To make a comparison study between two psychotherapy approaches is not an easy task. There are many criteria to be followed, many aspects to be pointed out, many angles from which things can be viewed.
Virgiliu Ricu, Psychologist M.D.Bucharest, Romania
To make a comparison study between two psychotherapy approaches is not an easy task. There are many criteria to be followed, many aspects to be pointed out, many angles from which things can be viewed. Moreover, a complete comparison study cannot ignore the significant developments that have occurred within both approaches since their beginnings, especially within psychoanalysis, which makes this attempt even more difficult. This study does not claim to be an exhaustive one. On the contrary, it focuses strictly upon how each of the two psychotherapies conceived and treated the subject of the cure or of the change process.
Because psychoanalysis was chronologically the first and because Gestalt therapy developed mainly as a reaction against the former, this paper will treat psychoanalytic therapy first.
The cure process in traditional psychoanalysis is based on all the important discoveries that Freud made during his lifetime. It is beyond the purpose of this study to present here the psychoanalytic theory, along with all its clinical concepts and with all its phases of development. I will limit myself to only several aspects of Freud's theory that can serve to set forth the way he saw cure as possible.
In The Ego and the Id (1923), Freud formulated what has been called the 'structural model' or the 'second topography' the three-fold division of the mental apparatus into id, ego, and superego, which can be described as follows
"It (the Id) can be regarded as that area of the mind containing the primitive instinctual drives, with all their hereditary and constitutional elements. It is dominated by the pleasure principle, and it functions according to the primary process. During maturation and development and as a consequence of the interaction with the external world, a portion of the id undergoes modification to become the ego. The primary function of the ego was seen as the task of self-preservation and the acquisition of means whereby a simultaneous adaptation to the pressures of the id and the demands of reality can be brought about. It gains the capacity to delay instinctual discharge, or to control it by means of variety of mechanisms of defense. The third agency, the superego, was seen as developing as a sort of internal precipitated or residue of the child's early conflicts, particularly in relation to his parents or other figures of authority and his identification with them. The superego is the vehicle of the conscience, including that part of the conscience which is regarded as unconscious; for large parts of the superego, as well of the ego, and all of id, were seen as functioning outside consciousness. (..)
The ego's role was seen to be that of a mediator, a problem-solver, having at each and every moment to meet the demands arising from the id, from the superego, and from the external world. In order to resolve these often conflicting demands, the ego has at times to create the most complicated compromises, and in the last resort these compromises may result in the symptoms which, although painful and distressing to the individual who experiences them, represent the best possible adaptation that can bring about in the particular circumstances. Such compromises are regarded as entering into the formation of the character and personality, into choice of career and love-objects, and into all those things which go into making any one person a unique individual." [J. Sandler, 1973]
One of the most important assumptions of psychoanalysis is that any major psychological problem occurring in the present has its source in early childhood conflicts when the ego was weak and therefore forced to create difficult compromises between the demands of the id and parental interdictions (later introjected as superego) which referred especially to the sexual and aggressive behaviors.
The aim of psychoanalysis, in the terms of the structural model, becomes the strengthening of the ego in order to prevent symptoms or other painful compromises. The ego is strengthened through the process of "making what is unconscious conscious" or through insight, which comes as a consequence of the analyst's interpretations. The patient needs to become conscious of the demands of the id which he unconsciously represses, of demands of the superego, largely unconscious, and of the defense mechanisms (also unconscious) mobilized by the ego. By becoming conscious of all these, he understands for instance that he has no need to repress now, as an adult, his sexuality, and also there is no need for his ego to mobilize its energic defense mechanisms. The energy the ego gains by giving up to the defenses can be used for its own organizing purposes. The ego can face now the demands of the external world in a more adequate manner.
The vision of psychoanalysis being a deterministic one, the process of becoming conscious requires the patient to go back to the source of his conflicts. For this reason, the psychoanalytic cure is based on regression, recollection and on the process of experiencing again, in the here-and-now and in the presence of a neutral and interpreting analyst, those conflicts that occurred in his early childhood.
All the particulars of the analytic framework have been carefully set in order to make all these possible. By imposing some particular conditions, such as asking the patient to lie back on the couch and by keeping himself silent and out the visual sphere of the patient, the analyst facilitates the appearance of the regression. As a consequence of regression and of the repetition principle, the transference is supposed to appear.
