One of the many useful findings of sleep and dream research is the observation that dreams are heavily influenced by our preoccupations from the day. It’s even possible to train yourself to lucid dream (wake up within your dream and know that you’re dreaming) to the point of deciding when to lucid dream and what to lucid dream about (see Exploring the World of Lucid Dreaming).
One function of dreaming appears to be resolving incomplete situations from the very recent past (ie, the past couple of days). It’s possible to play with this function to help solve personal conundrums and dilemmas. Try this:
Your dreaming tonight is highly likely to be influenced by your referendum dilemma simply by virtue of it being an emotionally charged preoccupation. By directing this energy into a specific focus, and prompting yourself to contemplate it regularly, you’re seting up a temporary habit that stands a decent chance of repeating otself in your dreams.
Best case scenario, you wake with a resolution on how to vote. Possibly, you might wake up remembering a dream that is either obviously relevant (you dream about the referendum) or just feels relevant. Fortunately, I have already blogged about doing your own dreamwork, so for a bonus exercise, see: dream a little dream of me.
You don’t have to know which way to vote until you’re in the polling booth, and even then you could just draw a massive penis on your voting paper or write Votey McVoteface in block capitals across the top instead. It’s a secret ballot, no one will know how or if you voted, and it’s the height of bad manners to demand to know how someone voted. If you’re ok with letting everyone else decide for you, then actually you don’t have a problem at all.
Maybe you’re stuck because you don’t think it makes much of a difference either way. And then people like me who favour one side over the other come along to tell you that absolutely everything depends on how you vote, and you start to doubt yourself. Well on the one hand, that’s democracy, so tough. On the other hand, forget us, we have no idea what’s going to happen either, not in the long run.
And if after all of the above you’re still stuck, pencil in hand, and you don’t want to spoil your ballot paper? Toss a coin and enjoy the looks on everyone’s faces when you tell them that’s what you did.
The most elaborate of complexities can arise from the most elegant of simplicities. In gestalt, simplicity is achieved and maintained through a rigorous attention to the present moment, the legendary here and now.
Gestalt therapy can be stripped back to three basic questions:
1. What are you aware of now?
2. What do you need now?
3. What does this mean to you now?
Really, if you wanted to strip right back to bare bones, you could stick to question one. The entire body of gestalt therapy literature is essentially an elaboration on the question, “what are you aware of now?”. And arguably so is human experience, which is why the question works.
There is a cyclical flow to human experience, driven by awareness and organised by need. The function of these three questions is to explore this cyclical flow in the context of this person who is in therapy with me in this place at this time. It isn’t about diagnosing what is wrong with the person I am asking these questions. It’s about using these questions to explore the contact possibilities that exist between us.
The common by-products of this exploration are insight, realisation, and healing.
One of the arch-villains of gestalt therapy is the word “should”.
If you’re in therapy with a gestalt therapist, and you start talking about things you should be doing, chances are your therapist’s self-talk has started going, “holy shit! Introjection at twelve o’clock! Kill it! KILL IT WITH FIRE!”. This is because “should” is treated as a dog-whistle term for introjection, and if gestalt had a Wanted: Dead or Very Dead list, introjects would be towards the top.
Introjection is a hang-over from gestalt’s psychoanalytic heritage that hasn’t quite been deconstructed satisfactorily. Which is ironic, really, considering that that’s what introjection is all about. Essentially, introjection is the uncritical internalisation (metaphorically, swallowing whole) of the thoughts, opinions, rules etc of other people. Two main types of introjection can be identified: force-feeding (ie, I introject your rules because you force them down my throat), and inferences (ie, no one says anything directly, but I develop the impression that such and such is the case). The key factor is that I do not apply critical thought to (metaphorically, I don’t chew) what I take in.
A key force in gestalt therapy is semantics. The words you and I use to communicate don’t just contain valuable information about the kind of people we are, they also shape the very experiences we are attempting to communicate. In day to day therapy, this translates into drawing someone’s attention to the words they are speaking. This then raises that person’s awareness of how they are creating their experience in the moment.
