The Clinical Usefulness of Gestalt Therapy

Richard Tillett

ABSTRACT. This paper reviews the characteristics of Gestalt therapy and links these with
its clinical usefulness as one of the range of available psychotherapies.

Introduction

Despite the huge volume of published literature in psychotherapy, the relative

indications of each of the different approaches are as yet comparatively unexplored.
Research evaluation was originally directed towards establishing the efficacy of
psychotherapy as a treatment, and no clear differential benefit between different therapies
could be established, leading to the famous `Dodo verdict' (Luborsky et al 1975). More
recently meta-analytic techniques (e.g. Smith & Glass 1977, Svartberg & Styles 1991,
Crits-Christoph 1992) have allowed researchers to explore differential benefits with some
suggestion that cognitive and behavioural therapies produce greater effect sizes at least in
conditions which respond in the short- to medium-term. The evidence increasingly
suggests that longer-term dynamic psychotherapies are more appropriate for people with
intractable neurotic problems or major personality disturbances, especially where shorter-
term more focused therapies have been tried without success. The place of the humanistic
therapies (a wide and disparate group) has received little attention from researchers; the
term humanistic is itself unsatisfactory and causes confusion (Hinshelwood & Rowan
1988). There is also a methodological issue in the sense that both dynamic and humanistic
therapies are essentially creative acts of communication and difficult to operationalise.
Therapists attracted to these approaches because of their richness and complexity may
find the reductionism and constraints of research design inappropriate (Strupp 1986).
Gestalt therapy, one of many humanistic approaches deriving partly from
psychoanalysis, serves as an example. Though the theory and practice of Gestalt therapy
have been developing for over forty years (Perls 1947, Perls et al 1951, Yontef 1991),
there has been little or no research into its efficacy or differential benefit compared with
other therapies. The Gestalt literature abounds with descriptions of the creative and
effective use of Gestalt therapy though limitations have been acknowledged (Shepherd
1970).
This paper offers a personal account of the strengths and limitations of Gestalt therapy
from the perspective of health service psychotherapy provision.

Characteristics of the Gestalt Approach

As creativity and spontaneity are central to Gestalt, and as there is intrinsic antipathy
towards the concept of therapy as technique, it can be difficult to reach an

Dr R Tillett is a consultant psychiatrist/psychotherapist in Exeter. Address for correspondence:

Psychotherapy Dept, Wonford House Hospital, Exeter EX2 SAF.

British Journal of Psychotherapy, Vol 11(2), 1994

© The author
Richard Tillett 291

acceptable definition of Gestalt therapy. Some accounts (Yontef 1991) are clearer about
what Gestalt is not than what it is, while others (Clarkson 1991) emphasise the
continually evolving nature of the approach, making it difficult to identify. The
uniqueness of certain features of Gestalt therapy would be disputed by therapists from
other dynamic approaches. For example, both Gestalt and psycho-dynamic therapists
recognise the crucial importance of the patient-therapist relationship though different
conceptual frameworks are used to describe the process. Despite these difficulties of
definition Gestalt has, like other approaches, a broad `personality profile', originally
derived from the beliefs and practices of its creator and subsequently modified by other
practitioners, which allows it to be recognised and discriminated from other approaches (
Dryden 1984).
Firstly, it is an experiential therapy emphasising the development and expansion of
both physical and emotional awareness. Less emphasis is placed on the development of
intellectual insight and interpretation is used sparingly if at all. Description is preferred to
explanation and detailed attention to moment by moment process takes precedence over
discussion. Close attention is also paid to physical awareness and responses which may
provide clues to underlying (unconscious) process.
Secondly, Gestalt takes an existential approach to the relationship between therapist
and client, which is seen as central to the process of therapy. The therapist takes a more
disclosing and participant role in the relationship than would be usual in conventional
dynamic therapy, and the relationship is examined in terms of its immediate experience
by the patient. The potential of the relationship to serve as a forum for the re-enactment of
past or external process (transference) is acknowledged but the therapist will usually not
interpret this, preferring to act within the relationship in such a way as to heighten
awareness and facilitate change.
Thirdly, Gestalt moves beyond the conversational model of therapy to make use of
enactment and experimentation; in this respect it resembles other `active' approaches such
as psychodrama. The patient is encouraged not only to talk about an issue but also
actively to explore it using physical expression and dramatic enactment as appropriate.
Active experimentation allows the patient to try out new behaviours within what Perls
referred to as the `safe emergency' of therapy. The use of active techniques to provoke or
facilitate cathartic release of emotion forms part of the Gestalt approach but has tended to
be over-valued in the past both by therapists and observers.
Change may occur as the result of heightened awareness, as the result of interactional
process with the therapist, or by the use of enactment and experimentation. The therapist
may act in a number of different capacities including observer, participant and facilitator.