Although it is best visible in a psychoanalytic cure, the transference is an universal phenomena which occurs in every human relationship, especially in the relationships with authorities and with loved ones. In psychoanalysis, it is described as an actualization, in relation to the analyst, of some of the patient's wishes, feelings, and patterns of behavior which he initially developed in relation to significant figures of his early childhood, particularly his parents. According to Anna Freud, transference is everything that is not new in a therapy. The initial neurosis is so replaced by what is referred to as transference neurosis, which can be analysed and understood in the analyst's consultation room. As the transference phenomena allows the analyst to observe and to understand the patient's personal history, his relevant wishes and behavior patterns related to significant persons in his life, it is obvious why the analysis of the transference phenomena is regarded by psychoanalysts as being at the very centre of their therapeutic technique. All the rules and the conditions imposed both to the patient and the therapist find their reason of being in the facilitation process of transference appearance and of a pure transference neurosis development. The analyst will tend to adopt an attitude as reserved as possible and will limit his interventions to interpretations , confrontations, and reconstructions, which represents the major therapeutic interventions in psychoanalysis. He will try to prevent any personal influence on the patient and as far as possible he will apply the rule of neutrality, according to which the analyst is supposed not to make judgments, not to counsel, not to impose his personal values to the patient, not to interfere with his internal dynamics, and also the rule of abstinence, according to which
"the analytic treatment should be so organized as to ensure that the patient finds as few substitutive satisfactions for his symptoms as possible. The implication for the analyst is that he should refused on principle to satisfy the patient's demands and to fulfil the roles which the patient tends to impose upon him. In certain cases, and at certain moments during the treatment, the rule of abstinence may be given explicit expression in the form of advice about the patient's repetitive behavior which is hindering the work of recollection and the working out."[Laplanche & Pontalis, 1973]
These particularities of the analytic situation allow the occurrence of two distinct relationships between the patient and the analyst, the transferential relationship, and the working relationship, based among other things, on the patient's wish to recover and to co-operate in treatment. This working relationship, also called the treatment alliance, is regarded as including, as an essential part, the patient's motivation for continuing in analysis in the face of resistances.
After several hundreds of sessions, the patient is supposed to become conscious of his behavior patterns and relevant wishes and also of the secondary gains he gets from his illness. He can choose to repeat these experiences, risking the occurrence of symptoms, or to elaborate new ways of living; the psychoanalyst, always maintaining his neutrality, will respect the patient's choice whichever it might be. By exploring during the treatment new functioning modalities, healthier and healthier, and through the identification with the analyst, the patient is supposed to be cured and his personality reconstructed.
The question that this model of psychoanalysis has always been raising right from its beginnings refers to the capacity of the analyst to remain affectively neutral to the patient's personality and to the measure in which that neutrality is desirable.
Fritz Perls, who was also trained in psychoanalysis by Wilhelm Reich, doubted the therapeutic value of the analyst's neutrality and rejected it, just as the existentialists did before him. Disappointed by psychoanalysis' unsatisfactory efficiency, he tried to develop a different approach of psychotherapy, which appeared as a complex conceptual and methodological heritage composed of several influences, some psychoanalytic, some existential-experiential, and some psychodramatic. Yet it was Gestalt psychology that offered him a theoretical basis for his innovations.
Gestalt psychologists (Kohler, Koffka, Wertheimer) had emphasized perception as a process involving organization and apperception of patterned relationships in which some elements were perceived as 'figure' and others as 'ground'. Moreover, certain perceptual elements or stimuli were perceived in the context of the overall whole in which they were embedded.
Perls considered that the laws of perception as described by the Gestalt psychologists, along with their phenomenological and holistic emphases, could be equally valid for the whole personality system. In making the transition from simple perception to the whole gamut of personality functioning, he both retained the 'figure-ground' concepts of the original gestalt theory and concentrated with unusual specifity on the moment to moment flow of awareness.
Perls extended Gestalt phenomenology beyond mere sensation, to feelings and to thoughts and thus what was 'perception' for the original Gestaltists became 'awareness' for him.