I find it instructive to replace “I should” with “x wants me to”. The word should is most usually used to invoke an external authority. What Gary Yontef calls shouldistic-regulation (ie, regulating oneself according to external authority) stands in direct opposition to organismic self-regulation (ie, regulating oneself according to organismic need). When someone says, “I should do better”, they nearly always mean, “x wants me to do better”, where x is a significant internalised other. Shouldistic-regulation is striving to do better because I should. Organismic self-regulation is striving to do better because that’s what I need to do at this time.
The same applies to societal norms and moral codes. “I should not steal”, is really, “x wants me to not steal”. This is obviously the case with regards to force-fed introjects; someone has to do the force-feeding. This is less obviously the case with inferences because, at first glance, no one is doing any force-feeding. The modification I would make in this case is, “I imagine x wants me to”. That is, the inference I am making derives from either the kind of social atmosphere I am experiencing, or the extension of pre-existing rules.
Social atmospheres “give me the impression” that such and such is and isn’t acceptable. But social atmospheres emerge out of the interactions of actual people, allowing me to identify who it is that I am imagining wants me to x. Pre-existing rules give me a way of anticipating what possible rules might apply to a new area of activity. As pre-existing rules are put in place by actual people, I am again able to identify who it is I am imagining wants me to x.
The therapeutic objective in this odd little game is grounding social constructs in actual people. Moral codes do not spontaneously come into being of their own accord; they are created and maintained by people. The kinds of introjects that become the focus of significant therapeutic effort generally need to be traced back to their origin. And that origin is frequently “my dad”, or “my mum”, or “God”.
A hugely important part of therapy is deconstructing the introjected rules by which a person is constrained. That process will invoke resistance from the internalised originator of those rules. And frankly, if I’m going to be up against someone’s internalisation of God, I’d rather know about it!
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Image credit: jennydrewsomething.
This is the account of a three-year research project within the Gestalt therapy community in the UK. It is an example of clinically-based, mostly quantitative research carried out in a methodical and rigorous way, using voluntary effort and minimum funding. The results can be compared with national databases of similar UK studies and show that Gestalt psychotherapists are as effective as therapists trained in other modalities working in the NHS and in primary care (p22).
The issue of evidence-based therapy is a thorny one in the UK, and one which places Stevens et al’s research into an interesting political category. I have a mixed reaction to these research findings, so offer that reaction here. I’ll conclude with congratulations to the people who put this research together because (and I apologise for this in advance) it was clearly a hardCORE effort.
Let’s start with NICE guidance, because it’s not always all that nice. NICE (or The National Institute for Health and Clinical Excellence to its friends) is a laudable organisation with laudable aims.
From its what we do page: “we develop evidence-based guidelines on the most effective ways to diagnose, treat and prevent disease and ill health”.
From its who we are page: “the National Institute for Health and Clinical Excellence (NICE) was set up in 1999 to reduce variation in the availability and quality of NHS treatments and care – the so called ‘postcode lottery’”.
So, NICE exists in order to ensure that someone in BS6 gets the same quality of treatment as someone in S13. This is basically a Good Thing; no one really wants to die or experience extended pain and suffering because their doctor didn’t get the memo. Which of course leads us to how we decide what is effective in any given case, which in turn leads us to evidence-based care. If I’m going to be prescribed medication, I want it to be the most demonstrably effective medication for my condition, not the only one my doctor knows about (or worse, the one whose company was more effective at marketing to my doctor).
This is all classic medical model stuff. The human body is this really cool machine, and when it breaks or malfunctions, you just identify the faulty part(s) and fix it/them. Since the introduction of that model, infant mortality rates have dropped, diseases that used to be deadly are now fairly routine, and heart transplants are possible. I don’t think anyone really wants to throw out this particular baby.
The bath water, however, is another story. While the medical model allows for miracles when applied to physical conditions, it frequently stalls when applied to issues generally related to the experience of being human. The very idea of mental illness is itself a logical fallacy that presupposes a genuine separation between mind and body. And that leads us into problems because, having presupposed the existence of a distinct ‘part’ called the mind, the medical model then attempts to identify the part of the mind that is malfunctioning in order to fix it. Hence the rise of psychopharmacology and the fallacy of the chemical imbalance model of mental illness.
