Gestalt therapy and hypnosis
The Gestalt approach to therapy can be termed "phenomenological-existential" as it is concerned with an awareness of the here-and-now, working away from concepts and towards pure awareness (Clarkson, 1989). By the client becoming aware of their thoughts, feelings, etc the goal is for the individual to achieve insight into the situation under examination. As Yontef (1993) writes, insight is gained by studying the phenomomenological focusing, experimenting, reporting, and dialogue of the client. The philosophy behind this approach is that most people do not function in the world based on how the world, including themselves, is, but through a filter of self-deception, whereby one does not have a clear picture of oneself in relation to the world. Living that is not based on the truth of oneself leads to feelings of dread, guilt, and anxiety (Yontef, 1993).
The historical antecedents of Gestalt therapy are the experiences of its co-founder, Fritz Perls. Trained as a psychoanalyst, Perls rebelled against the dogmatic style of Freud's approach (as had other notable founders of schools of psychotherapy, Jung and Adler. In the preface to the 1969 edition of "Ego, Hunger and Aggression" Perls wrote of this period of time as follows, "Started seven years of useless couch life." (Perls, 1969)), and incorporated aspects of holism into the belief that ultimately the individual is responsible for creating his or her existence.
Additionally, the early decades of the 20th century are notable for their refutation of Newtonian positivism and its replacement with phenomenology. These two themes were then combined within the scaffolding of Gestalt psychology to produce an approach centred on the individual's relationship to their existence. The structure that Gestalt psychology offered was that perception should be considered as the recognition of patterns and relationships between items in the perceptual world which fulfils the central human need of giving meaning to perceptions, experiences and existence (Clarkson, 1989).
Reductionist approaches could neither account for the richness of perception, and its immediacy (for example, see Koffka, 1935; Gibson, 1966), nor take into account the importance of the observer. This led Perls to the idea that the actual awareness of an individual is more trustworthy than an interpretation of any data that a person might provide a therapist with and is primarily a description of movements between 'figure' and 'ground'. The figure is the item of attentional focus at any one time, and the ground is the remainder of perceptual awareness. These movements, or 'cycles of experience' can become disrupted by being incomplete or unresolved and it is this 'unfinished business' which Gestalt therapy attempts to address. These ideas probably did not constitute a therapeutic approach until 1951 when Perls opened the New York Institute for Gestalt Therapy, despite the fact that the first recognisable Gestalt therapy book was published in the 1940's (Perls, 1969).
Accompanying this combination of ideas, based on the thinking of Gestalt psychologists, philosophers (e.g., Lewin, 1952), and politicians (e.g., Smuts), was the fundamental concept of the person as basically healthy, striving for balance, health, and growth (Clarkson, 1989). The unfinished business referred to earlier is seen as an obstacle to these processes, restricting the person's ability to function fully, often termed by Gestalt therapists as 'dis-ease'. Van de Riet (Van de Riet et al., 1980) encapsulates the idea that dis-ease is a consequence when people do not experience themselves as being psychologically and physiologically in balance with their environment.
"As action, contact, choice and authenticity characterize health in gestalt therapy, so stasis, resistance, rigidity and control, often with anxiety, characterize the state called 'dis-ease'"
The stasis, resistance, rigidity, and control prevent graceful flow through cycles of experience.
Having briefly outlined the core of Gestalt therapy it is necessary to consider some of the techniques that Gestalt therapists use in order to consider how they might be incorporated into hypnotherapy. Although there are techniques that are closely associated with a Gestalt approach, there are two caveats we must bear in mind. First, as Berne (1970) noted, gestalt therapy does use any techniques exclusively:
"Dr. Perls is a learned man. He borrows from or encroaches upon psychoanalysis, transactional analysis, and other systematic approaches. But he knows who he is and does not end up as an eclectic. In his selection of specific techniques, he shares with other 'active' psychotherapists the 'Moreno' problem: the fact that nearly all known 'active' techniques were first tried out by Dr. J. R. Moreno in psychodrama, so that it is difficult to come up with an original idea in this regard" (Berne, 1970: 163-4).
Second, that in Gestalt therapy, technique is considered secondary to the relationship developed between the therapist and the client, as Resnick (1984) writes:
"every Gestalt therapist could stop doing any Gestalt technique that had ever been done and go right on doing Gestalt therapy. If they couldn't, then they weren't doing Gestalt therapy in the first place. They were fooling around with a bag of tricks and a bunch of gimmicks" (1984: 19).
Based on these two caveats we might argue that anything of an 'active' nature which is incorporated into hypnotherapy would constitute Gestalt, or alternatively that without explicit training in the Gestalt client-therapist relationship there is nothing we could do which would be Gestalt. However, as the spirit of Gestalt therapy is very much identified by its use of specific techniques that is the approach that will be taken in the following discussion.