Using Gestalt Therapy

Like other therapies, Gestalt can be used as an approach in its own right or in
combination with other types of psychotherapy.
Used on its own, Gestalt is (like many other approaches) most effective with people in
reasonable psychological health who wish to work on specific emotional problems. With
such people, for example with mental health professionals in short-term residential or
weekend groups (Tillett 1986), the clarity, intensity and immediacy of Gestalt are highly
effective. It is particularly useful with people who are inhibited, conscientious, over-
socialised or over-reliant on verbal skills and is effective in
292 British Journal of Psychotherapy

facilitating inter-personal contact in people whose response-ability has been impaired by

social training. Conversely it can be used to deepen contact with intra-psychic process in
people who are habitually and unproductively extroverted. The creative, playful, anarchic
part of the Gestalt `personality' may appeal especially to staff in the helping professions
who are preoccupied with practical and intellectual problems, and carry a high burden of
responsibility. Repressed infantile needs and behaviours which have been socialised into
the caring role can often be recognised and explored.
In the treatment of a broad range of neurotic and minor personality disturbances, most
types of psychotherapy are effective and Gestalt therapy is no exception. It is sometimes
possible to achieve substantial change in a surprisingly small number of sessions, and
many patients are attracted by the egalitarian treatment relationship and the use of active
technique. Gestalt, however, shares with other dynamic approaches a potential for depth
and intensity which may be unhelpful if therapy is to be kept brief and focused. Care
needs to be taken to establish a clear contract with the patient from the outset and, if a
brief contract is agreed, the use of exploratory and awareness-heightening techniques
needs to be cautious.
Some patients with more entrenched neurotic and behavioural problems will respond
positively to the Gestalt approach. Perls originally proposed eating as a paradigm of our
relationship with our environment, and some would suggest Gestalt as the treatment of
choice in eating disorders. My own experience is that it is sometimes effective but no
more than other approaches; in the light of available research it seems more sensible to
use a cognitive/behavioural approach initially, falling back on Gestalt and other dynamic
approaches if necessary. A useful account of the use of Gestalt psychotherapy with clients
suffering from bulimia is given by Merian (1993). People who abuse alcohol or drugs may
be attracted to the freedom and egalitarian form of treatment relationship which
characterises the Gestalt approach. Though they may appear superficially to use therapy
effectively, in my experience they tend not to progress and often act out destructively.
Such people do better with clear limit setting in a therapeutic relationship which
recognises the need for regression and allows it to occur so that it can be examined and
worked through.
People with histrionic personalities are often attracted to Gestalt therapy (either as
therapists or clients), but do not necessarily make effective use of it. Though Gestalt (like
psychodrama) harnesses the potential to act out, integration and learning may fail to occur
and cathartic expression of emotion may be over-valued. Contemporary Gestalt therapists
recognise the need for powerful emotions to be not only expressed but also worked
through and integrated.
Gestalt therapy is not effective as a primary treatment for active psychotic disturbance
though some of the theory may be useful in understanding the patient's process. In
between psychotic episodes and in people with serious personality disturbances, Gestalt
therapy may be useful though a modified approach is necessary. In major psychological
disturbances (including borderline and psychotic states) there is likely to be a major
disturbance of boundary function and a high level of perceived internal chaos. In these
circumstances, heightened awareness and intense emotional contact with the therapist are
unlikely to be beneficial and may well provoke clinical deterioration. In this situation a
Gestalt therapist has to modify substantially his/her approach by focusing on awareness
of the external objective environment rather than internal experience, by using discussion
rather than enactment and experimentation, and by reducing the amount of self disclosure
so as to reduce the intensity of the
Richard Tillett 293

therapeutic encounter. Therapy thus comes increasingly to resemble other forms of

dynamic psychotherapy.
As with other therapies, Gestalt can be used in conjunction with other approaches.
The judicious use of experimentation and enactment is not incompatible with a more
conventional approach to psychotherapy, working individually or with a group or family.
The use of enacted dialogue (often referred to as `the empty chair technique') has been
adopted very widely by counsellors and psychotherapists. Enacted dialogue may be useful
in exploring and resolving either intra-psychic conflict or `unfinished business' with
another person who cannot be involved in therapy in person. In bereavement, enacted
dialogue can provide a form of communication between the patient and the person who
has died, often with powerful and helpful results. In therapy with people who have been
abused, dialogue offers an opportunity to face the abuser but these encounters need
extremely careful management; the primitive feelings released are likely to prove difficult
to contain within the boundaries of a conventional one hour consultation, and may lead to
prolonged regression and other functional disturbance. It is important not to introduce
dialogue until the client is ready and it may be necessary to reduce the intensity initially,
for example, by a written rather than spoken dialogue.
The use of a third (empty) chair in consultation also facilitates exploration of
triangular relationships including those identified in the `triangle of insight' originally
described by Menninger and later elaborated by Malan (1979). In particular it can be used
to enact and explore the original relationships which lie behind transference projections,
and allows the therapist to act as facilitator rather than protagonist. It has to be
remembered however that `empty chair' dialogues are likely to contain material which has
been deflected from the therapist.
Other aspects of the Gestalt approach, including attention to physical body process, to
immediate experience as opposed to thinking, to `doing' rather than `talking about' may all
be used judiciously in conjunction with other psychotherapeutic techniques. Care needs to
be taken however to maintain a reasonably consistent `therapist personality', or the client
is likely to feel confused and unsafe.

