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Clients With Serious Mental Health Issues

It is difficult to have a discussion of Gestalt therapy in relation to clients with serious mental health issues because Gestalt therapy is holistic; it does not break a person down into separate "pieces" or variables, and, therefore, it is difficult to "classify" clients in the same

Table 8.1. Gestalt Therapy Intervention Strategies

Experiment

Purpose

Technique

Location of Feelings

To encourage the client to directly experience sensations in the body that are connected to his or her current feelings.

Instead of asking the client, "What are you feeling?" the therapist tells the client, "Show me where you are feeling this anxiety, apprehension, or nervousness."

Confrontation and Enactment

To help the client to confront old behaviors, feelings, or expressions by acting out the various parts. This confrontation of self and then the enactment of disowned thoughts, feelings, sensations, or actions allow the client to discover and then reown neglected parts of the self.

The client is told to "be your hand," "be your sorrow," "be your hatred." This forces the client to own what has been disowned. By identifying with all his or her "parts," the client can become what he or she "truly is" and be able to take responsibility for the self.

Empty-Chair or Two-Chair Strategy; also called the "Hot Seat"

To help the client to achieve clarity. This is an extension of the confrontation and enactment intervention. It allows the client to become cognizant of how his or her behavior may be affecting others and to gain insight into all pieces of the problem or issue.

The client is asked to play one or more roles in addition to his or her own self. The client speaks to the part of each person connected to the problem by moving back and forth between the chairs. This technique can also be used for issues that are internal within the client by having the client move back and forth among opposing forces and play out all the roles pertinent to the internal conflict. For example, in a conflict making a decision, the client can role play both the "pro" and the "con" sides of the decision-making conflict.

Making the Rounds

To teach the client, through a group therapy technique, to be a group member and make some form of contact with other group members or practice new ways of being with each group member.

The client is asked to engage each member of the group. For example, this engagement may be soliciting feedback from each member or making a statement to each member.

Dream Work

To help the client in the present to understand what may be going on in the here and now. Because images, fantasies, and dreams are the projections of the person, dreams can be seen as the metaphoric expressions of the content and can reveal certain aspects of the person. The dream is not interpreted or symbolized in Gestalt therapy. The dream is simply reenacted to bring awareness to the client regarding the different paths of self.

This technique asks the client to reenact the dream in the present and to play out the parts of the dream as if it were happening in the here and now. The client is told to animate the dream and give voice to all the people and parts. This allows the counselor or therapist to help the client come into contact with, own, and accept responsibility for parts of the self that may not be well known or accepted, as every part of the dream represents some aspect of the self.

Unfinished Business

To resolve the unresolved feelings that have been left over from interpersonal relationships, most notably feelings of worry, resentment, grief, guilt, or rage. This exercise is designed to bring incomplete gestalts to closure.

The counselor or therapist helps the client to recognize his or her "stuck" points. The emphasis is on helping the client to recognize and accept what "is" rather than what "could be."

Rehearsal

To help the client bring clarity out of confusion and enable the client to practice change. This intervention seeks to break the client from the habit of playing the prescribed role(s) he or she continues to play within society.

The client is asked to rehearse new sentences or actions that are different from his or her status quo.

Minimization

To eliminate the client's ability to minimize self-expression such as with the conjunction "but," as in "I would like to do this, but . . .," or "I am a good person, but..." and it prevents the client from disqualifying or taking away validity by adding ambiguity.

An example of minimization is when the counselor or therapist removes the client's use of the word but from his or her expressions by changing it to the word and. As in, "I am a good person, but . . ." to "I am a good person, and . . ." This removes the ambiguity, which allows the client to be noncommittal.

Exaggeration

To help the client be more aware of feelings behind gestures of expression and eliminate his or her ability to minimize. The client is asked to exaggerate some aspect of feeling or expressive act (e.g., a gesture, posture, voice, inflection, or verbal statement). This also enables clients to become aware of subtle signals and cues they are sending through their body language.

The client is asked to exaggerate repetitively some element of his or her being, which includes, but is not limited to, a motion or speech pattern. By using exaggeration, feelings that the client has but has not been aware of can become more apparent and the focus of attention. The client gains awareness of inner meaning of his or her experience.

Reversal

To help the client bring out polarities that exist within the self, such as "good girl vs. bad girl," the "caring person vs. the selfish person," the "puritanical person vs. the sexual person," "top-dog vs. underdog," and so on. The client is able to directly address parts of the self that have caused anxiety and, therefore, have been repressed.

The client is asked to reverse a statement or a way of being. If the client says, "I hate myself," he or she will reverse that statement to "I love myself." If the client is shy and inhibited, he or she would be asked to play the part of a gregarious exhibitionist. The truthfulness of this polarity is then explored for relevance, as overt behavior often represents latent impulses.

Exposing the Obvious

To bring out into the open the deep structures and processes going on within the client of which the client may be unaware.

The counselor or therapist pays close attention to the client in the here and now and exposes aspects of the client of which the client may be unaware. For example, "Are you aware that you are clenching and unclenching your hands?"

