Lastly, the essay addresses the ethical concern of self-harm and suicide, and the challenges a Gestalt therapist may encounter when working with depression.

Depression is a very common clinical issue presenting with a wide range of symptoms. It is prevalent through a broad, undefined section of society, affecting people at all socioeconomic levels, all races, ages, genders, and political orientations. The dominant paradigm of treatment relies on the use (at times misuse) of neuro-chemical medications. Mostly this treatment is combined with psychotherapy, and (too) often not. From a Gestalt perspective the work with a client presenting with depression is defined and understood primarily through creative adjustments, which represents functions of contact modulation. Gestalt work observes the clients contact functions and the way that the cycle of experience is not being completed (Hamilton, 1999). In other words, the Gestalt process is about exploring how does the client create and recreate his own depression, how does depression support client, and how can client and therapist bring novelty and change in the field. For example we may define clients depression as an introjection of worthlessness and powerlessness linked to specific environmental circumstances. Clients’ introjection of: “I am not good enough; I will never do well; I cannot do anything; I am not worth the effort” etc. is, from a gestalt perspective, informed and maintained by life experience as a background and its fixed figures. In turn such introjects creates inner conflict between introjected ideas and current desires or needs. These polar forces typically described as top-dog/underdog polarity can manifest as forms of retroflecting anger and aggression towards self. This retroflective process may take a form of: “I am bad and evil, or I’m stupid to think that I can influence my environment and reach out for my needs”. A Gestalt practitioner explores the figure (introjection, retroflection, projection) and ground (life experience, clients whole field) emerging as the experience of pain, emotional and/or physical, representing misunderstanding of others, life circumstances and isolation (Masquelier, 2006). By understanding clients’ figure/ground cycle of experience, and how it is disturbed, a gestalt therapist can both demonstrate to clients his/her own responsibility, and co-create experimental alternatives that provide opportunity for change (Mackewn, 2010). Depression seen from a gestalt perspective is a natural attempt of the whole organism/environment to adapt and survive. We may see clients’ depressive processes as a way of removing self from contact due to perceived unsupported emotions or even threatening environments, and as a way to self-withdraw (Hamilton, 1999). Clients are self-blaming as a way to maintain safety when it is perceived to be too dangerous to blame others. Therefore, Gestalt therapy work is the field sensitive relational experimental exploration of novel processes that support and challenge the clients to recognize and meet their needs, experiencing self and others in ways that promote wellness (Hamilton, 1999).

The clinical issue of depression is defined in various ways. In recent Cognitive Behavioral Therapy (CBT) theories, depression and vulnerability to depression are often seen as a result of childhood upbringing where there was not enough care and empathy.
Early cognitive behavioral theories propose the susceptibility to depression to be simplistically linear: the way an individual cognitively interprets the negative life events has a direct impact on depression susceptibility (Ellis, 1962). Those negative cognitive interpretations are based on a view of self as fundamentally worthless. They are seen to revolve around themes of failure, inadequacy or loss, and they stem from a rigid standard of judging self, others and events. It is the disappointment arising from such judgements that lead to depression. Whereas, in Gestalt theory, negative interpretations are the creative adjustment of the person to his whole life-field interactions, stemming from the time that such adjustment was the best way of maintaining homeostasis, getting the person needs met (Perls, Heferlman & Goodman, 1951).

Aaron Beck (1967, 1987) developed an important addition to the cognitive behavioral model that is slightly closer to the idea of introjection. He suggests that it is not just the cognitive process that effect vulnerability to depression, but the latent negative schema in the background of the individuals belief system that becomes manifest in stressful situations. These beliefs can be: “I am worth nothing if I am not loved by my beloved”; “any small failure proves my complete failure”. Such believes in the face of negative life events turn into low self-esteem and hopelessness. A research on the impact of developmental factors on individuals with such negative self-schema, makes evident that the result of childhood upbringing effect the development of cognitive vulnerability for depression (Abramson, 2006). The research stressed three factors contributing to cognitively vulnerability to depression: A) early childhood traumas and maltreatment; B) negative feedback from parents about the causes and consequences of negative live events; C) Parenting that is characterized by low emotional warmth (Abramson, 2006). Such research base evidence can be seen to be aligned and support the field perspective held by Gestalt therapy. Yet the interventions of Gestalt therapy differs from those of CBT in that it is not the behavior nor the cognition alone that is changed; rather by experimentation of the whole person/environmental situation the client is able to discover and become aware of his old behavior, constructing new meaning to life events past and present. There is however some similarity in the relational intervention system that James McCullough (2006) working with Cognitive Behavioral Analysis System of Psychotherapy (CBASP), developed. His model of personal involvement for the treatment of long-term depression patients stresses the importance of genuine interactions between therapist and clients with the purpose of client’s recovery. These interactions, claims McCullough, lead to a healthy relationship where caring and honest communication are experienced by clients. McCullough prospects, similarly to the relational Gestalt methodology, that the genuine response of the therapist provides a living in-the-moment feedback to the client about his/her impact on the other person, and this understanding helps client to change behavior. He is a firm promoter of disciplined personal involvement as the path of change rather than logical (cognitive) arguments (McCullough, 2006). Thus there are similarities among CBT and Gestalt therapy, yet a fundamental difference remains in the approach towards change. CBT views change as a result of corrective suggestions given by the therapist aimed at changing the behavior and/or the ideas that go with the behavior; while Gestalt therapy sees change as a result of clients new awareness and choice supported by the experimental, relational and humanistic relationship of therapist and client (Masquelier, 2006).