The techniques that are associated with Gestalt therapy are closely related to the idea that clients should want to work towards self-awareness through a mastery of their awareness processes. This is in contrast to patients who firstly are actually seeking relief from discomfort, although they may claim that they wish to change their behaviour, and secondly clients who expect that relief will come via the efforts of the therapist. Thus, Gestalt therapy is "an exploration rather than a direct modification of behaviour?the goal is growth and autonomy" (Yontef, 1993). The techniques are modifications and elaborations of the basic question, "What are you experiencing now?" and the instruction, "Try this experiment, or pay attention to that, and see what you become aware of or learn" (Zimberoff & Hatman, 2003).
Perhaps the most well known of all techniques that are identified as Gestalt is the empty chair. This is where clients project their representation of a person or an object, or part of themselves into an empty chair and they then present a dialogue between what is projected into the chair, and themselves. In some cases the client moves between the chairs, but either way, the idea is that inner conflicts become expressed and so the client heightens their awareness of them. This in turn forces the client to take responsibility for their difficulties so that they can make choices to resolve the sources of unfinished business (Stevens, 1975). As Becker (1993) writes, this is the whole point of Gestalt, to "take people who are conditioned and automatic and put them in some kind of aegis over themselves."
Similar to the empty chair, another common technique is known as topdog/underdog. A dialogue is performed between two aspects of the client's personality, the topdog representing the introjecting demander of perfection, expressed by "should" and "must", and the underdog, which is a manifestation of resistance to external demands. Through the dialogue "resolution, compromise, understanding or permanent divorce becomes possible" (Clarkson, 1989). This is attained by the individual becoming aware of their internal battles, which often lead to feelings of guilt, anxiety, and depression.
The Gestaltist focus on awareness is not confined to awareness of cognitive processes, such as dialogue, but also physiological processes through a process termed bodywork. This involves the client consciously noting where they experience tension in particular situations, or how their pattern of breathing changes. Once aware they can learn strategies to reduce these reactions, which have produced both physical and mental discomfort.
As Zinker (1978) writes, "this may include the person's awareness of his body, its weight on the chair, its position in space, its minute sounds and movements." Here the individual is taking responsibility for their body and taking charge of choosing how they want to react. Sometimes these tensions are based on a preoccupation with earlier circumstances. If the client is not responding to the current circumstances then they are seen as projecting the past to the present, so old patterns of responding, rather than new, experimental approaches are dominating their life (Parlett & Hemming, 2002). Working to release the physical manifestations of those old patterns can lead to greater engagement and awareness of one's thoughts and feelings (Zimberoff & Hatman, 2003). This approach is also known as establishing sensation function (Clarkson, 1989) and is considered useful for clients who have become 'alienated from their senses' or those with narcissistic attributes who have 'experienced it all' (Clarkson, 1989).
The importance of bodywork is made clear by Becker (1993) who suggests that physical expressions are closer to truth because the mind is engaged in deception and sabotage: Perl's basic assumption was that the body and its total processes are somehow anterior to and bigger than the mind. Gestalt conceives of the mind as an interference, as a way of blocking the total momentum of the organism in some way. Not only that, but the mind is not even the noble part of the organism that we always thought it was. For most people the mind and the creations of the mind work against the body. They work against the best interests of the total person.
In line with other psychodynamic approaches, Gestalt therapy includes dream work. The Gestalt position is dissimilar to Freud, in that Perls did not think of the unconscious as an inaccessible region of the mind which dreams could provide access to if interpreted correctly ? Freud's 'royal road to the unconscious' was Perl's royal road to integration. His view was more in line with Jung, who saw dreams as existential messages for the dreamer. In dream work the client is typically asked to relate the dream in the present tense as if they were experiencing the dream in that moment. From this the client develops an awareness of the existential message and how it consists of projected parts of the self.
The above descriptions of some of the techniques associated with Gestalt therapy should neither be considered exhaustive nor exclusive. As cited earlier, Resnick (1984) amongst others clearly believes that Gestalt therapy is not and cannot be tied to particular techniques, it is about the relationship between the client and the therapist.
An important part of this relationship is that the therapist is acting to guide the client towards greater self-awareness, responsibility and ownership of emotions, thoughts, sensations etc in order to complete any 'unfinished business' so that s/he may move smoothly through cycles of experience. The experienced therapist is able to adapt to the particular client in order to achieve this, relying on a wealth of techniques and skills. This essence of Gestalt therapy allies it more closely with cognitive behavioural approaches than typical psychodynamic methods because it relies less on interpretation of the client and more on their active participation. It is perhaps this that makes it possible to incorporate aspects of Gestalt therapy into hypno-therapeutic practice.
