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Meeting in Absence:

An Integrative Gestalt Approach to Depressive Experiences

Lewin de la Motte

2015


Gestalt Therapy Sydney

Forrest James & Ashleigh Power

Lewin de la Motte Meeting in Absence !2
According to the World Health Organisation, Depression is rated as the leading cause of disability and the

fourth highest contributor to the total ‘Global Burden of Disease’ (Reddy, 2010). By the year 2020 it is

estimated to rise to second place (Akiskal, 2000). There is considerable scientific support to show that

psychotherapy and pharmacotherapy are effective treatments for the symptoms of depression (Barth,

Munder, Gerger, Nüesch, et al. 2013; Linde, Rücker, Sigterman, et al. 2015) although studies indicate

that no form of psychotherapy is more effective than any other (Kamenov, Cabello, Coenen & Ayuso-

Mateos, 2015). Similarly the efficacy of antidepressants is underwhelming, revealing that 15% -30% of

people experiencing depression do not respond to medication (Francesetti & Roubal, 2013). In effect, at a

global level psychiatrists have stopped research into the underlying causes of depression and directed

attention towards a collaborative multidisciplinary approach to treatment, focused upon functionality

(Francesetti, 2014; Roubal & Rihacek, 2014). Gestalt therapy which utilises a personalised methodology

that emphasises restoring healthy functioning appears a promising angle to address such a widespread

collective suffering (Francesetti, 2015).

This paper is set into 4 sections. It begins with presenting the continuum of Gestalt definitions of

depression, revealing a flexible and evolving epistemology. It follows by providing a brief overview of a

multidimensional Gestalt diagnostic and treatment model which is wide enough to implement the

individualist perspective of the medical model within its structure (Roubal, 2012). In the third section it

describes the vast spectrum of depressive experience through a Gestalt methodology of treatment,

revealing an integrative approach to the activation of new relational pathways. Finally it presents common

ethical and practical difficulties faced by the psychotherapist in working with depressive experience.

Note: In charting this diverse terrain of human suffering this essay is limited to the exploration of unipolar

depression.
Lewin de la Motte Meeting in Absence !3
The Depressive Experience: A continuum of Definitions

Depression is a label which refers to a broad spectrum of human suffering (Spagnuolo Lobb, 2013,

Francesetii, 2015). Thus, contemporary Gestalt Therapy adopts a dimensional rather than categorical

definition of depression placing it along a continuum which measures gravity of absence felt at the

contact boundary (Francesetti, 2013, 2015; Spagnuolo Lobb, 2013). In this way it is pictured as relational

phenomenon; “depression is the way in which the subject experiences the surrendering of hope in the face

of the ineffectiveness of his/her vain attempts to reach the other” (Francesetti Gecele and Roubal, 2013, p,

330). Foundational Gestalt texts defined depression as a retroflection of energy which prevents the client

from flexible spontaneous patterns of contacting in the here and now (Perls, Hefferline and Goodman,

1951; Polster and Polster, 1973):

Depression is seen in Gestalt as unsatisfied needs. When expression is overt, there

normally is a release of pent up energy – for instance, the seeming lethargy of depression

will if unblocked, be replaced by what it concealed and held in check: raging or the clonic

movements of sobbing (PHG, 1951, p. 323).

These earlier Gestalt formulations of depression contained the semblance of the objectifying perspective

of the medical model, merely with different terminology (Roubal, 2012). Clients were referred to as

“retroflectors” when describing the patterns of contact perceived by the therapist where the client turns

energy which they wish to express outwards in on themselves in a punitive way (Francesetti, 2013). This

objectification is present in another definition where the therapist was seen to ‘work on the client’ and

focuses upon the individuals pathological mental states and accompanying social factors (Greenberg and

Watson, 1998). Greenberg’s definition of depressive organisation pictured the clients introjected negative

self talk or “depressogenic schemas” (for e.g. “Im a failure”) as the source of the depressive experience

(Greenberg ,Watson and Goldman, 1998). Such schemas were seen to arise out of a significant loss early
Lewin de la Motte Meeting in Absence !4
in life, and so become rigidly fixed in a Gestalten of self punitive thoughts which impede the mobilisation

of energy towards meetings ones organismic needs (Greenberg, Watson and Goldman, 1998). This

intrapsychic focus was later expanded to relate depression as a continuum and a form of creative

adjustment (Roubal, 2007).