The Gestalt perspective in working with depression unfolds through the fourfold methodology of: field theory principals; phenomenological exploration in the here and now; dialogical therapeutic relationship, and creative experimentation. These four methodological processes carry the therapy through all stages of the therapeutic alliance. Although they are distinct in their nature, they blend in the therapist style of work and they become one complete unit of work (Wyman, 2006). Firstly, understanding and exploring the clients’ field reveals how s/he is adjusting and creating the field. It is important to bring awareness to such creative adjustments and reveal how they support the client. In doing so the therapist employs the paradoxical theory of change, by allowing the client to be in full contact with self and other, and assimilation of contact naturally leads to change (Mann, 2010). In this process the therapist holds an I-thou attitude by practicing inclusion, presence, confirmation, commitment to dialogue, and resonance (Mann, 2010; Clemmence, 2012; Yontef, 1993). Such dialogical relationship is deeply rooted in the phenomenological experience of both client and therapist. The therapist will be informed about the co-created field by asking and exploring both the client and his own self about the experience of the relationship as bodily sensations, looking at the phenomenological manifestation in the field, movement of voice, sound, feelings, etc. (Clemmens, 2012). Consequently such an embodied relationship informs and supports client and therapist through the awareness of actual physicality, to explore deeper understanding, and bring about change (Clemmens, 2012).

Furthermore, in the therapeutic process client and therapist engaging in a relational dialogue may discover that client (or therapist) current way of perceiving and adjusting to reality can be expanded to meet his/her needs more effectively (Jacobs, 2012; Polster & Polster, 1973). The contact-full event of client/therapist meeting, however small it may initially be, is opening for further contact to unfold. The capacity of client’s expansion is dependent on the support to acquire emotional skills nurtured by attuned responsiveness to a contact-full dialogue (Jacobs, 2012; Mackewn, 2010). The field theory practiced by a Gestalt therapist holds that an individual is a subject. The subject is a subject when there is the knowing of ‘I am’, and this subjectivity is only defined by the interaction with the other (Bandin, 2012). Therefore the inter-subjectivity that co-creates the notion of ‘I am’ is the outcome of the therapeutic dialogue, where the therapist supports the client to experiment different ways of being by building relational grounds, and creating new relational, experiential possibilities of contact.

In this way the therapeutic field is made of therapist, client and the in-between. The therapist that is aware of the in-between can use it for the benefit of the client by a mutual investigation, co-creating an understanding of the in-between, and how subject impact subject in the relationship (Jacobs, 2012). In long-term experience of depression, for example the relational causes will become clear as the Gestalt practitioner explores the whole situation of the client, co-discovering how client’s field outside the therapy room impacts the immediacy of the experiential relationship unfolding inside the therapy room (Mckewen, 200). The process of discovering the client’s field can be supported by awareness exercises that repeat, exaggerate, enact or translate on the one hand, and on the other hand, restrict a certain behaviour (Naranjo, 1993). For example, the experience of heaviness and tiredness of a client experiencing depression can be experimentally exaggerated by placing a heavy object on the client’s area of felt heaviness. Such experiment may bring out awareness of the deeper emotional experience, and paradoxically can bring awareness of polar forces. By co-creating an experience that enhances the existing forces in the clients’ field, the therapist can support the client to discover new awareness and find novelty in the situation that begins to facilitate change in the whole field. Thus, change produced by the experiential and experimental methodology of Gestalt therapy is a central axis for therapy, and a good experiment allows a client to make contact with his/her existence, enabling to perceive, understand and articulate their life theme at a new level (Zinker, 1977).

