Case Study: George George is a 40 year old senior executive in a large company, a position he has only recently taken up. He was referred to counseling by his general practitioner to explore his mood swings. He has been married for nearly 5 years to a ‘warm and wonderful person’. There were no children yet, and the couple was wondering about the right time for having children. This has been an area of disagreement between George and his wife and has led to a number of heated arguments between the two of them.
George described himself as fairly conservative and not a risk taker, and said that sometimes he couldn’t believe he had accepted a job in such a large company. On questioning, George said that he sometimes felt OK and reasonably good about himself, but that these good feelings frequently gave way to incredible doubts and feelings of hopelessness, that he often felt ‘not good enough’ and ‘not worthy’. He had experienced these feelings before, but he felt they were more intense and more frequent since moving to his current position.
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He commented, “I’m not the person I thought I would turn out to be” and “I’m disappointed in myself”. He reports being able to keep it together at work and that his work in not suffering at this stage. He has become more restless and irritable with people, especially in social situations which he describes as excruciating and pointless. Introduction There are a number of potentially valuable therapies that vie for attention as possible curative options for George and his symptoms. However, gestalt therapy and REBT are the two approaches that I have decided to implement here.
I will give a very brief synopsis of each approach before offering in-session therapeutic techniques that I will apply with George. In closing I will discuss some of the differences between the two chosen approaches, as well as offering a justification for a preferred approach for treating George. The gestalt approach is a psychological approach that studies the organization of experience into patterns or configurations (Yontef & Jacobs, 2008). Gestalt psychologists believe that the whole is greater than the sum of its parts and study, among other issues, the relationship of a figure (the part of the field that stands out) to its background.
One goal of gestalt therapy is primarily to become aware of the elements that make up the various parts of a field, so that one becomes able to choose and/or organize one’s own existence in a meaningful manner (Jacobs, 1992; Yontef, 1982, 1983). An awareness of the relational field is a way of understanding how one’s context influences one’s experience. Gestalt theory suggests that people define themselves by how they experience themselves in their field in relation to others. Yontef & Jacobs (2008, p. 40) argue that this is an identity boundary that needs to be permeable enough to allow for connection to others but also to preserve autonomy by separation. They claim that an incessant fluctuation of connecting to and separating from relationships with others is necessary for effective self-regulation. The gestalt approach has a strong emphasis on experiential learning and focusing on what is actually happening in the ‘here-and-now’ (Yontef & Jacobs, 2008, p. 346). It is not concerned with past events per se, but rather how the past (or an anticipated future event) is experienced in the present.
The most conspicuous feature of gestalt therapy is the importance of raising client-awareness and finding self-acceptance by developing awareness skills (Yontef & Jacobs, 2008). Gestalt therapy is a collaborative approach that involves the therapist and the client to make sense of the relational field of the client, and the shared field with the therapist, as manifested during the therapeutic hour. The other form of therapy that I recommend for treating George is REBT. The fundamental premise of REBT is that nearly all emotions and behaviours are caused by what people believe about the situations that they face.
In other words situations themselves to not determine how people feel and behave. The ultimate goal ‘is to help clients make a profound philosophic change that will affect their future as well as their present emotions and behaviors’ (Ellis, 1994, p. 248). An ‘A-B-C’ model has been put forward to explain this process (see Ellis, 2008), which has been revised and extended to form an ‘A-B-C-D’ model (Froggatt, 1993). (A) represents the activating event, (B) is the belief about the event, and (C) represents the emotional and behavioural consequences following the beliefs.
Often people hold irrational beliefs about specific situations that result in various distressing experiences. REBT helps to break down this experience into a pragmatic process of change. The essence of the change process is (D) – disputing the validity of the core beliefs that is held by the client. Successful disputation, usually by the therapist, leads to a new affect and this can lead to a new and more appropriate feeling, thus a new personal philosophy (see Ellis, 1994, pp. 78–79). This model of therapy is framed within an obvious philosophical commitment to ‘rationality’ (Watson & Culhane, 2005).