"While awareness involves all three elements, Perls claimed that it was within the realm of awareness of feelings that the human organism experiences the greatest difficulty. Neurosis, he said, develops at that point in the flow of awareness where the feelings that would normally become figure are blocked off by the patient and kept in the background, because of the latter's 'phobic' attitude toward them; he 'avoids' them because of their unpleasantness. The Gestalt therapist's task is to pay careful attention to the patient's 'continuum of awareness' and to locate those precise points where he becomes 'stuck'; usually these points involve avoidances that disturb the rhythmic ebb and flow of healthy, present-centered awareness. In balanced awareness various emotions, perceptions, and needs intensify to a point where they become clearcut "gestalten." Once fully figured they will obey the law of all perception, and eventually become background. If these gestalten involve actual physical needs like hunger and thirst- the person is functioning most organismically if he turns his attention to those aspects of reality that can best satisfy them; once satisfied, they too, like other perceptions, should gradually fade from awareness." [Shaffer & Galinski, 1974].
Because it is so hard not to read "conscious" for 'figure', 'unconscious' for 'ground', 'repressed' for 'blocked off' and 'defense' for 'avoidance', and because the notion of the 'top-dog' exhaustively used by Perls is so roughly parallel to Freud's concept of superego, I dare to affirm that the perlsian model clearly retains the kind of psychodynamic thinking that characterizes psychoanalytic theory. Moreover, some psychoanalytic terminology like 'phobic', 'projection', and 'introjection'- has been incorporated directly into Gestalt language.
These are the reasons that lead me to consider that, in regard to theory, the perlsian model does not differ much from the psychoanalytic one, but it owes a lot to the latter. However, in his explanations Perls did not make very clear where the 'unpleasantness' of the feelings comes from, while in the Freudian model this is clearly marked by postulating the conflicts between the id demands and those of the superego. As Laura Perls states,
"The aim of Gestalt therapy is the awareness continuum, the freely ongoing Gestalt formation where what is of greatest concern and interest to the organism, the relationship, the group or society becomes Gestalt, comes into the foreground where it can be fully experienced and coped with (acknowledged, worked through, sorted out, changed, disposed of, etc.) so that then it can melt into the background (be forgotten or assimilated and integrated) and leave the foreground free for the next relevant Gestalt." [1973, p. 2]
This statement of Laura Perls seems to strongly agree with the freudian aim of making what is unconscious conscious. As we may notice so far, both Gestalt therapy and psychoanalysis aim to a more adequate adaptation of the patients to the present environment. Both of them consider that there is something that "blocks" this process of adaptation and hinder the patient from living in the present or in the here-and-now, as Perls liked to say. At this point we encounter the difference between gestalt therapy and psychoanalysis. Psychoanalysis postulates that this block has inevitably something to do with the patient's past. In other words, the "block" comes as a consequence of an intrapsychic conflict which has its source in his early childhood. Therefore, in order to live better in the present, one must go in the past, find the cause of the problem and then remove it. On the contrary, Perls did not consider this going back in the past necessary. In contrast, he tried to help the patient contact and even intensify his experience with vivid immediacy.
Perls postulated two ideas which later became the centerpiece of the theory of gestalt therapy. The first is that the proper focus of psychotherapy is the experiential present moment. In contrast to approaches which look at the unknown and even unknowable, its perspective is the here and now of living. The second idea is that every human being is inextricably caught in a web of relationship with all things. It is only possible to truly know one's self as one exists in relation to other things. These twin lenses, here-and-now awareness and the interactive field, define the subject matter of Gestalt therapy.
Perls often criticized psychoanalysis because, by asking the patient to report everything that came to his mind and by reducing the amount of the environmental stimuli available to him (through his placement on the couch), the psychoanalyst was minimizing the patient's opportunity for genuine contact with the environment. He also rejected the idea of a reserved behind the couch therapist.
As we have already mentioned before, this analytic setting was supposed to facilitate the appearance of regression in order to help the patient contact his unconscious and recollect his forgotten memories, wishes, trauma etc. Interpretations are mainly meant to facilitate these processes. Perls strongly disagreed with the analytic setting and also with the analytic tools. According to him, talking about one's problems is nothing more than "mind-fucking" and interpretation is a mistake because it forces the patient to become more abstracted and thus more strayed away from the present reality.