The client who is labelled as depressed in the medical model is seen by the Gestalt practitioner to be on a

continuum between "depressive adjustment” and “fixed depressing” (Roubal, 2007). A depressive

adjustment refers to an original adaptation to a difficult situation in which the client feels the best way to

protect themselves is by a kind of "economy of effort and conservation of resources" (Roubal, 2007, p6).

This adjustment is a creative attempt to withhold from expending a life force which appears threatened

(Roubal, 2007). It is seen as a reaction to an existential crisis; depression is an “implosion in the sense of

life direction, the person experiences loss of ego function (“Doing what i always do does not work

anymore”) and faces the existential question: “what do i choose?” (Phillipson, 2001, p. 232). When this

creative adjustment becomes a habitual way of relating, the client is seen to be acting from a “fixed

depressing” mode of contacting, a state akin to the medical definition of Major Depressive Disorder

(Roubal, 2007, Francesetti and Roubal, 2013). Modern psychiatric diagnosis has now stopped attempting

to define depression etiologically and instead similarly defines it as a continuum which varies according

to seriousness, dividing it into unipolar and bipolar according to a categorical observations of symptoms

(APA, 2013; Francesetti & Roubal, 2014). The following table is a simplification of the

psychopathological definition of depression;

Lewin de la Motte Meeting in Absence !5

Table 1: Characteristics of Depression in the DSM 4. (Francesetti & Roubal, 2013, pp. 324-325)
Figure 1: Depressive Disorders

Major Depressive Disorder (Ranges between Mourning to Melancholic)

This is characterised by an episode of Major Depression in a patient who has never experienced manic or hypomanic
episodes. At least five of the following symptoms should have been present for at least two weeks: A depressed
mood, a lack of interest in activities (these first two symptoms are essential for a diagnosis), weight loss or gain,
insomnia or hypersomnia, agitated or slow motor activity, lack of energy or fatigue, feelings of low self-worth
or guilt, reduced concentration or indecision and contemplation of suicide. In addition, these symptoms must
cause clinically important distress and impair work or social functioning.

Dysthymic Disorder

Chronically depressed mood lasting at least two years is accompanied by at least two of the following symptoms:
decreased or increased appetite, insomnia or hypersomnia, fatigue, reduced self-esteem, concentration or
decision-making difficulties or feelings of despair.

No Major Depressive Episodes should have occurred over the two years in question and there should be no history
of mania or hypomania. The symptoms must cause clinically important distress and impair work or social
functioning.

A Multidimensional Diagnosis

There is an ongoing dichotomy between a Gestalt diagnostic lens and the medical diagnosis of depression

(Brownell, 2010; Křivková, and Roubal, 2013; Roubal, 2012). On the one hand classical Gestalt

therapists have viewed diagnosis as a pathologising stance (Perls et al, 1951) while others have posited

that therapists cannot avoid diagnosing, they therefore have a choice to do it out of awareness or with

awareness (Yontef, 1993; Roubal, 2007). In effect there has been attempts by numerous authors to create

a uniquely Gestalt system of diagnosis (e.g. Baalen, 1999, Delisle, 1991; Dreitzel, 2010; Francesetti and

Gecele, 2009; Fuhr et al., 2000; Melnick and Nevis, 1998; Swanson, and Lichtenberg, 1998). These

models commonly use Gestalt frameworks such as the Contact Cycle and and Contact Styles which

enable psychotherapists to make sense of their clients experiences within a system which can be

developed within Gestalt academia and provide a bridge to other disciples (Roubal, 2012). This being

said, there is a linguistic challenge to communicate between the individualist paradigm and the relational

paradigm as they use different categorical terminology (Francesetti, 2015).

Lewin de la Motte Meeting in Absence !6

One bridge between the medical and Gestalt models of diagnosis of depression is that both are

phenomenologically based (Burley, 2012; Francesetti, Gecele, and Roubal, 2013). A mainstream

psychopathological approach identifies individual symptoms while a Gestalt phenomenological method

focuses upon the clients direct experience as an co created emergent phenomenon arising from a creative

adjustment to suffering (Roubal, 2012; Spagnuolo Lobb, 2015). Particularly the work of Gestalt

phenomenological psychiatry can be seen as building this bridge between paradigms (For e.g. Brownell,

2010; Harris, 1992; Philippson, 2001; Spagnuolo Lobb, 2002; Yontef, 2001). With the understanding of

phenomenology as a bridge, the question arises for the practitioner: how do I maintain a clear and

accurate diagnosis while still holding true to the original holistic paradigm of the Gestalt approach?