As the gestalt therapist approaches the deeper psychological layers of a client with a depressive process, it is probable to reach an existential question, at least, if not existential crises (Naranjo, 1993). Gestalt therapy is a humanistic existential and constructivist discipline, and the deep layers of existential questioning are welcomed. A client with depressive process is most likely to present the problem of meaninglessness. In small steps the therapist by inviting the client to enter and experience his own meaninglessness, supports the client to discover new meanings in the actual contact process between client and therapist (Dreitzel, 2010). This phenomenological-existential method provides the opportunity for a person to redefine self, and derive the new immediate definition from a direct and clear experience, rather than from a second-hand thought structures given from others (Yontef, 1993). In this process Gestalt therapy is welcoming and even valuing the process of depression as it may allow (or even force) an individual to go through the ‘dark night’, and come out of it strengthened with greater awareness and choice about his/her own life. Jan Resnick (1999) describes the depression process as a possibility to liberate from old identities of self that are overly reliant on the approval, need, and desires of significant others. Resnick proposes that by going through depression the client can get over and done with, completing the unfinished business and constructing a new identity with a healthy sense of separateness. Thus the meaninglessness and the existential desperation within a field of conventional (at best) or pseudo-cultural (at worst) belief systems and self-images that are out of awareness, are transformed through the existential phenomenological experiential enquiry to a clear personal and suitable, experience based, identity, with a personalized set of beliefs that provide a healthy ground for the individual to sense, feel, think, and act as a whole (Yontef, 1993).

However, it is important to sensitively consider the risk of depressive processes affecting self-harm, or even suicide. For some individuals the option of ending their existence is indeed tempting when no means or hope of fulfilling their needs is perceived. As a therapist it important to recognize this possibility in the clients mind, and to assess with the client what is the possible risk of acting on such possibility. It is important to explore the levels of risk by revealing the thoughts plans, details, or a preferred method, as well as the means to fulfill such intention. The risk assessment needs to include the whole field. For example including the protective factors, such as the level of commitment to relatives, friends or occupation; or a moral and religious objection. In the case of such danger therapist cannot maintain confidentiality; he/she must employ duty of care in the face of risk of harm, according to the agencies’ standards that the therapist is working with. While working with people in deep depressive processes there some challenges that a therapist needs to bear in mind. First of all the depressed process may take long time to change, and the therapist needs to take care not to react from a position of counter-transference (Dreitzel, 2010). For example clients lethargy or tiredness may be reacted against with impatience or annoyance. When the therapist himself is subject to depressive processes, it may be that the experience of the client may further affect the therapist as well. Similarly, when negative views of the world, people or society, are expressed, the therapist needs to be cautious not to react to them and remain in a field phenomenological exploration, bringing into dialogue his own experience (self-disclosure), finalized towards the benefit of the client’s growth process.

In conclusion, the work with depression as a clinical issue from a Gestalt perspective sees depression as an adaptive attempt of the whole organism/environment to survive. The Gestalt therapist accepts client where s/he is at, and explores how does the client create depression, how depression supports the client, and how can novelty and change arise within a new field context. CBT presents some similarities with the Gestalt approach in understanding early childhood experiences and influences, looking at personality functions having underlying factors affecting the depressive process. Gestalt therapy and CBASP both see a genuine relational interaction between therapist and client as central to the therapeutic process. Yet, it is in the approach towards change that CBT and Gestalt differ. The former uses corrective suggestions to change the behavior and cognitive process, while the latter achieves change paradoxically as a result of client’s new awareness and choice supported by the co-inquiry, experimentation and the relational therapeutic alliance. Depression, or depressive processes as can be seen with a Gestalt lens, are very significant for the exploration and growth of an individual. In therapy therefore, the figure of the client depressive process is examined and explored in the context of the therapeutic dialogue where there is a relational ground of inclusion, presence, commitment to dialogue, and shared lived experience of contact-full relating. This phenomenological-existential dialogue in itself informs the ground of the client that is in-turn able to give new and more suitable meaning to his own life experience, sharpening the figure and enabling awareness and greater choice to transform their depressive processes. The therapist needs be alert to the dangers of depressive processes and can meet the challenge by remaining attuned to the phenomenological-field as experienced in the therapeutic relationship. Thus the Gestalt therapy methodology is well designed to meet the challenges of working with the process of depression in its many variations presented as a clinical issue.

Reference list;

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Beck, A. T. (1967). Depression: clinical, experimentation, and theoretical aspects. New York: Harper & Row.
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Dreitzel, H. P. (2010). Gestalt and process. Uwe Giese, Berlin, Germany: Edition Humanistische Psychologie.

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Ingram, R. E., Miranda, J., Zindel, V. S. (1998). Cognitive vulnerability to depression. New York, NY: The Guilford Press.
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Resnick, J. (1999). In prase of depression. Psychotherapy in Australia, 5 (3), 28.

Wyman,L. (2006). The unit of work. Retrieved 8 October 2006, from the Foresight Group Website: www.theforesigntgroup.org/tabs.html

Yontef, G, M. (1993). Awareness dialogue and process. Highland, NY: The Gestalt Journal Press.
Zinker, J. (1977). Creative Process in Gestalt Therapy. New York: Vintage Books.