Explicitation or Translation

To encourage the client to give voice to a nonverbal expression – a bodily movement, visual image, physical symptom, and so on – which helps him or her to turn the explicit content into implicit reality. This enables the client to experience internally what has only been looked at externally.

The client is asked to verbalize or make explicit something affecting him or her. For example, "If your tears could talk, what would they say?" "If your body spoke words, what would they be?" "If the person who molested you as a child could really tell you his or her feelings, what would he or she say to you?"

Retroflection; also known as "Playing the Projection"

To help a client redirect his or her actions, thoughts, or energy, and regain lost power, energy, and self-support, by determining those aspects of self that have been projected onto others and then facilitate bringing back to the self. This enables the client to release his or her inhibitions, stop holding back impulses and choking off behavior, and stop projecting unwanted parts or disowned attributes of the self onto others.

The counselor or therapist has the client redirect to himself or herself what he or she has previously directed outward toward others. This splits the person into two, the giver and the receiver. When projecting, a person places onto someone else the traits, feelings, motives, and so on that he or she does not want to face within himself or herself. When a client makes a statement such as "I don't trust you," the projection is retroflected or "played with," and the client is asked to act out the role of the untrustworthy person.

Let the Little Child Talk

To enable the counselor or therapist to talk to the client's "inner child." As part of the personality is formed in childhood, many aspects of that child are still found within the adult and influence the "adult" in all of us.

The counselor or therapist begins by asking the client's permission to speak to his or her inner child. The client is then encouraged to "be a child" and express feelings, thoughts, and behaviors that have been repressed by adulthood. This allows the "adult" to listen to the opinions and feelings of the child and let go of restraints and allow the self to be nurtured.

Say It Again; also called "The Repetition Game"

To disrupt a patterned habit of expression and to call attention to ways of perceiving. This technique disables the client's ability to get emotional distance from sensitive feelings by rote expression This technique makes the client stop to experience the full impact of words and feelings.

The counselor or therapist instructs the client to keep repeating a sentence over and over. For example, a client says, "Nobody likes me." Through repetition, other messages come to the forefront. The end result is that the client may become aware that what he or she was really trying to express is that he or she has never felt loved.

"I Take Responsibility For . . . "

To help clients accept and recognize their feelings and actions, and take responsibility for them instead of projecting them onto others.

The counselor or therapist facilitates this by making the statement, "I take responsibility for ..." and then asks the client to fill in the blank. Typically, the client will make a statement such as, "I am uncomfortable in social situations and I take responsibility for my own feelings of dis-ease."

"l Have a Secret"

To explore feelings of guilt and shame and identify what attachments the client holds that keep him or her from resolving this conflict.

This is a group therapy technique in which group members are encouraged to think of a personal dark secret (but not disclose it to the group) and then imagine (project) how others would react to this secret if it were known.

Contact and Withdrawal

To help the client to understand the polar nature of existence and that it is okay for these polarities to exist. This helps the client to understand it is okay to withdraw from situations to preserve one's attention. For example, one must rest to have energy. This is a polarity, just as one must periodically withdraw from others to maintain closeness. Just as resting enhances energy, so too does temporary withdrawal enhance closeness.

The client is told that when he or she feels like withdrawing from a situation, he or she would close his or her eyes and fantasize about a place where he or she feels secure and safe. When the client feels this safety and security, the client then should open his or her eyes, having rested and enhanced energy, continue on, and reestablish contact.

Can You Stay With This Feeling?

To keep clients from running away from uncomfortable feelings or glossing them over without examination. It prevents the client from avoiding.

When the client expresses a feeling, mood, or state of mind that is unpleasant or uncomfortable and that he or she tries to discount, dispel, or minimize, the client is then asked to elaborate on the "what" and "how" of his or her feelings.

manner as is required by the Diagnostic and Statistical Manual of Mental Disorders (4th edv Text Revision [DSM-IV-TR]; American Psychiatric Association; see Lobb, 2003). Gestaltists do not believe in disease but rather in "dis-ease," and to suggest that disorders are of the mind is inimical to the Gestalt approach. Gestaltists believe disorders are holistic and organismic and that symptoms of dysfunction are not in an individual but rather are in the reality of a person's experience (White, 2009). An individual is seen as someone who is ultimately healthy and striving for balance, health, and growth (Hurley et al., 2006). Gestaltists also view symptoms as an individual's creative adjustment to a difficult situation in his or her life (Lobb & Lichtenberg, 2005).

Gestalt theory relates the development of pathology to the habitual self-interruption along the contact-withdrawal continuum. Contact-withdrawal is a concept that explains people's interactions with others (Bloom, 2009). People make contact with others from the outside boundary of themselves. Humans strive to be together with others in the world (Pack, 2009). When a person has a bad experience or experiences making contact with others, then he or she begins to withdraw to protect the self (Lobb, 2003). This self-protection prevents appropriate interaction with others, and therefore interactions that could be classified as pathological result instead.