Perls really feared that interpretation and abstraction could create an unreal world able to imprison the patient. He did not believe in the value of thinking per se and he considered that, for most of the patients, thinking was in the service of phobic avoidance. Psychoanalysis also clearly differentiated between intellectual insight and emotional insight and saw rationalization as a form of defense, but Perls went yet further when he said" Lose your mind and come to your senses!". Coming to one's senses, becoming aware of what one might hear, smell, see, mean that one is to live in the here-and-now and that is why Gestalt therapy has a large gamma of exercises that promotes physical awareness.
Obviously, physical awareness is not enough because awareness also includes thoughts and feelings. If the sensations naturally obey the law of all perceptions, it is not the same case for feelings, which often are blocked off by the patient and therefore the process of awareness continuum becomes also stuck. Just as in psychoanalysis, in gestalt therapy also the patient is expected to face his frightful feelings in the reassuring presence of the therapist. The difference lies in how the patient is invited to contact his so far repressed feelings. Psychoanalysis uses regression and recollection in order to do this. Because the methods used by psychoanalysis for encouraging regression were contradicting the principles of both here-and-now awareness and the interactive field, Perls had to seek another modality of approaching the repressed psychic contents and he thought he had found it in some sort of enactment and many other experiential tasks - techniques of patient focusing, exaggeration, guided fantasy, body techniques etc.
For instance, if the patient happened to say he was aware of some anger, the Gestalt therapist might ask him "What does your anger say? Be your anger." By asking the patient to speak for his anger, Perls intended to help him getting in touch with his anger on a different level - to become it, rather than talking about it. In Gestalt therapy the "It" statements often change into "I" statements in order to determine the patient to identify with his feelings and to assume more responsibility for himself. The perlsian innovative approach usually involved the patient in a highly theatrical dialogue with himself and asked for him to give dramatic expression to his feelings, conflicts, and preoccupations of the immediate moments. The similarities to psychodrama are more than obvious- although Perls made no mention of Moreno or of Psychodrama in his writings- but in the Gestalt setting the patient dramatizes and personifies various aspects of himself or of his behavior.
Moreover, just in psychodrama, the therapist acts as a stage or film director constantly instructing the patient as to what to do, while the patient writes the script and also follows the script. Perls seemed to have appreciated very much the enactments, because he used them a lot when dealing with dreams. For him, every person or even every object in the dream represents a projected aspect of the dreamer. Perls refused to interpret the dream and instead asked the dreamer to enact the elements of the dream in order to allow him to reintegrate what had been projected. Perls actually replaced the entire analytic setting with his own workshop format.
"The Gestalt therapy workshop format with which Fritz Perls became most identified toward the end of his life at Esalen and Vancouver Island and in the several taped and filmed demonstrations of his work was noncontinuous; its participants, whether professionals or non-processionals, met together anywhere from half-day to several weeks, and their formal contact ceased at the workshop's end. Perls worked with the group in a pure way; his contact was focused on a single patient rather than on the group-at-large, and in this work the patient's attention was diverted away from the reality of the group and the therapist and directed toward his own internal self. This particular variant of the Gestalt therapy approach to groups represents the model in its purest form, and it is the one that we shall present.
The workshop begins with the therapist's asking who in the group wants "to work". Whoever volunteers then takes the "hot-seat", which is a chair facing the therapist. The participant at this point becomes the"patient". He may begin by stating a particular life problem that disturbs him; if silent, he may be asked by the therapist to express his immediate awareness. However he begins, the focus is on his moment-to-moment "here and now" experience as much as possible; intensification and exaggeration of this experience is encouraged by a variety of exercises to be described below. The patient's "therapy" develops much as it might in the context of individual Gestalt therapy. Here, in the group setting, the other participants function much as a kind of "Greek chorus" [Denes Radomisli,1971] that hopefully resonates and empathizes with the patient to a point where they, too, through identification, gain from the patient's experience. At certain points the group might be called in by the therapist, but usually in a structured way for the purpose of furthering the therapist's work with the patient. For example, a go- around exercise might be suggested wherein the patient goes to every participant with the same sentence-beginning " I want you to like for my "- and then is to finish differently for each person. The patient might remain in the hot seat anywhere from ten to thirty minutes; he works until he and the therapist have some sense of closure. Typically from three to six participants take the hot-seat in any single session.