Using Gestalt Therapy with George Gestalt theory suggests that the concept of the client’s world can never be fully understood in therapy apart from the relational context in which it occurs with the counsellor (Cowan & Presbury, 2000). For this to happen in a productive and supportive manner, the first step will be to establish a respectful, interactive dialogue between George and I. This means that self-disclosure on the part of the therapist is practiced (Bean, 2008). This is done by reflective statements of what I understanding is being communicated to me by George.
Typically, the gestalt therapist offers feedback on how he perceives the client and the client can then add to this feedback by correcting, rejecting, resisting or accepting this exchange of information (Bean, 2008). My attunement to George’s process will enable me to hold a space of acceptance that will convey a ‘compassionate and understanding environmental field’ for him to become aware of (Yontef & Jacobs, 2008, p. 347). This initial process helps to bring the dynamic client-therapist relationship into awareness; a veritable ‘intersubjective matrix’ (Stern, 2004).
This matrix-type process, also known as inclusion, will allow me to observe George to safely connect with his anxiety and self-doubt and he will come to accept those parts of himself, as he progresses to accept his ‘whole’ self. I will ask George to express and clarify what is important by helping him focus his awareness on aspects of his process from moment to moment. If however the separation between George and I becomes muted or unclear, we will experience confluence. Thus, it would be difficult for George to distinguish between what is his own perception or values from those of my own.
This will then prevent George from moving forward from his self-doubts. This can be understood by the gestalt theory of impasse (Yontef & Jacobs, 2008, p. 344). According to Yontef & Jacobs (2008, p. 344) an impasse is a situation in which external support is not forthcoming and the person believes he cannot support himself. The individual attempts to manipulate the environment to do his seeing, hearing, thinking, feeling, and deciding for him. Since George does not know how to effectively self-regulate, external support (such as wanting the therapist to provide him with answers) becomes a replacement for self-support.
George will get through the impasse because I will draw attention to what aspects of his troubles have been kept from his awareness, without doing his work for him by ‘rescuing’ him. George will then be ready to take responsibility for his experience. A strong, empathetic and supportive client-therapist relationship lessens fear and improves the field conditions to make change possible by ‘trying something new’ (O’Shea, 2005). At this point I will introduce the gestalt ‘two-chair experiment’. Asking George to sit opposite to an empty chair and to talk to his internal critic may help to connect him to, and not resist, his internal conflict.
This process embodies ‘physical knowing’ (Malfait & Wollants, 2009). The purpose of this experiment is not to push George to speak or make any changes, but to gain awareness of whether he is talking/ feeling or not, of his desire to talk/ feel, of what is preventing him from talking/ feeling, what supports him to talk/ feel, and what he does with ease and with difficulty; to come to know the various parts of his whole self. This process refers to the gestalt principle of the Paradoxical Theory of Change which suggests that ‘change happens when you become who you are, rather than who you are not’ (Yontef & Jacobs, 2008, p. 29). I will direct George to acknowledge, not refute, the part of him that is anxious and self-doubting during the experiment as this can lead towards greater self-acceptance and compassion (Neff, Kirkpatrick & Rude, 2007). The two-chair experiment will encourage George to become aware of the boundaries that distinguish between connection and separation, resulting in a greater capacity for healthy self-regulation. This is done by direct experiencing, rather than just talking about a situation. He will live his experience rather than describe it in a detached way.
In terms of his ‘heated arguments’ with his wife, I will ask him to talk to the ’empty-chair’ as if he is talking to his wife and discuss his concerns about having children. In doing so, unpleasant feelings will be incited and experienced for George to get acquainted with. His ability to embody his various states during the experimentation process will aid him to understand his suppressed feelings and to manage them more effectively (Malfait & Wollants, 2009). Instead of trying to avoid or cover these feelings, George will be encouraged to become more curious of his feelings/ needs/ desires/ fears as they arise.
I will ask him questions to enhance and intensify his experience. Questions such as ‘can you go through that in slow motion? ‘, ‘can you describe every de tail of what is happening? ‘ will lead him towards a greater degree of awareness. His changing moods and his ambivalence can therefore be used as a barometer to what is happening in his inner world, encouraging him to investigate them, rather than simply being self-critical. Bringing George’s attention to his bodily responses during therapy by experimentation is an important characteristic of gestalt therapy.