Brief Case Example

A twenty-five-year-old woman was referred for urgent psychiatric assessment. She

was agitated and withdrawn and expressed a number of bizarre ideas some of which
could be construed as delusional. Symptomatic enquiry elicited a ten year'history of
recurrent dysthymia and behavioural disorder, including anorexic eating disturbance,
recurring preoccupation with self-harm (enacted on one occasion by a drug overdose),
strained, hostile, dependent relationships with her family of origin, and an almost
complete failure to establish close relationships in adult life. Though her presentation had
very much the `feel' of psychosis, in the absence of any specific features diagnostic of
major psychosis a provisional diagnosis of borderline personality disturbance was made,
low dose neuroleptic medication recommended and a series of further exploratory
appointments offered.
In the first few sessions, discussion was focused around her immediate practical and
social problems and her ambivalent response to treatment; no attempt was made to
explore her deeper feelings or to probe the dynamics of her family of origin. Her agitation
lessened (though she made only limited use of medication) and it was
294 British Journal of Psychotherapy

possible to establish some rapport. Her manner remained strange and distant and she
continued to express a number of ideas which could be construed as delusional, though
many became recognisable as metaphorical or allegorical statements. After the fifth
session it was agreed jointly to embark on exploratory psychotherapy for an initial period
of six months.
In subsequent sessions she was encouraged to talk more about her feelings, to explore
the possible meanings of some of her strange ideas and to look in more depth at her family
background and childhood experience. Therapeutic rapport deepened during this process
and interpretive discussion was sometimes used to examine and limit intensification of
emotional contact.
By about the tenth session the situation seemed secure enough for further exploration,
and enacted dialogues (using the `empty chair') were used to explore relationships in her
family of origin. The dialogues with each of her parents were predictably powerful
emotionally, and led naturally on to exploration of the complex triangular relationship
between her and them. She began spontaneously to make connections between her
relationship with her parents and her relationship with me, and by the twentieth session
the treatment relationship had become a primary focus of exploration. At this stage she
was encouraged to attend closely to her internal experience during the sessions, and use
was made of physical cues. For example, attention was drawn to the wide variety in her
tone of voice, which at times was high pitched, nasal and whining, and at other times
deeper and more resonant. This eventually led to a crucial discussion about her anxiety
about her sexuality, about whose destructive potential she entertained primitive anxieties.
Subsequently she was able to acknowledge and discuss her conflicting sexual feelings
towards me. In subsequent weeks, she reported a major reduction in her internal agitation
and significant progress in practical matters; she changed her unskilled job for one more in
keeping with her potential, embarked on canoeing lessons and joined a bird watching club.
Some weeks later a further dialogue occurred, this time between the regressed infantile
part of herself and her fantasised adult self (an extroverted, aggressive, sexually powerful
`bitch'). During this she spontaneously recognised the possibility of a compromise
solution. At the time of writing (ten months from referral) she continues to make progress;
having stopped medication for several weeks now she expresses few, if any, bizarre ideas
and her social presentation is much less strange. There has been some slight softening in
her relationship with her parents and she has begun to talk tentatively about making social
relationships. We have talked about the possibility of her joining a weekly out-patient
psychotherapy group.
Such a condensed account inevitably fails to convey much of the atmosphere or
detailed content of the sessions which lie at the heart of therapy. It does, however,
illustrate the importance of assessment and diagnosis, the use of collateral medication,
deliberate management of the pace and intensity of therapeutic contact and the use of
Gestalt technique in conjunction with a more orthodox dynamic approach. Despite the
patient's obvious psychotic potential at presentation she proved to have sufficient ego
strength to tolerate and make use of therapy. A number of other brief case illustrations can
be found elsewhere (Tillett 1991), while the Gestalt literature abounds with detailed and
vivid descriptions of `pure' Gestalt therapy.