The Gestalt therapy group format, as it gradually evolved in the hands of Perls, became a means whereby anyone, whether professional or non-professional, wether "therapist" or "patient" in his extra-workshop life situation, could gain greater contact with his immediate experience. Unlike psychoanalytic and experiential groups, Gestalt group therapy did not involve a prolonged relationship to a group with which one slowly reconstructed his original relationship with his family of origin and through which he gained insight into his life as it had been lived historically. Perls' approach simply required one to focus intensively on his "stream of awareness" via the guidance of therapist who, much like a Zen Master, facilitated this meditative process." [Shaffer & Galinski, 1974].
In elaborating his Gestalt workshop format, Perls replaced the couch with "the hot-seat" and "the empty chair". Instead of making interpretations, he offered experiments that enable patients to discover for themselves. Rather than maintaining distance, he met patients and guided active awareness work.
The body language, most often ignored in psychoanalysis, became of great interest for the gestalt therapist. "What do your hands say?" is a frequent Gestalt question. The therapist might also ask the patient to intensify aspects of his nonverbal behavior - "Notice that chopping motion you are making with your arm? Intensify it."
Especially when dealing with the resistances, the therapist might ask for intensification or exaggeration. The reason lies in that any form of resistance must be first fully gestalten in the foreground in order to become ground afterwards and to let then the repressed feelings occur in the foreground (one may easily notice that this strategy has much in common with the psychoanalytic concept of "siding with the resistance"). The same conception lays at the basis of the paradoxical theory of change the patient is expected to change only when his right not to change is accepted. Similarly, only when we fully accept an aspect of our personality does change become possible.
The techniques of Gestalt therapy are experimental tasks meant to expand direct experience. All of them have in common the general principles of Gestalt therapy emphasis on direct experience and experimenting (phenomenology), use of direct contact and personal presence (dialogic existentialism), and emphasis on the field concepts of what and how and here and now.
The principle of interactive field allows the therapist to give up his usual reserved attitude. Moreover, as one of the most basic principles of the Gestalt therapy states that experience occurs at the boundary, the therapist's active presence is regarded as necessary. For gestaltists, growth occurs from real contact between real people. The therapist is alive, warm, honest, direct and the patients can see, hear and be told how they are experienced, how the therapist feels, what the therapist is like as a person. Within these parameters, all the therapeutic interventions are so much patterned according to the context and to the personalities of the therapist and the patient that everything is considered secondary to the direct experience of both participants.
Described in this manner, the Gestalt therapy workshop format looks very different from the analytic one. Yet, as we shall see, they are based on the same conception in what concerns the cure process. Fundamental to Perls' theory is the assumption that the organismic, autonomous self, if left to its own natural biological rhythms and not contaminated by the toxic "shoulds" of a moralistic and pressuring society, can find its way to an aware, authentic existence. The therapist's task is therefore to help the patient externalize these introjected "shoulds", then to approach the self and the introjected "shoulds" in order to help them live more comfortably with each other. Perls was really convinced that the ultimate goal of psychotherapy was integration and the therapist has not so much to help the patient resolve his conflicts as to integrate them more coherently - a conviction which underlies his holistic conception concerning personality.
Because the toxic "shoulds" of a moralistic and pressuring society are so similar to the freudian superego's demands, I may say that the cure processes in both Gestalt and psychoanalysis have in common the idea of externalizing an introjection. But they use different tools in order to do this. While psychoanalysis uses the transference interpretations, in Gestalt therapy the most used technique for externalizing an introjection is the "empty chair" technique.
The Gestalt therapy workshop format, noncontinuous and short termed, seems to have more particular appeal for already analyzed therapists than to the ordinary patients. There are very qualified voices which consider that the perlsian workshop style departed markedly from the medical model of psychotherapy and came closer to a short-term educational-therapeutic experience; consequently, its area of application became more limited. In addition, the role of the leader and his impact upon the participants must not be ignored. He has to actively guide the process of awareness and constantly instruct the patient as to what to do. He has to be very skilled in suggesting techniques that will help the patient to intensify his experience, be alert to nonverbal clues and be very able to identify contact-avoiding behaviors.