Malfait & Wollants (2009) argue that not allowing the physical cues to unfold during the experimentation process are indications of the client trying to control or alter their true feelings and energy within their body- thus rebelling against the paradoxical theory of change principle. They argue that this acts to dis-connect the client as opposed to connect him to his field. A newly formed relationship between George and his body will provide new meanings to the sensations/ anxieties and tensions he experiences.
This level of awareness will therefore provide a space for George demonstrate a more connected and honest account of his here-and-now lived experience, rather than being frightened of his anxiety- which manifests through avoidance behaviour (not taking risks, rejecting attitude towards social situations), and mood swings (heated arguments with wife). Engle & Holiman (2002) support in-session experiments and argue that they can assist clients to become more aware of the diversity of selves that make up a person, their thoughts, feelings and actions that belong to each self.
This awareness will support George to establish a more compassionate relationship with himself and develop a greater sense of understanding, and therefore, empowerment over his internal processes. This degree of being self-aware will allow both George and I to notice the impact that this has on his presentation during therapy and his capacity to remain or resist being present. O’Shea (2005, p. 57) points out that this is a valuable process for the therapist to understand the field of the client, maintaining a supportive therapeutic presence which will ultimately lead to positive change. Using REBT with George
The other form of therapy that I believe will be beneficial to George is REBT. Since George’s cognitions appear to be salient at influencing his moods and behaviours, a course of REBT will provide him with various skills to combat his debilitating experiences. To begin with, I will be clear about the nature of the client-therapist relationship in the REBT setting. This relationship is somewhat different from the reciprocal, self-disclosing relationship found with the gestalt approach. REBT therapists ‘do not necessarily believe that a warm relationship is a necessary or a sufficient condition for effective personality change’ (Ellis, 2008, p. 88). Good rapport is still necessary, but overstressing the client-therapist relationship could be an oversight because it can obscure the ultimate goal of helping in REBT and distract both the client and therapist from the real work to be done (Ellis, 2008, p. 188). The A-B-C model will be progressed through with the direct guidance from the therapist. The essential feature of the therapy will be to dispute some of George’s irrational thinking which will lead to a new belief (B) for the inference of a situation. I will provide George with specific REBT theory on what he is doing to approach his dilemmas with trepidation.
This theory centers on the notion that ‘humans think, emote, perceive and behave simultaneously’ (Ellis, 2008, p. 188). In George’s case, his self-critical thoughts (‘I’m disappointed in myself’ and ‘I’m not good enough’) are not discrete processes but rather attached to his behaviours (restless and irritable with others) and his emotions (mood swings). Acquainting George with the ABC model of REBT is the crucial first step in changing the paradigm in which George has organized his inner structure. This model will help George to understand that his thinking or beliefs lie between the events that influence his feelings and actions.
For example, George’s lack of enthusiasm to participate in social situations (A) may be attached to his belief about ‘not being the person I thought I would be’ (B) and therefore result in his feelings of ‘hopelessness’ or ‘self-doubt’ (C), experiencing these situations as ‘excruciating’ (C). We can’t change or control everything that the world presents to us (A), therefore REBT is strongly concentrated on the (B) and (D) section of the model, so that (C) can be much less self-denigrating and disturbing to George.
In therapy I will illustrate to George how he can make a choice to change his dysfunctional behaviours and show him how he does this using a number of techniques. One technique is to categorize George’s beliefs into the various cognitive distortions that fit with his thinking (see Appendix A). This particular type of cognitive assessment occurs at the level of ‘automatic thinking’ which have specific biases to maintaining a particular belief (Leahy, 2003, p. 7). For example, George may think ‘the people at work think that I am useless as a senior executive’.
This constitutes as ‘mind-reading’ since there is no clear evidence for this, even though it could be true. The underlying assumption that results from this automatic thinking is ‘I need to be approved of by everyone at work to be valuable’, which, as George has indicated, inevitably leads to core beliefs such as ‘I am not worthy or I am not good enough’. It is the core beliefs that are more difficult to change and can implicate George’s vulnerability to continuing anxiety issues and even depression (see Ingram, Miranda, & Segal, 1998).