Practitioner Effects

Other factors which affect the applicability of Gestalt therapy relate to the
practitioners who adopt it as an approach. Because of its characteristics as a therapy,
Richard Tillett 295

Gestalt attracts lively, creative people who are often frustrated by traditions and
established practices. There is a clear conflict between the radical underlying philosophy
of Gestalt theory and establishment values, and thus a danger of Gestalt therapists being
stereotyped as unorthodox, rebellious and invested in radicalism (as Perls himself was).
This is increasingly inappropriate; although some Gestaltists are still intolerant of
theoretical explanation or discussion, and uncomfortable with systems of diagnostic
classification, there is an increasing recognition of the need to compromise between the
traditional values of Gestalt and those of the wider psychotherapy community.
The Gestalt approach construes the encounter between therapist and client as an
egalitarian, collaborative partnership to which both client and therapist contribute from
their immediate human experience; the role of the therapist is more transparent and self-
disclosing than in other forms of psychotherapy. This can lead to a blurring of the usual
role boundaries between therapist and client, and either participant may have difficulties
as a result. The client may experience a re-enactment of previous boundary ambiguity or
transgression, while the therapist may find it difficult to work for prolonged periods from
such an `exposed' position. The egalitarian nature of the Gestalt treatment relationship
may also be used as a way of denying real differences in the roles of therapist and client,
and may restrict the potential benefit of an appropriately 'parent-child' therapeutic
relationship.
The emphasis on the direct encounter between client and therapist, and the interest in
physical manifestations of emotional process, have led many Gestalt therapists to accept
physical contact as a natural part of therapy. This raises a number of complex ethical
issues which are usefully explored by Kepner (1987). The use of physical touch in
therapy and the mutually disclosing nature of the treatment relationship may lead to an
erosion of the normal boundaries to a point where erotic contact can be construed as an
acceptable part of the therapeutic relationship. Perls' own indiscretions in this area,
together with other aspects of his extroverted and charismatic approach, have contributed
to a memorable, if misleading, folklore about Gestalt. Contemporary Gestalt therapists
are agreed that any form of sexual engagement with, or exploitation of, a client is entirely
unacceptable.
To refrain entirely from any form of physical contact with a patient, however, may be
unnecessarily restrictive and is out of keeping with normal social behaviour. The
complete avoidance of contact can also be used by either therapist or client as a way of
denying important and sensitive issues about intimacy and sexuality in therapy. These
problems are effectively explored in papers by Woodmansey (1988) and Mann (1994).
Both they and Kepner (1987) agree on the potential for touch to be used as an enactment
of the therapist's unmet emotional needs, and all agree on the delicacy of the issues
involved. Kepner, a Gestalt therapist with a particular interest in body work, advocates
great care in the use of touch in patients with major psychotic or personality disturbances.
In my view the use of touch in therapy is best kept at a level which is consistent with
wider social norms, unless the therapist is very experienced. Therapists are not immune
from denying their erotic impulses and even if touch is used appropriately and without
erotic intent the client's subjective experience may be quite different. The urge to make
physical contact needs careful consideration by both therapist and client. For example,
the wish to assuage emotional pain by physical contact may be a serious therapeutic
mistake, representing a wish by either or both parties to avoid a painful
296 British Journal of Psychotherapy

experience and possibly re-enacting a past boundary transgression. The use of touch in
group or family therapy is usually less of a problem; the presence of others helps to
diffuse the intensity of contact though this does not prevent the development of erotic
attachments or fantasies which may still need to be identified and explored.

Conclusion

Though Gestalt has appeared only marginally in the evaluative research literature it
has nonetheless established its place in the range of available psychotherapies. The fact
that it has not become more widely recognised and researched, especially in public health
care systems, is partly due to its limitations as a therapy, and partly to its culture. As a
therapy it is powerfully effective in people who have the ego strength to use it but may
overwhelm the defences of people whose adjustment is less secure unless it is used
selectively or with modifications of technique. Experience in the NHS suggests that it
may be particularly valuable in training and therapeutic work with health professionals,
and in out-patient psychotherapy with patients with less serious pathology. Using a more
restrained technique, or using some aspects of Gestalt therapy with a more conventional
psycho-dynamic approach, enables effective work to be done with a wide range of people
including those with serious psychological disturbances. Using Gestalt therapy on an
eclectic basis in combination with other techniques may be confusing both to client and
therapist and requires both experience and expertise. The use of Gestalt on an ad hoc
basis by the inexperienced is not recommended.
Historically, Gestalt therapy has tended to attract people impatient with orthodoxy
and it is still seen as an alterntive therapy. There is, however, an increasing recognition in
the Gestalt field that this alienation is unproductive and redundant. In the past twenty
years Gestalt therapists have come increasingly to accept the advantages of integration
with other approaches, and it is to be hoped that further rapprochement can develop
without Gestalt losing its unique individuality.

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