It has been mentioned before that the Gestalt therapist used to act much like a Zen Master. At least Perls did so. Thanks to his training in psychoanalysis, he could identify the conflicts the patient was experiencing and then he could suggest techniques apt to help the patient becoming aware of his conflicts. And because it is very difficult to be a Zen Master, it seems also difficult to be a skilled Gestalt therapist. Perls was such a skilled therapist, extremely creative and charismatic. I have serious reservations concerning charismatic leaders because it is very difficult for me to believe that the patient will reach his own identity in the active presence of such a charismatic therapist. It seems more likely that he will introject the therapist, which is just what happened with many of Perls' disciples. An American contemporary gestalt web site strongly supports this view
"Though Perls was himself widely read and keenly sensitive to intellectual influences in tune with his interests, his antipathy to intellectualizing extended sometimes to discouraging serious thought altogether. His manner and actions sometimes encouraged his students to imitate him, emulate his methods, and repeat his words thoughtlessly, introjecting him at the expense of finding their individual, considered responses to his teachings. At the same time, also following his example, others decided for themselves what constituted Gestalt therapy without distinguishing ideas from slogans."
In other words, due to his constant underestimation of thinking, Perls made possible and even facilitated uncritical introjections for his patients. The identification process with the therapist is unavoidable in any sort of therapy, but psychoanalysis facilitates critical introjections of the neutral, abstinent and not interfering therapist's analytical attitudes. There are these analyst's attitudes of neutrality and of abstinence that allow the patient to find his individuality.
The freudian model and the perlsian one are quite opposite to each other in what concerns the therapist's attitudes toward the patient. What made Freud choose the reserved, neutral, non-interfering attitude and what convinced Perls to adopt his own workshop format must obviously be searched for inside their own more or less conscious motivations. Before embracing the profession that would make him world famous, Freud had worked as scientific researcher in a lab. All his life he tried to attain the objectivity of a scientist and he never gave up to the researching side of his work. One of Freud's ambitions as a youth was to uncover a big secret of nature. It is sure that his analytic attitude allowed him to uncover many "secrets".
On the other side, Perls' youthful experience as a student-actor with Max Rhinehart in Germany might well have been influential in this respect. According to the psychoanalytic theory, an actor is a person who gets his exhibitionist tendencies socialized. It is certainly difficult for a person with strong exhibition tendencies to adopt the analyst's specific reserved, nondirective, noninterfering attitude. One can say that, by adopting the Gestalt format in which the therapist guides the patient just like a film director, and the other participants act as a Greek chorus or as an audience, Perls unconsciously felt like being in "movie business". His need for an audience could also be traced in his rejection of the individual therapy sessions
"Lately, however, I have eliminated individual sessions altogether except for emergency cases. As a matter of fact, I have come to consider that all individual therapy is obsolete and should be replaced by workshops in Gestalt therapy. In my workshops I now integrate individual and group work. " [Perls, 1967].
As expected, his opinion was not then shared by most Gestalt therapists (including Laura Perls and Paul Goodman), and also is not currently recognized Gestalt theory or practice. Since Perls' death, Gestalt therapy has evolved and his followers have been working more explicit with psychodynamic themes. In what concerns group sessions, there has also been an increase in emphasis on group process, including relation between group members, and a decrease in formal, one-to-one work in group.
It is significant that contemporary psychoanalysis, especially the interpersonal psychoanalysis, becomes very sensitive to the here-and-now and to the interactive field within the analytic work. The emphasis lays on the relationship with the analyst which is now seen as being at the very center of the therapy. The analytic work is more and more focused upon how the patient, in his fantasies and unconscious thoughts, uses the analyst in the here-and-now. Moreover, the analysts show openness to the idea of admitting the inevitable effects of their own subjectivity on the interpersonal process. Yet, unlike the Gestalt therapists, they still remain nondirective, preferring not to interfere with the patient's internal dynamics.
Contemporary psychoanalysis and contemporary Gestalt therapy do not seem to be as opposite as they were at their beginnings; moreover, they tend to have many things in common. I can also say that they tend to accept each other.
Copyright 2001 Virgiliu Ricu M.D. All rights reserved.
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