George’s mind-reading is not only perilous to his health but his expectation that he must be approved of by everyone is a standard that he will continue to fail to live up to. Therefore, it is necessary for George and I to consider some alternative perspectives and choices on how to respond to the events (A) that cause him anxiety. Rather than examining how a belief could be accurate I will encourage George to seek out a new belief, and to help him understand how his previous thinking could be erroneous or inaccurate. Corey (2009, p. 79) calls this process ‘philosophical re-structuring’. This may require a number of sessions and homework assignments so that George can essentially become an ‘expert’ at following his cognitive processes and patterns of thinking. This type of thinking offers George an opportunity to reframe the circumstances around the activating event by considering a more positive assumption. Ongoing homework (one of REBT’s most distinguishable characteristics) will be assigned and completed as this will be a key element to George’s recovery.
For homework, I will ask George to keep track of his activating events and look for as many alternatives to the belief attached to an event as possible. Another way to reframe his (A)’s and to provide George with an opportunity to ‘think flexibly’ to combat the rigidities of his beliefs is to use an in-session emotive technique such as rational-emotive imagery or ‘the feared fantasy technique’ (Burns, 1999, pp. 130-136). This is a form of mental practice that requires George to imagine himself thinking, feeling and behaving in the way he desires to behave in a stressful situation.
I will guide George through an imaginative scene that would normally upset him a great deal, with as many vivid details as possible. I will ask him to feel the unwanted intense feelings as much as possible, and then to gradually change them to more desired, positive feelings. Corey (2009, p. 307) stresses the importance of clients practicing this type of activity ‘several times a week for a few weeks’ so that the client can reach a point where he is no longer troubled by the event. For homework I will ask George to continue this exercise until he has used it for as many (A) situations as ossible and that he felt ready to face them in real life. REBT theory states that ‘people rarely change a profound self-defeating belief unless they act against it’ (Ellis, 2008, p. 188). Therefore, one final technique I will implement into the therapy is a behavioural technique known as exposure. Since REBT is strongly tied to the notion that actions can change cognitions, exposure therapy will help George to confront and reframe certain ‘fearful’ work and social situations (Antona & Garcia-Lopez, 2008).
Using the example of his reluctance to participate in social situations, I will ask him to volunteer to organize the next social gathering at work, and, if appropriate, I will ask George to make an effort to host it by talking to as many people as possible throughout the event. This exercise will indicate to George that interacting with others at work is not so unpleasant (B) and will also decrease his social anxiety and work-related self-doubt (C). Regardless of the preparation work, George may still experience varying degrees of discomfort in anticipation of (or actually being in) the specific situation (A).
Nevertheless, it is acting within the activating-event-context where irrational beliefs are altered and the most desired outcomes (C) are obtained (Coles & Heimberg, 2000; Haug, Hellstrom, Blomhoff, Humble, Madsbu, & Wold, 2000). Conclusion One major difference between gestalt therapy and REBT is the focus of therapy. Gestalt connects the person to the symptom and is process-oriented, whereas REBT focuses on changing the belief system so that the symptom can be changed, lessened or eradicated, thus being content-oriented. Gestalt therapy goes where the client goes with sharing, understanding and becoming aware of their experience.
REBT challenges, instructs and directs the client to alter their experience. Gestalt therapy also requires the therapist to engage with the client in an interactive dialogue rather than directing and instructing the client as found in REBT. Ultimately I would choose to use REBT with George because it is logical and has a very clear and practical application. It appeals to my own understanding of logic and my knowledge of psychology. REBT offers a variety of ways of disputing the ‘irrational’ aspects of people’s problems in a ‘common-sense’ type of manner.
There is no deep analysis required and no indistinct interpretations offered to the client from the therapist. REBT exhibits a ‘matter-of-fact’ and easy to follow method, application and theory. In addition, REBT’s highly effective, active-directive, homework-assigning, and discipline-oriented approach has been shown to be more effective in briefer periods and with fewer sessions (Hajzler & Bernard, 1991; Silverman, McCarthy, & McGovern, 1992). Another justification for choosing REBT before gestalt therapy as the preferred method to treat George is his gender.