Interestingly Levendula (1963) suggests the view that a Gestalt therapist would be in a more advantageous position if he would combine his approach with hypnotic techniques. For example, the Gestalt therapist teaches the increasing of awareness through experimental exercises. The hypnotherapists can achieve this much more easily by directing the patient's attention to become sharply aware of an idea or sensation or memory which thereby becomes a "bright Gestalt" while the rest of the perceptual field recedes into a background. The hypnotic state itself corresponds to the Gestalt-background principle, and the Gestalt formation becomes more or less an automatic function of it. ?the combination of Gestalt therapeutic principles with hypnosis enriches both approaches.
From this it is clear that Gestaltists are being advised to incorporate hypnotherapy into their practice. The following discussion will consider whether hypnotherapists can introduce aspects of Gestalt therapy into their work.
One of the central tenets of Gestalt therapy is that clients experience events in the present, that is they re-enact past events in the present. By re-living them they can focus on their experiences, both psychological and physiological and thus gain understanding. Awareness was considered "the key to unlock insight and ultimately bring behaviour change" (Zimberoff, & Hartman 2003). Bringing the experienced past into the experiential present is one important property of hypnosis.
Through hypnotic age regression, working with dreams etc clients can re-experience events that have occurred at some other time as if they were happening in the here and now. This is not merely a cognitive reliving of a copy of the event, but a fully nuanced resurrection of the experience. As Zimberoff, & Hartman (2003) state, "Keeping the client's awareness on concrete detail is a constant in hypnotic age regressions, because it promotes presentness emotionally and viscerally (emphasis in original). Of equal importance is that the client's awareness can be focused on different aspects of their experience through repeated re-experiencing of it, allowing for a detailed, and concrete re-living of the experience in all its original strength and from physiological and psychological perspectives. This then fulfils Rosen's (1972) view that "Patients move best when they are moved" (emphasis in original).
It is clear that the Gestalt concern with realistic, present, re-experiencing of events is an important aspect of hypnosis. The concerns of Gestalt therapy with direct insight, rather than insight through interpretation would be a novel addition to hypnotherapy. To include this perspective is a philosophical and conceptual shift rather than a technical one and depends on the therapist's own preferences. However it is quite possible to achieve.
Hypnosis is also useful in intensifying aspects of an experience, by directing the client to pay closer attention to particular details. For example, someone who wishes to stop smoking might be asked to strongly feel the sense of relief and strength from being able to take deep breaths of fresh, clean air. Greenberg and Malcolm (2002) have demonstrated that success in using such techniques as the empty chair are at least partially determined by the degree of emotional arousal experienced during the use of this technique. Here we can envisage that the client can be asked to imagine a dialogue, or in the case of multiple actors in the re-lived scenario, a conversation, where they can concentrate on aspects of themselves or others that are blocking their ability to resolve past issues.
Many hypnotic techniques are relatively passive in that the client is asked to view an event, rather than to participate in it, but there is no conceptual reason why this more active, almost didactic approach could not become a more integrated aspect of hypnotherapeutic practice. Indeed, in clients who are able to speak whilst hypnotised it might allow the therapist even greater understanding of the experiences that the client is reliving, and for the therapist to take a more active, flexible role in directing the client's interactions.
As described earlier, Gestalt therapy makes use of experimentation in order for client's to experience new sensations, and to become aware of old patterns of responding. For this to work we are effectively asking the client to suspend disbelief, for example to suspend the idea that they cannot say something to their parent. This may be difficult for some clients, especially where they have developed strong conscious strategies to protect them from predicted negative outcomes. Hypnosis, by inducing an altered state of consciousness, may be able to circumvent these strategies, allowing the client to explore options in a safe fantasy world that is experienced as vivid and real. S/he can then explore conversations with others, actions etc that may not be considered options when in a non-hypnotic state.
As suggested earlier, this active participation of clients is not common, but there is no reason why clients who have strong powers of visualisation cannot be directed under hypnosis to engage in experimentation. Usefully as a single scene can be replayed many times under hypnosis it allows the client to perform a variety of experiments and to compare and contrast the resultant emotions etc. Naturally they can also be directed to pay close attention to the details of these new experiences, so that they can be vividly recalled post-hypnotically.
As Gestalt therapy is primarily concerned with the client's willingness to take responsibility, and the therapist's ability to develop novel ways in which the client can come face-to-face with aspects of their life they have projected onto others, or denied control of, the main way in which hypnotherapy can incorporate aspects of Gestalt technique is twofold. Firstly hypnotherapeutic practitioners must be trained in Gestalt conceptual philosophy so they fully understand their role, and have the intuition and flexibility to carry it out in a range of situations and across a broad spectrum of clients. Secondly, just as Freud selected patients who were willing to accept his fundamental law of psychotherapy, perhaps the hypnotherapist must be selective at consultation with clients who show a motivation to change and a willingness to take responsibility for that change. Without these two features hypnotherapy cannot truly address "the key problem of people in our times?inner deadness" (Clinebell, 1981).
References
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