The conclusion of all this is that, when presented with people whose suffering has more to do with the experience of being human rather than their human machinery, NICE continues to assume it is essentially dealing with a machine and seeks standardisation. And that standardisation requires an evidence-base that strips away the humanity of the individual in order to discover the essential underlying problem. Which simply isn’t possible when there is no essential underlying problem; the so-called malfunction is itself an expression of the humanity of the individual.
And this leaves a major problem for gestalt, because the NHS is the main provider of ‘mental health’ services, and its IAPT (improving access to psychological therapies) programme follows NICE guidance. And NICE guidance strongly favours CBT for treating mental health problems because, as Stevens et al acknowledge, it has a bigger evidence base:
CBT has had the most exposure to clinical trials since it uses set protocols which enable standardised collection of quantifiable data (p22).
Given why NICE has been established, this is understandable. From the perspective of the medical model, clinical trials establish efficacy of method, and set protocols allow for standardisation. Try establishing a protocol for ‘sitting with the uncertainty’ or ‘intuiting my client’s desensitisation on the basis of changes in my own bodily experience’. Quite.
So that’s my meander into NICE and evidence-based therapy. What I’m establishing here is the political ground against which Stevens et al’s research needs to be taken: the therapeutic hegemony of CBT.
Research findings, self-validation, and the equivalence paradox
The key finding of this research is that gestalt psychotherapists are shown to be as effective as other types of psychotherapist according to CORE data. Stevens et al used three other studies with which to compare results. I’m not entirely clear why these three particular studies were used or which other studies were passed over for inclusion, so I think the article would have benefited from a literature review. The result of the comparison is that two studies with large datasets provide benchmarking material, whilst the third study focused on minimally trained mental health counsellors.
My response to these results has been interesting. I was angry at first, in the ‘well tell me something I don’t know and this is just political maneuvering not real research’ vein that is the clearest sign one of my buttons has been pressed; the animal anger of being prodded somewhere sore. A bit of licking later and I realise I am relieved. As a therapist, I sit with a great deal of doubt. I doubt that I’m effective. I doubt that gestalt is effective. I doubt that psychotherapy is effective. After all, if it’s all essentially placebo, then I’ve spent a lot of money, time and energy training in the interpersonal equivalent of prescribing sugar pills. My anger was masking a more fundamental feeling of ‘thank fuck for that!’. There is something vindicating about seeing quantitative research with headline numbers that appear to prove what I do is effective.
Now, pursuing that need for external validation appears highly antithetical to the gestalt therapy that Perls et al originally set down, and I think that will make this research controversial within the gestalt community. On the one hand, I practice a therapy that emphasises organismic self-regulation and the importance of self-validation over living up to externally imposed standards. On the other hand, the rise of CBT as the NICE approved therapy of choice is a genuine social challenge that I want to make contact with, not avoid. As Stevens et al point out:
If as Gestalt therapists we do not take seriously the challenge to articulate and evaluate our therapeutic claims we may be left talking only amongst ourselves and limited to working only with those clients who can afford to pay privately (p26).
I have introjected gestalt therapy if I use the ‘but Perls said I should discern things for myself and not be concerned with empirical validation’ line of defence to block contact with a genuine social challenge. If need organises the organism/environment field, then the fact that standardisation and evidence-based practice is organising the field of psychotherapy provision demonstrates the operation of powerful needs. Furthermore, if many gestalt therapists are, like me, not trained in quantitative research methods and don’t have backgrounds in academic psychology, then we are in danger of not contacting the woods for our own projected trees.
All of which serves to focus me on the CORE methodology and what Stevens et al identify as the equivalence paradox: “treatments that have different and incompatible theoretical backgrounds, philosophies and techniques tend to have the same degree of success as measured by CORE” (p24). In addition, the study focusing on minimally trained practitioners showed what I would have hypothesised; that minimally trained practitioners were less effective than professional practitioners.
This equivalence paradox speaks to an intuition in me that for all our different approaches to doing therapy, as practitioners we are all essentially undertaking the same journey only with different preferred routes and ways of travel. Psychotherapy theory seems to have more to do with the preferences of the therapist than it does the effectiveness of the therapy itself. Which is incredibly ironic because it means that, in the arena of working with the human experience, diversity of method actually leads to standardisation of efficacy!