Gender is known to be an influential factor regarding men’s lack of access, use and commitment to psychotherapy compared to women (McCarthy & Holliday, 2004). Concerns some men have with therapy include the ‘feminine’ modes of intervention such as verbal expressivity, vulnerability and emotional awareness, skills that have been previously known to be difficult for men to acquire in Western society (Meth & Pasick, 1990). Therefore, a brief, action/ solution-oriented and systematic technique may be less off-putting to him.
Even though I highly value and appreciate the significance of the ‘here-and-now’ experiential work of gestalt therapy, REBT is a discursive approach which can lead to more productive therapeutic work with George in terms of traditional gender-based receptiveness to treatment (Sinclair & Taylor, 2004). Therefore, REBT, in this instance, is the recommended method for George. References Antona, C. J. , & Garcia-Lopez, L. J. (2008). Effects of exposure and cognitive restructuring in social phobia. International Journal of Psychology, 40 (2), 281-292. Bean, P. (2008). To be as a whole person is to be with the whole person.
Gestalt Journal of Australian and New Zealand, 5 (1), 7-12. Burns, D. D. (1999). The feeling good handbook. (Revised ed. ). New York, NY: Plume. Coles, M. E. , & Heimberg, R. G. (2000). Patterns of anxious arousal during exposure to feared situations in individuals with social phobia. Behaviour Research and Therapy, 38, 405- 424. Corey, G. (2009). Theory and practice of counselling and psychotherapy. (8th Ed. ). Belmont, CA: Thomson Brooks/ Cole. Cowen, E. W. , & Presbury, J. H. (2000). Meeting client resistance and reactance with reverence. Journal of Counselling and Development, 78, 411-419. Ellis, A. 1994). Reason and emotion in psychotherapy: Revised and updated. Secaucus, NJ: Carol Publishing Group. Ellis, A. (2008). Rational emotive behaviour therapy. In Corsini, J. & Wedding, D. (Ed. ). Current Psychotherapies (pp. 187-222). Belmont, CA: Thomson Brooks/ Cole. Engle, D. , & Holiman, M. (2002). A case illustration of resistance from a gestalt-experiential perspective. Psychotherapy in Practice, 58 (2), 151-156. Froggatt, W. N. (1993). Choose to be happy: Your step-by-step guide. Auckland: Harper Collins. Hajzler, D. , & Bernard, M. E. (1991). A review of rational emotive outcomes studies.
School Psychology Studies, 6 (1), 27-29. Haug, T. T. , Hellstrom, K. , Blomhoff, S. , Humble, M. , Madsbu, H. P. , & Wold, J. E. (2000). The treatment of social phobia in general practice. Is exposure therapy feasible? Family Practice, 17 (2), 114-118. Ingram, R. E. , Miranda, J. , & Segal, Z. V. (1998). Cognitive vulnerability to depression. New York, NY: Guilford Press. Jacobs, L. (1992). Insights from psychoanalytic self-psychology and intersubjectivity theory for gestalt therapists. The Gestalt Journal, 15 (2), 25-60. Leahy, R. L. (2003) Cognitive therapy techniques: A practitioner’s guide.
New York, NY: Guilford Press. Malfait, R. , & Wollants, G. (2009). The body as a guide. Gestalt Journal of Australia and New Zealand, 6 (1), 21-28. McCarthy, J. , & Holliday, E. L. (2004). Help-seeking and counselling within a traditional male gender role: An examination from a multicultural perspective. Journal of Counselling and Development, 82, 25-30. Meth, R. L. , & Pasick, R. S. (1990). Men in therapy: The challenge of change. New York, NY: Guilford Press. Neff, D. K. , Kirkpatrick, L. K. , & Rude, S. S. (2007). Self-compassion and adaptive psychological functioning. Journal of Research in Personality, 41, 139-154.
O’Shea, L. (2005). Exploring the field of the emerging therapist. Gestalt Journal of Australia and New Zealand, 1, 47-62. Silverman, M. S. , McCarthy, M. , & McGovern, T. (1992). A review of outcome studies of rational-emotive therapy from 1982-1989. Journal of Rational-Emotive and Cognitive Behaviour Therapy, 10 (3), 111-186. Sinclair, S. L. , & Taylor, B. A. (2004). Unpacking the tough guise: Toward a discursive approach for working with men in therapy. Contemporary Family Therapy, 26 (4), 389-408. Stern, D. N. (2004). The present moment in psychotherapy and everyday life. NY: W. W. Norton.