As a result of this hindered progress along the contact-withdrawal cycle, people's needs are not met and they become inhibited in their awareness and expression. As a consequence, they begin to internalize to meet their needs satisfaction. Part of the process of this internalization is that people begin to introject that which they cannot get from themselves and internalize messages given by others that they begin to see as truth. Believing they are bad encourages people's fear of abandonment by others, and they then begin to block their awareness, put up defenses, and retroflect (turn back on the self) to prevent expressing their wants or needs and to keep others from leaving them (Lobb & Lichtenberg, 2005). This is the Gestalt theory of pathology.

Conversely, normal, healthy behavior occurs when people act and react as total organisms – unfragmented, self-regulating, and able to converse along the contact-withdrawal continuum by not self-interrupting (Lobb & Lictenberg, 2005). The healthy person concentrates on one need (the figure) at any present time, delegating other needs to the background. When the need is met, the gestalt closes and is completed, and no business is left unfinished. When the need is unmet, the gestalt remains open and the person accumulates unfinished business (Clarkson, 2004).

Research supports that Gestalt therapy works best for overly socialized, restrained, and constricted individuals who intellectualize and have trouble clarifying their feelings (Seligman & Reichenberg, 2009). After having defined the above and stated that Gestalt therapy does not categorize clients according to the DSM-IV-TR criteria, it can also be said that Gestalt therapy has not been limited by the above constraints. In fact, Gestalt therapy has been adapted to be used for a variety of modalities and issues. It has been used in art therapy (Lobb & Amendt-Lyon, 2003), play therapy (Daniels, 2004), educational therapy (Garcia, Baker, DeMayo, & Brown, 2005), family and couples therapy (Lynch, Lynch, & Zinker, 2005), group therapy (Schoenbert, Feder, Frew, & Gadol, 2005), crisis counseling (O'Connell, 1970), career counseling (Martz, 2001), child and adolescent counseling (Reynolds & Mortola, 2005; Toman, Bauer, McConville, & Robertson, 2005), and pastoral counseling (Knights, 2002) and has been foundational in many of the touch therapies (Zimmer & Dunning, 1998) as well as eye movement desensitization and reprocessing therapy (Tobin, 2004).

Seligman and Reichenberg (2009) stated that Gestalt therapy can be used successfully with the following disorders: mood, anxiety, somatoform, factitious, adjustment, and some personality disorders or personality traits such as avoidant, dependent, narcissistic, histrionic, and obsessive-compulsive. A literature review demonstrates that Gestalt therapy has been used for a variety of issues, including, but not limited to, alcoholism and substance abuse issues (Clemmens & Matzko, 2005), autism (Brosnan, Scott, Fox, & Pye, 2004), phobias (Imes, 1998), depression (Ellison, Greenberg, Goldman, & Angus, 2009), sexual abuse (Imes, 1998), psychosomatic complaints (Wolfert & Cook, 1999), sexual dysfunction and sexuality (Melnick, 2000), body image (Kepner, 2001), issues with self-esteem (Shub, 2000), grief and mourning (Sabar, 2000), developmental issues (Wolfert & Cook, 1999), workplace enhancement and worker adjustment issues (Kirk, Wood, Bums, Howard, & Rice, 2001), terminal illness (Strumpfel & Martin, 2004), schizophrenia (Uhlhaas & Silverstein, 2005), posttraumatic stress disorder (Hardie, 2004), geriatric issues (O'Leary & Nieuwstraten, 1999), emotional injury (Greenberg, Warwar, & Malcolm, 2008), bulimia (Denham-Vaughan, 2005), and with special populations such as those who have been institutionalized (e.g., long-term hospitalization and hardcore criminals; Wolfert & Cook, 1999).

It should be noted that caution has been mandated for the use of Gestalt experiments. Although these experiments may seem simple and easy to apply, many are not suitable for all clients, especially those clients who are emotionally fragile, because most of these techniques are very intense. The same cautions are espoused when counselors work with clients who are severely psychotic, severely disturbed, in crisis, or poorly motivated to change (Seligman & Reichenberg, 2009).

The skill of the Gestalt counselor or therapist is at issue when working with these types of clients. Improper methods or the inability to work with the client through the trauma, grief, rage, or other intense emotions brought up by these techniques can leave the client in a very vulnerable position. Individuals with more severe issues or disturbances will need long-term intensive counseling or psychotherapy. Although this can be done within the bounds of Gestalt therapy, it must be done with caution and skill.

Lobb (2003) advised that when counselors work with clients who are psychotic, paranoid, or schizoid, it is prudent to limit activities to those that strengthen a client's contact with reality. Gestalt therapy may also be contraindicated for some issues and populations. These might include those clients with a problem with impulse control, those who act out, or those who are delinquent. For these individuals, Gestalt therapy may reinforce those behaviors. In addition, Gestalt therapy may not be suited for all cultures because its sometimes confrontational nature can make clients from some non-Western cultures uncomfortable (Seligman & Reichenberg, 2009).

 
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