(Roubal, 2012). The Three Perspectives Diagnostic Model (Roubal, 2012) provides an integrative

framework which enables personalised and specific treatment while still being flexible enough contain

variety of therapeutic approaches within it (Roubal, 2012). It outlines points of view to approach the

depressive situation which the therapist can move between fluidly between;

Roubal, (2012, p. 31).

Lewin de la Motte Meeting in Absence !7

The first direction leading from the “Psychopathological Perspective” focuses upon the description of

symptoms from an individualist lens (Roubal, 2012, Francesetti, 2015). It seeks to ask the question: how

can I critically and accurately diagnose what is not functioning for the client? (Roubal, 2012). It

consciously pathologizes using ‘I-it’ language (Buber, 1970) by focusing upon phenomenological

symptoms according to a list of criteria (see Table 1) (APA, 2013; Gecele, 2015). Despite the

dehumanising effects this can have, a psychopathological perspective paves the way for an intentional and

precise means of differentiating between the range of appropriate methods available to the therapist

(Roubal,and Rihacek, 2014).

The second vantage point is the “Contextual Perspective” which pays attention to the structures of support

within the clients relational systems and seeks to understand the roles which arise within these contexts

(Roubal, 2012). The Gestalt therapist emphasises functionality (Delisle, 1991, Zinker, 1977), shifting

focus away from linear causality of symptoms to a wider circular causality (Roubal, 2012). This Gestalt

diagnostic differs from the medical view of diagnosis, as is demonstrated in a recent meta review of 248

studies on the treatment of depression where 80% of methods used focused upon symptom reduction and

did not take into account ratings of functionality (for e.g. managing stress, maintaining daily routine, or

solving problems) (Kamenov, Cabello, Coenen & Ayuso-Mateos, 2015). In a Gestalt contextual

perspective symptoms are seen as means of survival and ways to fulfil roles in their social situations

(Roubal, 2012). The depressing individual will tend to become fixed in rigid roles and the therapist task is

to discern what the function of these roles are for and how they have helped the client survive in non

supportive environments (Roubal, 2012). For e.g. they learn about the clients world, the quality of their

relationships, possible history of similar depressive tendencies of relatives, their social situation, the
Lewin de la Motte Meeting in Absence !8
duration and onset of their current suffering, and the kinds of treatments they have already experienced

(Roubal, 2012).

At the other end of the spectrum a Gestalt “Field Perspective” describes the complexity of the relational

field through the moment to moment aesthetics of contact (Roubal, 2012; Francesetti and Gecele, 2009;

2011, Francesetti, 2013). ‘Aesthetics’ refers to the unique flavour of the contact arising between the

practitioner and client in the therapeutic situation (Francesetti, 2015; Roubal, and Rihacek, 2014). It asks

the question of How do we co create this depressive experience now? (Roubal, 2007). In such a diagnosis

the practitioner can observe lifelessness and absence of vitality as the most obvious indicator of the

depressive experience (Roubal, 2007, Francesetti, Gecele and Roubal, 2013). Another key characteristic

phenomena is the distinct lack of direction and warping of a sense of space and time (Francesetti and

Roubal, 2013). Other characteristics such as a phenomenologically sensed heaviness, desensitisation,

emptiness or hopelessness often arise when meeting in a depressing field (Roubal and Rihacek, 2014). All

observable phenomenon are seen as co created functions of the field, the attentional focus resting upon

the tricky movable frontier - the contact boundary between therapist and client (Jacobs and Hycner, 2009;

Yontef & Jacobs, 2010). In this way Gestalts dialogical pillar serves as the attitudinal lens, offering the

curiosity, presence and openess to the in-between as essential qualities to help sustain interest

(Francesetti, 2015).

A Gestalt Method for the Treatment of Depressive Experiences

The phenomenological focus for the Gestalt practitioner is somewhat different to the medical practitioner

in the treatment of depression (APA, 2013; Francesetti and Gecele, 2009). The interventions employed are

oriented by an awareness of the clients figure formation / interruption process, rather than solely upon an

outcome of a different behaviour (Burley, 2012, Francesetti, 2015, Frank, 2001). In this way the therapist
Lewin de la Motte Meeting in Absence !9
pays attention to how the clients need organises the formation of their figures and aims to meet them at

the contact boundary with patience and embodied presence (Francesetti & Gecele, 2013, Frank, 2001). By

this persistent availability to the co created “depressogenic field”, the therapist seeks to span the absence

at the contact boundary and in this genuine and compassionate attempt to reach the other, new relational

patterns of contact have the potential to emerge (Francesetti and Roubal, 2013).