On the other hand, maybe the equivalence paradox is actually an inherent flaw in CORE methodology itself. Perhaps the statistics are simply recording client expectation of what should be the case rather than effectively measuring what actually is the case. A key question there would be whether the clients in the minimally trained practitioner study knew that their therapists were minimally trained and adapted their expectations accordingly.
Politics and dialogue
Where I seem to end up with all this is a sense that Stevens et al have provided gestalt practitioners in the UK with a valuable opportunity to take part in a national conversation. That makes this research political as it has more to do with positioning gestalt in the professional field than it does developing gestalt practice. Both are valid reasons for research.
Ultimately, politics is an opportunity for dialogue about how key collective issues are to be addressed. And dialogue, as I am keenly aware as a gestalt practitioner, necessitates a willingness to open to contact with an other in such a way that risks being forever changed by the process.
And by definition that works both ways. Stevens et al used the CORE methodology not because it is finely attuned to the needs of gestalt practitioners; the writers acknowledge that there is no gestalt therapy box on the forms that need to be filled in (p23) and that filling out forms every session is quite alien to gestalt’s relational approach (p26).
Rather, the CORE methodology was used because it is a well-established outcome measure that allows for comparison with many other studies, including CBT (p22). In therapeutic terms, Stevens et al decided to learn and use the language of the people they are trying to reach rather than impose their own. Once gestalt therapy as a profession is part of that ongoing conversation, we can then also deconstruct introjections about what should count as an evidence-base and better dispel projections about gestalt therapy as an approach.
Finally, what this also highlights for me is the politics of research as an activity in itself. Having conducted my own, qualitative research, I’ve needed to address the issue of researcher bias and the various political and philosophical assumptions that underlie research as an activity. Basically, who asks what questions and why?
With respect to the gestalt CORE project, the GPTI (Gestalt Psychotherapy and Training Institute) discussion list was the birth place of the CORE project, growing out of “gestalt therapists’ concern to find a way to research the effectiveness of their work” (p22). GPTI also funded costs associated with CORE software and training for the first year to get the project started. Gestalt therapists volunteered to take part in data collection, and The British Gestalt Journal hosted a recruitment page with information about the project and downloadable forms.
One way of looking at this research, then, is this: a group of gestalt therapists, with funding from a gestalt therapy organisation and assistance from a gestalt therapy journal, have conducted research whose findings claim gestalt therapy is as effective as other therapies. This appears to justify one of Babette Rothschild’s favourite phrases: outcome focused research is some of the most biased research there is.
I think this bias is real and would hopefully be recognised by Stevens et al. However, I don’t think that recognition of vested interests damages the research. Rather, I think it opens up nicely the same question of vested interests for outcome focused research in general, and CORE studies in particular. After all, “the CORE measurement is primarily designed to provide managers and practitioners with evidence of service quality and effectiveness” (p23). The whole point is to demonstrate the level of effectiveness, not falsify.
Consequently, the inevitable criticism that can be levied at Stevens et al (ie your research is biased by the vested interests of those concerned) applies equally to other studies and only serves to demonstrate the impossibility of the neutral researcher; the motivation to research has to come from somewhere.
What I hope this post portrays is my attempt to reconcile my own thoughts and feelings about the possibility of evidence-based therapeutic practice with my recognition that this is an important piece of research for gestalt therapy.
My congratulations go out to Christine Stevens, Jane Stringfellow, Katy Wakelin, and Judith Waring for putting together this research. This was research conducted by volunteers, outside of academia, and with minimal funding. That is in contrast to CBT as an approach, which has an easier time gathering an evidence-base precisely because there is a greater abundance of resource aimed at producing that evidence-base.
In conclusion, I think those involved can consider this to be three years well spent, and I’ve enjoyed the challenge of chewing over this research.
Stevens et al (2011) The UK Gestalt psychotherapy CORE research project: the findings; The British Gestalt Journal, Vol. 20 (2), pp22-27 (online ref)
I’ve been quiet on the blogging front of late. This is because I’ve been directing most of my spare time and energy into a research project exploring the gestalt approach to working with dreams. Not only am I fascinated with the subject matter but I’ve also become somewhat entranced by the research process itself. Lots of material for future blog posts I’m sure!
