Integrating CBT, Gestalt, and Person-Centered Therapy

Introduction: Perspectives on Therapy and Personhood

It is impossible to develop a theory of therapy without first developing a theory of personhood. Therapy is a practice designed to help clients come as close as possible to a fully realized life. But this can become simply tautological if we define therapy as the return to full functionality and define full functionality as the state to which a therapist hopes to return a client. For therapy to be effective, the therapist must begin with an independent and established sense of what mental health is — and this in turn depends on the therapist having a well-developed, though not finalized or static, sense of human nature. In this paper I examine my concepts of both therapy and human nature and discuss how the two are related. I believe that therapists are drawn to certain models of therapy and certain clinical techniques because those models mesh with the therapist's understanding of the human condition. This is certainly true for me.

To some extent I am adopting an eclectic approach in this paper — and in the journey I am beginning as a clinician — because I believe that all of the major therapeutic traditions have important ideas to add to the toolkit that a skilled clinician needs. Thus I weave a number of traditions and perspectives into my view of human nature and into my thinking about how the therapist can best serve a client. Another way of framing this is to say that I draw on as many perspectives as possible when considering what it means to be a person, what it means to be a therapist, and what it means to be healed. I am focusing primarily on three theoretical models of treatment, each of which has significant implications for the therapist-client relationship: Gestalt therapy, cognitive behavioral therapy, and person-centered psychology.

Gestalt therapy can be viewed as an existential therapy in that it guides a client toward focusing on the present moment. One of its greatest strengths is that while some present-centered approaches can lead to solipsism, Gestalt therapy provides constant reminders of the complex, overlapping social contexts in which all human thought and behavior takes place. It thereby avoids what is often seen as a significant limitation of classical psychoanalysis — the tendency to look too long and too deeply into a mirror, which can blind one to the interactions of the moment that the social self should be engaging in.

In a session guided by Gestalt therapy principles, the client is encouraged to take stock of her relationship with every aspect of the current moment, including the relationship between client and therapist. The therapist helps the client become more aware of the constant adjustments she makes to her own behavior in response to the continuous feedback she receives from the world around her. No one in Gestalt therapy, in other words, is an island — however much one might wish to be.

Gestalt Therapy and the Relational Self

Gestalt therapy can be understood as a type of field theory in that the self exists only in relation to an "other." Without an other, there can be no self. From this starting point it becomes clear that such a concept of self cannot be static, since each person's experience of the other changes as her environment changes (Beisser, 1970, pp. 67–68). Gestalt therapy might be seen as a kind of panoramic lens that takes in the entire circle of activity surrounding the client, rather than a hand mirror held up to the client's face. It insists that if one's sense of self depends on the assessment and incorporation of the world around one, then one's sense of self is never complete. "Self" for the Gestalt therapist is not something intrinsic or inherent within the client; it is not properly located within the individual psyche at all but exists in the existential space that lies between the individual and each external aspect of her life. As we learn to negotiate the relationships between ourselves and a world of others, we create a continuity of self that allows us both to regulate our relationship with an ever-changing world and to maintain a sense of coherence.

For the Gestalt therapist, a dysfunctional self may be too weak — or too discontinuous — to allow an individual to engage in meaningful relationships with others or with herself. Alternatively, a dysfunctional self may be so rigidly attached to established relationships that the individual cannot engage spontaneously. A healthy self lies between these two poles, with authentic but flexible commitments to other people, to work and other meaningful pursuits, and to society as a whole.

The primary role of the Gestalt therapist is not to fix — or even truly direct — the client's healing. Rather, the therapist-client dyad is a partnership in which the client takes the leading edge while therapist and client work together to co-create an authentic, flexible, connected self. The present that matters most in Gestalt therapy is the present-ness of the therapeutic hour itself.

The focus on the dynamics of the therapeutic moment does not imply an automatic or easy transfer of those dynamics into other areas of the client's life — a limitation true of other therapeutic modalities as well. However, the Gestalt therapist proceeds from the position that any difficulties the client has in establishing a strong yet flexible self in relation to the therapist will be mirrored or re-enacted in other relationships. Progress the client makes in forming a healthy relationship with the therapist therefore provides what might be seen as practice for other relationships.