Work with the depressive adjustment of mourning is very different to working with the other end of the

spectrum of fixed depressing known as “melancholia” in the DSM 5 (Roubal, 2007). In working with

sadness or mourning the therapist encourages a natural response to a loss (Francesetti and Roubal, 2013).

The therapist does not try to interfere or control the grieving process, they allow it to unfold as the client

becomes able assimilate the polarity of feeling the presence of the relationship which has ended, and at

the same time be aware of its absence (Francesetti, 2015). It is in opening to this “presence in absence”

which creates a future (Francesetti, and Roubal, 2013, p, 334). While at the other end of the spectrum, this

kind of approach could harm the client in a severe fixed depressing or melancholic state (Smith , 1985).

Working with severe fixed depressing calls upon firmer boundaries with clear embodied presence

(Křivková, E., Roubal, J. 2013). The therapist “has to emphasise security, structure and learning” (Roubal,

2007, p.10). Meeting the client at their capacity, at times the task simply becomes to “be present and

available with hope” (Francesetti and Roubal, 2013, p. 337). The work is primarily concerned with

“creating a safe environment, a safe relational field, in which the patients self healing powers can be

activated” (Francesetti and Roubal, 2013, p. 336). Receiving adequate supervision and collaborating with

psychiatrists and other colleagues is imperative at this level of depression (Francesetti, 2015). Mood

stabilising drugs may often be of benefit as they reduce the intensity of experiencing by functionally
Lewin de la Motte Meeting in Absence !10
desensitising the client to their excessive negative self talk, allowing for more contact (Křivková and

Roubal, 2013). This is achieved through activation of the lower basal ganglia system of the brain which

has to do with the lower phases of the awareness cycle, (perceiving, integrating and withdrawing)

(Křivková and Roubal, 2013).

Once this safe reliable contact is established, the therapist can look for fleeting glimpses of when the

client mobilises their energy towards contact with the therapist, and use these moments to help the client

become aware of the patterns of contacting that is happening (Francesetti and Roubal, 2013). In turn

leading them into an awareness of how they can confirm themselves and move into more expression of

energy and intentionality little by little (Spagnuolo Lobb, 2015). After this stage the therapist encourages

looking for minor sources of contextual support and beginning to help them draw links to how they can

begin to move towards meeting their needs in other life contexts (Roubal, 2004). Working from the

Contextual perspective, the therapist explores with the client how the depressive adjustment (e.g. limiting

emotions in fear of expressing needs) fits into the clients life story, how it serves or hinders the client in

all of their relationships (including with the therapist) (Francesetti, 2013). It is hoped the clients then learn

how to accept contact and support from the therapist as practice for opening to being able to support

themselves (Francesetti and Roubal, 2013). A key goal for the therapist across depressive experience is to

attempt to “sustain feeling, awareness desire and choice, in teaching the patient to differentiate that which

is one’s own from that which is not, that which is desired from that which is not” (Francesetti, and

Roubal, 2013, p, 341). At any point there is a possibility for the therapist to shift to a Relational Field

Perspective in order to attune to the unique flavour of the ‘Gestaltung’ process which is being co created

(Francesetti, 2015). This perspective holds the potential to transform the experience of 'absence' at the

contact boundary into a sensitised aware presence of beauty (Roubal, 2007; Francesetti and Gecele, 2009;

2011).
Lewin de la Motte Meeting in Absence !11
A commonly written about approach to treatment of depression involves paying attention to the

emergence of aggression (Frank, 2001; PHG, 1951, Roubal, 2007). This method acts as a means to

engage the intentionality of the client and to support this intentionality to transform into aware action

(Burley, 2012; PHG, 1951). It is important that the figure of aggression be situated within the body -

attempts should be made to make it corporeal (Frank, 2001; Spagnuolo Lobb, 2015). This paves the way

for the manifestation of impulse and energy in the clients situation, it enables introjects to flow outwards

rather than inwards in a punitive fashion (PHG, 1951; Roubal, 2009). The patient first needs to have the

grounds of self support to be able to incorporate and assimilate the retroflective energy (e.g. self criticism

and anger) which could be released in the therapy (Francesetti & Roubal, 2013). It is also important that

in this process the therapist supports the awareness of aggression rather than the aggression in its entirety