In the meantime, I’d like to give an introduction to the gestalt approach to dreams, as it strikes me as an approach that warrants more attention and exploration.
Essentially, the gestalt approach to dreams is to become and experience as much of the dream content as possible. This is in contrast to an analytic approach in which the dream’s meaning is interpreted; either as your way of symbolically coding what you know to be true but want to avoid knowing (Freudian tradition), or as your way of manifesting collective archetypal forces (Jungian tradition).
Classic gestalt dreamwork involves telling your dream in the first person, present tense as if you’re back in the dream and it’s happening right now. That re-activates much of the energy tied up in the dream. The rough methodology of dreamwork involves choosing parts of the dream that attract your attention and ‘becoming’ them.
If I’m sat at a desk in my dream, then I can speak as me, or I can speak as the desk. I can become aware of other characters and objects in the dream and speak as them. As I do this, I notice what I become aware of and feel as I speak from the desk part of myself. Spontaneously, I might make new connections, reach new insights, or connect with feelings that I usually stop myself from connecting with.
By focusing on the here and now of dream exploration, gestalt shifts the focus from finding some meaning for the dream, to making contact with whatever is tied up in the dream. We don’t need to answer the question ‘What does this dream mean?’. One dream can answer a dozen different questions at a dozen different times, the only real relevance test being does the dream seem in some way relevant to you now?
And like anything in gestalt, you can self-verify this through experimentation:
Phase 1 Recall your dream. If you can, speak it out loud; if not, think it through or write it down. Stay in the first person, present tense (eg ‘I am walking down the road and notice a squirrel up ahead’). Notice what you become aware of as you recall your dream.
Phase 2 When you’ve finished recalling, choose something from the dream that you’d like to play the part of for a while. To start with, it helps if you switch seats to become this dream aspect. Now, speak from that dream aspect and explore your perspective in the dream (eg ‘I am a squirrel and I’m standing here in the road and…’). Explore what you’re thinking, how you feel, what you’re aware of (eg ‘I am a squirrel and I’m thinking….’, ‘I am a squirrel and I’m feeling….’, ‘I am a squirrel and I’m aware of…..’).
Phase 3 Create a dialogue between you as you, and you as the dream aspect. Keep one seat for you, one seat for the dream aspect, and change seats to speak as each part. Having spoken as the dream aspect, what would you like to say to it? Is there anything you’d like to ask it? So, I ask the squirrel ‘what are you doing in the road?’. When I change positions and become the squirrel, I answer ‘I’m giving you an amusing example to use in your blog’. The idea is to suspend your expectations and go with whatever comes up until you feel you’ve reached a natural conclusion. You can then repeat phases 2 and 3 for as many other parts of the dream as you want.
What’s key in the three phases above is that the exploration takes place in the immediacy of felt experience, and allows meaning to arise spontaneously out of creative exploration. Everything in your dream is taken to be some aspect of yourself, and so you’re invited to re-absorb some of those energies and perspectives.
This is the approach that came to characterise gestalt dreamwork, and is heavily influenced by the charismatic example of Fritz Perls. What’s especially interesting for me is the theory that sits behind this way of working. Essentially, the methodology above rests on the idea that dreams are projections of the dreamer. That is, everything in the dream is some aspect of self that has been dis-owned and which the self is attempting to get rid of.
Projection is pretty much like trying to throw a part of yourself away. You can’t throw parts of your selfaway though, so they instead become experienced as something external to yourself. Working with projection is a matter of re-owning projected aspects of self. This is why Perls described dreams as ‘the royal road to integration’; by re-owning aspects of the dream, I am re-owning aspects of my self and so moving towards greater self-integration.
Of course, this way of working with dreams doesn’t fly with everyone; not everyone is entirely comfortable about dialoguing with their inner squirrel. And that’s fine; the above is just one way of working with dreams in gestalt, and I generally adapt my method according to what’s appropriate for the given situation. My research interest is in what happens if gestalt therapists work with dreams in a deliberately different way that emphasises different gestalt concepts.
That’s proving to be a very interesting voyage of discovery for me. And if I give my voyage a voice and ask myself where I’m taking me? I just laugh and tell myself to wait and see!
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Image credit: www.theodysseyonline.com: On the Importance of Dreams.
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