One of the most important functions of the Gestalt therapist is that she can derive important information about the client's experiences with other people by examining her own experience of the client. By reflecting on how she perceives and responds to the client, the therapist gains an accurate sense of how the client is perceived by others. This insight can then be shared with the client, giving the client a clearer understanding of how she appears to the world and enabling her to re-think and re-make her connections with other people.

It is essential that the Gestalt therapist have no fixed idea of how the client "should" change throughout therapy, since this modality does not presuppose any specific outcome for the self. One might even argue that a major goal of Gestalt therapy is to help the client develop a more fluid — paradoxically stronger — sense of self. Gestalt therapists are deeply concerned with change but see change as arising from a complete acceptance of what one is in the present. It is only when the client accepts who she is that she becomes able to shift and make fundamental changes. This aspect of Gestalt therapy has a certain Zen-koan quality: change is only truly possible when one is no longer actively seeking to change. Put another way, change must be based on stability.

Gestalt therapy has important connections to the Socratic method in that it is grounded in dialogue. Much of what the Gestalt therapist does is create as many opportunities as possible for authentic dialogue to occur. Dialogue requires both participants to be fully present, fully engaged in the moment and in their relationship with the other. In service of this, the therapist is careful to be authentic herself, presenting who she is in the moment rather than hiding behind any kind of false self.

The following describes the process of Gestalt therapy:

Gestalt therapy is a phenomenological-existential therapy founded by Frederick (Fritz) and Laura Perls in the 1940s. It teaches therapists and patients the phenomenological method of awareness, in which perceiving, feeling, and acting are distinguished from interpreting and reshuffling pre-existing attitudes. Explanations and interpretations are considered less reliable than what is directly perceived and felt. Patients and therapists in Gestalt therapy dialogue — that is, communicate their phenomenological perspectives. Differences in perspectives become the focus of experimentation and continued dialogue. The goal is for clients to become aware of what they are doing, how they are doing it, and how they can change themselves, and at the same time to learn to accept and value themselves.

The Therapist as the Authentic Other

In this way, the therapist models for the client what it is like to be fully present in the moment, demonstrating not only that such presence is possible but also that — far from being threatening or self-annihilating — a commitment to being fully oneself in the present leads to a life that is more satisfying, more pleasurable, and less stressful because it is less internally discordant. This triad — greater satisfaction, greater pleasure, and reduced internal discord — can serve as a description of overall mental health. Other factors can of course be added, since health is a complex concept, but these three I believe summarize the key indices of mental well-being. Gestalt therapy is grounded in the assumption that human nature is flexible and adaptive, and that by bringing together an authentic other and a troubled self, that self may begin to heal through interaction.

As I begin to describe cognitive behavioral therapy, I want to note that it is connected both to Gestalt therapy and to my overall understanding of human nature through its focus on the here-and-now. Cognitive behavioral therapy and Gestalt therapy are both grounded in the idea that people can change — an essential part of my understanding of human nature, and indeed an underpinning of all therapeutic approaches. Both modalities also posit that clients gather the strength to undergo important changes by focusing on the present in the presence of a caring, attentive, and authentic therapist.

CBT is based on the cognitive model of emotional response: it holds that our thoughts cause our feelings and behaviors, not external things such as people, situations, or events. The benefit of this premise is that we can change the way we think in order to feel and act better, even when the external situation does not change.

In this respect, both Gestalt therapy and CBT break sharply from classical psychoanalytic therapy, which can be understood as an excavation into the past. Freud, for example, believed that the farther and more meticulously the therapist and client could travel together into the past, the closer both would come to the truth. Gestalt therapy and CBT, by contrast, take the present moment as the springboard for change — more like rappelling than careful excavation: a temporary but repeated letting go of security as the client swings clear of old restraints to find new footholds, secure in the knowledge that should she slip, the therapist will be there to lend a steadying hand (Crocker, 1999, p. 37).

Throughout this paper, I argue that it is impossible to believe in authentic change for the client unless one focuses on the present, for it is only in the present moment that change is possible. Too strong a connection to either the past or the future precludes genuine change.

Conclusion

Therapy is a wonderful, complex dance — sometimes a waltz, sometimes a jig, sometimes a form without any rules at all. Although I have gathered a number of precepts to help me work with any client I may encounter — regardless of cultural background, gender, age, race, religion, or any of the other parameters that define human experience and belief — I remain fundamentally aware that every encounter with every client requires a certain degree of spontaneity. The therapeutic encounter will always offer surprises, because therapy is above all about the process of growth and change.