(Francesetti and Roubal, 2013). The client is encouraged to move physically, both within the session (with

a focus on how they are moving) and beyond the session through physical activities (Spagnuolo Lobb,

2015). This kind of experimentation can be done creatively according to the unique qualities of the

therapeutic relationship, the therapists style and can be influenced by a sound Phenomenological Method

(Yontef, 2007; Zinker, 1977).

Ethical and Practice Challenges

Comparatively to the empirical literature describing the methodology for working with a depressing

client, there are few research studies which have outlined the ethical and practice challenges which arise

in such a relationship (Roubal, & Rihacek, 2014). One such study demonstrated qualitative research of 40

research studies covering both the relational and psychoanalytic experience of depression relate it as a

contagious phenomena (Joiner, & Katz, 1999). Contagious countertransference phenomenon are common

when working with depressing clients, such as feeling inadequate, fearful or helpless (McWilliams, 2011,

Roubal, & Rihacek, 2014). Similalry it is important to hold an intention to avoid falling into patterns of

feeling resigned, blaming or consoling the depressive client (Roubal, 2007, Francesetti, 2015). All
Lewin de la Motte Meeting in Absence !12
responses are common co created field organisations the client often eliciting these responses from other

relationships in their life (Francesetti and Roubal, 2013; Spagnuolo Lobb, 2015). The primary challenge

being the ability to simply be present and non judgemental in the face of such fixed relational patterns

(Roubal, 2007). The therapist should become reflexively aware of barriers to their own experience of the

client (for e.g. their judgements, tendency to objectify, countertransference tendencies etc) (Spagnuolo

Lobb, 2015). Due to the complexity and contagiousness of the depressive experience the therapist should

never work with an extreme cases of fixed depressing alone (Spagnuolo Lobb, 2015). Often the client will

also need pharmacological support and so it is important to make clear with the client from the outset that

you may need to consult with your supervisor or refer on to other practitioners and as to be able to best

serve them (Francesetti and Gecele, 2009).

In extreme cases the therapist should know that they are being called upon to sit with clients in the pits of

their despair, hopelessness and shame and will be served by developing the qualities of non judgmental

patience and commitment to compassionately attend to the client - especially in the moments where there

appears to be no therapeutic benefit (Roubal, 2004; Gecele, 2013). The therapist may even struggle to

stay awake in the sessions where the depressive pull of isolation feels like a vacuum (Francesetti, and

Roubal, 2013). In other words they to remain open and available to explore the process of depressive

adjustment as it arises with the client as a means of opening to the unique quality of contact that is present

(Francesetti, 2015). Contact in whatever form is the doorway to healing (Gecele, 2013, Yontef, 1993,

Jacobs and Hycner, 2009).

Conclusion

This paper is written in the spirit of a collaborative approach to the diagnosis and treatment of depression.

It points toward a integrative Gestalt methodology, which is informed by he psychopathological

perspective yet firmly rooted in a phenomenological and relational field perspective which honours the
Lewin de la Motte Meeting in Absence !13
diversity of experience across the continuum of depression. Both fields agree that in mapping the

complex territory of the depressive experience, the therapist is served by becoming aware of the

importance of an integrative and multimodal approach (Francesetti, 2015, Roubal, 2012). A Gestalt Three

Dimensional Model (Roubal, 2012) takes into account the importance of a clear symptomatic

psychopathological focus, embedded within an awareness of the contextual influences and the co created

nature of the field-relational phenomenological experience of depression (Francesetti, 2015; Roubal,

2012; Spagnuolo Lobb, 2015). It is imperative that all therapists regardless of orientation are able to shift

between the lenses they view their clients with and see them as dynamic human beings, creatively

adjusting to the sufferings of life. Another key consideration is that the depressive experience is felt as a

co created function of a depressive field and not solely the effect of a dysfunction. In this way,

contemporary Gestalt therapy presents a radical and flexible approach to the treatment of depression as a

field relational phenomenon which is broad enough to contain within it a psychopathological approach to

diagnosis and treatment (Francesetti, 2015).

Lewin de la Motte Meeting in Absence !14

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