Watson, P. J. , & Culhane, S. E. (2005). Irrational beliefs and social constructionism: Correlations with attitudes about reality, beliefs about people, and collective self-esteem. Journal of Rational-Emotive & Cognitive Behaviour Therapy, 23 (1), 57-70. Yontef, G. (1982). Gestalt therapy: Its inheritance from gestalt psychology. Gestalt Theory, 4 (1/2), 23-39. Yontef, G. (1983). The self in gestalt therapy: Reply to Tobin. The Gestalt Journal, 4 (I), 55-70. Yontef, G. , & Jacobs, L. (2008). Gestalt therapy. In Corsini, R. J. , & Wedding, D. (Ed. ). Current psychotherapies (pp. 328- 367).
Belmont, CA: Thomson Brooks/ Cole. APPENDIX A Cognitive Distortions: 1. Mind reading: You assume that you know what people think without having sufficient evidence of their thoughts. “He thinks I’m a loser. ” 2. Fortune telling: You predict the future–that things will get worse or that there is danger ahead. “I’ll fail that exam” and “I won’t get the job. ” 3. Catastrophizing: You believe that what has happened or will happen will be so awful and unbearable that you won’t be able to stand it. “It would be terrible if I failed. ” 4. Labeling: You assign global negative traits to yourself and others. I’m undesirable” or “He’s a rotten person. ” 5. Discounting positives: You claim that the positives that you or others attain are trivial. ” That’s what wives are supposed to do–so it doesn’t count when she’s nice to me. ” “Those successes were easy, so they don’t matter. ” 6. Negative filter: You focus almost exclusively on the negatives and seldom notice the positives. “Look at all of the people who don’t like me. ” 7. Overgeneralizing: You perceive a global pattern of negatives on the basis of a single incident. “This generally happens to me. I seem to fail at a lot of things. ” 8.
Dichotomous thinking: You view events, or people, in all-or-nothing terms. “I get rejected by everyone” or “It was a waste of time. ” 9. Shoulds: You interpret events in terms of how things should be rather than simply focusing on what is. “I should do well. If I don’t, then I’m a failure. ” 10. Personalizing: You attribute a disproportionate amount of the blame to yourself for negative events and fail to see that certain events are also caused by others. “The marriage ended because I failed” 11. Blaming: You focus on the other person as the source of your negative feelings and you refuse to take responsibility for changing yourself. She’s to blame for the way I feel now” or “My parents caused all my problems. ” 12. Unfair comparisons: You interpret events in terms of standards that are unrealistic—for example, you focus primarily on others who do better than you and find yourself inferior in the comparison. “She’s more successful than I am” or “Others did better than I did on the test. ” 13. Regret orientation: You focus on the idea that you could have done better in the past, rather on what you can do better now. “I could have had a better job if I had tried” or “I shouldn’t have said that”. 14. What if?
You keep asking a series of questions about “What if” something happens and fail to be satisfied with any of the answers. “Yeah, but what if I get anxious? Or what if I can’t catch my breath? ” 15. Emotional reasoning: You let your feelings guide your interpretation of reality–for example, “I feel depressed, therefore my marriage is not working out. ” 16. Inability to disconfirm: You reject any evidence or arguments that might contradict your negative thoughts. For example, when you have the thought “I’m unlovable”, you reject as irrelevant any evidence that people like you. Consequently, your thought cannot be refuted. That’s not the real issue. There are deeper problems. There are other factors. ” 17. Judgment Focus: You view yourself, others and events in terms of evaluations of good/bad or superior-inferior, rather than simply describing, accepting, or understanding. You are continually measuring yourself and others according to arbitrary standards, finding that you and others fall short. You are focused on the judgments of others as well as your own judgments of yourself. “I didn’t perform well in college” or “If I take up tennis, I won’t do well” or “Look how successful she is. I’m not successful”. (Source: Leahy, 2003, p. 32)